- Email: [email protected]
Music therapy
by Edward A. Roth, MM, NMT, MT-BC, and Susan Wisser, RN, MSN, MBA, CCM
M
any people are influenced by music on a daily basis. Typically, with varying degrees of awareness, many of us use music to achieve some type of goal in our daily lives. Some use music during exercise to motivate ourselves and set the pace. Others use music at the end of the day to unwind and to relax. Some use it to keep calm in rush-hour traffic or to enhance the experience of a long road trip. Indeed, humans have used music for therapeutic purposes throughout recorded history.1 By using music in a prescribed fashion with predictable results in the clinical setting, however, is a more recent development. During and after World War II, physicians used music to calm soldiers who were suffering from what was referred to as shell shock. Music also was used to distract injured soldiers from their pain while they recovered from surgery. Over the years, the use of music as a therapeutic agent in the clinical setting has necessitated the development of trained professionals who are both equally competent musicians and skilled clinicians. Music therapy has developed into a viable treatment mode and is defined by the American Music Therapy Association2 (AMTA) as “an established health service, similar to occupational therapy and physical therapy. Music therapists assess emotional well-being, physical health, social functioning, communication abilities, and cognitive skills through musical responses.” Several misconceptions surround music therapy, which is a bit of a misnomer. TCM 52
May/June 2004
One common misperception is that patients have to have some musical training or background to benefit from services. This is not the case, because many music therapy interventions are based on the universal response to music and then are individualized to meet each patient’s needs. Developing the Science Within a rehabilitation program, music is shown to be an effective tool to structure movement with predictable cuing patterns; engaging and sustaining attention; stimulating, pacing, and clarifying verbal articulations; and motivating clients to increase compliance. Neurologic music therapy (NMT), a specialized certification, is defined as “the therapeutic application of music to cognitive, sensory, and motor dysfunctions due to neurologic disease of the human nervous system.”3 Neurologic music therapy is a researchbased model with standardized treat-
ment protocols based on scientific knowledge of music perception and subsequent brain and behavior functioning. No longer is it sufficient to base therapeutic interventions on intuition or phenomenologic data; interventions within the NMT model are based on the translation of musical responses as therapeutic mechanisms into clinical techniques. Many people have an intuitive sense that music can be used to enhance or to facilitate daily goals, to be used therapeutically, if you will, and many of us “self-medicate” daily. Neurologic music therapy asks two primary questions: does this collective intuition mean that music can be used therapeutically, and what are the physiologic, neurologic, and psychologic mechanisms by which therapeutic changes occur as a result of music perception or production? The aesthetic or pleasurable responses that many of us have to music do not directly
or logically translate into a therapeutic response, which is why neuroscience and rehabilitative medicine have weighed in with evidence from both the laboratory and the clinic.
Documenting the Reality of an Internal Time Keeper Why do people tap their toes to music, often without thinking about it? Why is it difficult to concentrate on something else when your favorite song is on the radio? Viewing music as a culturally based form of art, no immediate connection exists between the response many of us have to music and something that would be considered therapeutic, medicinal, or rehabilitative. The physiologic, neurologic, and psychologic responses we have to music need to be translated into meaningful therapeutic
responses. Neuroscience is beginning to understand how the mammalian nervous system responds to timeordered sound, particularly how humans synchronize movement to music with a clearly articulated beat. In a gross overview, it appears that while humans (and other mammals) perceive rhythmic music, it has an excitatory effect on neurons in the spinal cord.4 These neurons have a readying or priming effect on the musculature system, which facilitates subsequent motor function with greater efficiency. Many recent theories that attempt to explain the effect of rhythm on motor performance assume the existence of internal timekeepers, which contribute to the control of repetitive and sequential movements and can entrain to external timekeepers.5 One can visualize the entrainment effect as two oscillating gears with the external timekeeper (music) being the stronger, primary gear, and the internal timekeeper as the weaker, secondary cog. The external timekeeper functions as a timing cue and stabilizes the activity of the internal timekeeper. The fact that we are able to execute rhythmic movements, such as walking,
running, dancing, playing music, and performing certain athletic feats, without the presence of external timing cues strongly supports the notion of an internal timekeeper. In fact, the entrainment or the synchronization effect is so strong and the brain as a central pattern processor is so efficient, that timing fluctuations in the presentation of auditory cues at thresholds even below perceptibility are processed and subsequent motor performance altered proportionately. Muscle activity as measured by electromyograph (EMG) patterns has been shown to be influenced by auditory rhythmic cues below the level of perceptibility.6 A great deal of the motor rehabilitation literature addressing the effects of rhythm on movement is, indeed, based on this oscillator-entrainment model. The best example of this process is in the rehabilitation of people with gait disorders, including stroke, Parkinson’s disease, Huntington’s disease, and cerebral palsy. APPLICATION IN THE REHABILITATION SETTING Physical Therapy: Gait and Lower Extremity Within the parameters of normal daily living, walking is the most intrinsically rhythmic act we perform regularly. Recently, clinical studies investigating the facilitative effect of rhythm on gait with both normal and diagnosed populations have been published with convincing results. Thaut et al7 investigated the effect of rhythm on gait parameters in patients with hemiparetic stroke. After an assessment of cadence (steps per minute), patients were asked to walk to a musical beat, emphasizing May/June 2004
TCM 53
The study found that patients who performed gait exercises to music had significant increases in cadence, velocity, and stride symmetry.
heel strikes on the strong rhythmic pulses. The study found that patients who performed gait exercises to music had significant increases in cadence, velocity, and stride symmetry. Because the rhythmic pulse was presented in a highly predictable fashion, patients were able to calculate when to step because they could anticipate when the next beat would occur. It is very important to restate here that this process occurs preconsciously, meaning patients do not need to think about when to step but rather simply walk to the beat of the music and allow the auditory-motor networks to operate naturally. This therapeutic music intervention is known as rhythmic auditory stimulation (RAS), because the rhythm provides the stimulation necessary for the injured nervous system to operate in a more optimal and natural manner.
by Thaut et al8, one of the primary questions asked was “Can auditory rhythm improve the even timing of sequential arm movements during tasks with different spatial requirements compared with uncued timing?” Participants were engaged in a sequence of arm-reaching tasks in which they reached in front of them in alternating flexion and extension movements of the elbow. For each task, participants were directed to touch targets in a predetermined order. Each sequence comprised four movements made to different targets of varying distances from the participant. Participants first performed each task without auditory cuing. The second condition involved the subjects moving in time to a rhythmic auditory cue, which was a metronomic click imbedded in instrumental background music.
Occupational Therapy: Reach and Upper Extremity The RAS principles also are used in upper extremity rehabilitation, when appropriate, in an intervention known as therapeutic instrumental music performance (TIMP). In a study performed
The results were robust and significant: without auditory cuing, participants were unable to produce evenly timed movement patterns. Dissimilarly, auditory cuing significantly decreased the variability of movement duration by 30% to 60%. Even when target distances
TCM 54
May/June 2004
were increased three times, movement durations remained relatively constant in the cued condition. These data suggest that, with a rhythmic auditory cue, participants perform movements in more evenly timed and smooth patterns, whereas, without a rhythmic auditory cue, movements are more rigid, irregular, and abrupt. A similar study9 investigated the influence of auditory rhythm on muscle activity as measured by changes in EMG patterns of the biceps and triceps muscles. Electromyograph electrodes were attached to the biceps and triceps, and participants performed a series of downswings and upswings by flexing and extending the elbow and hitting a target drum pad on completion of the downswing. The first series of movements were performed in synchrony with the participants’ individually determined tempo without music. The second series of movements were performed to an external cue—music matched to the original tempo in the first condition. The third series of movements were performed to music that had a tempo slower than the internal tempo used in the first two conditions. The results showed that auditory rhythm had a distinct activating influence on EMG patterns in biceps and triceps during functional arm movements. Onset of biceps activity occurred earlier, before target contact, resulting in cocontraction between the two muscle groups under the auditory cuing condition. Triceps activity before contact with the target had an earlier onset, and duration of biceps activity after target contact increased under the influence of an auditory rhythmic cue. These data suggest that the use of auditory rhythm as a timing cue for motor activity could modify muscle activity in a therapeutically favorable manner to increase the stability, fluidity, and accuracy of sequential arm movements. In a recent project10 at Bronson Medical Center in Kalamazoo, Michigan, music therapists used TIMP to rehabilitate lost or diminished upper extremity functioning in individuals who had a stroke. Standardized rehabilitation exercises used by physical therapists were per-
formed through musical instruments. For example, elbow flexion and extension exercises were performed by having the patient reach in front of himself, in a manner that is kinematically appropriate and therapeutically purposeful, to strike a drum or cymbal with a mallet. The therapists created music that contained the most appropriate musical elements for clear cuing to enhance the chances for success. It is crucial for music therapists to use live music with this type of experience so they can manipulate the rhythm and tempo to match patients’ needs. This type of manipulation cannot be done with recorded music. The only viable alternative is using digital music that the music therapist can control in real time. Speech Therapy: Language Facilitation Melodic intonation therapy (MIT) has been widely used by speech-language pathologists with aphasic patients. According to Sparks and Holland,11 MIT is a step-by-step procedure that uses melody based on the natural prosody of functional phrases to stimulate verbal expression. Later, the melody is faded into chant, and finally the chant is faded into normal speech. Musical speech stimulation (MSS) is an NMT intervention. This musical analogue of phrase completion exercises1 taps into the unimpaired ability to sing to facilitate spontaneous verbalizations. Patients are asked to complete phrases within familiar songs, such as You Are My Sunshine. This approach is a training model, and automatic singing is practiced until functional expression emerges as automatic speech. Patients who are apraxic benefit from MSS under the same principles that guide RAS procedures, which, in this case, facilitate oral-motor timing. The natural prosody of phrases is created within a song to best resemble functional speech and to provide the appropriate cues for proper intonation. Cognitive Therapy: Ordering the Thought Process One of the main tasks of our perceptual systems is to perceive and decode patterns. Music is a highly organized and
structured stimulus in time, because it refers to rhythm and tempo; in space, because it refers to pitch; and in force, because it refers to dynamics.12 Familiar music tends to be comforting, and new or novel music attracts our attention and can maintain it over a sustained period. Music therapists frequently use music paired with nonmusical information because patients typically are more alert and can sustain attention over longer periods. They also use it as an encoding and decoding strategy in memory tasks.
completion of an undergraduate degree in music therapy and a 1040-hour clinical internship, the music therapist then sits for a certification examination given by the Certification Board for Music Therapists. Those who pass are given the credential Music Therapist-Board Certified (MT-BC). Case managers should hire only music therapists who hold this credential to ensure professional preparation and competence. The AMTA Web site (www.musictherapy. org) can provide more information on educational preparation, training, and qualifications.
It is crucial for music therapists to use live music with this type of experience so they can manipulate the rhythm and tempo to match patients’ needs.
A university setting with a department of music therapy is a good place to begin a search for a music therapist. Faculty or students may be able to provide services to private clients. If proximity does not make that feasible, the school may have a listing of alumni. Also, you can request a referral list from AMTA’s Web site.
Use of music as a mnemonic device is very common when attempting to teach someone novel information. As children, we learn letters within the melodic and rhythmic framework of the alphabet song. The music helps us encode the nonmusical information within a highly predictable musical structure and decode it more efficiently (and accurately) within that structure. As adults, we find ourselves humming the tune to figure out where to file a patient’s chart alphabetically. In rehabilitation, music therapists provide short and catchy songs for a variety of tasks, such as remembering scheduling and sequenced events. Patients are better able to recall and perform the tasks that have been encoded into memory within a song. THE CASE MANAGER’S CHALLENGE: MAKING IT HAPPEN Music therapists are individuals with specific educational preparation. Case managers should look for degrees specifically in music therapy at both the baccalaureate and master’s levels. Upon
Creative case managers may successfully locate a music therapist through other community networks. Special education teachers within the local school system may know of a contact, community and adult education program planners may offer a lead, or music teachers or conductors may know the name of a colleague. Certainly rehabilitation centers, extended care facilities, and recreational and respite programs should not be overlooked. Once contacted, the music therapist will be able to provide information to the case manager that will help focus the goal to incorporate music therapy into a client’s care plan. The case manager needs to understand the approaches to music therapy used by each therapist because individual practices can vary widely. It is important to match the therapist’s strengths to the client’s needs. The therapist can help the case manager understand the current trends in music therapy in that community. Where are courses held? Are sessions for groups or individuals? What do they cost, and who usually pays? What specific outcomes are anticipated? What is the usual duration of involvement or treatment? Is the client involved in creating the May/June 2004
TCM 55
music (hands-on) or is it received more passively? What instrumentation is used? The questions that need to be asked are many, and, to be successful, the case manager must be well informed before moving ahead with a specific proposal. Health care payers increasingly are willing to consider covering complimentary or alternative medicine, given the consumer movement toward health maintenance; proactive management of chronic conditions; and healthy, lower-stress lifestyles. These goals frequently are consistent with music therapy, in addition to its use in acute rehabilitation. The case manager most likely will need to educate decision makers about music therapy. Some anecdotal literature may describe a similar application. A growing body of evidence-based data provides objective outcomes. The case manager should be prepared to interpret these for the payer and to describe their relevance. Payers respond most favorably to specific proposals, especially when being led into unfamiliar territory. Thus, the case manager’s thorough knowledge of the music therapy being sought is critical. The request for services should specify goals and anticipated outcomes, target dates at which progress will be evaluated, a description of therapeutic activities, the therapist’s qualifications, and cost projections. PAYMENT CONSIDERATIONS Creativity is a hallmark of case management. It is a frequent necessity in the task of locating funding sources. When searching for coverage for music therapy, the case manager should consider the following. Health Insurance Determine the degree of flexibility, if any, in benefit application and provider assignment. A simple approach to incorporating music therapy into the care plan is to fold it under traditional therapy billings. This requires the appropriate oversight of the music therapist by the corresponding rehabilitation team member. In many cases, music therapists, in their billing practice, simply reference the appropriate CPT code paired with TCM 56
May/June 2004
the type of treatment provided. Groundwork must be laid that educates all and broadens the concept of available modes.
jects. Refer to AMTA’s Web site for a list of colleges and universities with music therapy programs. ❑ References
The feasibility of this approach hinges on the flexibility of benefits, the openmindedness of therapists, and strong relationship-building skills. The case manager may need to introduce the strategy to various parties, make introductions, and facilitate the creation of a process that will accomplish the goal. A wide and varied network of professionals and facilities should be considered. Explore relationships with acute rehabilitation units, skilled nursing facilities, outpatient centers, adult day care programs, assisted living and residential sites, and home health care agencies. Workers’ Compensation This state-regulated option is potentially less rigid than standard health insurance benefits. If the case manager can set forth a plan to demonstrate outcomes that enhance the goal of returning to work, music therapy is likely to be given a nod of approval on a trial basis. Aspects of music therapy also may be incorporated in the accommodations provided to the returning worker. Stress management and stimulus reduction are two issues that may be managed through musical influence. The work environment may be modified with music or private headphones used for individual musical input. Other Insurance Auto and personal injury policies generally carry some degree of medical coverage and should be explored if applicable. When available, liability settlements may provide funds. Long-term care policies also should be investigated. Last But Not Least The case manager should not overlook the alternative of private pay. Group sessions can be quite reasonable. Clients who are discouraged with traditional care may be very motivated to invest in a well thought-out trial of music therapy. The case manager may also wish to contact academic centers regarding the possibility of qualifying for and participating in grant-funded research pro-
1.
Merriam AP. The anthropology of music. Evanston: Northwestern University Press; 1964. 2. American Music Therapy Association. Music therapy and medicine. Available from: http://www.musictherapy.org. 3. Thaut MH. Techniques of neurologic music therapy in neurologic rehabilitation. In: Thaut MH. Training manual for neurologic music therapy. Fort Collins (CO): Colorado State University; 1999. 4. Rossignol S, Melvill-Jones G. Audiospinal influences in man studied by the H-reflex and its possible role in rhythmic movement synchronized to sound. Electroencephalogr Clin Neurophysiol 1976;41:8392. 5. Thaut M, Rathbun J, Miller R. Music versus metronome timekeeper in a rhythmic motor task. Int J Arts Med 1998;5:4-12. 6. Staum M. Music and rhythmic stimuli in the rehabilitation of gait disorders. J Music Ther 1983;20:69-87. 7. Thaut MH, Rice RR, McIntosh GC. Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. J Neurol Sci 1997;151:207-15. 8. Thaut M, Brown S, Benjamin J, Cooke J. Rhythmic facilitation of movement sequencing: effects on spatiotemporal control and sensory modality dependence. In: Pratt R, Spintge R, editors. Music medicine. Vol. 2. St. Louis: MMB Music; 1996. p. 104-12. 9. Thaut M, Schleiffers S, Davis W. Analysis of EMG activity in biceps and triceps muscle in a gross motor task under the influence of auditory rhythm. J Music Ther 1991;28:64-88. 10. Roth E. The effects of therapeutic instrumental music performance (TIMP) on the upper extremity rehabilitation of hemiparetic stroke patients. Current project. 11. Sparks R, Holland A. Method: melodic intonation therapy for aphasia. J Speech Hear Disord 1976;41:287-97. 12. Berlyne DE. Aesthetics and psychobiology. New York: Appleton-Century-Crofts; 1971.
Edward A. Roth, MM, NMT, MT-BC, is an assistant professor of music therapy at Western Michigan University in Kalamazoo, Mich. Susan Wisser, RN, MSN, MBA, CCM, is president of Wisser and Associates, a case management consulting company in Haslett, Mich. Reprint orders: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 579-2838; reprint no. YMCM 166 doi:10.1016/j.casemgr.2004.03.004
M
any people are influenced by music on a daily basis. Typically, with varying degrees of awareness, many of us use music to achieve some type of goal in our daily lives. Some use music during exercise to motivate ourselves and set the pace. Others use music at the end of the day to unwind and to relax. Some use it to keep calm in rush-hour traffic or to enhance the experience of a long road trip. Indeed, humans have used music for therapeutic purposes throughout recorded history.1 By using music in a prescribed fashion with predictable results in the clinical setting, however, is a more recent development. During and after World War II, physicians used music to calm soldiers who were suffering from what was referred to as shell shock. Music also was used to distract injured soldiers from their pain while they recovered from surgery. Over the years, the use of music as a therapeutic agent in the clinical setting has necessitated the development of trained professionals who are both equally competent musicians and skilled clinicians. Music therapy has developed into a viable treatment mode and is defined by the American Music Therapy Association2 (AMTA) as “an established health service, similar to occupational therapy and physical therapy. Music therapists assess emotional well-being, physical health, social functioning, communication abilities, and cognitive skills through musical responses.” Several misconceptions surround music therapy, which is a bit of a misnomer. TCM 52
May/June 2004
One common misperception is that patients have to have some musical training or background to benefit from services. This is not the case, because many music therapy interventions are based on the universal response to music and then are individualized to meet each patient’s needs. Developing the Science Within a rehabilitation program, music is shown to be an effective tool to structure movement with predictable cuing patterns; engaging and sustaining attention; stimulating, pacing, and clarifying verbal articulations; and motivating clients to increase compliance. Neurologic music therapy (NMT), a specialized certification, is defined as “the therapeutic application of music to cognitive, sensory, and motor dysfunctions due to neurologic disease of the human nervous system.”3 Neurologic music therapy is a researchbased model with standardized treat-
ment protocols based on scientific knowledge of music perception and subsequent brain and behavior functioning. No longer is it sufficient to base therapeutic interventions on intuition or phenomenologic data; interventions within the NMT model are based on the translation of musical responses as therapeutic mechanisms into clinical techniques. Many people have an intuitive sense that music can be used to enhance or to facilitate daily goals, to be used therapeutically, if you will, and many of us “self-medicate” daily. Neurologic music therapy asks two primary questions: does this collective intuition mean that music can be used therapeutically, and what are the physiologic, neurologic, and psychologic mechanisms by which therapeutic changes occur as a result of music perception or production? The aesthetic or pleasurable responses that many of us have to music do not directly
or logically translate into a therapeutic response, which is why neuroscience and rehabilitative medicine have weighed in with evidence from both the laboratory and the clinic.
Documenting the Reality of an Internal Time Keeper Why do people tap their toes to music, often without thinking about it? Why is it difficult to concentrate on something else when your favorite song is on the radio? Viewing music as a culturally based form of art, no immediate connection exists between the response many of us have to music and something that would be considered therapeutic, medicinal, or rehabilitative. The physiologic, neurologic, and psychologic responses we have to music need to be translated into meaningful therapeutic
responses. Neuroscience is beginning to understand how the mammalian nervous system responds to timeordered sound, particularly how humans synchronize movement to music with a clearly articulated beat. In a gross overview, it appears that while humans (and other mammals) perceive rhythmic music, it has an excitatory effect on neurons in the spinal cord.4 These neurons have a readying or priming effect on the musculature system, which facilitates subsequent motor function with greater efficiency. Many recent theories that attempt to explain the effect of rhythm on motor performance assume the existence of internal timekeepers, which contribute to the control of repetitive and sequential movements and can entrain to external timekeepers.5 One can visualize the entrainment effect as two oscillating gears with the external timekeeper (music) being the stronger, primary gear, and the internal timekeeper as the weaker, secondary cog. The external timekeeper functions as a timing cue and stabilizes the activity of the internal timekeeper. The fact that we are able to execute rhythmic movements, such as walking,
running, dancing, playing music, and performing certain athletic feats, without the presence of external timing cues strongly supports the notion of an internal timekeeper. In fact, the entrainment or the synchronization effect is so strong and the brain as a central pattern processor is so efficient, that timing fluctuations in the presentation of auditory cues at thresholds even below perceptibility are processed and subsequent motor performance altered proportionately. Muscle activity as measured by electromyograph (EMG) patterns has been shown to be influenced by auditory rhythmic cues below the level of perceptibility.6 A great deal of the motor rehabilitation literature addressing the effects of rhythm on movement is, indeed, based on this oscillator-entrainment model. The best example of this process is in the rehabilitation of people with gait disorders, including stroke, Parkinson’s disease, Huntington’s disease, and cerebral palsy. APPLICATION IN THE REHABILITATION SETTING Physical Therapy: Gait and Lower Extremity Within the parameters of normal daily living, walking is the most intrinsically rhythmic act we perform regularly. Recently, clinical studies investigating the facilitative effect of rhythm on gait with both normal and diagnosed populations have been published with convincing results. Thaut et al7 investigated the effect of rhythm on gait parameters in patients with hemiparetic stroke. After an assessment of cadence (steps per minute), patients were asked to walk to a musical beat, emphasizing May/June 2004
TCM 53
The study found that patients who performed gait exercises to music had significant increases in cadence, velocity, and stride symmetry.
heel strikes on the strong rhythmic pulses. The study found that patients who performed gait exercises to music had significant increases in cadence, velocity, and stride symmetry. Because the rhythmic pulse was presented in a highly predictable fashion, patients were able to calculate when to step because they could anticipate when the next beat would occur. It is very important to restate here that this process occurs preconsciously, meaning patients do not need to think about when to step but rather simply walk to the beat of the music and allow the auditory-motor networks to operate naturally. This therapeutic music intervention is known as rhythmic auditory stimulation (RAS), because the rhythm provides the stimulation necessary for the injured nervous system to operate in a more optimal and natural manner.
by Thaut et al8, one of the primary questions asked was “Can auditory rhythm improve the even timing of sequential arm movements during tasks with different spatial requirements compared with uncued timing?” Participants were engaged in a sequence of arm-reaching tasks in which they reached in front of them in alternating flexion and extension movements of the elbow. For each task, participants were directed to touch targets in a predetermined order. Each sequence comprised four movements made to different targets of varying distances from the participant. Participants first performed each task without auditory cuing. The second condition involved the subjects moving in time to a rhythmic auditory cue, which was a metronomic click imbedded in instrumental background music.
Occupational Therapy: Reach and Upper Extremity The RAS principles also are used in upper extremity rehabilitation, when appropriate, in an intervention known as therapeutic instrumental music performance (TIMP). In a study performed
The results were robust and significant: without auditory cuing, participants were unable to produce evenly timed movement patterns. Dissimilarly, auditory cuing significantly decreased the variability of movement duration by 30% to 60%. Even when target distances
TCM 54
May/June 2004
were increased three times, movement durations remained relatively constant in the cued condition. These data suggest that, with a rhythmic auditory cue, participants perform movements in more evenly timed and smooth patterns, whereas, without a rhythmic auditory cue, movements are more rigid, irregular, and abrupt. A similar study9 investigated the influence of auditory rhythm on muscle activity as measured by changes in EMG patterns of the biceps and triceps muscles. Electromyograph electrodes were attached to the biceps and triceps, and participants performed a series of downswings and upswings by flexing and extending the elbow and hitting a target drum pad on completion of the downswing. The first series of movements were performed in synchrony with the participants’ individually determined tempo without music. The second series of movements were performed to an external cue—music matched to the original tempo in the first condition. The third series of movements were performed to music that had a tempo slower than the internal tempo used in the first two conditions. The results showed that auditory rhythm had a distinct activating influence on EMG patterns in biceps and triceps during functional arm movements. Onset of biceps activity occurred earlier, before target contact, resulting in cocontraction between the two muscle groups under the auditory cuing condition. Triceps activity before contact with the target had an earlier onset, and duration of biceps activity after target contact increased under the influence of an auditory rhythmic cue. These data suggest that the use of auditory rhythm as a timing cue for motor activity could modify muscle activity in a therapeutically favorable manner to increase the stability, fluidity, and accuracy of sequential arm movements. In a recent project10 at Bronson Medical Center in Kalamazoo, Michigan, music therapists used TIMP to rehabilitate lost or diminished upper extremity functioning in individuals who had a stroke. Standardized rehabilitation exercises used by physical therapists were per-
formed through musical instruments. For example, elbow flexion and extension exercises were performed by having the patient reach in front of himself, in a manner that is kinematically appropriate and therapeutically purposeful, to strike a drum or cymbal with a mallet. The therapists created music that contained the most appropriate musical elements for clear cuing to enhance the chances for success. It is crucial for music therapists to use live music with this type of experience so they can manipulate the rhythm and tempo to match patients’ needs. This type of manipulation cannot be done with recorded music. The only viable alternative is using digital music that the music therapist can control in real time. Speech Therapy: Language Facilitation Melodic intonation therapy (MIT) has been widely used by speech-language pathologists with aphasic patients. According to Sparks and Holland,11 MIT is a step-by-step procedure that uses melody based on the natural prosody of functional phrases to stimulate verbal expression. Later, the melody is faded into chant, and finally the chant is faded into normal speech. Musical speech stimulation (MSS) is an NMT intervention. This musical analogue of phrase completion exercises1 taps into the unimpaired ability to sing to facilitate spontaneous verbalizations. Patients are asked to complete phrases within familiar songs, such as You Are My Sunshine. This approach is a training model, and automatic singing is practiced until functional expression emerges as automatic speech. Patients who are apraxic benefit from MSS under the same principles that guide RAS procedures, which, in this case, facilitate oral-motor timing. The natural prosody of phrases is created within a song to best resemble functional speech and to provide the appropriate cues for proper intonation. Cognitive Therapy: Ordering the Thought Process One of the main tasks of our perceptual systems is to perceive and decode patterns. Music is a highly organized and
structured stimulus in time, because it refers to rhythm and tempo; in space, because it refers to pitch; and in force, because it refers to dynamics.12 Familiar music tends to be comforting, and new or novel music attracts our attention and can maintain it over a sustained period. Music therapists frequently use music paired with nonmusical information because patients typically are more alert and can sustain attention over longer periods. They also use it as an encoding and decoding strategy in memory tasks.
completion of an undergraduate degree in music therapy and a 1040-hour clinical internship, the music therapist then sits for a certification examination given by the Certification Board for Music Therapists. Those who pass are given the credential Music Therapist-Board Certified (MT-BC). Case managers should hire only music therapists who hold this credential to ensure professional preparation and competence. The AMTA Web site (www.musictherapy. org) can provide more information on educational preparation, training, and qualifications.
It is crucial for music therapists to use live music with this type of experience so they can manipulate the rhythm and tempo to match patients’ needs.
A university setting with a department of music therapy is a good place to begin a search for a music therapist. Faculty or students may be able to provide services to private clients. If proximity does not make that feasible, the school may have a listing of alumni. Also, you can request a referral list from AMTA’s Web site.
Use of music as a mnemonic device is very common when attempting to teach someone novel information. As children, we learn letters within the melodic and rhythmic framework of the alphabet song. The music helps us encode the nonmusical information within a highly predictable musical structure and decode it more efficiently (and accurately) within that structure. As adults, we find ourselves humming the tune to figure out where to file a patient’s chart alphabetically. In rehabilitation, music therapists provide short and catchy songs for a variety of tasks, such as remembering scheduling and sequenced events. Patients are better able to recall and perform the tasks that have been encoded into memory within a song. THE CASE MANAGER’S CHALLENGE: MAKING IT HAPPEN Music therapists are individuals with specific educational preparation. Case managers should look for degrees specifically in music therapy at both the baccalaureate and master’s levels. Upon
Creative case managers may successfully locate a music therapist through other community networks. Special education teachers within the local school system may know of a contact, community and adult education program planners may offer a lead, or music teachers or conductors may know the name of a colleague. Certainly rehabilitation centers, extended care facilities, and recreational and respite programs should not be overlooked. Once contacted, the music therapist will be able to provide information to the case manager that will help focus the goal to incorporate music therapy into a client’s care plan. The case manager needs to understand the approaches to music therapy used by each therapist because individual practices can vary widely. It is important to match the therapist’s strengths to the client’s needs. The therapist can help the case manager understand the current trends in music therapy in that community. Where are courses held? Are sessions for groups or individuals? What do they cost, and who usually pays? What specific outcomes are anticipated? What is the usual duration of involvement or treatment? Is the client involved in creating the May/June 2004
TCM 55
music (hands-on) or is it received more passively? What instrumentation is used? The questions that need to be asked are many, and, to be successful, the case manager must be well informed before moving ahead with a specific proposal. Health care payers increasingly are willing to consider covering complimentary or alternative medicine, given the consumer movement toward health maintenance; proactive management of chronic conditions; and healthy, lower-stress lifestyles. These goals frequently are consistent with music therapy, in addition to its use in acute rehabilitation. The case manager most likely will need to educate decision makers about music therapy. Some anecdotal literature may describe a similar application. A growing body of evidence-based data provides objective outcomes. The case manager should be prepared to interpret these for the payer and to describe their relevance. Payers respond most favorably to specific proposals, especially when being led into unfamiliar territory. Thus, the case manager’s thorough knowledge of the music therapy being sought is critical. The request for services should specify goals and anticipated outcomes, target dates at which progress will be evaluated, a description of therapeutic activities, the therapist’s qualifications, and cost projections. PAYMENT CONSIDERATIONS Creativity is a hallmark of case management. It is a frequent necessity in the task of locating funding sources. When searching for coverage for music therapy, the case manager should consider the following. Health Insurance Determine the degree of flexibility, if any, in benefit application and provider assignment. A simple approach to incorporating music therapy into the care plan is to fold it under traditional therapy billings. This requires the appropriate oversight of the music therapist by the corresponding rehabilitation team member. In many cases, music therapists, in their billing practice, simply reference the appropriate CPT code paired with TCM 56
May/June 2004
the type of treatment provided. Groundwork must be laid that educates all and broadens the concept of available modes.
jects. Refer to AMTA’s Web site for a list of colleges and universities with music therapy programs. ❑ References
The feasibility of this approach hinges on the flexibility of benefits, the openmindedness of therapists, and strong relationship-building skills. The case manager may need to introduce the strategy to various parties, make introductions, and facilitate the creation of a process that will accomplish the goal. A wide and varied network of professionals and facilities should be considered. Explore relationships with acute rehabilitation units, skilled nursing facilities, outpatient centers, adult day care programs, assisted living and residential sites, and home health care agencies. Workers’ Compensation This state-regulated option is potentially less rigid than standard health insurance benefits. If the case manager can set forth a plan to demonstrate outcomes that enhance the goal of returning to work, music therapy is likely to be given a nod of approval on a trial basis. Aspects of music therapy also may be incorporated in the accommodations provided to the returning worker. Stress management and stimulus reduction are two issues that may be managed through musical influence. The work environment may be modified with music or private headphones used for individual musical input. Other Insurance Auto and personal injury policies generally carry some degree of medical coverage and should be explored if applicable. When available, liability settlements may provide funds. Long-term care policies also should be investigated. Last But Not Least The case manager should not overlook the alternative of private pay. Group sessions can be quite reasonable. Clients who are discouraged with traditional care may be very motivated to invest in a well thought-out trial of music therapy. The case manager may also wish to contact academic centers regarding the possibility of qualifying for and participating in grant-funded research pro-
1.
Merriam AP. The anthropology of music. Evanston: Northwestern University Press; 1964. 2. American Music Therapy Association. Music therapy and medicine. Available from: http://www.musictherapy.org. 3. Thaut MH. Techniques of neurologic music therapy in neurologic rehabilitation. In: Thaut MH. Training manual for neurologic music therapy. Fort Collins (CO): Colorado State University; 1999. 4. Rossignol S, Melvill-Jones G. Audiospinal influences in man studied by the H-reflex and its possible role in rhythmic movement synchronized to sound. Electroencephalogr Clin Neurophysiol 1976;41:8392. 5. Thaut M, Rathbun J, Miller R. Music versus metronome timekeeper in a rhythmic motor task. Int J Arts Med 1998;5:4-12. 6. Staum M. Music and rhythmic stimuli in the rehabilitation of gait disorders. J Music Ther 1983;20:69-87. 7. Thaut MH, Rice RR, McIntosh GC. Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. J Neurol Sci 1997;151:207-15. 8. Thaut M, Brown S, Benjamin J, Cooke J. Rhythmic facilitation of movement sequencing: effects on spatiotemporal control and sensory modality dependence. In: Pratt R, Spintge R, editors. Music medicine. Vol. 2. St. Louis: MMB Music; 1996. p. 104-12. 9. Thaut M, Schleiffers S, Davis W. Analysis of EMG activity in biceps and triceps muscle in a gross motor task under the influence of auditory rhythm. J Music Ther 1991;28:64-88. 10. Roth E. The effects of therapeutic instrumental music performance (TIMP) on the upper extremity rehabilitation of hemiparetic stroke patients. Current project. 11. Sparks R, Holland A. Method: melodic intonation therapy for aphasia. J Speech Hear Disord 1976;41:287-97. 12. Berlyne DE. Aesthetics and psychobiology. New York: Appleton-Century-Crofts; 1971.
Edward A. Roth, MM, NMT, MT-BC, is an assistant professor of music therapy at Western Michigan University in Kalamazoo, Mich. Susan Wisser, RN, MSN, MBA, CCM, is president of Wisser and Associates, a case management consulting company in Haslett, Mich. Reprint orders: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 579-2838; reprint no. YMCM 166 doi:10.1016/j.casemgr.2004.03.004