[ARTICLE] The Use of Therapeutic Music Training to Remediate Cognitive Impairment Following an Acquired Brain Injury: The Theoretical Basis and a Case Study – Full Text


Cognitive impairment is the most common sequelae following an acquired brain injury (ABI) and can have profound impact on the life and rehabilitation potential for the individual. The literature demonstrates that music training results in a musician’s increased cognitive control, attention, and executive functioning when compared to non-musicians. Therapeutic Music Training (TMT) is a music therapy model which uses the learning to play an instrument, specifically the piano, to engage and place demands on cognitive networks in order to remediate and improve these processes following an acquired brain injury. The underlying theory for the efficacy of TMT as a cognitive rehabilitation intervention is grounded in the literature of cognition, neuroplasticity, and of the increased attention and cognitive control of musicians. This single-subject case study is an investigation into the potential cognitive benefit of TMT and can be used to inform a future more rigorous study. The participant was an adult male diagnosed with cognitive impairment as a result of a severe brain injury following an automobile accident. Pre- and post-tests used standardized neuropsychological measures of attention: Trail Making A and B, Digit Symbol, and the Brown– Peterson Task. The treatment period was twelve months. The results of Trail Making Test reveal improved attention with a large decrease in test time on both Trail Making A (−26.88 s) and Trail Making B (−20.33 s) when compared to normative data on Trail Making A (−0.96 s) and Trail Making B (−3.86 s). Digit Symbol results did not reveal any gains and indicated a reduction (−2) in free recall of symbols. The results of the Brown–Peterson Task reveal improved attention with large increases in the correct number of responses in the 18-s delay (+6) and the 36-s delay (+7) when compared with normative data for the 18-s delay (+0.44) and the 36-s delay (−0.1). There is sparse literature regarding music based cognitive rehabilitation and a gap in the literature between experimental research and clinical work. The purpose of this paper is to present the theory for Therapeutic Music Training (TMT) and to provide a pilot case study investigating the potential efficacy of TMT to remediate cognitive impairment following an ABI.

1. Introduction

An acquired brain injury (ABI) can result in impairment in a variety of domains including motor, speech, emotional, and cognitive. Cognitive impairment is the most common sequelae following an ABI [1,2,3,4] and is a result of deficit in one or more areas of cognition such as the various forms of attention, working memory, memory, executive function, or processing speed [5,6,7,8,9,10,11]. An individual with cognitive impairment may experience challenge to suppress distraction, remain on task, shift between tasks, follow directions, organize and initiate a response, or have difficulties with memory. Cognitive impairment can impact participation and progress in rehabilitation therapies for any of the above domains due to reduced attention, poor executive functioning, or impaired memory. The inability to attend to instructions of the therapist, to cognitively plan and organize a response, or to remember rehabilitation objectives outside the therapy session can potentially disqualify an individual from participation in rehabilitative programs or may impede progress in them. Furthermore, cognitive impairment is reported by family and caregivers as a significant source of stress [8,12,13,14]. Addressing cognitive impairment should be a priority in patient treatment following an acquired brain injury. Therefore, it is important to have on-going research into potentially effective cognitive rehabilitation tools.Music training has been noted in the literature to impact areas of non-musical functioning including phonological awareness [15], speech processing [16], listening skills [17], perceiving speech in noise [18] and reading [19,20]. Of significance to the theory of Therapeutic Music Training, the literature demonstrates the impact of music training on cognitive abilities including attention and executive functioning [21,22,23,24,25,26,27].Therapeutic Music Training (TMT) is a music therapy model in which the use of music training, specifically learning to play the piano, is used to address and remediate cognitive impairment following an acquired brain injury [28]. TMT is informed by clinical work and is grounded in literature. The hypothesis of the efficacy of TMT to remediate cognitive impairment is supported by literature regarding the influence of music training on cognition [23,24,25,29], musician’s enhanced abilities in attention, working memory, and cognitive control [26], theories of attention [30,31,32,33,34,35] and the neuroplasticity of the brain, including following injury [36,37,38,39,40]. Because of the engagement of the prefrontal cortex and the demands placed on working memory and attention during TMT, it can be an effective tool to address cognitive impairment. Although functionally interconnected, specific aspects of cognition such as working memory, attention, executive function, and memory are targeted in TMT tasks. TMT is a remedial approach to cognitive rehabilitation, that is, the goal is to drive, strengthen, and improve the underlying neural processes involved in the target cognitive areas. This is in contrast to a compensatory approach to cognitive rehabilitation, in which the goal is to provide the individual with strategies and accommodations to deal with the outcomes of cognitive impairment. The tangible outcome of producing a song provides motivation for the client to engage in cognitive rehabilitation and to remain in the rehabilitative process for an extended period of time as is required to stimulate a neuroplastic response and for the remediation of neural processing to take place.TMT is distinct from modified music education in that the goal of TMT is the remediation of cognitive processes rather than music performance. Tasks involved in learning to play the piano are designed with the goal of placing demands on the various components of cognition. The sequencing and pacing of tasks are determined by the cognitive goals with consideration to target cognitive processes and the time required to drive and strengthen the networks involved. Novelty and the gradual increase in complexity of tasks are utilized to place on-going demands on attention networks and to gradually benefit higher cognitive processes. This is in contrast to modified music education, in which the primary goal is the acquisition of musical abilities and performance.TMT is distinct from other models of music therapy in that it uses music training as the intervention for rehabilitative purposes. TMT contrasts from other music therapy models which use music primarily for expressive purposes, lack corrective feedback from the therapist, or use isolated music tasks which are not intended as music training. TMT is distinct from Neurologic Music Therapy (NMT) [41] in addressing cognitive goals as NMT does not use music training in its music-based rehabilitative interventions. Bruscia highlighted the importance of the music therapist’s “non-judgemental acceptance of what the client does musically” [42] (p. 3). While the TMT therapist would express empathy and support to the client, s/he would also provide constructive and corrective feedback as required in the learning to play an instrument. As in other models of music therapy, the therapist’s use-of-self and the role of the client–therapist relationship are important contributors to the success of the therapy.Remarkably, much of cognitive rehabilitation is not grounded in the literature [36,43,44,45]. This may be due in part to the fact that rehabilitation therapy used to address cognitive impairment is most often based on a compensatory approach, accommodating or supporting the impairment, rather than attempting to remediate the cognitive processes that have been impaired. While the use of music and instrument playing for motor rehabilitation has been widely investigated [41,46,47,48], there is sparse literature investigating the potential efficacy of music-based cognitive rehabilitation interventions. This paper provides a brief introduction to the theory for TMT. This case study investigates the hypothesis of the potential effectiveness of therapeutic music training, TMT, to remediate cognitive impairment and serves as a pilot project to inform future, more rigorous studies. This investigation can contribute to the literature regarding music-based cognitive rehabilitation and inform clinical practice. There is a gap between cognitive experimental research and treatment applications [49]. The hypothesis for TMT has been informed by clinical work and this study can help fill in the gap between experimental research and clinical application. […]

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