Prof. Tony Wigram, keynote, Cadiz 2010

Prof. Tony Wigram CADIZ EU Conference 2010 Copyright

The religion of Evidence Based Practice: Helpful or harmful to music therapy?

Prof. Tony Wigram

Aalborg University


Evidence Based Practice and a Clinical situation

• Responses to music therapy compared with other interventions, controls or situations

• Kate: Shows almost every aspect of her pathology in the clinical meeting with the family

• Kate: Music therapy shows hand use, turn-taking, developing communicative engagement and reciprocal affective attunement


Evidence Based Practice in music therapy

• “....challenges are being presented to music therapists to demonstrate that they are providing treatment and interventions that are supported by studies, articles and expert opinion within the hierarchy of EBP. Many therapists may be unprepared to respond to demands for evidence, and may not have the resources at their disposal to collect, analyse and accumulate evidence.....”

• Wigram, T (2002) Indications in Music Therapy. British Journal of Music Therapy 16,(1)


What are clinicians really supposed to do about this?

• “...Most music therapists are, after all, employed to treat patients, write reports, and attend meetings closely connected to their clinical caseload.......they are certainly not paid to be researchers...”

• Wigram, T (2002) Indications in Music Therapy. British Journal of Music Therapy 16,(1)


USA American Music Therapy Association (AMTA) INITIATIVE IN

RESEARCHAMTA have prepared important documentation that ALLmusic therapists must attend to – clinicians, educators, managers and researchers• Explaining the hierarchy of EBM/EBP• Explaining differences between efficacy and

effectiveness • Explaining Research Utilisation – drawing on many

types of research to support clinical practiceAMTA propose more…• Research based music therapy education


EFFECTIVENESS or EFFICACY?

• Efficacy: Using a well-controlled experiment, can we show that the treatment affects the outcome? (Presumes outcomes are operationalized and can be measured via valid and reliable technology)

• Effectiveness: Does the treatment affect the outcome in the real world? Effectiveness studies usually follow efficacy trials.


Relevant studies, articles and books in the literature

The Hierarchy of EBP• High Quality meta analyses• Randomised Controlled Trials (RCT’s)• Reviews of case-control/cohort studies• Case controlled trials• Case reports/ case studies• Qualitative studies (still not included in the

Oxford Centre list)• Expert Opinion


John Eisenberg, former head of Agency for Healthcare Research and Quality(AHRQ), observed that there is “sufficient evidence to suggest that most clinicians' practices do not reflect the principles of evidence-based medicine but rather are based upon:… - tradition- their most recent experience- what they learned years ago in (medical) school or - what they have heard from their friends.”

http://www.ahcpr.gov/


A broader understanding of Evidence Based Practice

• An Approach to health care that promotes the collection, interpretation and integration of valid, important and applicable a) patient-reported, b) clinician-observed and c) research-derived evidence


What does the literature show?

• Analysis of 4 journals for the last two years: 2008-2009

• Categorized published articles into those that would meet criteria for Evidence Based Practice:

1) Controlled studies

2) Case reports


2008 - 2009 Total Number of Articles

EBP:Case reports

EBP:Controlled studies

Percentage of articles usable for EBP

Journal of Music Therapy

41 6 8 34%

Nordic Journal of Music Therapy

18 6 1 38%

Music Therapy Perspectives

24 4 1 20%

British Journal of Music Therapy

14 4 0 28%

TOTALS 97 17 10 27.8%


2008 - 2009 Total Number of Articles

EBP:Controlled

studies

Percentage of articles usable for EBP

Journal of Music Therapy

41 8 20%

Nordic Journal of Music Therapy

18 1 5.5%

Music Therapy Perspectives

24 1 4.2%

British Journal of Music Therapy

14 0 0%

TOTALS 97 10 10.3%


Music Therapy in Autism Spectrum Disorder and Developmental Disability

Type of Evidence

Edgerton 1994 Evidence based Clinician ObservedOldfield 2005 Evidence based and Clinician ObservedKim 2008 Evidence based RCT

Walworth 2007 Clinician observedKern and Aldridge 2006 Case seriesBuday 1995 Case study randomised crossoverBrownell 2001 Case studies quasi RCTFarmer 2003 RCTHairston 1990 Clinician observedThaut 1988 Experimental studyGold et al 2003 RCTWhipple 2004 Meta review)


Edgerton 1994 - Mean Scores for group

– change from first to last session significant (p < .01)

(graph by CLE, reproduced from JMT)


Impact on a Meta Review

• Gold, C., Voracek, M., & Wigram, T. (2002). Effects of music therapy with mentally ill children and adolescents: A meta-analysis. Journal of Child Psychology and Psychiatry and Allied Disciplines

• Edgerton study: ES - d = 4.56 (Small effect = .20, Medium effect = .50 and large effect = .80 +)

• This skewed the results of the meta review to suggest a large mean effect of music therapy when including all 11 studies in the analysis (d = .99)

• When the Edgerton study was excluded as an outlier, the mean effect of music therapy for the remaining 10 studies fell to a more conservative medium to large effect (d =.61)


Oldfield 2005: Music Therapy Diagnostic Assessment (MTDA) and

Autism Diagnostic Observation Schedule (ADOS) study: Design

• Over a period of two years 30 children attending the Croft children’s Unit and receiving the ADOS and the MTDA were investigated

• A scoring system for the MTDA, similar to the already existing ADOS scoring system was devised


RESULTS

• There was a 72 % level of agreement when the findings from each assessment identified a diagnosis. The MTDA provided comparable information to the ADOS. Both are play based assessments, and therefore explore the nature of behaviour by a similar method


Cochrane reviews• The Cochrane Library

• Dementia. 2003 (Vink AC, Birks JS, Bruinsma MS, Scholten RJPM)

• Schizophrenia or schizophrenia-like illnesses 2005 (Gold C, Heldal TO, Dahle T, Wigram T)

• Autism spectrum disorder 2006 (Gold C, Wigram T, Elefant C.) 2006

• Coronary Heart Disease 2007 (Bradt & Dileo) • Depression. 2008 (Maratos AS, Gold C, Wang X, Crawford MJ.)

• Dr. John Lumley, professor of Vascular Surgury and President of the Music Therapy Charity said that even Dr. Archie Cochrane would have been astonished, and disapproving of the way his dream of a library of quality research reviews are now being used to exclude all other evidence in funding priorities.


Music Therapy for Autistic Spectrum Disorder: A Cochrane Review

Christian Gold, PhD Bergen University, NorwayTony Wigram PhD, Aalborg University, DenmarkCochavit Elefant PhD, David Yellin College, Israel


OutcomesBrownell2002

Repetitive behaviours outside therapy sessions (inclassroom). Inter-rater reliability 0.86 to 0.94

Buday 1995 Imitating behaviour in sessions (rating of a video recordingwith sound turned off to ensure blinding of raters; inter-rater agreement 98%).a) sign imitationb) speech imitation

Farmer 2003 responses within sessions (inter-rater agreement 91%).a) verbal responsesb) gestural responses


Findings

• MT may help children with ASD to improve communicative skills both gestural (p= .0006) and verbal (p=.0009)

• whether these effects are persistent remains to be shown

• LIMITATIONS: ARTIFICIAL EXPERIMENTAL SETTING:– HIGH LEVEL OF STRUCTURE WITHIN MT– INTENSIVE, EXTREMELY SHORT-TERM MT

• for clinical practice:– MT is a promising option to help children with ASD

improve some of their core problems


Kim, J; Wigram, T & Gold, C (2008) The effects of improvisational music therapy on joint attention behaviors in autistic children: A randomized controlled study. Journal of Autism and Developmental Disorder

http://www.springerlink.com/content/a8303q12263805n4/

Main Question: Do children show observable and measurable changes in joint attention behavior in response to improvisational music therapy?

Design: Repeated measures design with subjects randomly assigned to the order of experimental and control conditions.

10 subjects: Half the group had music therapy first and free play second, the other half had free play first and music therapy second

http://www.springerlink.com/content/a8303q12263805n4/


Early Social Communication Scale (Mundy

et al) – joint attention and social interaction 8

10

12

14

16

18

20

22

Time point

ES

CS

-Jo

int A

tten

tion

1 2 3

56

78

9

Time point

ES

CS

-So

cia

l In

tera

ctio

n

1 2 3


Inter-observer reliability

Dependent variable Agreement ICC

• Eye contact frequency 0.96• Joy frequency 0.91• Emotional synchronicity 0.90 • Initiation of engagement by the child 0.93• Musical synchronicity frequency 0.96• Turn-taking frequency 0.94• Initiation of interaction 0.86• Imitation 0.69


Selected session analysis findings; music therapy vs. free play

Eye contact Duration a significant effect (p<.0001) was found comparing the music therapy condition with free

play

MT play

02

04

06

0

Condition

Eye

co

nta

ct d

ura

tion


Initiation of engagement by child with autism

condition (p<.0001), session (p= .0010) and session part (p= .0292).

1.MT 4.MT 8.MT 12.MT 1.play 4.play 8.play 12.play

05

1015

20

First part of session (unstructured)

Session number and condition

Initi

atio

n o

f en

ga

ge

me

nt f

req

ue

ncy

1.MT 4.MT 8.MT 12.MT 1.play 4.play 8.play 12.play

05

1015

20

Second part of session (structured)

Session number and condition

Initi

atio

n o

f en

ga

ge

me

nt f

req

ue

ncy


Therapeutic interventions

Highest ‘success’ rate for any intervention: about 50%

• no single therapy helps everyone• no single therapy helps everything• hard to know who will benefit from what

What helps?• early intervention• intense intervention• structure and predictability• increasing ‘attention’ to others• building up motivation


Research Autism UK Website

• Music Therapy submission by Tony Wigram, Christian Gold & Amelia Oldfield

• Evaluations by Prof. Tony Charman (UCL); Prof. Patricia Howlin (St. George’s Medical School & Prof. Dido Green (Guy’s Hospital)

• Music Therapy graded with two ticks based on the research evidence: 2 ticks represents Strong Positive Evidence of effect.


1, 2 & 3 tick interventions

• 1 Tick: TEACCH; Social Stories, Gluton free Casein free diet, Milieu training, Visual Schedule

• 2 Ticks: Cognitive Behaviour Therapy; Music Therapy, Anti Depressents (also 3 Hazards); Melatonin

• 3 Ticks: Early Intensive Behavioural Intervention (LOVAAS); Olonzapine; PECS; Risperidone (also 3 Hazards)


Relevant texts for EBP: 1Research and Clinical

• Effectiveness of Music Therapy Procedures, Third Edition: AMTA Publications (2000)

• Reviews of research and documentation in the following areas:• Music Research in medical Treatment• Music for Physical Rehabilitation• Music Therapy and Speech Rehabilitation for Brain Injured patients• Music with children who are hearing impaired• Music therapy for Visually impaired• Music Therapy with Disabled Children and Youth• Group Music Therapy in Acute Mental Health• Music Therapy for Older people• Music therapy in Hospice and Palliative care

• An excellent resource, albeit now 10 years old, that offers an extensive resource of reviews, publications, and evidence based documentation.


Relevant texts for EBP: 2Research

• Ansdell, G; Pavlicevic M & Proctor, S (2001) Presenting the Evidence: A Guide for Music Therapists Responding to the Demands of Clinical Effectiveness and Evidence-Based Practice. London: Nordoff Robbins Music Therapy Centre

• Excellent resource• Helps students or early career clinicians. • The text also provides resources, help and references.• Again this is 9 years old, but still very relevant.


Relevant texts for EBP: 3Research

• Dileo, C and Bradt, J (2005) Medical Music Therapy: A Meta-Analysis & Agenda for Future Research

• Extraordinary range of research studies involving music therapy and music interventions.

• Exclusively meta reviews that give statistically significant results or music and music therapy interventions.

• These meta reviews give substantially more and comprehensive information, and demonstrates where music or music therapy is an indicated treatment

• This text is a very substantial contribution to Evidence Based Practice.


Quantitative Research Studies 1994-2012

• Cochavit Elefant (Israel) 1998-2002 COMMUNICATION IN RETT SYNDROME

• Dikla Kerem (Israel) 2003-2008 INFANTS WITH COCHLEAR IMPLANTS

• Karin Schou (Denmark) 2004-2007 POST CARDIAC SURGURY PATIENTS

• Marith Bergström-Isaacsön(Sweden) 2006-2012 AUTOMIC AROUSAL IN RETT SYNDROME


Mixed design – quantitative and qualitative Research Studies 1994-2007

• Hanne Mette Ochsner Ridder (Denmark) 1999–2003ALTZHEIMERS AND DEMENTIA

• Lars Ole Bonde (2003-2005) (Denmark) REHABILITATION OF CANCER SURVIVORS

• Jinah Kim (Korea) 2003-2006 JOINT ATTENTION IN AUTISM

• Helen Odell- Miller (UK) 2002-2007 EFFECTIVE INTERVENTIONS IN PSYCHIATRY

• Carola Maack (Germany) 2006-2012 COMPLEX POST TRAUMATIC STRESS DISORDER

• Bolette Beck (Denmark) 2007-2013 WORK RELATED STRESS DISORDERS


Qualitative Research Studies 1993-2007

• Wolfgang Mahns (Tyskland) 1993-1997 INTELLECTUAL DISABILITY

• Gudrun Aldridge (Tyskland) 1993-1997 FEMALE CANCER PATIENTS

• Niels Hannibal (Danmark) 1995-1999 PSYCHIATRIC IN-PATIENTS

• Ulla Holck (Danmark) 1996-2000 COMMUNICATION IN AUTISTIC CHILDREN

• Trygve Aasgaard (Norge) 1997-2000 CHILDREN WITH CANCER

• Jos De Backer (Belgien) 1998-2004 ADULT PSYCHIATRY/PSYCHOTICS

• Rudy Garred (Norge) 1999-2003 PHILOSOPHICAL STUDY ON DIALOGUE


Qualitative Research Studies 1993-2007• Torben Moe (Danmark) 1995 - 2000

ADULT PSYCHIATRY/SCHIZOTYPICAL• Inge Nygaard Pedersen (Danmark) 2003-2007

COUNTERTRANSFERENCE IN ADULT PSYCHIATRY• Randi Rolvsjord (Norge) 2004-2007

RESOURCES OF PATIENTS: ADULT PSYCHIATRY• Sanne Storm Wich (Faroen) 2004-2009

VOICE ASSESSMENT TOOL: ADULT PSYCHIATRY• Valgerour Jonsdottir (Island) 2005-2010

RESOURCES OF PARENTS OF HANDICAPPED• Charlotte Lindvang (Danmark) 2005-2011

SELF EXPERIENCE TRAINING IN MUSIC THERAPY • Lisa Summer (USA) 2007-2009

GUIDED IMAGERY AND MUSIC: NORMAL POPULATION


Relevant texts for EBP: 4Clinician Observed

• Bruscia, K (Ed.)(1991) Case Studies in Music Therapy. Barcelona Publishers. Penn. USA.

• Wigram, T and de Backer, J (1999) Clinical Applications of Music Therapy in Developmental Disability, Paediatrics and Neurology. Jessica Kingsley Publishers: London

• Wigram, T and De Backer, J. (1999) Clinical Applications of Music Therapy in Psychiatry (1999) Jessica Kingsley Publishers: London

• Hadley, S (2003) Psychodynamic Music Therapy: Case Studies Ed.Susan Hadley. Barcelona Publishers. Penn. USA.

• These texts (and many more besides) address the second arm of Evidence Based Practice with well documented case examples of the effect of music therapy, from case reports by experienced clinicians


Relevant texts for EBP: 5Client reported

• Hibben, J (1999) Inside Music Therapy: Client Experiences. Barcelona Publishers

This text addresses the third arm of Evidence Based Practice – Clientreports. Often forgotten – the clients’ experiences are critical and essential.The story of Helen (Chapter 1, p.5) 18 year old suicidal depressed patient in a high security hospital: “My intellect was always way ahead of my emotions, but in music therapy I had no control over that intellect; emotions came first in the music we played…Music Therapy opened

up channels that felt way beyond my understanding and clearly showed my inability to connect my intellect to my emotions ”


Relevant texts for EBP: 6Client reported

• Hibben, J (1999) Inside Music Therapy: Client Experiences. Barcelona Publishers

Denise Grocke:The stories from Denize Grocke’s study on Pivotal Moments in GIM (narrative 33), reported more comprehensively in her doctoralstudy. In her interview of her pivotal GIM session, Bernadette talks about finding her voice, and subsequently being able to make decisions in her life.

Inge Nygaard Pedersen: (in Wigram, T., Nygaard Pedersen, I., & Bonde, L.O. (2002) A Comprehensive Guide to Music Therapy. TheoryClinical Practice, Research and Training. London: Jessica Kingsley Publications.) Reporting a case of a 41 year old man with personality disorder, the thoughts of the client three years after the therapy finished are written down by the client:


SHORT SUMMARIES OF ARTICLES: ESSENTIAL INFORMATION

• Authors

• Title

• Subjects

• Measures or data collected

• Results

• Conclusion


EXAMPLE• Hammer, Susan E. (1996) The Effects of Guided

Imagery Through Music on State and Trait Anxiety, Journal of Music Therapy, 33 (1), 47-70.

• A study investigating the effects of Guided Imagery through Music (GIM) and relaxation techniques on stress and anxiety levels. 16 subjects involved in alcohol and chemical dependency rehabilitation participated - consisting of an experimental group receiving 10 treatment sessions and a control group receiving no treatment. Stress levels were measured through the State-Trait Anxiety Inventory (STAI) and individual self-reports and evaluations. Test results showed that the experimental group experienced a decrease in perceived situational stress that was statistically significant. Verbal reports and observations corroborated this. Results indicate that GIM may be of benefit to persons with chronic stress and anxiety.


EVIDENCE BASED PRACTICEMusic Therapy in Psychiatry

Type of Evidence

Gold 2007 Meta ReviewOdell-Miller 2007 Clinician Observed

Hannibal, N 1999 Case study clinician ObservedMoe, T 2000 Case study clinician observedDe Backer, J 2005 Case study clinician observedNygaard Pedersen, I 2007 Phenomenological case studies Odell-Miller, H 2007 SurveyRolvsjord, R 2007 Case study clinician observedStorm, S 2007++ Experimental/ assessment toolMaack, C 2007++ RCT


Previous research

• Cochrane Review: Music Therapy for people with psychotic disorders– rigorous inclusion criteria– 4 RCTs to date (2 Chinese, 2 European)– MT vs. standard care, 1-3 months– positive effects on symptoms of schizophrenia

(depending on number of therapy sessions)• negative symptoms• general symptoms and (social) functioning

• available: www.thecochranelibrary.com or www.uib-no/people/cgo022

http://www.thecochranelibrary.com/

http://www.uib-no/people/cgo022


Important review including both psychotic and non-psychotic patients(Gold 2007):

Included studies

• 15 studies included out of a pool of 166– 8 RCTs, 3 CCTs, 4 uncontrolled studies– from all parts of the world (from Netherlands

to China)• most compared MT vs. standard care• included 689 patients total

– 456 psychotic, 233 non-psychotic (mostly depression)

– Number of sessions ranged from 6-78


Findings on symptoms

• Effect on anxiety : Overall effect significant

p < .01

• Effect on general symptoms: sessions significant p < .01

• Effect on functioning: sessions significant p < .01

• Effect on depressive symptoms: sessions significant p < .001


Findings

• the effects of MT increase with the no. of sessions and negative symptoms respond more quickly than general symptoms

• These results confirmed and extended findings from a previous review by– confirming the ”dose-response” relationship– Including in the new sample non-psychotic

disorders which further extended the findings


CONCLUSION: WHAT DOES IT ALL MEAN!!!

Research is vital to:• Establish the value of music therapy• Create jobs• Guide clinicians in the best and most effective

approachesResearch for evidence: we have many studies

that provide research evidence and clinician observation but....

• We need MORE research results• We need to use the research we have to argue

our value• We need to find out more from our clients – what

really does help them?

Health & Medicine

Prof. Tony Wigram, keynote, Cadiz 2010