Music in Medicine

Until the latter part of the eighteenth century the institutional treatment of mentally diseased people consisted of custodial care. This meant shelter, food and restraint. The quality of the shelter varied in most instances from very bad to poor. The quality of the food was not as varied—it was just bad. The quality of the restraint was excellent. With few exceptions commitment meant life internment. Violent patients were chained to the wall, for who could tell when they might become violent again after a period of calm? The mentally deranged were not considered as patients with a disease of the mind but as inmates who had lost communal value and social desirability. Dr. Philippe Pinel of the Salpêtrière Hospital in Paris thought otherwise and began to consider these people as still human. Among the reforms he introduced was the use of activities to keep the mind and body occupied doing things. This concept grew slowly at first but eventually reached universal acceptance, was considered of real therapeutic value and named occupational therapy.

During the first World War many military patients were confined to hospitals for prolonged periods while awaiting complete recovery. It was noted that those who busied themselves with such physical activities as required the use of their wounded extremities regained the use of these extremities sooner those who remained idle physically. Thus was born a branch of Occupational Therapy which was known as functional to differentiate it from previous psychiatric use.

Functional Occupational Therapy is used to increase three functions: muscle power, joint mobility and co-ordination of movements. It finds its greatest use in those patients who fall under the care of those medical specialists known as orthopedic surgeons and neuro-surgeons. Orthopedic patients are those who have disease or disability of one or more joints or bones. The most common disease of joints is called arthritis, of which there are several kinds of varieties. The most common disability of bone during war-time is fracture. Arthritis usually prevents complete joint motion. In some instances the joint is put at rest to hasten healing. Almost all fractured bones are kept fixed by plaster casts or traction and prevented from movement during healing. The prolonged rest, necessitated by diseases of bones and joints, permits muscles to become weakened or atrophied, and also permits joints to lose some of their range of motion. When the course of disease has reached that point where rest is no longer required, the chief aim of medical treatment is to restore former function. This means the restoration of power and mobility. This is accomplished by means of physical and occupational therapy. Physical therapy includes the use of heat, massage and guided exercise. Occupational therapy is exercise through work—purposeful, productive work with an incentive. The incentive is twofold—to produce something useful and to hasten recovery.

Patients who have had destruction or other disease of the nerves which activate their muscles develop varying degrees of loss of muscle-power known as palsy or paralysis. When a nerve is pressed or cut, it usually heals in such fashion as to permit return of muscle-power. During the period of its impairment, there is not only a loss of power, but frequently concomitant disturbance in the skin, the joints and still other functions. As a result of the nerve disturbance or the disuse which follows, the portion of the body which is paralyzed loses the ability to use its muscles with facility and maximum economy. There are almost no motions performed by single muscles. Most activity results from the contraction of a group of muscles and these are usually in delicate balance with other groups of muscles which either assist or prevent overaction. The delicate adjustment of muscle groups, which is normally present, results in co-ordinated movements. Following nerve disease or, for that matter, the immobilization of joints and muscles, co-ordination is usually lost to more or less degree. Muscles must be re-trained to work together. Such co-ordination can be accomplished by special exercises, but even more rapidly and efficiently by imitating the motions of life. This is the aim of functional occupational therapy.

There are other disease conditions which can profit from the use of occupational therapy. These include other disabilities which are accompanied by loss of power, motion or co-ordination. When the skin is burned, healing is usually accompanied by some degree of scarring. If the scar includes a joint on its flexor surface (i.e. inside the bend) there will result a deformity known as a flexion contracture. If nothing is done about this, the crippling process will become progressive and some day reach a stage beyond correction other than that offered by plastic surgery. The early stretching of such joints will not only prevent progressive disability but may result in some improvement.

Many other indications for the use of occupational exercise will be met, but since this is not a text on medicine, the preceding types of disabilities will serve as examples of the conditions commonly seen.

The crafts first used in functional work were carry-overs of those most beneficial in mental disease, and for the most part were restful and simple, such as basketry, weaving and the graphic arts. More recently, almost all the arts and crafts have been used, as well as motorized tools.

The results of occupational exercise will depend upon the attractiveness of the objects which can be produced, the energy required, the skill and patience of the occupational therapy worker and patient, and the stage and extent of the disability. For those who are not “handy”, or who have become increasingly clumsy with disability, there may be impatience, tedium and fatigue. Occupational therapy is always seeking new activities or modalities as they have become known in practice. Music can be used as exercise in occupational therapy as well as for background and interludes of relaxation.

The fingers of professional pianists and violinists are very strong, for instrumental manipulation requires and develops strength and co-ordination. Music as an exercise can be used not only for its effect on most of the joints and muscles of the body, but to increase the use of the lungs and larynx. It focuses attention through the use of visual, auditory and tactile senses and stimulates mental activity and interest.

Many instruments may be employed for the mobilization of joints and muscles. When a musical instrument is prescribed as the occupational therapy activity for a patient, there may be some resistance on the part of the patient because of a lack of general or musical education, or the fear of studying something new. The success with which this resistance may be overcome will depend upon the skill of the musical aide not only as a musician but as a teacher. The musical aide will have to convince the patient that the fundamentals of music are far less difficult to learn than is popularly supposed. Much of the notoriety about music lessons is developed among children who dislike regimentation, interference with their play periods, and the length of time it takes the minute hand to circle the clock. The musical aide may cite that observation and impress the patient with the greater ease of adults in learning to play. Interest may be aroused by naming the other patients who have recently learned to play and by demonstrating the advantages in earlier recovery that music offers.

Regardless of their initial attitude towards music lessons, most patients will soon be pleased with their progress and ability to master musical notation. Visits to the craft shop will usually be made on an appointment basis and the patient will leave as soon as his “time” is up. The knowledge newly acquired through instrumental instruction will keep the patient at work longer and the musical aide will find him returning for further practice without coaxing and for desirably longer periods.

Piano. Before considering the use of the piano in occupational therapy, the work of Ortmann[64] should be reviewed.

A joint is the point at which two bones connect. In any moveable joint the essential feature is a sliding of one surface on another. Joined to the sides of the two bones near their ends are ligaments which are strong and inelastic and hold the joints within the joint cavity, and which prevent the joint from exceeding its normal range of motion. But the function of holding the bones together and keeping them in different positions belongs to the controlling muscles. Bones are usually activated by at least two sets of muscles which effect the movements in opposite directions. Normally muscles are under a slight but constant tension known as tonus, and the simultaneous pull of muscles on both sides of the joint presses the bone surfaces closer, and keeps the muscle in a state which makes immediate action possible.

Joints move by virtue of the contractions of the muscles. Most movements are made not by one muscle alone, but rather by the co-ordinated contraction of various muscles and the simultaneous relaxation of their antagonists. As a result of muscle contractions, a chemical change takes place which produces substances in the muscle that interfere with good muscle action. Ordinarily these waste products are carried away by the circulating blood with sufficient speed to prevent noticeable effects. If, however, the muscle produces these deleterious chemicals faster than the blood stream can carry them away, fatigue results. The earliest manifestation of fatigue is inability to relax, and the second contraction may be initiated before relaxation is complete. The second effect of fatigue is interference with rate and quality of contraction. Only relatively brief periods of relaxation are necessary for complete recovery, but these periods are important. When normal muscles practice on the piano, the fatigue limit is rarely reached, but for the weakened muscles of patients, fatigue must be guarded against by limiting duration of continuous playing and by proper interludes of rest. Ordinary piano-playing offers short rest periods because there is a reflex relaxation after the sound is produced and it requires less muscle energy to keep the key depressed than to depress it.

Muscles are excited into contraction by minute bio-electrical impulses which enter through their motor nerves, but the property of contraction is independent of the nerve and can also be accomplished by artificial external stimuli of electricity or mechanical force. The quality of contraction is a function governed by the health and nutrition of the muscle. The nutrition of the muscle depends upon its blood supply, which depends in part upon its warmth. Delicate motions are difficult for cold muscles and artificial warming is advisable before exercise, a fact which assumes greater importance in cold weather.

From the viewpoint of patient interest and instruction, the piano is the best instrument. When equipped with pianola fixtures, it is the one instrument that gives the widest range of activities. Because the piano is difficult to move, playing is restricted to the room in which it is housed and there need be no concern about its interference with other patients if the practice room is sound-proofed, or is situated some distance from the other patients. The piano offers excellent opportunity for flexion of the fingers and thumb, extension, abduction and adduction of the wrist, as well as flexion and abduction of the shoulders and exercise of the neck and back.

The piano can be adapted for use by patients with extremities in hanging casts, which can be supported by sling arrangements attached to the piano or the patient’s neck. It can even be used satisfactorily with a cumbersome airplane splint if a very low bench is substituted for the usual piano chair. The height of the bench can be arranged so that the key-board and hand are on the same level, and the challenge of this position will make the patient try all the harder to use his fingers.

For the contractures resulting from burns of the hands, the piano offers an excellent medium with which to increase joint motion. In depressing the keys the fingers are forcibly flexed. The key surface is much broader and easier to manage than that of the typewriter key. The piano, therefore, offers less of a psychological deterrent to use than does the typewriter. Mistakes at the piano are less annoying because there is nothing to erase but a memory, and the memory of unpleasant things is fortunately short-lived. By means of special musical arrangements and additional notation written next to the printed notes, some fingers can be exercised singly or in any combination desired. The physical exercise or co-ordination of selected fingers can be obtained more subtly by the use of marked music than is possible with most crafts. Some instructors may prefer to mark the keys of the piano with the letters to which they correspond, but this is not really needed in the instruction of adults. A large diagram of the piano keys placed above the musical scale for which they stand may be located to advantage on the wall over the piano.

It is recommended that the first piano lessons cover fifteen minutes and that the time be increased five minutes daily until the lesson fills a half hour period. Inasmuch as the strain of piano playing is very slight, the first lesson may last thirty minutes if the physician so decides. The patient should be encouraged to practice freely at other times during the day as long as his interest can be sustained. Chief attention must be placed on the use of the fingers requiring exercise. As is true in all forms of functional occupational therapy, the impatient patient will try to speed his work by using unaffected joints or by improper use of muscles. The musical aide must guard against this temptation. Although standard music for beginners should be used, it is well for the teacher to use simple arrangements of popular tunes at each session for the incentive that it will give the patient. If the patient expresses the desire to play a certain melody, the instructor should write his own arrangement if none is available.

The keys of the piano can be reached effectively in many ways and it is possible to exercise almost any of the muscles of the upper extremity by playing from different levels. To exercise the muscles of the shoulder girdle, loud notes may be played by holding the hands fixed and raising and lowering the shoulders. The shoulder itself can be abducted and adducted by wide lateral movements along the keyboard. Flexion and extension of the wrist is accomplished by staccato movements. Lateral motion of the wrists is partially restricted by the bony structure but can be accomplished by arpeggio work.

Thumb action plays a very important part in piano playing. The opponens action (touching the last finger with the thumb) is very necessary in playing arpeggios, particularly with large intervals played legato. In fact there is hardly any known purposeful activity which is more useful for full exercise of the opponens range than this activity. The music must be fingered with numbers that will keep the index finger on one note as the thumb passes under for the next higher note at an interval of two or three tones. In order to depress the key, flexion of the thumb is necessary. The thumb can be abducted to almost any degree by the playing of chords or by playing legato passages.

All motions of the fingers are possible. For active or passive extension of the fingers much use should be made of the black keys. If the hand is held in position to play the white notes in the normal manner, the black keys can be played only by extension. Various degrees of flexion of the joints are possible by ordinary playing. Spread of the fingers which is a function of the dorsal interossei muscles can be accomplished by practising chords, the span of which should be increased as power and range improve.

Violin. In most activities requiring the use of both hands, the more delicate motions are performed by the right hand in right-handed persons. For the violin family the situation is reversed, and these stringed instruments are of greatest value for exercise of the left fingers and right elbow. If the interest of the patient is great, there is no reason why the normal positions cannot be interchanged so that fingering is accomplished by the right hand on a violin with reversed strings.

The violin is recommended for flexion of the left fingers, but is of greater value for flexion and extension of the right elbow. It is secondarily valuable for the flexion and extension of the wrist and abduction and adduction of the shoulder. The motion analysis for the cello and bass viol are similar to that of the violin. The heavier instruments require more motion at the shoulder. String instruments are less popular than the piano because two fundamental techniques must be learned simultaneously; correct fingering and correct bowing. The vibration of the struck piano strings is relatively uniform with variable pressures[II.], but the quality of the violin sound as produced by the beginner can be discouragingly unpleasant.

Plectrum Instruments. The plectrum instruments afford excellent exercise of the wrist of the right hand and the fingers of the left. The ukulele, when brushed by the fingers, offers better extension of them than is found in most crafts. The guitar offers even stronger flexion for the fingers which depress the strings than does the violin. All these instruments require supination and pronation at the wrist and some flexion and extension of the elbow. They are more popular than bowed instruments and have the added advantage of being so easy to learn that the performer will be able to play simple song accompaniments in a relatively short period of time. The variety of instruments in this category permits a wide range of energy requirements.

Foot Instruments. Although there are several instruments in which the lower extremities are used, there are only two which are readily adaptable to hospital use—the pianola and the parlor organ. For the former, no knowledge or musical ability is required and its use is open to all. The distance between the bench and the pedals will determine to some extent the energy expended and the range of joint motion which can be accomplished. The speed of playing is related to the energy which is required. If the library of pianola rolls is large and inclusive enough to meet the demands of the patient’s taste, an adequate amount of work can be expected.

The foot-pumped organ is also an excellent ankle exerciser. Even the untrained will find some interest in the timbre of the notes and the qualities of sound emitted with the pulling of different stops. The lingering sounds and the novelty of playing an organ which is no longer a commonplace in the home, are great incentives to playing. Instruction on the organ, which has a smaller keyboard and slower manipulation than the piano, is pleasant and simple. For combined upper and lower extremity disabilities, the organ is an excellent instrument. Every hospital music department should own one. There are enough unused organs in the attics of this country to supply the needs of most hospitals.

The bass drum with foot pedal attached is obviously not a solo instrument, but when used in ensemble or with a full set of traps and snare drum, it can sustain some interest and result in some benefit to those suffering with ankle disabilities. Its use is limited to activity of the muscles and joints below the knee. It can be used by patients wearing a leg-brace pivoted at the ankle.

“Pocket” Instruments. Of all the wind instruments available for the instruction of beginners, those which require no reed or lip knowledge are most desirable. Easiest to play is the “kazoo”, or any other instrument which embodies the principle of a membrane vibrating to the sound of the human voice. Only the ability to hum is needed and it is valuable for the patient who is difficult to teach because it permits even the dullest to participate. The kazoo is especially useful for children or psychiatric patients and can supply the melody for “rhythm bands.” The ocarina, song-flute and related instruments are relatively easy to master but the sound emitted is annoying to many. The recorder is easy to play and produces a pleasant sound. The harmonica has been developed into an instrument that is not unpleasant to listen to, but the beginner’s efforts may not be too welcome. The fife requires greater effort to operate and is harsh to the ears of some. The flute is too difficult for hospital use and the beginner in his anxiety might experience a “black-out” from sustained blowing.

The reed and brass wind instruments are not suitable for functional use. Their use is limited to chronic patients because of the large amount of time required to learn to operate them satisfactorily.

Wind instruments can be used for patients whose pulmonary pathology has cleared to such an extent that the physician feels lung exercise is indicated. The early use of lung exercise following atypical virus pneumonia has been found especially beneficial.

Wind instruments may also be used for exercising the facial muscles during the recovery phase of facial palsy. Their possibilities in stretching the scars about the mouth and cheeks should be considered.

Percussion Instruments. The snare drum offers motion to the wrists, elbows and shoulders. Few men or children can resist the temptation to play the snare drum. The desire for prolonged playing is not too great, but if recorded music is played during the exercise the duration can be prolonged for an adequate period. The bass drum, as previously mentioned, permits flexion and extension of the ankle when used with the pedal, and this, too, can be made interesting if recorded music is played simultaneously.

Other percussion instruments may not be generally available in hospitals but the possibilities offered by them will be listed. The kettle drum offers rotation of the arms. The xylophone and marimba do not evoke great ranges of motion but bring the muscles of the upper extremities, neck, and back into play, and promote co-ordination. For children, the toy xylophone is a welcome plaything and an excellent form of occupational therapy for the upper extremities. A new toy, the Typatune, operated like a typewriter affords opportunity for finger exercise.

There are still other instruments which may be classed as musical that offer opportunities for exercise. It is just possible that a portable hand organ may be available. The novelty of operating one of these is not to be underestimated as an incentive to work, particularly in younger people. Both the hurdy-gurdy and the hand-cranked victrola offer exercise to the wrist, elbow and shoulder. By placing these instruments at different distances from the floor or patient, many ranges of motion can be obtained.

The harp offers excellent exercise to the serratus muscles as well as to the muscles and joints of the upper extremities, but its operation is more complicated than that of most instruments, and even if available, would require the instruction of a harpist, of whom there are too few.

Technique

Assignment of patients to instrument-playing should be made in the same manner as other assignments in functional occupational therapy. The physician should prescribe the instrument which best meets the convalescent’s needs. He should explain to the musical aide in the presence of an occupational therapist the motions desired and the precautions to be followed. He should set the time limits for the first and succeeding lessons. In general, it may be said that the first lesson should last about fifteen minutes, or until such time as the patient shows signs of fatigue. This period should be extended gradually to a half hour. The patient should be encouraged to return to the instrument as often as is practicable for further study. When the number of patients receiving lessons is large, a regular schedule for additional practice periods will have to be posted. After a relatively short period, the musical phase of occupational therapy will operate smoothly and the physician will be able to delegate most of the details to the occupational therapist, who should frequently supervise the lessons to ensure desired joint motion and to note progress. The occupational therapist should make progress measurements and notes. When properly supervised, the use of music as functional occupational therapy can be as scientific as any other branch of occupational therapy and is the one use of music at this time which may properly be termed “musical therapy”.

The following table is offered as a reference for some of the motions possible with a few of the instruments described.

Voice

Singing has long been used for the treatment of stammering and other speech impediments. Singing can also be used to exercise the jaws, larynx, lungs and diaphragm. With proper instruction, singing can be an excellent exercise for the muscles of the chest and abdomen as well as a breathing exercise.

For the patient with a recently wired fractured jaw, singing gives gentle joint motion and restores confidence in the ability to use the jaw again. The same thing applies to patients with recovering tempero-mandibular joint pathology. A patient with poor jaw motion cannot articulate well, but can sing more nearly like the well patient than he can talk. Singing can begin at the level of humming and progress through scale practice to actual song instruction.

When several patients are available for vocal exercises, a trio, quartet or other group arrangement will create greater interest. Except in hospitals devoted to the treatment of chronic disease, the turn-over in patients will make group singing uncertain.