A Snapshot of Music Therapy to Support Stroke Recovery.
A cerebrovascular accident (CVA), commonly referred to as a stroke, happens when the supply of blood to a part of the brain is reduced or stops flowing. The result of this is that the brain tissue is deprived of nutrients and oxygen (Mayo Clinic, n.d.). Brain cells begin to die within minutes of a stroke occurring, and rapid treatment is essential to minimize damage (Mayo Clinic, n.d.). The consequences of a stroke depend on where and how much damage occurred to the associated brain region (Heart and Stroke Foundation of Canada, n.d.).
There are three types of stroke: ischemic, hemorrhagic, and transient ischemic attack (TIA). An ischemic stroke is the result of a blood vessel in the brain being blocked or clotted. Blockages are caused when plaque builds on the inner wall of an artery, whereas a hemorrhagic stroke is the result of an artery in the brain breaking open. This disturbed flow of blood damages the brain. TIA's are the result of a small clot that momentarily blocks an artery. They are commonly referred to as a mini stroke, and are an indication that a stroke may happen in the future (Heart and Stroke Foundation of Canada, n.d.).
It is a common misconception that strokes only affect older adults. In fact, strokes can happen in children and all persons across the lifespan; a number of factors, such as high blood pressure, smoking and alcohol use can increase the incidence of a person experiencing a stroke. The effects of a cerebrovascular accident (CVA) range from mild to severe, and many people never fully recover. According to Rodgers (2013), one-third of those affected recover fully, one-third die, and one-third of survivors suffer long-term disability. Over 400,000 individuals are living with the effects of stroke in Canada, at a prevalence of 1.15%. This number is expected to rise to between 654,000 and 726,000 persons by 2038 (Krueger et al., 2015). Sequelae of stroke may include hemiplegia, apraxia, abulia, confusion, and depression (Mallory, 2006), compromising quality of life for affected individuals. Complications from stroke may involve: pain, numbness, paralysis or loss of muscle movement, difficulty speaking and swallowing, memory loss and thinking difficulties, and emotional problems (Heart and Stroke Foundation, n.d.).
Implications for Music Therapy Practice with Individuals Recovering from a Stroke
The experience of depression following a stroke has been described as having "invisible wounds" which other people, however well meaning, are frequently not aware exist (Terry, 2010). As a result, the condition often remains undiagnosed and inadequately treated, although close to 30% of patients develop depression either in the early and/or late stage following a CVA (Paolucci, 2008). This can impact their readiness to engage in rehabilitation, ability to reintegrate socially, and overall quality of life. Maratos, Crawford and Procter (2011) acknowledge that music therapy seems to be effective in mitigating effects of post-stroke depression, and suggest that this may be due to opportunities within a therapeutic framework for active music making, providing patients with aesthetic, physical and relational experiences. It has been shown (Blood & Zatorre, 2001; Hunter et al., 2010; Salimpoor et al., 2009) that music-induced emotions can have a modulating impact on affective responding. Too often patients recovering from a CVA experience a lack of pleasure and meaningfulness, as well as a sense of helplessness, resulting in negative effects on self-esteem and self-efficacy. Calibrated, active music therapy interventions using Neurologic Music Therapy (NMT) techniques such as Therapeutic Instrumental Music Performance (TIMP), in conjunction with Music Psychotherapy and Counselling (MPC), while incorporating client preferred music styles, may provide clients with the intrinsic motivation needed to engage in and commit to a comprehensive rehabilitative program. The therapeutic relationship, as well as providing therapeutic direction, may serve to intensify this positive affective experience (Kirschner & Tomasello, 2009; Liljestrom et al., 2013; Nayak et al., 2000). The combined effects of active participation in music making, positive affective responding and therapeutic interaction may provide a powerful, non-pharmacological means of addressing functional and psychotherapeutic post-stroke therapeutic goals.
This case example is from the clinical music therapy work of Dr. Clements-Cortes. Sam is a 78 year old male who suffered a stroke, which resulted in an injury to the frontal region of the left hemisphere in his brain. A complication from his stroke was Broca's aphasia, which is a specific type of non-fluent aphasia. Aphasia can be defined as "loss of the ability to understand speech or communicate using language" (American Heart Association, n.d.). Broca's aphasia is also known as expressive aphasia, and causes a person to have difficulty speaking and forming sentences or even words. A technique that is very useful in assisting stroke patients in regaining some functional language is melodic intonation therapy (MIT). MIT is an intonation-based technique that was created based on observations that persons with aphasia can accurately produce articulated words while singing, but no longer through speaking (Yamadori et al., 1977). "MIT is a hierarchically structured treatment that uses intoned (sung) patterns that exaggerate the normal melodic content of speech across three levels of increasing difficulty. The intonation works by translating prosodic speech patterns (spoken phrases) into melodically intoned patterns using just two pitches" (Schlaug et al, 2010, p. 658-59).
When I began working with Sam it was clear that he was suffering from a depressed mood and was grieving the losses he was experiencing as a result of the stroke. Together we formed the goals for his music therapy treatment which included:
1 To use music, especially MIT and Therapeutic Singing (TS) to facilitate and regain short functional speech statements or sentences.
2 To use music for enhancing mood, self-expression and emotional exploration and release.
3 To use music to strengthen the connection to his identity
We worked together for four months, two times per week. It would have been better if sessions could have taken place three times per week, but it was not possible given our schedules to coordinate with his other therapies. His wife and son took an active role and attended therapy sessions with Sam. They participated during the MIT and TS portion of the session, and then would leave so Sam and I could work on his other two goals. Their attendance contributed to the success of the therapy sessions, as they were able to practice the MIT and TS exercises with Sam in between our sessions. At the end of our therapeutic process together, Sam was able to say a few words and sentences with cueing, including: Hello, I am thirsty, I am hungry, I have to go to the bathroom, and I want a cup of coffee. Through clinical improvisation, Sam was able to express and release emotions that he was keeping bottled up inside, such as sadness and anger. Through choosing, singing and performing songs that Sam had a connection to, his sense of identity was strengthened and he said he felt a little more like himself when he was able to connect to this music. Sam's positive affect increased, and his wife and son noted that he was more motivated to participate in his other therapies. Sam and his family moved to another city to be closer to other relatives and that is why our therapy process was terminated.
With the prevalence of stroke being so high, and given the negative impact of depression on post-stroke recovery, it is essential to offer effective therapies that will support a person's functional as well as psychosocial needs, with clear goals established for each. Rehabilitation is a long process, and music therapy may fulfill an integral role in enabling persons to partake in rigorous therapy, while improving mood, self-esteem, and quality of life.
Blood, A. J., & Zatorre, R. J. (2001). Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. Proceedings of the National Academy of Sciences U. S. A., 98(20), 11818-11823.
Heart and Stroke Foundation (n.d.). What is stroke? Retrieved September 16, 2018 from http://www.heartandstroke.ca/stroke/what-is-stroke
Hunter, P. G., Schellenberg, E. G., & Schimmack, U. (2010). Feelings and perceptions of happiness and sadness induced by music: Similarities, differences, and mixed emotions. Psychology of Aesthetics, Creativity, and the Arts, 4(1), 47-56.
Kirschner, S., & Tomasello, M. (2009). Joint drumming: Social context facilitates synchronization in preschool children. Journal of Experimental Child Psychology, 102, 299-314.
Krueger, H., Koot, J., Hall, R. E., O'Callaghan, C., Bayley, M., & Corbett, D. (2015). Prevalence of individuals experiencing the effects of stroke in Canada: Trends and projections. Stroke, 46(8), 2226-2231.
Liljestrom, S., Juslin, P. N., & Vastfjall, D. (2013). Experimental evidence of the roles of music choice, social context, and listener personality in emotional reactions to music. Psychology of Music, 41, 577-597.
Nayak, S., Wheeler, B. L., Shiflett, S. C., & Agostinelli, S. (2000). Effect of music therapy on mood and social interaction among individuals with acute traumatic brain injury and stroke. Rehabilitation Psychology, 45(3), 274-283. doi:http://dx.doi.org/10.1037/0090-55220.127.116.114
Mallory, B. S. (2006). Stroke. In G. Cooper (Ed.), Essential Physical Medicine and Rehabilitation. Totowa, NJ: Humana Press.
Maratos, A., Crawford, M. J., & Procter, S. (2011). Music therapy for depression: it seems to work, but how? The British Journal of Psychiatry, 199, 92-93.
Mayo Clinic (n.d.) Stroke. Retrieved September 16, 2018 from https://www.may oclinic.org/diseases-conditions/stroke/symptoms-causes/syc-20350113 Paolucci, S. (2008). Epidemiology and treatment of post-stroke depression. Neuropsychiatric Disease and Treatment 4(1), 145-154.
Rodgers, H. (2013). Stroke. In M. P. Barnes & D. C. Good (Eds.), Handbook of Clinical Neurology (Vol. 110, pp. 427-433). Retrieved from http://www.sciencedirect.com/science/handbooks/00729752/110
Salimpoor, V. N., Benovoy, M., Longo, G., Cooperstock, J. R., & Zatorre, R. J. (2009). The rewarding aspects of music listening are related to degree of emotional arousal. PLoS ONE [Electronic Resource], 4(10), 1-14.
Schlaug, G., Norton, A., Marchina, S., Zipse, L., & Wan, C. Y. (2010). From singing to speaking: facilitating recovery from nonfluent aphasia. Future Neurology, 5(5), 657-665.
Terry, R. (2010). Invisible wounds: A survivor's perspective on the emotional challenges of recovery. Stroke Connection(May/June), 10-12. Retrieved from http://www.strokeassociation.org/STROKEORG/StrokeConnectionMagazine/Rea dSCNow/SCM-MayJun-2010_UCM_313857_Article.jsp#.VuXLkvHUseM
Yamadori A, Osumi Y, Masuhara S, Okubo M. (1977). Preservation of singing in Broca's aphasia. Journal of Neurology neurosurgery, and psychiatry, 40, 221-224
Dr. Amy Clements-Cortes is Assistant Professor, Music and Health Research Collaboratory (MaHRC), University of Toronto; Academic Coordinator/Instructor, Ryerson Chang School; Instructor and Supervisor, Wilfrid Laurier University; Certified Music Therapist and Registered Psychotherapist. Amy has extensive clinical experience working with clients across the life span. She has given over 100 conferences and/or invited academic presentations, and has published extensively in peer review journals and has contributed chapters to a number of books. She is the Past President for the World Federation of Music Therapy, Managing Editor of the Music and Medicine journal, Director of Notes By Amy www.notesbyamy.com.
Amy is on the editorial review board of the Journal of Music Therapy, Voices, Austin Palliative, Arts in Psychotherapy, Global Journal of Health, and Music Therapy Perspectives.
Catherine Haire is a former educator and current Ph.D. Candidate in the Music and Health Sciences program at the University of Toronto. Her research interests span rehabilitation of motor control, affect, and cognition, with a particular focus on persons who have sustained a cerebrovascular accident (CVA).
Amy Clements-Cortes, PhD, RP, MTA, MT-BC, FAMI, NMT-Fellow
Catherine Haire, MMT, MEd, RP, MTA, MT-BC, NMT-Fellow
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|Title Annotation:||music makers : music and healing|
|Author:||Clements-Cortes, Amy; Haire, Catherine|
|Publication:||Canadian Music Educator|
|Date:||Sep 22, 2018|
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