La indefinición ante Europa

Research is a process of discovery. The knowledge gained from one study quite typically presents a new set of questions that need to be addressed in consequent studies. The process is continuous. Each study becomes a new link in a chain of knowledge building that is aimed at defining and refining our scientific framework for academic study. Music therapy researchers typically focus on applied research. Questions or hypotheses that drive their research arise out of assumptions (or even gut feelings) in clinical work where experience over many years has revealed apparently consistent and reliable effects of therapy. Music therapy research is frequently built upon the findings and conclusions from a series of clinical anecdotes, examples or reports. Consequently, the formulation and exploration of aspects of clinical work relating to specific questions has provided the main motivation for investigation.

This chapter is concerned with just such a series of experiments, undertaken for a doctoral thesis (Wigram 1996), that were founded on assumptions, clinical experiences and anecdotal reports or research findings previously documented in the field of vibroacoustics (Chesky 1992; Chesky and Michel 1991; Lehikoinen 1988; Madsen, Standley and Gregory 1991; Skille 1982, 1986, 1989a, 1989b, 1992; Skille and Wigram 1995; Wigram and Weekes 1989; Wigram 1993, 1995).

The author had been working for several years in a large long-stay hospital for people with severe learning disability and multiple handicaps, using music primarily as an active and interactive tool within the improvisational model of

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music therapy typical in Europe. The potential for using vibroacoustic therapy as a receptive tool was ripe for exploration and this chapter will document the sequence of studies that were undertaken, defining them as a series of case examples where the findings from one study raised questions leading to the subsequent studies.

Research into vibroacoustic therapy began after a period of pioneer devel-opment when clinicians and other professionals exploring the effects of music vibration and sound vibration reported positive effects on a variety of physical dis-abilities and psychological problems. Music was already being used effectively in medical procedures (Dileo 1999; Spintge 1982; Spintge and Droh 1982; Standley 1995) and evidence had been presented documenting reductions in pain (Brown, Chen and Dworkin 1991; Chesky 1992; Chesky and Michel 1991; Curtis 1986), stress (Maranto 1994) and to meet emotional needs (Bonny 1976; Clark 1991;

Goldberg 1995). Vibroacoustic (VA) therapy as developed in Norway and England is a treatment where a combination of relaxing music and pulsed, sinusoidal low frequency tones ranging from 25Hz–75Hz is transmitted through bass speakers built into a bed or chair, upon which a patient sits or lies, usually supine. This method was developed during the early 1980s by Olav Skille, a Norwegian headteacher of a school for children with multiple handicaps.

The anecdotal evidence from Skille’s clinical trials reported a variety of bene-ficial effects on muscle-tone, heartrate and general well-being (Skille 1989). He documented a number of reports on his clinical experiences with a wide variety of mental and physical disabilities or disorders. As well as describing the physically relaxing effects of vibrational sound therapy on children and adolescents with high muscle-tone and severe spasticity, he also explored its effects on people with pulmonary disorders such as asthma, cystic fibrosis, pulmonary emphysema, general physical ailments such as ulcers, poor circulation and post-operative con-valescence and even psychological disorders with somatic effects such as insomnia, anxiety, self-injurious behaviour, autism, depression and stress (Skille 1992).

The original foundation for some of the research studies described in this chapter was Skille’s anecdotal reports of the relaxant effect of vibrational stimuli on people with high muscle-tone and spasticity, and suggestions from his experi-ments that different frequencies have resonant effects on different parts of the body (Skille 1982, 1989a, 1989b, 1992). This formed the main inspiration for the sequence of studies that are presented here as a series of ‘case examples’. Both direct and related research from other fields provided some theoretical support and credence to VA therapy as a potentially effective intervention for some disorders or illnesses. Standley (1991) found that finger temperature (an indication of deeper relaxation) increased significantly in the presence of vibrotactile and auditory stimuli. Darrow and Gohl (1989) reported that children with hearing impairments

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identified rhythmic changes more successfully when auditory stimuli were paired with vibratory stimuli than when they were presented alone.

There were also results which showed no particular benefit. Madsen, Standley and Gregory (1991) found no significant differences between groups in physical behaviour in trials of college students, and no significant changes were found in subjects’ respiration, pulse or behaviourally observed relaxation in another study by Pujol (1994). Therefore, as Hodges had already reported in a review of more than 21 studies, we find inconsistent and contradictory results when looking at the effects of music generally on physiological parameters (Hodges 1980).

The theoretical foundation for research into the effects of music vibration and sound vibration is underpinned by general research on the effects of vibration, low frequency sound and infrasound. A substantial amount of work had already been undertaken in collating this material between 1983 and 1985 by the Forsvarets Materiel Verk (FMV) of the Swedish Defence Material Administration, who estab-lished an inclusive bibliography and summary of articles on low frequency sound and infrasound (Forsvarets Materiel Verk 1985). Many of the research studies doc-umented work exploring the physical effects of vibration (Berglund and Berglund 1970; Hagbarth and Eklund 1968; Wedell and Cummings 1938). Specific appli-cations of vibration for its use as a tool in physiotherapy were underpinned by the work of Stillman (1970) who advocated the use of vibratory motor simulation and promoted the development of vibratory massage. This was further developed by Carrington (1980) and Boakes (1990) in the fields of physiotherapy and occupa-tional therapy. Boakes looked in particular at the effects on muscle physiology via muscle receptors and advocated that vibration within the range of 20Hz–50Hz causes an inhibition of muscle impulses, so inducing muscles with degrees of spasticity to relax. She further describes the effects of vibrational frequencies within the range of 50Hz–100Hz as stimulating most tonic vibratory reflex impulses, inducing muscles to contract and therefore causing antagonist muscles to relax, which is of great benefit to those who have spasticity.

Therefore, research in the fields of vibration and in the applied clinical use of vibration supported the potential for sound generated vibration as a treatment. In addition, research on the effects of infrasound and low frequency sound had been undertaken on a very wide scale, looking at its influence on the environment, in everyday situations, and the potential problems it can cause where very high levels were recorded (Bryan and Tempest 1972; Englund et al. 1978; Møller 1984; Von Gierke and Nixon 1976). Griffin (1983) reported the negative effects of low frequency vibration as a general discomfort and annoyance, interference with activities and potential to produce motion sickness. Many of the studies under-taken on the effects of vibration, low frequency sound and infrasound had

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explored and reported discomfort and detrimental effects. Consequently, the application of sound as a ‘treatment’ to alleviate or reduce physical problems or disabilities had not been considered until the early 1980s when some of the pioneers began to use sound vibration as a physical treatment (Chesky 1992;

Chesky and Michel 1991; Skille 1992; Wigram 1993, 1995). At the same time, a small number of pioneers in the fields of physiotherapy and occupational therapy were applying whole body vibration using mechanical stimuli, also for the purposes of reducing muscle-tone (Boakes 1990).

A combination of low frequency sound vibration used together with different forms of music was seen as a new approach with potential for a wide field of appli-cation, once efficacy and effectiveness could be demonstrated. Current practice, following such research, shows that VA therapy is a systematic form of intervention requiring a therapeutic relationship between therapist and patient, and involves musical experiences, thus meeting Bruscia’s (1998) criteria for definition as a form of music therapy. Comprehensive reviews describing the equipment to be used, treatment indications and contraindications, and collected clinical reports and research studies can be found in Hooper (2001), Wigram (1997b) and Wigram and Dileo (1997a, 1997b). The anecdotal results from empirical investigations in the early to middle 1980s led to a series of experimental studies.

Table 8.1 shows the sequence of studies that were undertaken in order, defining the area of investigation, the subjects that were involved in the study and briefly, the method that was used.

VA therapy for people with multiple handicaps

This first study focuses on the effect of VA therapy in reducing muscle-tone in patients with spasticity. Cerebral palsy is caused as a result of an injury to a part of the brain before it is fully developed. The three main types of cerebral palsy are spasticity, athetosis and ataxia. The patients in this study suffer from spastic disorders. People with spasticity have different levels of muscle spasm, causing a rigidity of the muscles. A spasm is an involuntary and sometimes painful con-traction of the muscle, muscle group or of the muscle wall of a hollow organ.

Spasms of the whole body are referred to as convulsions, painful spasms of muscles or limbs as cramp, and those in the stomach and abdomen as colic. In cerebral palsied patients the most common form of spasm is a tonic spasm involving a firm strong contraction causing rigidity in the muscles.

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Patients with spasticity are usually found to have:

1. a loss of control and differentiation of fine voluntary movements 2. suppression of normal associated movements

3. presence of certain normal associated movements

4. hypertonus of the ‘clasp knife’ type, with a following build-up of resistance to passive movement (stretch reflex)

5. exaggerated tendon reflexes and possible clones of the other joints 6. depression of superficial reflexes.

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Table 8.1 Six experimental studies in VA therapy with clinical and non-clinical subjects

Study n= Research focus and method

1 10 A study investigating reduction in muscle-tone, blood pressure and heartrate in patients with high muscle-tone, quadriplegic cerebral palsy and severe learning difficulties. Comparison of treatment with placebo conditions in a within-subjects, repeated measures design.

2 27 A follow-up study investigating reduction in muscle-tone, blood pressure and heartrate in patients with high muscle-tone, quadriplegic cerebral palsy and severe learning difficulties. Comparison of treatment with placebo and control conditions in a within-subjects, repeated measures design.

3 39 A study investigating non-clinical subjects reported perception of a sensation of vibration in their bodies when presented with ten different low frequency tones between 20Hz–70Hz.

4 52 A follow-up study investigating non-clinical subjects’ reported perception of a sensation of vibration in their bodies when presented with 20 different low frequency tones between 20Hz–70Hz.

5 60 A study investigating changes in non-clinical subjects’ level of arousal, heartrate and blood pressure to VA therapy when compared with a placebo and control conditions, employing a between groups design.

6 60 A study investigating changes in non-clinical subjects’ level of arousal, heartrate and blood pressure to three different rates of amplitude modulation of a 40Hz sinusoidal tone, and a constant tone, employing a between groups design.

Source: Wigram (1996)

More typically, in spastic patients, we find an increase in flexor tone and this is often greater than extensor tone. Imbalances in the strength of muscles lead to contracture of spastic muscles, and weakness resulting from disuse of their opponents (Jones 1975).

Research into the effects of background music to assist relaxation in cerebral palsied adults with spasticity shows significantly improved decreases in muscle tension (Scartelli 1982). A placebo group of patients receiving EMG Bio-Feedback alone showed a mean decrease of 32.5% in muscle tension, whereas a treatment group receiving EMG Bio-Feedback training together with sedative background music demonstrated a mean decrease of 65%.

Study 1

For this first study, a repeated measures within-subjects design was used. Ten subjects were selected to take part in the experiment, which tested the hypothesis that sedative music, in combination with a pulsed low frequency sinusoidal tone of 44Hz, would have a greater effect in reducing muscle-tone in cerebral palsied subjects than sedative music alone. The two experimental conditions were a 30 minute treatment on the vibroacoustic unit, which consisted of a tape of sedative music, and a pulsed 44Hz low frequency sinusoidal tone (condition A), and the same sedative music presented without the pulsed, low frequency tone (condition B).

The 44Hz low frequency sinusoidal tone acted as an independent variable.

Each subject undertook six trials in each condition, randomly ordered. The subjects undertook two trials each week over a period of six weeks. Changes in range of movement were measured on spinal mobility and limb flexion and extension using a centimetre ruler/measure to record the range of movement before and after each trial. The experiment was designed as a within-subjects study with single blind evaluation. The experiment evaluated the influence of VA therapy treatment consisting of relaxing music and a pulsed, sinusoidal low frequency tone, compared with the same music played through the vibroacoustic unit without a pulsed sinusoidal low frequency tone.

The subjects were three male and seven female subjects resident in a large hospital for people with moderate to severe learning disability. Ages ranged from 28 to 77 years (Mean 44.2, S.D. 12.39), and they were all diagnosed as profoundly handicapped. All had measurably high muscle-tone that affected each of them in differing ways, although there were some affected muscle groups that were shared in common by all. The most common problems were flexor-spasm in their arms and legs, and adductor-spasm causing difficulties in separation of the legs, which in turn can lead to ‘scissoring’ of the legs.

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The equipment used in this experiment was purpose-built. The frame of a sprung bed was used, and two 18 inch speakers were mounted in boxes underneath the springs, with the cones directed upwards. The speaker boxes contained two inch by eight inch ports for acoustic balance, and the cone of each speaker was approximately two inches below the springs of the bed so that the subject would be lying within two inches of the surface of the speakers.

The speakers were so positioned in the bed that, when the subject lay on the bed, one speaker was placed under the thoracic and upper abdominal area of their body and the other speaker was placed under the lower thighs, knees and upper calves. On top of the springs was a single polythene sheet (as a precaution against incontinence), and on top of this was a half-inch pile sheepskin rug.

The speakers were powered by an Amba-414 purpose built amplifier. The maximum potential output from the amplifier was 80 watts per channel (RMS). A vibroacoustic stimulus of relaxing music combined with a pulsed, sinusoidal, low frequency sound wave, and the music in condition B was played through a Technics RS-T11 stereo cassette deck.

Intensity and tone controls on the amplifier were graded numerically. In the procedure of this experiment, the controls of master volume and bass volume were consistently set at the same point. When the subjects were treated with low frequency sounds and music, the bass and master volume was set at +7 on the numerical scale. When the clients were treated with music alone, the master volume was set at +7, and the bass and treble tone controls were set at zero ensuring that an equal balance of tone and equivalent volume was maintained in the music-only condition. The subjects were treated horizontally, and the speakers were set into the bed with the cones facing up. The equipment was isolated electrically, and recordings were used so the style of music, intensity of the low frequency tone and general intensity of the music were all constant for each trial.

A marker pen was used to mark points on the subjects’ bodies for mea-surement, and a conventional cloth tape-measure with centimetre markings was used to record the range of movement before and after each trial. The music used in both conditions was ‘Crystal Caverns’ by Daniel Kobialka. This music is described as ‘New Age’, and is tonal, melodic and harmonic non-pulsed music produced on a synthesizer. The piece lasted 30 minutes, and a 44Hz sinusoidal tone, pulsing at a speed of approximately eight seconds peak to peak was recorded from a function generator with the music on the tape.

Table 8.2 defines the nine measures that were used to evaluate improvement in range of movement. Due to differences between subjects, not all nine measures were used for each subject, as can be seen in Table 8.3.

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Baseline measurements were taken of the minimum range of movement. Then measurements were taken of the degree of extension for each of these movements before and after each trial. Each subject had a different set of measurements, although there were some measurements that were common to many of the subjects. The measurements were normalised into percentages, and a calculation then made of the subject’s percentage improvement in range of movement in each of the conditions.

Before and after each trial an independent evaluator (who was not present during the trial) measured the maximum possible extended range between each of the two marked points in each measurement (blind evaluation).

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Table 8.2 Physical measurements taken before and after each trial

Trial

number Measurement Purpose of measurement

1 The extreme point of the left shoulder to the extreme point of the right shoulder

To measure rounded shoulders

2 The extreme point of the right

shoulder to the right radial artery To measure extension of the right arm

3 The extreme point of the left

shoulder to the left radial artery To measure extension of the left arm 4 The right elbow to the right seventh

rib To measure raising the right elbow

from the body

5 The left elbow to the left seventh rib To measure raising the left elbow from the body

6 The tip of the nose to the navel To measure degree of kyphosis 7 The right side greater trochanter to

the right side lateral malleolus To measure extension of the right leg 8 The left side greater trochanter to the

left side lateral malleolus To measure extension of the left leg 9 The centre base of the right patella

to the centre base of the left patella To measure abduction of the hips.

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Table 8.3 Mean scores of increased or decreased range of movement within minimum and maximum ranges,

shown as percentage scores for both conditions

Measures 1 2 3 4 5 6 7 8 9 Means

Table 8.3 gives the mean scores in percentages of increases or decreases in range of movement within a minimum and maximum range. In the box on the extreme right are the means of all the measurement means for each subject. The means of all the scores of the subjects are shown in the box in the bottom right hand corner of the table, and show a 13% improvement in their range of movement in the treatment condition and 1% improvement in the placebo condition. A Wilcoxon Matched-Pairs Signed-Ranks test on the mean percentage improvement in range of

Table 8.3 gives the mean scores in percentages of increases or decreases in range of movement within a minimum and maximum range. In the box on the extreme right are the means of all the measurement means for each subject. The means of all the scores of the subjects are shown in the box in the bottom right hand corner of the table, and show a 13% improvement in their range of movement in the treatment condition and 1% improvement in the placebo condition. A Wilcoxon Matched-Pairs Signed-Ranks test on the mean percentage improvement in range of