Recently I had the opportunity to participate in a training for Neurologic Music Therapy in Cleveland, OH. The training took place over a 4-day period, for 9+ hours each day, with each day focusing on a different goal area NMT could address.
What is NMT?
Neurologic Music Therapy is a more specialized model of music therapy; it provides specific, individualized and standardized interventions for those affected by neurologic injury or disease. Some of these can include cerebral palsy, Parkinson’s disease, autism spectrum disorder, stroke, TBI, and Alzheimer’s Disease. NMT differs from traditional music therapy by the way it views how music works: in traditional music therapy, music is viewed as a model for social science; NMT, on the other hand, sees music as a language hard-wired in the brain. This means that music elements such as rhythm and melody can assist in recovery from brain damage by forming and integrating new neural pathways, since both the left and right sides of our brains are involved in processing music. The integration of the sensory information we take in while engaged in music, both passively and actively, improves our ability to store and recall information, increase cognitive stimulation, and promote a better understanding of stimulation of our senses. This in turn impacts all areas of functioning, including movement and communication abilities. In essence, our brains and our bodies are “wired” for music.
Neurologic Music Therapy treatment planning follows five steps:
2. Decide which therapeutic goals to target
3. Design of functional, nonmusical interventions
4. Translation of nonmusical interventions into therapeutic musical-based interventions
5. Transfer of therapeutic learning from musical-based interventions into functional, nonmusical real-world applications
Assessment is essential in NMT: it gives the therapist a framework and basis on which to select techniques and track progress. In NMT, the majority of assessments have been designed by other professions and are not music-based; this is helpful because it lets the MT conduct assessments that can be generalized. Assessment is done at the beginning of a treatment and at regular intervals throughout the treatment, in order to determine if there is improvement or success with the musical-based intervention.
NMT focuses on 3 key goal areas: 1. Speech and language, 2. Sensorimotor, 3. Cognition. A fourth goal area, psycho-social, is in its beginning stages of being developed. With each goal area, specific techniques are utilized. Listed below are each goal area and the specific techniques used to target that goal area:
*Musical Sensory Orientation Training (MSOT)
*Musical Neglect Training (MNT)
*Auditory Perception Training (APT)
*Musical Attention Control Training (MACT)
*Musical Mnemonics Training (MMT)
*Echoic Memory Training (MEM)
*Associative Mood and Memory Training (AMMT)
*Musical Executive Function Training (MEFT)
Speech and Language
*Melodic Intonation Therapy (MIT)
*Musical Speech Stimulation (MUSTIM)
*Vocal Intonation Therapy (VIT)
*Rhythmic Speech Cuing (RSC)
*Oral Motor Respiratory Exercises (OMREX)
*Therapeutic Singing (TS)
*Developmental Speech and Language Training through Music (DSLM)
*Symbolic Communication Training through Music (SYCOM)
*Patterned Sensory Enhancement (PSE)
*Therapeutic Instrumental Performance (TIMP)
*Rhythmic Auditory Stimulation (RAS)
*Music Psychotherapy and Counseling (MPC)
Some of the most common NMT techniques are: Melodic Intonation Therapy (MIT), Patterned Sensory Enhancement (PSE), Rhythmic Speech Cueing (RSC) and Musical Attention Control Training (MACT).
Melodic Intonation Therapy (MIT) and Rhythmic Speech Cuing (RSC)
Melodic Intonation Therapy was developed in the early 1970’s and in its beginning stages was mainly used by speech-language pathologists working with patients with non-fluent expressive aphasia, where speech output is reduced severely and is typically limited to utterances of four words or shorter; therefore, a patient with expressive aphasia can comprehend what is being said or read, but is not able to produce meaningful sentences. Other types of aphasia, such as Wernicke’s aphasia or global aphasia, are poor candidates for MIT. Recently research has been done showing that MIT could benefit other populations with deficits in speech, such as autism spectrum disorder and Down syndrome.
There are six steps in MIT:
1. Hum the melody of the phrase while tapping
2. Sing the phrase while tapping the client’s hand
3. Have the client join in singing the chosen phrase over and over
4. Fade out the therapist
5. Therapist sings alone then client echoes
6. Have client recall the phrase when prompted
It’s important that the melody of the phrase be very distinct, so the client can associate the melody with the phrase for recall purposes. For example, if the phrase chosen is a question, the melody should go up in pitch, the way questions are commonly spoken. The melody should also not be well-known; each melody for each statement should be unique, but simple to remember.
Rhythmic Speech Cueing, on the other hand, is used to improve intelligibility (dysarthria), reduce stuttering and cluttering (fluency disorders) and rhythmic sequencing (apraxia). RSC has been found to be effective with clients with Down syndrome, Parkinson’s disease, and TBI.
In RSC, tempo or speed is the most important factor for success; it has to be set precisely according to the specific therapeutic goal. The tempo is presented usually with a metronome, but live instrument playing can also be used. Two modes of cueing are used: metric and patterned. In metric cueing, the client is asked to match either one syllable or one full word to one given beat. In patterned cueing the client reproduces a pre-structured rhythmic sentence at a given tempo; this differs from metric cueing in that the syllables or pauses are not of equal duration and there can be longer and shorter syllables. Typically metered cueing is attempted first, then patterned if metered is not successful.
Since my training, I’ve used both techniques with multiple clients who present with speech deficits; for some MIT has been more successful, while with others RSC has worked well. It depends on what the main speech deficit is: if speech output is severely limited, but the client has good comprehension skills, MIT will most likely be a better fit. If the client needs to improve intelligibility and has issues with stuttering, then RSC will probably work best. With all the clients, though, an assessment was done pre-treatment, and will continue to be administered at regular intervals.
Patterned Sensory Enhancement (PSE)
Patterned Sensory Enhancement is a technique that uses acoustic elements of music like rhythm, melody, and dynamics to provide various types of cues for movements that reflect functional movements of activities of daily living. It’s usually applied to movements that aren’t rhythmical by nature, such as standing-to-sitting or hand and arm movements of reaching out and grasping. PSE is also used to work on increasing physical strength and endurance, improve balance and posture and increase functional motor skills of the upper limbs. Clients of all age ranges and populations can benefit from this NMT technique.
Three different types of cues are targeted through the music elements: spatial, temporal, and force. In spatial cueing, pitch, dynamics, sound duration, and harmony are the music elements used; for example, if the pitch goes up, the movement goes up or away from the body. If the volume increases, the movement gets larger. For temporal cues, tempo, meter, rhythmic pattern, and form are used as music elements; for example, the client’s internal metronome (heart rate and breathing) can be utilized for meter. And for force cues, elements like dynamics, harmony, and tempo are used; for example, more dynamics or accents should be used depending on where the work is most needed. Harmonic cluster chords can be played when the client should tense up, then resolve when the client is to relax.
In order to implement PSE, there are four steps:
1. Do the movement with your client and set the tempo
2. Using a metronome, talk the client through the movement rhythmically, using verbal cues
3. Maintain verbal cues while slowly bringing the music in
4. Fade out verbal cues and let the music facilitate the movement
PSE has been beneficial to several of my clients who exhibit issues with strength, balance and posture, and range of motion. The tambourine is an excellent instrument to use as a target to hit or kick to improve range of motion, as is a triangle or chime tree. These instruments can also work well for clients in the beginning stages of strengthening, as there doesn’t need to be much force to produce sound. Each client responds to different music as well; for some of my clients, music with a country feel is more motivating; for others a rock beat works better.
Music Attention Control Training (MACT)
Music Attention Control Training targets attention and perception deficits. A lot of times MACT is paired with Music Neglect Training (MNT) or Auditory Perception Training (APT). In Music Attention Control Training, the goal is to practice focused, sustained, selected, divided and alternating attention functions. Several populations can benefit from this technique, including autism spectrum disorder, dementia/Alzheimers, psychiatric disorders, and ADHD (attention deficit hyperactivity disorder).
The first subset of MACT is Focused Attention, which is the ability to direct one’s mind to a particular thing; in music therapy, this can be achieved through drumming circles, during which participants must focus on the specific rhythm designated to them and ignore what rhythms are occurring on either side of them.
The second subset of MACT is Selective Attention, which is the ability to avoid distractions as you focus on one thing. A drum circle also applies to Selective Attention, but can also be done in individual sessions through interventions that require the client to start and stop on various instruments when they hear a certain melody or motif played on the piano or autoharp.
Sustained Attention is the third subset of MACT and deals with concentration and holding your attention over a period of time. This can be done in both individual and group sessions during which pitched and non-pitched instruments are played together, with the client following as closely as possible to the melody introduced by the therapist. The MT can then change elements of the melody, such as tempo, note duration, dynamics, pitch or register. The client must attempt to follow the MT’s changes as best as possible.
Alternating Attention, the fourth subset of MACT, attempts to switch the client’s attention back and forth from one stimulus to another. The sound sources or stimuli should be kept far away from one another, and the client is directed to follow with their musical responses alternating cues that come from two or more different sources. Each cue must have a different response so that the alternating attention shift leads to a different response.
Divided Attention is the fifth subset and looks to improve the ability to sustain attention to two things at the same time. In this technique, the instruments or sound sources should be kept in close proximity. This is best used in a group setting, as the client has to track two musical stimuli at the same time and adjust their playing when a change in one of the stimuli occurs; in individual sessions the MT would have to play two different instruments.
I’ve found these techniques to be quite useful with my clientele. Many of them display deficits in attention or concentration, which can hinder their everyday life; for example, a client distracted by outside sources, such as a tablet or iPad could benefit from these techniques using tambourines. During their daily life the concentration is focused on the tablet, their head is down, and should the client have to cross the street, the potential for injury is high. With MACT, the client is instructed to hit one tambourine at a time while walking in a safe environment. The client has to maintain their attention on the tambourine, to hit the correct one, while also keeping the attention on where they are walking.
In summation, am I happy I took the training? Absolutely. Neurologic Music Therapy has given me a new way of thinking about how I work with my clients. I see things I never noticed before, and I put together interventions in different ways. Obviously these techniques are not applicable to every client; with some, a more traditional form of music therapy is best. That doesn’t mean that NMT or traditional music therapy is bad or wrong, it just means that every person is different in the way they respond to things. And as music therapists we need to be able to switch between the various techniques, in order for us to best serve our clients.
information for this blog post came from Erin's training session and the Handbook of Neurologic Music Therapy, edited by Michael H. Thaut and Volker Hoemberg