Sarah Johnson, MM, MT-BC, NMT Fellow, is a music therapist at Poudre Valley Hospital in Fort Collins, Colorado. Sarah Thompson, MM, MT-BC, NMT Fellow, is the music therapist and owner of Rehabilitative Rhythms in Denver, Colorado. In this AMTA.Pro symposium, Johnson and Thompson discuss the role of music therapy in the continuum of care in stroke rehabilitation from the perspective of in-patient and out-patient services. They walk through the process, beginning with initial assessment, and moving through treatment and discharge, following the progress of a 60-year-old stroke patient.

[display_podcast]

— + —

Stroke Rehabilitation: Continuum of Care

November, 2009 AMTA.Pro Symposium

Sarah Johnson, MM, MT-BC, NMT Fellow and Sarah Thompson, MM, MT-BC, NMT Fellow

Introduction

Disclaimer: We will use NMT terms, but this is not the NMT training

We are assuming that you have basic knowledge of stroke etiology and common deficits that one might see with a stroke survivor. We hope you will learn from this symposium whether you are new to stroke rehab, or you already have experience in stroke rehab. Please reference the supporting texts.

This  symposium will cover a case study of  “John, ” a discussion of the continuum from in-patient to out-patient, including assessment, setting goals, designing interventions, and helpful tips

Case Study

John is a 60-year-old gentleman who had a left hemisphere embolic stroke. John is manager at a retail store, who lives with his wife in a ranch style home. John and his wife have 2 grown kids. One of his children lives in the same town, and the other lives a few hours away. John’s wife works part-time.

One evening while watching television, John’s wife looked at him and noticed that he had a facial droop. She asked him if he was feeling OK and he answered with a mumble. He tried to get up and couldn’t stand. His right arm was hanging at his side. She called 911 and John received immediate medical care to maximize his chances at recovery. John had MRI’s and other diagnostics to confirm that he had a left hemisphere embolic stroke.

Note: Please familiarize yourself with National Stroke Association – F-A-S-T. See references.

Several days later when John was medically stable, it was time for John to transfer to a different unit. Because he was in relatively good health before his stroke, John, his doctor’s and his family were able to make the choice to transfer to an in-patient rehab unit where he would receive a minimum of 3 hours of therapy per day.

Note: If patients are unable to handle 3 hours of therapy per day, they may transfer to a skilled nursing facility for their rehab. (They would engage in therapy at a slower pace and with less intensity.) – NMT’s may work here

Assessment

Key Points: 1. Important to ALWAYS do an assessment. 2. What type you do depends on your setting. 3. Review what assessment has already been done by other professionals. 4. What to make the best use of your time with the client. 5. Which assessments you are trained or qualified to do (i.e. standardized assessments)

In-patient assessment

1. How patient’s come to rehab.

2. Focus of rehab e.g. safety and  independent transfers, return to least restrictive environment,  independence with self-care, gait, speech and re-training of cognitive skills.

3. Strength of inpatient; ease of interaction with other therapies.

4. NMT assessment at PVH, i.e.  incorporates information from discipline’s assessments, general chart information, functional assessment in group setting: warm-up and gait/pre-gait, social, motor, cognitive, vocal, affective, willingness to participate in a group, response to music etc., and documentation of assessment: include things like endurance, level of participation, level of assistance or cueing needed, description of skilled NMT interventions to address functional goals, frequency and duration of treatment, rehab potential.

Note: an example of documentation  is included in audio discussion

Out-patient (clinic or private practice)

1. How patients come to rehab

2. Focus of rehab – return to highest level functioning possible; driving/work; may involve more cognitive work

3. Strength of out-patient; focus on home and community re-integration

4. Assessment process: Therapist can use standardized tests (see references for helpful ones.) Use a functional assessment in individual situation. Get HIPAA releases and access to background info prior to assessment

Spend time planning your assessment based on what information you have from other disciplines.  After in-patient treatment, patient may have progressed significantly in certain areas and be at an overall higher level of functioning. Plan assessment based on what still needs to be done, i.e. if the speech therapist has already done the Attention Process Training (APT) test, you probably don’t need to.

5. Assessment summary – integrate information

In-Patient Treatment

Utilizing the Transformational Design Model (TDM) from “A Scientific Model of Music in Therapy and Medicine” by Michael Thaut

We are following the TDM (see references) with the initial step being diagnostic and functional assessment of the patient. John can stand and take a few steps with assist from Physical therapist and an aide. Because of his right sided weakness, he requires assist from the aide to manage a front wheeled walker, and cueing and facilitation from the PT to ambulate. .

After assessment, the next level of the TDM is developing therapeutic goals and objectives. The overall goal is to facilitate gait training. A sample objective might be: Patient will walk 50’ with minimal assist, utilizing front wheeled walker by ___________.

After establishing goals and objectives the next step would be to design a functional, non-musical exercise. NOTE: This is the step where working with other therapists is very important so that you understand what an appropriate non-musical exercise would be) An example of a physical therapy interventions for John might be: Standing in the parallel bars and working on the swing phase and heel strike of his gait pattern.

The fourth step of the TDM would be the translation of this non-musical exercise into a functional therapeutic music intervention. For John, I would choose to utilize the NMT technique of Patterned Sensory Enhancement (PSE) to facilitate the functional movement patterns of the physical therapist’s exercise. I would utilize the music to provide temporal, spatial and force cues for optimizing the movements.

The fifth step of this process would be to transfer these skills back to the “real world” of the patient. In John’s case we would want this intervention to translate into more effective gait training so that he will regain his ability to walk.

Note: it is always important to choose treatment techniques based on diagnosis and functional goal area. Neurologic Music Therapy techniques have been researched and developed in three domains; Sensorimotor, Speech and Language, and Cognitive.

Out-Patient Treatment

Utilizing  the Transformational Design Model (TDM) from “A Scientific Model of Music in Therapy and Medicine” by Michael Thaut

Since we are following the Transformational Design Model (TDM), the first thing we would do is an assessment in the out-patient setting.

Level II of the TDM is Goals and Objectives. What is the current level of functioning? John has expressive aphasia. After in-patient therapy and NMT treatment with Modified Melodic Intonation Therapy (MMIT), he could say 2 sentences with moderate cueing.

Level II of TDM. Goal: to improve expressive speech. Objective: John will utilize 3 sentences in appropriate functional situations with no cueing.

Level III and IV of the TDM: Musical exercise is to have John sing functional phrases that he would typically use on a daily basis. Use the speech technique of Melodic Intonation Therapy (MIT), but because of the musical logic (level IV), will capitalize on the musical elements: – rhythm of speech patterns – translate prosody of speech into melodic pattern – use musical expertise to make MIT more functional – follow the protocol for MODIFIED Melodic Intonation Therapy. Use MMIT to increase functional language skills.

Level V of the TDM: Transfer to functional situations. Goal: John will be  able to greet customers in his work at the retail store. Eventually, have conversation.

Other aspects of neurologic music therapy treatment: For John, I also would continue the sensorimotor techniques since he still needs in the area, but would take things further. For example, gait training might focus on different surfaces, and more functional speed for situations like using a crosswalk. In addition, I would use Music Attention Control Training (MACT) and Musical Executive Function Training (MEFT) to improve John’s cognitive skills for daily tasks like work, driving, and chores at home.

Tips

1. Just because you are working with a stroke survivor, doesn’t mean you will always do all of these techniques. You may use more techniques than we have discussed.

2. Patterned Sensory Enhancement (PSE) tip: Remember the importance of maximizing spatial, temporal and force cues. PSE is not a stagnant stimulus – have fluidity and flexibility

3. Therapeutic Instrumental Music Performance (TIMP) tip: PSE elements are essential to your musical facilitation.  The “end product” of their playing has to be musically viable. It is always imperative to think about functional movement patterns, not just strange ways to play instruments

4. Rhythmic Auditory Stimulation (RAS) tip: There are different levels of complexity with RAS. Some people are too distracted by songs, others are not. Some patients are distracted by the NMT walking in front of them, others greatly benefit from the extra visual cuing. Use of a song is really helpful for some people, helping them “relax” into their gait kinematic pattern.  If you use a song, utilize their preferred genre of music

5. Modified Melodic Intonation Therapy (MMIT) tip: The technique is modified because we as NMT’s need to use the musical properties (rhythm and melody) more to enhance speech. Try to interview the family to find a phrase to start with. Consider if metric tapping or patterned cueing is better for the patient (tapping thesteady beat vs. tapping the rhythm of the phrase)

6. Musical Speech Stimulation (MUSTIM) tip: Remember to use overlearned songs. Interview the family for favorites

7. Music Attention Control Training (MACT) tip: Think about situations they will face in daily life, not just making difficult exercises when you structure your intervention. Start with basic (sustained attention) and work into more complex types of attention.

8. Musical Executive Function Training (MEFT) tip: Think about the progression of having the MEFT exercise be very structured, and then move to less structured.

9. Know your population: Be sure you are knowledgeable about different types of stroke and how different strokes affect people, depending on what brain structures are affected.

10. Provide written materials. Families in crisis may not be able to remember what you have told them. Always explain why you are doing what you are doing, and make it functional for the family. Perhaps include charts of the patient’s progress……in gait parameters for example

11. Charting tip: Be sure to demonstrate your skilled knowledge as a music therapist by listing what techniques you will use and what they address, be sure to mention how it is a skilled intervention.

12. Recommendations for homework in the out-patient setting. All other disciplines give homework to maximize therapy.

Professional tips: (1) Interact with other rehab professionals. (2) Try to educate others and doctors. (3) Educate yourself about what other therapies do. (4) NMT’s have a lot to offer in the rehab world, but we must be open and communicate.

Discharge

A. Advocate for continued treatment if appropriate. Be an advocate for NMT’s in the community, e.g.  community groups (NMT group at Rocky Mountain Stroke Association) or community exercise classes in Fort Collins facilitated by Sarah Johnson and Ruth Rice, DPT.

B. Use technology: Consider using technology to create customized home programs for people.

Closing

Thanks for joining us for the AMTA.Pro Symposium, “Stroke Rehabilitation: Continuum of Care.” Please feel free to comment on any aspect of this AMTA.Pro Symposium. We welcome you feedback.

Sarah Johnson, MM, MT-BC, NMT Fellow, is an NMT at Poudre Valley Hospital in Fort Collins, Colorado. She is a member of the Inpatient Rehab department, working mainly on the Life Skills Rehabilitation Unit, the in-patient, acute rehab unit. Sarah is also a member of the Outpatient Children’s Therapy Services, working with developmentally delayed and autistic children in our outpatient clinic. Sarah is as an adjunct faculty member at Colorado State University, facilitating the graduate music therapy student practicums and working as a member of the clinical staff for the Center for Biomedical Research in Music (CBRM.) Sarah also assists with the NMT training Institutes and Fellowship trainings. Contact: [email protected].

Sarah Thompson, MM, MT-BC, NMT Fellow has worked with the neurorehabilitation population for over 6 years in the in-patient, out-patient and private practice settings. Her clinical experience includes work at Poudre Valley Hospital and The Center for Neurorehabilitation Services in Fort Collins, CO. She has also completed a number of special projects in this population including a music therapy group sponsored by the National Multiple Sclerosis Society, an educational seminar for the Parkinsons Association of the Rockies, and current weekly groups for the Rocky Mountain Stroke Association. Sarah has also achieved third party reimbursement from private insurance, workers compensation and the Traumatic Brain Injury Trust Fund of Colorado. In addition to her work in neurorehabilitation, Sarah works with individuals with developmental disabilities, and individuals in hospice. She currently works in Denver, CO where she runs a private practice called Rehabilitative Rhythms. Contact: [email protected].

Examples of Standardized Tests Appropriate for Stroke Patients

Examples of Tests Used by Physical Therapists

Assessment Name Focuses On
Berg Balance Scale Functional balance
Gait Speed Walking speed
TUG – Timed up and Go Risk for falls
Functional Reach Assessment Risk for falls

Examples of Tests Used by Occupational Therapists

Assessment Name Focuses On
Reality Comprehension Clock Test Assesses orientation to time, visual spatial awareness, memory, comprehension of task, number recognition, number sequence
SLUMS – St. Louis University Mental Status Assesses mild cognitive impairments. Used to assess dementia levels. It’s similar to the MMSE.
LOTCA – Lowenstein Occupational Therapy Cognitive Assessment Orientation, visual and spatial perception, visualmotor organization, thinking operations
MVPT – Motor Free Visual Perceptual Test Spatial relationship, Visual closure, Visual discrimination, Visual memory, figure ground

Examples of Tests Used by Speech Therapists

Assessment Name Focuses On
Modified Barium Swallow Swallowing

(Dysphagia)

National Outcomes Measurement System (NOMS) Demonstrates the value of speech therapy
Boston Diagnostic Aphasia Examination Expressive speech

Examples of Other Tests

Assessment Name Focuses On
Barthel Index Independence level with daily activities
Frenchay Activities Index Daily activities in the last 3-6 months

*Check with other professionals in your setting to see what tests they are using, and to figure out what tests might be appropriate for you to use.

References

Albert, M., Sparks, R., & Helm, N. (1973). Melodic intonation therapy for aphasics. Archives of Neurology, 29, 130-131.

American Stroke Association (2009). www.strokeassociation.org.

Belin, P., Van Eeckhout, P., Zilbovicius, M., Remy, P., Francois, C., Guillaume, S., Chain, F., Rancurel, G., & Sampson, Y. (1996). Recovery from nonfluent aphasia after melodic intonation therapy. Neurology, 47, 1504-1511.

Bhogal, S.K., Teasell, R., Foley, N.C., & Speechley, M. (2003). Rehabilitation of aphasia: More is better. Topics in Stroke Rehabilitation, 10 (2), 66-76.

Bonakdarpour, B., Eftekharzadeh, A., & Ashayeri, H. (2003). Melodic Intonation Therapy with Persian aphasic patients. Aphasiology, 17, 75-95.

Brown, S.H., Thaut, M.H., Benjamin, J., Cooke, J.D. (1993). Effects of rhythmic auditory cueing on temporal sequencing of complex arm movements. Proceedings Society for Neuroscience, 227.2. [Abstract]

Butefisch, C., Hummelsheim, H., Denzler, P., & Mauritz, K.H. (1995). Repetitive training of isolated movements improves the outcome of motor rehabilitation of the centrally paretic hand. Journal of the Neurological Sciences, 130, 59-68.

Cadalbert, A., Landis, T., Regard, M., et al. (1994). Singing with and without words: Hemispheric asymmetries in motor control. Journal of Clinical and Experimental Neuropsychology, 16(5), 664-670.

Center for Biomedical Research in Music (2009). http://www.colostate.edu/depts/cbrm/.

Clark, C. & Chadwick, D. (1980). Clinically Adapted Instruments for the Multiply Handicapped. St. Louis, MO: Magnamusic-Baton.

Cohen, H. (1999). Neuroscience for rehabilitation: 2nd edition. Philadelphia: Lippincott, Williams and Wilkins.

Cross, P., McLellan, M., Vomberg, E., Monga, M., & Monga, T.N. (1984). Observations on the use of music in rehabilitation of stroke patients. Physiotherapy Canada, 36, 197-201.

Gylys, B.A. & Wedding, M.E. (1999). Medical terminology: a systems approach. Philadelphia: F.A. Davis Company.

Gutman, S.A. (2001). Quick reference neuroscience for rehabilitation professionals. Thorofare, NJ: Slack Incorporated.

King, B. (2007). Language and speech: distinguishing between aphasia, apraxia, and dysarthria in music therapy research and practice. Music Therapy Perspectives, 25, 13-18.

Luft, A.R., McCombe-Waller, S., Whitall, J., Forrester, L.W., Macko, R., Sorkin, J.D., Schulz, J.B., Goldberg, A.P., & Hanley, D.F. (2004). Repetitive bilateral arm training and motor cortex activation in chronic stroke: A randomized controlled trial. JAMA, 292 (15), 1853-1861.

McIntosh, G.C., Thaut, M.H., Rice, R.R., & Prassas, S.G. (1993). Auditory rhythmic

cuing in gait rehabilitation with stroke patients. Canadian Journal of Neurological

Sciences, 20, 168. [Abstract]

McIntosh, G.C., Thaut, M.H., Rice, R.R., & Prassas, S.G. (1995). Rhythmic facilitation

of gait kinematics in stroke patients. Journal of Neurologic Rehabilitation, 9, 131.

[Abstract]

Naeser, M.A. & Helm-Estabrooks, N. (1985). CT scan lesion localization and response to Melodic Intonation Therapy with nonfluent aphasia cases. Cortex, 21, 203-223.

National Stroke Association (2009). www.stroke.org.

Norton, A.,Zipse, L.,Marchina, S. & Schlaug, G.(2009). Melodic Intonation Therapy Shared insights on how it is done and why it might help. The Neurosciences and Music III:  Disorders and Plasticity: Ann. N.Y. Acad. Sci. 1169: 431-436.

Prassas, S.G., Thaut, M.H., McIntosh, G.C., & Rice, R.R. (1997). Effect of auditory rhythmic cuing on gait kinematic parameters in stroke patients. Gait and Posture, 6, 218- 223.

Safranek, M.G., Koshland, G.F., & Raymond, G. (1982). The influence of auditory rhythm on muscle activity. Physical Therapy, 2, 161-168.

Schauer, M. & Mauritz, K.H. (2003). Musical motor feedback (MMF) in walking hemiparetic stroke patients: Randomized trials of gait improvement. Clinical Rehabilitation, 17, 713-722.

Schneider, S., Schonle, P.W., Altenmueller, E., & Munte, T.F. (2007). Using musical instruments to improve motor skill recovery following a stroke. Journal of Neurology, 254 (10), 1339-1346.

Sparks, R.W. & Deck, J.W. (1994). Melodic Intonation Therapy. In R. Chapey (Ed.), Language Intervention Strategies in Adult Aphasias. Baltimore, MD: Williams & Wilkins, 368-386.

Sparks, R.W., Helm, N., & Albert, M. (1974). Aphasia rehabilitation resulting from melodic intonation therapy. Cortex, 10, 313-316.

Sparks, R.W. & Holland, A.L. (1976). Method: Melodic intonation therapy for aphasia. Journal of Speech and Hearing Disorders, 41, 298-300.

Teasell, R.W., Bhogal, S.K., Foley, N.C., & Speechley, M.R. (2003). Gait retraining post-stroke. Topics in Stroke Rehabilitation, 10 (2), 34-65.

Thaut, M.H., Kenyon, G.P., Hurt, C.P., McIntosh, G.C., & Hoemberg, V. (2002). Kinematic optimization of spatiotemporal patterns in paretic arm training with stroke patients. Neuropsychologia, 40, 1073-1081.

Thaut, M.H. (2005). Rhythm, Music and the Brain: Scientific Foundations and Clinical Applications. New York: Routledge.

Thaut, M.H., McIntosh, G.C., & Rice, R.R. (1997). Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. Journal of Neurological Sciences, 151, 207-212.

Thulborn, K. R., Carpenter, P. A., Just, M. A. (1999). Plasticity of language-related brain function during recovery from stroke. Stroke, 30 (4), 749-754.

Whitall, J., McCombe, Waller, S., Silver, K.H., & Macko, R.F. (2000). Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke, 31 (10), 2390-2395.

Wiebers, D. (2001). Stroke-free for life. NewYork: HarperCollins.

Yoo, J.(2009). The role of therapeutic instrumental music performance in hemiparetic arm rehabilitation. Music Therapy Perspectives, 27 (1), 16-24.

© Copyright 2009 by the American Music Therapy Association, Inc.. All Rights Reserved. Content herein is for personal use only. No part may be reproduced in any form or by any means, electronic or mechanical, including photocopying or recording by any information storage or retrieval system, without express written permission from the American Music Therapy Association.

Neither the American Music Therapy Association nor its Board of Directors is responsible for the conclusions reached or the opinions expressed in any of the AMTA.Pro symposiums.