Clinical

Multi-disciplinary perceptions
of music therapy in complex
neuro-rehabilitation
Wendy L Magee, Keith Andrews
Although there is growing evidence that music therapy has a significant role to play in rehabilitation
of patients with complex neuro-disabilities, its provision in rehabilitation units varies widely
internationally. Understanding the role it plays in therapeutic outcomes appears to be one of the
barriers in developing music therapy service provision in the UK, where it remains under-resourced in
rehabilitation units.
This paper reports on a retrospective study of referral patterns to an established music therapy
service in a multidisciplinary (MDT) neuro-rehabilitation setting in England. Referrals over a 2-year
period were analysed to examine the reasons for referral to music therapy both in terms of priority
and frequency, as well as which members of the multidisciplinary team were referring.
The results indicate that where music therapy is integrated into MDT programmes it is perceived by
the team to have a particular role in the rehabilitation of communication and emotional health needs.
Key words: music therapy, brain injury, neurological rehabilitation, referrals, multidisciplinary,
communication, emotional expression
Magee WL, Andrews K (2007) Multi-disciplinary perceptions of music therapy in complex neuro-rehabilitation. Int J
Ther Rehabil 14(2): 70–5

A
s a developing clinical discipline, music
therapy has attracted less interest in the
UK than other allied health professions.
In one survey of rehabilitation units in
the National Health Service only a total of 1.8 whole
time equivalent music therapists were identified
in four units of the 56 neurological rehabilitation
units surveyed (Andrews and Turner-Stokes, 2005).
Because so few multidisciplinary (MDT) teams
come in contact with music therapists it probably is
not surprising that there is not a more positive drive
to include music therapy as part of the rehabilitation
provision. This is despite increasing descriptive and
empirical reports of its positive effects on functional
outcomes for people with neurological conditions.
Wendy L Magee is This report presents the results of a study of the
International Fellow perceptions of multidisciplinary teams as to the
in Music Therapy value and role of music therapy in an inpatient
and Keith Andrews neurological rehabilitation service for adults with
is Director, Institute
of Neuropalliative
acquired brain injury resulting in complex neuro-
Rehabilitation, Royal disabilities. The results identify trends in referral
Hospital for Neuro- patterns over a 2-year period covering source of and
disability, West Hill, reason for referral.
Putney, Music therapy is ‘a systematic process of inter-
London SW15 3SW
vention wherein the therapist helps the client to
Correspondence to: promote health, using music experiences and the
WL Magee relationships that develop through them as dynamic
forces of change’ (Bruscia, 1998). Interventions
involve a broad range of music-based methods
which most usually involve the client in actively
making music in dialogue with the therapist (Magee,
2002). Within the field of neurological rehabilitation
there is a growing body of evidence demonstrating
its effectiveness to address expressive communi-
cation disorders (Cohen, 1988, 1992; Pilon et al,
1998; Cohen and Masse, 1993 Baker, 2002; Baker
and Wigram, 2005) and physical functioning (Thaut
and McIntosh, 1992; McIntosh et al, 1993; Thaut
et al, 1993; McIntosh et al, 1995; Thaut et al, 1995;
Prassas et al, 1997; Thaut et al, 1997a; Thaut et al,
1997b; Hurt et al, 1998). Further empirical stud-
ies indicate its success in improving psychologi-
cal functioning including mood states (Magee and
Davidson, 2002), self-esteem (Purdie et al, 1997),
levels of agitation (Baker, 2001), and social interac-
tion and participation in rehabilitation (Nayak et al,
2000) (Cochrane reviews are currently in develop-
ment to examine the quality of this evidence).
With only 12% of rehabilitation units in the UK
expressing a perceived need for inclusion of music
therapy in their services (Andrews and Turner-
Stokes, 2005), there is clearly a gap between the
perception of what music therapy can contribute
to rehabilitation and the emerging evidence of the

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specific role it can play. Its role in neurological encouraged to give priority weighting to the refer-
rehabilitation is poorly understood and difficult to ral goals.
demonstrate with such scant service provision. Data from referrals in the brain injury service
The Royal Hospital for Neuro-disability (RHN) were collected for a 2-year period, covering three
in London is a medical charity offering rehabili- units for profound brain injury, rehabilitation of
tation and continuing care for adults with severe complex needs and neuro-behavioural disorders.
neurological disabilities stemming from disease or Average occupancy for the three units in total across
trauma. A long-standing and well-established music
therapy service distinguishes RHN from other neu-
TABLE 1.
rological rehabilitation facilities, with 3.6 whole
Frequency of music therapy referrals by
time equivalent (WTE) qualified staff at the current discipline
time covering both clinical and research activity.
Music therapy is fully integrated into collabora-
tive MDT working in the rehabilitation programmes
including:
Referral source Frequency

Goal-setting

Case review Multidisciplinary Team (MDT) 30

Managerial forums. MDT forum* 18
SLT/OT 5
Referrals are made by any member of the treatment
SLT/Psychology 3
team, relatives and by service-users themselves OT/PT 1
where the reasons for referral are identified clearly
SLT 27
by the referrer before acceptance of the referral. As
the experienced rehabilitation teams at RHN are OT 24
familiar with music therapy working practices and Psychology 14
the specific benefits it brings to neuro-rehabilita-
Music Therapy 6
tion of complex needs, this data yields important
insights into the role of music therapy in neuro- PT 3
rehabilitation as perceived by the MDT. Other 6
Nursing
METHODS Physician
Social Work
Dietician
Referrals to music therapy were generated inde-
Self-referral
pendently from team members using a referral Relative
form. On occasions, referrals were generated from
* Examples of subsets of MDT groupings
service users/families. Reasons for referral to music
therapy were categorised into six domains based on OT=Occupational therapist; PT=Physiotherapist;
the health needs used in the multidisciplinary clini- SLT=Speech and language therapist
cal documentation system. These domains included:

Physical presentation

Occupation TABLE 2.

Cognitive function Reasons for referral: frequency of priority one and overall frequency

Communication skills and social relationships,
Frequency of Overall frequency

Emotional expression Reasons for referral Priority 1 rating of referral

Behaviour.
Referrers were required to identify as specific n % n %
goals as possible within each of the relevant health Communication skills/social relationships 40 36.7 75 26.8
domains selected in the referral. Emotional expression 29 26.6 66 23.6
As apparent from the descriptive literature and
clinical practice, music therapy is often seen as a Behaviour 18 16.5 50 17.9
forum in which a combination of health needs can Cognitive function 14 12.8 45 16.1
be addressed, rather than specific targeted goals. Physical presentation 6 5.5 25 8.9
For this reason, referrals to music therapy are usu-
ally multifaceted, including goals across two or Occupation 2 1.8 19 6.8
more of the heath needs categories. Referrers are Total 109* _ 280 _
encouraged to refer for as many reasons as they *n = 109 rather than the total number of 110 referrals as goal data was not
feel appropriate (n=1–6). In order to identify pri- available for one of the referrals.
ority reasons for referral, therefore, referrers are

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 Clinical
the period was 59.4 beds, covered by 1.7 WTE
music therapists whose clinical responsibilities
included direct and indirect patient care.
RESULTS
Sources of referral
During the 2-year period from which data were col-
lected, the music therapy service received 110 refer-
rals across the three identified rehabilitation areas.
Table 2 presents the results of frequency of referral
by discipline or disciplinary groupings. The most
frequent source of referral was from MDT group-
ings (Table 1), most notably MDT forums.
The other MDT groupings demonstrate that com-
bined speech and language therapy and occupa-
tional therapy referrals were the next most frequent
source of MDT referral. Single disciplines referring
were most commonly speech and language therapy
followed by occupational therapy. Referrals from
clinical psychology were the third most frequent,
although it should be noted that one of the units had
a vacant post for clinical psychology for the greater
part of the data collection period.
The ‘Other’ category included incidents of sin-
gle referrals from a particular source such as social
work, physicians, nurses and the less likely disci-
pline of dietetics. Given that nursing is ward-based
and the primary care intervention, it is notable that
only one referral in a 2-year period came from this
source. However, all the individual source of refer-
rals were disciplines which also took part in MDT
forums and so may have been party to some extent
in referrals from team forums.
Reasons for referral
Table 2 presents the results analysing reasons for
referral by both frequency of priority (i.e. given
as priority 1) and also the overall frequency (i.e.
given as priority 1–6). The priority and overall
frequencies of reasons for referral descend in a
corresponding manner across all six categories,
with communication skills and social relationships
having the highest rating for both priority and fre-
quency (36.7% and 26.8% respectively). This is
closely followed by emotional expression which
rated 26.6% of priority referrals received and
23.6% of referrals overall. Behaviour and cognitive
function follow consecutively with nearly parallel
results, where behaviour rated as the third highest
priority for referrals (16.5%) and cognitive func-
tion as the fourth highest priority (12.8%). Overall
frequency for these two goal areas reflected these
priority ratings, with the overall frequency of refer-
ral for behaviour being 17.9%, and cognitive func-
tion being one of the reasons for referral in 16.1%
of referrals overall.
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Physical presentation was referred as a priority
goal in only 5.5% of cases, although was given as
one of the reasons for referral in 8.9% of refer-
rals overall. ‘Occupation’, covering leisure, prevo-
cational and vocational skills and social activities,
was the least frequent reason for referral to music
therapy, with only 1.8% referrals outlining this as
a priority goal area, and 6.8% outlining this within
overall reasons for referral.
DISCUSSION
The findings indicate that referral to music ther-
apy is influenced by a number of factors. Part of
this is how well the team have been ‘educated’ by
the music therapist into the most appropriate refer-
rals. However, if this was a main influence referrals
would have been more evenly distributed throughout
the differing disciplines. Most of the referrals came
from those members more specifically involved
in communication and psychological assessment
– speech and language therapists, occupational ther-
apists and clinical psychologists. There were few
referrals from physiotherapists, nurses, doctors and
other clinical disciplines who were equally involved
in the MDT and clinical management of patients.
It is perhaps surprising that nurses who are gener-
ally more patient-advocate orientated did not refer
more patients. It therefore seems that where the cli-
nician had a professional knowledge base that made
the contribution of music therapy particularly rel-
evant there was greater inclination to refer patients.
This supports the view that a perception of clinical
relevance is important in referral of patients and
indicates the need for greater education of other
clinical disciplines to ensure appropriate referrals.
It also suggests that the reason why music therapy
is not more widely available is that the knowledge
base of what it can achieve is not widely available
– especially among doctors who are likely to be the
professional group instigating the availability of the
service.
The reasons for referral were mainly for commu-
nication, emotional or cognitive support. This may
be because those most likely to refer were those
disciplines with particular interest in those areas or
because these were seen as the most important func-
tions and therefore were more likely to be referred
by speech and language therapists, clinical psychol-
ogists and occupational therapists.
The concept of music therapy’s primary role in
addressing communication skills is in line with
the empirical studies and a long history of pub-
lished case studies describing the effects for peo-
ple with aphasia. Similarly, the evidence base for
music’s potential to elicit and assist with emotional
responses is reflected in referral patterns to assist
with emotional expression, often a secondary hand-
icap within neuro-rehabilitation which impacts on
the patient’s involvement in rehabilitation overall.
The referral patterns may also be influenced by
the nature of the organization in that the patient
group had very complex neurological disabilities
including those with low awareness states, cogni-
tive impairment or challenging behavioural dis-
orders. The inclusion of music therapy in MDT
rehabilitation programmes may therefore have been
seen to have impact on the wider programme, as
intervention to address emotional expression for
non-verbal patients is poorly provided within ver-
bal therapies.
Additionally, the results demonstrate that music
therapy was perceived to have a considerable contri-
bution in the assessment and treatment of behaviour
and cognition as well. Both of these health needs are
under-represented in the existing research of music
therapy with this population, suggesting that further
research on these factors is warranted.
These results of established integrated MDT
practice do highlight some discrepancies between
clinical practice and research into music therapy in
neuro-rehabilitation. While the greatest evidence for
the efficacy of music therapy is in the rehabilitation
of gait training, referral for physical presentation
was much less frequent in both priority and overall
reason. This discrepancy may be explained by dif-
ferences in the severity of disabilities presenting in
this setting compared to the research studies. It may
also suggest a need for improved working prac-
tices or communication between music therapy and
physiotherapy, who referred less frequently to music
therapy overall.
Similarly, the low incidence of referrals from
nursing staff and physicians, with whom music
therapists work closely on rehabilitation wards, is
notable, although may be masked by the referrals
from MDT forums. This study suggests that work-
ing practices may benefit from review, particularly
in terms of communication with these key disci-
plines, so as to optimize the understanding of what
music therapy may bring to the patient’s care.
The lower incidence of referrals for ‘occupation’
as a priority affirmed a good understanding of the
role of music therapy, as it is at risk of being mis-
understood as something to keep patients ‘busy’ or
‘happy’ by the uninitiated. Involvement of the music
therapist in MDT forums may offer some expla-
nation of this result, as this inclusion assists with
understanding the role of a particular discipline and
its perspective on care provision. However, it might
also be considered that ‘occupation’ was a less fre-
quent reason for referral as a result of the lack of
importance given in rehabilitation to leisure skills
and access to leisure.
International Journal of Therapy and Rehabilitation, February 2007, Vol 14, No 2
Rehabilitation with patients with complex and
severe disabilities should be aiming to optimize
quality of life, a large part of which may be how to
enhance the patient’s time spent in activities with
significant others.
CONCLUSION
If music therapy is to become more accepted as
a rehabilitation discipline in line with other allied
health professions then there needs to be a greater
understanding of the contribution it can make.
The results indicate that it has a perceived role in
all areas of rehabilitation, and in particular in the
domains of communication/social relationships,
emotional expression, behaviour and cognition.
While particular allied health disciplines were
likely to refer patients, other disciplines, especially
doctors who usually are the instigators of clinical
services, did not refer. Inclusion in MDT forums
provides the main contact point with non-allied
health professional staff. A considerable amount
of work is required by music therapists to dem-
onstrate to the medical profession and managers
of rehabilitation services that they have an impor-
tant contribution to make, especially in the field of
communication, emotional support, cognitive and
behavioural management. IJTR
The authors would like to acknowledge the staff of the Music
Therapy Department at the Royal Hospital for Neuro-disabil-
ity who were involved in data collection, in particular music
therapy assistant Claire Stonier for her assistance with data
collation. We would like to acknowledge support from the
Neuro-disability Research Trust and Department of Health
NHS Research and Development funding for this study. The
views expressed in this publication are those of the authors
and not necessarily those of the NHS Executive.
Conflict of interest: none.
KEY POINTS

Emerging research suggests that music therapy within neurological
rehabilitation addresses expressive communication disorders, physical and
psychological functioning.

Where music therapy is integrated into multidisciplinary rehabilitation
programmes it is perceived by the team to have a particular role in
rehabilitating communication and emotional health needs.

Music therapy also has perceived clinical benefits for the domains
of cognition and behaviour, highlighting the need for research of its
effectiveness in these areas.

Integrating music therapists into the rehabilitation team ensures optimal
referrals and application of music therapy into multidisciplinary goals
73
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 Clinical

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COMMENTARIES
What role does music therapy play
in neurological rehabilitation? And
what role could it play in the future?
What the authors of this study
found out probably represents the
situation in most European coun-
tries: that despite a growing corpus
of empirical evidence, the potential
benefits of music therapy in the
field of neurological rehabilitation
are often underestimated.
Effectiveness and efficacy research
studies have pointed out that music
therapy provides several effective
intervention strategies such as:

Gate rehabilitation

Speech rehabilitation

Training of executive functions.
On the other hand famous repre-
sentatives of neurosciences, such as
Robert Zatorre (Zatorre and Peretz,
2001)), Stefan Koelsch (Koelsch et
al, 2004)), Luisa Lopez and Maria
Majno (Lopez, 2005)) implemented
extensive research programs on
music and the brain that influence
music therapeutic interventions
especially in the field of neurology.
Evidence appears to support
the potential of music therapy to
modulate:

Attention

Emotion

Cognition and speech

Motor behaviour

Communicational skills.
That does not mean that enough
work has been done. Rather, it
implies that it is worth investing
more endeavours into neuro-scien-
tific music therapy research.
But nevertheless it seems obvi-
ous that current research underpins
music therapy as relevant adjuvant
intervention in the field of neuro-
logical rehabilitation.
Empirical evidence is not the only
crucial point responsible for the
dissemination of an intervention,
as the large amount of less empiri-
cally validated but widely used clini-
cal cures point out. Also historical
developments of disciplines, their
image and self-image, and aspects
of fashion as well as competition
between different disciplines play
major roles in the recognition of
music therapy and others.
In other words the conceded
relevance and recognition of an
intervention is not only the result
of rational processes in modern
health care systems such as empiri-
cal founded effectiveness and effi-

Music therapy researchers
cacy but also of irrational factors as
should enhance efforts to take
described above. Therefore it is not
part in interdisciplinary clinical
sufficient to produce valid empirical
studies and quality assurance
results.
programs of the institutions that
Additional efforts are neces-
they work in.
sary to enhance rational decisions
pointing out the relevance of music
therapy in the field of neurological
TK Hillecke
rehabilitation:
Professor of Psychology

Music therapeutic contents
Faculty of Music Therapy
(interventions, studies, clinical
Heidelberg University of Applied
situations) should be published
Sciences
in relevant specialized journals
Maaßstr. 26
of neurology and neurological D-69123 Heidelberg
rehabilitation and not mainly in Germany
music therapy journals

Representatives of music therapy
Avanzini G, Lopez L, Koelsch S, Majno M (2005) The
should offer more contributions Neurosciences and Music II: From Perception to
to national and international Performance. Ann New York Acad Sci 1060
congresses of neurological reha- Koelsch S, Kasper E, Sammler D, Schulze K, Gunter TC,
Friederici AD (2004) Music, language, and mean-
bilitation
ing: Brain signatures of semantic processing. Nat

Music therapists should enhance Neurosci 7(3): 302–7
educational efforts in the clinical Lopez L (2005) Music Therapy: The Long Way to Evidence-
teams that they work in Based Methods - Pending Issues and Perspectives.
Annals of the New York Academy

Music therapists and music
therapy organizations should of Sciences 1060: 269–70
adequately inform the public Zatorre RJ, Peretz I (2001) The Biological Foundations of
Music. Ann New York Acad Sci 930.
and representatives of the health
care systems

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 COMMENTARIES
Wendy Magee’s paper is an impor-
tant contribution to the under-
standing of music therapy’s role
in neurorehabilitation. Her well
executed study gives a clear picture
that shows positive trends in music
therapy’s use as a primary therapy
agent but also clearly delineates the
obstacles music therapy still faces.
Although the study is based
on data generated in the UK, my
impression is that these results may
be not too far away from the situ-
ation in other countries. The data
show that a lack of communication
to disseminate the positive clinical
effects of music therapy to the med-
ical community is one critical factor
in the small employment of music
therapy in neurorehabilitation. The
other major result seems to show
that when music therapy is used, it
is used in the more traditional social
International Journal of Therapy and Rehabilitation, February 2007, Vol 14, No 2
science paradigm of emotional,
social, and cognitive support.
One factor that seems critical
to keep in mind is that the use of
music therapy as a central therapy
modality in neurorehabilitation is
fairly new – based on an emerg-
ing new research data base that is
driven by a new neuroscience based
research paradigm. These research
efforts go back about 15 years,
so when considering that it takes
about 17 years for basic research to
be translated into actual treatment
application that the patient sees, it
is not surprising maybe that we are
just now seeing the beginnings of
music therapy being employed in
neurorehabilitation.
I believe, however, that the ulti-
mate fate of music therapy – like
all other treatment disciplines `- will
be determined by generating the
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convincing clinical research evi-
dence that helps put music therapy
techniques on a solid ‘hard-science’
basis for motor, speech/language/
psychosocial and cognitive rehabili-
tation goals.
Promising beginnings have
occurred - and one group of partic-
ular techniques of rhythmic motor
training has actually met state-of the
art review standards for evidence
based medicine. So, one may think
that as the quality and quantity of
basic and translational research in
biomedical research in music contin-
ues and grows, the acceptance of
neurologic music therapy will grow
as clinical techniques meet stand-
ards of research evidence.
It is good to keep in mind that in
this challenge music therapy is not
alone – all rehabilitation disciplines
must find higher levels of evidence
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base. However, it is critical, as the
authors point out, that music thera-
pists are able and understand the
necessity to communicate compe-
tently about the current and contin-
ually emerging research base which
is stronger in neurologic music ther-
apy even at this point than may be
commonly known.
Lastly, as a challenge to their
own profession, I may add to the
author’s timely study – the rapidly
changing knowledge base requires
special efforts by music therapists of
continuing professional education.
Michael H Thaut
Professor of Music
and Neuroscience
Center for Biomedical Research in
Music
Colorado State University
Fort Collins, CO 80523
75