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Music Therapy and TBI

Understanding the effects of rhythmic auditory stimulation on subjects' gait.

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Rhythmic auditory stimulation (RAS) is a neurologic music therapy (NMT) intervention that uses auditory rhythm as an external timekeeper to synchronize and, over time, entrain desired movement frequencies that are intrinsically rhythmic -- specifically gait.1 The intervention is based on an audio-spinal facilitation mechanism that influences rhythmic movements synchronized to sound.2,3

The body of research surrounding RAS has focused on patients with a diagnosis of stroke or Parkinson disease, with a growing database developing for patients diagnosed with traumatic brain injury. The purpose of this study was to examine the immediate and long-term training effects of RAS on gait parameters of an adult male with traumatic brain injury.

Study Participant 

The participant was a 26-year-old male, five years-post traumatic brain injury. Initial Glasgow Coma Scale indicated a score of 5-6 increasing to 9-11 prior to discharge from acute care approximately 2.5 months later.

The participant resided in a residential program requiring 24-hour care. He demonstrated severe motor planning deficits characterized by inability to initiate and carry out movements. The right ankle underwent gastric release and ankle fusion two years post injury.

His ambulation was characterized by halting gait requiring occasional tactile cues to initiate stepping with left lower extremity. Gait qualities also included a narrowed base of support with occasional crossovers, requiring moderate person assist of two persons. The participant showed asymmetrical stride and step length and slowed cadence with much variability noted within therapy sessions. He was unable to balance independently during standing or ambulation.

Procedures

Typical gait analysis methods such as the 6-minute test, Timed Up and Go, and the Dynamic Gait Index4 require that the subject be an independent ambulator, which the participant was not. The footprint analysis method described by O'Sullivan & Schmitz (2001) was used in this study because it allowed investigators to provide assistance for gait while measuring the variables of velocity, cadence, stride length and step length.

These variables are commonly measured in previous research involving gait.5 Not only was the tool an efficient method to measure these variables, but a practical application in the clinical setting.

A footprint analysis was used to measure the participant's gait characteristics during ambulation in both pre- and post-test trials. Ten yards by 48 inches of clear plastic runner was placed in a straight course on the carpeted surface on which the subject was to ambulate, followed by 9 feet of runner to provide for a turn at the end.

The subject's heels were marked with varying colors of paint for each trial to signal heel strikes. Three passes were completed within Trial 1. Each pass was timed to assess cadence and velocity. Trials were also videotaped to provide a subjective analysis of gait. 

    • Pass 1 -- Baseline ambulation, no treatment; 

    • Pass 2 -- Ambulation under the influence of RAS matched to subject's cadence = 50 spm; 

    • Pass 3 -- Ambulation under the influence of RAS with a 10% increase in tempo = 60 spm.

Immediate effects of RAS were measured, a 5-week training program was completed, and long-term effects were measured during post-test trials.

Training Program for RAS

The environment, auditory cues, and therapy techniques were kept similar across experimental trial sessions and training sessions. A standard Oscar Schmidt autoharp was used to provide auditory cues within RAS interventions.

The music therapist presented the auditory cues live, synchronized to a metronome, which was utilized by the therapist with headphones. For both trial and training sessions, auditory cues consisted of single strums of the autoharp to cue each step and was, as mentioned earlier, synchronized to a metronome.

The RAS training program was set up as two sessions per week, over the duration of 5 weeks. The subject already ambulated twice a week during physical therapy sessions; thus, RAS was simply added to physical therapy sessions.

During each training session, the subject ambulated 3-4 passes. The tempo of auditory cues was increased by 5 percent each week as follows: Week 1 (60 spm), week 2 (63 spm), week 3 (66 spm), week 4 (69 spm), week 5 (72 spm).

Results

Immediate entrainment effects of RAS included increased cadence (41 percent), velocity (72 percent), stride lengths (left 29 percent, right 22 percent) and step lengths (left 28 percent; right 13 percent).

After 5 weeks of training, long-term training effects included increases in cadence (77 percent), velocity, (149 percent) stride lengths (left 55 percent; right 45 percent), and step lengths (left 61 percent; right 28 percent). Width of walking base decreased (-69 percent).

Immediate Effects of RAS:
Without RAS   With RAS Percent Change 
 Cadence  41 spm  58 spm  +41
 Velocity  16 yds/min  28 yds/min  +72
 Left Stride Length  28"  35"  +29
 Right Stride Length  29"  35"  +22
 Left Step Length  16"  21"  +28
 Right Step Length  13"  14"  +13

Pre- and Post-treatment Data:
  Baseline  Post-treatment  Percent Change
Cadence   41 spm  73 spm  +77
 Velocity  16 yds/min  40 yds/min  +149
 Left Stride Length  28"  43"  +55
 Right Stride Length  29"  42"  +45
 Left Step Length  16"  26"  +61
 Right Step Length  13"  16"  +28
Width of Walking Base 5" 2" -69


Subjective Analysis

Pre-test trials showed moderate toe touch prior to heel strike in the right lower extremity during baseline ambulation. The participant's head was down, with a posterior center of gravity, and a step-through of 1-2 inches maximum. His gait pattern was asymmetrical with slow right lower extremity swing phase and quick left lower extremity swing phase. Right lower-extremity toe clearance was primarily through circumduction.

Post-test trials revealed dramatic improvement in the ability to decelerate at the end of the 10-yard course. The participant improved activation of the right lower extremity with increased hip and knee flexion during pre-swing and swing phase.

The participant showed increased knee extension and heel strike with rocking through to toe-off in right swing phase. Decreased anterior/posterior trunk rocking was noted during right swing phase. The subject's ability to employ stepping strategies to regain balance improved.

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Conclusions

Post-treatment data for cadence, velocity, stride, and step parameters indicate considerable improvement in participant ambulation as affected by RAS. Width of walking base decreased; however, the participant's level of assistance did not increase as cadence and velocity increased.

Investigators hypothesize the decreased width of base was potentially due to increased velocity and the effect of tonal influence of adductors as affected by RAS, as well as visual deficits. The results of this study correspond with previous findings in RAS research and may support the use of this intervention for pathologic ambulation in the TBI population.

Recommendations

It was indicated, post-study, that the participant's narrow base of support may have been due to visual deficits, including possible right side neglect. Further investigation is recommended to study the effects of RAS combined with visual cueing on width of walking base.

References

1. Thaut, M., Nickel, A., Kenyon, G., Meissner, N., & McIntosh, G. (2005). Rhythmic auditory stimulation (RAS) for gait training in hemiparetic stroke rehabilitation: An international multicenter study. Proceedings Society for Neuroscience, 756.6.

2. Pal'tsev, Y., & El'ner, A. (1967). Change in the functional state of the segmental apparatus of the spinal cord under the influence of sound stimuli and its role in involuntary movement. Biofizika, 12, 1064-1070.

3. Rossignol, S., & Jones, G. (1976). Audio-spinal influence in man studied by the h-reflex and its possible role on rhythmic movements synchronized to sound. Electroencephalography and Clinical Neurophysiology, 41, 83-92.

4. O'Sullivan, S., & Schmitz, T. (2001). Physical rehabilitation: Assessment and treatment. Philadelphia: F. A. Davis Company.

5. Oberg, T., Karsznia, A., & Oberg, K. (1993). Basic gait parameters: Reference data for normal subjects, 10-79 years of age. Journal of Rehabilitation Research, 30 (2), 210-223.

The authors acknowledge Cindy Barrus, director of Spectrum Health Post Acute NeuroRehab, for her assistance with this study; the study participant and family; Spectrum Health Continuing Care; and Western Michigan University.

Erin Wegener both completed her internship and is now employed with Spectrum Health Continuing Care. She received her bachelor's and master's degrees in music therapy from Western Michigan University. She has spent the first five years of her career working in a neurologic rehabilitation setting serving individuals with brain injury, stroke and dementia. Edward Roth is an associate professor of music therapy at Western Michigan University where he directs the Music Therapy Clinic and serves as director of the laboratory for Brain Research and Interdisciplinary Neurosciences (BRAIN). Jeralyn Hunter graduated from GVSU in 1991 and 1993 with a BSc in biology and a master's in physical therapy. Jeralyn's passion is neurologic rehabilitation, with recent years focusing on long-term rehabilitation of individuals with severe TBI.

 

Excellent article. Thank you for publishing such well documented research and writing in a manner that is accessible to people outside of our profession.

Angie Kopshy,  Music Therapist,  Music Therapy Services of PortlandDecember 06, 2012
Portland, OR




     

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