Enriched Music Therapy Benefits Stroke Patients Long Term

Enriched Music Therapy Benefits Stroke Patients Long Term

Daniel M. Keller, PhD

November 03, 2016

HYDERABAD, INDIA — An enriched intervention approach using music therapy encompassing movement, cognitive focus, psychological well-being, and social interaction benefits stroke patients in the long term, a study shows.

Stroke often leads to depressed mood, social isolation, and diminished feelings of well-being, the researchers point out, and mental distress can impair motor recovery and increase the risk for future stroke.

Addressing the mental, social, and physical domains at the same time, their integrative approach differs from traditional ones that provide separate, isolated occupational, physical, and speech therapies and psychological, social work, and physiatry services.

Preeti Raghavan, MD, from Rusk Rehabilitation at the New York University School of Medicine in New York City, said music is a "universal language," and this sort of enriched intervention approach is appropriate for all types of ethnic communities and may be especially beneficial in areas with limited resources.

She presented her findings here at the World Stroke Congress (WSC) 2016.

Biological Underpinnings

Animal experiments have shown that environments enhanced with sensory stimuli facilitate post-stroke recovery by promoting neurogenesis and neuronal survival, the authors note. Brain-derived neurotrophic factor can enhance learning when training is intensive, and oxytocin promotes social bonding, is neuroprotective, reduces infarct size and inflammation, and enhances neuroplasticity.

Studies in humans have shown two-way signaling between the auditory and motor cortices that underlies beat perception. Rhythms promote efficient recruitment of motor units, leading to improved motor outcomes.

For the Music Upper Limb Therapy–Integrated (MULT-I) preliminary feasibility study, Dr Raghavan recruited patients with chronic hemiparesis from a stroke that occurred at least 6 months earlier. They had to be able to open and close the hand partially on the affected side, with an upper limb score of no greater than 60 on the Fugl-Meyer Scale, meaning there was still room for improvement. Participants could not have a major disability, as indicated by a modified Rankin Scale score greater than 4.

Patients (five groups of three) participated in biweekly 45-minute sessions for 6 weeks. They did not have to have any prior musical training. One occupational therapist and two music therapists provided a 1:1 therapist-to-patient ratio.

Each session consisted of an initial 5 minutes of stretching, 35 minutes of music making, and 5 minutes of discussion. Each person chose a percussive instrument. The only requirement was that patients had to be able to hold an object with which to hit the instrument or to shake the instrument (such as maracas).

Therapists videotaped the group interactive music sessions, reviewed them, and adjusted subsequent interventions based on those observations.

Disability was reduced and well-being improved after the MULT-I program, and these improvements persisted. Modified Rankin Scale measures went from 2.4 before the program to 2.0 afterward (P = .03) and to 1.5 one year later (P = .04 vs before). World Health Organization well-being scores improved from 14 before the program to 18 afterward (P = .03) and the same one year later.

Dr Raghavan said that in the discussion period, even after just the first session, participants commented that they felt function "coming back to what I used to be doing" and "I see that the rhythm is there; it's going to my brain, telling me how to maneuver it."

The experiences in the music sessions carried over into daily life. Participants described benefits going beyond the music-making sessions, such as dancing again, taking the subway, using the affected arm in cooking, dressing, or rising from a chair.

Music Benefits Multiple Domains

Dr Raghavan explained the multiple benefits of music. In the physical domain, it promotes movement, she said, especially repetitive movements by coupling auditory and motor mechanisms. It also distracts attention from the physical efforts required. In the mental domain, music benefits mood and cognitive recovery while eliciting strong behavioral responses, and it integrates cognitive, emotional, and sensorimotor brain functions. Finally, interactive group music benefits patients' social functioning by promoting spontaneous interaction and facilitating development of relationships. Music is also a means of verbal and nonverbal communication.

She said that some of the lessons learned are that "music therapy can provide an enriched environment, it could be relatively low cost, it could be compatible with existing values in different parts of the world, it could address social isolation…and attention." The enriched environment program also has observable results in terms of reduced motor impairment and improved well-being.

Session chair Patrik Michel, MD, head of the stroke center at Lausanne University Hospital in Switzerland, commented to Medscape Medical News that Dr Raghavan presented convincing evidence "that several factors, in particular subjective well-being, were actually improved through this kind of therapy" using professionals to lead an enriched group music program.

He said that usually in rehabilitation, any different kind of enriched therapy activating previously unsolicited brain regions will usually lead to an improvement in patients' function. "This is just tapping into a domain where we have underused the brain that is going beyond traditional motor rehabilitation, traditional speech rehabilitation but just using new auditory, emotional, and musical clues to improve function," he said.

Professor Michel said it will be important to figure out the best amount of music therapy to provide and the best form of music therapy. In this study, the patients were active participants in the sessions, compared with the more traditional music therapy in which patients passively listen to music.

There was no commercial funding for the study. Dr Raghavan and Professor Michel have disclosed no relevant financial relationships.

World Stroke Congress (WSC) 2016. Presented October 28, 2016.

For more Medscape Neurology news, join us on Facebook and Twitter

What's It Like to Be a Parish Nurse?

Jacqueline H. Walker, RN, BSN, LTC(R)

Disclosures

August 24, 2017

From the Army to the Church

I like being able to help others, assist them in becoming self-sufficient, and give them information on preventing health issues and maintaining a healthy lifestyle within my church community.

Figure 1. Jacqueline H. Walker, BSN, LTC(R), RN. Courtesy of Jacqueline Walker.

Over the course of my nursing career, which spans 45 years, I have worked at numerous hospitals and military installations in the United States and abroad. I have even earned the honor and the privilege of retiring as a nurse in the United States Army with a rank of Lt. Colonel. However, my most rewarding nursing experiences are attributed to my role as parish (or faith community) nurse.

 What Is Parish Nursing?

According to the Westberg Institute for Faith Community Nursing:

Faith community nurses are licensed, registered nurses who practice holistic health for self, individuals and the community using nursing knowledge combined with spiritual care. They function in paid and unpaid positions as members of the pastoral team in a variety of religious faiths, cultures, and countries. The focus of their work is on the intentional care of the spirit, assisting the members of the faith community to maintain and/or regain wholeness in body, mind, and spirit.

I've been the parish nurse at Trinity Baptist Church in Birmingham, Alabama, since February 2016 (Figure 2).

Figure 2. Jacqueline in front of the church where she serves as parish nurse. Courtesy of Jacqueline Walker.

I have been doing nursing in my church for much longer, but the title has made it more formal. (Parish nurses have a well-defined role, with scope and standards of practice outlined by the American Nurses Association.) I provide services according to the needs of the congregation. We work with the Congregational Health Program at Samford University and the Brookwood Baptist Medical Center. I set the goals for the Health Ministry, and I report to the pastor of my church to discuss the activities I have planned for each month and what I will need to accomplish our goals. To determine the health needs of the congregation, I conducted a survey and identified their top health concerns (exercise and health, weight control, arthritis, hypertension, diabetes, and the relationship between faith and health).

I am autonomous in deciding how I spend my time, and my hours vary. Although I am a senior now, I continue to teach classes on health and spirituality. I provide educational materials to the members of the congregation and I coordinate health fairs every 2 years. I also assist other organizations with their health and wellness programs. I lead support groups and encourage participation in charity walks. I also lead a group of nurses, laypersons, and a doctor to assist in rapid response in medical emergencies while at church. Although I am a volunteer, I maintain my RN license and carry malpractice insurance.

My 'Patients'

Figure 3. One of Jacqueline's roles is to provide health educational materials to the congregation. Courtesy of Jacqueline Walker.

As a parish nurse, my "patients" are the members of the congregation of a church that I have attended since I was 12 years old. My interest in the health of church members is long-standing. I remember, while in my twenties, working with my most memorable senior group at the church—a group that helped me realize that I would be in the helping profession for the rest of my life. Many of the seniors called me "Nurse" when they didn't recall my name. However, they knew that if they had a health concern, they could depend on me to explain what was happening and share the necessary steps to feel better or seek the appropriate medical intervention.

We would meet at the church on Monday mornings in the gym and have devotion, which consisted of a song, a prayer, and a Bible verse. We walked all around Bush Hills, a main thoroughfare near the church. At the end of one of these walks, I remember that one of my members would have to take a few moments to catch her breath before talking with me. For a long time, no matter when I would return from an active-duty tour, she would always inform me that she was still walking. Maintaining this type of community connection is a very important aspect of parish nursing.

My pastor at that time established a group called "Healthy Breakfast and Exercise for Seniors." I was given the responsibility of presenting them with a topic on spirituality and health each week. I enjoyed seeing their faces light up when they were able to answer a question. I admired the determination they demonstrated during the CPR course I led. Some could no longer blow hard enough to make the chest rise or push hard enough to hear the click on the manikin. However, in their faces, I could see their will to persevere, and most of them eventually completed the course successfully. These seniors had so much to share, so many stories to tell. They strived for a purpose every day, something to make them get out of bed. Even today, I am heartened when I can help church members of any age feel empowered to take control of their health.

The Challenges of Parish Nursing

The work of a parish nurse can be challenging, however. Sometimes there are not enough human and material resources to accomplish our goals. Sometimes, on the day of an event, there is simply not enough help. However, I always find joy in seeing other people smile and I am fulfilled when I am being of service. For me, if a church member learns at least one thing to make his or her quality of life better, then the sacrifice of my time and talent is worth it.
Many people have found that it isn't always easy to pray with someone who is dying, hurting, or suffering. As parish nurses, we learn that it is OK to be silent and the importance of touch.

Jacqueline Walker would like to acknowledge the assistance of Tonya Williams-Walker in the preparation of this article.

Treating sepsis with vitamin C

Treating sepsis with vitamin C
Could vitamin C help treat sepsis? Some medical experts in Norfolk, Virginia, think so.
A recent study from Eastern Virginia Medical School saw surprising success with a treatment plan combining vitamin C with steroids. The outcomes were so stunning that the National Institutes of Health (NIH) gave the researcher $3.2 million to dig in a little deeper.
Sepsis, a condition caused by infection, is responsible for 258,000 deaths each year. Seniors and babies are at greatest risk. Symptoms range from shivering and fever to breathlessness and confusion. If untreated, it could lead to septic shock or death.
Ordinarily, sepsis is treated with IV fluids, antibiotics, vasopressors or steroids. The Eastern Virginia study found that the effectiveness of steroids improved when combined with high doses of intravenous vitamin C. It’s a revelation that shot ripples of hope through medical communities worldwide.
“This study is very new,” says Dr. Joseph Bellezzo, chair of emergency medicine at Sharp Memorial Hospital, noting that the doctor behind the study is well-regarded in medical circles and that new clinical trials may begin as a result of his work.
Given in very high doses, vitamin C can have negative effects — some as extreme as renal failure. But according to Bellezzo, “Vitamin C in doses suggested by the study has no negative impact at all. And unlike previous treatment trends, the cost is close to nothing.” So the question now is: What’s the harm in trying?
“Sepsis patients are very vitamin-depleted,” says Dr. Bellezzo. “Knowing this, and knowing that vitamin C does no harm, and weighing the success of the study, it seems like something we should be actively looking at.”
As an ER physician, Dr. Bellezo can’t administer vitamin C unless his ICU counterparts continue the treatment post-ER. So he plans to work with them on establishing a protocol. “I want to test it out and measure outcomes,” he says. “It can only help the patient, not harm them.”
But Ashkan Khabazian, PharmD, a pharmacist at Sharp Memorial Hospital, is reluctant to call it a cure. He’s seen trends like this one rise (and fall) before, and sees a need for more thorough, in-depth research. “I’m not saying we should rule it out,” says Khabazian, “because vitamin C has benefits. But one single-center study isn’t enough to completely change our practice.”
When taken orally, vitamin C doesn’t have much effect on the body; but administered intravenously, it can. By protecting the lining of your blood vessels and assisting chemicals that force your blood vessels to “squeeze,” vitamin C can play a role in improving blood flow to the vital organs — a key element in the treatment of sepsis. Its role in clinical bedside medicine has been under-examined, and it hasn’t been a major player since treating scurvy back in the day.
Although some hospitals are trying the protocol, Khabazian would like to see larger, randomized, controlled multi-center trials confirm the benefit found in the initial study before making vitamin C a regular part of sepsis treatment at Sharp.
We may have a ways to go before vitamin C shows its true value. But if proven successful, it will be worth the wait. A treatment that’s low-risk, low-cost and effective? Seems too good to be true. And it just may be. But like any new medical breakthrough, we need to start somewhere.