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The Use of Music Therapy in Stroke Rehabilitation
(Released March 2011)

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  by Rita Safranek  

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Types of Music Therapy Used in Post-Stroke Rehabilitation

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Melodic Intonation Therapy (MIT) employs a highly-structured, repetitive technique in which short, high probability phrases are initially sung and tapped out syllabically by the therapist and patient together and finally spoken by the patient alone (Overy). Schlaug, Marchina, and Norton’s examination of the efficacy of MIT in treating patients with Broca’s area aphasia found that the MIT-treated patient’s gains surpassed those of the control-treated patient. Treatment-associated imaging changes indicate that MIT’s unique engagement of the right hemisphere, both through singing and tapping with the left hand to prime the sensorimotor and pre-motor cortices for articulation, accounts for its effect over non-intoned speech therapy (Schlaug). In cases of left hemisphere damage that impedes volitional speech production, an increased use of the undamaged right hemisphere for the exaggerated prosodic features of speech supports and stimulates the damaged left hemisphere, allowing the right hemisphere to play more of a role in language function (Hobson).
Aphasia Tones July 2, 2010, concert
The Aphasia Tones' July 2, 2010, concert, YouTube. The Aphasia Tones are a choir of patients with aphasia.

Parsons used the case of a neurologically stable male singer with severe Broca’s aphasia to evaluate the efficacy of MIT to facilitate propositional speech using a pre-versus-post treatment design. The findings suggest that MIT did facilitate [the patient’s] speech praxis, and that “combining melody and speech through rehearsal promoted separate store and/or access to the phrase representation” (Wilson). The results indicate that the act of combining melody and speech promoted different storage or access to the sung phrases that became apparent once the initial benefits of rehearsal had subsided, resulting in more effective, longer-term production in the presence of expressive aphasia (Wilson).

There are contraindications for music interventions. Cohen & Ford found that individuals with severe apraxia in conjunction with aphasia showed greater benefits from conventional verbal interventions without rhythm and melody, possibly because persons with severe apraxia may find the musical component distracting (Hobson).

Dysarthria is a common form of speech impairment, affecting 20-50% of stroke patients (Tamplin). It refers to disorders of speech articulation caused by imperfect coordination of pharynx, larynx, tongue, or face muscles as a result of nervous system damage. Dysarthria is often characterized by reduced verbal intelligibility, voice volume or range, abnormal rate of speech, and poor prosody. Singing can address various factors affecting speech product, including rate of speech, articulation, breach control, and prosody. It promotes “active movement of the facial muscles and articulators that may assist articulation, as well as facilitate the improvement of non-verbal aspects of communication” (Tamplin).

When using music therapy to treat dysarthria, frequency of sessions is significant. Where multiple clinical sessions per week are impractical, the use of a practice CD by the patient between sessions may be beneficial (Tamplin).

The music therapy protocol for treating dysarthria includes preparation exercises designed to relax the neck, jaw, and tongue muscles. Oral motor and respiratory exercises are aimed to develop breath control and increase respiratory capacity. To build on respiratory control and strength, rhythmic articulation exercises include strong rhythmic pulse cues to structure vocalizations. Melodic exercises using vowel-consonant blends are introduced in order of articulatory difficulty. In treating dysarthria, Rhythmic Speech Cuing involves the use of strong rhythmic pulse and emphasis on natural speech rhythms to cue more normative speech patterns (Tamplin).

Characteristics of songs useful for therapeutic singing with dysarthric patients include slow tempo, appropriate phrase lengths for individual patients, and appropriate key to facilitate maximum pitch range of individual patients. Criteria for inappropriate songs include complex lyrics or rhythmic patterns, wide pitch range, difficult melodic lines, fast tempo, and negative lyrical content (Tamplin). Songs that are used range from “Twinkle, Twinkle, Little Star” and “Happy Birthday” to age-appropriate pop tunes.

Another area of stroke rehabilitation where music therapy is having an impact is in motor function, including walking. Motor impairments are common after a stroke. Unfortunately, useful therapies for them are scarce. Motor and auditory temporal processing are parallel neural processes, allowing them to be coupled. As a result, the motor system is responsive to the auditory system (Yoo). Structured training and repetitive motor learning are known to improve motor deficits in stroke rehabilitation through cortical rearrangement. According to animal studies, cortical plasticity is increased by the behavioral relevance of the stimulation and its motivational value (Schneider). Successful neurological music therapy to facilitate motor recovery takes into account the established principles of repetitive training and increased motivational drive to the inherent rewarding value of making music. Neurologic Music Therapy emphasizes the scientific use of music based on accepted neuroscientific evidence. Therapeutic Instrumental Music Performance is an NMT technique for sensorimotor training. To improve gross or fine motor skills, TIMP uses movement patterns in the playing of musical instruments (Yoo).

International Aphasia Movement Founder Harvey Alter
International Aphasia Movement Founder and Director Harvey Alter speaks about the power of music therapy, YouTube

A study of 77 inpatients from a neurological rehabilitation hospital, all suffering from moderate impairment of motor function of upper extremities following strokes, offers the first evidence that music-supported training is more efficient than functional motor training with regards to finger dexterity and tour applied clinical tests: Box and Block Text, Nine Hole Pegboard Test, Action Research Arm Test, and Arm Paresis Score. Fifteen 30-minute sessions of music-supported training in addition to conventional treatment not only improved motor performance, but also seemed to be more efficient in terms of recovery of fine motor functions compared to constraint-induced therapy (CIT) of skilled movements (Schneider). In CIT, use of the impaired extremity is enforced by shaping procedures, often combined with immobilization of the healthy extremity for several hours per day.

A study by Hayden, Clair, Johns, and Otto examined the effect of rhythmic auditory stimulation (RAS) on post-stroke gait training. In all conditions for one-limb stance, cadence, velocity, stride length, and posture head tilt, improvements across time were statistically significant in all conditions. There were no statistically significant improvements for the Timed Up and Go Test and the Functional Reach Test” (Hayden).

Deficits in gait performance are not only caused by paresis, but also by complex abnormalities in motor control. Schauer and Mauritz examined the effect of rhythmical auditory stimulation in a musical context for gait therapy in hemiparetic stroke patients, when the stimulation is played back measure by measure, initiated by the patient’s heel strike. The data suggest that musical motor feedback improves the entire stride execution. The common speculation may be rejected that the subjects try solely to meet the musical meter with the heal-strike moments while walking in time with music and practice some form of artificial gate. In contrast, the subjects adapt their entire gate pattern to the interval between successive musical beats (Schauer). 

In a study on the effects of music-supported therapy on motor impairments, a group of 32 stroke patients with no prior musical experience received 15 sessions of music-supported  
therapy over a period of three weeks. A control group of 30 patients received standard rehabilitation procedures. In the music therapy group, fine and gross motor skills were trained by using either a MIDI piano or drum pads. The results showed that music-support therapy yielded significant improvement in fine as well as gross motor skills with respect to speed, precision, and smoothness of movements. Neurophysiological data show these improvements are “accompanied by electrophysiological changes indicative of better cortical connectivity and improved activation of the motor cortex” (Altenmuller).

Music therapy is also showing promise in several other areas of stroke rehabilitation. Most common after a severe stroke, dysphagia is the inability to swallow fluids and/or foods. It can negatively affect the patient’s quality of life and be potentially fatal if aspiration occurs. Musical components can be added to the traditional speech therapy utilized to facilitate oral, vocal, and respiratory functions that restore the swallowing function (S. J. Kim). It is hypothesized that rhythm entrains motor control, which synchronizes motor movements with auditory rhythmic cues that occur subliminally. Rhythmic auditory cueing can facilitate the rehabilitation of motor movements without involving cognitive processing. A patient’s breathing pattern can be synchronized with exercise cued by ascending or descending melody lines on a keyboard.

swallowing
Swallowing mechanisms hindered by dysphagia

Another area where music therapy has shown benefits in stroke rehabilitation is with cognitive deficits. There are shared cognitive and perceptual mechanisms and shared neural systems between musical cognition and parallel nonmusical cognitive functions that provide access for music to affect general non-music functions, such as memory, attention, and executive function (Thaut).  Music therapy is part of Congressman Gabrielle Gifford’s cognitive rehabilitation. She suffered a traumatic brain injury after being shot in the head in January 2011.

In a study to determine whether everyday music listening can facilitate the recovery of cognitive functions and mood after stroke, Sarkamo, Tervaniemi, Laitinen, and Forsblom divided 60 patients with a left or right hemisphere middle cerebral artery stroke to a music group, a language group, or a control group. Post hoc tests of the change scores showed that at the three-month stage, verbal memory recovery was significantly better in the music group than in the control group or in the language group. Focused attention recovery was significantly better in the music group than in the control group and marginally better in the music group than in the language group. These gains continued and were seen in tests at the six-month stage. The music group also experienced less depressed and confused moods than the control group (Sarkamo, 2008).

A study examined the long-term effects of daily music and speech listening on auditory sensory memory after middle cerebral artery stroke. The results show that just listening to music and speech after neural damage can induce long-term plastic changes in early sensory processing (Sarkamo, 2010).

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