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Rhythmic Auditory Stimulation:
Investigating the Clinical Efficacy of RAS in Improving Gait During Neurorehabilitation

By Elizabeth Huber, SPT

RAS

Background

Only one time in my physical therapy shadowing experience did I get to see the effects of music on gait recovery, but that one time was enough to spark my interest in the relationship between rhythmic input and motor output. During my acute care clinical rotation last year, I was able to incorporate music into treatment interventions because my clinical instructor was a big proponent of the use of music, not only for the facilitation of various therapeutic activities with patients, but also for attention and mood disorders among patients with dementia. However, it was not until I completed my Critically Appraised Topic (CAT) in our Evidence Based Practice II course last semester that I realized the considerable amount of research that exists in support of the use of rhythmic auditory stimulation (RAS) with gait training. My CAT looked specifically at the effects of RAS on gait parameters of patients with hemiparesis after having a stroke, but as I completed the literature search for the CAT, I noticed that RAS has favorable outcomes among patient populations of other neurological conditions as well.

It has become clear to me through my time in the clinic, though, that RAS is not utilized as much as it should be, especially if the positive findings linked to the intervention are, in fact, valid. I feel that if clinicians were more aware of the current evidence on the clinical efficacy of RAS with gait training, RAS would be used in neurorehabilitation more often. I am confident after completing this Capstone Project that, when appropriate, I will incorporate RAS training into my treatment interventions with my future patients. The aim of the project is to inform future students in UNC’s DPT program of the benefits of RAS and to motivate them to want to learn more about the intervention in order to use it in their clinical rotations.

 

Overview

Rhythmic auditory stimulation (RAS) is a type of intervention that, when combined with gait training, has been shown to enhance improvements in gait parameters among a variety of patient populations, including individuals with stroke, Parkinson disease, multiple sclerosis, cerebral palsy, and traumatic brain injury.1,2 The intervention, which was developed by Dr. Michael Thaut and colleagues at the Center for Biomedical Research in Music,3 elicits movement via neural connections that exist between the auditory system and motor centers in the brain.4 In other words, the brain responds to rhythmical auditory input by increasing activation of motor areas, which leads to increased mobility.5 This phenomenon has been utilized in combination with gait training, leading to clinically-significant improvements in parameters including gait velocity, stride length, single leg support, and functional balance, as well as improvements in cadence and gait symmetry that were insignificant but larger than improvements from gait training alone on those same outcome measures.6,7,8

After working with a number of patients with gait impairments during my past three clinical rotations, but not knowing enough about RAS to think to use it as an intervention, I was interested to educate myself and others on this topic so that we can being to utilize RAS more. Since RAS is a specific intervention that is not typically included in our curriculum, I created this Voicethread presentation in hopes that it might be incorporated into one of the neuro courses in the future to increase students’ awareness of the clinical efficacy of RAS.

 

Project Products

Voicethread presentation:
https://unc.voicethread.com/myvoice/thread/9046451/51311020/51307783

Presentation in PDF form for note-taking:
RAS Voicethread Presentation in PDF form

 

Evaluation & Self-Assessment

After completing this presentation, some fellow classmates assessed my presentation to determine whether or not the language and content was at an appropriate level for the typical physical therapy student or clinician. I edited the content based on their feedback. I also plan to provide an in-service on this topic during my inpatient rehab clinical rotation this summer at which point I will provide clinicians with an in-service evaluation form to evaluate the content, as well as the way in which the information is presented. Additionally, if I encounter patients during my clinical who are appropriate for this intervention, my hope is to complete a case study that I will then add to my presentation. The presentation currently includes high quality research studies but lacks information from a personal patient experience.

Completing this Capstone Project has not only taught me a lot about the ways in which RAS can be used in the clinical setting, but it also taught me to analyze literature well enough to understand and summarize that which is clinically meaningful to physical therapists. As I considered the audience for whom this presentation was created, I frequently had to modify the content in order to make it as useful and pertinent as possible for future students and clinicians.  My midterm was a good wakeup call for me as I was advised to be careful about the information I was presenting in order to ensure that it was physical therapy related and not just something that a music therapist might do. Learning to make edits, additions, and deletions of information based on what I determined to be clinically significant to physical therapy students and clinicians was good practice for future presentations that I will give.

Another weakness for me while creating this Voicethread was that I worked independently (other than feedback on my midterm) on the presentation until sending the almost finalized product to my committee members. Luckily, there were not many changes required, and I had just enough time to take their suggestions into consideration and make the necessary changes. However, if I had been more proactive and in touch with my committee members throughout the semester, my final product could have been that much better.

Lastly, creating a Voicethread forced me to articulate exactly what I wanted the listener to gather from each slide, but I am sure there are times throughout the presentation at which I am either too wordy or do not explain a concept enough. Regardless, creating a product that will be viewed by others for years to come has been a wonderful and humbling experience, and I hope the confidence I gained from completing this project accompanies me into my future career and future endeavors.

 

Acknowledgements

First of all, I want to thank Haley Steele, PT, who was one of my Capstone Committee members, as well as my clinical instructor for my acute care rotation last year. I credit her with being the first to encourage me to investigate the many ways that music and rhythmic cueing can be utilized in physical therapy. I already had a passion for music, but she encouraged me to combine that passion with my passion for physical therapy. I would not have chosen this topic for my Capstone Project had it not been for her motivation and wonderful teaching! I also would like to thank my other Capstone Committee member, Dr. Carol Giuliani, PT, PhD FAPTA. Both she and Dr. Karen McCulloch, PT, PhD, NCS not only spent countless hours teaching us over the last few years but, more recently, they both took time out of their busy schedules to provide me with guidance and suggestions for this project. I have to say, when completing a presentation on concepts related to neurorehabilitation, it is a bit intimidating to ask for feedback from the best of the best, but I am thankful for their patience, instruction, and valuable feedback. Lastly, I would like to thank Lexie Williams, DPT who is currently in the Physical Therapy Neurology Clinical Residency Program at Boston University. She also assisted me by providing suggestions and valuable resources. Thank you all!

 

References

  1. Thaut MH, Leins AK, Rice RR, et al. Rhythmic auditory stimulation improves gait more than NDT/Bobath training in near-ambulatory patients early poststroke: A single-blind, randomized trial. Neurorehabil Neural Repair. 2007;21(5):455-459. doi:10.1177/1545968307300523.
  2. Ashoori A, Eagleman DM, Jankovic J. Effects of auditory rhythm and music on gait disturbances in Parkinson’s disease. Front Neurol. 2015;6:Article 234. doi:10.3389/fneur.2015.00234.
  3. Thaut C, Rice R. Rhythmic Auditory Stimulation (RAS). In: Thaut M, Hoemberg V, eds. Handbook of Neurologic Music Therapy. Oxford: Oxford University Press; 2014:94-105.
  4. Grahn JA, Brett M. Rhythm and beat perception in motor areas of the brain. J Cogn Neurosci. 2007;19(5):893-906. doi:10.1162/jocn.2007.19.5.893.
  5. Thaut MH, McIntosh GC, Hoemberg V. Neurobiological foundations of neurologic music therapy: Rhythmic entrainment and the motor system. Front Psychol. 2015;5(1185):1-6. doi:10.3389/fpsyg.2015.01185.
  6. Nascimento LR, de Oliveira CQ, Ada L, Michaelsen SM, Teixeira-Salmela LF. Walking training with cueing of cadence improves walking speed and stride length after stroke more than walking training alone: A systematic review. J Physiother. 2015;61(1):10-15. doi:10.1016/j.jphys.2014.11.015.
  7. Kim JS, Oh DW. Home-based auditory stimulation training for gait rehabilitation of chronic stroke patients. J Phys Ther Sci. 2012;24(8):775-777. doi:http://doi.org/10.1589/jpts.24.775.
  8. Kadivar Z, Corcos DM, Foto J, Hondzinski JM. Effect of step training and rhythmic auditory stimulation on functional performance in Parkinson patients. Neurorehabil Neural Repair. 2011;25(7):626-635. doi:10.1177/1545968311401627.

Image: http://hoop.lst.tfo.upm.es/

5 Responses to “Rhythmic Auditory Stimulation”

  1. Mary Runey

    Hey Elizabeth,
    Great project! The use of music is so beneficial to help a variety of patients. I have recently done some research and saw that it was also beneficial to help cognitive improvements and allow for better carry over of activities. Your project was well done with great resources. I plan to to use this nontraditional intervention in my future practice. Previously I have used music with patients with Parkinson’s disease but I have not used RAS with patients who have sustained a stroke. Your project does a great job of showing the effects of RAS and how to actually implement it into our practice. Overall, job well done!!!!

    Reply
  2. Carol Giuliani

    Elizabeth,
    Great job of trying to get the word out on this intervention and the good job of providing some of the neural integration information. Nice integration of the video clips. Seeing the actual effects makes the point quite well. Well done on sharing the effects in the literature. I think this is very valuable material for clinicians as well at PT students. I have a few suggestions for you as you prepare for your oral presentation at the clinical that you’ll get via KMAC. Congratulations on a job well done!

    Reply
  3. Elizabeth Huber

    Hey Whitney,
    Thanks so much for your feedback and for your great questions! I, like you, did not know much about RAS prior to researching it this year, both in the Evidence Based Practice course and this capstone course, but I agree that it could potentially be so useful in so many patient populations (including MS, with which I know you have a lot of experience). I am sure that just like any other intervention, RAS could be effective for one patient while not as successful for another with similar gait deficits. I’m sure this intervention is very patient-dependent.
    That being said, and to answer your question, I think the target cadence or ultimate gait speed that you might want the patient to reach will be completely dependent upon the specific patient. That is why an initial assessment of gait is so important in order to determine the correct tempo with which to begin RAS training. In all of the articles I read, I did not see a “target gait speed” –the only guidelines I saw in regards to setting the target tempo is to increase the tempo in increments of about 5-10% each time, but, again, this is patient-dependent and might have to be done on a “trial and error” basis. Instead of having a target tempo, I might instead have a target change in velocity. According to a study by Tilson et al. investigating a clinically meaningful improvement in gait speed after stroke, the MCID is 0.16 m/s for individuals 20-60 post-stroke.1 Therefore, I would encourage clinicians to use the MCID for each gait parameter in each patient population as a goal (and I do not have all of these values offhand but am sure they can be accessed easily).
    In response to your question about using RAS for runners, though I did not research this specifically, I do know anecdotally that runners have success using music to pace their runs during training. In fact, the phone apps “RockMyRun” and PaceDJ are both commonly used by runners to maintain a certain pace or work on increasing their pace during runs. So, yes, you bring up a great point, and I think it just demonstrates the broad reach that RAS training could have in the clinic. So many patient populations, including healthy athletes, could potentially benefit from this intervention! I am no expert in energy efficiency for running, but I did find an article by Farris and Sawicki (2012) that investigates and discusses the relationship between walking/running speed and power output, efficiency, and metabolic cost of transport (“COT”).2 The researchers found that efficiency peaked at an intermediate gait speed of about 1.5 m/s. They found COT to be lowest, though, at 1.25 m/s, which is similar to many individuals’ “preferred gait speed.”2 With running, though, efficiency of work was positively correlated to running speed, meaning efficiency increased with an increase in tempo.2 COT and running speed were negatively correlated, so as running speed increased, metabolic cost of transport decreased.2 These findings suggest that the more the runner is able to train and increase their average running speed, the more energy efficient their running pace might be.
    Thanks for your thought-provoking questions! They helped me to learn some more about the topic as well. Feel free to read more about the second topic—the article citation is below!

    1. Tilson J, Sullivan K, Cen S, et al. Meaningful gait speed improvement during the first 60 days poststroke: Minimal clinically important difference. J Am Phys Ther Assoc. 2010;90(2):196-208. doi:10.2522/ptj.20090079.
    2. Farris DJ, Sawicki GS. The mechanics and energetics of human walking and running: a joint level perspective. J R Soc Interface. 2012;9(66):110-118. doi:10.1098/rsif.2011.0182.

    Reply
  4. Whitney Huryta

    Hi Elizabeth,
    I really enjoyed your capstone project! I especially enjoyed listening to your voice thread. I honestly had never heard of the term Rhythmic Auditory Stimulation until reviewing your capstone. However, I now understand what it is and how it could be useful to our practice as physical therapists. I even love how you threw in the neuropathway information (reticulospinal pathway) and described how this pathway will allow for a muscular response to the auditory stimulus or even a tactile or visual stimulus.

    As I have a passion for working with people who have a neurological condition, I think your capstone will certainly enhance my practice in the future and I particularly appreciated your application of RAS to people who have had a stroke and for people who have PD. I also thought it was significant that RAS could improve gait parameters (gait velocity and stride length) better than treadmill training for people with stroke.

    Furthermore, the most useful piece of your presentation was that you walked us through how to utilize RAS with a patient! Is there a specific target frequency or metronome setting at which you would want to work up to and then at that point fade out the cueing with respect to gait? Also, do you think there is application for RAS for people who are training for various sporting events such as runners? If there is a specific tempo that would be most energy efficient, it may be beneficial to recommend for people to train to that tempo…possibly? thoughts?

    Overall, great job! I enjoyed your capstone and benefitted from listening to your voice thread!

    Reply
  5. KMac

    Hi Elizabeth – Gotta love any presentation that quotes Nietzhe – I still need to listen to your voicethread, but I like how you’ve shifted the presentation to be more PT appropriate and less about music therapy….we’ll make sure we find a time to refer entry level students to this content in the 784/785 series. More feedback will be coming to you from me a bit later, but congratulations for achieving this milestone!
    kmac

    Reply

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