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continuation from 3/3 MED 545 Music in Rehabilitation
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Date Created: 03/05/15
Music in Rehab 2 For resource citations you don39t have to put URL S for journal articles because they have printed versions Be speci c with range in descriptions the exact notes of range Include decades for the music 2122015 ACQUIRED BRAIN INJURY 1 STROKE Acquired brain injury Any brain injury acquired after birth Congenital is when it did NOT happen after birth Three causes CVA TBI and Hypoxic brain injury due to oxygen deprivation caused by maybe a heart attack near drowning electrical shock lightning strike choking allergic reaction or drug or alcohol abuse or exposure to toxic chemicals Glasgow coma scale a behavioral assessment of brain injury It is used when patient is in a coma Degree Of unconsciousness and to determine recovery They look at eye response verbal response and motor response chart A lower score means a higher amount of injury This was the rst scale that provided the rst indicators to really look for But it39s only for comas so what if your patient isn t Coma quotDisorders of consciousnessquot PostTraumatic Amnesia PTA The rate of amnesia postinjury Where they are in terms of injury and recovery CVA STROKE Stroke The sudden appearance of neurological symptoms as a result of an interruption of blood ow Infarct An area of dead or dying tissue resulting from the obstruction of blood vessels The one on the right of WHAT IS A STROKE is the one with the infarct 2 TYPES OF STROKES Ischemic CVA Caused by vessel blockage that prevents suf cient supply of blood to the brain This type of stroke is the most common 8087 of strokes Also more typically found in older adults Thrombosis a blood clot develops in the blocked part of the vessel causing an ischemic stroke Embolic a blood clot forms somewhere else in the body and breaks away to travel to some arteries in the brain and gets stuck in that artery Causing an ischemic stroke The precursor for both causes is arteriosclerosis a narrowing of the artery through a thickening of hardening buildup of plaque Second kind of stroke Hemorrhagic Stroke Damage in the brain due to ruptured blood vessels in the brain Its bleeding your hemorrhaging massive bleeding you can39t stop Most commonly caused by high blood pressure or hypertension Or congenital defects Can39t remember Two types of ruptured blood vessels Aneurysms A blood vessel becomes too weak to move the blood through and it expands and then pops AVM arteriovenous malformation a cluster of abnormally formed vessels Most closely related to a congenital defect to abnormally formed vessels and they can rupture 2 Areas this can happen Hemorrhagic CVA lntracerebral the rupture of vessels inside of the brain A rupture of small arteries deep in the brain It results in additional in ammation and swelling of brain tissue as well as damage to deeper structures Like the hippocampus basal ganglia cerebellum or brain stem thalamus etc This kind of hemorrhage 1 Symptoms tend to be really diverse There39s no speci c symptom list It really depends on where it is and since it happens so deeply it can affect many areas 2 It has a good prognosis better than ischemic stroke Subduralsubarachnoid meninges are layers that protect your brain and these are those areas underneath those layers lt s bleeding that happens underneath the protective brain covering dural and arachnoid space When this happens it forces blood to the brain and causes damage very quickly The onset is abrupt and is typically fatal N EU RAL AREAS IM PACTED Anterior Cerebral Artery ACA Serves Medial and Dorsal parts of the brain Symptoms include contralateral leg weakness because of the area of the motor cortex and somatosensory cortex that is affected If both hemispheres are impacted then you could have profound mentalcognitive symptoms because of damage to the frontal lobe Middle Cerebral Artery MCA Lateral parts of the brain This is the one most commonly affected 1 You39ll nd contralateral muscle weakness 2 Contralateral loss of sensation 3 Loss of speech production if on the left side None of this is speci c because it covers a wide area Posterior Cerebral Artery PCA Ventral and posterior This one is not as common Thalamus can be affected symptoms could be numbness or severe or chronic pain colorblindness occipital lobe color blindness and contralateral visual eld defect The loss of the blood supply location will determine what neural area or areas are impacted Two things to consider 1 Artery supply 2 Which hemisphere Remember her example of where damage occurs in the hands Study NEURAL AREAS OF IMPACTED slide pictures STROKE SYMPTOMS HEMISPHERE The hemisphere also affects what is affected in a stroke Most common for stroke to affect either one hemisphere or the other instead of both sides Left hemisphere CVA right side sensory motor dif culties The upper extremity is often affected Difficulties in balance is common and gait Hemiparesis Muscular weakness affecting one side of the body Hemiplegia paralysis of one side of the body Communication impairments Expressive aphasia and receptive aphasia and dysarthria Expressive aphasia may see disturbed prosody effortful and slow speech long pauses between words word nding dif culties poor word repetition it39s hard to repeat things Dif culty with word nding and sentence structure Slow and effortful speech as in the video of the woman in the night gown Lack of prosody or intonation Her sentences had a lot more slurring than even just the single words Receptive aphasia Speech itself is uent But the language is incorrect or inappropriate They may use nonsensical words mispronounce words or may use too many words Use of nonsensical words don39t always follow through on directions NOT COGNITIVE it39s a language processing skill The video showing the man saying quotit39s a footballquot while he39s gesturing to his mouth He is not disturbed as the woman with expressive aphasia He may not even be aware of his aphasia This is commonly the difference between the two aphasias Aphasia is a language disorders There are other types of aphasias but we won t get to them Dysarthria a SPEECH disorder Poor articulation poor voice control and distorted or slurred speech as if they are drunk They don39t the oral motor or vocal control It39s the oral motor and voice control that is affected but noting cognitive Muscle weakness Video Boy who is making a blog and drools a lot He39s speaking about the impairment What he39s saying makes sense and you can make out what he39s trying to say It39s just the physical act that39s stiff and dif cult Cognitive impairments of Left Hemisphere CVA short attention span poor short term memory impaired analytical and abstract thinking There39s poor frustration tolerance form working so hard fatigue and disinhibited behavior can t control behaviors as well as inappropriate laughing and crying RIGHT HEMISPHERE CVA Biggest differences are in cognition and social emotional Left side sensory motor dif culties upper extremities often affected Sensory motor dif culties involves dif culty with posture balance and weight shifting like in walking There39s also impairments in handeye coordination hard to eat cook and other ADLs Communication Very verbose and tangential speech No aphasias or dysarthria but They say too many words on an offtopic tangent There will be some comprehension dif culties such as following fastpaced conversations and understanding meanings in conversations Also dif culties in nonverbal communication behaviors such as eye contact gestures and vocal intonation When you lack vocal intonation it39 aprosody They have dif culty understanding recognizing and interpreting nonverbal communication from others raising brows crying etc 2172015 STROKE SYMPTOMS HEMISPHERE continued Accident on the right side of the brain BOTH sides can have hemi the two of them Cognitive impairments there are more in right CVA than there are in left CVA in general Poor attention skills in general short attention span poor selective attention as well as alternating and divided Poor problem solving skills Poor initiation and completion of tasks Learning and memory poor short term memory and dif culty learning new information Left visual neglect is also seen in a right CVA this is an ATTENTION disorder NOT A VISUAL IMPAIRMENT It39s an inattention to contralateral visual information Social Emotional effects Emotional Lability Lability is the regular occurrence of unstable disproportionate emotional displays Unstable meaning it can happen quickly and be trigger easily Disproportionate meaning under or over exaggerated More likely it39ll be over exaggerated There39s poor body image and at affect in the social emotional effects of right CVA as well as apathy impulsivity egocentricity and poor insight MOTOR DEFICITS This is not speci c to a hemisphere This is referring to CVA39s in general 1 Reduced muscle strength and endurance over all even on the unaffected side 2 Reduced exibility 3 Disturbed muscle tone 4 Abnormal gait patterns Muscle tone remember that you can see as the person regains their functions there will be three stages of muscle tone that goes towards the typical level of functioning 3 muscle tone stages 1 Flaccid limp dif culty initiating movement then 2 Muscle spasticity more tightness Movements are there but they are awkward and uncoordinated and 3 Return to normal muscle tone and smooth coordinated movements Gait characteristics abnormal gait comes with dif culties in weight shifting decreased exibility strength and endurance Poor balance and posture decreased arm swing poor foot clearance the opposite foot automatically swings when the other takes a step with a stroke you may not be able to lift your toes and then you39ll trip when walking uneven stride length distance of one heel strike to another The shorter stride leg is the affected leg The unaffected leg just catches up quickly remember the video of the quotthreepoint gaitquot with the woman walking with the cane She didn39t really lift her toes at all TREATMENT With a CVA you can do drug therapy but only effective if they are within 3 hours of the accident It39s to reduce the blood ow Anticoagulants to reduce blood pressure to dilate vessels reduce the extent of the damage etc Once a person has a stroke they39ll commonly receive the physical occupational and speechlanguage pathology Physical mostly focuses on gait for stroke patients Occupational will mostly focus on developing and recovering daily working skills upper extremity sensory motor skills ne and gross motor and cognitive skills like decision making meal planning etc Speechlanguage pathology will of cially diagnose which diagnosis it is and take care of it from there Music therapists will cotreat a lot They39ll see what goals and objectives would be appropriate to work on in music therapy TBI CP amp MS ACQUIRED BRAIN INJURY TBI TBI DEFINED TBI a wound to the brain that results from a blow to the head Most often an external mechanical force They are nondegenerative and noncongenital Open head and closed head Music therapists mostly see closed head Open head the skull is penetrated such as a gunshot wound or a sort of laceration Effects are localized and speci c to where the blow was Closed head When the skull is not penetrated Some causes car accidents sporting injuries assault a fall combat injuries recreational activities like skiing etc These TBls could have localized or generalized effects Localized effects involve a coup andor countercoup Coup brain bruised A swelling of the brain Countercoup a secondary bruising that happens on the opposite side Often caused by the swelling from the original coup More discreet impairments with speci c impacts Generalized effects could be that the WHOLE BRAIN swells up with the coup Sometimes a TBI can lead to seizures can of course impact functioning DAI Diffuse axonal injury injury to axons or white matter tracks in the brain Hydrocephalus can also lead to more generalized impairment increased uid on the brain that brings pressure on the brain Continuum Of effects TBI can be a concussion most closedheaded TBls ARE concussions Nausea problems with concentration balance sensitivity of lights and sounds are temporary affects You may have complete loss of consciousness Impact of the closedheaded TBI will depend on the intensity of the impact itself and the extent of the damage from that impact There are a variety of symptoms that don39t present that same way from person to person headache fatigue drowsiness nausea vertigodizziness and loss of balance some numbness sensitivity to lights and sounds and blurred vision Cognitively memory and concentration problems may be seen Slurred speech too Mood changes and feelings of depression and anxiety ACUTE TREATMENT There39s the Glascowcoma scale as we talked about before Or the Posttraumatic amnesia or a CT scan to assess brain damage There may be a surgical procedure to reduce swelling and minimize it getting worse Primary goal to limit any secondary damage like seizures Once the person is stable functional goals can be worked towards SMA Supplementary Motor Area FUNCITONAL IMPAIRMENTS Gross motor functioning impairments in strength balance speed and coordination Fine motor skills decreased speed and coordination It s harder to grasp objects and it takes a lot of time and effort Impairments in tone and movements too Spasticity speaks to tone It is tightness from increased muscle tone It makes them stiff and movements very dif cult Ataxia is impairments to movement patterns Unbalanced uncoordinated and jerlq movements Damage to the cerebellum could lead to ataxia Movements are strongly connected to the length they are in a coma The longer the harder it39ll be to get to some sort of functional motor skill Sensory hearing and visual Hearing loss if generally unilateral one side If it happens it39s generally with higher frequencies Visual impairments visual processing could be impaired overall If TBI results to damage in cranial nerves you could have limitations in eye movements for tracking and moving them up and down This could lead to double vision and decreased acuity accuracy FUNCTIONAL IMPAIRMENTS CONTINUED Dysarthria the slurred speech we saw earlier No control of oral motor muscles There may be generalized processing issues NOT aphasia like not being able to take turns or a less appropriate use of language Social communication behaviors are impaired More could be starting a conversation or engaging in a conversation Attention learning and memory executive functioning could all be cognitive challenges in TBIs In general with cognition there could also be slower processing They can39t respond right away they need to think about what you said and then think about what they are going to say Socialemotionalbehavioral challenges with impulsivity Or impaired ability to regulate in general It could be emotional regulation behavior regulation to self manage and control behaviors like kids shifting from recess to in the classroom there could be social isolation that person and their family now has to get used to a new normal that involves a strong emotional process or you could just not want to see anyone at the moment or mood and personality changes TREATMENT Severity the more severe the worse the prognosis Also length of time in ICU Age of injury whether it occurs in childhood rather than adulthood And older adult may have a worse prognosis than someone in their twenties Environmental factors like the stronger your support network access to resources and services socioeconomic standing Each of these make a difference MOST TBI39s are mild 75 with full recovery because they39re mainly just concussions Interdisciplinary physical speech recreational occupational social workers psychologist etc As an adult the team will also look for the adult to have a good community reintegration They are different now so they may need help with adjusting to the new normal They may need a new job how are their friends and family going to adjust OTHER NEUROLOGICAL DISORDERS CEREBRAL PALSY A group of disorders Neurological disorders that lead to motor impairments It39s common to have cognitive impairments with that Not always but very common Most are congenital Some are acquired but most are congenital They permanently impact body muscle movements and coordination BUT NOT DEGENERATIVE No recovery but it doesn39t get worse Therapy can really help to maintain or improve their functioning Different types of cp spastic dyskenetic and ataxic Each of the three have speci c areas in motor processing that are affected In spastic CP motor cortex abnormal increase in muscle tone the most common CP commonly congenital they will often have shorter muscles imbs pelvis and spine may have deformities when they39re adults because those muscles didn39t develop correctly Dyskenetic CP Basal Ganglia Slow writhing types of distorted movements and movement patterns It impacts walking and ability to control their muscles Ataxic cerebellum is impacted Trouble maintaining posture and movements are jerlq and uncoordinated Other cognitive de cits with CP are common Attention learning and memory visual and hearing impairments hyperactivity and impulsivity CP there39s a lot of variability between individuals 2242015 CEREBRAL PALSY They39ll receive physical therapy occupational therapy and speech pathologist MULTIPLE SCLEROSIS Affects the white matter of neurons in the brain A degenerative disease of the CNS white matter White matter the myeinated axons The disease attacks and destroys the protective myein sheath around the axons The quotattack and destroyquot usually happens in patches where just parts of it are destroyed There isn39t a rhyme or reason as to what is destroyed and when It s like a plaque or scar like a scab on your knee In ammation can be caused All of this contributes to the behaviors of the disease quotSclerosisquot is Greek for hardness When we have these plaques and destroyed myein neuronal impulses are delayed blocked or dispersed they just go anywhere go rogue The common areas where myein is affected is the spinal cord brainstem the cerebellum and the optic nerve The causes are unknown but there does seem to be a genetic predisposition and more common in women twice as likely Less common in people from a normal European background check online Age of diagnosis is very young 1840 The disease itself can last 2040 years You can have remissions and relapses in MS Remission is a period of time when the symptoms go away Happens when in ammation subsides Relapse is when symptoms come back Symptoms are very unpredictable They also vary individually Sensory impairments very common for legs to feel heavy and numb eventually they are wheelchair bound There will be a decreased pain and temperature perception increased pain in certain areas optic nerve may experience ashes darkening etc Nystagmus is an involuntary jerlq eye movement It39s like an eye muscle spasm There can also be hearing loss and vertigo Motor deficits overall dif culty walking and eventually need a wheelchair Increased fall risk Muscularly can have abnormal muscle tone lack of muscle control or there may be muscle weakness Cognitive slower information processing memory de cits and disturbed executive functioning Emotionally Depression anxiety frustration especially as you lose functioning you previously had and decreased motivation Treatment To maintain functioning as long as possible such as steroids drugs to regulate immune system lots of physical and emotional rest stress anxiety or extreme temperatures can exacerbate symptoms therapies are geared towards motor gait maintaining functional movements and cognitive issues of domains NEW LECTURE SPEECHLANGUAGE SPEECH Look from Music and Development The ability to produce and articulate sounds Language socially shared rules for a communication system Syntax semantics etc Communication The idea of having meaningful exchanges of communication Verbal nonverbal musical or other mediums SPEECH PRODUCTION Music in rehabilitation the most common area we work on is speech producing and articulating sounds Different components to work on 1 Vocal aspect respiration 2 Articulation involving a place of articulation and you need an articulator lips or tongue 3 Fluency contour and rhythmic elements COMMUNICATION Music therapy can work on especially nonverbal communication skills oooppsss SPEECH AND LANGUAGE DEFICITS AND NOODS Rate pace of speech Fluency the general pauses timing and rhythm of the speech Prosody in ection Respiration and articulation are precursors to speech consonant vowel combinations lnitiation onset and starting speech Production producing any sort of speech whether it has functional meaning or not Functional production has meaning quotI39m hungryquot Practice to relearn and allow for rewiring to happen to do it over and over again SPEECH AND LANGUAGE TRAINING RATIONALE Four reasons why SCIENTIFIC LOGIC 1 Differential Hemispheric Processing Understanding the way in which the brain processes speech and processes music Left hemisphere is dominant in speech processing Aspects are processed in the right hemisphere too Music processing also takes place in both sides of the brain but differently on each side Rhythm and tempo are in the left while melody and pitch are in the right Left is with spatial temporal aspect for speech processing Right is more holistic aspect of speech like intonation and prosodic factors These are both parallel to the musical processing SCIENTIFIC LOGIC II Gestalt gestalt theory Our brain likes patterns and organizes information into patterns Music is a good gestalt It is highly patterned and organized which makes it easier for our brain to process musicbased information Time rhythm temporal timing organization and pitch organization etc SCIENTIFIC LOGIC III Priming the brain for these processes prepares the brain for this new processing There are shared and paralleled processing in language and music Music can prime areas of the brain needed for speech and language SCIENTIFIC LOGIC IV Rhythmic entrainment Our motor system entrains to rhythm Rhythm helps organize it Our muscles and muscle groups organize movements in time This parallels with oral motor skills to help with uency and rate Even with initiation too MUSTIM Uses FAMILIARCOMMON SONGS quotYou are my sunshinequot quotstarspangled bannerquot etc To stimulate nonpropositional speech speech not meant to express any sort of meaning it39s very context specific or any sort of speech that doesn39t have a semantic meaning initiation production PRIMARY GOAL To stimulate speech production Can be used with any of speech and language disorders we39ve talked about apraxia aphasia and dysarthria It s a treatment to get just any sort of speech production going OMREX Exercises designed to address 2 skills articulation CONTROL and respiration STRENGTH GOAL to improve muscular control of speech or respiratory apparatuses and to practice the production of speech sounds It39s appropriate for dysarthria and apraxia VIT Vocal exercises Used to improve voice control It can be pitch dynamics in ection or timbre This is not as commonly used because it39s more specialized to use the OTHER techniques but these exercises for VIT are more foundational like scales Used for dysarthria THERAPEUTIC SINGING A speech technique Designed to help a person practice speech production any and all aspects It39s a practice piece Very common for the end of the session It is different because TS is to encourage the client to sing the whole time for the whole song SYCOM To train NONVERBAL communication behaviors Speci c to music improvisation Verbal can be incorporated too if it39s vocal improvisation but it may not be using words either It teaches turn taking dialoging back and forth 2262015 Language is hwen we use symbols to communicate some intent such as written or said out loud through your body when we know what the symbols mean and the receiver knows what they mean it39s language Speech it s the physical transmission of sound That39s typically has some type of meaning But it doesn39t have to be a symbol or word such as mm mmmm or mhm There39s a strong motor or movement component to make speech happen We want to be very clear when using these terms above They are related but not interchangeable BASED ON THE WORKSHEET The process of motor for speech and language begins with the brain See the CNS CNS MOTOR PLAN When we think umbrella and say umbrella itjust activates the plan to use the movements to say umbrella They become very welllearned movements Next nerve impulses The signals along the axons of the neuron Then once the nerves get to the muscles they produce movements This produces air ows and pressures which then all creates speech Physiologic part ve step process 1 Respiration make sure to have enough air to produce the sounds We expand the lungs 2 Phonation vibrating the vocal folds and making sounds Controlling what the folds are doing 3 Resonance the unique timbre of each voice 4 Articulation the air ow is leaving the body and interacting with different articulating structures Lips teeth tongue and both palates and yourjaw 5 Fluency it should all be perceived as a uid and intelligible sound Fluency really reveals how the other steps prior to it are doing because if one is weak we will hear it in the uency Dysarthria A neurogenic speech disorder Arises in the nervous system There is a problem in the brain but nowhere else The brain is not allowing the structures to move as they should Fundamental movement de cit They can39t move as they should for speech This leads to impairments in speech intelligibility DYSARTHRIA There is a problem with nerve impulses getting to where they need to go Disturbance in the transmission of nerve impulses to speech musculature They39re not getting there at the right time or with the right strength There39s dif culty controlling and coordinating speech movements Six different types They have similar features but the underlying neurology can be very different for each HYPOKINETIC DYSARTHRIA Characteristics of dysarthria 1 Disturbed rate the speech rate tends to be accelerated even though there is overall less movements Lots of fast rushes of speech that is unclear and dif cult to understand 2 Articulation errors can39t re ne structures such as distortion substitution omission errors etc 3 Disturbed prosody it sounds like the melody of our speech There39s a very strong rhythmic component It should add a lot of in ection CLINICAL POPULATIONS WITH DYSARTHRIA Usually comorbid Developmental Cerebral Palsy spastic dysarthria Rehabilitative Parkinson s and TBI RHYTHMIC SPEECH CUEING RSC For patients with severe dysarthria Works REALLY well with this population Goals to modify speech rate to spread out the distribution of speech sounds and gain control to improve speech intelligibility ASSESSMENT Determine the client39s habitual speech rate HSR First establish HABITUAL SPEECH RATE Have the client read out loud simple sentences you have prepared Measure the time it takes for them to read those sentences in seconds BIG PAUSES ARE INCLUDED Divide total number of words by reading time Multiply by 60 so that answer will equal words per minute wpm Typical speech rate is 190 wpm Now establish ENTRAINMENT VIA FlNGERTAPPING Entrainment sounds serving as signals that drives the motor responses Here the tapping is to drive the speech motor response Adding nger tapping strengthens the signal ofjust rhythmic cues alone It39s a combination of what we re hearing and what we re doing with our hands We want to know that client can tap nger in time with habitual rate for 15 seconds Once we know our patient can do that we want to see that they can entrain at a slower tempo Repeat at new tempo set at 60 of habitual speech rate It39s to compensate for the fast spurting We want to slow it down and spread it out so that it39s more even For example take 204 times point 60 and that equals 122 So you reset the metronome at 122 Now move on to Speech cueing 3 Client wi tap nger and speak sentences at 60 of habitual rate Use one of two approaches First is metered rhythmic cueing METERED RHYTHMIC CUEING Give equal duration to each syabe or word spoken out loud It will sound robotic but the goal is to sound intelligible This is best for severely impaired speakers The second one is Patterned rhythmic cueing PA39I I39ERNED RHYTHMIC CUEING Give relative durational value is given to each syllable based on natural speech patterns You more or less say it with natural speech rhythm but at the set pace Best for midy impaired speakers The other approach will make the speech of those with mild impairments worse Fourth step is to reassess determine client39s habitual speech rate using a new list of sentences when and how often you reassess will be based on how often you see them sentences are usually 6 to 10 words THESS ON RSC BYJOY OUELLETI39E For those with PD it39s hard to tap and speak at the same time They tend to rush It improves when the therapist taps and the client just speaks This may range from ten to thirty minutes or they may be built up They should be every day But re training the brain is exhausting APHASIA A LANGUAGE DISORDER Dysarthria is of speech EXPRESSIVE APHASIA or Broca39s aphasia or non uent aphasia Inability to produce meaningful speech and language a motor component and cognitive component CHARACTERISTICS Adequate comprehension can mentally formulate a language response and have dif culty quotgetting the words outquot It39s telegraphic language instead of quotgetting a cup of coffeequot it becomes quotcup of coffeequot Poor organization of words incorrect grammar repetitive language and telegraphic language It s slow and labored 50 wpm They also have abnormal prosody CLINICAL POPULATIONS WITH APHASIA Stroke Cerebrovascular accident MELODIC INTONATION THERAPY For patients with severe Broca39s Aphasia It is NOT APPROPRIATE FOR OTHER TYPES OF APHASIA On occasion it can work for patients with apraxia GOAL OF MIT To have uent output of language Saying what you want to say that makes sense to other people Look at more handouts HOW TO DO MIT 3315 Broca39s aphasia is most likely a lefthemisphere stroke GOALS OF MIT To improve the uent output of language 7 principles of MIT 1 Most appropriate for those with expressive or Broca39s aphasia 2 To structure the music in a very intentional way emphasize melody rhythm and points of stress 4Step protocol it39s important to go slowly The four steps are hierarchal they may not all happen in a single session but as the client is moving on they will move on to the next step when they39re ready You may leave off one session on level 2 but when you come back you will bring them back to level 1 and still go as far as you can Find handout Level 1 MT hums and hand taps The client hums the melody and MT continues hand tapping MT fades little by little in singing until client does it independently Level 2 Brings a little bit comprehension Humming by MT then sing the sentence with the hand tapping and then the MT has the client sing the sentence with them The MT eventually fades Then they mirror each other of singing it back and forth between them Followed by a comprehension question It39s a recall of what they just said I want a cup of coffee what do you want a cup of Step 3 Response latency This incorporates a delay in the responding A mirroring of each other but incorporating an organized delay Another comprehension question but this one is more contextual it will provide enough context but won t bring in exactly what you just said This will help with transference When you wake up in the morning what do you drink Step 4 transitioning to strictly singing the melody to the spreschetimme the speech song You39re not singing the melody but it39s a speech song It39s speaking with exaggerated prosody No hand tapping A quotsingsongquot like manner It begins with the hand tapping but it eventually fades It39s the same back and forth mirroring as before incorporating delays in responses Same contextual comprehensive sentence When you wake up in the morning what39s the rst thing you ask for These steps kind of blend together There is de nitely some overlap which takes each substep to move smoothly between each other Scaffolding If the client struggles somewhere you can prompt them by reminding them about hand tapping or humming or singing 3 Melodies of MIT are very structured The melody should be based on natural speech prosody Make melodies out of functional sentences Do not use familiar melodies they should be originally composed This way nothing is triggered to be counterproductive Limit the vocal range Stick between quotdoquot and quotsoquot Between C and G The contour and rhythm match the natural prosody when they speak the phrase As treatment progresses more sentences will be learned 4 This technique is based on a gradual progression of task length and difficulty Only doing one step forever or how they blend together and building endurance 5 When the client makes a mistake you do not have them do it again Do not retry errors What you do is go back a couple of steps f client doesn39t say it alone correctly then you just go back and sing it together again Overall there39s a lot of nonverbal direction especially in the later steps 6 When working with the client you39re going to want a lot of functional sentences so that you39re using different ones on each session day Otherwise it could become very repetitive 7 Practice Sessions should be frequent At least daily if not multiple times a day They don39t have to be long just have to be really frequent COGNITION Four cognition categories in NMT techniques Attention executive functioning learning and memory and psychosocial training Attention organizing and orienting to sensory input Executive functions management of cognitive processes Memory and learning memory training MACT Attention the selective awareness of or selective responsiveness to the sensory environment Several different types Focused attention the ability to respond to a speci c stimulus Sustained attention the ability to maintain a consistent response during a continuous activity Selective attention the ability to maintain a behavioral or cognitive focus in the face of competing stimuli Alternating Attention the ability to shift your focus to move between tasks Like shifting between having dinner and attending to your waiter Divided attention the ability to respond simultaneously to multiple tasks Driving a car Multitasking MACT The use of music experience andor musical elements to perform a speci c type of attention Musical elements include accompaniment timbre rhythms lyrics sudden abrupt changes nonverbal cues and pauses and dynamic levels IMACT isn39t used for focused attention Sustained shaking and stopping with egg shakers example Selective attention body percussion example Two different rhythms going on at the same time Maintain your focus on your rhythm while others are playing something else Alternating attention pairing different strumming patterns with movements There are different stimuli and shifting your behavior based on your observation Divided attentionAdaptive music lesson Playing piano or learning by rote Practice the MACT behavior There must be multiple opportunities for the client to practice the speci c attention More scaffolding The order that they39re presented in the example above that39s the hierarchy of them all MSOT targets focused attention MSOT The use of music live or recorded to stimulate arousal and to facilitate meaningful responsiveness and orientation to time place and person Orientation of time place and person incorporates elements of focused attention MSOT is precursor to attention to MACT There39s a large continuum of what you can work on Basics are working on stimulating arousal singing to a client and just searching for a cue for their response that indicates that they39re processing and responding in SOME WAY Even ifjust heartbeat Then you could look for opening their eyes and looking at you There are indications that they are paying attention to you orienting and watching you They sense you39re there Advanced stages include music for more active engagement It could be to tap their hand To squeeze your hand This helps to train their basic attention maintenance to maintain it for some period of time MSOT is very commonly used for coma states from TBls strokes maybe other diagnoses It39s also done pretty early in the treatment process You39re providing auditory processing stimulation You know ahead of time what responses you39re looking for Be very careful with the music stimulus You may play familiar music or strip to a hummed melody Ere on the side of being conservative Musical Neglect Training The most common type of neglect is a processing issue Their eye balls see it but there39s a disconnect to the visual sensory processing areas Then the information isn39t processed and hence the neglect Usually with TBI or right hemisphere CVA lt s perceived by not processed or properly distributed You use music to redirect visual attention to the left visual eld Or stimulate movement on the left side of the body You draw them to perceive what39s in their left visual eld
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