Music therapy to promote interpersonal interactions in early paediatric neurorehabilitation.

Bower, Janeen ; Shoemark, Helen

Introduction

Human beings are fundamentally social beings (Trevarthen, 2001). In everyday life, social capacity is evident in basic and sophisticated communication behaviours. While a person's speech and language are the most obvious of these, there is a range of more basic behaviours concerned with how to be with others, how to seek companionship or how to express affections (Lyons-Ruth, 1998; Trevarthen, 2001). An acquired brain injury (ABI) has the potential to impact on an individual's social capacity and thus their ability to interact with people (or, interpersonally interact) and create meaningful relationships. In turn, this may affect the individual's potential for successful rehabilitation as relationships are at the core of rehabilitation (Gilbertson & Aldridge, 2008). Music is fundamentally a social medium and provides an ideal vehicle through which a patient may re-establish or rehearse social capacity and interpersonal relationships (O'Callaghan, 1999).

This article presents a case study of a paediatric patient with an ABI who had emerged from coma and posttraumatic amnesia (PTA) and was able to produce some speech. Due to receptive and expressive language deficits, however, he was unable to successfully use his speech to relate to others. The clinical music therapy program promoted basic interpersonal interaction skills, other than speech and language, in the early stages of ABI recovery. Music therapy and subsequent co-facilitated music therapy/speech pathology interventions successfully engaged the patient in musical interactions and provided the opportunity to musically rehearse appropriate interpersonal interactions to enhance social capacity.

The evidence highlighting the impact of music therapy for paediatric patients with an ABI has been provided by clinical case studies (Kennelly & Edwards, 1997; Rosenfeld & Dun, 1999) which present a clear distinction between the application of music therapy for children in coma and states of reduced consciousness, and music therapy in functional goal-oriented rehabilitation. More recently, Gilbertson and Aldridge (2008) highlighted the use of music therapy as an effective means for re-establishing meaningful relationships with patients with severe ABIs. This article continues the tradition of using an exemplar case study to illustrate a previously unreported experience. As a relatively new clinician on a paediatric neurosciences and rehabilitation unit, the primary author was unable to locate direct evidence to support her work with a patient with an ABI during a discrete phase between emergence from coma and the commencement of functional speech rehabilitation. She identified that music therapy was successful in enhancing social capacity in a patient who was able to speak but was unable to interpersonally interact. The ability to seek and accept interaction, on some level, is essential for engagement in speech rehabilitation. Through reflexive considerations and discussions of sessions, developmental theory and knowledge about neural networks involved in music and language processing informed the authors' suggestion that music therapy promoted basic interpersonal interaction skills, other than speech and language, in the early stages of ABI recovery.

Literature Review

Acquired brain injury is a term used to refer to an injury or insult to the brain that occurs from birth onwards (The Royal Children's Hospital Melbourne, 2007a). The most common causes of paediatric brain injuries in Australia are traumatic brain injuries, meningitis/encephalitis, stroke, hypoxia and non-accidental injuries (Headway Victoria, 2005). Even a minor brain injury can have a significant impact on an individual child's physical functioning, cognition, personality, communication skills and behaviour (Bradt, Magee, Dileo, Wheeler & McGilloway, 2007).

A moderate to severe ABI typically results in a period of coma followed by PTA as the patient regains consciousness (The Royal Children's Hospital Melbourne, 2007b). Coma is a state of profound and deep unconsciousness and unresponsiveness from which the individual cannot be roused even by painful stimuli. PTA is a period of hours, weeks, days or months after the injury when the patient exhibits a loss of day-to-day memory. The patient is unable to store new information and therefore has a decreased ability to learn. PTA is characterised by confusion, disorientation, restlessness and agitation (National Institute of Neurological Disorders and Stroke, 2009). Functional rehabilitation traditionally commences after the acute coma/PTA phase and aims to maximise the individual's recovery (Headway Victoria, 2005).

Neuropsychological Aspects of Music

It is increasingly accepted that human beings are innately musical (Mithien, 2005; Peretz, 2006). The potential to process music is evident from infancy (Trehub, 2001) and infants respond to the musical elements of early interpersonal or social interactions before they have acquired the ability to process language (Trevarthen & Aitken, 2001). Trevarthen (2001) argued that the ability to interact and engage with others is a fundamental need of all humans. For patients with acquired or degenerative neurological conditions, who are unable to process language, music therapy may offer the opportunity to address this fundamental need and therefore reduce the isolation of these individuals (O'Callaghan, 1999).

Emergent knowledge about the neurological processing of music informs the clinical practice of music therapy for paediatric patients with an ABI. As a complex stimulus, music activates a global firing of neurological connections including both the cortical and subcortical regions of the human brain (Peretz, 2006; Tomaino, 2002). While there is an overlap in neural activation between music and language processing, music stimulates the primitive regions of the brain through to the most highly developed cortical areas (Boso, Politi, Barale & Emanuele, 2006; Ozdemir, Norton & Schlaug, 2006; Peretz & Zatorre, 2005). The limbic system, a subcortical region of the brain associated with emotional behaviours and memory, is also suggested to be involved in the processing of musical stimuli (Boso et al., 2006; Tomaino, 2002). Andrade and Bhattacharya (2003) proposed music is likely to be processed with some degree of automation, that is, neurologically processed at an unconscious, automatic level. Arguably, this makes music a valid vehicle for therapy with patients with an ABI, as music may be able to bypass damaged areas of the brain to access intact, undamaged capabilities (O'Callaghan, 1999).

Music Therapy for Patients in Coma

Vocal improvisation and live singing of familiar songs have been reported as successful in eliciting a range of physiological, behavioural, communicative and emotional responses which indicate an increase in coma arousal and orientation levels for patients with brain injuries (Ghiozzi, 2005; Kennelly & Edwards, 1997: Magee, 2005; Rosenfeld & Dun, 1999: Tamplin, 2000). Music therapy for these patients may have the potential to activate subcortical regions of the brain, including the limbic system, to provide a cognitive path to the emotional components of consciousness and increase the patient's awareness of their surroundings (Rosenfeld & Dun, 1999). It may therefore be the inherent emotional and non-verbal nature of music that stimulates arousal responses (Magee, 2005). Magee (2007) however warned that there is a risk of over interpreting emotional behaviours from patients in low awareness states, stating these behaviours may be limbic behaviours which are not cortically mediated and do not suggest any discrimination between meaningful and non-meaningful auditory stimulation. Such responses are non-purposeful and do not represent an emerging awareness (Magee, 2007).

Music therapists are able to manipulate musical parameters to provide a controlled, structured and organised auditory environment in which a patient with altered neurologic functioning is able to respond (Magee, 2005). The structure and organisation inherent in music encourages an auditory environment that is effective in reducing agitation and confusion, and increasing orientation and communication in adult patients in PTA as they emerge from coma (Baker, 2002).

Music Therapy in Functional Language Rehabilitation

Singing and speaking are natural pathways for human expression (Cohen, 1994). They share the common elements of melody, rhythm and articulation however during the act of singing these aspects are often exaggerated (Baker & Tamplin, 2006; Cohen, 1992, 1994).

Facilitated patient singing has been reported to be successful in increasing vocal range, intonation, articulation and intelligibility in paediatric and adult patients with acquired and degenerative neurological conditions (Baker, 2000; Baker, Wigram, & Gold, 2005; Cohen, 1994). Vocal and breathing exercises have been reported to increase breath support for sustained phonation (Baker & Tamplin, 2006; Kennelly, Hamilton, & Cross, 2001) and the use of rhythmic speech cueing has been reported to improve rate of speech and speech intelligibility (Hurt-Thaut & Johnson, 2003).

Despite shared neurologic pathways, music and language also have considerable distinct neural circuits (Ozdemir et al., 2006). The application of music therapy, particularly singing instruction, for patients with neurologic speech disorders aims to bypass damaged language centres of the brain and activate the more global music capabilities to encourage the re-development of expressive communication (Baker & Tamplin, 2006). Reports of music therapy in language rehabilitation have focussed primarily in the expressive language or speech production domain.

It is suggested that music is potentially a stimulating, fun and evocative medium that may increase motivation and focus in paediatric patients during speech rehabilitation exercises (Kennelly, Hamilton, & Cross, 2001; Kennelly & Brien-Elliot, 2001). Likewise, Kennelly, Hamilton, and Cross (2001) described the clinical application of music therapy with a paediatric patient to address global language goals including the ability to follow simple instructions, retrieve single words within the structure of a familiar song and the ability to make choices.

Music therapy to address the needs of patients with an ABI is an expanding field however the majority of current literature refers to the adult population. The use of music therapy for paediatric patients with an ABI remains underrepresented in the literature.

Music Therapy to Increase Social Capacity

The examination of relationships within music therapy in the context of neurorehabilitation is gaining momentum in the literature. In giving a rationale for using music as a treatment medium in neurorehabilitation, Magee (2005) noted the underpinning elements of music as a powerful social medium that conveys emotional states and further that early communication relies on musical parameters (Trevarthen & Aitken, 2001). Gilbertson (Gilbertson & Aldridge, 2008) demonstrated that music therapy broadens the potential of existing rehabilitative treatment possibilities, particularly in the re-establishment of relationships. Further, idiosyncratic and isolated patient behaviours transitioned to more conventional and integrated behaviours throughout the program of improvisational music therapy in early neurorehabilitation (Gilbertson & Aldridge, 2008).

The use of music to encourage communicative responses for patients in altered states of consciousness draws upon knowledge of pre-verbal communication with infants (Magee, 2005). The prosodic or musical parameters of early parent-child interactions promote interpersonal interaction and emotional communication and regulation before the capacity for language has developed (Bargiel, 2002; Trainor, 2002; Trehub, 2001; Trevarthen, 2001). Jochims (1994) argued that this pre-verbal, emotionally focussed language applied to patients with neurological deficits is capable of reaching the healthy regions of the brain, re-stimulating the fundamental communication competencies.

The shared experience of music-making provides a therapeutic medium in which social capacity is stimulated through approachable avenues of interpersonal interaction which do not yet require speech and language. The following clinical case study provides an illustration of how this may be implemented.

Introducing "Rick" (1)

Rick was ten years old when he sustained a diffuse ABI as a result of encephalitis and a seizure disorder. Rick was previously well before being admitted to a regional hospital with nausea, vomiting, muscle pain and drowsiness. After a significant deterioration in his condition, including several generalised tonic clonic seizures and decreased consciousness, Rick was transferred to the intensive care unit (ICU) at the Royal Children's Hospital Melbourne.

At admission to the ICU, Rick had a GCS (2) of 8-9 suggesting a moderate to severe brain injury. Rick's condition continued to deteriorate in ICU. Increasing seizure activity was observed despite anti-convulsant drug therapy. Rick was sedated and required ventilatory support due to prolonged apnoeic (cessation of breathing) episodes that followed the seizures. Rick spent a total of 42 days in the ICU diagnosed with suspected viral encephalitis and seizure disorder of unknown aetiology. An MRI showed focal oedema in the left temporal middle cortex and subcortical white matter. When weaned from ventilation, Rick was transferred to the Children's Neuroscience Centre (CNC). At the time of transfer Rick was eye opening but not fixing or following. He was spontaneously moving both upper and lower limbs, however had severe to moderate weakness in his limbs and poor head and trunk control. He showed reflexive responses to painful stimuli and attempts to pull out his nasogastric tube. He did not follow commands or respond to voices. Rick had a tracheostomy tube inserted and was subsequently non-verbal. Rick continued to have four or more seizures a day followed by prolonged apnoeic episodes. The seizures remained unresponsive to drug therapy. A repeat MRI showed evidence of minor cerebral atrophy (cell and tissue death) however no focal intracranial abnormality was noted. Rick also developed a cortical vision impairment. Rick's level of alertness was noted by the medical team to improve with decreasing levels of antiepileptic drugs. Rick spent a total of 37 weeks as an inpatient on the CNC (3).

Pre-morbidly, Rick had undiagnosed but suspected ADHD with reported learning and concentration difficulties.

Music therapy sessions with Rick

On referral, the Nursing Care Manager outlined Rick's agitation and a lack of communication, and family anxiety and distress. Rick was wait-listed for a music therapy program which commenced approximately twelve weeks after his admission to the ICU. Music therapy sessions were limited to twice weekly due to availability of the service.

At the commencement of the music therapy program Rick was assessed by medical and nursing staff to have emerged from coma and PTA. His tracheostomy tube had been removed and he was able to spontaneously speak. Rick was unresponsive to commands and his expressive language was echolalic, jargon and situationally inappropriate, suggesting damage to both expressive and receptive language capabilities. He had decreased verbal intelligibility due to an increased rate of speech and decreased breath support. Rick remained disorientated, agitated and disinhibited. Over his admission the physiotherapists and occupational therapists noted slow improvements in Rick's motor skills. At the commencement of the music therapy program he was able to grasp objects that were placed in his hands, maintain trunk control for unassisted sitting and briefly maintain head control. He showed an increasing awareness of object purpose, for example throwing a football or hugging a soft toy.

Music therapy assessment of Rick was an ongoing process. As an inpatient in an acute hospital setting, conditions and responses were constantly changing and assessment for Rick consisted of ongoing observations, re-evaluation on a session-by-session basis and ongoing discussion with the multi-disciplinary treatment team. (4) The initial goals for music therapy with Rick were to assess his responses to musical stimuli and musical interaction. As the music therapy program progressed, goals were to promote music and interpersonal interactions to increase engagement in therapy. Throughout the early stage of the music therapy program a variety of music therapy methods were used, these included:

1) Each session began with a sung greeting to emulate a traditional, socially appropriate greeting. The same song was used in each session to promote predictability and reduce confusion. The improvised songs repeated the simple lyric "Hello Rick" and the melodic intervals and rhythmic component of the lyric were exaggerated to offer a more engaging stimulus than regular speech. Further, the musical elements, not the lyric or language components of the phrase, were exaggerated. Referral information from the Care Manager reported that Rick appeared to have damaged receptive language capabilities and was not responding appropriately spoken language.

2) Similarly a "Goodbye Song" was used to cue the conclusion of the session.

3) The music therapist sang familiar songs with guitar accompaniment, initially to observe if a response could be evoked from Rick. The therapist took careful note of any change in Rick's behaviours that may indicate either an awareness of the music stimulus or a reduction in the reported agitation and confusion. As the music therapy program progressed and changes in Rick's behaviour were observed, familiar songs were used to encourage active engagement in therapy.

4) Rhythmic activities, including structured and free drumming improvisation were used to facilitate non-verbal interactions between Rick and the music therapist and a subsequent increased awareness of therapist initiated interpersonal interactions.

Outcomes of early music therapy sessions

For the first five music therapy sessions Rick did not respond either verbally or physically to the singing of his name or familiar songs. No behavioural responses indicating an awareness of this musical stimuli were observed and he did not respond to attempted verbal interactions. At this point Rick's mother requested the therapy continue despite an apparent lack of response. Rick's mother believed that his previous enjoyment of music would be fundamental in his ongoing rehabilitation. As Rick demonstrated no visible response to listening to musical stimuli, he was offered the opportunity to play the music for himself. Referral information reported that he had an increasing awareness of object usage therefore the music therapist placed a bongo drum in reach and placed his hands the drum. Rick hit the drum with both hands insistently before cursing loudly (which was common in other situations at this time) then continuing to play in a similar manner. While he was able to use the drum object appropriately and express that he had hurt his hands by cursing, Rick's playing was not responsive to physical, verbal or musical cues from the music therapist.

After approximately five sessions an increase in Rick's awareness of the music interventions was noted when the music therapist sang his favourite song, "Hound Dog" by Elvis Presley. Rick responded by singing along in a sing-and-scat (5) style during the breaks between lyrics of the song. Rick consistently repeated the same phrase throughout the verses of the song. His improvised singing created a form of musical turn taking with the music therapist who sang the usual lyrics. Rick's mother reported that prior to becoming ill, Rick sang this song in this style. This was the first time since acquiring a brain injury that Rick had been observed by either staff or family to respond to a musical stimulus.

After this session Rick's participation evolved in three ways. He began to sing along with the lyrics of familiar songs. He also began to respond to the singing of his name by repeating the phrase "Hello Rick" and he participated in music therapy for increasing periods of time.

Music therapy and speech pathology were concurrently addressing similar goals for Rick, however while significant gains in engagement were being made during music therapy interventions, little progress was being made during speech pathology interventions. During speech pathology sessions Rick was difficult to engage and appeared to lack attention. Co-facilitated music therapy/speech pathology sessions were commenced to make use of Rick's increasing participation in music therapy, aiming to decrease impulsivity, facilitate simple interaction skills to promote social capacity and address aspects of speech production. Rick continued to participate in two music therapy sessions per week; one of these was solely music therapy and the second was a co-facilitated music therapy/speech pathology session. These sessions continued for the duration of Rick's inpatient hospital stay.

Combined music therapy and speech pathology interventions

The combined music therapy/speech pathology program utilised a similar routine as established in the music therapy sessions. The sung greeting offered the opportunity to rehearse appropriate social interactions and ultimately stimulate spontaneous greetings. Therapeutic song singing and rhythmic speech cueing (Hurt-Thaut & Johnson, 2003) were utilised to facilitate clarity of speech production, including intelligibility, rate of speech, pitch range and volume. An increased number of familiar songs were incorporated into the sessions to promote memory recall, word finding capabilities and to generate automatic speech as a starting point for higher language processing and production. Drumming improvisation was employed to encourage non-verbal interaction skills and the ability to follow instructions to decrease impulsivity. Initially, simple games of go and stop were played on the drum. Gentle physical prompts, including holding Ricks hands away from the drum, encouraged Rick to stop, listen and wait for the command "go" before re-commencing playing. As the game progressed, Rick was verbally and physically encouraged to allow the therapist to take a turn on the drum in a simple turn taking exercise.

Outcomes of combined music therapy and speech pathology sessions

Throughout the program of co-facilitated music therapy and speech pathology sessions Rick continued to progress in his ability to interpersonally interact and engage in therapy. Rick progressed from producing echolalic phrases during the sung greeting, to responding with an appropriate sung greeting incorporating the names of the therapists. At the time of discharge from hospital, Rick was able to form appropriate and spontaneous spoken responses to greetings and farewells without musical cues.

As drumming improvisations progressed, Rick was able to participate in increasingly complex rhythmic dialogues without physical or verbal prompts. He was able to follow the commands, without physical prompts, of "go" and "stop" during drum playing and was also able to stop and wait for the therapists to have a turn playing the drum before recommencing playing. The ability to take turns formed a basis for interactions and Rick was encouraged to use these skills in verbal interactions. Further, he was also able to follow increasingly difficult multi-stage commands, for example, "play the drum three times with your left hand". During free drumming improvisation, Rick was able to listen to, and incorporate aspects of the music therapist's drumming in his own playing in a form of call and response, without physical or verbal prompts. Parallel to these musical interactions, simple verbal interactions and conversations were stimulated during therapy sessions. At discharge, Rick was able to participate in simple verbal dialogues on topics he enjoyed. His speech was, however, at times still repetitive, echolalic and situationally inappropriate. He continued to be impulsive however pre-morbidly Rick had suspected ADHD and it is difficult to assess the impact of this on his behaviour post ABI.

The speech pathologist assessed an improvement in Rick's verbal intelligibility throughout the course of co-facilitated therapy. The application of rhythmic cueing stimulated a decrease in Rick's rate of speech production, which inturn enhanced the clarity and intelligibility of his speech. At discharge, Rick was assessed by the speech pathologist to have average speech intelligibility for his age.

The length of time that Rick was able to sustain appropriate participation in therapy continued to increase during the course of co-facilitated music therapy and speech pathology. Before discharge, Rick was able to actively participate in therapy sessions for approximately an hour.

Before discharge the speech pathologist administered a comprehensive language assessment. During the assessment of his language comprehension Rick was able to correctly recall information approximately 40 percent of the time, when the information was presented verbally. However, when similar information was presented with a simple improvised melody, Rick was able to correctly recall the information 100 percent of the time. Language and comprehension tasks incorporated multistage commands including, "Nod your head if the sky is blue". During the assessment Rick improvised back to the speech pathologist "Clap your hands if you think I'm hot (good looking)!" This improvised sung phrase indicated the use of spontaneous humour, suggesting an increased ability to meaningfully interpersonally interact.

Discussion

The exploration of this clinical example of music therapy with a 10-yearold patient with a global ABI highlights the potential of music therapy to reestablish meaningful interpersonal contact prior to functional speech rehabilitation. Rick had regained consciousness post coma and was able to produce some spontaneous speech, his speech was however confined to a limited repertoire of phrases that were used in a repetitive manner. These phrases were contextually inappropriate. At the commencement of the music therapy program he was unresponsive to interpersonal interaction and was unable to formulate meaningful interactive speech. For Rick, music provided a familiar and predictable structure to support and encourage appropriate interpersonal responses and an increase in interpersonal interaction corresponded with increased successful participation in functional speech rehabilitation. Music therapy and speech pathology were effectively combined to enhance social capacity and provide the opportunity to non-verbally rehearse appropriate interaction skills. For Rick, functional speech rehabilitation included addressing aspects of speech clarity and production.

Rick's presentation had many confounding aspects. His behaviours of agitation, confusion, disorientation, impulsivity and disinhibition would traditionally be attributed to PTA. In this instance however the medical team had assessed Rick as having already emerged from coma and PTA and determined that these clinical aspects were a result of his ABI and ongoing seizure activity. Disinhibition and impulsivity may have been presenting features of the undiagnosed ADHD, and not a direct result of the ABI.

At the commencement of music therapy, Rick's receptive and expressive language deficits resulted in an inability to interpersonally interact and thus successfully engage in functional speech rehabilitation. The primary aim of music therapy therefore was to facilitate interpersonal interactions. His initial lack of response to musical stimuli suggested that music was unable to potentiate Rick's interaction capability, however, Rick's mother perceived music therapy to be of benefit. Her knowledge and sense of music as part of Rick's wellbeing and motivation pre-morbidly was respected as a valid reason to continue. Rick's medications were also under constant review from the medical staff and the doctors anticipated that changes in his medications might affect his presentation and potential could be realised at any point.

Rick's unique presentation provided many challenges during music therapy sessions. Because Rick was able to speak but unable to formulate meaningful interactive language to communicate, he did not conform to a more expected progression as presented by Gilbertson and Aldridge (2008) who described the use of improvisational music therapy to establish relationships with paediatric patients who were initially non-verbal. Rick's first meaningful response to auditory stimulation (singing in his favourite song) was an early presentation of situationally appropriate expression. As it was noted by staff and family as different from his response to non-meaningful auditory stimulation, it indicated that this was an intentional response (Magee, 2007). Rick's participation in music therapy increased and he was observed by the music therapist, and later the speech pathologist, to become increasingly responsive during musical interactions. Increasingly, brain studies have highlighted the global and subcortical processing of musical stimuli, and for Rick, music may have provided a familiar structure that was successful in stimulating a meaningful interpersonal response when traditional language capacities were unavailable or impaired (Boso et al., 2006; Ozdemir et al., 2006).

Rick responded appropriately to musical greetings before he was able to respond to spoken greetings. Literature describing early mother-infant interactions highlights the potency of music to facilitate interpersonal interaction in individuals who may be unable to process language (Trevarthen & Aiken, 2001). Rick's initial response to the sung greeting was echolalic however even a repeated phrase indicated some arousal in response to the therapists interactions compared to Rick's earlier non-responsiveness. Throughout the course of music therapy and combined music therapy/speech pathology this progressed to appropriate sung greetings and finally socially appropriate spoken greetings. In early mother-child interactions the infant responds to the prosodic and temporal aspects of the exchange, not the language component (Magee, 2005; Trehub, 2001). It was to these prosodic elements that Rick first responded. Arguably it was the music that was at the core of these early interpersonal exchanges with Rick. It might be argued that Rick's responses triggered neural substrates of spoken communication, but it was beyond the scope of this clinical scenario to verify such a claim.

The initial intention of the drumming improvisation was to utilise Rick's emerging object awareness as a vehicle for non-verbal expression and interaction. While Rick was able to express the pain of hurting his hand on the drum by cursing, he did not respond to the therapist's responses nor did he change his playing in any way in response to her musical variations. His apparent lack of awareness of the therapist indicated his cursing was expressive but not necessarily interactive. As Rick's social awareness increased, drumming improvisation did become interactive and provided an avenue for rehearsing turn-taking and following instructions, interactive skills which were transferred to spoken communication. Rick's use of spontaneous humour with the speech pathologist just before discharge from hospital represented a significant development in interpersonal interaction.

Participation in functional speech rehabilitation assumes the primitive capacity to participate in interpersonal interactions remains intact. Music provided a predictable and familiar structure that allowed Rick to experience himself in relation to another, and also provided non-verbal rehearsal and exploration of interpersonal interactions. Potentially, these aspects lead to Rick re-engaging in meaningful interpersonal interactions. Increased interpersonal skills allowed Rick to successfully engage in aspects of functional speech rehabilitation.

Conclusion

The ability to successfully socially interact is fundamental in not only functional rehabilitation but also a meaningful life (Gilbertson & Aldridge, 2008). Before he could successfully participate in rehabilitation addressing aspects of speech production, it was necessary for Rick to be able to interact, on some level, with the therapists. Rick's clinical presentation highlights the benefits of music therapy to promote the re-establishment of successful interpersonal skills in a patient, who as a result of an ABI, lacked the social capacity to engage with others. Music therapy further provided Rick appropriate opportunities to non-verbally rehearse basic interaction skills that transferred into his broader social interactions.

A single clinical case study provides a context and person-specific insight and while it is useful in illuminating potential, it does not test the hypotheses as to why the application of music was effective in reaching Rick when language alone was not. Potentially, music may have bypassed the damaged language centres of Rick's brain to be processed on a sub-cortical and emotional level (Baker & Tamplin, 2006; Boso et al., 2006; Tomaino, 2002). Nonetheless, it was the prosodic aspects of the musical interactions that initially allowed Rick to communicate on an interpersonal level. In a patient who was able to talk but unable to interact, music was successful in promoting meaningful connections with others.

Acknowledgment

The authors wish to acknowledge that this work was undertaken by Janeen Bower and reflexively constructed for this article with Helen Shoemark. Janeen Bower would like to thank Beth Dun, Senior Music Therapist, The Royal Children's Hospital Melbourne for her early review of the material and Jane Mah, Speech Pathologist, for her ongoing clinical collaboration and support of this clinical work.

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Janeen Bower BMus RMT NMT

The Royal Children's Hospital Melbourne

Helen Shoemark PhD RMT NICU-MT

The Royal Children's Hospital Melbourne

(1) Parental permission was given for this story to be reported and the patient's name has been changed to protect confidentiality

(2) The Glasgow Coma Scale is a standardised assessment to measure the degree of brain impairment. The assessment involves three determinants: eye opening, verbal responses and motor response all of which are evaluated independently according to a numerical value that indicates the level of consciousness and degree of dysfunction. A score of 13-15 indicates a mild brain injury. A score of 9 to 12 is considered to reflect a moderate brain injury and a score of 8 or less reflects a severe brain injury (Lehmkuhl, 2009).

(3) The Children's Neuroscience Centre at the Royal Children's Hospital Melbourne is a 32 bed inpatient ward that provides clinical services for babies, children and adolescents with disorders of the neurological and visual systems (Royal Children's Hospital Melbourne, 2008). The ward incorporates the Neurology and Neurosurgical departments and 8 of the 32 beds are allocated for inpatient rehabilitation.

(4) For further reading related to the ongoing nature of music therapy assessment in an acute medical setting refer to Shoemark (2008).

(5) Scat singing is a jazz term for the use of improvisation with nonsense words and syllables. Scat singing gives singers the ability to sing improvised melodies and rhythms, to create the equivalent of an instrumental solo using their voice (Westrup & Harrison, 1988).