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"Music Therapy in the field of Neurological Rehabilitation“

Vienna, 16.o9.2015

FH-Prof. Priv.-Doz. Mag. Dr. Gerhard Tucek Head of Research / Vice-Director Health Department

Program Director Music Therapie

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“... Music therapy is the professional use of music and its

elements as an intervention in medical, educational, and

everyday environments with individuals, groups, families, or

communities who seek to optimize their quality of life and

improve their physical, social, communicative, emotional,

intellectual, and spiritual health and wellbeing. Research,

practice, education, and clinical training in music therapy are

based on professional standards according to cultural, social,

and political contexts” (WFMT, 2011)

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Definition

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federal law in Austria

(Musiktherapiegesetz – MuthG)

Jahrgang 2008

Ausgegeben am 2. Juli 2008 Teil I

93. Bundesgesetz: Musiktherapiegesetz –

MuthG

(NR: GP XXIII RV 552 AB 596 S. 61. BR: AB 7960

S. 757.)

[CELEX-Nr.: 32003L0109, 32004L0038,

32005L0036]

93. Bundesgesetz über die berufsmäßige

Ausübung der Musiktherapie

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Music Therapy is based on therapeutical relationship which is structured by musical means

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federal law

(Musiktherapiegesetz – MuthG)

Jahrgang 2008

Ausgegeben am 2. Juli 2008 Teil I

93. Bundesgesetz: Musiktherapiegesetz –

MuthG

(NR: GP XXIII RV 552 AB 596 S. 61. BR: AB 7960

S. 757.)

[CELEX-Nr.: 32003L0109, 32004L0038,

32005L0036]

93. Bundesgesetz über die berufsmäßige

Ausübung der Musiktherapie

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Regulates:

Academic Training

Pledge of documentation & secrecy

350 h. clinical training (BSc, MSc)

300 h. supervision(BSc, MSc)

60 h. legal affairs (BSc, MSc)

60 h. ethics (BSc, MSc)

Two approaches:

• Orientation on process and relationship : introspection

• Behavioristic orientation: change of behaviour

Training oriented (not MT-specifc)

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• Gold, C., Solli, H. P., Krüger, V., & Lie, S. A. (2009). Dose-response

relationship in music therapy for people with serious mental disorders:

Systematic review and meta-analysis. Clinical Psychology Review, 29(3), 193-

207.

• Bradt J, Magge WL, Dileo C, Wheeler BL, McGilloway E (2010). Music therapy for

acquired brain injury Cochrane Database of Systematic Reviews 2010 Jul

7;(7):CD006787. doi: 10.1002/14651858.CD006787.pub2.

• Bradt J, Dileo C, Music interventions for mechanically ventilated patients.

Cochrane Database of Systematic Reviews (in press) Issue 12. Art. No.:

CD006902. DOI: 10.1002/14651858.CD006902.pub2

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Reviews & Data Base

„Melodic Intonation Therapy“ (Schlaug et al. 2009, Norton et

al. 2009, Zumbansen et al. 2014),

„Neurologic Music Therapy“ (Thaut 2009, 2015)

„Music Supported Therapy“ (Altenmüller et al. 2009,

Altenmüller & Schlaug 2015)

… clear research profile but ignore therapeutic

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Training oriented therapy with music:

Altenmüller E, Marco-Pallares J, Münte TF, Schneider S. (2009) Neural reorganization underlies

improvement in stroke-induced motor dysfunction by music-supported therapy. Ann N Y Acad

Sci. 2009 Jul;1169:395-405. doi: 10.1111/j.1749-6632.2009.04580.x.

Altenmüller E, Schlaug G. (2015) Apollo's gift: new aspects of neurologic music therapy. Prog Brain

Res. 2015;217:237-52. doi: 10.1016/bs.pbr.2014.11.029

Amengual JL, Rojo N, Veciana de Las Heras M, Marco-Pallarés J, Grau-Sánchez J, Schneider S,

Vaquero L, Juncadella M, Montero J, Mohammadi B, Rubio F, Rueda N, Duarte E, Grau C, Altenmüller

E, Münte TF, Rodríguez-Fornells A. (2013) Sensorimotor plasticity after music-supported therapy in

chronic stroke patients revealed by transcranial magnetic stimulation. PLoS One. 2013 Apr

17;8(4):e61883. doi: 10.1371/journal.pone.0061883.

François C, Grau-Sánchez J, Duarte E, Rodriguez-Fornells A. (2015) Musical training as an

alternative and effective method for neuro-education and neuro-rehabilitation. Front Psychol.

2015 Apr 28;6:475. doi: 10.3389/fpsyg.2015.00475. eCollection 2015. Review.

Grau-Sánchez J, Amengual JL, Rojo N, Veciana de Las Heras M, Montero J, Rubio F, Altenmüller E,

Münte TF, Rodríguez-Fornells A. (2013) Plasticity in the sensorimotor cortex induced by

Music-supported therapy in stroke patients: a TMS study. Front Hum Neurosci. 2013 Sep

3;7:494. doi: 10.3389/fnhum.2013.00494.

Norton A, Zipse L, Marchina S, Schlaug G. (2009) Melodic intonation therapy: shared insights on

how it is done and why it might help. Ann N Y Acad Sci. 2009 Jul;1169:431-6. doi:

10.1111/j.1749-6632.2009.04859.x.

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Raglio, A.; Oasi, O.; Gianotti, M.; Rossi, A.; Goulene, K.; Stramba-Badiale, M. (2015) Improvement of spontaneous language in stroke patients with chronic aphasia treated with music therapy: a randomized controlled trial. Int J Neurosci.

Rodriguez-Fornells A, Rojo N, Amengual JL, Ripollés P, Altenmüller E, Münte TF. (2012) The involvement of audio-motor coupling in the music-supported therapy applied to stroke patients. Ann N Y Acad Sci. 2012 Apr;1252:282-93. doi: 10.1111/j.1749-6632.2011.06425.x.

Rojo N, Amengual J, Juncadella M, Rubio F, Camara E, Marco-Pallares J, Schneider S, Veciana M, Montero J, Mohammadi B, Altenmüller E, Grau C, Münte TF, Rodriguez-Fornells A. (2011) Music-supported therapy induces plasticity in the sensorimotor cortex in chronic stroke: a single-case study using multimodal imaging (fMRI-TMS). Brain Inj. 2011;25(7-8):787-93. doi: 10.3109/02699052.2011.576305. Epub 2011 May 11.

Schlaug G, Marchina S, Norton A (2009). Evidence for plasticity in white-matter tracts of patients with chronic Broca's aphasia undergoing intense intonation-based speech therapy. Ann N Y Acad Sci. 2009 Jul;1169:385-94. doi: 10.1111/j.1749-6632.2009.04587.x..

Thaut MH, Gardiner JC, Holmberg D, Horwitz J, Kent L, Andrews G, Donelan B, McIntosh GR. (2009) Neurologic music therapy improves executive function and emotional adjustment in traumatic brain injury rehabilitation. Ann N Y Acad Sci. 2009 Jul;1169:406-16. doi: 10.1111/j.1749-6632.2009.04585.x.

Thaut MH. (2015) The discovery of human auditory-motor entrainment and its role in the development of neurologic music therapy. Prog Brain Res. 2015;217:253-66. doi: 10.1016/bs.pbr.2014.11.030. Epub 2015 Feb 2.

Zumbansen A, Peretz I, Hébert S. (2014) The Combination of Rhythm and Pitch Can Account for the Beneficial Effect of Melodic Intonation Therapy on Connected Speech Improvements in Broca's Aphasia. Front Hum Neurosci. 2014 Aug 11;8:592. doi: 10.3389/fnhum.2014.00592. eCollection 2014.

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Communication is essential for

humans. Our brain is „calibrated“

to successful social interaction

today social interchange is the

most important trigger of biological

(vegetative) reactions

Bauer, Joachim: Warum ich fühle, was du fühlst. Intuitive Kommunikation und das Geheimnis der Spiegelneurone. 16. Auflage, Heyne 2006.

Importance of therapeutic Relationship

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Refusing a „mirroring attitude“ in a

shared social space causes

psychological AND biological effects

Pain-area (physiological) is activated during social isolation

Professional therapeutic relation: boundary / connection

Insel, Thomas: Is social attachment an addictive disorder? Physiology and Behavior 79. 351-357, 2003

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MTs work with clients within a therapeutic relationship

• Therapeia: to accompany and serve clients

• “... use of music and its elements in a therapeutic relationship” WFMT 1996

• Relation evolves over time; within sessions

• Meeting in ‘Now-moments’ (Stern 2004, 2010)

• Meaningful music as part of a relation

• Musical elements are depending on their meaning in particular sessions

• The musical structures are a mutual product of performing

• Moments and situated cognition of change (Fachner 2014)

• Change processes are based on „kairological“ principles (Fachner)

• MTs identify elements that are “best suited to stimulate...”

• Psychophysiologic „Right Moments“ for Therapy (Tucek et al (2015 in

preparation)

(Fachner)

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Duncan, Miller, Wampold, Hubble (2011): The heart and soul of change. American

Psychological Association

• How do we appear

to our patients?

• How does this

influence the

outcome?

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Storch, M. & Tschacher, W. (2014). Embodied Communication: Kommunikation beginnt im Körper, nicht im Kopf. Verlag Hans Huber.

Channel Theory:

Communication as a delivered & decoded message between a sender and a receiver

Common understanding of communication

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Storch, M. & Tschacher, W. (2014). Embodied Communication: Kommunikation beginnt im Körper, nicht im Kopf. Verlag Hans Huber.

Embodied Communication:

„Synchronisation“: communicating people negotiate and create a mutual understanding.

„Sense of Coherence“: feeling of being understood as a consequence of synchronisation on a physical, non-verbal and mental level.

New modell of communication

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• “Although the therapeutic use of music is found in many helping professions, the mechanisms behind its healing effect remains unclear.” (Lin et al., 2011, p. 34)

• “Finally, with regard to music therapy, future work needs to determine which types of music (taking into account individual experiences and preferences) are best suited to stimulate specific limbic and paralimbic brain structures (e.g. the hippocampus in depressive patients or dopaminergic system activity in patients with Parkinson’s disease).” (Koelsch, 2010, p. 137)

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Mechanisms and remedies

• Ideally we would be able to measure ongoing activity on therapist and client

• Not possible in daily practice

• Social neuroscience • Dyadic measurements of ‘Interactive brains’

Two EEGs registered at same time; phase synchronisation measures (Lindenberger / Muller et al 2009 – 13)

Simultaneous EEG recording of 4 players; measuring ERD/S of Alpha sources (LORETA) (Babiloni et al 2011)

• To identify synchronization processes of mutual processing of content

Pfeiffer, U., Timmermans, B., Vogeley, K., Frith, C., & Schilbach, L. (2013). Towards a neuroscience of social interaction. Frontiers of Neuroscience.

Fachner, J. (in press). Measuring music and musical responses. In B. Wheeler (Ed.), Music therapy research: Barcelona Publishers

Fachner, J. (2014). Communicating change – meaningful moments, situated cognition and music therapy: A reply to North (2014). Psychology of Music.

Fachner, J., & Stegemann, T. (2013). Electroencephalography (EEG) and music therapy: On the same wavelength? Music & Medicine, 5(4), 217-222

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Music therapy with individuals

with Unresponsive Wakefulness Syndrom

Which influence has brain activity on behavioral changes?

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A neuro-anthropological perspective on music therapy research and

practice in neurological rehabilitation

Julia Vogl

University of Vienna (Department of Social & Cultural Anthropology),

IMC Krems – University of Applied Science (Department of Music Therapy)

What do we understand by the neuro-anthropological approach in a research setting?

• humanistic science – same approach as in therapy;

To look at the patient as a human SUBJECT not as an object of the study;

To do research WITH the patient not on the patient:

react on the needs of the patient;

adapt study designs;

see research as a real reciprocal process.

The anthropological approach – “Kremser Modell”

• relational medicine – relational research;

• holistic approach - trying to bridge brain and environment;

• drawing on insights of anthropology and psychology regarding individual-environment interaction.

Music is created by the embodied brain, influenced by culture and shaped and inspired

by our relationship to and our perception of the environment.

Why is it important to look at the patient’s “culture”?

• To humanly engage with the differentness of a patient, particularly with DOC, and get a deeper understanding of the patient's needs;

• To empathize with the lived human experience of the patient’s situation and to approach the patient as an individual human being.

What is it that music does?

• Music creates a special kind of frame for the therapeutic intervention;

• To find new ways of connecting with the patient and to establish a communication beyond words;

• To transform the foreign, clinical environment (Umwelt, “around-world”) of patients to their contemporaries (Mitwelt, “with-world”).

Why is it important to do interdisciplinary research and to combine research methods?

• When doing research within a therapeutic setting with

human interaction many important aspects happen on a subjective level which cannot be sufficiently illustrated in objective terms;

• Look at the patient’s situation. When and how does a patient actually benefit from music therapy and what exactly does he benefit from?

Is there a place for a subjective level in RCTs?

To do high quality research and remain being a good therapist.

To get objective data for evidence of efficacy in music therapy and at the same time not to forget about the essential qualities of music therapy:

relational aspects of therapy;

being aware of the patients’ needs at the very moment;

being sensitive for this within the whole research process;

see the patient as an individual human being.

How can we bring the research results back to the practical clinical therapeutic setting?

Do research not only for justification but show the essence of Music Therapy.

Objective data is an indicator for an increased activity in brain areas and the subjective meaning dimension is an indicator for the importance of the interpersonal relation.

Important knowledge is not only generated via an objective machine but via human interaction through the whole research process and in the therapeutic setting at the bedside.

Look at the entire research project with

every experience, sensation, meaning and

perception as an important source of

knowledge.

Bring together the different inner and

outer worlds of every individual involved:

How do they share their experiences,

expressions and the underlying research

script?

Realize the importance not only of the

objective data but also of the lived

experience, relationship aspects and all

the social interactions.

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A PILOT STUDY INTO THE EFFECTS OF MUSIC THERAPY

ON DIFFERENT AREAS OF THE BRAIN OF INDIVIDUALS WITH UNRESPONSIVE

WAKEFULNESS SYNDROME

Astrid Maria Heine, MSC.

Music therapy with individuals with unresponsive wakefulness sydrom (UWS)

• Practical work for over 20 years

• Research on music processing (Verger et al., 2014;…)

• Research on music therapy (O‘Kelly et al., 2013; Magee et al., 2014;…)

Bridging the gap between research and practice

Neuroanthropological perspective

Music therapy practice

Neuroscientific research

Individual

Flexible

Not standardizable

Neuroscientific methods

Quantitative analyses

Neurological knowledge

On which levels can we expect effects of music therapy on individuals with UWS?

atient Unresponsive Wakefulness Syndrome

BEHAVIOR PHYSIOLOGY NEUROLOGY

Observable

tension, breath,

posture, eyes,…

Heart rate,

Vegetative NS,

Respiratory rate

Lesions and

activity in the brain

Neuroanthropological perspective

Methods to explore the effects of music therapy

on individuals with UWS

atient Unresponsive Wakefulness Syndrome

BEHAVIOR PHYSIOLOGY NEUROLOGY

Video Analysis

(Feldpartitur)

Heart Rate

Variability

(HRV)

Positron Emission

Tomography

(PET)

Neuroanthropological perspective

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Neuroscientific and neuroanthropological perspective in music therapy research

Interdisciplinary pilot study:

Neurology – OA Dr. Steinhoff

Univ.-Prof. Dr. Schnider

Nuclear medicine – OA Dr. Weiss

Univ.-Prof. Dr. Hajek

Music therapy – Prof.(FH) Priv.Doz. Mag. Dr. Gerhard Tucek

Beatrix Gmeiner, MSc.

Astrid Heine, MSc.

Cultural and social anthropology – Mag. Julia Vogl

Prof.(FH) Priv.Doz. Mag. Dr. Gerhard Tucek

Course of the study

Randomised, controlled pilot study

Music therapy group (n=4) Control group (n=3)

PET 1 (rest) PET 1 (rest)

Baseline 24h-HRV Baseline 24h-HRV

PET 2 PET 2

5 weeks music therapy 5 weeks standard care

PET 3 PET 3

24h-HRV 24h-HRV

Music therapy

• 3 times a week for 5 weeks

• Individual, live music therapy

• Information of personal background

Patient 1:

The harp has been one of their favorite instruments ever since they had had a wonderful vacation in Ireland.

The patient used to play songs of the 1950s in a band in his youth.

Music therapy

• Tailoring the therapy as well as the research setting to the present conditions and needs of the patient.

• Adapting the therapy to the posture of the patient or changing the intensity of the light.

• Interpretation of the patient’s needs, conditions and sensitivity are based on signs like facial expression, tonicity or breath.

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Heart Rate Variability Mixed-methods-design

Collection and analysis of

• quantitative data (HRV)

• qualitative data (video recordings, therapy logs)

based on Grounded Theory

? Which changes in HRV can be found during the MT session

and during five weeks?

? And which changes can be observed because of events

noticed in video recordings?

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HRV

analysing tool

LEBENSFEUER ®

from

Autonom Health ®

5 min.

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Moving from wheelchair to bed

Coughing P1

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Video analysis on behavioral changes:

>Wakefulness

>Tonus (Tension)

>Facial expression

>Attention

>Breathing

>Eye contact

>Communication

Watzlawick, P.; Beavin, J.H.; Jackson, D.D. (2000). Menschliche Kommunikation: Formen, Störungen, Paradoxien. Bern: Huber.

Stern, D.N. (2010). Der Gegenwartsmoment.: Veränderungsprozesse in Psychoanalyse, Psychotherapie und Alltag. Frankfurt: Brandes & Apsel Verlag.

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Feldpartitur: Cloudversion SaaS micro 1.0

Pre-Post-Design: 1st and 5th week (3,5 min.)

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Patient 1

Week 1

Week 5

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Patient 2

Week 1

Week 5

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Patient 2 - Eye contact

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Results

• Individually different changes in behavior

Patient 1: more awake, attentive, active

Patient 2: more relaxed, less awake and attentive

•Closed eyes ≠ not awake, not attentive

-> challenge for assessment and interpretation

•Importance of qualitative information

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Changes in Brain Activity (PET)

PET 1 (week 1): no music therapy (rest)

PET 2 (week 2): music therapy

PET 3 (week 6): music therapy

Respected Areas:

Hippocampus, Frontal Areas, Cerebellum

Analyzing tool:

Scenium (Syngo Scenium Ver.1.2.0.13 Siemens)

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34 34 39

-16 -20 -19

-30

-20

-10

0

10

20

30

40

50

Frontal Hippocampus Cerbellum

in P

RO

ZE

NT

%

Changes in activity (%) between PET 2 and PET 3

music therapy group control group

Music therapy patient

Control group patient

PET 2 –PET 1 = change in activity

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CONCLUSION

Brain images and behavioral changes require a careful interpretation!

Information collected during the research process is important because it

influences the interpretation and results!

Individual, subjective value of music therapy

Neuroanthropologocial research

Research WITH humans as SUBJECTS

„One cannot not communicate“ (Watzlawick et al., 1967)

Watzlawick, P.; Beavin-Bavelas, J.; Jackson, D. (1967). Pragmatics of Human Communication - A Study of Interactional Patterns, Pathologies and Paradoxes. New York: W. W. Norton.

How is knowledge generated?

Reflection

KNOWLEDGE

Culture Environment Brain

INTERACTION

Thank you for your attention!

Further reading:

Vogl J., Heine A.M., Steinhoff N., Weiss K. and Tucek G. (2015) Neuroscientific and neuroanthropological perspectives in music therapy research and practice with patients with disorders of consciousness. Front. Neurosci. 9:273. doi: 10.3389/fnins.2015.00273

Steinhoff N., Heine A.M., Vogl J., Weiss K., Aschraf A., Hajek P., Schnider P. and Tucek G. (2015) A pilot study into the effects of music therapy on different areas of the brain of individuals with unresponsive wakefulness syndrome. Front. Neurosci. 9:291. doi: 10.3389/fnins.2015.00291