Rhythmic Auditory Stimulation

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

By Elizabeth Huber, SPT

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/