Occupational Therapy and Music

1. Occupational Therapy and Music Incorporating the Piano into OT Practice

2. Overall Benefits • Body Awareness & Proprioception • Fine Motor Skills & Finger isolation • Bilateral UE coordination & Apraxia • Trunk control & Upright tolerance • Balance: sit vs. stand • Upper Extremity Strength • Gross UE movements • Attention to Task (divided, sustained, focused) • Sequencing

3. Overview of the Piano 1) A-B-C-D-E-F-G G-F-E-D-C-B-A 2) Pattern of black keys. Groups of 2 and 3. 3) High and Low sounds

4. Movements Involved in Playing the Piano Involves: • Shoulder flexion, extension, horizontal abduction/adduction • Finger & Thumb flexion, abduction, adduction • Thumb extension • Lateral & forward trunk flexion • Supination & pronation Efficient movement Avoids: • Wrist deviation • Wrist flexion & extension

5. How to Play the Piano Using Good Body Mechanics & Ergonomics • Shoulder movements lead the arm across keyboard • Forearm movements lead finger movements • Fingers point at the keys; fingertips depress keys directly from above • Trunk stable, back upright, shoulders relaxed • Shift weight to play high & low notes • Adjust body to avoid straining neck & eyes

6. Adapting the Keyboard for Patients • Towel underneath keyboard to angle keys towards patient • Applying post-it notes to keys • Writing letters on post-it notes • Masking tape: Low – Middle – High • Masking tape A B C D E F G • Taping different textures on the keys • Also: wrist weights, mirror therapy, therapy ball Materials needed: tape, colored post-its, small pieces of desensitization materials, towel, wrist weights, therapy ball, mirror

7. Outline of Therapy Sessions30 minutes • Warm-up (exercises) • Teach a piece or exercise that focuses on specific skills • Patient practices piece/skills learned on ‘keyboard’ or table

8. Deficits of Stroke • Right/Left Inattention • UE Hemiparesis or Hemiplegia • Visual Deficits: Field Cut, unilateral neglect • Decreased Trunk Control • Debility • Decreased Hand Function & Coordination • Decreased sensation

9. Inattention Activities - Attending to Affected hand: • Place on surface in front of keyboard • Reach hand past keys • Place hand on keys • Unaffected hand reaches towards affected hand on keyboard • Use tape 1-2-3-4-5 to attend to left side of keyboard Activities – Attending to Affected side: • Use low or high sounds of keyboard. Right Neglect: High sounds. Left Neglect: Low sounds 2) Cross hands over midline (bilateral integration) 3) Therapist sits on client’s affected side

10. InattentionAdapting the Keyboard 1) Colored Post-Its on left or right side of keyboard 2) One color Post-Its on specific keys 3) Writing A-G on the keys; patients scan across keyboard 4) Using a mirror to ‘reflect’ affected hand: (mirror therapy)

11. HemiplegiaIncreasing Hand Coordination & Use of Affected UE From Least to Most Difficult • Making a fist and playing groups of 2 & 3 black keys • Playing 3-4 keys using fingers 2-5 as a unit • Playing fingers 2-3 and 3-4-5 together (supination/pronation) • Playing keys using opposition • Playing keys using individual fingers

12. HemiplegiaIncreasing Bilateral CoordinationPlaying Hands Together: Bilateral Integration • Playing A-G with 2nd/3rd fingers & thumbs • Playing all A’s, etc. using arc motions 3) Playing 1 note with RH, playing 2 notes with LH (alternating) 4) Playing LH & RH farther apart 5) Playing LH & RH in parallel/contrary motion

13. Debility Increasing UE Strength • Perform ‘exercises’ with wrist weights • Bicep & Brachioradialis: Support elbow on table (working up to self-supporting elbow) • Shoulder Flexion & Horizontal Abduction/Adduction: Playing across the keyboard • ‘Bouncing’ around keyboard • Zone of Proximal Development: Bed – Head of bed – W/C - EOB – Therapy ball - Stand Increasing Finger Strength (from least difficult to most difficult) • Oppose 2nd finger & thumb/3rd finger & thumb • Walking fingers across keyboard • Finger flexion & Supination/Pronation: Playing down-down-up or down-down-down-up

14. Decreased Sensation • Tape different textures onto a combination of keys • Playing the keys with different parts of the hand & fingers • Experimenting with producing softer or louder sounds

15. Traumatic Brain Injury Deficits • Decreased attention to task • Decreased sequencing • Decreased memory • Decreased communication • Increased impulsivity

16. Using the Keyboard to Increase Attention to Task • Following written or spoken directions to play series of notes • Playing A-G and G-A • Spelling words: dad, cab, deaf, feed • Learning and playing a piece • Playing longer combinations of notes • Patient closes/opens eyes, listens, and says high/low OR tries to re-play those notes • Repeating combination of notes played by therapist • Learning a piece by ear

17. Using the Keyboard to Increase Memory • Patient learns/plays exercises; patient asked to recall and play exercises • Patient memorizes part of a piece or sequence of notes (patient adds to this each session) • Patient plays LH & RH sequence (either of notes or finger numbers) • Patient learns a piece by ear • Singing and figuring out a piece

18. Using the Keyboard to Improve Sequencing Playing (and saying): • A B C D E F G and G F E D C B A • Combinations: ABC, DEF, FGA, CDC, FGF, etc (increase more difficult combinations) • Black keys: group of 2 and group of 3 • Switch between Left & Right hands (to a beat) (continue to switch between hands in different patterns) • Switch between fingers: 234, 451, 231, etc Playing and spelling: • Words: DAD, DEAD, FEED, BED, BEG

19. Case Study Multiple Fractures • 63 year old male, s/p MVA • Interest in learning piano, right-hand dominant • Decreased R hand strength & AROM • Right hand edema • Intact cognition • Piano in his home Patient used keyboard to increase AROM & strength of R hand Patient played a sequence of notes using all fingers Patient learned Happy Birthday to You Patient able to learn that piece, write it down, play it at home

20. Evidence • 3 patients post-stroke: 6, 35-minute outpatient sessions; flexion/extension exercises with affected arm using electronic keyboard. Results: significant improvement on Fugl-Meyer wrist & hand portions • 18 patients with TBI. Results: patients receiving standard treatment with music therapy showed significant improvement in social functioning compared to patients who only received standard treatment • 20 patients post-stroke: 3 weeks, 15 sessions; music supported training program (fine and gross motor exercises using electronic keyboard). Results: Patients showed increased motor control in ADLs compared to patients receiving conventional treatment. Patients also had increased speed, precision, and smoothness of movement. Keyboards used: MIDI keyboards and drum pads

21. Warm-Up • AROM/AAROM of UE’s • Black Keys • White/Black Keys up & down keyboard • Playing all the A’s, B’s, C’s, etc up & down keyboard • Playing a group of keys up & down keyboard • Playing in 3rds/4ths/5ths • Follow the Leader

22. Exercises With decreased finger strength: Oppose fingers & thumb; Play with individual fingers 1)Playing A-G with 2nd/3rd & thumbs 2) Playing all A’s, B’s, C’s, etc. using arc motions 3) Playing A-G with 2nd fingers, 3rd fingers 4) Playing 1 note with RH, playing 2 notes with LH 5) Playing LH and RH farther apart (combinations, black keys, etc) 6) Making a fist and playing groups of 2 & 3 black keys 7) Playing 3-4 keys using fingers 2-5 as a unit 8) Playing fingers 2-3 and 3-4-5 together (supination/pronation) 9) Walking fingers across keyboard 10) Playing LH & RH in parallel/contrary motion 11) Playing down-down-up or down-down-down-up 12) ‘Bouncing’ around keyboard

23. Pieces Children’s: • Twinkle Twinkle Little Star • Old McDonald • Bingo • Mary Had a Little Lamb • I’m a Little Teapot • Hush Little Baby • Rain Rain Go Away • It’s a Small World • Row, Row, Row Your Boat Holiday: • Jingle Bells • Silent Night • We Wish you a Merry Christmas • Happy Birthday Popular: • Lullaby & Goodnight • America the Beautiful • You are my Sunshine • Doe a Deer

24. References • Yoo, J. (2009). The role of therapeutic instrumental music performance in hemiparetic arm rehabilitation. Music Therapy Perspective, 27, 16-24. • Nayak S., Wheeler B., Shiftlett S., & Agostinelli S. (2000). Effect of music therapy on mood and social interaction among individuals with acute traumatic brain injury and stroke. Rehabilitation Psychology, 45, 274-283. • Schneider S., Schonle P., Altenmuller E., & Munte, T. (2007). Using musical instruments to improve motor skill recovery following a stroke. Journal of Neurology, 10, 1339-1346.