based upon nine levels of disability, from no disability to extreme vegetative state (Rappaport et al., 1982). Subscales assess the survivor of a TBI in the five categories of arousal (score 0–3), cognition for ADLs (score 0–4), dependence on others (score 0–5), and psychosocial adaptability (score 0–3). See Appendix C.
Music Therapy
Individuals who have survived a TBI are often referred to music therapy to address their inability to consistently respond to their environment and loved ones. Often, music has played an important role in an individual’s life. Initially, reaching them through music during low awareness states is the paramount reason why the individual is referred to music therapy. As the individual becomes more alert, music therapy may aid in orientation, attention to task, and memory. When the individual with TBI becomes overwhelmed and agitated, music therapy relaxation techniques can calm and provide respite. The active
playing of music instruments can restore motor and coordination skills. The singing of songs and playing of wind instruments can facilitate communication. Self-expression may be facilitated through lyric analysis, song composition, or music improvisation. Group music therapy sessions can provide a venue to engage in socialization. Finally, survivors of TBI may be referred to music therapy to gain support from peers who have experienced similar tragedies.
Wilson (1990) states music therapists might assume a major responsibility in three modalities of medical practice. He suggests that physical, cognitive, and emotional areas of patients with neurological impairments be targeted during rehabilitation. Similarly, Thompson and Murray (1990) state that music therapy assessment requires several sessions and should encompass each of the following domain areas: cognitive, communication, motor, social, and visual. The music therapist, in working with the interdisciplinary team, can ensure maximum rehabilitation benefits for the patient and a more comprehensive treatment program by addressing domains suggested.
To assess the patient’s environmental alertness, the music therapist may play live, patient- preferred music. The music therapist may present the music both aurally and tactilely to one side of the patient to elicit consistent sound localization skills. The patient’s cognitive status is also assessed through the medium of music. For example, when evaluating the patient’s sequential memory, the therapist may play rhythm instruments in a sequence and ask the client to repeat what was presented. The patient’s physical functioning may be assessed through instrument play. For example, to assess the areas of fine and gross motor function, the music therapist may provide opportunities for the patient to manipulate and play various music instruments. The area of communication may be assessed through participation in song and call-and-response music interventions. The social/emotional domain may be assessed through the patient’s overall participation level in individual and group music therapy sessions. The patient’s level of functioning determines to what extent each modality will be assessed. For instance, if a patient is in a deep coma, only the area of environmental alertness will be actively addressed. Since each patient has their own individual strengths and weaknesses, no two patients can be assessed using the same techniques.
The most important part of music therapy assessment with the patient who has sustained a TBI is the determination of the patient’s music preferences. Often, the individual has severe cognitive deficits and is unable to provide this information. The music therapist may begin by interviewing family members and friends to obtain information about the patient’s personal music listening preferences. The music preferences of this clinical population have more to do with the patient’s age group than as a function of their diagnosis. Therefore, the music therapist can consult the music therapy literature for music preference studies with regard to the age group of each individual.
Daveson (2008) introduced the Meta-Model of Music Therapy in Neuro-Disability (MIND) as a five-step process in assessing the rehabilitation needs of individuals with neurodisabilities. The first step is providing the rationale for music therapy treatment with regard to motor, communication, cognitive, social/emotional, behavioral and occupational needs. The second step is determining restorative, compensatory, and/or psycho-social-emotional treatment approaches. In step three, the initial assessment is completed and treatment focus is identified. In step four, measurable goals and objectives are formulated. Finally, in step five, appropriate music therapy models are identified to aid the individual in attaining treatment goals.
O
VERVIEW OFM
ETHODS ANDP
ROCEDURESThe following methods and procedures are most commonly used with individuals who have sustained a TBI. These have not been sequenced to reflect relative significance, effectiveness, or complexity.
Receptive Music Therapy
• Music Listening for Sensory Stimulation: The therapist presents age-appropriate, patient- preferred music, either live or recorded, to enhance environmental stimulation.
• Music to Increase Attention Span: The therapist presents vocal and/or instrumental music, either live or recorded, to engage the patient musically.
• Songs for Receptive Language Skills: The therapist presents songs that tell a story, and the patient is asked to relay the story back in proper sequence.
• Emotional Expression Songs: Lyrics of a popular song are discussed and a meaning or central theme is pinpointed in relation to the patient’s current emotional state.
• Music Relaxation: The therapist designs a relaxation experience with music.
• Music for Gait Training: Patient-preferred music is used to retrain an individual to walk. • Music for Range of Motion: Songs are used to increase upper- and lower-extremity range
of motion and endurance.
Improvisational Music Therapy
• Music Instrument Improvisation: Music co-created in the moment by the therapist and patient for nonverbal means of expression.
• Story Improvisation: The patient chooses music instruments, vocalizations, and or/body percussion to depict a story based on feelings and emotions related to the rehabilitation process.
Re-creative Music Therapy
• Song Orientation: The use of songs to prompt and reinforce knowledge of temporal, spatial, and personal information.
• Activities of Daily Living Songs: The use of simple melodic lines to increase sequential memory.
• Song Communication: Using vocalization and singing techniques to improve verbal communication.
• Songs for Speech Production: The use of songs with simple or repetitive melodic lines to increase vocal articulation, volume, and prosody.
• Melodic Intonation Therapy: Words, short phrases, and sentences are coupled with melodic and rhythmic components.
• Musical Instrument Instruction: The therapist teaches the patient to play a selected instrument.
Compositional Music Therapy
• Songwriting: The therapist-assisted process of creating music and lyrics to communicate thoughts and feelings.