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Therapeutic Music and Nursing in Poststroke Rehabilitation (CE)
Individuals who experience stroke undergo a critical rehabilitation process with the aid of professionals including physical, occupational, and speech therapists, as well as primary care from nursing staff. However, the extent of the role that music can play in facilitating the rehabilitation process is unknown. Board-certified music therapists are employed in several capacities within the rehabilitation environment. There is a need for nursing professionals in this area to better understand the role a music therapist may play and how they can assist clients in using music in a therapeutically beneficial way. The purpose of this article is to educate nurses about music therapy and provide evidence for the therapeutic use of music in the rehabilitation setting for victims of stroke.
According to the American Stroke Association (ASA), 795,000 people suffer a stroke each year in the United States (2010). Stroke is the third-leading cause of death in the United States (Goldstein et al., 2006) and the leading cause of long-term disability that affects survivors with both physical and mental disabilities (Hadidi, Treat-Jacobson, & Lindquist, 2009). The effects of stroke occur in three main areas crucial to quality-of-life measures: physical, cognitive, and psychological. Partial or complete loss of movement and strength in an extremity or bilateral loss of control may be the most recognizable effect of stroke. Confusion and problems with thinking and memory are common poststroke effects of cognition. One-third of stroke victims experience depression following the event (Hackett, Anderson, House, & Xia, 2009). All of these poststroke impairments may lead to difficulties not only for the client but also for his or her family.
The confluence of the professions of music therapy and hospital nursing is bound by their histories. Isa Maud Ilsen was a musician and nurse who founded the National Association for Music in Hospitals in 1926 (Davis & Gfeller, 1999, p. 24). This event may be seen as the informal beginning to training musicians as therapists. Several nurses and physicians provided music in hospital wards with the goal of palliating the symptoms of the patients. Dr. Evan O’Neill Kane wrote to the Journal of the American Medical Association to support using a phonograph in the operating arena as an antianxiety measure for patients (Kane, 1914). McGlinn (1930) followed up with an article promoting phonograph use in obstetrics practice.
Music Therapy, Music, and Stroke in Reviewed Literature
Music therapists have been formally using music to address effects of disease and disorder in people in the United States since the 1940s (American Music Therapy Association [AMTA], 1999). Overall, 5,000 board-certified music therapists (MT-BC) are practicing worldwide and approximately 3,000 are members of the AMTA (Certification Board for Music Therapists, 2010). A large number of practicing music therapists work alongside nursing professionals in hospitals and skilled nursing facilities. Research on the uses of music with medical populations has been published for centuries (including a treatise titled “Music, Physically Considered” in a 1789 issue of Columbian Magazine). Specific and systematic inquiries into application of music as a therapeutic medium have recently become common in the healthcare literature and music therapy journals (Frandzel, 1996).
Cross, McLellan, Vomberg, Monga, and Monga (1984) were among the first to examine the use of music with stroke patients, although not specifically as music therapy. Thompson, Arnold, and Murphy (1990) addressed the need for the profession to examine stroke (also known as cerebrovascular accident) and how a music therapist may assess a client for goals and objectives. Recent research has explored specific aspects of stroke and has included investigators from the fields of neuroscience, psychology, and music, among others.
Neurologic Music Therapy
Abiru and colleagues (2007) found evidence supporting the use of neurologic music therapy (NMT), a therapeutic application of music toward nonmusical goals, for rehabilitation in stroke clients. Bradt, Magee, Dileo, Wheeler, and McGilloway (2010) conducted a Cochrane Systematic Review of the effects of music therapy on acquired brain injury, with an emphasis on stroke rehabilitation. This meta-analysis included seven studies with 184 total participants and suggested that an NMT protocol called rhythmic auditory stimulation (RAS) may benefit patients poststroke. McIntosh, Thaut, and Rice (1996) formalized RAS for clinicians to use music as an external auditory cue for gait training in stroke clients and found 164% improvement in cadence, stride length, and velocity.
RAS may look to the observer like therapists encouraging the client to simply walk to the beat from a metronome or music source. However, a music therapist and physical therapist typically collaborate to identify the appropriate goals, cadence, and adaptations necessary for an RAS gait training session. Hayden, Clair, Johnson, and Otto (2009) used the RAS protocol (N = 15) in varying lengths of treatment and found significant gains made in cadence and one-limb stance the earlier RAS was nested within conventional treatments. Thaut and Abiru (2010) conducted a review of RAS for movement disorders and concluded that RAS was effective specifically for clients with stroke and Parkinson’s disease, despite the differences in gait features of the two populations. Furthermore, they hypothesize a multiple auditory-motor pathway theory in which music—the auditory stimulation—accesses and entrains motor processors to enhance stability in motoric stimulation. Altenmüller, Marco-Pallares, Münte, and Schneider (2009) used a 3-week rehabilitation model on 32 clients poststroke. Using an electronic piano (index finger, fine motor) and drums (entire upper-extremity movement), they found music-supported therapy resulted in significant improvements in speed, precision, and smoothness of movements, as well as increased mobility in daily activities. Furthermore, neurophysiologic data showed evidence of more significant changes in neural circuitry and activation of the motor cortex in the music group than the control group. Yoo (2009) found similar results with the NMT protocol called Therapeutic Instrumental Music Performance (TIMP) in three patients poststroke.
As early as 1954, in a study by Fields, familiar music was selected for the purpose of facilitating client movements with musical instruments (Baker & Roth, 2004). In this early study there were four participants who coordinated their movements to music. Results showed that neural connections were strengthened every time movements were performed and over time these movements, a nonmusical goal, became easier to perform.
Särkämö and colleagues (2008) demonstrated a mood/arousal model of preferred music listening for 54 stroke patients following a right- or left-middle cerebral artery (MCA) stroke. Significant improvements in the domains of verbal memory and focused attention were noted in the music listening group 3 and 6 months following the stroke as compared with speech listening and a control group. All three groups also received traditional care in the single-blind, randomized study. Music group participants also reported less depression and confusion than the control group. Kim and Tomaino (2008) found great importance in the ability of a music therapist to adjust to temporal issues in cuing speech for seven clients with nonfluent aphasia. They also used several NMT speech/language protocols, including modified melodic intonation therapy (Sparks & Holland, 1976) and musical speech stimulation (Thaut & Abiru, 2010).
Based on the literature, listening, walking, moving, and singing to music all have some positive effect on individuals affected by stroke. Although it is ideal to have an MT-BC on staff to administer the protocols, other healthcare professionals (including nurses) may provide some therapeutic benefits of music to these clients (Forsblom, Laitinen, Särkämö, & Tervaniemi, 2009). Music therapy can complement areas such as physical, occupational, and speech therapy, or it can be used as a separate therapy altogether. Music also may be used in a social context that can elevate the mood of a client recovering from a stroke and help facilitate social interactions between the client and therapist or among a group of inpatient clients in a therapeutic group that uses music (Murrock & Higgins, 2009; Nayak, Wheeler, Shiflett, & Agostinelli, 2000). In a variety of ways, music may affect physical, cognitive, and psychological components of the poststroke rehabilitation process.
Physical Rehabilitation and Music
At first glance, motor impairment following a stroke has the most obvious impact on client participation in poststroke recovery efforts. Even the simple use of a metronome may mark time intervals for brain impulses to stimulate upper- or lower-extremity motor activities. Using measured time intervals with a metronome or music recording of the client’s preference also offers the caregiver a measuring device. This leads to the technique of RAS. For example, playing a song such as Johnny Cash’s “Walk the Line” can be used to measure stride velocity. If the client is walking on the beat accurately for 1 minute, he or she will have walked 104 steps/minute, and one may divide that total by the distance covered to determine stride length. Individuals who have experienced a stroke typically will need to develop a longer, more symmetrically balanced stride, which means a slower velocity and cadence. Cadence and velocity are two important measurements used in physical therapy and may be manipulated by an external auditory stimulus such as music. The music can help facilitate recording these measurements by the physical therapists at each session or can be used to assist nursing staff during client ambulation maintenance. At a minimum, a metronome (purchased at music stores for $15–$20) will emit a pulse for the client to walk. Even this minimal auditory stimulus has demonstrated improvement in gait (Thaut, McIntosh, & Rice, 1997).
Active music making is a way to stimulate the body’s senses and organize the brain. In traditional therapy, the tasks may involve the repetitive stacking or reaching for an item. Research shows that a music therapist could incorporate a piano or a drum with this repetitive motion, leading to a more stimulating and therapeutic environment (Schneider, Schönle, Altenmüller, & Munte, 2007). Rehabilitation units may mimic some aspects of what a music therapist would do in this case. Purchasing basic instruments (consult a music therapist for age-appropriate choices) for a small group of clients to play along to a video or audio recording is another means to provide physical activity. Using maracas promotes hand-eye coordination; playing a piano keyboard increases fine motor finger dexterity; playing drums on either side of the body increases trunk flexibility. All of these musical interventions may be integrated into a single song determined by the group and facilitated by caregivers.
Incorporating music into a rehabilitative program can have very positive neurological effects in reaching functional, nonmusical goals. The combination of a dynamic rhythm with repetitive motion leads to the restoration of motor function and can also lead to greater brain plasticity (Jeong & Kim, 2007). Plasticity, or cortical reorganization, means developing the connections needed to perform a task in secondary areas of the brain, after the primary area has sustained damage. Thaut and Abiru (2010) found that this neuroplasticity may imply the possibility of restored function through appropriate learning and training stimuli. The changes in typical neural circuitry are significant when the brain processes music.
When a stroke occurs many victims experience sudden confusion, loss of the ability to communicate, loss of coordination, and trouble walking. During the recovery process some or all of these symptoms may remain, which can lead to anxiety about what has happened, the institutional surroundings, the medical care being provided, and what the future may hold for the individual client. Särkämö and colleagues (2008) found self-directed, poststroke music listening can enhance recovery of cognition and improve mood.
The most frequently used inpatient medical treatment for anxiety is oral or intravenous sedative drugs (Chlan, 2000). Some of the physiological responses seen with sedative drugs are a decrease in respiratory and heart rates. This type of response may also occur when listening to pleasant and relaxing music. Ellis and Thayer (2010) explored the association between music and the autonomic nervous system (ANS), which controls the respiratory and circulatory systems, among others. They suggest that the ANS may be the pathway that music uses to establish a therapeutic health effect. Music is also a nonpharmacological nursing intervention that does not lead to extreme muscle relaxation and central nervous system depression, both side effects of sedative medication that can cause further delays in the rehabilitation process (Chlan, 1995).
Ramasubbu and Goodyear (2008) found depression to be the most common mood disorder following a stroke, affecting 30%–50% of survivors. The effects of depression weigh heavily on the client’s cognition and motivation during the rehabilitation process. The client’s lack of desire to regain abilities that were lost in an instant may be devastating to the client, his or her family, and all of those who care for the individual.
Dopamine is one of the neurotransmitters believed to be a factor in depression. Listening to preferred music stimulates a reflexive, neurological pleasurable response, thus increasing the brain’s release of this neurotransmitter. Magee and Davidson (2002) found music therapy may reduce anxiety and depression in clients with neurological conditions. Music therapy may provide emotional modulation and arousal through the therapeutic relationship between the music therapist and the client. A goal of this therapeutic process may be for the client to have a better outlook for his or her recovery process and feel more motivated during and outside of the therapy session, hence the previously mentioned correlation to increasing one’s quality of life. The music therapist is able to facilitate the process of this self-selection of music with the client and give the client the tools needed to progress toward his or her nonmusical goals.
Therapeutic Music Implications for Nurses
Nurses continually adapt to improved treatments as a result of advancements made by technology. Although music as a “therapy” may be seen as a medical advancement, the framework for its use in nursing was posited by Florence Nightingale, who “believed it was nurses’ responsibility to control the environment to put the patient in the best environment for healing to occur” (McCaffrey, 2008). And just as music is inherently considered an “art,” so is much of nursing practice. Incorporating music into our client’s treatment plans, when appropriate, is also a way to individualize a client’s treatment. By working together, clients, their families, and medical personnel can all reap the benefits of music in the healing process.
There are several ways for nurses to incorporate the benefits of music into the care they provide to their clients. Nurses may consider referral to a music therapist if one is employed or contracted at the facility. Clients with the issues discussed above may benefit from a formalized therapeutic process, just as they might benefit from referral to a physical or occupational therapist (physical needs) or a unit psychologist, chaplain, or social worker (cognitive, psychological needs). Many facilities employ volunteer coordinators who may be able to arrange one-to-one musical visits with clients or group social activities with music. Finally, simply informing clients of the benefits of music listening and setting them up with music on a stereo or television may be part of a plan of care. Although this action may seem basic, it may provide an impetus for the client to better understand how to manage his or her symptoms from the stroke.
McCaffrey and Locsin (2007) found that music can assist in the healing and rehabilitation process by reducing anxiety, pain, and overall stress that occurs with any medical situation. Their article specifically examined active listening to music as a nursing intervention. These reductions may decrease anxiety and with it, the sedatives and pain medications being administered, which is a common goal for older adults. Lessening medication side effects can also encourage a greater level of autonomy and participation in self-care for the poststroke rehabilitation client.
Chlan (1998) provided a comprehensive overview of the interaction between nursing and music therapy that distinguished the role of MT-BC and how nursing professionals may understand the therapeutic effects of music for their clients. This article provides an overview specific to stroke rehabilitation. Nursing professionals can promote the evidence base of music in caring for the needs of clients who have severe physical, cognitive, or psychological issues to overcome during the rehabilitation process from a stroke. It is during poststroke recovery efforts and in the management of long-term manifestation of stroke symptoms that more research is needed. Music listening, music making, and music therapy offer evidence-based clinical options that coincide with neurological models of mood, arousal, and music processing.
Ideally, an MT-BC would be on staff or work on a contract basis at a facility to coordinate staff members’ music efforts in individualized client care. If there is an MT-BC on staff, we encourage collaboration between nursing staff and the MT-BC to help provide holistic care to the client. If there is no MT-BC on staff, we recommend searching for one in the area or looking into partnerships based on grant funding or research opportunities.
Nursing professionals can collaborate with rehabilitation staff, such as physical therapists, occupational therapists, and speech-language pathologists to use music in a controlled, effective, and evidence-based manner with clients, especially immediately after a stroke. Make staff aware of the client’s listening preferences and the effective changes of a client in music and nonmusical periods. Nursing professionals, if asked by a facility to also conduct socialization activities, should look into the possibility of purchasing or creating small instruments for a video, audio, or live music “play along” to increase physical activity in a group setting and increase socialization to address isolation and depression issues. At a minimal level, consider the recommendations from Särkämö and colleagues (2008) and encourage poststroke clients to actively listen to musical favorites for 30 minutes a day. Note changes in cognition or mood, or measure them for data collection in charting.
The issues discussed in this article indicate that there is a continuous need to have the best scientific, evidence-based treatment options in place for individuals who suffer a stroke and their families when these life-altering accidents occur. As evidenced through history, the addition of music therapy does promote the progression of treatment in the therapeutic rehabilitative environment. We must continue to promote and refine the use of self-selected, client-preferred music in the therapy process for poststroke rehabilitation within medical facilities, outside in the community, and within the family home environment.
About the Authors
Andrew J. Knight, MA MT-BC, is an assistant professor of music therapy at the University of North Dakota in Grand Forks, ND. Address correspondence to him at Andrew.firstname.lastname@example.org.
Nikki Wiese, CMA, is a cardiology office nurse at the Med Center One Q&R Clinic in Bismarck, ND.
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