The World Health Organisation (2017a) defines rehabilitation as “a set of interventions designed to optimise functioning and reduce disability in individuals with health conditions in interaction with their environment” (p. 1). Neurorehabilitation is a subset of rehabilitation specific to individuals with neurological disorders (Dimyan, Dobkin, & Cohen, 2008; Polgar et al., 1997). Those with neurological disorders demonstrate a variety of sequelae including physical, cognitive, behavioral, and communication impairments, which can lead to psychosocial and daily living difficulties (WHO, 2006). With the broad definition of rehabilitation and the complexity of sequelae in people with neurological disorders, the goals to be addressed in neurorehabilitation are extensive.
Music therapy research in neurorehabilitation has steadily grown since the 1980s and demonstrated potential to address the sequelae of neurological disorders (Baker & Tamplin, 2006). For physical impairments, Weller and Baker (2011) report a number of studies that showed consistent positive and significant outcomes of music therapy interventions (e.g. auditory stimulation, movement to music, active music making) for physical rehabilitation of people with neurological disorders. Music therapy studies have been conducted with people of all ages across a wide range of neurological disorders including stroke, cerebral palsy, Erb’s palsy, Parkinson’s disease, and Rett syndrome (Freedland et al., 2002; Howe, Lövgreen, Cody, Ashton, & Oldham, 2003; Jeong & Kim, 2007; Kwak, 2007; Luft et al., 2004; Pacchetti et al., 2000; Rahlin, Cech, Rheault, & Stoecker, 2007; Rochester et al., 2005; Schauer & Mauritz, 2003; Schneider, Schonle, Altenmüller, & Munte, 2007; Thaut et al., 2007; Whitall, McCombe, Waller, Silver, & Macko, 2000; Yasuhara & Suyiyama, 2001). These studies show the diversity of populations with whom physical rehabilitation is addressed across both acquired and degenerative neurological disorders. In particular, there are various dimensions of physical rehabilitation which music therapy can benefit, such as different movement types (e.g. gait, fine and gross motor movements in both upper and lower extremities), and movement qualities (e.g. balance, strength, dexterity, mobility, coordination, range of motion, functional uses) (Magee, Clark, Tamplin, & Bradt, 2017; Tamplin, 2006; Weller & Baker, 2011).
According to the Cochrane review by Magee et al. (2017), studies using music interventions to target cognitive impairments, including memory, attention, executive functioning, and orientation rehabilitation for people with acquired brain injury (ABI) were examined (Pool, 2013; Särkämö et al., 2008; Mueller, 2013; Baker, 2001). The review shows that orientation was the only outcome that had significant improvements in response to live music listening (Baker, 2001; Magee et al., 2017). In people with disorders of consciousness due to ABI, music therapy has been shown to be effective in stimulating behavioural responses, such as facial expression, blink, and respiratory rate (Fernandes et al., 2014; O’Kelly, 2013). For behavioural problems, music therapy has demonstrated effectiveness in reducing agitation and other challenging behaviours in people with brain injury (Baker, 2001; Hitchen, Magee, & Soeterik, 2010).
For communication impairments, Tamplin (2008) found that singing and vocal exercise improved normative speech production, including speech intelligibility and naturalness, in people with acquired dysarthria. Music therapy has also been reported to improve speech repetition, naming, reading, and verbal fluency in people with acquired aphasia (Jungblut, 2004; Särkämö et al., 2008; van der Meulen, van de Sandt-Koenderman, Heijenbrok-Kal, Visch-Brink, & Ribbers, 2014). Music therapy thus has potential to address both speech and language aspects of communication impairments.
Music therapy also offers great benefits for emotional and social domains in neurorehabilitation. Participating in group music therapy can enhance mood, confidence, motivation, social engagement, peer support, as well as reduce psychological distress for people with acquired neurological injury. (Tamplin, Baker, Grocke, & Berlowitz, 2014; Tamplin, Baker, Jones, Way, & Lee, 2013).
Although the existing studies demonstrate many benefits of music therapy to address neurorehabilitation goals, there is limited literature on the prevalence of music therapy services that are actually provided in clinical practice. Tamplin (2006) examined the reason for referral for 88 patients (aged 18-82 years) from a rehabilitation hospital in Australia between 2004 to 2005. Most patients were referred to music therapy to address social and emotional goals. Relaxation, physical rehabilitation, communication rehabilitation, cognitive rehabilitation, pain management, motivation, and sensory stimulation were also common reasons for referral to music therapy. Although this study reports on the scope of music therapy services provided in a real-world situation, it was based only on one rehabilitation hospital in Australia and was published over a decade ago.
Despite limited research on the real-world situation of music therapy services in neurorehabilitation specifically, survey studies have indicated a general growth of the music therapy profession worldwide, with an increasing number of music therapists working in neurorehabilitation (Jack et al., 2016; Kern & Tague, 2017). Kern and Tague (2017) surveyed music therapists (N = 2,495) via the World Federation of Music Therapy about the status of music therapy practice and trends worldwide. Based on respondent answers to the question about work settings (n = 2,331), 5.2% described their work setting as rehabilitation in general, 19.6% of respondents worked with neurological disorders, 12.4% worked in traumatic brain injury (TBI), 12.2% in stroke rehabilitation (12.2%), and 10.6% worked with Parkinson’s disease (PD) (Kern & Tague, 2017). These clinical populations are consistently represented in the music therapy neurorehabilitation literature (Baker & Tamplin, 2006; Gilbertson, 2005; Thaut et al., 1996; Weller & Baker, 2011). However, Kern and Tague (2017) did not clarify the context of work where the music therapy services were provided to these populations, except for the stroke rehabilitation population. Also, as participants were able to provide multiple responses, there could be some overlap among these populations. For example, brain injury (e.g. stroke, TBI) could be categorised under acquired neurological disorders, while PD could be categorised under degenerative neurological disorders (Tamplin, 2015). Kern and Tague (2017) separated these populations rather than listing stroke, TBI, and PD as subcategories of neurological disorders. As a result, it is not possible to determine the exact proportion of music therapists working in neurorehabilitation around the world.
With the extensiveness and complexity of music therapy practice in neurorehabilitation shown in the existing literature, it is important to know the real-world situation of current music therapy services provision in this field. Such knowledge may suggest pathways for developing research and training curriculum that respond to clinical need. Despite the growth of music therapy as a profession (Kern & Tague, 2017), to our knowledge no study has yet examined the extent of music therapy services provision specifically in neurorehabilitation. Therefore, we conducted an international survey aiming to gather descriptive data on the scope and prevalence of music therapy services in neurorehabilitation. Specifically, in terms of populations served and goals addressed, as well as music therapy approaches and interventions utilised. Additionally, we conducted a qualitative content analysis to determine the opinions of music therapists on training for future music therapists in neurorehabilitation and general feedback. This study received ethics approval from Human Research Ethics Committee at the University of Melbourne.
The participants in this study were active professional music therapists credentialed from a regulating music therapy organisation. The participants needed to have experience working in neurorehabilitation. A snowball sampling method was used to purposively recruit the participants who met these inclusion criteria.
Participants were recruited in two ways. Firstly, an invitation, plain language statement, and hyperlink to the online survey were emailed to music therapy organisations then forwarded to their members. These organisations included: The World Federation of Music Therapy, Australian Music Therapy Association (AMTA), and academy of Neurologic Music Therapy (NMT). Secondly, the recruitment package was sent to 74 registered music therapists (RMT) who identified their expertise as neurological, rehabilitation, and/or NMT trained on the website of AMTA (http://www.austmta.org.au).
We developed a 25-item online survey based on the existing literature on music therapy in neurorehabilitation (See Appendix). The first two items were for identifying eligibility and for the participants to provide consent. The remainder of the survey was divided into six parts according to the areas of investigation including:
1. Participant demographics
2. Professional background information
3. Populations served in neurorehabilitation
4. Goals of music therapy services in neurorehabilitation
5. Music therapy approaches and interventions used in neurorehabilitation
6. Feedback on music therapy training in neurorehabilitation and other feedback (optional)
The survey consisted of closed-ended multiple-choices, questions with single and multiple answers, closed-ended questions with text answers, Likert scale questions (i.e. never, rarely, sometimes, often, or always), and open-ended questions. The option “Other” was provided throughout the survey in case participants had other answers which were unlisted. The draft survey was reviewed and then piloted with two music therapy researchers at the University of Melbourne. The finalised survey took approximately eight minutes to complete.
Data collection procedure
After deciding to take part in the study, participants clicked on a hyperlink leading to the first page of the online survey on Google Forms®, where they had to first confirm their eligibility before they could proceed to the plain language statement and consent form. Participation in this study was completely voluntary. The participants were allowed to withdraw from the study at any time as well as skip any questions they did not wish to answer.
The survey was opened for four weeks, and a reminder email was sent to the organisations, institution, and music therapists in the second week. Additionally, the participants were encouraged to forward the survey to other music therapists with experience working in neurorehabilitation. All submitted survey responses were kept in the password-protected database of Google Forms® and were completely anonymous in order to protect participant confidentiality.
We used descriptive statistics and qualitative content analysis to analyse the data. For the closed-ended questions, we used frequency distribution and converted the data into percentages. For Likert scale questions, we calculated the mean (M) of the responses in each question. Then, we used the class interval to create five categories including almost never, rarely, sometimes, often, and almost always in order to define the calculated mean of each question. The calculated class interval size was 0.8. Therefore, the means were defined as following:
1. The mean from 1.00 to 1.79 was defined as ‘almost never’.
2. The mean from 1.80 to 2.59 was defined as ‘rarely’.
3. The mean from 2.60 to 3.39 was defined as ‘sometimes’.
4. The mean from 3.40 to 4.19 was defined as ‘often’.
5. The mean from 4.20 to 5.00 was defined as ‘almost always’.
For the opened-ended questions, we followed the procedure of qualitative content analysis by (a) reading and re-reading the responses, (b) identifying meaning units, (c) condensing the meaning units, (d) formulating codes for the condensed meaning units, and (e) categorising the codes into categories and sub-categories (Erlingsson & Brysiewicz, 2017; Ghetti & Keith, 2016). Both authors discussed the coding and categorisation process. The first author conducted the first round of coding, and the second author conducted the second round of coding. Inter-coder reliability was then calculated.
The survey received 75 responses from people who identified themselves as music therapists with professional experience working in neurorehabilitation. Seven were excluded as they did not identify any music therapy credential from a professional music therapy organisation. Another three were excluded because they were inactive and retired. Therefore, 65 survey responses were analysed in this study (N = 65). We could not calculate the response rate because the snowball sampling method used in this study did not allow us to record the number of people who received an invitation to participate. As not every participant responded to all questions, the number of participants who responded to each question is provided.
Demographics and Professional Background
Demographic and professional background information is presented in detail in Table 1. The majority of the participants were female (84.6%) and represented all age ranges. Most participants were aged between 30-39 years (35.4%) and were practicing music therapy in Australia (36.9%) or the USA (33.9%). Other countries represented (29.2%) included Finland, Germany, Hong Kong, Canada, Japan, Poland, Argentina, China, Netherland, and Russia with approximately 1-3 responses from each country.
Most participants held the credential of MT-BC (50.8%) following with the credential of RMT (47.7%) and had been working for 1-5 years in neurorehabilitation (49.2%). Few participants (9.1%) reported other credentials (e.g. CMT, DMtG, LPMT, MTA).The majority of participants held a Master’s degree (49.2%) and provided neurorehabilitation music therapy services in hospitals (52.3%). Others worked in a private business setting (33.8%), private venue (e.g. home) (30.8%), or aged care organisation (23.1%). Other settings (23.1%) included community organisation, university, rehabilitation-specialised institution, kindergarten, and non-profit clinic.
A great majority of participants had completed additional training in NMT (80%), 7.7% for GIM training, and another 7.7% for NICU-MT training. Other training (10.8%) included Author Hull Drum Circle, RBL, MTACB, MATADOC, MTE, Hypnomusictherapy, EBQ instrument, sound massage, and functional music therapy.
Every participant reported inter-professional collaboration when working in neurorehabilitation with incidence of collaboration by discipline shown in Figure 1.
Figure 1. Collaborated professionals in music therapy services in neurorehabilitation
Note. Multiple responses were allowed. Other professional collaborations included child life therapists, recreational therapists, medical practitioners, special education resource teachers, neurologists, pulmonologists, art therapists, early intervention keyworkers, and nutritionists.
Table 1. Demographics and professional background
Note. All 65 respondents answered the demographics and professional background questions. Some participants reported multiple credentials, work settings, role titles, and additional training
The populations served by music therapy services in neurorehabilitation represented all age groups. The participants mostly worked with ABI (M = 3.89). Clinical symptoms addressed by respondents are also presented in Table 2.
Table 2. Populations served in music therapy services in neurorehabilitation
Note. Participants were not required to answer all questions. Abbreviations: ABI - Acquired Brain Injury, SCI - Spinal Cord Injury, PD - Parkinson’s Disease
Goals of music therapy
The music therapy goals in neurorehabilitation addressed by respondents were divided into six categories as presented in Table 3. Attention (M = 4.25) was the most prevalent goal.
Table 3. Goals of music therapy services in neurorehabilitation
Note. Participants were not required to answer all questions
Music therapy approaches and interventions
The participants reported a variety of music therapy approaches being applied when working in neurorehabilitation. NMT (87.7%) was the most prevalent as presented in Figure 2. The prevalence of music therapy interventions used in neurorehabilitation by respondents are presented in Table 4. Singing (M = 4.44) was the most commonly used intervention.
Table 4. Interventions used in music therapy services in neurorehabilitation
Note. As the participants were allowed to skip the question they did not wish to answer, some participants did not answer to some questions.
Figure 2. Approaches for music therapy services in neurorehabilitation
Note. Multiple responses were allowed. Other approaches included family-centered, patient-centered, existential-integrative, and solution-focused approaches.
Qualitative content analysis
Forty-seven participants provided suggestions for the development of music therapy training for preparing future music therapists to work in the field of neurorehabilitation. These are listed in Table 5. The inter-coder reliability of this question was .92.
Table 5. Suggestions for the future development of music therapy training
Notes. 47 participants responded to this question. Some responses covered multiple categories.
Eleven participants provided general feedback covering multiple topics as presented in Table 6. The inter-coder reliability of this question was .85.
Table 6. General feedback
Notes. Only 11 participants responded to this question. Some responses covered multiple categories
Importance of inter-professional collaboration
The results from this survey showed that all participants reported collaboration with other professionals when working in neurorehabilitation. This can be supported by the nature of practice in neurorehabilitation where inter-professional collaboration is promoted and considered as the key strategy to successful rehabilitation (Tamplin, 2006; WHO, 2006; Wirz & Rutz-Lapitz, 2015). A perceived need for more training in music therapy courses on inter-professional collaboration in neurorehabilitation was presented in the qualitative content analysis. Speech pathology and occupational therapy collaboration strategies could be prioritised as these were most frequently reported.
The scope of clinical populations served
Music therapy services provided in the context of neurorehabilitation cover a vast range of clinical populations. Our survey results showed that the respondents worked with clients who had neurological disorders ranging from acquired conditions, degenerative conditions, congenital disorders, and post-neurosurgery conditions. The range of clinical populations found in the survey may not fit within some definitions of rehabilitation. In some literature sources, rehabilitation is defined as the process of restoration to the optimal state of functioning after acquiring conditions that cause the loss of capabilities and/or debilitation such as illness, injury, or trauma (Bruscia, 2014; Dirckx, 2012; Loewy, 2013; Martin, 2015). Although this definition focuses on people with acquired neurological conditions, music therapy interventions used in this context may also benefit people with congenital and degenerative neurological disorders (Baker & Tamplin, 2006; Wade, 2015). On the other hand, the World Health Organisation (2017a) defined rehabilitation as “a set of interventions designed to optimise functioning and reduce disability in individuals with health conditions in interaction with their environment” (p. 1). Health conditions in this context were defined as acute or chronic disease, disorder, injury, trauma, and other conditions related to congenital anomaly, and genetic predisposition (WHO, 2017b). In line with this, rehabilitation-focused music therapy has been described with people who had degenerative and congenital neurological disorders (e.g. PD, dementia, cerebral palsy, Erb’s palsy, Rett syndrome) (Alves-Pinto, Turova, Blumenstien, & Lampe, 2016; Staum, 2000; Wang et al., 2013; Weller & Baker, 2011).
Some participants reported non-neurological disorders under the “Other” choice in clinical populations. However, non-neurological disorders including lupus and hematological disorders may have an impact on the nervous system (Muscal & Brey, 2010; Sussman & Davies-Jones, 2014). Some participants also responded to the “Other” choice in clinical population question using categories such as developmental disorders, cancer, and genetic disorders which are umbrella terms that may cover neurological disorders, disorders that may impact the nervous system, and disorders that may spread to the nervous system. Several participants reported that music therapy services were provided to clients with autism in a neurorehabilitation unit. Grob (1998) suggested that the music therapy services with clients on the autism spectrum may fall into the rehabilitation category if the clients are responsive to facilitated communication and show a degree of abstractive ability because it could be considered as restoring or gaining access towards an untapped ability. Although autism is usually categorised as a developmental disorder, it involves neurological or neurophysiological factors (American Psychiatric Association, 1994).
Our results indicate that music therapists working in neurorehabilitation predominantly work with patients living with ABI. Other clinical populations served include other acquired neurological conditions, degenerative neurological conditions, congenital neurological conditions, post-neurosurgery conditions, and other conditions that relate to and/or have an impact on neurological impairments. These findings challenge several existing definitions of rehabilitation because the clinical populations served by music therapists who responded to this survey were not limited to acquired neurological conditions. It is possible that participants lost track of the scope of the survey and provided responses based on their experience outside the neurorehabilitation context, however the questions contained a reminder of the scope of the study throughout the survey.
The prevalence of clinical symptoms and goals vs. the existing literature
A recent Cochrane review of music interventions for ABI (Magee et al. 2017), revealed moderate quality evidence for music interventions for gait velocity and length rehabilitation; low quality evidence towards other aspects of gait rehabilitation and quality of life; very low-quality evidence towards arm movement and overall communication; and no strong evidence on cognitive rehabilitation for people with ABI. However, our survey found that speech, motor, and cognitive impairments were all highly prevalent clinical symptoms addressed by respondents.
The prevalence of speech and cognitive impairments in neurological populations, and the limited evidence of studies on music therapy interventions in these areas indicates the need for further research. However, Magee et al. (2017) reviewed only clinical trials in ABI, whilst our survey gathered data on the overall practice of music therapy in neurorehabilitation. Although we found that ABI was the most prevalent clinical population served, our results on the clinical symptoms and goals may have related to other clinical populations served. Therefore, future studies could also survey music therapy services provided to the ABI population specifically and/or use other statistical methods.
The prevalence of Neurologic Music Therapy (NMT)
Neurologic music therapy (NMT) was the most frequently reported music therapy approach that participants drew upon and was a frequently reported suggestion for future music therapy training. The majority of survey participants were NMT-trained. However, as the survey was distributed via the academy of NMT, the results were likely to favor NMT approaches and training. Some NMT techniques, especially Rhythmic Auditory Stimulation, are very well supported by neurorehabilitation research (Altenmüller & Schlaug, 2013; Magee et al., 2017; Weller & Baker, 2011). This evidence base may explain the prevalence of NMT techniques used by respondents. A small number of non-NMT-trained participants reported that they still drew upon the NMT approach (as presented in Table 1 and Figure 2). Therefore, NMT clearly has a strong influence on music therapy practice in neurorehabilitation.
Although this study received responses from participants that represented all regions of the world, the global representativeness is questionable due to the high representation from the USA and Australia. The international survey by Kern and Tague (2017) gathered information on music therapy practice status and trends from over 18 countries around the world. This present study gathered responses from only 12 countries using a snowball sampling method. It is possible that music therapy in neurorehabilitation is more frequently practiced in the countries represented in our survey, however, it may just be that our sampling method did not adequately reach a representative sample of countries. Future surveys could be circulated via all national music therapy organisations and/or via the World Federation of Music Therapy in order to achieve a wider distribution.
Using a pre-defined definition of neurorehabilitation from the literature may help participants focus on a particular aspect of their clinical experience. As this study aimed to survey current clinical practice, we avoided providing any pre-defined definition of neurorehabilitation so as not to influence participant contributions. However, this meant that neurorehabilitation may have been interpreted quite differently by participants. Finally, as the survey was only distributed in English, this limited international participation and likely situates the research findings within specific cultural contexts.
In conclusion, this international study explored the current scope and prevalence of music therapy services in neurorehabilitation. We used the survey method to gather information from the real-world practices of the participating music therapists. The survey outcomes suggest that inter-professional collaboration, especially with speech pathologists and occupational therapists, is vital in the work of music therapists working in neurorehabilitation. Moreover, music therapists can expect to see an extensive range of clinical populations with neurological impairments when working in this field. Further research on music therapy for cognitive and communication rehabilitation is highly recommended in order to respond to the prevalence of the clinical symptoms found and goals formulated in this context. Also, the survey outcomes suggest that NMT is frequently applied by the participating music therapists and recommended by some participants for future music therapy training. Furthermore, future research and training could focus on therapeutic singing techniques which were the most prevalent techniques being used by our participants in their neurorehabilitation work. Finally, the results of this study should be considered by academic teachers in building the curriculum for the future music therapy students and by music therapy researchers in providing research to respond to the needs in the practice.
This study would not have been possible without generous support from the staff at the University of Melbourne. I would like to profoundly express my gratitude towards Dr. Jeanette Tamplin, the co-author, who contributed her precious time supervising me and collaboratively editing this article. Moreover, I would like to thank Dr. Katrina McFerran who introduced me to the world of music therapy research and participated in the pilot trial of this survey. Also, I would like to thank Dr. Felicity Baker who taught me the survey design and participated in the pilot trial of this survey. Finally, Dr. Tamplin and I would like to wholeheartedly thank all participants for contributing their valuable time, knowledge, and experience to this study and to the field of music therapy in neurorehabilitation.
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 The credentials included Music Therapist – Board Certified (MT-BC), Registered Music Therapist (RMT), Certified Music Therapist (CMT), Deutsche Musiktherapeutische Gesellschaft (DMtG), Licensed Professional Music Therapist (LPMT), and Music Therapist Accredited (MTA).
 The acronymic additional trainings included Neurologic Music Therapy (NMT), Guided Imagery and Music (GIM), Neonatal Intensive Care Unit – Music Therapy (NICU-MT), Rhythm, Breath, Lullaby (RBL), Music Therapy-Assisted Childbirth (MTACB), Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC), and Music Therapy Entrainment (MTE).