Many thanks to Dr Wendy Magee for continuing to contribute and feed into this important consultation on behalf of the profession.
 
Please follow this link to the DoH website: A new ambition for stroke - a consultation on a national strategy

Association of Professional Music Therapists (APMT)

Position Statement for the DoH Stroke Strategy

About music therapists.

Music therapists have clinical expertise in using music-based methods to address communication, mood and physical functioning after stroke as part of interdisciplinary care. Music therapy can therefore make a valuable contribution to patient care through specialist knowledge and skills within the stroke care team.

Music therapy aims to improve functioning through the use of music-based methods which optimize an individual’s ability to engage with their environment and maintain relationships with people. Thus, by improving function across a range of health domains, music therapy helps to improve quality of life overall.

Input to the stroke care pathway.

Music therapists have a valuable part to play during the rehabilitation phase of recovery[1] addressing communication, physical and psychosocial functioning. There is greatest evidence for patient benefits within this phase. The treatment process includes assessment (determining whether music therapy can help); intervention in either individual or group settings dependent on the patient’s specific problems; contribution to discharge guidelines and recommendations. On occasion, intervention may be delivered in collaboration with another health discipline, dependent on the patient need. There is little evidence as yet for music therapy in the post rehabilitation phase of the care pathway, once the patient is discharged to community settings. However, given that depression following stroke contributes to abnormal quality of life more than one year post-stroke[2], emerging research suggest that music therapy may be able to contribute to community services to address psychological functioning [3].

Proposed staffing levels.

The APMT recommends at least 0.6 WTE music therapist for every 10 beds in a rehabilitation setting. Staffing levels must ensure

·        Service delivery appropriate for rehabilitation i.e. repeated contacts across the week to ensure effective relearning can take place

·        Both direct and indirect patient care such as involvement in interdisciplinary forums, documentation and training.

These are the very basic requirements in order to ensure optimal use of resources and to minimize any risk in service delivery.

Supporting evidence.

In the UK music therapy is a scarce resource in NHS rehabilitation settings. In 2005 a survey of rehabilitation units found only 1.8 WTE in post spread across four units, although a further 9 units expressed the perceived need for music therapy. Posts were mostly part-time, averaging at only 0.18 WTE per 10 beds. The perceived need for additional music therapy resources in the 2005 survey averaged at 0.55 WTE per unit. Therefore, although music therapy is currently a scarce resource in rehabilitation, services have identified the need for its inclusion in treatment programmes. Where integrated into neurological rehabilitation teams music therapy is perceived to have a role in rehabilitating communication, social, emotional and behavioural functioning[4]. Therefore, a strong argument is made for staffing levels which enable music therapy to be involved in interdisciplinary forums in order to ensure its contribution to patients’ care is optimised and resources are not mismanaged. A Cochrane review of the evidence for music therapy in stroke rehabilitation is currently underway[5].

1. Role in Communication Therapy.

Rationale.

Over one third of stroke survivors have persistent speech, language or communication problems[6]. Six months following a stroke 15% of stroke survivors still experience communication problems[7].

Vulnerability: risk issues.

Research has shown that the health-related quality of life experienced by people with communication problems after stroke is significantly affected by their emotional distress, the severity of their communication impairment and their overall health[8].  Therefore intervention should aim to reduce the risk of emotional dysfunction, including improving the person’s communication function.

The role of the music therapy in improving communication disorders after stroke.

Music therapists have specialist skills in using methods which can improve speech parameters, vocal functioning and expressive language output as part of an interdisciplinary treatment programme. Intervention helps to maximise the communication function in people following stroke.

Supporting evidence.

The best evidence to date is from random and clinical controlled trials with small numbers of subjects. These reveal that music therapy has positive outcomes with people who have had stroke on expressive communication disorders[9][10][11][12] (i.e. aphasia) and speech disorders[13][14][15] (i.e. dysarthria, dyspraxia). Music therapy has also been found to improve social communication skills in individuals with acquired neurological conditions[16] which is a wider part of communication functioning.

2. Role in psychosocial rehabilitation.

Rationale.

Many people have mood disorders after a stroke.  Depression commonly occurs after a stroke, with an estimated prevalence as high as 30% in the first year after the event[17]. It is well known that poststroke depression affects quality of life, functional recovery, cognitive function and health care use in stroke survivors[18].

Incidence.

Clinically significant depression is frequent after stroke[19] and does not reduce within the first 15 months [20].

Vulnerability: risk issues.

Within the rehabilitation phase of the care pathway, mood disorders can effect an individual’s motivation to engage in their rehabilitation, resulting in a waste of resources and poor outcomes for the patient. Depressive symptoms and functional outcome are correlated in post stroke recovery [21]. Mood disorders can also affect the individual’s ability to engage in their social network e.g. with family and friends, resulting in increased isolation and risks of prolonged mood disorders. Music therapy is a motivating medium which can motivate the individual to engage in their broader rehabilitation programme.

The role of the music therapy in improving psychosocial functioning after stroke.

Music therapists have specialist training to address psychological needs through psychotherapeutic methods. Improving mood disorders and psychosocial well-being helps to maximise emotional functioning following stroke and engage the patient in their rehabilitation. Careful assessment identifies whether individual or group intervention is most appropriate for the individual patient’s needs and intervention may be either unidisciplinary or provided collaboratively with other disciplines.

Supporting evidence.

Music therapy has been shown to have positive effects on mood and emotional functioning [22][23] as well as improve engagement in wider rehabilitation programmes[24].

3. Role in physical rehabilitation.

Vulnerability: risk issues.

Physical disability following stroke can reduce independent function delaying discharge to community settings. Intervention must aim to increase independence as quickly as possible. Music therapy has a role to play in improving functional mobility, thereby assisting the individual to return to community settings.

The role of music therapy in improving physical functioning after stroke.

Music therapists can contribute to primarily interdisciplinary physical rehabilitation interventions, and, in particular, to gait retraining through rhythmic auditory stimulation (RAS). Intervention primarily would be implemented collaboratively with other disciplines such as physiotherapy and occupational therapy in order to optimize patients’ functional recovery. Music therapy can also contribute to rehabilitation of upper limb functioning through goal-directed instrument playing tasks. Music therapy provides an enjoyable and motivating medium for the rehearsal of repetitive tasks and movements.

Supporting evidence.

There have been several controlled clinical trials demonstrating the effects of RAS to improve gait and gait parameters[25][26][27][28][29][30] including the carry over of functional improvements into community programmes.

Dr. Wendy L. Magee for the Association of Professional Music Therapists
International Fellow in Music Therapy
Institute of Neuropalliative Rehabilitation
Royal Hospital for Neuro-disability
West Hill London SW15 3SW
Ph: (+44) 208 780 4500 x 5146 
Email: drwmagee@rhn.org.uk

16^th November, 2007