procedure for song composition. Providing more structure for a concrete thinker with a shorter attention span can be accomplished by providing simple carrier phrases, such as “I feel sad when …” or “I’m proud of ….” The music therapist will provide a variety of rhythmic meters and melodic lines. In the final step, the patient will decide on the music to support their lyrics.
The patient at a higher cognitive level will be encouraged to compose 100% of the music lyrics, melody, and rhythmic components. In the first step, the patient will pinpoint a theme and formulate a poignant statement that will be used as the song’s chorus. Next, they will write lyrics to express the chosen theme. The final step is to compose the music. The patient may elect to compose a melody or rap. They may choose to play rhythm or melodic instruments and/or use vocalizations and/or body percussion. Finally, they may instruct the music therapist to play on an accompanying instrument.
Baker, Kennelly, and Tamplin (2005) suggest a nine-stage process to creating lyrics in the song writing process. They are as follows: 1) brainstorm ideas, 2) select topics, 3) expand topics, 4) identify themes and develop chorus, 5) further develop themes, 6) brainstorm ideas, 7) choose one theme, 8) outline and refine themes, and, finally, 9) compose lyrics.
Adaptations
. Lyric substitution of familiar songs is a possible adaptation. It is suggested that themusic therapist not sing the song in its original format when doing a lyric substitution. Due to cognitive deficits, the patient may not be able to formulate their own song lyrics after they have recently heard the original lyrics. The music therapist can provide carrier phrases from the original song to provide the TBI patient with a starting point to which to add their own lyrics. The melodic line will already be provided but the patient can direct the music therapist to change the music style and meter. The patient can also provide 100% of the song lyrics to a known song, which will be coupled with the original melodic line.
R
ESEARCHE
VIDENCEReceptive Music Therapy
Many studies have reported on the efficacy of music and songs to elicit responses from those individuals in a comatose state. Boyle (1995) reported on the use of improvisational music to arouse an individual
with a TBI from a vegetative comatose state. According to Tomaino (1998), when a song is presented, the rhythm first helps to focus the patient’s attention. After the patient’s attention is maintained, then the melody stimulates an emotional response. Knox and Jutai (1996) concurred with this premise, stating that music motivates the individual to maintain attention, therefore allowing the survivor of a TBI to comprehend what has been presented to them. Seibert, Fee, Basom, and Zimmerman (2000) reported on the use of music listening with a young adult who had sustained a brain injury. His experiences with past oboe performances were used to enhance sensory stimulation and awareness.
Two studies with patients in comatose states were completed by Riganello, Quintieri, Candelieri, Conforti, and Dolce (2008) and later by Riganello, Candelieri, Quintieri, and Dolce (2010). These two research studies examined the use of passive music listening with comatose patients. The researchers concluded that the heartbeat of the patients changed with the music. This suggests that emotional content is still processed even in patients with low alertness levels. Mitchell, Bradley, Welch, Button, and Peter (1990) studied the effects of a vigorous sensory stimulation program administered to comatose patients. The results indicated that the length of coma was shorter and the recovery more rapid when music stimulation was used. This study concluded that coma arousal procedures are effective and therefore should be used with patients who have sustained a severe TBI.
Receptive methods have also been reported to address emotional needs with those who have sustained a TBI. Barker and Brunk (1991) used known songs to facilitate a lyric fill-in to aid survivors of a TBI to express their positive rehabilitation successes. Goldberg, Hoss, and Chesna (1988) investigated the use of traditional psychotherapy with a 41-year-old brain-damaged patient. The patient engaged in Guided Imagery and Music (GIM) to aid her in working through recent life changes as a direct result of her injury. Results indicated that the role of music provided an appropriate container through its inherent form and structure. This in effect provided the patient with a safe environment to express her images and thoughts. Pickett (1996-1997) also used GIM to aid a survivor of a TBI to work through both physical and emotional losses. The conclusion was that psychotherapy is a viable approach to use with this clinical population.
Improvisational Music Therapy
The use of improvisational music therapy methods with the TBI population is very sparse. Gilbertson (2005) completed a review of the literature on music improvisation with individuals with TBI and advocated for music improvisation to be used to provide a venue for emotional expression. Formisano, Vinicola, Penta, Matteis, Brunelli, and Weckel (2001) investigated the use of music instruments and vocal improvisation to increase communication skills of those individuals emerging from a coma. It was found that while music improvisation did not significantly facilitate a “musical dialogue” (p. 627), it did decrease inertia and/or psychomotor agitation. Magee (1999) utilized music improvisation with a cognitively higher-functioning brain-injured client. The researcher stated that the client was able to communicate expressively when improvisatory approaches were used. Magee stressed the importance of music therapy being a flexible intervention with these individuals, as it may well be the only opportunity a brain-injured patient has to express him/herself emotionally.
Re-creative Music Therapy
The most widely used music therapy method to aid in the recovery of survivors of TBI is re-creative. Clayes et al. (1989) examined the role of music and music therapy in the rehabilitation of traumatic brain- injured patients. The researchers concluded that music could be effective in the reintroduction of patients to the environment. This is facilitated through call-and-response activities that can be related to daily
living skills, such as clothes selection, random movement, and verbalization. Gervin (1991) has reported the use of songs to provide the structure for the acute traumatic brain-injured client to successfully dress his or herself. The role of the music is paramount in helping the patient correctly recall the sequence of activities of daily living, thus rendering him/her more independent. Hurt, Rice, McIntosh, and Thaut (1998) found that the anticipation of the beat in music and song aided the individual with a TBI to produce a more fluid gait.
The singing of songs has also proven to be the catalyst for survivors of TBI to regain expressive communication and motor skills and enhance mood. Lucia (1987) reported the use of vocal warm-ups, vocalizing, rhythmic speech drills, and singing known songs to increase speech communication skills. A secondary goal was to enhance motor rehabilitation. After the warm-up was completed, songs were coupled with range-of-motion exercises to increase gross motor skills. A total of 14 successive exercises were developed in conjunction with an occupational therapist. Exercises of the shoulder, wrist, and neck were targeted. Cohen (1988, 1992, 1994), Cohen and Masse (1993), and Cohen and Ford (1995) have extensively researched the effects of speech and song to decrease the rate of speech and increase speech production and purposive speech with neurologically impaired persons. Therapeutic goals also focused on the physical tools needed for functional speech, specifically, articulation, vital capacity skills, and oral- motor exercises, to strengthen facial muscles necessary for speech production. This was accomplished through the playing of wind instruments and singing.
Baker and Wigram (2004) also used songs to increase vocal expression and intonation in patients. The researchers noted that singing decreased physical tension and improved posture, which in turn led to vocal freedom and mood enhancement. Baker and Wigram (2004) found singing to reduce muscle tension, thus enhancing vocal range in persons with TBI. Furthermore, the researchers found singing to elevate mood and increase vocalizations. Baker, Wigram, and Gold (2005) concluded that singing positively affected intonation and thus expressive communication in survivors of TBI. Tamplin (2008) used vocal exercises to increase the communication skills of dysarthric patients. Results showed that these techniques were successful in improving speech intelligibility and naturalness and decreased the amount and length of pauses in expressive language.
Compositional Music Therapy
Several researchers have reported on the use of music composition to provide an outlet for emotions for those recovering from a TBI. Thaut (1990) states that by utilizing different aspects of music, the patient is given an outlet for expression and validation of his/her personal thoughts and feelings. He advocates that the process of songwriting be used to facilitate an individual’s or group’s perception about their personal rehabilitation experience. Glassman (1991) reported on a case study of a woman who survived a TBI. The use of songwriting was successful in providing an outlet to use words to express feelings. Baker, Kennelly, and Tamplin published a series of studies highlighting songwriting themes (2005a) according to age group (2005b), gender differences within songwriting (2005c), and songwriting to provide a venue for identity and self-concept (2005d), written by survivors of TBI. Barker and Brunk (1991) used art and music group projects to treat patients recovering from a TBI. Music composition was one of the techniques employed, where the group created their own lyrics and rhythmic chant. This process was successful in facilitating each TBI survivor’s motor, cognitive, communication, and emotional skills.
S
UMMARY ANDC
ONCLUSIONSAdvances in medical treatment have increased the likelihood of people surviving a TBI. Severity scales have been developed to better assess the survivor’s alertness level and ability to think, communicate,
move, express emotions, and socialize effectively with others. The music therapy literature is heavy on re- creative and receptive methods. The re-creative method targets sequential memory skills needed to perform ADLs and speech and language skills needed for expressive communication. Receptive methods have been reportedly used to arouse the comatose patient to more consistently respond to their environment and for the higher-functioning patient, to provide a venue for emotional expression. There are a few studies that highlight composition, and even fewer that address improvisation methods. Both of these music therapy methods focus on emotional expression, socialization, and providing a sense of community with others who have sustained a TBI.
Although music therapy has proven to be a viable treatment with this clinical population, there needs to be more reported research with the use of composition and improvisation methods with survivors of TBI. The lack of research using composition and improvisation methods may be in part due to the level of individuals with TBI that music therapists traditionally see in treatment. Inpatient treatment usually is for a length of 30 days or less, and the patients are usually more severely impaired. When the patient advances to a more independent stage, such as a RLA level V or greater, they are usually discharged to outpatient rehabilitation for a short period or to their home. Often, music therapists do not have the opportunity to work with individuals who are able to return, even in a limited capacity, to their home and/or work environments.
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A
PPENDIXA
G
LASGOWC
OMAS
CALEEYES Open: Spontaneously 4 To Verbal Command 3 To Pain 2 No Response 1
BEST MOTOR RESPONSE To Verbal Commands: Obeys 6 To Painful Stimulus: Localizes Pain 5 Flexion-Withdrawal 4 Flexion-abnormal 3 Extension 2 No Response 1
BEST VERBAL RESPONSE Oriented and Converses 5 Disoriented and Converses 4 Inappropriate Words 3 Incomprehensible Sounds 2
No Response 1
GCS TOTAL 3–15
In public domain. Taken from: Teasdale, G. & Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet. Jul 13;2(7872) 81-4. PubMed PMID: 4136544.
Appendix B
R
ANCHOL
OSA
MIGOS–R
EVISEDThe Rancho Scale is free and available online at the Rancho Los Amigos National Rehabilitation Centers See: http://rancho.org. Taken from: Hagen, Malkmus, Durham & Stenderup (1974)