Being an Active Member in Co-Treating
By Renee De Luca, MusicWorx Intern
NMT and Me
Within the field of music therapy, there are many different approaches. I have found since starting this internship, I come from a vastly different background than my co-interns and they all bring in their own strengths in relation to the programs they completed. Due to the specific training I have had, one of my most prominent strengths is my knowledge of neurologic music therapy (NMT) techniques. This training helps me communicate and be an active member co-treating with other therapists, and other interns on my team expressed that they want more education in this area.
Neurologic music therapy (NMT) is a special training for Board Certified music therapists (MT-BC). The practice looks at how music is processed in the brain, and how we can use that to maximize rehabilitation. Other practices may have a similar outlook, but NMT has published, widely recognized research-based techniques. My undergrad was taught primarily by NMT professors, who had a strong knowledge and understanding of how to effectively use these techniques in almost every setting. Therefore, even though I personally am not NMT certified, I have an in depth understanding of the framework and science behind NMT techniques, which helps me become a more effective member of the care team when co-treating with a variety of other therapists. Keep in mind while reading this blog, that I am not NMT certified, but currently working at becoming an NMT.
What to do when co-treating?
(For the sake of this blog, I will refer to physical therapy for examples)
Walking into a cold call co-treating session, you never know what to expect. Often the session has lots of movement, talking, and items all over the room. The physical therapist will likely look at you with uncertainty, and a patient may request some motivating music. Playing in the corner of the room may be easy while they go about their own session. A patient may casually sing, ignore, or be completely distracted by your presence. These variables can at times be very stressful or pressuring to deal with, so how can we as music therapists be better prepared to co-treat a session? Additionally, how can we communicate with other professionals regarding why our presence may be beneficial?
With all the moving parts, it makes sense why you might just stand in the corner. However, we as music therapists can be so much more effective if we use our knowledge of the brain and music and be an active part of that session. But how do we just jump in? How do we communicate that our presence may be beneficial? Personally, I find an action plan is helpful. Here is a brief outline of how to start the process of becoming an influential presence in the hospital room.
1. Assess what the goals/objectives of the session are.
One way to assess what the primary goals are for the session is to ask the primary therapist. They can clarify the action that is being requested of the patient and what their action plan is. Whether you walk in before the session started or during the session, you can always ask for clarification. Additionally, you can listen to and watch what the primary therapist is telling the patient to do and what the patient is doing.
- Is the patient moving their arms in the sagittal plane or another?
- Are there bilateral movements?
- What coordination of motor skills is being asked?
- How might this be difficult for the patient?
Dissecting each movement down to its most basic element will allow you to adjust your tempo cues, spatial cues, and instrument engagement.
Once you finish figuring out the goals, you can move on to how you can help.
2. How do the instruments on hand need to be used to facilitate a successful and motivational experience?
Thinking about the target movement, a music therapist can construct the playing of a musical instrument in a way that turns non-musical behavior into musical behavior. For example, if a patient is working on grabbing items from above their head, the patient can hold a mallet and hit a drum overhead in time with musical accompaniment. The musical structure will provide framework for the brain to calculate time, exertion, and duration of movements and promote neuroplasticity, and the instrument use will motivate and create a more positive experience.
Packing tip: Going floor to floor sometimes doesn’t allow us to take all the instruments we desire, we do not have the enough instruments to distribute to all therapists, or someone may have taken the cart. As such, I recommend taking at least one percussive instrument with a mallet. One paddle drum can make a world of a difference in a patient’s experience and success rate
3. How can the music be used to facilitate/prompt this movement or action?
Musically, as therapists we like to play preferred music to build rapport. Not only can this be beneficial, but also can be distracting when patients are first learning what to do from the other therapist in the room. Understanding the types of cuing we can use as music therapists will be useful to helping our patients. There are three main types of cues: temporal, spatial, and force. Temporal cues are the time, duration, and pace. For example, patients synchronizing their movements with quarter notes during a song provide the motor planning and sequencing of when to contract and relax their muscles. Spatial cues are the range, space, and pitch. A spatial cue may look like a few notes to demonstrate small movements, or a rapid, intense, up-scale to facilitate standing up, and a slowly descending, relaxing scale when the patient sits down. The previous example also demonstrates force cues. Force cues are the changing of dynamics to represent the movement a patient makes.
Simple accompaniment that matches the actions of a patient is a good way to start and entrain the patient. Entraining is the process of determining or modifying the circadian rhythm. For example, when a patient is using extra muscle or going against gravity, play loud and with force as opposed to playing relaxing and quiet if they are going back to resting positions. Also notice how the movement or action can be broken down into a time signature, and that certain time signatures will facilitate the cues best for a patient more than others. For example, if the patient is walking with a walker, ¾ time signature would best entrain with the movement. With all the cues incorporated in a slower, steady, simple rhythm, the entrainment process will become successful, and the motor planning can take place. It is also very important to keep a steady beat and slowly modulate tempo to reduce fall risks when working with gait training.
4. Implement and Re-assess
Once the session begins, the therapist should note if there is any difficulty for the patient to process. The therapist may need to drop melody and harmonic sounds and leave rhythm only or simplify accompaniment. The therapist may need to adjust the song they are using, improvise basic modeling accompaniment, or just sing the action. You may need to adjust their tempo or rhythmic complexity or time signature.
Communicating with Professionals
Communicating to other professionals can be an overwhelming task. I often get the statement from others: “So, you just play music they like for them right?” or, “Why didn’t you play the music they like?” Using the basic knowledge of NMT techniques, I can politely defend my actions in the session and educate the other therapist I am co-treating with.
Here is a brief outline of some scenarios and verbiage that could give you ideas on how to communicate with professionals. If you outline your own, try to capture the reason for your clinical decision that is backed up evidence and terminology that they will understand and use day to day.
Speech and Language:
Scenario 1: Patient had a stroke and is unable to talk, but can sing when prompted. The music therapists (MT) sing simple phrases that match speech intonation and the patient sings the phrases back.
- Explanation: We used the patient’s ability to sing to stimulate and bring about voluntary speech by singing or chanting phrases that resemble natural speech intonation, and generalize by slowly removing the music.
Scenario 2: Patient that struggles to breathe and MT sing together in a session to their favorite tunes.
- Explanation: These singing activities will facilitate and encourage initiation, development, and articulation of speech/language while encouraging and strengthening the respiratory apparatus.
Scenario 3: The patient speaks too fast and slurs words together. MT asks the patient to pat their leg to a specified beat, and then talk or sing over this beat.
- Explanation: The body percussion provides rhythm to control the rate of speech and help with the motor planning of speech.
Scenario 4: The patient struggles to swallow or coordinate the muscles involved in speaking. MT teaches the patient a wind instrument.
- Explanation: Wind instruments are used to enhance articulation, respiratory strength, and functional This focuses on the muscle and the coordination of muscles to produce speech or swallowing.
Scenario 1: Physical therapist is working on standing up with patient. MT provides music accompaniment that matches the motions and strength needed to complete motions.
- Explanation: We use rhythm, melody, harmony, and dynamics to provide temporal, force, and spatial cues to enhance coordination and motivation.
Scenario 2: Patients have a limited range of motion. MT holds paddle drums and patient hits the drums on cue at a distance just out of their typical range.
- Explanation: This exercise emphasizes range of motion, endurance, and strength of the patient. The musical sound provides reinforcement and motivation to continue movement, and also provides a framework to process the movement.
Scenario 3: Patient is working on walking again. MT provides stable beat music with no words to the tempo of the patients walk.
- Explanation: This facilitates the rehabilitation of movements that are intrinsic, biological, and rhythmic by using the psychological effects of auditory rhythm for movement which produces functional and stable gait patterns and provides motor planning/processing.
Scenario 1: Patient had a stroke and ignores half of their body. MT places a variety of instruments around them that they play in order just outside their neglected visual field.
- Explanation: Active music making brings attention to the neglected or unattended visual The patient will engage in exercises where they will start in a field of their body they acknowledge and slowly shift over that line to the neglected portion and expand their field. Auditory cues give feedback showing they did not finish the scale or chord and compels them to keep searching.
Scenario 2: Patient struggles to make decisions. MT has the patient write a song.
- Explanation: Improvisation and composing practices executive function skills by giving the patient an opportunity to organize, problem solve, decide, and reason the choices being made.
Conclusion: The Do’s and the Don’ts
- Analyze actions
- Understand how to cue patients using the music and utilize instruments in traditional/non-traditional ways to provide auditory feedback
- Be an active member
- Get Creative! – Adapt instruments on the spot and use the room
- Enjoy the music making and the successes of the patient
- Keep a steady beat for action processing
- Just play receptive music in the background (unless it seems to help process)
- Keep music static
- Be afraid to try something new or use instruments in a non-traditional way
- Be bound by techniques
- Modulate tempos too fast or have unsteady beats – it becomes a fall risk or creates confusion for patients