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Music Therapy in Pediatric Preoperative Care

Recently, a patient’s mother expressed concern over an extensive dental procedure for her child with autism. Her primary concern was her child’s anxiety prior to the procedure. The MT expressed that she would like to be present pre-op to help regulate anxiety before the operation if it all possible. 

This scenario leads to the question of how music therapy can be used to help pediatric patients in pre-operative conditions.  In a 2015 pilot study, 103 neurotypical pediatric patients participated in a music therapy preoperative program at an ambulatory surgical center (Gooding et al., 2015, pg. 191). These patients were between the ages of 2-9 years of age and set to undergo various procedures such as hernia repairs, dental restoration, tonsillectomies, adenoidectomies, and port-a-cath removals. Approximately 30-45 minutes before each procedure was to take place, a music therapist would provide a 20-minute session for the patient. Prior to the session, the music therapist used two standardized scales- the Modified Yale Preoperative Anxiety Scale (YPAS-m) and the Child-Adult Medical Procedure Interaction Scale- Short Form (CAMPIS-SF) to rate the patients’ anxiety and procedural distress. After the session, the music therapist completed the ratings again. Additionally, parents of the patients were given a questionnaire to fill out post-session as well.

Within this study, the music therapist utilized musical alternate engagement interventions. Ghetti (2012, pg. 3) defines these as “music [that] is used to motivate and structure the patient’s active engagement with the music stimuli and therapist in order to reduce awareness of the … anxiety-provoking stimuli”. In Gooding’s study, the music therapist used singing, songwriting/lyrics analysis, instrument play, movement to music, musical games, and music listening interventions to help the patient’s anxiety (Gooding et. al, 2015, pg. 193). Through these interventions, the music therapist was able to educate the patient on the procedure in a non-threatening manner, facilitate distraction, give outlets for self-expression, and help ease and transition the patient before their respective operation (Gooding et. al, 2015, pg. 192). Gooding found that there was improvement in both the patients’ affect and emotional expression, with 84.5% of patients showing a positive affect after the session, with only 23.3% of patients showing a positive affect prior to the session. Of the 73 parents/guardians that completed the questionnaire, the mean response to the statement “My child benefited from music therapy” fell between “Agree” and “Strongly Agree”. Additionally, the mean response of the statement “I benefited from music therapy” also fell between “Agree” and “Strongly Agree”. (Gooding et. al, 2015, pg. 197). 

In 2017, Millett & Gooding created another study that examined the potential differences in efficacy between active and passive music therapy interventions. Similar to Gooding’s study in 2015, those patients that received active music therapy interventions (musical alternate engagement) were engaged in a 15-minute session through active instrument play, a musical game, improvisation, and extensions/adaptations to help distract the patient (Millett & Gooding,, 2017, 468 ). An example of an active music therapy session plan can be seen below (Gooding et al., 2015, Table 2): 

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Consequently, those patients elected to receive passive music therapy were aided through music-assisted relaxation interventions such as singalongs to family-preferred music or age-appropriate music. In this type of music therapy, music is used to “entrain and gradually reduce elevated vital rhythms” (Presner et. al, 2001, pg. 86). The music therapist began by entraining the patient to the music that she played. Entrainment was possible through the iso-principles of music therapy, a technique in which the music therapist initially matches the music to a patient’s mood and then gradually alters the music to change the temperament of the client. (Davis et. al, 2008, pg. 30). By the end of the session, the iso-principle guided the music therapist to decrease the music stimulation by playing less active picking patterns, play at a softer dynamic, and transition to less musical activity overall in order to bring the patient to a state of relaxation (Millett & Gooding, 2017, pg. 467). 

When comparing the two different types of music therapy interventions- active vs. passive- Millett & Gooding  (2017, pg. 460) found that there were no significant differences in the efficacy of either treatment. However, there was found to be significant reduction in both the patients’ anxiety as well as parental anxiety with either treatment. In studying the relationship between parental anxiety and patient postoperative behaviors, children with parents exhibiting anxiety were 3.2 times more likely to experience negative postoperative behaviors that could last 6 months after the initial procedure (Kain et. al, 1996, pg. 1238). Because of this, decreasing not only patient anxiety but parental anxiety is imperative to the well-being of the child, both pre- and post-procedure. 

Overall, in both the Gooding (2015) and Millett & Gooding (2017) studies, music therapy was viewed as an effective preoperative intervention not only for the patients but also their parents as well. Decreasing parental anxiety levels leaves the child feeling less anxious about the procedure as well, decreasing the chance of negative postoperative behaviors. While these findings were based on those of neurotypical children, research should be expanded to a more inclusive pool, including neurodiverse children as well. 


- Sarah Deal, Music Therapy Intern





References



Davis, W.B., Gfeller, K.E., & Thaut, M.H. (2008). An Introduction to Music Therapy: Theory 

and Practice (3rd ed.). The American Music Therapy Association. 


Ghetti,  C.M. (2012). Music therapy as procedural support for invasive medical

procedures: Toward the development of music therapy theory. Nordic Journal of

Music Therapy, 21, 3–35. https:// doi:10.1080/08098131.2011.571278


Gooding, L.F., Yinger, O.S., &  Iocono, J. (2015). Preoperative Music Therapy for Pediatric

Ambulatory Surgery Patients: A Retrospective Case Series. Music Therapy

Perspectives, 34(2), 191-199. https://doi.org/10.1093/mtp/miv031


Gooding et. al. (2015). Preoperative Music Therapy for Pediatric Ambulatory Surgery

Patients: A Retrospective Case Series- Table 2. [Photograph]. Retrieved from

https://doi.org/10.1093/mtp/miv031


Kain, Z. N., Mayes, L. C., O’Connor,  T. Z., & Cicchetti, D. V. (1996). Preoperative anxiety in

children: Predictors and outcomes. Archives of Pediatric Adolescent Medicine,

150(12), 1238–1245.


Millett, C.R. & Gooding, L.F. (2017). Comparing Active and Passive Distraction-Based

Music Therapy Interventions on Preoperative Anxiety in Pediatric Patients and

Their Caregivers. Journal of Music Therapy, 54(4), 460-478. 


Prensner, J.D., Yowler, C., Smith, L.F., Steele, A.L., &  Fratianne, R. B. (2001). Music therapy

for assistance with pain and anxiety management in burn treatment. Journal of

Burn Care & Rehabilitation, 22(1), 83-88. 



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Using Orff Techniques in Music Therapy 



 

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Rhythm. Movement. Play. Success. Improvisation. Speech. These words, among others, encompass some of the key ideas behind Carl Orff’s philosophy of music education. Although the Orff approach was not created as a music therapy protocol, its core ideas of music, movement, rhythm, and improvisation are easily included in music therapy sessions (Darrow, 2008, p. 19). Orff methods are versatile, success-oriented techniques that can be used with music therapy populations across the lifespan.

Orff is a German approach to music education. Founder Carl Orff was interested in modern dance. In traditional ballet, music and movement were created separately; Orff wanted the music and movement to become one. Orff taught students how to create rhythm patterns using body percussion--snapping, clapping, patsching, and speech. After teaching the basics, Orff encouraged students to improvise over an ostinato rhythm pattern or drone (Ramsay, 2018, p. 9). Music Therapists use these Orff techniques in skilled music therapy settings to address therapeutic goals in both individual and group settings. 

In the late 1920’s, Orff’s travels inspired him to incorporate unpitched percussion instruments, such as marimba and recorders, into his technique. These types of instruments came to be known as Orff Instruments and are essential to the technique. Combining instruments and movement, Orff would begin by teaching children rhythmic patterns using body percussion and then transfer these patterns to instruments (Ramsay, 2018, p. 10). The Orff method of teaching gained popularity throughout the 1940’s and 1950’s and is still common in American and European music education classrooms. In more recent years, the approach has been gaining popularity in music therapy training (Ramsay, 2018, p .9). 

 Orff provides clients opportunities to participate in multisensory interventions. These may be playing, singing, moving, or listening. This variety gives clients multiple areas to succeed and, in the group setting, can reach clients with different strengths (Schumacher, 2013, p. 113). In working with groups, Orff encourages individuals to be creative. The improvisation required by the Orff approach encourages clients to move out of their comfort zones together, as well as build relationships, trust, and rapport among the group (Schumacher, 2013, p. 113). Common interventions used with children include therapeutic singing, songwriting, music and movement, and instrument play. All of these interventions can incorporate Orff techniques (Orff, 1989). 

A sample intervention is a structured instrument play. In a group setting, divide the group into three parts. Teach the first group rhythm number one by patsching (patting knees) and speaking the rhythm. Teach the second group rhythm number two by clapping and speaking the rhythm. Teach the third group rhythm number three by snapping the rhythm. Once the rhythms are successfully played on body percussion, transfer them to instruments. Review each rhythm with the instruments and give each group a chance to get comfortable with their rhythm before layering. Once all of the groups are comfortable playing their rhythms, signal certain groups to play softer and others to improvise over the background rhythms. This opportunity for variety and improvisation is fundamental to the Orff approach (Ramsay, 2018, p 9-11). 

The following intervention is an example of this technique. Begin by dividing the group into three sections and assigning parts. The first group will play the top rhythm by patsching or patting their knees. The second group will play the second rhythm by clapping their hands. The final group will play the third rhythm by snapping their fingers. Have each group practice their part individually and then together. Then, begin layering the parts. Once all groups can successfully play their body percussion rhythms, transfer the rhythms. The first group will play their rhythm on drums, the second group will play rhythm sticks, and the third group, shakers. Again, have each group play their part independently before layering the rhythms and fading the verbal prompts. 

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This intervention addresses the following goals:

  • Auditory processing by discriminating different sounds

  • Social skills like cooperating in a group, listening to peers, impulse control, and attention

  • Motor planning to execute rhythm and play of instrument  

  • Improving Expressive language by chanting words in rhythm


Orff techniques are simple and easily adaptable to multiple populations. Patients respond well to interventions that are based on the Orff theory of education given their activity-oriented nature. Although this approach is typically associated with music education, the Orff approach is growing in popularity amongst music therapists. Orff interventions are a valuable tool for the music therapist since they are so easily adaptable and comprehensible. It also provides structure for the clients in music therapy sessions while leaving plenty of room for improvisation and self-expression. This allows for patients to feel safe and supported in their music making, leading to them feeling more comfortable within the setting of a group and a session. Orff interventions are something that any population can engage in and enjoy, and are supported through both past and present research. 




-Rachel Buchheit, Music Therapy Intern


References

 

Darrow, A., & American Music Therapy Association. (2008). Introduction to approaches in

music therapy (2nd ed.). Silver Spring, MD: American Music Therapy Association.

Schumacher, Karin. (2013). The importance of “Orff-Schulwerk” for musical social-integrative pedagogy and music therapy (English translation: Gloria Litwin). Approaches: Music Therapy & Special Music Education, 5(2), 113-118.

Orff, G. (1989). Key concepts in the Orff music therapy : Definitions and examples. London; New York: Schott.

Ramsay, S. (2018). Orff Schulwerk Certification Course: Level One Resource Book, 9-11. 


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Meet Ms. Sarah

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My name is Sarah Deal and I am thrilled to be starting my music therapy internship at Therabeat. While attending the University of Georgia, I was a double major in both music therapy and music education. I recently completed my student teaching specializing in elementary general music. Balancing two majors at one time has not always been easy but has been extremely rewarding working with so many people from all different walks of life. I am so excited to begin my journey at Therabeat in becoming a board-certified music therapist.


To me, one of the most special parts about working at In Harmony is the close-working relationship that the therapists have with each other, regardless of specialty. It is so incredible to witness therapists from the various areas (OT, PT, ST, and MT) come together to create a holistic course of treatment for our clients. Beyond just the knowledge shared, their interest in each child and their family is genuine as well. In observing pre- and post- treatment conversations between parents, caregivers, and therapists, it is very apparent that In Harmony is a truly nurturing environment for everyone involved. 


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Going forward into my internship, I am eager to learn from the various specialists in the clinic. I hope that I am able to take knowledge and expertise from them and to become a more well-rounded music therapist for my own clients. Since I first walked into the clinic two years ago for mini-camp, I have wanted to be a Therabeat intern and feel so blessed to be living out my dream. 



Best, 


Sarah Deal, Music Therapy Intern


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Meet Ms. Jasmine

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Hello! My name is Jasmine Bailey and I am one of the newest music therapy interns here at Therabeat. My primary instrument is flute, but I enjoy playing the piano, guitar, and ukulele as well. I enjoy all types of music, and I am constantly on the search for new music. I recently finished my graduate coursework at Georgia College & State University, and I am looking forward to graduating in May 2020!

 While at GCSU, I was able to work with various populations from children with special needs to patients in a skilled nursing unit. However, my favorite clinical experience was working with K-2 students with special needs in a special education setting. I was able to work with the same students for an extended period of time, and thus was able to see the significant strides that they made in their developmental growth. Through this clinical experience, I realized that I wanted to work with children with special needs after graduation. 

Therabeat Inc. was my first choice for my internship. I was drawn to this facility for several reasons. First, this facility offered the opportunity to work with children who have various diagnoses. Secondly, this facility offered the opportunity to learn from several awesome and highly qualified music therapists. Third, this facility offered opportunities to learn more about and co-treat with physical therapists, occupational therapists, and speech language pathologists. Finally, this facility offered the opportunity to learn more about the private practice setting.

My first week of my internship has been a whirlwind to say the least. Although I feel like a deer caught in the headlights, I have been so excited to absorb all of the great things happening here. I have been able to meet some of the awesome kiddos receiving music therapy services and learn more about them. I have been able to observe physical therapy sessions, and I look forward to observing occupational therapy sessions and speech sessions. 

I can already tell that Therabeat is the perfect place for me to grow both professionally and personally. I truly appreciate the friendly and collaborative nature amongst all of the therapeutic disciplines. I look forward to making new connections with the kids and their parents. I’m so excited for what lies ahead! 

Yours Truly, 

Jasmine Bailey, Music Therapy Intern

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Music Therapy and Movement with Older Adult Stroke Patients

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Music Therapy and Movement with Older Adult Stroke Patients

Every year approximately 800,000 Americans have a stroke, making it one of the most common causes of death (“Stroke,” Centers, 2017, para.1). Strokes typically require invasive treatment and long term recoveries which have a significant impact on the victim as well as their family. Music therapy is more commonly being used along with other medical therapies in stroke recovery. Research shows that music therapy can help improve cognitive processing, language skills, and motor movement.

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         A stroke occurs when blood supply to the brain is interrupted. There are two types of strokes: ischemic and hemorrhagic. An ischemic stroke is caused when blood supply to the brain is blocked. This can happen when an artery becomes blocked, particularly in places where the artery narrows. Hemorrhagic strokes occur when a blood vessel ruptures and bleeds into the brain, an example of this would be an aneurysm that ruptures (“Stroke,” Cleveland, 2017, para 2-4). Of the two types of stroke, ischemic is much more common and makes up about 87% of all strokes that occur each year (“Stroke,” Centers, 2017, para. 1).  Common symptoms of a stroke include sudden loss of speech, slurred speech, sudden vision changes, sudden weakness, dizziness or paralysis, and debilitating headache with vomiting (“Stroke,” 2018, para. 2).

 Recovering from a stroke can be very difficult and often requires the patient to go through inpatient rehab. Treatment and recovery time varies from patient to patient, as the part of the brain that suffered the most damage will determine the other areas that suffer. A patient may be paralyzed or experience great weakness on one side. With this comes pain and other sensations like numbness and tingling. Patients often have to go through rigorous physical and occupational therapy to regain lost function. Patients often experience depression and may have trouble controlling their emotions through recovery as they adjust to their new normal (“Stroke,” 2018, para. 9).   

Improved motor activity is a major goal for stroke patients. Gait is often affected after experiencing a stroke. A case study investigated the use of neurologic music therapy (NMT) for gait training in addition to standard practice of care in the inpatient rehabilitation setting following stroke. A 41 year old male who suffered a right middle cerebral artery stroke, rupture of aneurysm caused by an infected thrombus, and uncal herniation was the participant in the study. NMT was used during the first week of physical therapy treatment as an adjunct standard care 2-3 days a week.  The participant went from a 33 on the Functional Independence Measure (FIM) and a 0/56 on the Berg Balance Scale to a 92 on the FIM and a 10/56 on the Berg Balance Scale.This means the participant’s balance increased significantly as well as their ability to function independently and complete activities of daily living. NMT was an integral part of the patient’s gait training (Spaulding & Harris, 2017, p.1). Music has a way of motivating individuals. Gait training requires the patient to be motivated to improve their motor functioning. 

Entrainment is a common music therapy technique used for stroke patients. Entrainment is the synchronization of music to movement. The pulse or tempo of the rhythm is matched with the timing of specific movements. Rhythm provides predictable structure that helps the brain plan movement. Music engages both sides of the brain which may help the brain build new pathways helpful in relearning movement. Music is also a motivator and helps increase endurance. A 2013 study investigated the immediate effect of rhythm on kinematic movement patterns, especially reaching trajectories, variability of movement timing, and elbow range of motion. This study was focused on hemiparetic arm reaching movements of patients with stroke. Elbow range along with both cyclical movement timing and smoothness of reaching trajectories improved significantly (Thaut, 2013, p. 32). Research was conducted on the effect of repetitive rhythmic arm training using a Patterned Sensory Enhancement (PSE) protocol and assessed with the Wolf Motor Function Action Test (WMFT) and the self reporting Motor Activity Log (MAL). The improvements were evident throughout both assessments (Thaut, 2013, p. 32). The positive results of this study speak to the relevance of music therapy as an effective treatment. A third study was conducted using Constraint Induced Therapy (CIT). Trunk flexion and shoulder rotation were compared in a discrete arm reaching versus cyclical reaching task cued by auditory rhythm. Thaut concludes, “The rhythmic cyclical task reduced trunk flexion and increased shoulder and trunk rotation comparable to normal patterns whereas in the discrete task subjects relied mostly on extended forward flexion of the trunk to reach the targets” (2013, p.32). Music therapy uses entrainment as one way to improve motor movement of stroke patients.  

When working on motor functioning, the experience can often be quite painful for patients. Music therapy can aid in managing pain perception. In a study on the effects of music therapy on pain perception of stroke patients during upper extremity joint exercises, positive effects and verbal responses were observed. Ten stroke patients participated in the study where music conditions consisted of either a song, karaoke accompaniment, or no music. Subjects repeated three conditions and rated their perceived pain on a scale immediately following each condition. The subjects played the piano, drums, and rhythm instruments and reacted positively during music therapy treatment sessions. The music therapy sessions helped reduce pain during physical exercises designed to increase the patient's hand function. (Kim & Koh, 2005, p. 1).

         Music therapy is extremely beneficial for those who have suffered from a stroke. Strokes impact many people in a variety of ways so it is crucial to have treatment plans in place. Music therapy is effective in improving the quality of life for those who have experienced a stroke. Research also shows that music therapy improves speech and language skills, cognitive functioning, and motor functioning for stroke patients. It is crucial that research continues and more studies on the use of music therapy take place within the field of medical music therapy and stroke.  

 

References

Kim, S. J., and Koh, I (2005). "The Effects of Music on Pain Perception of Stroke Patients during Upper Extremity Joint Exercises." Journal of music therapy, 42.1 (2005): 81-92. Retrieved August 12, 2019 from https://search-proquest-com.bunchproxy.idm.oclc.org/docview/1097310?accountid=8570&rfr_id=info%3Axri%2Fsid%3Aprimo

 

Pfeiffer, C., and Sabe, L. (2015). "Music Therapy and Cognitive Rehabilitation: Screening of Music Cognition in Adult Patients with Right Hemisphere Stroke." Psychomusicology 25.4,  392-403. Retrieved August 12, 2019 from https://search-proquest-com.bunchproxy.idm.oclc.org/docview/1783684326?accountid=8570&rfr_id=info%3Axri%2Fsid%3Aprimo

 

Spaulding, A., and Harris, B. (2017). “Neurologic Music Therapy for Gait Training Following Stroke: A Case Study.” Archives of Physical Medicine and Rehabilitation, vol. 98, no. 10, Retrieved August 12, 2019 from https://www.sciencedirect.com/search/advanced?docId=10.1016/j.apmr.2017.08.272

 

“Stroke.” (2017). Centers for Disease Control and Prevention, Centers for Disease Control and Prevention. Retrieved August 12, 2019 from www.cdc.gov/stroke/facts.htm

 

“Stroke.” (2017). Cleveland Clinic, The Cleveland Clinic Foundation. Retrieved August 12, 2019 from my.clevelandclinic.org/health/diseases/17519-stroke

“Stroke.” (2018). Mayo Clinic, Mayo Foundation for Medical Education and Research, Retrieved August 12, 2019 from www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/syc-20350113

 

Thaut, M. H. (2013). "Entrainment and the Motor System." Music Therapy Perspectives, 31.1,  31-34. Retrieved from https://search-proquest-com.bunchproxy.idm.oclc.org/docview/1514320468?accountid=8570&rfr_id=info%3Axri%2Fsid%3Aprimo

 

 

 

 


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