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Music Therapy Interventions in Pediatric Rehabilitation: A C

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Kaleigh Noel

on 19 February 2014

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Transcript of Music Therapy Interventions in Pediatric Rehabilitation: A C

Music Therapy Interventions in Pediatric Rehabilitation: A Case Study s/p TBI
Rehabilitation
Taub (1980) discussed five ways in which therapies can support the rehabilitation process:
Help to prevent complications which can obstruct the natural recovery process
Teach adaptive strategies to use unaffected parts of the body in place of the affected parts
Retrain the affected parts through specific exercise techniques
Ensure the availability and proper use of correct physical aids
Prevent long-term disabilities due to not the original loss but rather learned non-use that results in the individual not using the affected limb although use is possible.

Music Therapy Interventions in Rehabilitation
"Patients receiving music therapy have been found to be significantly more involved in their rehabilitation, more socially interactive, and show trends suggesting improved mood."
Procedure
Due to the nature of the patient's admission, each music therapy session was structured in a similar way to promote familiarity and routine.
In Conclusion...
This case study found that Music Therapy Interventions can facilitate:

Improved cognition (Attention & Memory)
Increased positive and appropriate behaviors
Positive Mood State and increased self-esteem
Rehabilitation of a neglected upper extremity

within a comprehensive rehabilitation program for an adolescent male recovering from a Traumatic Brain Injury.
Traumatic Brain Injury (TBI)
Areas of Deficit following TBI
Glasgow Coma Scale
Levels of Cognitive Functioning Scale
Developed by the Rancho Los Amigos Hospital, Downey, CA
Members of an Interdisciplinary Rehabilitation Team in a Pediatric Inpatient Program
A Music Therapist can also be a valuable and integral member of this interdisciplinary team.
Music therapy interventions can be adapted in both an individual and group setting to not only facilitate completion of the patient's rehabilitation goals, but also to contribute to an engaging, meaningful experience for the patient.
NMT Techniques to Promote Cognitive Functioning
NMT Techniques to Facilitate Communication Goals
NMT Techniques to Restore Functional Movement
Rationale for Music Therapy Interventions
Three aspects of music therapy interventions promote patient motivation and action in therapy:
Purpose
Participant
Kaleigh Thomas
Music Therapy Intern
Nationwide Children's Hospital

Pt was
admitted
to Nationwide Children's Hospital's inpatient rehabilitation on October 30, 2013.
Received
referral
for music therapy services from Brittany Mikuluk, CCLS, on November 18, 2013.
Referral indicated that music therapy interventions could address:
Anxiety
Coping with hospitalization
Emotional Expression
Rehabilitation of memory and motor skills
Music listening for comfort and decreasing agitation
Music Therapy Assessment
An individualized music therapy assessment was performed during the initial session on November 20, 2013.
Process includes extensive chart review and a personal evaluation of the patient's strengths and needs.
Per chart review and observations during session:
RANCHO IV-V
Disoriented
Agitated
Right-side neglect
Perseverative speech - negative self-statements, pain
Displayed inappropriate and unsafe behaviors
requiring frequent redirection
Music Therapy Interventions Used in Sessions
Treatment Goals and Objectives
Therapeutic Instrumental
Music Performance (TIMP)
Associative Mood and Memory Training (AMMT)
Songwriting
Results
Maintaining Attention and Observed Behaviors
TIMP Intervention Data
Associative Mood and Memory Training Intervention

Data taken through entirety of all three sessions
Data collected during the TIMP intervention showing an increase in both the use of RUE in this exercise as well as an increase in accuracy of imitation, which correlates with short term memory recall.
Songwriting
Rehab Song

I have the power to change who I am and who I become
I am good enough, strong enough, and I can do anything
I am in control of my own thoughts, my words, and my actions
I show respect for others and am respected in return
and I trust that all my hard work will pay off!
Discussion
References
Thank you!

Questions?
Songwriting

1. I am a positive, powerful, and worthwhile human being.
2. I am good enough, strong enough, and I can do anything.
3. I accept and respect myself for who I am.
4. I am in control of my own thoughts, my words, and my actions.
5. I am at peace with myself and the world around me.
6. I have the power to change who I am and who I become.
7. I accept change and am open to new possibilities.
8. I show respect for others and am respected in return.
9. Every day is another chance to make things right.
10. When I believe in myself, so do others.
11. I trust that all of my hard work will pay off.
12. The more grateful I am, the more reasons I find to be grateful.


Create Your Own:
13. I am confident in my ___________________________.
14. I deserve to be ________________________________.
15. I am a ______________________________________.
16. When I believe in myself, _________________________.
Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and
Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a
serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003
Davis, W. B., Gfeller, K. E., & Thaut, M. H. (2008). An introduction to music therapy: Theory and
practice. (3 ed., pp. 261-304). Silver Spring, Maryland: The American Music Therapy Association,
Inc.
Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency
Department Visits, Hospitalizations and Deaths, 2002–2006. Atlanta (GA): Centers for Disease
Control and Prevention, National Center for Injury Prevention and Control; 2010
Gilbertson, S. K. (2005). Music therapy in neurorehabilitation after traumatic brain injury: A literature
review. In D. Aldridge (Ed.), Music therapy and neurological rehabilitation: Performing health (pp.
83-138). Philadelphia, PA: Jessica Kingsley Publishers.
Hagen, C., Malkmus, D., & Durham, P. (1979). Levels of cognitive functioning. In Professional Staff
Association of Rancho Los Amigos Hospital (Ed.), Rehabilitation of the head-injured adult:
Comprehensive physical management. Downey, CA: Rancho Los Amigos Hospital.
Magee WL, Davidson JW (2002) The effect of music therapy on mood states in neurological patients: a
pilot study. J Music Ther 39(1): 20–9
Music therapy and medicine. (2006) Silver Spring, MD: American Music Therapy Association.
Retrieved from http://www.musictherapy.org.
National Institutes of Health Consensus Development Panel on Rehabilitation of Persons with
Traumatic Brain Injury. (1999) ‘Rehabilitation of persons with traumatic brain injury.’ Journal of
the American Medical Association. 282, 10, 974-983.
Nayak S, Wheeler BL, Shiflett SC, Agnostinelli S (2000) The effect of music therapy on mood and
social interaction among individuals with acute traumatic brain injury and stroke. Rehabil Psychol
45: 274–83
O’Shanick, G.J. (1986). Neuropsychiatric complications in head injury. Advanced Psychosomatic
Medicine, 16, 173-193.
Office of Communications and Public Liason, National Institute of Neurological Disorders and
Stroke. (2013). NINDS traumatic brain injury information page. Retrieved from National
Institutes of Health website: http://www.ninds.nih.gov/disorders/tbi/tbi.htm
Purdie H, Hamilton S, Baldwin S (1997) Music therapy: facilitating behavioural and psychological
change in people with stroke–a pilot study. Int J Rehabil Res 20: 325–7
Rossignol, S., & Melvill Jones, G. (1976). Audio-spinal influences in man studied by the H-reflex and its
possible role in rhythmic movement synchronized to sound. Electroencephalography and Clinical
Neurophysiology, 41, 83-92.
Särkämö T, Tervaniemi M, Laitinen S, Forsblom A, Soinila S, Mikkonen M, Autti T, Silvennoinen HM,
Erkkilä J, Laine M, Peretz I, Hietanen M (2008) Music listening enhances cognitive recovery and
mood after middle cerebral artery stroke. Brain 131: 866–76
Synder-Smith, S. and Winkler, P. (1990) “Traumatic head injuries.” In D.A. Umphred (ed)
Neurological Rehabilitation. St. Louis, MO: CV Mosby.
Taub, E. (1980). Somatosensory differentiation research with monkeys: Implications for rehabilitation
medicine. In L. P. Ince (Ed.), Behavioral psychology in rehabilitation medicine (pp. 371-401).
Baltimore: Williams and Wilkins.
Thaut, M.H. (1999). Training manual for neurologic music therapy.
Thaut, M. H. (2005). Rhythm, music and the brain. New York: Taylor and Francis.
Intervention seemed appeared to be effective in inducing a positive mood state, as:
T's affect brightened
Increase in observed positive interactions with staff
No negative comments about self observed after intervention or in following session
Effective in capturing attention -- no redirections given to reengage T during this experience throughout all three music therapy sessions.
Facilitated long-term memory recall as T would spontaneously sing words to the chorus of each song.
Brightened affect observed in each session during this experience -- T would sing chorus of each song selected with enthusiasm
Results
LTG 1: T will demonstrate improved
cognition
by discharge.
C1: T will demonstrate improved
attention
, requiring
min-to-no redirections for engagement
during throughout entire session.
Goal achieved 12/13 - T required
no
cues to attend to interventions during final treatment session.
C2: T will demonstrate
improved short-term memory
AEB
ability to imitate back simple rhythms with 100% accuracy
during TIMP.
Goal not achieved - T demonstrated
improved ability
over course of sessions with
95% accuracy of imitation
during final session.

LTG 2: T will demonstrate socially appropriate behavior by discharge. (
Behavioral/Social/Emotional
- Psychosocial)
BSE1: T will demonstrate
increased ability to interact positively and appropriately
with staff (and/or peers) by discharge. (
TR Goal
)
Goal achieved - T demonstrated a significant decrease in undesired behaviors (inappropriate speech - cursing, telling staff "I love you," describing feeling "poopy," and unsafe behaviors) and a significant increase in appropriate behaviors by final session.
BSE2: T will demonstrate
increased self-esteem
AEB his ability to select at least four applicable positive affirmations of self during Songwriting intervention.
Goal achieved 12/6 - T selected 5 affirmations and requested to sing song x8, encouraging staff to sing song with him

LTG 3: T will
increase use of dominant hand
(RUE) by discharge. (
Motor
)
M1: T will
utilize his RUE at least 50% of the time
(in an alternating pattern) during TIMP intervention.
Goal achieved 12/13 - T used
RUE 60% of the time
in TIMP intervention during final session.
**Final session co-treat with OT, OT encouraged use of RUE using mallet to strike the drum - may have an effect on patient utilizing RUE more this session. Data still shows an upward trend throughout all three sessions.

T was discharged from NCH on December 18, 2013
Data suggests that music therapy interventions were effective in facilitating rehabilitation goals for a patient with a TBI, however, there are many other important factors to consider.
T had a rigorous therapy schedule on Rehab including PT, OT, ST, TR, and MT. These therapies were able to work with T on a much more frequent basis and facilitated similar goals.
Music Therapy interventions were utilized one time per week for one 30 minute session.
Music Therapy was not referred to T until almost one month after his initial admission to Rehab.
Music Therapy interventions could be more effective if T received interventions earlier in admission as well as received interventions at an increased frequency.
Music Therapy interventions have been shown in research to improve motivation in treatment, and it would appear from T's behavior and affect during sessions that this was the case.
Music Therapy could exploit this effect of intervention by co-treating more frequently with other specialists to augment their goals more directly, leading to achieving their goals more quickly and contributing to cost-effectiveness of treatment.
Due to the nature of this case study, additional research should be completed to further explore effects of Music Therapy intervention with this population. Recommendations for further studies include:
Larger sample size to promote validity
Recording sessions to ensure objectivity and accuracy in data collection
17 year old male with no significant prior medical history
Involved in a motor vehicle accident on September 21, 2013.
Found unresponsive at scene of accident and rushed to nearest ER - GCS 4
Diagnosed with severe traumatic brain injury (TBI) with many complications as a result of the injury:




Prior to accident, T was right-hand dominant and independent with all activities of daily living (ADLs).
When T was admitted, he was determined:
Large subdural hematoma
Occipital laceration
Dysphagia
Diabetes insipidus
Respiratory failure resulting in tracheostomy
Right hemiparesis due to vascular compression syndrome from an internal brain herniation prior to a decompressive craniectomy
RANCHO IV-V (confused, inappropriate, agitated)
Disoriented
Dependent for all ADLS
Nonverbal, but inconsistently answered simple question using a "thumbs up" and "thumbs down" for "yes" and "no," respectively
Purposeful movement in LUE and LLE with right-side neglect
TBI is a form of acquired brain injury and is caused by an injury to the head that disrupts the normal function of the brain.
TBIs range in severity, from "mild" to "moderate" to "severe."
Not all trauma to the head results in TBI
TBI is a serious health problem in the United States as each year:
1.7 million people
sustain a TBI, and of those 1.7 million
52,000 die
as a result of the injury
275,000
are hospitalized
1.365 million
are treated and released from an ED
Leading causes of TBI:
Falls (50%) among children aged 0-14 years
Motor Vehicle Crashes (MVC) and traffic-related incidents (17.3%) among all age groups
Results in largest percentage of TBI-related deaths (31.8%)
(Faul
et al
., 2010)
Immediate clinical signs can include alterations in autonomic function, consciousness, motor function, pupillary responses, ocular movement, and other brainstem reflexes.
(Snyder-Smith & Winkler, 1990)
Cognition
Sensory Processing
Communication
Motor Ability
Mental Health
Behavior
(Faul
et al
., 2010)
Measurement tool to assess comatose states with scores ranging from 3 to 15.
(O'Shanick, 1986)
Physician
Psychologist
Neuropsychologist
Social Worker
Hospital School Teacher
Early Intervention Specialist
Physical Therapist
Speech-Language Pathologist
Occupational Therapist
Recreation Therapist
Massage Therapist
Child Life Specialist
Exact areas of deficit following a brain injury depend on:
Severity & location of injury
Age
General health of the individual
Common goal areas for rehabilitation following TBI include:
(Hagen, Malkmus, & Durham, 1979)
(Nayak
et al.
, 2000)
Mood states, especially depression, anxiety, and confusion, have been shown to improve after music therapy intervention.
(Magee & Davidson, 2002), (Purdie
et al.
, 1997), (Särkämö
et al.
, 2008)
Techniques in Neurologic Music Therapy (NMT) are specialized to address the needs of a patient in rehabilitation, as they were developed specifically to facilitate goals in the areas of communication, physical, socioemotional, and cognitive deficits.
(Davis, Gfeller, & Thaut, 2008)
What is Music Therapy?
"Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.

It is an established health service similar to occupational therapy and physical therapy and consists of using music therapeutically to address physical, psychological, cognitive and/or social functioning for patients of all ages."
(AMTA, 2006)
(Davis, Gfeller, & Thaut, 2008)
(Davis, Gfeller, & Thaut, 2008)
(Thaut, 2005), (Davis, Gfeller, & Thaut, 2008)
The act of playing an instrument provides immediate auditory feedback, which encourages purposeful movement, thus reinforcing goal-oriented movement to play the instrument.
The patient will enjoy playing the instrument, which can stimulate and maintain a patient's motivation for physical rehabilitation.
Rhythmic and melodic patterns produced while exercising with a musical instrument facilitate motor memory, thus helping the patient to perform and remember sequences of movement.
(Thaut, 2005), (Davis, Gfeller, & Thaut, 2008)
Explore the efficacy of music therapy interventions in rehabilitation of a pediatric patient who had sustained a TBI.








Increase the body of music therapy research, as though there is support for intervention in adult rehabilitation, there is a lack of support for working with the developing brains of adolescents in a rehabilitation setting.
Utilizing therapeutic music experiences to induce a positive mood state, increase self-esteem, and increase positive and appropriate behaviors, improve cognition, specifically attention and memory, and to facilitate physical rehabilitation of the neglected upper extremity.

Goals
: C1 (Attention), C2 (Short-Term Memory),
M1 (Increase use of RUE)
Utilized at beginning of every session
Required the patient to imitate rhythms modeled by this intern (or other staff present)
T was encouraged to
exactly
imitate rhythms as this intern modeled them - including using correct pattern of alternating hand strokes
Once T repeated back rhythms with ~50% accuracy, he was given the opportunity to create his own rhythms to be mimicked by staff
This intern would then model T's rhythms incorrectly
50% of the time for further assessment of attention
and short-term memory.
Goals
: C1 (Attention), C2 (Short-Term Memory)
Second intervention utilized in each session
Used popular musical selections to facilitate long-term memory recall and induce a positive mood state
Provided opportunity for self-expression and autonomy
Song selections by T: "Ho Hey" by the Lumineers x2, "Home" by Edward Sharpe and the Magnetic Zeros, "I Will Wait" by Mumford and Sons x2, "Radioactive" by Imagine Dragons, and "Little Talks" by Of Monsters and Men.
Pt denied knowledge of songs before each selection was
performed live; however, pt spontaneously began singing
along to correct words in chorus.
Goals
: C1 (Attention), C2 (Short-Term Memory), BSE1 (Positive & Appropriate Behaviors), BSE 2 (Self-Esteem)
Third intervention utilized in second session only.
Incorporated into session plan after observing T frequently making negative comments about himself ("too stupid" or "too dumb" to do this) during initial session
Use to promote positive self-thought and increase self-esteem
Used a "Positive Affirmations Blues Songwriting Template," which required T to read through the template, and select at least 4 statements to then sequence in his preferred order to create his "Rehab Song."
T selected 5 positive affirmation statements that were then incorporated into a standard Blues progression and
repeated x8 per patient request
Physiological Mechanisms of Music
Using music as a "facilitating stimulus" in physical exercise is based upon three physiological mechanisms:


Audio-Spinal Facilitation
Patterned Sensory Stimulation
Rhythmic Entrainment
(Davis, Gfeller, & Thaut, 2008)
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