Rebekah Keenan is an experienced Neurologic Music Therapist working at STEPS Rehabilitation. She uses a variety of approaches and techniques to meet the individual needs to clients, whether that’s tapping into the emotional and psychological benefits of must and working creatively to support the wellbeing of clients; or using music and rhythm to improve movement and motor function.

In this “Day in the life of article….” Rebekah details what a typical day at STEPS looks like and the incredible impact that NMT can have on a client’s rehabilitation progress.

9.30 am

I arrive at STEPS, change into my uniform and set up a series of instruments in the dedicated music room, which is located in the heart of one of the residential floors. It’s a homely therapeutic space that also houses a beautiful grand piano that used to be played by Jules and Toria’s brother – Alexander – who the building is named after. My plan for the day is usually prepared a week in advance of the session, so my first task is to read the client handover note and get a verbal handover from the inter-disciplinary care and therapy team on shift, which ensures that I am completely up to date with everything that I need to know about the clients I’ll be working with that day.

10.00am

Patient X: young gentleman with traumatic brain injury. A pedestrian involved in an RTA who arrived at STEPS having come straight from hospital post injury. Having had a tracheostomy in situ since his accident he has recently been de-cannulated and since then, the impact of his brain injury has become evident. He presents with speech difficulties, that incudes significant dysarthria in the form of slurred, nasal, monotone and strained speech that is often unintelligible to the listener.

Goal: To develop greater breath control, voice projection and intelligibility of speech.

Approach & techniques used:

  • Deep breathing exercises with particular attention on musically cuing a series of voiced sounds on the out-breath and sustaining these to help build breath control. Putting power behind breath and placing inhalation carefully within lyrics of songs (and later in therapy within speech) will help him to learn to complete phrases at full sound capacity. These exercises form part of the OMREX – Oral Motor & Respiratory exercises technique.
  • X loves to use his voice, so singing & vocal exercises have been a motivating approach to rehabilitate speech. He struggles to project his voice, speaks very quietly and shows limited pitch variation. Vocal Intonation Therapy (VIT) technique uses melody through singing and repetition of simple phrases or sounds to develop voice quality and intonation. Musically led exercises encourage playful movement of the voice from low to high and high to low as well as finer pitch variation in the mid-range where the pitch of naturals speech lays. Voice projection and inflection in the voice through fun musical/vocal activities prompt active use of & development of the voice.
  • Intelligibility of speech is being worked upon through the use of a Rhythmic Speech Cuing (RSC) technique, which is a rate control technique that uses auditory rhythm to cue speech patterns. Through repetition this helps with articulation, pronunciation and clarity of speech. This technique has an immediate impact on the client’s’ intelligibility due to the rhythmic prompts he can hear. Outside of therapy a simple verbal reminder to slow his speech has the same effect.

11.00am

Patient Y: a lower limb amputee who lost his leg in a motorbike accident. He is a residential amputee client whose rehabilitation includes fitting and learning to use a state-of-the-art prosthetic limb. As a man who led an active lifestyle pre-accident, Y wants to be as independent and as active as possible post injury through focussed and individualised rehabilitation.

Goal: Development of stability, balance and posture alongside gait re-education & gait training.

Approach and techniques used: Joint Neurologic Music Therapy and Physiotherapy session. Interdisciplinary working with this client enables integration of multiple approaches to work towards individualised aims which proves beneficial to progress.  With prosthetic limb in situ, the client engages with some simple exercises to challenge balance and body awareness. Gentle rocking side to side encourages equal weight transfer between leg and prosthetic, orientation of the hips to midline position and weight bearing exercises enable the client to tolerate longer periods on the prosthetic limb. Co-ordination of arm and lower limb prosthetic movements challenges balance. Proprioception tasks challenge movement of the prosthetic in space on the floor toward target spots (whilst not looking). Squats and focussed ‘stand to sit’ exercises address specific knee bend issues. Specific movement patterns such as side steps, knee lifts, toe raises, heel lifts all contribute to effective gait. Movement patterns structured with rhythm and musical cues lead to greater precision and self control, which has an impact on improved stability, posture and balance.

The client then engages in walking with the NMT technique Rhythmic Auditory Stimulation (RAS). RAS is a scientific walking technique that uses rhythm and musical cues to entrain walking pattern and acts as a facilitating stimulus for training optimum gait. Initially time is spent walking to a steady metronome beat with musical cues in the parallel bars until the client becomes more stable on their prosthetic at which point, they move out of the bars and into other spaces with the assistance of a crutch or stick.

Patient Y is learning to shift their weight over their prosthetic as they walk, they are developing an awareness of where their prosthetic is in space (proprioception) so placing the heel more accurately, getting efficient prosthetic knee bend and lift as they step through and both speed and stride length is increasing as they become more confident on their prosthetic limb. Progression for this client could include incorporate it challenges such as walking on a gradient, gravel, cobbles or incorporating a step and/or obstacles to challenge gait & balance. Overcoming these can have a huge impact on boosting a client’s confidence and self-esteem.

Patient Y will complete a block of inpatient therapy and then most likely return home for a couple of weeks to trial self-management of his prosthetic. He will then return for two weeks rehab, have two weeks at home, this being repeated until the patient is ready to manage fully at home.

12-12.30pm

I use the gap in my client timetable to log clinical notes from the morning session onto our digital system

12.30-1.00pm

Usually, I’ll have my lunch in the café, either with colleagues or using the time to catch up on my emails. It’s lovely because we have our lunch alongside clients which helps to create a warm and inclusive atmosphere that STEPS is so well known for.

1.00-2.00pm

After lunch I’ll either attend a client review meeting, interdisciplinary team (IDT) meeting or undertake some CPD training.

2.00-3.00pm  UPPER LIMB GROUP

The Upper Limb Group is jointly led by myself and a Physiotherapist. The group uses NMT techniques and Physio led exercises to encourage nerve/muscle activation and facilitate individualised functional movements and sequenced patterns of movement.

Patterned Sensory Enhancement (PSE) and Therapeutic Instrumental Musical Performance (TIMP) exercises are carried out to a simple metronome rhythm and live music cues and prompts slow, steady movements that are repeated. Patterns of movement are driven by musical accompaniment to further entrain motor movements. Integrating instruments into exercises give spatial configurations to movements whilst providing auditory feedback and strengthening motor learning. The purpose of these activities is to develop activation of the shoulders/arms/hands/core, develop greater control over one’s movements, extend range of movement, improve posture, develop strength & endurance & encourage reaching out of one’s base of support strengthening sitting balance.

A variety of patients attend the group as exercises can be adapted to suit the individualised needs of those present. We have a combination of patients who are rehabilitating upper limb function associated with brain injury, stroke, spinal cord injury and /or orthopaedic injury. What is striking about this and the groups that STEPS run is the sense of peer support, opportunity for social engagement & interaction within rehabilitation and the impact this has on patient’s self-esteem and confidence.

3.00-4.00pm

Patient Z: a lady in her 40’s who survived a stroke following complications during surgery. As a result, she suffered with cognitive deficits such as left sided neglect and difficulties with attention. Lack of awareness to her left side meant she would not notice people on her neglected side and would eat only food from the right side of her plate for example.

Goal: To retrain the visual field of neglect so that she develops greater awareness and functional use of their left side.

Approach and techniques used: In NMT her left sided neglect could be addressed through the technique Musical Neglect Training (MNT) to encourage greater awareness and use of left sided vision and work on reducing left sided neglect. By using musical instruments in a certain way, it is possible to retrain the visual field of neglect. Placing a series of desk bells across her whole visual field - including her neglected side - and asking her to play the bells in simple sequenced patterns according to her colour, subtly encourages her to visually search for the colours she did not immediately see.

Patient Z is learning to use her left sided vision much more spontaneously. Finding a specific instrument visually, as well as gaining auditory feedback from playing that instrument increases motivation and gives her a functional objective as she increases her visual range to her left side.

Patient Z also has difficulties with sustained attention, so being able to attend to a musical task for its entirety is progress. Over the course of therapy gradually increasing the length of tasks will subtly encourage more sustained attention. Incorporating more complex elements of attention into musical tasks will challenge her attention skills preparing her for situations outside of therapy in everyday functioning eg. encouraging selective focus on a task whilst distractions are present – talking to a peer whilst in the café full of background noise OR alternating attention between two different stimuli – following a recipe & cooking the food.

4.00-5.30pm

I tend to use the last hour or so to log clinical notes from each session onto the digital system and liaise with other members of staff to our interdisciplinary approach to client rehabilitation programmes. Individual sessions are invaluable but joint working alongside other therapists is also a unique and positive part of STEPS’ approach. This interdisciplinary way of working within sessions allows for complete collaboration between therapists that focusses on the individual needs of the client.

Our collaborative groups include:

  • Upper Limb Group (described above)
  • Balance Group (NMT/PT led) for amputees and/or patients with gait, balance, coordination & initiation of movement problems due to neurological or spinal cord injury. Aim: To improve efficiency of movement patterns by developing greater precision and self control and to improve stability, posture & balance.
  • Voices Group (NMT/SLT led) for patients with changes to voice, speech and communication secondary to injury or medical condition. Aim: To improve breath support, learn how to use the voice efficiently, learn phonation, pitch control, vocal power, learn about resonance, articulation and practice oral motor control.
  • Cognitive Music Group (NMT/SLT led) for patients with engagement difficulties & attention deficit. Aim: To develop specific cognitive skills around social engagement, attending to task, challenging different types of attention & learning executive function skills.

We also have plans for a Relaxation Group (pain management/healthy sleep/anxiety/mindfulness/wellbeing); Aqua Balance Group; and Music/Art Therapy Group to name a few. It’s great being part of the STEPS team as there is a genuine desire to think imaginatively about how we can work collaboratively to get the very best out of rehabilitation therapies for clients.

FURTHER INFORMATION

About Rebekah Keenan, Neurologic Music Therapist

Rebekah is our Neurologic Music Therapist (NMT) and Psychological Therapies Lead. She qualified as a Music Therapist in 2003 with a PGDip and since then has practiced as a HCPC registered Music Therapist. She has also completed her Masters in Music Therapy, and in 2017 she completed her International Neurologic Music Therapy training through The Academy of Neurologic Music Therapy, becoming an Affiliate in 2017 & a Fellow in 2019.

About STEPS Rehabilitation

STEPS is a multi-award winning, specialist residential and outpatient rehabilitation facility in Sheffield for patients with neurological conditions, acquired brain injury, spinal cord injuries, stroke, amputation, orthopaedic and other complex trauma injuries.

About NMT

Music Therapy from a registered therapist can be particularly beneficial within a rehabilitation setting as it uses a variety of approaches & techniques to meet the individualised needs of patients. On the one hand the emotional & psychological benefits of music & working creatively can have a significant impact on the wellbeing of patients. For example, a patient who has suffered a traumatic event might use song writing to express feelings & anxieties. Alternatively, a  patient who suffers with chronic pain may use joint music making with the therapist & independent music making in between therapy sessions as a distraction technique from the pain they are experiencing. Some patients engage musically as a means of non-verbal expression, but this can then prompt important verbal expressions that would not otherwise have been communicated.

As well as the more traditional Music Therapy approaches to meeting patient’s needs NMT provides specific techniques that are objective driven & strongly supported by neuroscience. The focus of NMT is on three areas: 1) Improvement of movement & motor function (music & rhythm is used as a stimulus for re-learning patterns & sequences or movement – walking/gait, functional tasks such as drinking from a cup or simple active movement. 2) Improvement of speech, language & voice production (respiratory & vocal exercises that incorporate lyrics & rhymes can help breath control, articulation, pitch, communication). 3) Improvement of cognitive functions (musical tasks can exercise spatial/visual neglect, attention functions, executive function skills, memory, emotional regulation & auditory perception).  I work closely with the therapy team at STEPS contributing to shared patient goals, optimising rehab outcomes, and working alongside other therapists (interdisciplinary working) to carry out regular joint sessions where appropriate, through which our multiple approaches contribute to achieving individualised aims.