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

Introduction

Neurologic Music Therapy (NMT) focuses on supporting non-musical goals, harnessing the unique way in which music is processed in the brain to build new neural pathways around areas that have been damaged by disease or injury. The evidence-based, neuroscientific model of music therapy is made up of 20 standardised clinical techniques for speech & language training, cognitive training, and sensorimotor training. Each technique has its own  research base and clinical protocol.

The methodology that underpins use of the techniques is called the Transformational Design Model (TDM) and 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

Beth is 16 years old and has an acquired brain injury and cerebral palsy following a birth injury. She was referred for an NMT assessment by her case manager in 2019 to support her non-verbal communication and provide Beth engaging opportunities for self-expression, pleasure and enjoyment. During the course of the assessment, a range of further functional aims emerged, including cognitive goals for choice-making, direction-following, and attention skills, as well as movement goals for gross motor skills and use of her weaker right arm. Neurologic Music Therapy was therefore able to offer her holistic support across a range of domain areas so regular liaison, collaboration and joint-work with speech & language therapy, occupational therapy, and physiotherapy was essential.

One of the cognitive training techniques that was explored with Beth in ongoing sessions was Musical Sensory Orientation Training (MSOT). MSOT is particularly valuable to use to support those with clinical conditions that affect attention, arousal, and sensory response. It includes 3 levels: ‘sensory stimulation’, ‘arousal and orientation’, and ‘vigilance and attention maintenance’. Essentially, live/recorded music, instruments, and musical activities are used to access sensory channels, provide sensory stimulation for neuronal growth, and modify state (ie. to calm or stimulate depending on the needs of the individual). Through these sensory activities MSOT looks to elicit basic behavioural responses such as dishabituation, localisation, and visual tracking. In more advanced recovery or developmental stages, active engagement in simple musical exercises increases vigilance and trains basic attention maintenance (Thaut, 2005).

A BIGmack switch was introduced into Beth’s session as part of MSOT level 3 activities (TDM step 4). BIGmack switches are a simple AAC device where a one-message recording can be entered in the device. The recording can then be activated by pressing the button. Whilst Beth had previously had opportunities to use a BigMack at home, it was not explored regularly or in a consistent context, and it was unclear whether Beth was able to use the device purposefully. (see fig. 1)

Simple, repetitive songs were introduced live for Beth to listen to in sessions, such as ‘This Little Light of Mine’. Following a period of listening to support initial familiarity, a single word at the end of a phrase was then recorded into the switch for Beth to activate at set points in the song (e.g. ‘shine’). Exaggerated musical cues were used to support her anticipation of her turn and to prompt a response. To help simultaneously target some of her physical goals including wheelchair driving (TDM step 2), the switch was positioned strategically in positions directed by her occupational therapist (TDM step 3), to provide Beth a motivating visual target that helped shift her attention from the potential discomfort associated with the movement, to the switch itself, all structured within an engaging musical framework.

This little light of mine,

I’m going to let it _____

This little light of mine,

I’m going to let it _____

This little light of mine,

I’m going to let it _____

Let it _____

Let it _____

Let it _____

Initial physical facilitation was provided by Beth’s support workers to support these activations and was then gradually reduced as she became more familiar with the task.  Beth showed great motivation with MSOT activities and was so engaged that this approach was highly effective. As sessions progressed, her activations became more context-appropriate and purposeful; she was able to wait for her turn, showing awareness and understanding of the activity. Additionally, in having an engaging activity in which to practice repeated upper limb movement, her movements also gradually became more controlled. New and more complex songs were then introduced to Beth and consistent engagement from session to session demonstrated that she was able to retain and recall new musical information, opening up new creative ways that could be used to support and integrate her educational learning goals too. (see fig. 2)

Now that Beth’s use of a BIGmack switch is consistent and reliable, sessions are progressing to look at using a yes/no mounted switch to support Beth to communicate her needs and choices day to day (TDM step 6).

Another technique that has been explored in sessions is Developmental Speech and Language Training Through Music (DSLM). “DSLM uses developmentally appropriate musical materials and experiences to enhance…language development” (LaGasse 196). Concepts that have been explored using a DSLM approach include feelings, with Beth’s neuropsychologist recommending looking at the four foundational ones within the Zones of Regulation first: happy, sad, angry, worried. Original songs for each feeling were created and featured corresponding body response cues to support her understanding.

e.g.

The Worry Song

When I worry, I get a knotted tummy

My palms can feel sweaty, and my chest gets tight

When I worry, I get a knotted tummy

My thoughts go round and round, and I don’t feel right

When I worry I get a knotted tummy

It’s difficult to sleep and my head might ache

When I worry I get a knotted tummy

I do not want to eat and lie wide awake

When I worry

When I worry

When I worry

Within a DSLM approach, these songs were then combined with additional cues including visual cards (PECS) and actions (MAKATON signs), to help reinforce learning and understanding. Each song was also then recorded onto Beth’s EyeGaze to be activated by her selecting the corresponding picture. Training with family and support workers is essential for reinforcing Beth’s understanding of different feelings, and sessions include ample time for modelling ideas and ways to integrate feelings and songs each day as part of developing her emotional identification. A longer-term psychosocial aim is for Beth to being able to reliably understand and communicate her feelings; this work is currently ongoing and involves close liaison with neuropsychology.

Whilst NMT continues to be a valuable and engaging support that is able to target a range of functional and psychosocial goals, for Beth, her experience of sessions is primarily of something enjoyable where she experiences success with what she can do independently.

“She’s always responded to music and I always thought she had a good memory but now we have a way to really show that. We love using the switch – I use it with her everyday now, recording little songs or messages into it for her to activate on our drive to school. She smiles and laughs and I do too” (Beth’s Dad, December 2021)

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

LaGasse, B A (2014). ‘Developmental Speech and Language Training Through Music (DSLM)’, in Thaut, M.H and Heomberg, V. (ed.) Handbook of Neurologic Music Therapy. Oxford: Oxford University Press, pp. 196-216.

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

‍