For non-psychiatric patients, musical programming should be based upon patient requests. For stimulation the important factors are rapid tempo, accentuated rhythm, and elevated volume. For sedation, slow tempo and reduced volume are indicated, as well as simple recognizable melodies. Some discussion of the selection to follow is a valuable aid to the enjoyment of listening. Live musicians should be used as often as possible.
CHAPTER THREE
MUSIC AS OCCUPATIONAL THERAPY
Until the latter part of the eighteenth century the institutional treatment of mentally diseased people consisted of custodial care. This meant shelter, food and restraint. The quality of the shelter varied in most instances from very bad to poor. The quality of the food was not as varied—it was just bad. The quality of the restraint was excellent. With few exceptions commitment meant life internment. Violent patients were chained to the wall, for who could tell when they might become violent again after a period of calm? The mentally deranged were not considered as patients with a disease of the mind but as inmates who had lost communal value and social desirability. Dr. Philippe Pinel of the Salpêtrière Hospital in Paris thought otherwise and began to consider these people as still human. Among the reforms he introduced was the use of activities to keep the mind and body occupied doing things. This concept grew slowly at first but eventually reached universal acceptance, was considered of real therapeutic value and named occupational therapy.
During the first World War many military patients were confined to hospitals for prolonged periods while awaiting complete recovery. It was noted that those who busied themselves with such physical activities as required the use of their wounded extremities regained the use of these extremities sooner those who remained idle physically. Thus was born a branch of Occupational Therapy which was known as functional to differentiate it from previous psychiatric use.
Functional Occupational Therapy is used to increase three functions: muscle power, joint mobility and co-ordination of movements. It finds its greatest use in those patients who fall under the care of those medical specialists known as orthopedic surgeons and neuro-surgeons. Orthopedic patients are those who have disease or disability of one or more joints or bones. The most common disease of joints is called arthritis, of which there are several kinds of varieties. The most common disability of bone during war-time is fracture. Arthritis usually prevents complete joint motion. In some instances the joint is put at rest to hasten healing. Almost all fractured bones are kept fixed by plaster casts or traction and prevented from movement during healing. The prolonged rest, necessitated by diseases of bones and joints, permits muscles to become weakened or atrophied, and also permits joints to lose some of their range of motion. When the course of disease has reached that point where rest is no longer required, the chief aim of medical treatment is to restore former function. This means the restoration of power and mobility. This is accomplished by means of physical and occupational therapy. Physical therapy includes the use of heat, massage and guided exercise. Occupational therapy is exercise through work—purposeful, productive work with an incentive. The incentive is twofold—to produce something useful and to hasten recovery.
Patients who have had destruction or other disease of the nerves which activate their muscles develop varying degrees of loss of muscle-power known as palsy or paralysis. When a nerve is pressed or cut, it usually heals in such fashion as to permit return of muscle-power. During the period of its impairment, there is not only a loss of power, but frequently concomitant disturbance in the skin, the joints and still other functions. As a result of the nerve disturbance or the disuse which follows, the portion of the body which is paralyzed loses the ability to use its muscles with facility and maximum economy. There are almost no motions performed by single muscles. Most activity results from the contraction of a group of muscles and these are usually in delicate balance with other groups of muscles which either assist or prevent overaction. The delicate adjustment of muscle groups, which is normally present, results in co-ordinated movements. Following nerve disease or, for that matter, the immobilization of joints and muscles, co-ordination is usually lost to more or less degree. Muscles must be re-trained to work together. Such co-ordination can be accomplished by special exercises, but even more rapidly and efficiently by imitating the motions of life. This is the aim of functional occupational therapy.
There are other disease conditions which can profit from the use of occupational therapy. These include other disabilities which are accompanied by loss of power, motion or co-ordination. When the skin is burned, healing is usually accompanied by some degree of scarring. If the scar includes a joint on its flexor surface (i.e. inside the bend) there will result a deformity known as a flexion contracture. If nothing is done about this, the crippling process will become progressive and some day reach a stage beyond correction other than that offered by plastic surgery. The early stretching of such joints will not only prevent progressive disability but may result in some improvement.
Many other indications for the use of occupational exercise will be met, but since this is not a text on medicine, the preceding types of disabilities will serve as examples of the conditions commonly seen.
The crafts first used in functional work were carry-overs of those most beneficial in mental disease, and for the most part were restful and simple, such as basketry, weaving and the graphic arts. More recently, almost all the arts and crafts have been used, as well as motorized tools.
The results of occupational exercise will depend upon the attractiveness of the objects which can be produced, the energy required, the skill and patience of the occupational therapy worker and patient, and the stage and extent of the disability. For those who are not “handy”, or who have become increasingly clumsy with disability, there may be impatience, tedium and fatigue. Occupational therapy is always seeking new activities or modalities as they have become known in practice. Music can be used as exercise in occupational therapy as well as for background and interludes of relaxation.