Still Making Music: How Students with Traumatic Brain Injury Can Continue with Musical Activities

Traumatic Brain Injury

Traumatic brain injury (TBI), of which concussions are a part, is a common problem in the United States. An estimated 1.4 million Americans experience a TBI each year, with approximately 50,000 people dying from their injuries. ¹ All age groups are at risk for TBI, but there is a larger occurrence among children and young adults. ² While it is not within the scope of this article to provide an exhaustive list of all related types of traumatic brain injury, there are some key definitions that can be addressed. Traumatic brain injury may be described as an injury that occurs when a sudden trauma damages the brain. Common causes of traumatic brain injury include automobile accidents, sports injuries, and physical violence. A TBI may result any time the head suddenly and violently hits an object or when an object enters the skull and pierces the brain tissue. ³ The Brain Injury Association of America defines TBI as “an alteration in brain function, or other evidence of brain pathology, caused by an external force.” ⁴ TBI can cause physical changes in the brain such as swelling, increased inflammatory response, neurodegeneration, and cognitive impairment. ⁵ TBI is often described in degrees of severity, from mild to severe. Depending on the severity of the injury, effects can last for a couple of hours or throughout a person’s lifetime. But regardless of the severity of a student’s injury, he or she can benefit from musical activities, whether through listening to music, performing on an instrument, or singing.

Symptoms of TBI

Identifying TBI symptoms and their severity is crucial in understanding the ways in which a student can be musical afterward. The degree to which a person’s musicality is affected can depend not only on the specific injury but also on the severity of the injury. A person with a mild TBI due to a relatively simple sports injury will react in a much different fashion musically than will a person who remains in a coma for a long period due to severe trauma to the brain. A person may experience communication deficits as a result of TBI; the extent to which this person communicates may influence the ways he or she functions musically. Some injuries resulting from a brain injury may affect the person’s fine motor skills, perhaps necessitating a modified instrument for musical practice and performance.

Symptoms of TBI largely depend on whether the injury is mild, moderate, or severe. Symptoms of mild TBI include headache; confusion; light-headedness; dizziness; blurred vision or tired eyes; hearing loss, including ringing in the ears; bad taste in the mouth; fatigue or lethargy; a change in sleep patterns; behavioral or mood changes; and trouble with memory, concentration, attention, or thinking. ⁶ People with more severe forms of TBI may exhibit the same symptoms as those with mild TBI but with greater severity, such as extended periods of coma. Other symptoms of TBI may be present, such as a headache that worsens or does not go away, repeated vomiting or nausea, convulsions or seizures, an inability to awaken from sleep, dilation of one or both pupils of the eyes, slurred speech, weakness or numbness in the extremities, loss of coordination, and increased confusion, restlessness, or agitation. ⁷

Musical Activities

Engaging in musical activities while recovering from a mild injury may be limited depending on a physician’s advice or the comfort level of the injured student. A physician may advise a patient against participating in any activity that could hamper the recovery process. If singing or playing a musical instrument is uncomfortable for a student recovering from a TBI, musical activities can be limited to music listening. These suggestions are intended for music students with TBI, though they may be helpful when working with non–music students with TBI as well. A student with a disability related to a TBI that needs classroom modifications may have a Section 504 plan or an Individualized Education Plan (IEP). Music teachers should consult these documents when planning instruction for students with TBIs. For specialized assistance, music teachers can refer students to the school’s guidance counselor or exceptional children director. School social workers can also suggest occupational or physical therapists who can assist students in need. Some therapists may even come to a school to provide assistance. Music teachers may wish to consult Occupational Safety and Health Administration guidelines about classroom safety issues. Some music classrooms could be modified or renovated so that students with TBIs can learn in an environment suited to their needs. These school resources help ensure that a high-quality music education is provided.

Music Listening Activities

Damage to the head’s peripheral audio structures is a common result of head injuries and may result in hearing loss. ⁸ A decreased ability to communicate is one primary effect of hearing loss. The level of student communication is dependent on the severity of the hearing loss. While students with slight hearing loss may have some difficulty with hearing quiet speech, those with mild hearing loss may miss as much as 50 percent of conversations unless the conversation is face-to-face. Students with mild or severe hearing loss may also have a limited vocabulary because speech and language will be impaired. Students with severe hearing impairments may be able to hear only loud sounds, and as a result, they may be more aware of vibrations than sound. They will rely more on vision than hearing as their primary method of communication. ⁹

The severity of the hearing loss will dictate the interventions used in a music classroom. If a student has only a slight or mild hearing loss, simply seating the student at the front of the room so he or she can hear the teacher better may be the only intervention needed. Students with more severe hearing loss may need equipment (hearing aids, microphones, etc.) to enhance their hearing. Some students with a hearing aid might not need further intervention. They may be able to sit where they want to and still be able to hear adequately. Students with a severe or profound disability may need an assistant who can use sign language to assist in their normal classroom activities. Students with severe hearing loss that is either permanent or long-lasting may be more successful on large instruments such as low brass and some percussion because the vibrations are more apparent with these instruments.

Some students with TBI may be sensitive to the loud volume levels that frequently occur in most school bands and orchestras. For some, general music classrooms may be too loud as well, especially when instruments are being used. For these students, limiting exposure to loud sounds, either through reducing loud sounds or providing breaks from them, may be helpful. ¹⁰ Music teachers can provide music listening activities that include selected pieces of music or music that is currently rehearsed by an ensemble. General music teachers can provide listening assignments based on musical instrument identification or pitch change identification. They can also encourage the student to listen to recordings of songs that the class will sing in the future. Another example of a listening assignment is a handout that includes rehearsal strategies paired with an MP3 player and headphones placed in a separate room to allow the student to remain engaged with the ensemble’s current music selections. The music teacher may even be able to use a few microphones and a small audio mixer to transmit the rehearsal to a separate room. The student would be able to listen to the rehearsal while safe from loud sounds.

No matter the severity of a student’s injury, he or she can benefit from musical activities.

Music teachers can also provide music listening assignments that include a student’s preferred music. Since one of the symptoms of mild TBI may include mood change, listening to one’s preferred music may help in alleviating a depressed mood. ¹¹ Students recovering from a TBI may be used to listening to music on a daily basis. Due to their injuries (especially if they are mild), they may find themselves wondering if they should be exposed to any level of sound. Of course, comfort level should be taken into account when engaging in any musical activity. The volume level of music may need to be adjusted to suit the needs of the injured student. Current MP3 players often have a maximum volume setting that a teacher can adjust to suit student needs.

Performance Activities

Music teachers can assist students with TBI in music practice and performance. Remember that any suggestions for musical activities discussed in this article are not in place of a physician’s recommendations. Singing or playing an instrument at home or in a school ensemble would be the likely scenario for musical performance. Music therapy settings are also a common locale for music-making. In one study, small group improvisation in a music therapy setting increased the emotional adjustment of people recovering from TBI. ¹² Family members rated the moods of people with traumatic brain injury higher after these individuals engaged in music-making activities. ¹³ Researchers Felicity A. Baker and Tony Wigram found that singing elevated the moods of people with TBI. ¹⁴

Modified or digital instruments can be wonderful music-making tools.

One common music-making activity in schools is playing an instrument in the school orchestra or band. Physical coordination is largely responsible for the success of school musicians. Fine motor skills are needed when playing woodwind and string instruments. Students who develop fine motor function deficiencies may have more success on brass instruments rather than woodwinds since brass instruments do not require students to use as many fingers. ¹⁵ Gross motor skills such as grip strength are needed simply to hold these instruments correctly. Unfortunately, many school-age children with TBI have a deficiency in gross motor skills ¹⁶ that may prevent them from even holding an instrument properly. Fortunately, there are solutions available.

Since many instruments are designed with sound quality in mind rather than for ease of holding the instrument, adaptations may be necessary. Modified instruments are available for students who have physical challenges that make playing instruments difficult. There are many ways in which instruments can be modified. Instruments can be made more ergonomic and less likely to cause strain. ¹⁷ Velcro straps can be used to secure some lightweight percussion instruments (especially drumsticks and mallets) to a person’s wrist. Students who want to play in the band or orchestra can be guided toward choosing an instrument that has a built-in support system or one that can be adapted easily. Examples of instruments with built-in support systems include clarinet and saxophone neck straps, bass clarinets floor pegs, and bassoon seat straps. Larger brass instruments such as euphoniums can have lap pads, while tubas can be placed on a stand or a harness designed to support the weight of the instrument. ¹⁸

Students interested in playing guitar can use modified instruments and equipment such as larger picks or spiral picks. A spiral pick is designed to wrap around a student’s finger so that holding the pick is no longer an issue. ¹⁹ Instrument stands designed to hold the guitar can be helpful as well. A student with a strength deficiency may find the electric guitar easier to play than the acoustic guitar because the electric guitar usually uses a lighter string gauge. ²⁰

Choral students may need specific modifications because of the nature of choral rehearsals and performances. Choral music teachers should be aware of instances where students may need to sit during part of a rehearsal or performance. Students who may become dizzy or light-headed after standing for long periods may need to stand on the floor rather than on a riser to avoid falling.

Listening to one’s preferred music may help in alleviating a depressed mood.

Occupational therapists are good resources for more ideas on adapting musical instruments for use by students with physical difficulties. Electronic and digital instruments may be a factor in a student’s ability to perform music, especially if gross motor function limits dexterity. Instruments such as keyboards or digitized woodwind instruments may offer a possibility in these cases. Modified or digital instruments can be wonderful music-making tools as long as the student is able to continue making music in a comfortable, safe manner.

Keep on with Music!

More than a million people undergo some type of traumatic brain injury in America each year. School-age children are particularly susceptible to brain injuries. Many of these individuals also engage in musical activities of some type, whether through listening to music, singing, or performing on musical instruments. To give up music entirely because of a brain injury may mean a less fulfilling school experience for the student who values music. There are many examples of students with TBI who continue to participate in their preferred musical activities, from the teenager listening to his preferred music to the orchestra student performing the music she enjoys along with her peers. Examples like these offer encouragement to those with traumatic brain injuries so that they do not have to give up an activity they love.