The interface of music therapy and speech pathology in the rehabilitation of children with acquired brain injury.

Kennelly, Jeanette ; Hamilton, Lennie ; Cross, Jill 等

Abstract

This article discusses the role and conjoint uses of music therapy and speech pathology to aid the treatment of acquired neurological speech and language difficulties in children attending a rehabilitation unit. Research, descriptive case studies, models for intervention and techniques used in conjoint music therapy and speech pathology are described to support the use of this approach for children with acquired speech and language difficulties. Two case studies presented to illustrate the benefits of conjoint music therapy/speech pathology. Interventions addressed the areas of facilitation of vocalisations, enhancement of vocal quality, improved breath support for speech, rhythm, coordination and timing of speech and the social uses of language. Implications for clinical practice and research using this specialised coordinated approach are also presented and discussed.

Introduction and Literature Review

When a child receives an acquired brain injury they may present with a variety of speech, language and communication needs which require careful individualised program planning. A number of authors have suggested that communication abilities may play the pivotal role in determining the quality of survival after head trauma (Najenson, Sazbon, Fiselzon, Becker & Schechter, 1978), particularly in the area of long term recovery (Bond Chapman, Nasits, Deering Challas & Paige Billinger, 1999). Communication disorders are also recognised as having a negative influence on long-term vocational outcome (Brooks, McKinlay, Symington, Beattie & Campsie, 1987) and social re-intergration (Oddy, 1984; Malkmus, 1989).

Supporting literature in the area of adult rehabilitation suggests that the conjoint use of music therapy and speech pathology has an important and effective role to play in the treatment of acquired speech, language and communication disorders. Whether these areas involve initial work with patients emerging from a coma (Claeys, Miller, Dalloul-Rampersad & Kollar, 1989; Kennelly & Edwards, 1997); receptive and expressive aphasia (Magee, 1999; O'Callaghan, 1999); oral dyspraxia and dysarthria (Magee, 1999); problem solving (Lee & Baker, 1997) or word retrieval and abstract thought (Robb, 1996), it is evident that such areas of need can be successfully addressed through this combined intervention.

There appear to be many similarities in the ways children develop communication and musical skills. Brigg's (1991) and Browne (1999) describe models of musical and speech/language development that show a number of parallels, particularly in terms of vocal skills. Through such comparison of these models of development, it is proposed that the conjoint disciplines of music therapy and speech pathology may prove effective in treating a variety of speech, language and communication needs.

Singing and speaking are natural pathways for human expression (Cohen, 1994) and share the common elements of vocal frequency and frequency range; rhythm or rate; intensity or volume; diction or articulation and lyrics or language. When singing an individual must be able to produce different vocal frequencies in order to follow a desired melody; match the rhythm and stay in time with the tempo and have adequate breath control to achieve desired volume and appropriate, natural phrasing.

These skills are also essential for optimal verbal communication. As songs generally contain greater frequency, rhythm and volume ranges than speech, music therapy may assist to retrain these skills for verbal communication. Songs generally contain repetition of melody, phrasing, rhythmic and volume patterns suitable for retraining of speech.

Song lyrics are also useful as they are generally familiar and repetitive and prove useful in supporting language activities and reinforcing articulation (Michel & Jones, 1991; Thaut, 1992). Rhythm and melody provide excellent structures to assist the child to organise, sequence and remember verbal information.

Observational and clinical case descriptions have been documented through the years describing the way in which music and verbal communication interact and impact on each other. As early as 1736 reports by Olof Dalin described a man who could not say a word but who could sing hymns and recite well-known prayers (Keith & Aronson, 1975).

In 1940 Loebell described a case study of a six and a half year-old boy who could not speak but expressed his desires and feeling by humming the beginnings of certain songs. He knew many songs and selected appropriate melodies for each communication in such a manner that pertinent text made obvious what he wanted.

In the 1970's there were numerous reports of stroke patients where singing was the catalyst for the return of verbal communication. Keith and Aronson (1975) described a patient who regained functional communication after singing therapy. Rogers and Fleming (1981) documented information about a 48 year old woman with severe oral apraxia whose speech first came with music therapy. Unfortunately neither the form of music therapy nor the methods of speech pathology intervention were well described.

Perhaps the most well known method, which integrated speech pathology and music, was Melodic Intonation Therapy (MIT) as first described by Sparks, Helm & Albert (1973) and today is also used by music therapists in rehabilitation settings (Baker, 2000). MIT was developed to assist the global aphasic who had little if any useful language. This therapy relied on the three elements--melodic line, rhythm and points of stress. Each intoned utterance was based on the melodic pattern, rhythm and stress points of verbal utterances and used a vocal range of 3 to 4 notes only, similar to the recitative occurring in opera. It used a sequence of steps, which gradually increased the length of the units and diminished the dependency on the clinician and the reliance on intonation.

It was hoped that by the end of the program the patient would be capable of using spoken prosody for uttering sentences taught in the program structure. It should be noted however that this program taught a limited range of functional phrases only, with no expected generalisation.

The use of music therapy to address paediatric speech delay (Seybold, 1971) and disorder (Hibben, 1991) supports the significant role that this discipline has to play in addressing acquired neurological speech and language disorders in children. Such literature suggests that children who receive music therapy exhibit a greater amount of spontaneous speech than matched controls (Seybold 1971; Hibben 1991) and that the use of music therapy facilitates interaction in a group setting, the ability to tolerate longer periods of closeness, acceptance of responsibility for behaviours and may help to effect emotional change (Hibben 1991).

The use of music therapy to address speech disorders in a variety of paediatric populations includes hearing impairment (Darrow & Starmer, 1986 and Leung 1985), articulation disorders (Ogden, 1982) and developmental verbal apraxia (Krauss and Galloway, 1982). However limited literature exists to inform the specialised area of paediatric acquired neurological speech and language disorders.

Literature exploring the use of music therapy in the treatment of these disorders is largely focused on the adult population. Cohen reports on the use of singing as therapy for adults with speech difficulties including dyspraxia and a variety of dysarthrias related to a wide range of neurological disorders including right sided craniotomy (1988); traumatic brain injury (1992); CVA (1992, 1993, 1995) and cerebral palsy (1993).

The singing interventions reported in Cohen's 1992 study included:

a) physical exercises to increase relaxation of head neck, shoulders and trunk to improve pre-articulatory movement patterns;

b) rhythmic speech and singing drills using pacing and rhythmic patterns to address disorders of rate;

c) breathing exercises to improve breath control, phrasing and volume;

d) vocal exercises focusing on pitch to improve intonation;

e) vocal exercises focusing on diction to improve articulation and lead to increased intelligibility.

Results from Cohen's studies were generally positive with reported changes in rate, pitch variability and intelligibility. Unfortunately nonhomogenous treatment groups with respect to the type of neurological disorder, type of speech disorder and age of patients were used in some studies raising questions regarding the influence of these variables on speech outcomes.

The Role of Music Therapy in Addressing Speech, Language & Communication Needs in Paediatric Rehabilitation

The following case examples have been derived from clinical work undertaken at a paediatric hospital in Australia. Within this setting music therapy services are provided to both inpatients and outpatients of a rehabilitation unit. This unit provides comprehensive and integrated rehabilitation for children and adolescents with a range of disabilities resulting from motor vehicle and other accidents, illness and disease. The multidisciplinary expertise includes a broad variety of medical, nursing, allied health and engineering staff.

In this unit music therapy has been used to meet a number of needs for children with an acquired brain injury, particularly in the areas of speech, language and communication. These sessions take the form of individual sessions or conjoint work with the speech and language pathologist. Individual/conjoint programs are conducted at bedside and/or within the rehabilitation department itself. Initial work may begin with the children when he or she is unconscious and unable to respond to any verbal commands. Therefore a variety of communication needs may be met through this conjoint therapy including responses to one stage commands through changes in breathing, eye opening and squeezing hands/fingers; articulation, fluency and rate; voice quality and intonation; word finding, social interaction, auditory/verbal memory and vocabulary development.

Case Studies

The following case studies illustrate the conjoint use of music therapy and speech patho logy. The first study, Tracey, explores treatment of a motor speech disorder while the second, Cathy, focuses on language rehabilitation. Written permission has been obtained from these patients and their families in order for this material to be presented.

Music to promote speech skills

Tracey was almost twelve years of age when she was involved as a pedestrian in a motor vehicle accident. Prior to this incident she lived at home with her two parents and two younger siblings. She had always been physically well and was academically ranked in the top 10% of her class. Following the accident where she received severe multiple injuries, Tracey was intubated and ventilated in the nearby regional hospital. Her initial Glasgow Coma scale upon. arrival was 3. Tracey was then transferred to the major city hospital due to the seriousness of her condition. A CT scan showed a diffuse axonal injury, multiple small cerebral contusions, intraventricular blood, multiple fractures and a ruptured spleen. Throughout her hospitalisation, Tracey remained in a prolonged period of coma followed by post traumatic amnesia. Tracey was mute for a total of four months. She had severe spastic quadriplegia and severe dysphagia. Medical complications including raised intracranial pressure and uncontrolled hypertension. During her period of unconsciousness Tracey received separate music therapy and speech pathology intervention. Music therapy was aimed at promoting orientation and providing sensory stimulation where appropriate. A variety of responses were observed during these sessions including changes in rate of breathing, eye opening, spontaneous limb movement and changes in facial expressions.

Gradually as Tracey began to make purposeful utterances, the speech pathologist made a referral for joint music therapy/speech pathology services. At this stage, Tracey's communication difficulties included dysarthna (poor pitch and volume control; poor prosody and slowed rate) and language difficulties (high level language difficulties and impaired social skills). Cognitive difficulties included memory impairment, psychomotor slowing, impaired problem solving, rigid thinking and impaired social judgement. Tracey was not motivated to participate in individual speech pathology sessions when focusing on her dysarthria

Music therapy assessment revealed that Tracey enjoyed listening to and playing music. She had previously learned piano and clarinet at school and enjoyed listening to a variety of age-appropriate popular music, particularly the Spice Girls. Goals outlined by both the speech pathologist and music therapist concerned Tracey's dysarthria and were aimed at improving her speech intelligibility. Specifically, the goals were to improve breath control, pitch, volume and co-ordination of breath and voice.

The overall structure of these sessions included warmup exercises (breathing exercises on sustained vowel sounds ie singing sustained sounds such as "ah, ee and ooh"; melodic variation exercises using major and minor scales) and the singing of known and preferred song material. The structure of this program followed a similar outline to that used in Cohen's 1992 study. These exercises were performed both with acoustic guitar accompaniment by the music therapist for harmonic support and without accompaniment to encourage Tracey to concentrate on the use of solfege hand signs used in scalic passages. Solfege is a system of syllables used for pitch recognition. Such hand signs were used to support and improve Tracey's intonation skills. Descriptive clinical notes kept by both therapists and anecdotal evidence given by Tracey's carers who were often present during these sessions indicated that this joint form of therapy assisted in improving Tracey's intelligibility. Both Tracey's participation in sessions and her speech intelligibility were noted to improve with the use of joint music therapy and speech pathology. Increased motivation and enjoyment, particularly with the repetitious vocal I breathing exercises were noted. Increased rate of speech and pitch range and improved intonation were evident, particularly during Spice Girls songs such as "Wannabe" and "Stop Right Now".

During this time Tracey also continued to receive individual speech pathology and music therapy sessions. The speech pathology intervention focused on language skills while music therapy intervention provided emotional support for Tracey and assisted her adjustment to hospital. Tracey engaged in song writing to assist self expression and these songs were also incorporated into joint speech/music therapy program to promote the previously mentioned goals.

Music to promote language skills

At the time of her accident Cathy was almost three years of age. She lived at home with her two parents and three older siblings. Prior to her accident she had been physically well and developmental milestones were within normal limits. Her mother reported that Cathy always loved music, especially dancing around the home whenever she listened to it.

Cathy was involved in a motor vehicle accident where she was backed over by a car. With an initial GCS of 5, she was intubated and ventilated and transferred to the nearby hospital. Once medically stable she was transferred to a major city hospital due to her critical condition and impending rehabilitation requirements.

A CT scan revealed multiple cranial and facial fractures, displacement of her right eye, damage to both optic nerves, extensive cerebral contusions and haemorrhages and multiple infarcts.

Initially Cathy received music therapy in joint sessions with the physiotherapist, occupational therapist and speech pathologist in order to met a variety of rehabilitative needs. However it was soon discovered and recommended that a joint music therapy/speech pathology program was required to concentrate solely on her language rehabilitation.

Cathy had a vision impairment, severe aphasia and right hemiplegia. Her communication difficulties included delayed and disordered language development, severe word finding problems, difficulty responding appropriately to questions and difficulty following directions.

A music therapy assessment revealed that Cathy appeared to enjoy music, smiling and laughing when she heard familiar preferred songs. She tried to engage and interact with the therapists through song singing and instrumental play. Following a joint therapy assessment, the following goals were focused upon: to improve the ability to follow simple directions, to demonstrate a consistent yes/no response, to increase and encourage the exploration of vocal sounds and to encourage the facilitation of single word responses.

Cathy's mother was usually present and involved in these joint therapy sessions. Initially this program began with using the technique of eliciting one-word utterances. Favourite and known songs such as "Old Macdonald Had a Farm" and "If You're Happy and You Know It" were used to evoke one-word utterances. Accompanied (using guitar and/or percussion instruments) and unaccompanied songs acted as the stimuli to encourage any utterance Cathy was able to make on cue. The elements of tempo, volume, timbre and rhythm were explored and varied in order to first match Cathy's responses and then further extended and explored to encourage a variety of vocalisations. This then in turn lead to cloze activities where Cathy was encouraged and prompted to retrieve words. For example, in "Old Macdonald", Cathy would initially complete the phrase "and on that farm he had a--" with the same animal name each time. Gradually, through repetition of this song and other animal songs and nursery rhymes, she was able to retrieve other animal names.

By the end of this joint therapy program, Cathy was able to indicate verbally her choice and selection of preferred song material, follow directions particularly in the areas of instrumental play and sing entire sets of lyrics to her favourite songs. She was also able to aurally recognise selected song material through the harmonic, melodic and rhythmic elements presented to her with little or no verbal cues (spoken or sung). Anecdotal evidence given by the therapists and Cathy's mother reported that these skills were then transferred to Cathy's everyday communication where she began to interact verbally in a spontaneous and purposeful manner with family and friends.

Discussion

As illustrated in the preceding case examples, the songs and vocal exercises used with these children present as enjoyable. Each child was motivated, focused and less likely to become bored with the speech exercises. Music is stimulating, fun and an evocative medium to work with and children of all ages seem particularly responsive to this medium (Kennelly, 2000). However it is important to stress that these may not be the only reasons why this treatment application appears so successful. As one acknowledges the similarities between the structural elements of speech and music, it is also necessary to further investigate and link such knowledge with an understanding of the hemispheric processing of musical skills and behaviours.

Recent scientific studies have questioned widely the view that music is processed in the right hemisphere of the brain as previously believed. Areas of focus have included hemispheric dominance rather than hemispheric specialisation and the possible location of a music centre in the brain rather than an entire hemisphere being responsible for musical skills and behaviours. Numerous investigators have concluded that there is no one area of the brain responsible for musical processing (Bever, 1988; Taylor, 1997, 1988, 1989)

There are also underlying neurological, physiological, behavioural and other relevant frameworks and theories which while not conclusive, appear to support and validate the use of music in activating, arousing and triggering a multitude of idiosyncratic responses from each patient. O'Callaghan (1999) reported on the neurological, neuropsychological and radiological studies which provide the evidence that separate neural pathways and cerebral areas are used for the execution of musical and language skills. Although it is beyond the scope of this article to outline and explore these frameworks it is nevertheless important for speech and language pathologists, music therapists and other health care professionals to further consider and research.

Clinical Implications

While there is limited research evidence to support this specialised area of clinical work in paediatric rehabilitation, the following factors for consideration have arisen from the conjoint work carried out in this rehabilitation unit. These factors may present pertinent questions for future research and encourage clinicians to further explore and investigate the possibilities of joint work between music therapists and speech and language pathologists.

Such questions include:

a) how relevant is the use of age appropriate / known and preferred music for each patient?

b) what are potential considerations for use of musical elements such as rhythm, tempo and melody to achieve best outcomes?

c) how to determine if the music may be overstimulating or impeding responses, particularly when children spontaneously use body movements as they sing?

d) when and how to consider the possibility of contraindications depending on the specific area of brain injury, the patient's perception of the music which is played and /or sung, and idiosyncratic responses to this music?

e) how to determine if the appropriateness of the accompaniment may be used to evoke appropriate responses (ie using melodic, rhythmic, harmonic or no accompaniment)

Conclusion

As reported by Magee (1999), terms such as 'cost effectiveness' and 'outcome measures' are fast becoming part of common work practice in health care. Clinicians are constantly being asked to explore a variety of evidence-based research, best practice and models of service delivery, which can support and justify the work being done. This article suggests possible areas for future research and describes some examples of the conjoint use of music therapy and speech pathology in the rehabilitation of children with acquired brain injury.

Based upon the literature in adult rehabilitation and developmental delay in children, music therapy has both an individual and conjoint role to play in expanding the communication potential of children with acquired neurological communication disorders. Additional clinical case study documentation and a variety of research paradigms are needed to expand this literature base and further investigate how the conjoint use of music therapy and speech pathology can be used to enhance the quality of life for children who are communicatively impaired.

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Jeanette Kennelly, BMusEd, PGDipMThy

Royal Children's Hospital Foundation / Senior Music Therapist

Lennie Hamilton, BSpThy

Acting Senior Speech Pathologist, Statewide Paediatric Rehabilitation Service

Jill Cross, MA (Speech Pathology); DipSpThy

Speech Pathologist, Statewide Paediatric Rehabilitation Service, Royal Children's Hospital & Health Service District, Brisbane