Elizabeth Nightingale, Neuro Services Lead at Chiltern Music Therapy, NMT experts in the medicolegal sector

Introduction

Neurologic Music Therapy (NMT) is an evidence-based, neuroscientific model of music therapy. It is made up of 20 standardised clinical techniques that can be used to support rehabilitation of speech & language, movement, and cognitive skills. The focus is therefore on supporting non-musical goals and harnessing the unique way in which music is processed in the brain to build new neural pathways around those areas that have been damaged by disease or injury. Supporting emotional wellbeing and adaptation to life after injury also forms an important part of this work.

Each technique has its own  research base and clinical protocol and the methodology that underpins the use of each technique is called the Transformational Design Model (TDM). The TDM is made up of 6 steps:

1. Diagnostic and Functional clinical assessment of the patient
2. Development of the therapeutic goals/objectives
3. Design of functional, non-musical therapeutic exercise structures and stimuli
4. Translation of step 3 into functional therapeutic music exercises
5. Outcome reassessment
6. Transfer of therapeutic learning to functional applications for Activities of Daily Living (ADLs)

Case study

Lionel had a right MCA stroke in 2021 and was referred to Neurologic Music Therapy by the multidisciplinary team at the Regional Neurologic Rehabilitation Unit at Homerton Hospital where Chiltern Music Therapy run a bi-weekly clinic. His referral to NMT was to support with his left-sided visual neglect and memory difficulties.

There are 9 cognitive training techniques within NMT, covering areas from attention, to executive functions, memory, auditory perception, orientation and arousal, visual neglect, and mood. One of the cognitive training techniques explored with Lionel was Musical Neglect Training. Neglect training involves active performance exercises on musical instruments which are structured in time, tempo, and rhythm, with an appropriate spatial configuration of instruments to help focus and redirect attention to the neglected side (Thaut 2005*). Neglect Training exercises can also involve receptive music listening to stimulate hemispheric brain arousal whilst engaging the patient in active music-making on their neglected side. In line with step 1 of the TDM, screening tests including the clock-drawing test were used, where Lionel was given a blank piece of paper in his midline and asked to draw a clock with all the numbers, set at a specified time.

TDM step 1:  Lionel’s clock drawing test before NMT (see Fig. 1)

In Lionel’s NMT sessions, a combination of structured neglect training exercises alongside exercises targeting music-making on the neglected side with recorded music were used. During structured exercises, an instrument such as set of chime bars would be initially configured in his visual field and he was then instructed to play up and down the scale. The chimes were then gradually shifted into his neglected side, essentially using the auditory melodic feedback to help retrain the brain to expect and anticipate the next chime.(see Fig. 2)

Using patient preferred music is so essential even when targeting something functional as, as well as increasing motivation and engagement, it also helps to elevate mood and help reconnect people with their identity – an essential part of rehabilitation. Lionel was a massive Eagles fan so classic songs like Hotel California were used to engage him in active music-making on percussion instruments during less structured Musical Neglect Training exercises. But did it work?...

TDM step 5:  Lionel’s clock drawing test after NMT (see Fig. 3)

The difference in Lionel’s clock drawing tests speak for themselves but far more important than test outcomes is the functional carryover to everyday.  Objects such as drinks and Lionel’s glasses were deliberately positioned on his neglected side to look at this and he began to initiate reaching for these unprompted, initially following his NMT sessions, and then more broadly across the day.

Another cognitive training technique explored with Lionel was Musical Mnemonics Training. As music is processed and stored differently in our brains to verbal information, this means it is also retrieved differently in our brains. This technique uses music as a mnemonic device to sequence and organise information and add meaning, pleasure, emotion, and motivation in order to enhance the person’s ability to learn and recall the information involved (Thaut 2005). Think adding rhythm and melody to help you recall a phone number, or a formula for an exam, for example.

Due to how Lionel’s memory had been affected following his stroke, he found it incredibly difficult to recall certain events and information. One thing he found particularly upsetting was not being able to recall the date of his daughter’s wedding in a few months’ time. Working towards being able to attend the wedding was a huge personal motivator for him in his rehabilitation. Using Musical Mnemonics Training, information about the day was broken down into smaller steps and set to a song by adapting the lyrics to the chorus of Get Me To The Church On Time. The idea was to give him a new strategy to support him to recall the information so that, once familiar, he could internally ‘hear’ the song as and when needed, to prompt his memory.  The technique was successful and within 3 sessions, Lionel began to use the strategy independently.

As Lionel approached discharge, his wife shared that Lionel had told her his NMT sessions had become his favourite part of the week, even joking with her that drummer Don Henley from the Eagles might be out of job. Even though NMT sought to address something practical and support him with his personal rehab goals, his overriding experience of NMT was of having fun playing along to his favourite music.

For more information on Neurologic Music Therapy, or to discuss a potential referral, you can reach Elizabeth on elizabeth@chilternmusictherapy.co.uk

*Thaut M H (2005). Rhythm, Music and the Brain: scientific foundations and clinical applications. New York: Routledge.

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