Neurologic Music Therapy: Rhythm, Walking and Speech After Stroke and Parkinson's

What is neurologic music therapy and how is rhythm used after stroke and Parkinson's? The logic, limits and key points of the method for families and carers.

A woman who has been spending her days at the hospital since her father's stroke notices something surprising one evening. Her father struggles to say his daughter's name and his sentences break off halfway; but when a folk song from his youth rises from the radio of the patient in the next bed, her father murmurs the chorus word for word. As she goes home that night, she has one question in her mind: "Could music help my father speak?" This question introduces many family members to the concept of neurologic music therapy. In this article we look at what neurologic music therapy is, how rhythm is used in walking and speech work, how much of it research supports today, what families should pay attention to, and the emotional burden this process places on you.

What Is Neurologic Music Therapy?

Neurologic music therapy is the planned use of musical elements such as rhythm, melody and song to support functions such as movement, speech and attention after illnesses or injuries that affect the brain. Stroke, Parkinson's disease, traumatic brain injury and some other neurological conditions are the areas in which this work is most often mentioned.

What distinguishes this approach from general music therapy is that its focus is more on functional goals. For example, the aim might be for the person to take more regular steps, to say a word more fluently, or to be able to use their hand to repeat a particular movement. Emotional support is of course important; but here music often functions as an "exercise tool".

Let us make one point clear from the start: neurologic music therapy is not a treatment on its own. Neurological rehabilitation is a process carried out jointly by different professionals such as a neurologist, physiotherapist, speech and language therapist and occupational therapist. Music-based work can, where appropriate, be a supportive element accompanying the work of this team. If you are curious about the general framework of work done with music, you can read our article on music therapy.

Rhythm and Walking: Linking Steps to a Tempo

The work most often mentioned in connection with neurologic music therapy is walking to rhythm. The basic idea is this: when we hear a regular tempo, our body naturally tends to fall in with that tempo. Our steps falling into order when a march is played, or our feet keeping time of their own accord at a wedding, are everyday examples of this tendency.

In rehabilitation, attempts are made to use this tendency as follows:

• The person's current walking speed and step pattern are observed.
• A metronome beat or music with a clear rhythm is chosen at a tempo matching this speed.
• The person tries to match their steps to these beats.
• Over time, the tempo is changed in small steps towards the goal set by the professionals.

This kind of work is being researched especially in Parkinson's disease and after stroke. In Parkinson's, it is known that some people's steps become smaller as they walk or that they suddenly "freeze"; whether a rhythmic cue can help at these moments is one of the questions researchers are interested in. We look at other work involving movement and rhythm in Parkinson's in our article on dance therapy for Parkinson's.

Before trying it at home

Walking to rhythm looks simple; you might think of downloading a metronome app to your phone and getting your loved one walking. But there is an important risk here: falling. Balance problems are common after a stroke or with Parkinson's, and the wrong tempo, the wrong floor surface or tiredness can lead to a fall. So before starting any rhythmic walking work at home, always consult the physiotherapist or doctor who is following your loved one. If the professional considers it appropriate, they will tell you at what tempo, for how long and with what safety precautions you can work.

Song and Speech: Melody as a Bridge to Words

As in the example at the start of this article, it is observed that some people who struggle to speak after a stroke can sing the words of familiar songs. This is intriguing for families and researchers alike. The reasons for it are still being researched; but this observation has given rise to the idea of using melody and rhythm as a bridge in speech work.

In speech-focused music work, the following may be done:

• Melodic intoning: Short sentences that are useful in daily life ("I want water", "Good morning") are sung to a simple tune at a slow tempo. Over time, the melody is reduced to move closer to speech.
• Syllable work with rhythm: Words are spoken broken into syllables, with hand or table taps.
• Completing familiar songs: A line of a song the person knows well is started and the person is invited to continue. This may support both word production and emotional engagement.
• Breath and voice work: Holding long notes can be used in work on breath control and vocal strength.

This work does not replace the programme run by the speech and language therapist; it needs to be planned in harmony with it. Being able to sing a song does not mean that the person's everyday speech will improve of its own accord. It is important, both for the patient and for themselves, that families hold realistic expectations about this.

Working the Hands and Attention

Neurologic music therapy is not limited to walking and speech. Some work focuses on arm, hand and finger movements, and some on attention and memory:

• Using instruments: Striking a drum, touching a cymbal or pressing particular keys on a simple keyboard can make movements that require repetition more engaging. For example, someone who struggles to use their paralysed arm may take part in the work for longer when they focus on "keeping time with the song's beat" instead of on an exercise repetition.
• Attention work: Exercises such as making a movement when a particular sound is heard or noticing a change in rhythm can be used to train attention span.
• Memory and sequencing: Short songs or rhythmic patterns can be tried as a tool to help remember information in sequence.

The basic principle is the same here: the rehabilitation team decides which work is appropriate, for which person and with which goal.

How Is a Programme of Work Planned?

A music-based rehabilitation programme does not begin with "let's sing a bit together". Although practice varies from institution to institution, the process generally follows these steps:

1. Assessment: The person's movement, speech, attention and balance are reviewed together with the findings of the rehabilitation team. The person's relationship with music, the genres they like, their hearing and how quickly they tire are also established.
2. Goal setting: Goals should be small and observable. Instead of "walk better", something like "be able to walk to the end of the corridor, with support and without stopping".
3. The work itself: A tempo, song or instrument suited to the goal is chosen. The tempo and duration are adjusted within the session according to the person's performance.
4. Home programme: If the professional considers it appropriate, the family may be given simple, short work that can be done safely at home.
5. Review: At set intervals the team assesses what is working and what needs to change.

Let us say a 68-year-old retired teacher with a Parkinson's diagnosis often hesitates when passing through the hallway at home. The team sets a short walking goal for him; the sessions use the tempo of a march he loved in his youth. Over the weeks, some days go more smoothly and some are harder. This fluctuation is part of the nature of neurological conditions; one bad day does not mean the work has been wasted.

Does Neurologic Music Therapy Really Work?

This is the most important question families ask, and it calls for an honest answer. Walking to rhythm, speech work with song and similar practices are a widely researched area in the literature. However, the research on which this article is based did not examine a source confirming the effect of these practices at the level of a systematic review. For this reason we do not give any figure here for the size of the effect.

The limitations seen across research on music- and arts-based approaches in general should also be kept in mind for this area: a considerable proportion of studies are carried out with small samples, blinding is difficult because participants know what they are taking part in, follow-up periods are often short, and the distinction between "music therapy" and "exercise accompanied by music" is not always clear.

This picture does not mean that music has no place in rehabilitation. But there is a difference between a method "being researched" and it "having been shown definitively to work". Be cautious about any practice that tells you "he will be walking within a few sessions" or "her speech will come back completely".

The legal framework in Turkey

In Turkey, music therapy is one of the methods defined in the Regulation on Traditional and Complementary Medicine Practices, which came into force on 27 October 2014. Within this framework, the authority to practise rests mainly with certified physicians; according to statements by the Ministry of Health, certified allied health personnel may also work under a physician's supervision in some methods such as music therapy. If you are considering music-based work for your loved one, it is important that it is carried out with the knowledge of the rehabilitation team and at an authorised healthcare institution.

Your Burden as a Family Carer

A diagnosis of stroke or Parkinson's changes the life not only of the patient but of the whole family. Days spent in hospital corridors, physiotherapy appointments, changes to the household routine, taking time off work, sharing the burden of care between siblings... During this process, most family carers set their own needs aside.

Some relatives cling to each new method with great hope and experience deep disappointment when the expected change does not come. Others wear themselves out with the thought "I should be doing more". Even a gentle and much-loved tool such as music turning into a "test of success" can put pressure on both the patient and you.

The value of singing a song together with your loved one is not measured only by how many words come out; simply being able to be together in that moment is meaningful in itself.

In Turkey, the burden of care often falls on the shoulders of one family member, frequently a daughter or daughter-in-law. Within the extended family, a burden that is not shared, on grounds such as "you live closer" or "your job is more flexible", can over time turn into silent anger and guilt. Having these feelings does not make you a bad child or spouse; they are natural reactions to a long-term caring process.

It may help to ask yourself the following questions: When did you last do something on your own, just for yourself? How are your sleep, appetite and patience? When you ask for help, who can you get support from? We look at the effects of the burden of care on mental health in detail in our article on carer burnout.

Suggestions for time spent with music at home

Beyond the structured work recommended by professionals, time spent with music at home can be a moment that nourishes the relationship:

• Make a list of songs your loved one liked in their youth and listen to them together.
• When singing, do not try to correct them or press them to "sing it again".
• Choose short periods when they are rested, not the hours when they are tired.
• Keep the volume at a level that is not disturbing; in some neurological conditions there may be sensitivity to loud sound.
• If the music brings back a memory and makes your loved one sad, make room for that feeling; you do not have to switch straight away to a cheerful song.

When Should You Seek Professional Support?

Changes in mood can be common after a stroke or with Parkinson's. It is wise to seek support from a mental health professional, both for your loved one and for yourself, in the following situations:

• If you see listlessness, bouts of crying, loss of interest or hopelessness in your loved one that has lasted for weeks,
• If they constantly refuse to take part in rehabilitation work and you think a low mood lies behind this,
• If you yourself feel exhausted, angry, guilty or helpless,
• If you notice that your loved one or you have lost hope in living or are thinking of self-harm. In that situation, do not wait; in an emergency, call 112 (emergency services).

You can find general information on assessing and supporting such changes in mood on the depression and mood page. Where needed, an assessment by a psychiatrist may also be part of the process.

Frequently Asked Questions

Does neurologic music therapy replace physiotherapy?

No. Music-based work is thought of not as a replacement for physiotherapy, speech therapy and medical follow-up, but as a supportive element that sits alongside them where appropriate. Make any change to the rehabilitation plan in discussion with your team.

My loved one does not enjoy listening to music; should we still try it?

Music may not be enjoyable or suitable for everyone. Forcing against a person's preferences can create resistance to the work. Other motivational tools can be used in rehabilitation instead of music; it is a good idea to discuss this with your team.

Who decides which music will be used?

In structured work, the tempo and choice of music are decided by the professional according to the goal. However, the person's favourite genres and cultural background are also taken into account; a familiar folk song or popular song can make it easier for the person to take part.

• #stroke rehabilitation
• #Parkinson's
• #rhythm
• #family carers

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Eda Erkan Alapala

Klinik Psikolog. İstanbul Kent Üniversitesi Klinik Psikoloji Tezli Yüksek Lisans mezunu; bilişsel davranışçı terapi, çocuk merkezli oyun terapisi ve çocuk-ergen psikoterapisi alanlarında eğitimlerini tamamlamıştır.

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