Background

The World Health Organisation (2017a) defines rehabilitation as "a set of interventions designed to optimise functioning and reduce disability in individuals with health conditions in interaction with their environment" (p. 1). Neurorehabilitation is a subset of rehabilitation specific to individuals with neurological disorders (Dimyan, Dobkin, & Cohen, 2008; Polgar et al., 1997). Those with neurological disorders demonstrate a variety of sequelae including physical, cognitive, behavioral, and communication impairments, which can lead to psychosocial and daily living difficulties (WHO, 2006). With the broad definition of rehabilitation and the complexity of sequelae in people with neurological disorders, the goals to be addressed in neurorehabilitation are extensive.

Music therapy research in neurorehabilitation has steadily grown since the 1980s and demonstrated potential to address the sequelae of neurological disorders (Baker & Tamplin, 2006). For physical impairments, Weller and Baker (2011) report a number of studies that showed consistent positive and significant outcomes of music therapy interventions (e.g. auditory stimulation, movement to music, active music making) for physical rehabilitation of people with neurological disorders. Music therapy studies have been conducted with people of all ages across a wide range of neurological disorders including stroke, cerebral palsy, Erb's palsy, Parkinson's disease, and Rett syndrome (Freedland et al., 2002; Howe, Lovgreen, Cody, Ashton, & Oldham, 2003; Jeong & Kim, 2007; Kwak, 2007; Luft et al., 2004; Pacchetti et al., 2000; Rahlin, Cech, Rheault, & Stoecker, 2007; Rochester et al., 2005; Schauer & Mauritz, 2003; Schneider, Schonle, Altenmiiller, & Munte, 2007; Thaut et al., 2007; Whitall, McCombe, Waller, Silver, & Macko, 2000; Yasuhara & Suyiyama, 2001). These studies show the diversity of populations with whom physical rehabilitation is addressed across both acquired and degenerative neurological disorders. In particular, there are various dimensions of physical rehabilitation which music therapy can benefit, such as different movement types (e.g. gait, fine and gross motor movements in both upper and lower extremities), and movement qualities (e.g. balance, strength, dexterity, mobility, coordination, range of motion, functional uses) (Magee, Clark, Tamplin, & Bradt, 2017; Tamplin, 2006; Weller & Baker, 2011).

According to the Cochrane review by Magee et al. (2017), studies using music interventions to target cognitive impairments, including memory, attention, executive functioning, and orientation rehabilitation for people with acquired brain injury (ABI) were examined (Pool, 2013; Sarkamo et al., 2008; Mueller, 2013; Baker, 2001). The review shows that orientation was the only outcome that had significant improvements in response to live music listening (Baker, 2001; Magee et al., 2017). In people with disorders of consciousness due to ABI, music therapy has been shown to be effective in stimulating behavioural responses, such as facial expression, blink, and respiratory rate (Fernandes et al., 2014; O'Kelly, 2013). For behavioural problems, music therapy has demonstrated effectiveness in reducing agitation and other challenging behaviours in people with brain injury (Baker, 2001; Hitchen, Magee, & Soeterik, 2010).

For communication impairments, Tamplin (2008) found that singing and vocal exercise improved normative speech production, including speech intelligibility and naturalness, in people with acquired dysarthria. Music therapy has also been reported to improve speech repetition, naming, reading, and verbal fluency in people with acquired aphasia (Jungblut, 2004; Sarkamo et al., 2008; van der Meulen, van de Sandt-Koenderman, Heijenbrok-Kal, Visch-Brink, & Ribbers, 2014). Music therapy thus has potential to address both speech and language aspects of communication impairments.

Music therapy also offers great benefits for emotional and social domains in neurorehabilitation. Participating in group music therapy can enhance mood, confidence, motivation, social engagement, peer support, as well as reduce psychological distress for people with acquired neurological injury. (Tamplin, Baker, Grocke, & Berlowitz, 2014; Tamplin, Baker, Jones, Way, & Lee, 2013).

Although the existing studies demonstrate many benefits of music therapy to address neurorehabilitation goals, there is limited literature on the prevalence of music therapy services that are actually provided in clinical practice. Tamplin (2006) examined the reason for referral for 88 patients (aged 18-82 years) from a rehabilitation hospital in Australia between 2004 to 2005. Most patients were referred to music therapy to address social and emotional goals. Relaxation, physical rehabilitation, communication rehabilitation, cognitive rehabilitation, pain management, motivation, and sensory stimulation were also common reasons for referral to music therapy. Although this study reports on the scope of music therapy services provided in a real-world situation, it was based only on one rehabilitation hospital in Australia and was published over a decade ago.

Despite limited research on the real-world situation of music therapy services in neurorehabilitation specifically, survey studies have indicated a general growth of the music therapy profession worldwide, with an increasing number of music therapists working in neurorehabilitation (Jack et al., 2016; Kern & Tague, 2017). Kern and Tague (2017) surveyed music therapists (N = 2,495) via the World Federation of Music Therapy about the status of music therapy practice and trends worldwide. Based on respondent answers to the question about work settings (n = 2,331), 5.2% described their work setting as rehabilitation in general, 19.6% of respondents worked with neurological disorders, 12.4% worked in traumatic brain injury (TBI), 12.2% in stroke rehabilitation (12.2%), and 10.6% worked with Parkinson's disease (PD) (Kern & Tague, 2017). These clinical populations are consistently represented in the music therapy neurorehabilitation literature (Baker & Tamplin, 2006; Gilbertson, 2005; Thaut et al., 1996; Weller & Baker, 2011). However, Kern and Tague (2017) did not clarify the context of work where the music therapy services were provided to these populations, except for the stroke rehabilitation population. Also, as participants were able to provide multiple responses, there could be some overlap among these populations. For example, brain injury (e.g. stroke, TBI) could be categorised under acquired neurological disorders, while PD could be categorised under degenerative neurological disorders (Tamplin, 2015). Kern and Tague (2017) separated these populations rather than listing stroke, TBI, and PD as subcategories of neurological disorders. As a result, it is not possible to determine the exact proportion of music therapists working in neurorehabilitation around the world.

With the extensiveness and complexity of music therapy practice in neurorehabilitation shown in the existing literature, it is important to know the real-world situation of current music therapy services provision in this field. Such knowledge may suggest pathways for developing research and training curriculum that respond to clinical need. Despite the growth of music therapy as a profession (Kern & Tague, 2017), to our knowledge no study has yet examined the extent of music therapy services provision specifically in neurorehabilitation. Therefore, we conducted an international survey aiming to gather descriptive data on the scope and prevalence of music therapy services in neurorehabilitation. Specifically, in terms of populations served and goals addressed, as well as music therapy approaches and interventions utilised. Additionally, we conducted a qualitative content analysis to determine the opinions of music therapists on training for future music therapists in neurorehabilitation and general feedback.

This study received ethics approval from Human Research Ethics Committee at the University of Melbourne.

Methods

Participants

The participants in this study were active professional music therapists credentialed from a regulating music therapy organisation. The participants needed to have experience working in neurorehabilitation. A snowball sampling method was used to purposively recruit the participants who met these inclusion criteria.

Participants were recruited in two ways. Firstly, an invitation, plain language statement, and hyperlink to the online survey were emailed to music therapy organisations then forwarded to their members. These organisations included: The World Federation of Music Therapy, Australian Music Therapy Association (AMTA), and academy of Neurologic Music Therapy (NMT). Secondly, the recruitment package was sent to 74 registered music therapists (RMT) who identified their expertise as neurological, rehabilitation, and/or NMT trained on the website of AMTA (http://www.austmta.org.au).

Instrument design

We developed a 25-item online survey based on the existing literature on music therapy in neurorehabilitation (See Appendix). The first two items were for identifying eligibility and for the participants to provide consent. The remainder of the survey was divided into six parts according to the areas of investigation including:

1. Participant demographics

2. Professional background information

3. Populations served in neurorehabilitation

4. Goals of music therapy services in neurorehabilitation

5. Music therapy approaches and interventions used in neurorehabilitation

6. Feedback on music therapy training in neurorehabilitation and other feedback (optional)

The survey consisted of closed-ended multiple-choices, questions with single and multiple answers, closed-ended questions with text answers, Likert scale questions (i.e. never, rarely, sometimes, often, or always), and open-ended questions. The option "Other" was provided throughout the survey in case participants had other answers which were unlisted. The draft survey was reviewed and then piloted with two music therapy researchers at the University of Melbourne. The finalised survey took approximately eight minutes to complete.

Data collection procedure

After deciding to take part in the study, participants clicked on a hyperlink leading to the first page of the online survey on Google Forms[R], where they had to first confirm their eligibility before they could proceed to the plain language statement and consent form. Participation in this study was completely voluntary. The participants were allowed to withdraw from the study at any time as well as skip any questions they did not wish to answer.

The survey was opened for four weeks, and a reminder email was sent to the organisations, institution, and music therapists in the second week. Additionally, the participants were encouraged to forward the survey to other music therapists with experience working in neurorehabilitation. All submitted survey responses were kept in the password-protected database of Google Forms[R] and were completely anonymous in order to protect participant confidentiality.

Data analysis

We used descriptive statistics and qualitative content analysis to analyse the data. For the closed-ended questions, we used frequency distribution and converted the data into percentages. For Likert scale questions, we calculated the mean (M) of the responses in each question. Then, we used the class interval to create five categories including almost never, rarely, sometimes, often, and almost always in order to define the calculated mean of each question. The calculated class interval size was 0.8. Therefore, the means were defined as following:

1. The mean from 1.00 to 1.79 was defined as 'almost never'.

2. The mean from 1.80 to 2.59 was defined as 'rarely'.

3. The mean from 2.60 to 3.39 was defined as 'sometimes'.

4. The mean from 3.40 to 4.19 was defined as 'often'.

5. The mean from 4.20 to 5.00 was defined as 'almost always'.

For the opened-ended questions, we followed the procedure of qualitative content analysis by (a) reading and re-reading the responses, (b) identifying meaning units, (c) condensing the meaning units, (d) formulating codes for the condensed meaning units, and (e) categorising the codes into categories and sub-categories (Erlingsson & Brysiewicz, 2017; Ghetti & Keith, 2016). Both authors discussed the coding and categorisation process. The first author conducted the first round of coding, and the second author conducted the second round of coding. Inter-coder reliability was then calculated.

Results

The survey received 75 responses from people who identified themselves as music therapists with professional experience working in neurorehabilitation. Seven were excluded as they did not identify any music therapy credential from a professional music therapy organisation. Another three were excluded because they were inactive and retired. Therefore, 65 survey responses were analysed in this study (N = 65). We could not calculate the response rate because the snowball sampling method used in this study did not allow us to record the number of people who received an invitation to participate. As not every participant responded to all questions, the number of participants who responded to each question is provided.

Demographics and Professional Background

Demographic and professional background information is presented in detail in Table 1. The majority of the participants were female (84.6%) and represented all age ranges. Most participants were aged between 30-39 years (35.4%) and were practicing music therapy in Australia (36.9%) or the USA (33.9%). Other countries represented (29.2%) included Finland, Germany, Hong Kong, Canada, Japan, Poland, Argentina, China, Netherland, and Russia with approximately 1-3 responses from each country.

Most participants held the credential of MT-BC (50.8%) following with the credential of RMT (47.7%) and had been working for 15 years in neurorehabilitation (49.2%). Few participants (9.1%) reported other credentials (e.g. CMT, DMtG, LPMT, MTA) (1). The majority of participants held a Master's degree (49.2%) and provided neurorehabilitation music therapy services in hospitals (52.3%). Others worked in a private business setting (33.8%), private venue (e.g. home) (30.8%), or aged care organisation (23.1%). Other settings (23.1%) included community organisation, university, rehabilitation-specialised institution, kindergarten, and non-profit clinic.

A great majority of participants had completed additional training in NMT (80%), 7.7% for GIM training, and another 7.7% for NICU-MT training. Other training (10.8%) included Author Hull Drum Circle, RBL, MTACB, MATADOC, MTE, Hypnomusictherapy, EBQ instrument, sound massage, and functional music therapy (2).

Every participant reported interprofessional collaboration when working in neurorehabilitation with incidence of collaboration by discipline shown in Figure 1.

Figure 1. Collaborated professionals in music therapy services in
neurorehabilitation

Collaborated Professionals (65 respondents)

Speech Pathologist       87.7%
Occupational Therapist   86.2%
Social Worker            65.6%
Nurse                    63.1%
Physiotherapist          61.5%
Neuropsychologist        46.2%
Clinical Psychologist    41.5%
Pastoral Care Worker     29.2%
Psychiatrist             20.0%
Counsellor               12.3%
Other                    13.5%

Note. Multiple responses were allowed. Other professional
collaborations included child life therapists, recreational therapists,
medical practitioners, special education resource teachers,
neurologists, pulmonologists, art therapists, early intervention
keyworkers, and nutritionists.

Note: Table made from bar graph.

Populations served

The populations served by music therapy services in neurorehabilitation represented all age groups. The participants mostly worked with ABI (M = 3.89). Clinical symptoms addressed by respondents are also presented in Table 2.

Goals of music therapy

The music therapy goals in neurorehabilitation addressed by respondents were divided into six categories as presented in Table 3. Attention (M = 4.25) was the most prevalent goal.

Music therapy approaches and interventions

The participants reported a variety of music therapy approaches being applied when working in neurorehabilitation. NMT (87.7%) was the most prevalent as presented in Figure 2.

The prevalence of music therapy interventions used in neurorehabilitation by respondents are presented in Table 4. Singing (M = 4.44) was the most commonly used intervention.

Figure 2. Approaches for music therapy services in neurorehabilitation

Music Therapy Approache (65 respondents)

NMT                                    87.7%
Humanistic Approaches                  56 9%
Cognitive-B ehavioural Approaches      33.8%
Developmental Approaches               30.8%
Resource-Oriented Music Therapy        27.7%
Creative Music Therapy                 26.2%
Behavioural Approaches                 26.2%
Community Music Therapy                24.6%
Psychodynamic Approaches               20.0%
Biomedical Music Therapy               15.4%
Culture-Centered Music Therapy         12.3%
BGTM                                    7.7%
Not applicable or not sure              1.5%
Other                                   3 0%

Note. Multiple responses were allowed. Other approaches included
family-centered, patient-centered, existential-integrative, and
solution-focused approaches.

Note: Table made from bar graph.

Qualitative content analysis

Forty-seven participants provided suggestions for the development of music therapy training for preparing future music therapists to work in the field of neurorehabilitation. These are listed in Table 5. The inter-coder reliability of this question was .92.

Eleven participants provided general feedback covering multiple topics as presented in Table 6. The inter-coder reliability of this question was .85.

Discussion

Importance of inter-professional collaboration

The results from this survey showed that all participants reported collaboration with other professionals when working in neurorehabilitation. This can be supported by the nature of practice in neurorehabilitation where inter-professional collaboration is promoted and considered as the key strategy to successful rehabilitation (Tamplin, 2006; WHO, 2006; Wirz & Rutz-Lapitz, 2015). A perceived need for more training in music therapy courses on inter-professional collaboration in neurorehabilitation was presented in the qualitative content analysis. Speech pathology and occupational therapy collaboration strategies could be prioritised as these were most frequently reported.

The scope of clinical populations served

Music therapy services provided in the context of neurorehabilitation cover a vast range of clinical populations. Our survey results showed that the respondents worked with clients who had neurological disorders ranging from acquired conditions, degenerative conditions, congenital disorders, and post-neurosurgery conditions. The range of clinical populations found in the survey may not fit within some definitions of rehabilitation. In some literature sources, rehabilitation is defined as the process of restoration to the optimal state of functioning after acquiring conditions that cause the loss of capabilities and/or debilitation such as illness, injury, or trauma (Bruscia, 2014; Dirckx, 2012; Loewy, 2013; Martin, 2015). Although this definition focuses on people with acquired neurological conditions, music therapy interventions used in this context may also benefit people with congenital and degenerative neurological disorders (Baker & Tamplin, 2006; Wade, 2015). On the other hand, the World Health Organisation (2017a) defined rehabilitation as "a set of interventions designed to optimise functioning and reduce disability in individuals with health conditions in interaction with their environment" (p. 1). Health conditions in this context were defined as acute or chronic disease, disorder, injury, trauma, and other conditions related to congenital anomaly, and genetic predisposition (WHO, 2017b). In line with this, rehabilitation-focused music therapy has been described with people who had degenerative and congenital neurological disorders (e.g. PD, dementia, cerebral palsy, Erb's palsy, Rett syndrome) (Alves-Pinto, Turova, Blumenstien, & Lampe, 2016; Staum, 2000; Wang et al., 2013; Weller & Baker, 2011).

Some participants reported non-neurological disorders under the "Other" choice in clinical populations. However, non-neurological disorders including lupus and hematological disorders may have an impact on the nervous system (Muscal & Brey, 2010; Sussman & Davies-Jones, 2014). Some participants also responded to the "Other" choice in clinical population question using categories such as developmental disorders, cancer, and genetic disorders which are umbrella terms that may cover neurological disorders, disorders that may impact the nervous system, and disorders that may spread to the nervous system. Several participants reported that music therapy services were provided to clients with autism in a neurorehabilitation unit. Grob (1998) suggested that the music therapy services with clients on the autism spectrum may fall into the rehabilitation category if the clients are responsive to facilitated communication and show a degree of abstractive ability because it could be considered as restoring or gaining access towards an untapped ability. Although autism is usually categorised as a developmental disorder, it involves neurological or neurophysiological factors (American Psychiatric Association, 1994).

Our results indicate that music therapists working in neurorehabilitation predominantly work with patients living with ABI. Other clinical populations served include other acquired neurological conditions, degenerative neurological conditions, congenital neurological conditions, post-neurosurgery conditions, and other conditions that relate to and/or have an impact on neurological impairments. These findings challenge several existing definitions of rehabilitation because the clinical populations served by music therapists who responded to this survey were not limited to acquired neurological conditions. It is possible that participants lost track of the scope of the survey and provided responses based on their experience outside the neurorehabilitation context, however the questions contained a reminder of the scope of the study throughout the survey.

The prevalence of clinical symptoms and goals vs. the existing literature

A recent Cochrane review of music interventions for ABI (Magee et al. 2017), revealed moderate quality evidence for music interventions for gait velocity and length rehabilitation; low quality evidence towards other aspects of gait rehabilitation and quality of life; very low-quality evidence towards arm movement and overall communication; and no strong evidence on cognitive rehabilitation for people with ABI. However, our survey found that speech, motor, and cognitive impairments were all highly prevalent clinical symptoms addressed by respondents.

The prevalence of speech and cognitive impairments in neurological populations, and the limited evidence of studies on music therapy interventions in these areas indicates the need for further research. However, Magee et al. (2017) reviewed only clinical trials in ABI, whilst our survey gathered data on the overall practice of music therapy in neurorehabilitation. Although we found that ABI was the most prevalent clinical population served, our results on the clinical symptoms and goals may have related to other clinical populations served. Therefore, future studies could also survey music therapy services provided to the ABI population specifically and/or use other statistical methods.

The prevalence of Neurologic Music Therapy (NMT)

Neurologic music therapy (NMT) was the most frequently reported music therapy approach that participants drew upon and was a frequently reported suggestion for future music therapy training. The majority of survey participants were NMT-trained. However, as the survey was distributed via the academy of NMT, the results were likely to favor NMT approaches and training. Some NMT techniques, especially Rhythmic Auditory Stimulation, are very well supported by neurorehabilitation research (Altenmuller & Schlaug, 2013; Magee et al., 2017; Weller & Baker, 2011). This evidence base may explain the prevalence of NMT techniques used by respondents. A small number of non-NMT-trained participants reported that they still drew upon the NMT approach (as presented in Table 1 and Figure 2). Therefore, NMT clearly has a strong influence on music therapy practice in neurorehabilitation.

Limitations

Although this study received responses from participants that represented all regions of the world, the global representativeness is questionable due to the high representation from the USA and Australia. The international survey by Kern and Tague (2017) gathered information on music therapy practice status and trends from over 18 countries around the world. This present study gathered responses from only 12 countries using a snowball sampling method. It is possible that music therapy in neurorehabilitation is more frequently practiced in the countries represented in our survey, however, it may just be that our sampling method did not adequately reach a representative sample of countries. Future surveys could be circulated via all national music therapy organisations and/or via the World Federation of Music Therapy in order to achieve a wider distribution.

Using a pre-defined definition of neurorehabilitation from the literature may help participants focus on a particular aspect of their clinical experience. As this study aimed to survey current clinical practice, we avoided providing any pre-defined definition of neurorehabilitation so as not to influence participant contributions. However, this meant that neurorehabilitation may have been interpreted quite differently by participants. Finally, as the survey was only distributed in English, this limited international participation and likely situates the research findings within specific cultural contexts.

Conclusions

In conclusion, this international study explored the current scope and prevalence of music therapy services in neurorehabilitation. We used the survey method to gather information from the real-world practices of the participating music therapists. The survey outcomes suggest that inter-professional collaboration, especially with speech pathologists and occupational therapists, is vital in the work of music therapists working in neurorehabilitation. Moreover, music therapists can expect to see an extensive range of clinical populations with neurological impairments when working in this field. Further research on music therapy for cognitive and communication rehabilitation is highly recommended in order to respond to the prevalence of the clinical symptoms found and goals formulated in this context. Also, the survey outcomes suggest that NMT is frequently applied by the participating music therapists and recommended by some participants for future music therapy training. Furthermore, future research and training could focus on therapeutic singing techniques which were the most prevalent techniques being used by our participants in their neurorehabilitation work. Finally, the results of this study should be considered by academic teachers in building the curriculum for the future music therapy students and by music therapy researchers in providing research to respond to the needs in the practice.

Acknowledgements

This study would not have been possible without generous support from the staff at the University of Melbourne. I would like to profoundly express my gratitude towards Dr. Jeanette Tamplin, the co-author, who contributed her precious time supervising me and collaboratively editing this article. Moreover, I would like to thank Dr. Katrina McFerran who introduced me to the world of music therapy research and participated in the pilot trial of this survey. Also, I would like to thank Dr. Felicity Baker who taught me the survey design and participated in the pilot trial of this survey. Finally, Dr. Tamplin and I would like to wholeheartedly thank all participants for contributing their valuable time, knowledge, and experience to this study and to the field of music therapy in neurorehabilitation.

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Sussman, J. D., & Davies-Jones, G. A. B. (2014). Neurologic manifestations of hematologic disorders. In M. J. Arminoff & S. A. Josephson (Eds.), Aminoffs neurology and general medicine (5th ed., pp. 505-537). New York, NY: Oxford University Press.

Sarkamo, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila, S., Mikkonen, M., ... Hietanen, M. (2008). Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain: A Journal of Neurology, 131(3), 866-876. doi:10.1093/brain/awn013

Tamplin, J. (2006). Development of a music therapy service in an Australian public rehabilitation hospital. Voices: A World Forum for Music Therapy, 6(1). doi:10.15845/voices.v6i1.245

Tamplin, J. (2008). A pilot study into the effect of vocal exercises and singing on dysarthric speech. NeuroRehabilitation, 23(3), 207-216.

Tamplin, J. (2015). Music therapy for adults with traumatic brain injury or other neurological disorders. In B. L. Wheeler (Ed.), Music Therapy Handbook (pp. 454-467). New York, NY: Guilford.

Tamplin, J., Baker, F., Grocke, D., & Berlowitz, D. J. (2014). Thematic analysis of the experience of group music therapy for people with chronic quadriplegia. Topics in Spinal Cord Injury Rehabilitation, 20(3), 236-247. doi:10.1310/sci2003-236

Tamplin, J., Baker, F., Jones, B., Way, A., & Lee, S. (2013). 'Stroke a Chord': The effect of singing in a community choir on mood and social engagement for people living with aphasia following a stroke. NeuroRehabilitation, 32(4), 929-941. doi:10.3233/NRE-130916

Thaut, M. H., Leins, A. K., Rice, R. R., Argstatter, H., Kenyon, G. P., McIntosh, G. C., ... Fetter, M. (2007). Rhythmic auditory stimulation improves gait more than NDT/Bobath training in near-ambulatory patients early poststroke: A single-blind, randomized trial. Neurorehabilitation and Neural Repair, 21(5), 455-459. doi:10.1177/1545968307300523

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van der Meulen, I., van de Sandt-Koenderman, W., Heijenbrok-Kal, M. H., Visch-Brink, E. G., & Ribbers, G. M. (2014). The efficacy and timing of melodic intonation therapy in subacute aphasia. Neurorehabilitation and Neural Repair, 28(6), 536-544. doi:10.1177/1545968313517753

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Appendix: The Online Survey Questionnaire

Music Therapy Services in Neurorehabilitation Study

This study is part of the Master of Music Therapy program at the University of Melbourne.

(*) Required

Are you a music therapist with experience working in neurorehabilitation? (*)

Mark only one oval.

[??] Yes (Please continue)

[??] No (Do not continue with survey - please leave the survey now. Thank you)

Welcome to My Survey

Music therapy has potential in addressing various needs in neurorehabilitation. Besides, the music therapy profession has grown recently according to the increasing numbers of graduates, referrals, and positions opened. A large number of music therapists registered with Australian Music Therapy Association are working with a vast range of neurological patients. Therefore, it is possible that music therapy services in neurorehabilitation may have expanded

This study aims to survey the music therapists working in neurorehabilitation and collect data regarding to music therapy services from a larger number of registered music therapists who work in different settings with different populations. The outcomes will provide data regarding the current scope of work and prevalence of music therapy services in neurorehabilitation. The outcomes can be applied to music therapy training and to the research area of music therapy in neurorehabilitation.

If you agree to participate, you will be asked to complete an online survey that will take approximately 8 minutes. The questions will be about the populations served, music therapy goals, music therapy techniques, and your music therapy approaches in neurorehabilitation according to your experience.

(*) None of this will impact on your relationship with the University of Melbourne, and your participation in this study is completely voluntary. Your answers will be completely anonymous, and the Human Research Ethics Committee has approved this project.

Should you require any further information, or have any concerns, please do not hesitate to contact the Chief Researcher (Prof Katrina McFerran) on the numbers provided below. Should you have any concerns about the conduct of the project, you are welcome to contact the Executive Officer, Human Research Ethics, The University of Melbourne, on ph: +61 3 8344 2073.

If you would like to participate, please show that you have read and understood this information by ticking the box below. If you have any questions, please feel free to ask, either now, or at any time during the process.

By submitting this online survey, you are giving consent for your responses to be used in this study.

Thank you for your participation and your contribution to the training of music therapy students at the University of Melbourne.

The survey will be closed on 30th September 2017 at 11.59pm (AEST--Australian Eastern Standard Time UTC +10)

Sincerely,

Prof Katrina Skewes McFerran

(Supervisor and Coordinator of Minor Thesis in Music Therapy) Melbourne Conservatorium of Music

Ph: +61 3 8344 7382

Dr Jeanette Tamplin

(Supervisor of Minor Thesis in Music Therapy)

Melbourne Conservatorium of Music

Ph: +61 3 8344 3003

Mr Napak Pakdeesatitwara

(Music Therapy Masters Student)

Melbourne Conservatorium of Music

Email: nnakdeesatit@student.unimelb.edu.au

Ph: +61 4 5003 2910

Mark only one oval.

[??] Yes, I have read and understood the plain language statement, and I agree to participate.

[??] No, I do not (Do not continue with the survey--please leave the survey now, Thank you)

Demographics

What is your gender?

Mark only one oval.

[??] Male

[??] Female

[??] Decline to state

[??] Other:

What is your age?

Mark only one oval.

[??] 20-29

[??] 30-39

[??] 40-49

[??] 50-59

[??] 60+

What is your country of practice?

Professional background information

Please indicate your music therapy license type.

Check all that apply.

[??] MT-BC

[??] RMT

[??] ACMT

[??] CMT

[??] Inactive

[??] Retired

[??] Other

How many years have you been working as a music therapist in the field of neurorehabilitation?

What is the highest level music therapy qualification you have?

Mark only one oval.

[??] Bachelor's

[??] Post Graduate Diploma

[??] Master's (coursework)

[??] Master's (research)

[??] PhD or Doctorate

[??] Other:

What is the type of the facility in which you provide music therapy services in neurorehabilitation? (multiple answers possible)

Check all that apply.

[??] Hospital

[??] School

[??] Aged care organization

[??] Community organization

[??] Private home/venue

[??] Private business

[??] University

[??] Corporate business

[??] Not applicable

[??] Other:

What is your role title? (multiple answers possible)

Check all that apply.

[??] Music therapist

[??] Educator

[??] Researcher

[??] Administrator

[??] Not applicable

[??] Other:

Do you have any additional training in music therapy? (multiple answers possible)

Check all that apply.

[??] Neurologic Music Therapy (NMT)

[??] Guided Imagery and Music (GIM)

[??] No additional training

[??] Other:

Which of these professionals do you have experience working in collaboration with? (multiple answers possible)

Check all that apply

[??] Physiotherapist

[??] Occupational therapist

[??] Speech pathologist

[??] Social worker

[??] Pastoral care worker

[??] Nurse

[??] Clinical psychologist

[??] Neuropsychologist

[??] Counsellor

[??] Psychiatrist

[??] Not applicable

[??] Other:

Populations served

Please rate the prevalence of the age groups of your clients in
neurorehabilitation.
Mark only one oval per row.

               Never   Rarely   Sometimes   Often   Always

Infants        [??]    [??]     [??]        [??]    [??]
Preschoolers   [??]    [??]     [??]        [??]    [??]
Children       [??]    [??]     [??]        [??]`   [??]
Adoiescents    [??]    [??]     [??]        [??]    [??]
Adults         [??]    [??]     [??]        [??]    [??]
Older adults   [??]    [??]     [??]        [??]    [??]

Please rate the prevalence of the conditions you work with in the field
of neurorehabilitation.
Mark only one oval per row.

                              Never   Rarely   Sometimes   Often  Always

Acquired Brain Injury (ABI)   [??]    [??]     [??]        [??]   [??]
Spinal Cord Injury (SCI)      [??]    [??]     [??]        [??]   [??]
Parkinson's disease           [??]    [??]     [??]        [??]   [??]
Huntington's disease          [??]    [??]     [??]        [??]   [??]
Multiple sclerosis            [??]    [??]     [??]        [??]   [??]
Dementia                      [??]    [??]     [??]        [??]   [??]
Other (please specify)        [??]    [??]     [??]        [??]   [??]

If you have experience working with other conditions in neurorehabilitation, please specify.

Please rate the prevalence of the clinical symptoms you work with in
the field of neurorehabilitation.
Mark only one oval per row.

                         Never   Rarely   Sometimes   Often   Always

Altered states of        [??]    [??]     [??]        [??]    [??]
consciousness
Post-traumatic amnesia   [??]    [??]     [??]        [??]    [??]
Motor impairments        [??]    [??]     [??]        [??]    [??]
Speech impairments       [??]    [??]     [??]        [??]    [??]
Language impairments     [??]    [??]     [??]        [??]    [??]
Cognitive impairments    [??]    [??]     [??]        [??]    [??]
Challenging behaviors    [??]    [??]     [??]        [??]    [??]
Social difficulties      [??]    [??]     [??]        [??]    [??]
Emotional difficulties   [??]    [??]     [??]        [??]    [??]
Loss of identity         [??]    [??]     [??]        [??]    [??]
Psychological trauma     [??]    [??]     [??]        [??]    [??]
Pain                     [??]    [??]     [??]        [??]    [??]
Other (please specify)   [??]    [??]     [??]        [??]    [??]

If you have experience working with other symptoms in neurorehabilitation, please specify.

Goals of music therapy

Please rate the prevalence of the music therapy goals.you work towards in neurorehabilitation:

Goals for physical rehabilitation
Mark only one oval per row.

                             Never   Rarely   Sometimes   Often   Always

Upper extremity gross motor  [??]    [??]     [??]        [??]    [??]
movement
Upper extremity fine motor   [??]    [??]     [??]        [??]    [??]
movement
Lower extremity gross motor  [??]    [??]     [??]        [??]    [??]
movement
Lower extremity fine motor   [??]    [??]     [??]        [??]    [??]
movement
Gait rehabilitation          [??]    [??]     [??]        [??]    [??]
Balance and posture          [??]    [??]     [??]        [??]    [??]
Range of movement            [??]    [??]     [??]        [??]    [??]
Strength                     [??]    [??]     [??]        [??]    [??]
Endurance                    [??]    [??]     [??]        [??]    [??]
Coordination                 [??]    [??]     [??]        [??]    [??]
Relaxation                   [??]    [??]     [??]        [??]    [??]
Pain management              [??]    [??]     [??]        [??]    [??]
Dexterity                    [??]    [??]     [??]        [??]    [??]
Activities of Daily Living   [??]    [??]     [??]        [??]    [??]
(ADLs)
Other (please specify)       [??]    [??]     [??]        [??]    [??]

If you have experience working towards other physical rehabilitation goals, please specify.

Goals for cognitive rehabilitation
Mark only one oval per row.

                         Never   Rarely   Sometimes   Often   Always

Orientation              [??]    [??]     [??]        [??]    [??]
Stimulating response     [??]    [??]     [??]        [??]    [??]
Spatial exploration      [??]    [??]     [??]        [??]    [??]
Memory                   [??]    [??]     [??]        [??]    [??]
Attention                [??]    [??]     [??]        [??]    [??]
Executive functioning    [??]    [??]     [??]        [??]    [??]
(mental flexibility)
Skills learning          [??]    [??]     [??]        [??]    [??]
Following instruction    [??]    [??]     [??]        [??]    [??]
Other (please specify)   [??]    [??]     [??]        [??]    [??]

If you have experience working towards other cognitive rehabilitation goals, please specify.

Goals for behavioral management
Mark only one oval per row.

                         Never   Rarely   Sometimes   Often   Always

Managing agitation       [??]    [??]     [??]        [??]    [??]
Managing perseveration   [??]    [??]     [??]        [??]    [??]
Managing impulsivity     [??]    [??]     [??]        [??]    [??]
Other (please specify)   [??]    [??]     [??]        [??]    [??]

If you have experience working towards other behavioral goals, please specify.

Goals for communication rehabilitation
Mark only one oval per row.

                            Never   Rarely   Sometimes   Often   Always

Respiratory                 [??]    [??]     [??]        [??]    [??]
function/strength/control   [??]    [??]     [??]        [??]    [??]
Speech rate control         [??]    [??]     [??]        [??]    [??]
Intelligibility             [??]    [??]     [??]        [??]    [??]
Speech naturalness          [??]    [??]     [??]        [??]    [??]
Speech repetition           [??]    [??]     [??]        [??]    [??]
Naming                      [??]    [??]     [??]        [??]    [??]
Verbal responses to         [??]    [??]     [??]        [??]    [??]
questions
(Responsive speech)
Articulation                [??]    [??]     [??]        [??]    [??]
Prosody                     [??]    [??]     [??]        [??]    [??]
Verbal fluency              [??]    [??]     [??]        [??]    [??]
Speech comprehension        [??]    [??]     [??]        [??]    [??]
Written language            [??]    [??]     [??]        [??]    [??]
Other (please specify)      [??]    [??]     [??]        [??]    [??]

If you have experience working towards other communication rehabilitation goals, please specify.

Goals for emotional adjustment
Mark only one oval per row.

                             Never   Rarely   Sometimes   Often   Always

Exploring self-concept       [??]    [??]     [??]        [??]    [??]
Mood management              [??]    [??]     [??]        [??]    [??]
Identifying and expressing   [??]    [??]     [??]        [??]    [??]
emotional difficulties
improving seif-confidence    [??]    [??]     [??]        [??]    [??]
Improving self-esteem        [??]    [??]     [??]        [??]    [??]
Other (please specify)       [??]    [??]     [??]        [??]    [??]

If you have experience working towards other emotional goals, please specify.

Social goals
Mark only one oval per row.

                                   Never    Sometimes   Often   Always
                                   Rarely

Encouraging patients to socially
interact with others (e.g.         [??]     [??]        [??]    [??]
relatives, peers)
Offering appropriate environment   [??]     [??]        [??]    [??]
for social interactions
Facilitating social skills         [??]     [??]        [??]    [??]
learning
Other (please specify)             [??]     [??]        [??]    [??]

If you have experience working towards other social goals, please specify.

Music therapy approaches and techniques

Which of these theoretical approaches do you align yourself with? (multiple answers possible)

Check all that apply.

[??] Psychodynamic Approaches

[??] Humanistic Approaches

[??] Behavioral Approaches

[??] Cognitive-Behavioral Approaches

[??] Developmental Approaches

[??] Creative Music Therapy

[??] Bonny Method of Guided Imagery and Music

[??] Neurologic Music Therapy

[??] Community Music Therapy

[??] Biomedical Music Therapy

[??] Resource-Orientated Music Therapy

[??] Culture-Centered Music Therapy

[??] Not applicable or not sure

[??] Other:

Please rate the prevalence of the music therapy techniques you use.
Mark only one oval per row.

                               Never  Rarely  Sometimes   Often   Always

Rhythmic Auditory Stimulation  [??]   [??]    [??]        [??]    [??]
Movement to music              [??]   [??]    [??]        [??]    [??]
Music making on a musical      [??]   [??]    [??]        [??]    [??]
instrument
Music as a mnemonic device     [??]   [??]    [??]        [??]    [??]
Music-based attention          [??]   [??]    [??]        [??]    [??]
training
Instructional song             [??]   [??]    [??]        [??]    [??]
Song story                     [??]   [??]    [??]        [??]    [??]
Song reminiscence              [??]   [??]    [??]        [??]    [??]
Music listening                [??]   [??]    [??]        [??]    [??]
Improvisation                  [??]   [??]    [??]        [??]    [??]
Singing                        [??]   [??]    [??]        [??]    [??]
Oral motor exercise or vocal   [??]   [??]    [??]        [??]    [??]
exercise
Music-based speech and         [??]   [??]    [??]        [??]    [??]
language activities
Songwriting                    [??]   [??]    [??]        [??]    [??]
Song discussion                [??]   [??]    [??]        [??]    [??]
Group music making (either     [??]   [??]    [??]        [??]    [??]
vocal or instrumental)
Community group music making   [??]   [??]    [??]        [??]    [??]
(e.g. community choir)
Music and imagery              [??]   [??]    [??]        [??]    [??]
Guided Imagery and Music       [??]   [??]    [??]        [??]    [??]
(GIM)
Traditional Oriental Music     [??]   [??]    [??]        [??]    [??]
Therapy
Other (please specify)         [??]   [??]    [??]        [??]    [??]

If you have experience using other techniques, please specify.

For future music therapists

This is the last section of the online survey. By submitting this online survey, you are giving consent for this data to be used in this study.

Additionally, the following questions are optional, but your opinion will be greatly valuable to the future music therapy training as well as to the music therapy students.

In your opinion, what should the music therapy training focus on in order to prepare the future music therapists for the field of neurorehabilitation? (optional)

Please provide any other comments you have about music therapy services in neurorehabilitation, or any feedback you have about this survey (optional)

Napak Pakdeesatitwara and Jeanette Tamplin

Faculty of Fine Arts and Music, The University of Melbourne, Australia

Address correspondence to:

Napak Pakdeesatitwara napakmt@gmail.com

To cite this article: Pakdeesatitwara, N. & Tamplin, J. (2018). Music therapy services in neurorehabilitation: An international survey. Australian Journal of Music Therapy, 28, 62-90. Retrieved from https://www.austmta.org.au/journal/article/music-therapy-services-neurorehabilitation-international-survey

In plain language:

Neurorehabilitation is an extensive field of music therapy practice serving diverse clinical populations and addressing complex clinical needs. Since music therapy research and practice have developed over time and shown benefits for people undergoing neurorehabilitation, it is important to explore the current state of music therapy services being offered in this field. This article presents the results of an international survey examining the scope and prevalence of populations served in neurorehabilitation, goals formulated, and approaches and interventions being used by credentialed music therapists. The discussion suggests pathways for developing future research and training curriculum in response to the current practice of music therapy in neurorehabilitation.

(1) The credentials included Music Therapist--Board Certified (MT-BC), Registered Music Therapist (RMT), Certified Music Therapist (CMT), Deutsche Musiktherapeutische Gesellschaft (DMtG), Licensed Professional Music Therapist (LPMT), and Music Therapist Accredited (MTA).

(2) The acronymic additional trainings included Neurologic Music Therapy (NMT), Guided Imagery and Music (GIM), Neonatal Intensive Care Unit--Music Therapy (NICU-MT), Rhythm, Breath, Lullaby (RBL), Music Therapy-Assisted Childbirth (MTACB), Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC), and Music Therapy Entrainment (MTE).

(3) Other clinical populations included muscular dystrophy, autism, Guillain-Barre syndrome, cerebral palsy, Rett syndrome, cancer, blood disorders, developmental disorders, brain tumor, brain cancer, motor neuron disease, transverse myelitis, lupus, post-neurosurgery, profound intellectual and multiple disabilities, intracranial pressure, genetic disorders (e.g. Down syndrome), epilepsy, Chiari malformation.

(4) Other clinical symptoms included seizure and sensory impairments.

Table 1. Demographics and professional background

Gender          Female        Male

                55 (84.6%)    10 (15.4%)
Age             20-29         30-39        40-49        50-59
Range           17 (26.2%)    23 (35.4%)   13 (20%)     10 (15.4%)
Country of      Australia     USA          Other
Practice        24 (36.9%)    22 (33.9%)   19 (29.2%)
Credential      MT-BC         RMT          Other
                33 (50.8%)    31 (47.7%)    6 (9.1%)
Year of         Less than 1    1-5          6-10         Over 10
Experience       2 (3.1%)     32 (49.2%)   16 (24.6%)   15 (23.1%)
Qualification   Bachelor's    Master's     Doctoral     Other
                18 (27.7%)    32 (49.2%)    9 (13.9%)    6 (9.2%)
Work            Hospital      Private      Private      Aged Care
Setting                       Business     Venue        Organisation
                34 (52.3%)    22 (33.8%)   20 (30.8%)   15 (23.1%)
Role Title      Music         Other
                Therapist
                61 (93.8%)    22 (33.8%)
Additional      NMT           GIM          NICU-MT      Other
Training        52 (80.0%)     5 (7.7%)     5 (7.7%)     7 (10.8%)

Gender

Age             Over 60
Range            2 (3.1%)
Country of
Practice
Credential
Year of
Experience
Qualification
Work            Other
Setting         15 (23.1%)
Role Title
Additional      None
Training        10 (15.4%)

Note. All 65 respondents answered the demographics and professional
background questions. Some participants reported multiple credentials,
work settings, role titles, and additional training

Table 2. Populations served in music therapy services in
neurorehabilitation

Population                 Number of Responses   Mean   Definition
                           (N = 65)

Age Range
  Infant                   53                    2.04   Rarely
  Preschooler              54                    2.39   Rarely
  Children                 58                    2.62   Sometimes
  Adolescent               60                    2.77   Sometimes
  Adult                    63                    3.89   Often
  Older Adult              58                    3.81   Often
Clinical Population
  ABI                      64                    3.89   Often
  SCI                      56                    2.59   Rarely
  PD                       55                    2.82   Sometimes
  Huntington's Disease     54                    2.00   Rarely
  Multiple Sclerosis       54                    2.39   Rarely
  Dementia                 57                    3.39   Sometimes
  Other (3)                30                    2.60   Sometimes
Clinical Symptom
  Altered States of        61                    2.79   Sometimes
  Consciousness
  Post-Traumatic Amnesia   61                    2.41   Rarely
  Motor Impairments        64                    4.17   Often
  Speech Impairments       63                    4.18   Often
  Language Impairments     64                    4.09   Often
  Cognitive Impairments    64                    4.16   Often
  Challenging Behaviours   60                    3.38   Sometimes
  Social Difficulties      63                    3.43   Often
  Emotional Difficulties   64                    3.72   Often
  Loss of Identity         63                    3.25   Sometimes
  Psychological Trauma     63                    2.92   Sometimes
  Pain                     62                    3.16   Sometimes
  Other (4)                17                    1.35   Almost Never

Note. Participants were not required to answer all questions.
Abbreviations: ABI - Acquired Brain Injury, SCI - Spinal Cord Injury,
PD - Parkinson's Disease

Table 3. Goals of music therapy services in neurorehabilitation

Goal                          Number of Responses   Mean   Definition
                              (N = 65)

Cognitive
  Orientation                 63                    3.44   Often
  Response Stimulation        62                    3.68   Often
  Spatial Exploration         62                    3.24   Sometimes
  Memory                      64                    3.91   Often
  Attention                   63                    4.25   Almost Always
  Executive Functioning       63                    3.98   Often
  Skill Learning              64                    3.34   Sometimes
  Instruction Following       63                    3.62   Often
  Other                       18                    1.17   Almost Never
Emotional
  Exploring Self-Concept      63                    3.33   Sometimes
  Mood Management             64                    3.69   Often
  Identifying and             64                    3.72   Often
    Expressing Emotional
    Difficulties
  Improving Self-Confidence   64                    3.95   Often
  Improving Self-Esteem       64                    3.95   Often
  Other                       18                    1.44   Almost Never
Communication
  Respiratory Function,       62                    3.65   Often
  Strength, and Control
  Speech Rate Control         62                    3.61   Often
  Intelligibility             63                    3.71   Often
  Speech Naturalness          63                    3.40   Often
  Speech Repetition           59                    3.36   Sometimes
  Naming                      60                    3.20   Sometimes
  Responsive Speech           60                    3.53   Often
  Articulation                61                    3.82   Often
  Prosody                     62                    3.57   Often
  Verbal Fluency              63                    3.62   Often
  Speech Comprehension        60                    3.42   Often
  Written Language            62                    2.39   Rarely
  Other                       19                    1.74   Almost Never
Physical
  Upper Extremity Gross       64                    3.63   Often
  Motor Movement
  Upper extremity Fine        62                    3.47   Often
  Motor Movement
  Lower Extremity Gross       62                    3.48   Often
    Motor Movement
  Lower Extremity Fine        63                    3.03   Sometimes
    Motor Movement
  Gait Rehabilitation         63                    3.19   Sometimes
  Balance and Posture         62                    3.31   Sometimes
  Range of Movement           62                    3.63   Often
  Strength                    61                    3.39   Sometimes
  Endurance                   62                    3.55   Often
  Motor Coordination          63                    3.89   Often
  Relaxation                  62                    3.44   Often
  Pain Management             62                    2.92   Sometimes
  Dexterity                   61                    3.05   Sometimes
  ADLs                        62                    3.03   Sometimes
  Other                       17                    1.29   Almost Never
Social
  Encouraging Interactions    64                    3.80   Often
  Providing Environment       64                    3.63   Often
  Social Skills               62                    3.32   Sometimes
  Other                       19                    1.53   Almost Never
Behavioural
  Managing Agitation          62                    3.23   Sometimes
  Managing Perseveration      63                    3.13   Sometimes
  Managing Impulsivity        62                    3.24   Sometimes
  Other                       20                    1.65   Almost Never

Note. Participants were not required to answer all questions

Table 4. Interventions used in music therapy services in
neurorehabilitation

Music Therapy Intervention           Number of   Mean   Definition
                                     Responses
                                     (N = 65)

RAS                                  62          3.53   Often
Movement to Music                    59          3.95   Often
Making Music on a Music Instrument   60          4.05   Often
Music as a Mnemonic Device           60          3.25   Sometimes
Music-Based Attention Training       59          3.86   Often
Instructional Song                   58          3.00   Sometimes
Song Story                           58          2.66   Sometimes
Song Reminiscence                    59          3.36   Sometimes
Music Listening                      60          3.57   Often
Improvisation                        60          3.55   Often
Singing                              61          4.44   Almost Always
Oral Motor Exercise or Vocal         61          3.92   Often
Exercise
Music-Based Speech & Language        59          4.00   Often
Activities
Songwriting                          61          3.33   Sometimes
Song Discussion                      60          3.37   Sometimes
Group Music Making                   59          3.48   Often
Community Group Music Making         58          2.72   Sometimes
Music and Imagery                    58          2.35   Rarely
GIM                                  58          1.50   Almost Never
Traditional Oriental Music Therapy   56          1.25   Almost Never
Other                                18          1.78   Almost Never

Note. As the participants were allowed to skip the question they did
not wish to answer, some participants did not answer to some questions.

Table 5. Suggestions for the future development of music therapy
training

Category and Subcategory   Number of  Percentage  Example
                           Responses
                           (n = 47)

Theoretical Approaches     17         36.2%
  NMT                      15         31.9%
  Resource-Oriented MT      1          2.1%
  Integrated Approaches     2          4.3%
Inter-Professional          8         17.0%       Collaborative work
Collaboration                                     and professional
                                                  communication.
Therapeutic Skills          3          6.4%       Interpersonal skills.
Neurological Foundations   11         23.4%       Neuroscience,
                                                  neurology, and
                                                  body-mind connection.
Music Foundations           3          6.4%       Music skills and
                                                  knowledge.
Practical Opportunities     4          8.5%
MT Interventions            3          6.4%       Songwriting and
                                                  improvisation.
Anatomy                     2          4.3%
Ethics                      1          2.1%       Human rights.
MT Teaching                 3          6.4%       Smaller class size and
                                                  standardisation of
                                                  training.
Neurological Aspects        7         14.9%
of Music Participation
Clinical Knowledge          4          8.5%
Music Psychology            2          4.3%
Up-to-Date Research         2          4.3%
Clinical Process            8         17.0%
  Holistic Assessment       2          4.3%
  Appropriate Goals         4          8.5%
  Appropriate Use/          4          8.5%
  Modification
  of Interventions
Evaluation of Progress      1          2.1%

Notes. 47 participants responded to this question. Some responses
covered multiple categories.

Table 6. General feedback

Category                     Number of   Percentage  Example
                             Responses
                             (n = 11)

Feedback on the Study        3           27.3%       This is an
                                                     extensive survey.
Feedback on                  1           9.1%        Need more network
Professional Needs                                   opportunities and
                                                     support.
Comments on the survey       2           18.2%       Neurorehabilitation
                                                     should be defined.
Reflections on MT Practice   4           36.4%       Great step forward
in Neurorehabilitation                               to promote
                                                     rehabilitation of
                                                     brain functions
                                                     through MT.
Suggestions for MT           3           27.3%       I find that a
  Practice in                                        combination of
  Neurorehabilitation                                approaches is most
                                                     useful and helpful.

Notes. Only 11 participants responded to this question. Some responses
covered multiple categories