Can music help stroke recovery?

Can music therapy help to aid recovery from physical illness? Katie Haylor spoke with Alex Street, music therapist and researcher at the Cambridge Institute of Music Therapy Research at Anglia Ruskin University, who also works on the stroke ward at Addenbrooke's Hospital in Cambridge...

Alex - Let's say it's affected their left side, left side of their brain where the parts for speech are mainly represented. And so they can't speak anymore. But because of singing being something that is using both halves of the brain and more of the whole brain, sometimes somebody who can't speak can actually sing instead. If it's quite a mild stroke, those language areas aren't completely destroyed, it can be as simple as saying "sing what you want to say and beat your left hand to regulate your speech rate". I've encountered this sometimes where I can say "well if you could have anything to do eat now, what would you eat?". And I've assessed that they can understand language but they just can't speak. And they'll be able to tap and say "a cheese sandwich". And so then they can use that as a strategy to help them to communicate and sometimes then there's some spontaneous recovery and sometimes they need to do more of those kinds of exercises so that those parts of the brain actually become repaired or they use other pathways, other connections in the brain that then become more strongly connected with the speech areas.

Katie - It sounds like it's almost this kind of innate mechanism that we've got. I don't know if that's accurate. It feels like it should be.

Alex - Yes. Well we we can all perceive rhythm. We can tell when there's a regular beat, depending on how damaged certain areas are, we can tell when there's a change in rhythm. It's the structure of music and the way that the brain is activated by music. So music is processed globally by the whole brain. And that also means - and this has been found in various research - that we can draw out certain elements of music and use them to support rehabilitation. So for example walking is the most rhythmic movement that we do. If you have had a stroke and you can't walk very well, if you set a metronome or a very simple piece of music to the existing speed of walking, then you set the metronome or the music to that tempo, then as soon as they start walking to it their balance improves and the angles at which their legs are moving also have been found to improve. They can entrain to that beat or that music set to that tempo, and it can gradually be increased towards a normal walking pace.

Katie - So that's rhythm. What about melody though? Can melody be used to help people recover from physical damage?

Alex - Yeah. There's an intervention called the melodic intonation therapy and that's for people who have aphasia. And so again that's where the left side, where language is predominantly connected, and it affects word finding so that people might be speaking jargon and they might not know that, they might even not be able to monitor that they're doing that. It's not certain yet whether it's the melody or rhythm that supports speech recovery. But certainly for some people singing what they want to say they can do or you can sing a song to them that will be very overlearnt. So you mentioned something about music being an innate part of us. Well actually we do grow up and we're exposed to rhythm you know because that's the way our bodies work. We have pulse, we have breathing rate, heartbeat and also nursery rhymes and songs are a common parlence across cultures and it's often accompanied by rhythm, that rhythmic rocking. So sometimes you'll be singing to the infant and rocking them on your lap as well. You can use those songs with people who've had a stroke. Sometimes it might be something like row your boat or twinkle twinkle little star or something like that. And it's because it's so overlearnt that they might be able to sing "star" at the end of the line or they might be able to come in somewhere else.

And so that's the beginning of them starting to use to access language again. And so you'll do lots of those singing exercises and you can use the structure of music and the structure of song to help them start re-learning and the key to neuro rehabilitation is repetition. It's mass practice of the right thing. Any musician will know that they've achieved those skills in moving their fingers and whatever skills are needed to play the instrument that they're playing, through hours and hours and hours of practice.

Katie - As someone who learnt the cello for a number of years I can completely relate to that! A lot of practice!

Alex - Anybody who's working in neuro-rehabilitation is trying to do the same with that patient. They're trying to give them the government recommendation, 45 minutes a day, five days a week, for as long as improvement can be observed or measured. I worked with somebody who now is who's doing very well and had very little movement in the left arm. We ran a group every week that was co-facilitated by physiotherapy assistants. It's been running for over a year now. I saw him individually sometimes mainly in the group, and his range of movement, do how far he could reach, how he could grasp, the whole movement has increased dramatically and he didn't really have any other rehabilitation while he was there.

It's really devastating for people when they when they have something like a stroke you know - it's not from an accident or something, it just just happens you know so it's particularly cruel event really to experience.

Katie - If we talk about the theoretical person who's had a stroke. I'm guessing they're on all sorts of other interventions, physiotherapy, maybe they're on medication. Where does music therapy fit in?

Alex - Let's say somebody can't move their arm very well, so often with stroke one half of the body will be affected. So being asked to repeat the same arm movement again and again and again in physio and they do use other things like sports equipment and things like that. If they're doing it to a beat it actually becomes much easier because it's a temporal framework. They know when they've got to move their arm, when it's going to hit the target or the object that they could going to try and grasp and pick up and then when it returns back again.

So that's one thing. The other thing is that you can then do that as an interaction. So I might be playing something with a very strong pulse while they're performing that arm movement, and the arm movement results in them playing an instrument so they reach out and they hit a drum and I'm playing a chord sequence or something on the guitar while they're doing that. And so then they're not actually as conscious of how much they're repeating that movement, because they're playing music with me by performing that movement.

If you're playing a piece of music at 60 beats per minute and the person is hitting a drum on every beat in four four time and you do that for three minutes that's a hundred and eighty times that they've hit that drum. If they can move that quickly that point, often you have to do it on every first beat in that sort of tempo setting. So if you then do that for another 10 minutes, they're getting more of that massed practice that is going to change the parts of the brain that need to be changed. So they're recruiting new cells where the damaged cells were.

Katie - How widespread is music therapy in this clinical hospital setting?

Alex - Well not very much. And there are several reasons for that. So the predominant teaching of music therapy in the UK and Europe uses a model of music improvisation. It's more centred on the relationship with the music therapist rather than what needs changing in the brain. That is gradually changing, so there's this growing body of neuroscientific evidence that shows using brain imaging and EEG, how the brain responds to rhythm, melody, harmony, whole pieces of music.

It would be brilliant if at acute stage, every patient has an iPad next to their bed. It has the music based exercises, the neuropsych, the O.T., the speech therapy exercises, everything they need when they're discharged. All of that is transferred onto a tablet they have at home. The data is still collected so we know that they're doing the exercises and that they're responding to them. That's my dream project and that's what I'm working on with the other team at Addenbrooke's as well. There are some really good companies that we're partnering with in Cambridge that have secure data collection and data transfer systems set up.