A Collaboration Between Music Therapy and Speech Pathology in a Paediatric Rehabilitation Setting
Abstract
This article describes the importance of flexible music therapy practice when focusing on communication skills with a speech pathologist within a paediatric rehabilitation setting. A brief literature review on the combined use of music therapy and speech pathology in rehabilitation is provided. A case vignette is then used to illustrate the unique role of music therapy and the importance of changing the goals of music therapy in order to meet the patient’s needs.
Communication
But first, what is communication? What does communication involve? Let’s analyse and outline communication from a daily example.
Johnny wanted a chocolate during grocery shopping with mum. He smiled, tapped and asked his mum with a gentle voice. Sadly, his request was refused, so he gradually increased his protest. First, he frowned and begged, then he increased his vocal volume and intensity by screaming. After that, his breathing rate continued to increase, and he cried and stomped his feet and waved his arms. Finally he finished his dramatic tantrum with his whole body rolling and lying on the ground.
Communication is essential to human survival. As this example illustrates, it can involve verbal expression, corporal expression like gesture, movements, paraverbal expression like intonation, rhythm, breathing and our entire body (Littlejohn & Foss, 2008). When the capacity for speech has been impaired by a neurological injury, a human’s potential to communicate is limited. The results of such impairment significantly affect that person’s ability to communicate basic needs, but also leads to long term negative influences on the person’s vocational outcome (Brooks, McKinlay, Symington & Campsie, 1987), social re-integration and quality of life (Malkmus, 1989).
Music Therapy and Speech Rehabilitation
Literature exploring the combined use of music therapy and speech pathology in the rehabilitation treatment of speech impairments has largely focused on the adult population. Cohen was a frequent contributor to this field in the 1990s and identified benefits in using music, particularly singing, to expand the communication potential of people with speech disorders in a number of articles (Cohen, 1993, 1994 &1995). In 1992 she described how singing and speech share common elements and suggested that instruction in basic singing techniques, such as correct breathing patterns, coordinated phonation and efficient diction, could improve speech production even more effectively than singing without strictly specificied techniques. Cohen concluded that rhythmic speech, breathing and vocal exercises enhance patients’ speech rate, pitch, variability and intelligibility.
Baker and Wigram have noted in a number of articles (2000, 2004 & 2005) that song singing and vocal exercises are the most frequently employed and documented intervention with people with acquired neurological speech disorders. Furthermore, Baker described song singing as i) positively affecting a person’s physiological state by reducing tension and increasing vocal muscles, ii) stimulating neurological activation which may facilitate improvement in production of intonation, and iii) evoking changes in emotion, which directly affect the vocal output. The results of Tamplin’s investigation (Tamplin, 2008) further supports the benefits of music therapy and speech pathology with adults with neurogenic motor speech disorders. At the 11th World Congress of Music Therapy (2005), Tamplin described positive changes in the patients’ speech rate and intelligibility after participating in an eight-week music therapy program, which consisted of breathing exercises, intonation and articulation practice, rhythmic cuing and singing familiar songs.
In regards to the use of music therapy to address children with speech disorders, Hibben (1991) suggested that children who receive music therapy exhibit a greater amount of spontaneous speech than matched controls. She claimed that the use of music therapy facilitates social interaction, enhances emotional expression and promotes positive behaviours. Similarly, Kennelly, Hamilton, and Cross (2001) highlighted the parallels between music and speech and language development models and report that a collaborative approach between speech pathology and music therapy can be effective with children who have neurological speech impairment. These authors identified that music therapy had both an individual and conjoint role to play in expanding the communication potential of children with speech disorders and therefore, enhancing the quality of life for these children and their families.
Gilberston (2005) identified that out of forty-six papers on music therapy and rehabilitation, only fifteen described music therapy in paediatrics. The adult rehabilitation literature provides evidence of the benefits of music therapy, and therefore we expect these positive results would transfer to the paediatric population. However, it is important to consider that children are very different from adults neurologically. Children’s neuro-structure, cognition and emotion change daily in response to their continual growth. It is important for the music therapy profession that we continue to identify which of these results can be expected in working with children through close scrutiny of our work. The following case vignette contributes to the ongoing dialogue about clinical practice in neurorehabilitation.
Case Vignette
The purpose of this case vignette is to illustrate the benefits of using combined music therapy and speech pathology in neurorehabilitation. Some musical examples are included to demonstrate the specific vocal exercises that were developed together by the music therapist and speech pathologist. Written permission has been obtained from the patient and family in order for this material to be published.
The Clinical Context
The following case vignette has been derived from clinical work undertaken at a rehabilitation unit within a state paediatric hospital in Australia. In this unit music therapy services are provided to both inpatients and outpatients as one of ten different disciplines making up the multi-disciplinary team. The music therapy programs provide individual and joint-therapy work with the Speech Pathologist when addressing the goal of communication. All rehabilitation programs are conducted at the child’s bedside which is sometimes within an isolated treatment room on the rehabilitation unit.
The Patient
Sam is an eleven year-old boy who sustained a severe garrotting injury. He was riding a four-wheel motorcycle and ran into a barbed wire fence. Sam’s injuries included:
- neck to head cervical spine injury with dislocation,
- wound of lower neck area involving cutting through the windpipe and the right neck muscle,
- broken jaw,
- and cranial nerve palsies affecting lateral gaze, facial movement and tongue function.
Sam spent 19 days in the intensive care unit and required fixation of his cervical spine with application of a halo brace (figure 1) and tracheostomy. He remained an inpatient at the hospital for five months.
Figure 1. A patient with a halo brace and tracheostomy.
Sam’s subsequent speech impairment was due to damage to cranial nerve 12 which provides motor movements to the intrinsic and extrinsic muscles of the tongue. Initially, this resulted in complete paralysis of the tongue. There was also some impairment of the cranial nerves that innervate the pharynx and protect the airway during the swallow.
As the tracheostomy redirects breath below the level of the vocal cords, no voice can be achieved with a tracheostomy in place. Sam was initially required to use non-vocal communication, including mouthing and writing. Due to the aural motor injuries outlined above, Sam was also unable to swallow safely and had no oral intake. The speech pathologist’s goal at this acute stage was to provide regular swallow reviews.
Individual Music Therapy Program
Initially, Sam was referred to the music therapy program for improved verbal articulation and communication by the speech pathologist. As the medical team outlined that Sam's rehabilitation journey could be lengthy, they expressed their hope that music therapy would provide motivation as well as emotional support for Sam during his speech rehabilitation program.
Music Therapy Assessment
During the music therapy assessment, Sam was alert and remained lying in bed with minimal head, neck, shoulders and upper-arm movements. Although Sam was not able to verbalise due to the tracheostomy, he responded to closed-questions with thumbs up and down, and some facial gesture (ie. smile and frown).
| Referral reason | To increase verbal and non-verbal communication skills |
|---|---|
| Assessment included | An informal interview with Sam and his family, a medical chart review and liaison with the multidisciplinary team therapists, and initial music therapy session for assessment. |
| Therapist’s objectives | To identify Sam’s needs and preferences in music/music background To assess Sam’s current medical, communication, physical, emotional and cognitive status as represented musically To establish rapport with Sam |
| Session length | 45mins. |
| Assessment intervention | Sam’s response |
|---|---|
| Singing songs that chosen and well known to Sam |
|
| Listening to Sam’s favourite CD/music |
|
| Improvisation |
|
After discussing the initial music therapy assessment session, the multi-disciplinary team agreed that Sam's medical condition was not stable enough to commence his speech rehabilitation. Sam became fatigued easily and was unable to concentrate after 10mins of the session, requiring 5 minute breaks between activities. Therefore, the music therapy program focused mainly on Sam's psychosocial needs and empowering him within the hospital environment. The music therapy program goals were to empower Sam in:
- adjusting to hospital and his injury
- providing a range of opportunities for choice and control
- using musical instruments for non-verbal self expression
The actual methods used to address these goals included: song listening, drum improvisation and song parody – a technique where lyrics are substituted in known song. For song parody, Sam used a white board and marker to write his lyrics. This activity required a good level of concentration and upper limb movements, therefore, Sam would often participate only for 10mins before he became fatigued.
Combined Music Therapy and Speech Pathology Program
As Sam’s medical condition stablised and his recovery progressed, it became possible for him to participate in a more active rehabilitation program. This then became the priority focus of his treatment and a combined music therapy and speech pathology program was commenced. The combined program aimed to increase Sam’s tolerance in using the speaking valve. For successful use of the valve, a patient must have adequate space between the trachea and tracheostomy tube to ensure leak of air. If there is insufficient leak, the patient will demonstrate breathing distress due to lack of oxygen exchange. Tolerance of the speaking valve can be difficult initially due to the need for a change in breathing patterns.
When Sam demonstrated increased tolerance in using the speaking valve, the combined program goals increased to:
- maximise exhalation strength and breath control
- distract the patient from the unfamiliar sensation of exhaling
- reduce feelings of anxiety
- build tolerance to the valve
- increase articulation
- improve precision of tongue movements
- and increase range and length of verbalisations.
The Combined Intervention
The program during this stage of treatment used similar methods but changed their intention in order to address the most recent goals.
Song Singing
Each session began with singing familiar songs of Sam’s choice. Singing provided a predictable structure which enabled Sam to focus. It distracted him from the unfamiliar sensation whilst using the speaking valve, as well as increased his tolerance for the valve.
Drum and Vocal Improvisation
As outlined in figure 2, this improvisation exercise combines non-vocal (drum improvisation) and vocal (vocal improvisation) output. Sam was encouraged to play the rhythmic pattern on the drum then vocalize the same pattern with phonics/sounds that were suggested by the Speech Pathologist. The music therapist would then improvise a new rhythmic pattern on the drum which Sam repeated. The drumming provided an opportunity for Sam to practice the rhythmic pattern and to entrain his body into the right tempo, which maximised his ability to vocalise the pattern accurately as well as strengthen his breath control.
This exercise not only increased Sam’s communication capacity, but also provided motivation and increased feelings of physical and psychological control; therefore reducing Sam’s level of anxiety during the vocal exercise. Sam was able to create his rhythmic pattern, volume and tempo on the drum based on what he thought he could manage during vocal improvisation.
Figure 2. Example of drum and vocal improvisation exercise
Speech and Language Evaluation
An evaluation of Sam’s improved tongue control and speech production was conducted by the Speech Pathologist using the Frenchay Dyarthria assessment. This evaluates the rate and range of movements of all the speech articulators as well as measuring intelligibility at the word sentence and conversation levels. Sam made small gains throughout his inpatient stay but the most significant improvement was observed after placement of the shunt (a medical device designed to transport the excessive fluid in the brain into the chest) suggesting that recovery was spontaneous rather than the direct result of music and speech therapy intervention. At the time of Sam’s inpatient discharge, he was approximately 90% intelligible at the sentence level and in spontaneous speech. He could be difficult to understand if excited about what he was saying. However, Sam was able to identify the strategies he needed to improve the intelligibility that he had previously learned and practiced in the therapy sessions.
Family’s Evaluation
At the conclusion of inpatient treatment, a written questionnaire was offered to Sam and his mother to descriptively evaluate their experience of the combined music and speech therapy program.
Sam’s mother stated,
the individual music therapy program helped by lifting his spirits… he loved going to music therapy, it made him happy.
the combined program was most helpful [to Sam] because he seemed to enjoy it more than individual speech therapy. Sam doesn’t like ‘hard work’, so the music has distracted him. He was working and practicing, but it didn’t seem like work to him.
from this [rehabilitation] journey, I remember Sam making his music and writing songs the most, not the medical stuff.
Sam stated,
I hate the [vocal] exercises, whenever I say them, I feel stupid… because I can’t do them. But I love doing it in music, because you [the music therapist] made it fun. I love coming to music, and mum loves coming too.
It was fun to play [the drum improvisation] with mum. It was the only thing that made us laugh when we are locked in here [the hospital].
Conclusion
In keeping with the literature, this vignette demonstrates that music therapy and speech pathology can play complementary roles when addressing common goals in the areas of breath control, aural motor coordination and speech production. Through combining music therapy and speech pathology, we were able to offer an interactive and engaging rehabilitation program for this child. Music therapy maximised Sam’s potential and motivation in achieving his communication goals, while speech pathology provided therapeutic intervention and measurable outcomes while he re-learned his speech skills. Together, both disciplines assisted Sam to integrate back to his community as a communicating participant.
This vignette also illustrated that the provision of a holistic rehabilitation program requires flexibility in programming, and responsiveness to changes in medical status . This was evidenced at times where Sam’s body gesture and facial expression made it clear that he was not ready to focus on speech goals, and in response, the music therapist would alter the intended session plan to meet his more prominent psychosocial needs. As a music therapist, it was important to assess and evaluate the patient’s condition and needs before and during each session, to ensure the benefit of music therapy to the patient is being maximised.
Personal Comment
Music therapy plays a unique role within the allied health team in a paediatric rehabilitation setting. Reflecting upon my clinical practice at the hospital, functional goals (such as bilateral motor skills, communication skills etc) often become the major focus of my music therapy programs, working in collaboration with the other allied health therapists. The medical, nursing and allied health team, as well as the patient and family, focus heavily on "going home" and "getting better", however, we sometimes neglect the patient’s emotional well being amongst the busy and ongoing work of rehabilitation. As a music therapist, I experience the challenge and the importance of providing a well balanced functional and psychosocial program for the patients. It was evident from Sam’s program that the combined music therapy and speech pathology communication program was important for his communication outcomes, but the individual music therapy introductory program was equally important for Sam’s holistic well being. What was most important to the family was the way the music therapy program responded to the constantly changing needs of the patient as he journeyed through the complex emotional and physical journey of rehabilitation. In working together with our fellow professionals, I believe we communicate and share each other’s expertise and knowledge to promote a better, effective and patient-centered program that maximises the patient and families potential in moving forward to achieve their goals.
Acknowledgment
The author wish to thank Dr Katrina McFerran, Senior Lecturer in Music Therapy, University of Melbourne for her review of this article prior to submission.
References
Baker, F. (2000). Modifying melodic intonation therapy programs for adults with severe non-fluent aphasia. Music Therapy Perspective, 2, 107-111.
Baker, F. & Wigram, T. (2004). Rehabilitating the uninflected voice: Finding climax and cadence in the uninflected voice. Music Therapy Perspective, 22, 4-10.
Baker, F., Wigram, T., Gold, C. (2005). The effects of a song-singing programme on the affective speaking intonation of people with traumatic brain injury. Brain Injury, 19(7), 519-528.
Cohen, N. (1992). The effect of singing instruction on the speech production of neurologically impaired persons communication disorders. Journal of Music Therapy, 29, 87-102.
Cohen, N. (1993). The application of singing and rhythmic therapeutic intervention for persons with neurogenic communication disorders. Journal of Music Therapy, 30, 81-99.
Cohen, N. (1994). Speech and song: Implications for therapy. Music Therapy Perspectives, 12(1), 8-14.
Cohen, N. (1995).The effect of vocal instruction and visi-pitch feedback. Two case studies. Music Therapy Perspectives, 13, 70-75.
Gilberston, S. (2005). Music therapy in neurorehabilitation after traumatic brain injury: A literature review. In D. Aldridge (ed.) Music Therapy and Neurological Rehabilitation: Performing Health. London: Jessica Kingsley Publishers.
Hibben, J. (1991). Group music therapy with a classroom of 6-8 year old hyperactive learning disabled children. In Bruscia, K. (Ed) Case Studies in Music Therapy: USA, Barcelona Publishers.
Kennelly, J., Hamilton, L. & Cross, J. (2001). The interface of music therapy and speech pathology in the rehabilitation of children with acquired brain injury. Australian Journal of Music Therapy, 12, 13-20.
Littlejohn, S., & Foss, K. (2008). Theories of Human Communication (9th Ed.) Belmont, CA: Thomson Wadsworth.
Magee, W. (1999). Music therapy with brain injury rehabilitation: to what extent is our clinical practice influenced by the search for outcomes? Music Therapy Perspectives, 17, 20-26.
Malkmus, D.D. (1989). Community re-entry: Cognitive-communication intervention within a social skill context. Topics in Language Disorders, 9, 50-66.
Tamplin, J. (2008). A pilot study into the effect of vocal exercises and singing on dysarthric speech. NeuroRehabilitation, 23(3), 207-216.
