871380

research-article2019
JHNXXX10.1177/0898010119871380Journal of Holistic NursingDrumming to Improve Strength, Balance / Spak, Card

jhn
Qualitative Research

Music, Movement, and Mind: Use of

Drumming to Improve Strength, Balance, Journal of Holistic Nursing

Proprioception, Stamina, Coordination, and American Holistic Nurses Association

Volume XX Number X
XXXX 201X 1­–7
Emotional Status in a 12-Year-Old With © The Author(s) 2019
Article reuse guidelines:

Agenesis of the Corpus Callosum sagepub.com/journals-permissions

10.1177/0898010119871380
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A Case Study

David Spak, BA
Elizabeth Card, MSN, APRN, FNP-BC, CPAN, CCRP, FASPAN
Vanderbilt University Medical Center

The purpose of this article is to report a case study of the effect of therapeutic drumming on motor,
communication skills, and behavior of a preteen diagnosed with agenesis of the corpus callosum. This
12-year-old participated in 30- to 45-minute weekly sessions over a 12-month period in which rudimen-
tary drumming exercises were used to analyze and then measure any changes in equilibrium reactions,
postural transfers, and trunk control. Measurable documentation evidenced marked improvement in
motor skills while suggesting communication and behavioral improvement. The findings support the
theory that therapeutic drumming would benefit preteens with agenesis of the corpus callosum, which
provides promising evidence to other neurologic developmental diagnoses and therefore indicates a
need for further research. While the therapeutic nature of music is well documented, how the listener
participates can influence the effect of the music. For example, passive music listening can improve
pain or anxiety, however, active music listening with expected intentional action may improve physical,
mental, behavioral, and spiritual healing. Active music listening could be a valuable holistic nursing
intervention.

Keywords: nursing music intervention; rudiments; therapeutic drumming; agenesis of the corpus cal-
losum; congenital mirror movement; Myelination

Background that this case report examines further. Research

reports music’s ability to influence essential social
Music is cherished by every culture and an inte- functions, which increases social interaction between
gral part of the basic human experience. Listening peers (Rentfrow & Gosling, 2006) and disadvan-
and playing music has been reported as inherent to taged adults (Dingle, Brander, Ballantyne, & Baker,
a person’s life (Hauser & McDermott, 2003). Novalis
(n.d.) eloquently stated the importance of music
“Everything in life is a rhythm.” One could also say Authors’ Note: The authors acknowledge Jana Acy, BSN, RN,
that everything in life is holistic. Caring for the Vanderbilt Behavioral Health for the editing assistance. Please
address correspondence to David Spak, BA, Vanderbilt University
whole patient, not just the physical body, is a con- Medical Center, 1601 23rd Ave South, Nashville, TN 37232-
cept Florence Nightingale brought forward and one 2102; e-mail: druminsync@gmail.com
2  Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX
2012). Through evolution humans respond to sounds
as emotional expressions, response to music is emo-
tional, and the neurobiology of music listening is
unique and different from that of listening to unme-
tered spoken communication (Trimble, 2007).
Extensive research on music therapy has demon-
strated positive results with multiple populations,
including cancer patients (Bradt et al., 2015), those
with dementia (Van der Steen et al., 2017), manage-
ment of pain and anxiety (Kühlmann et al., 2018),
and positive use in the perioperative setting (Wu,
Huang, Lee, Wang, & Shih, 2017).
Reports of positive effects of music in the mental
health population include increased motivation and
positive self-esteem (Grocke et al., 2014) and
increasing feelings of well-being (Clift, Manship, &
Stephens, 2017). These research studies demon-
strate success in using passive music listening, and
this could be used as a holistic nursing intervention
for management of illness or to promote well-being.
Music combined with movement (active listen-
ing) has been used successfully to improve endur-
ance, eye-hand coordination, placidity of movement,
and balance in psychotic adolescence (Apter, Sharir,
Tyano, & Wijsenbeek, 1978) and rhythm in autistic
children (Stanutz, Wapnick, & Burack, 2014). A
2011 study by Albright at Florida State University
suggests a link between active music listening and
improvement of motor and communication skills for
young children. The present case study extends the
idea further by incorporating tactile methods via
Theratubes© (two unique plastic tubes used similar
to drumsticks) as well as rhythmic timing and by
assessing a preteen rather than children under 5
years. The cortex, subcortex, and cerebellum all con-
tribute to music processing and production. This
overlap of shared space in the processing of music
has been explored with reports of aphasiac patients’
ability to sing (Özdemir, Norton, & Schlaug, 2006).
The amount of literature supporting this strong
association between music, movement, and mind
has led to the development of neurologic music
therapy techniques that result in cortical plasticity
that potentially may be applied for rehabilitative gain
(Merzenich, Nahum, & Van Vleet, 2013).
Eye Movement Desensitization and Reprocessing
(EMDR) was first used in 1989 (Shapiro, 1995) as a
therapist-led cognitive behavioral therapy for trauma
patients. This therapy proved effective even when
delivered as a single session in a randomized clinical
trial (Shapiro, 1995; Shapiro, Kaslow, & Maxfield,
2011). It is believed that the bilateral eye move-
ments resulted in desensitization, reduction in
imagery vividness, reduced negative emotions and
reprocessing of the trauma memory, and overall
improvement in symptoms. EMDR has since been
used successfully in multiple populations: pediatric
trauma (Meentken et al., 2018), rape victims
(Edmond, Lawrence, & Schrag, 2016), and even
oncology patients (Faretta, Borsato, Civilotti,
Fernandez, & Pagani, 2016). The data on effective-
ness were so compelling that practice guidelines
inclusive of EMDR was adopted by the American
Psychiatric Association (Forbes et al., 2010) and the
Department of Veterans Affairs and Defense (Forbes
et al., 2010). Further investigations revealed that
other bilateral stimulations, such as “tap tones” were
as effective as EMDR (Shapiro, 1995). This may be
translated into additional holistic nurse–led active
music listening interventions.
Drumming involves bilateral stimulation (similar
to EMDR) with the added benefit of creatively mak-
ing music, increasing movement, and experiencing
play when delivered in a friendly, curious, and fun
environment. This case study reports the effects of
drumming intervention on balance, proprioception,
stamina, coordination, and emotional status in a
12-year-old child with agenesis of the corpus callo-
sum. The challenges for the child were created by
the therapeutic drumming instructor and assessor of
the child’s progress. These one-on-one weekly ses-
sions always took place with either parent observing.
A Case Study
Riley is a 12-year-old child with agenesis of the
corpus callosum (ACC). ACC is a rare birth defect
(congenital) in which all or a portion of the corpus
callosum is absent; most often the posterior portion
is missing. The corpus callosum is the white matter
that transmits signals across the hemispheres of the
brain, allowing each to effectively communicate
with the other. The corpus callosum is important for
processing and integrating sensory, motor, and cog-
nitive information. When the corpus callosum is
missing or malformed, these functions (even ability
to keep time or rhythm) may be affected (Nakamura,
Nagafuchi, Nakamura, & Kogure, 1984; Richards,
Plachez, & Ren, 2004). Riley was diagnosed with
partial ACC at 2.5 years of age and is missing more
 Drumming to Improve Strength, Balance / Spak, Card   3
Figure 1  Diagram of a Drum Set (Bhatt, 2013)
than 50% of the corpus callosum (posterior).
Additionally, he has congenital mirror movement
disorder (CMM). CMMs are involuntary, symmetric
movements. For example, the voluntary movement
of one extremity during the production of involun-
tary exact (mirroring) movements with the other
extremity (Verstynen et al., 2007). Other disabilities
include intellectual delay with an IQ of 68, attention
deficit disorder, obsessive-compulsive disorder, and
generalized anxiety. Additional complexity in physi-
cal function included left-sided weakness and ambly-
opia of the right eye. Riley has participated in
applied behavior analysis therapy and equine therapy
for approximately 4 years. Medications include
Intuniv, Zoloft, Inderal, and Melatonin. Riley’s fam-
ily found the therapeutic drumming instructor
though a referral from a friend.
Riley began weekly 30- to 45-minute therapeutic
drumming sessions on January 31, 2018, and is still
seen weekly. The initial evaluation revealed an
absence of equilibrium reactions and postural trans-
fers (shift of body weight using core to balance) as
well as deficits in manual and trunk control. These
insufficiencies proved that maintaining a center of
gravity as well as automatic reflexes was extremely
challenging.
After a year-long evaluation and analysis, the fol-
lowing events have provided conclusive data.
The first challenge was foot pattern warmups. At
Riley’s first therapeutic drumming session, he was
asked to sit on the drum stool behind the drum kit
placing the right foot on the kick-drum pedal and
the left foot on the hi-hat pedal (see Figure 1). This
was a 4-minute warmup intervention. Riley clearly
struggled to keep balance on the seat. Riley was
asked to press down on the right pedal and strike the
kick drum and then press on the left hi-hat, repeat-
ing a “left-right; left-right; left-right; left-right” pat-
tern. This resulted in Riley nearly falling off the
drum throne multiple times and an inability to com-
plete the 4-minute warmup. Additionally, Riley was
unable to concentrate on completing drumming and
talking.
Every session began with this “left-right” foot
pattern exercise. After 12 months, Riley is currently
able to balance on the drum throne. Riley’s stamina
has improved and can now complete the entire
4-minute warmup. Within 2 months of 30-minute
weekly sessions, Riley was able to speed up and slow
down the “left-right” foot pattern exercise, demon-
strating improvement in postural transfers (core
strength and coordination) and stamina.
4  Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX
Riley is now able to have conversations while
doing the above exercise. Balance on the drum
throne is no longer an issue, indicating a decrease in
concentration with the task at hand and improved
communication skills.
We then progressed to the egg shaker pass chal-
lenge. This required physical and functional use of
both left and right hands to cross the midline of the
body using the left and right hand while simultane-
ously focusing on motor skills. These motor skills
include muscle release and pincher grab. The asses-
sor tosses the egg shaker with his right hand to
Riley’s left hand. In turn, Riley passes the egg from
the left hand to the right. Then uses the right hand
to toss the shaker back to the assessor’s left hand.
Both upper extremities are used when Riley catches,
crosses, and returns the egg with a toss. By engaging
in these exercises, Riley’s brain necessitates informa-
tion sending and receiving feedback bilaterally. The
verbal directions of “Catch, pass, and toss” are
offered. When Riley began learning this specific
exercise, he could not catch the egg, due to poor
hand–eye coordination. Nor could he toss it back.
Riley simply could not judge when to “let go” of the
egg. The egg would drop in front of him when
released too soon, and likewise, it would elevate into
the air and back when released too late. This exer-
cise intervention was practiced weekly for 6 months.
Riley now successfully accomplishes this once
troublesome task. Riley is able to speed up, slow
down, and is even move the shaker in reverse. Riley
was also able to increase the distance from the
assessor and able to catch the shaker when tossed.
This demonstrates improvement in motor skills,
hand-eye coordination, and depth perception as well
as anticipatory timing.
Riley continues to show progress and improve-
ment. Recently, a second shaker was added to the
exercise. Riley successfully passed both shakers
simultaneously with the assessor as well as reversed
the toss with both shakers.
Next was the CMM disorder challenge. During
the first session with Riley, the assessor immediately
observed an interesting situation with Riley’s hands.
When Riley was asked to play an alternating single
stroke drumming pattern (left, right, left, right),
Riley’s right hand played while the left hand mir-
rored the right resulting in drumming with both
hands simultaneously. When the assessor asked
Riley to do the exercise with only one hand, Riley
played the correct pattern with the right hand while
the left hand, again, involuntarily mirrored the right.
Various exercises were attempted, such as raising
one arm in the air or placing one arm behind the
back. Regardless of the exercise, the opposite hand
always mimicked the hand or arm being assessed.
Riley’s parent confirmed the diagnosis of CMM dis-
order. After four of the 30-minute sessions, both
Riley’s parent and the assessor discussed how much
the mirror movement had improved. The assessor
focused the rudimentary exercises on the following:
•• Counting along with all rudimentary exer-
cises
•• Exercises crossing the midline
•• Crossing the sticks while practicing the
exercises and talking
•• Talking while doing one-arm exercises
•• Stretching the entire body across the left
and to the right while playing
Riley improved dramatically, and symptoms of
CMM disorder appeared to have diminished dra-
matically. Instructions for maintenance exercises,
for practice at home, focused on crossing the mid-
line, repetition, and counting while playing.
Due to an illness, Riley was not able to attend
any sessions or practice home maintenance exer-
cises for 4 weeks. Riley’s parent reported that there
was an incident where Riley waved goodbye with one
hand, and the cereal in the other hand spilled every-
where because of the mirror movement, which had
returned during this period without drumming.
Further elaborated that this was the recurrence of
CMM symptoms since the initial positive response
to the drumming exercise intervention initiated a
year earlier.
The Theratubes© challenge was our next step.
Theratubes© are plastic tubes used like drumsticks
measuring 1 1/4” in diameter and 16” in length. Riley
and the assessor began several rudimentary exercises
using the Theratubes© in which they would play pat-
terns such as single strokes (left-right; left-right) and
double strokes (left-left/right-right; left-left/right-right)
as well as other repeated patterns and exercises to
develop fine motor sequential hand skills (Sobierajewicz,
Naskrecki, Jaskowski, & Van der Lubbe, 2018). Riley
repeated specific exercises such as picking up, squeez-
ing, and finding the fulcrum point of the tubes
(Atkinson, 2012). Riley was eventually shown how to
 Drumming to Improve Strength, Balance / Spak, Card   5
flip the tube half a turn in the right hand. Riley tried
but released it too late, sending the tube sailing over
his shoulder approximately 10 feet. To accomplish this
particular skill, Riley needed to release and catch the
tube in a very small amount of time. At first, success-
fully performing this exercise proved to be quite diffi-
cult. However, Riley was persistent and practiced
diligently, every week, and even took a set of
Theratubes© home to continue practicing what Riley
called the “stick toss.”
Riley is now able to flip the Theratubes© 1/2 turn
in each hand. Additionally, Riley learned to alternate
flipping from left to right by releasing the tube out of
the left hand into the right and then flipping the
Theratubes© from the right hand into the left.
As an added bonus, Riley came to a session and
excitedly announced, “I have a surprise for you!”
Riley walked up four steps onto the stage (a chal-
lenging feat for Riley before the sessions began).
Riley turned around and said, “Watch this!” Then
began flipping the sticks 1/2 turn (left-right; left-
right) while walking across the stage, down the stairs
continuing to flip the tubes without interruption or
dropping either Theratubes©. This display demon-
strated increased social engagement with the
assessor, increased hand-eye coordination, proprio-
ception, and improved rhythm.
Discussion
The initial purpose of this case study was to
examine the behavioral effects of therapeutic drum-
ming. However, an unexpected finding seeks addi-
tional research of the effects of measurable
enhancement of motor (entrainment) and communi-
cation skills. Movements made with music tend to
follow the tempo/rhythm; this is known as entrain-
ment. The gains in Riley’s motor skills are both
remarkable and objective. Riley now can toss, cross,
catch, and flip rhythmically, as well as balance, climb
stairs, and even walk while flipping Theratubes©.
Riley’s parents report noticeable improvements at
home as well, indicating that therapeutic drumming
is beneficial outside the setting of the session. Riley’s
parents also notice improvement with aggression,
stress, and anxiety because of therapeutic drumming
and the use of Theratubes©. They believe it is
because he now uses his “sticks” when facing frustra-
tion at home, “drumming it out.” Furthermore, home
improvements of Riley’s progress were not initially
documented or measured, which supports the need
for additional research on therapeutic drumming as
well as active music listening with intentional actions.
Holistic Nursing Implications
Musicians and music therapists may create
music to inspire, heal, or increase function. However,
holistic nurses can use active music listening with
expected intentional action to improve physical,
mental, and spiritual healing for their patients.
Using Dr. Jean Watson’s theory of Transpersonal
Caring and using the selected Caritas Processes of
being authentically present, cultivating a helping–
trusting, authentic caring nurse/patient relationship
and creating a healing environment, nurses can use
active music listening to increase well-being (Watson,
2007).
The case study demonstrated an improvement in
stamina by making music. Holistic nurses can incor-
porate this concept through active music listening as
an intervention. Therefore, using active music lis-
tening while walking, a Parkinson’s patient would
walk to the beat of the music. If the tempo increased,
so would their pace (Roerdink, Bank, Peper, & Beek,
2011). By increasing pace and distance walked, an
increase in stamina could be obtained. Another
example, when caring for a postoperative or cancer
patient experiencing fatigue, the holistic nurse could
encourage purposeful movements using music, sim-
ilar to previously researched “tap tones” (Shapiro,
1995) to increase emotional well-being as well as
stamina. A healing environment could be created
using the patient’s selected music (Ebneshahidi &
Mohseni, 2008) to instill beauty, comfort, dignity,
and increase movement by following rhythm with
finger taps, hand movements, and even foot pump-
ing. This concept of creating a healing environment
has been disseminated by putting the research find-
ings in this case report into action through work-
shops for nurses using therapeutic drumming to
combat compassion fatigue and increase resiliency.
Oncology Nursing Society created an evidence-
based recommendation to combat fatigue with
increased movements and exercise (Focht et al.,
2013). By eliciting patient preferences for music and
honoring this preference for the activity, the nurse is
also developing an authentic caring relationship.
Improvements in coordination were measured
in our case study. Holistic approaches could be
6  Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX
replicated with a selection of songs with various
tempos for either previously mentioned walking or
movement activities. This is keeping with Watson’s
authentic presence by using the patient’s selection
of music and enabling the patient to complete these
activities (Watson, 2007).
Finally, our case study demonstrated that active
music listening improved emotional well-being. The
music used should be selected to align with a happy
point in a patients’ life. For example, asking an
elderly patient what music did they listened to as a
young adult? The nurse should encourage the patient
to reflect on that time in their life as the activity
while music listening. This reflection on the past
leads to insight, knowledge, or peace from past expe-
riences, and then using that emotional state to cope
with present experience (Johns, 2009; Price, 2004).
Holistic approaches could also include using the
patient’s listening devices (phone, MP3 players,
iPads, or computers), or the hospital’s television to
regularly listen to music.
In summary, passive music listening may inspire
or improve pain or anxiety; however, active engage-
ment while listening to music with intentional action
(movement or reflection) can result in improved
function and optimal wellness outcomes.
Declaration of Conflicting
Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
David Spak https://orcid.org/0000-0001-6149-4057
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David Spak, BA, is a Berklee College of Music Graduate and a
Grammy Award–winning drummer who has toured the world with
prominent multiplatinum artists like Blake Shelton, India.Arie, and
others. In 2013, he changed his career path working with child/
adolescent patients at Vanderbilt Psychiatric Hospital to spend
more time with his family. He also started a company called
DruminSync® in his studio. DruminSync® is a percussion-based
rhythmic theraplay program customized to an individual’s behavio-
ral and emotional needs/or disabilities. He has created and leads an
interactive therapeutic drumming group using rhythm and song
to promote healing, self-awareness, and self-expression.
Elizabeth Card, MSN, RN, APRN, FNP-BC, CPAN, CCRP,
FASPAN, is a nursing research consultant at Vanderbilt
University Medical Center, Nashville, TN. A practicing nurse
since 1990, she has served as principle investigator, co-investi-
gator, or study coordinator for more than 125 research projects
in the past 17 years. As the nursing research consultant, she
educates, mentors, and coaches Vanderbilt nurses in completing
original research projects.