VOLUME 9 | NUMBER 3 | JULY 2017

Special Issue:
Multidisciplinary Applications of Vibroacoustics
from Clinical Practice and Research to Future Directions

Editors
Joanne V. Loewy, DA, LCAT, MT-BC & Ralph Spintge, MD

Guest Editors
Esa Ala-Ruona, PhD & Marko Punkanen, PhD
Music & Medicine | 2017 | Volume 9 | Issue 3 | Page 146 | Editorial Team

Editorial Team

Editor in Chief
Joanne V. Loewy, DA, LCAT, MT-BC
Director, The Louis Armstrong Center for Music & Medicine, Mount Sinai Beth Israel, New
York, NY, USA
Icahn School of Medicine, New York, NY, USA

Editor in Chief
Dr. med. Ralph Spintge
Institute for Music Therapy, University for Music and Drama HfMT Hamburg
Dept. of Algesiology and Interdisciplinary Pain Medicine, Sportklinik Hellersen, Germany

Managing Editor
Amy Clements-Cortés, PhD, RP, MTA, MT-BC, FAMI
Music and Health Research Collaboratory, Faculty of Music, University of Toronto, Toronto,
Ontario, Canada

Production Editor
Erik Baumann, MA, MMT
Musicoterapia Peru, Lima, Peru

Book Editor
Reza Abdollahnejad, PhD
MPHA University of Adelaide, Australia

International Abstract Editor

Bernardo Canga, MMT
Department of Pediatrics Children’s Hospital of The King’s Daughters,
Eastern Virginia Medical School, Norfolk, VA, USA
Music & Medicine | 2017 | Volume 9 | Issue 3 | Page 147 | Editorial Board

Editorial Board
Joanne V. Loewy, DA, MT-BC, LCAT, The Louis Armstrong Center for Music & Medicine, Mount Sinai Beth Israel Medical Center, United States
Ralph KW Spintge, Institute for Music Therapy University of Music and Drama, Hamburg Germany. Director, Dep for Algesiology Regional Pain
Centre at Sportklinik Hellersen Lüdenscheid, Germany.
Trygve Aasgaard, PhD, Professor, Norwegian Academy of Music and Oslo University College, Norway
Reza Abdollahneiad, PhD, MPHA University of Adelaide, Australia
Eckart Altenmüller, MD, PhD, University of Music, Drama, and Media Hannover Institute of Music Physiology and Musicians' Medicine, Germany
Sivaprakash Balasundaram, MD, PhD,. Psychiatry, Mahatma Gandhi Medical College and Research Institute, India
Erik Baumann, MMT, Musicoterapia Peru, Lima, Peru
Bussakorn Binson, PhD, Chulalongkorn University, Bangkok, Thailand
Joke Bradt, PhD, MT-BC, Drexel University, United States
Linda Chlan, PhD, RN, FAAN, Ohio State University College of Nursing, United States
Andrew Coiro, Conservatoria Luisa D'Annuzio di Pescara, Italy
Hyun Ju Chong, PhD, MT-BC, Ewha Womans University, Korea
Isabel Fernandez Carvajal, MD, Universidad de Valladolid, Instituto de Biologia y Genetica Molecular (IBGM) Department
Sunelle Fouché, MA, Music Therapy Community Clinic Cape Town Area, South Africa
Tian Gao, PhD, MT-BC, Central Conservatory of Music, Beijing, China
Mitchell Gaynor, MD, NewYork-Presbyterian/Weill Cornell Medical Center, NYC, United States. Passed away in 2015
Stéphane Guétin, MD, Neurology Dept. Mémoire de Ressources et de Recherches (CMRR). Montpellier U Hospital, France
Annie Heiderscheit, PhD, MT-BC, LMFT Director, Master of Music Therapy Augsburg College Minneapolis, MN United States
Karen Johnston, MD Neurosurgery, Toronto, Canada
Klaus-Felix Laczika, Medical Unicersity Vienna Department of Internal Medicine I, Austria
ChihChen Sophia Lee, PhD, MT-BC, Professor, Director of Music Therapy, Southwestern Oklahoma State University.
Frances Hendriëhetta Le Roux, MSc, PhD, Private Practice, Fish Hoek, South Africa
Pornpan Kaenampornpan PhD Faculty of Fine and Applies Arts Khon Kaen University, Thailand
Pranee Liamputtong, La Trobe University, Australia
Marcela Lichtensztejn, MA, MT-BC, INECO - Institute of Cognitive Neurology, Argentina
Charles Limb, MD, Department of Otolaryngology, Johns Hopkins University School of Medicine Baltimore, United States
Yi-Ying Lin, Taipei Medical University Hospital, Taiwan
Peter McCann, MD, Department of Orthopedic Surgery, Mount Sinai Beth Israel
Yee Sien Ng, Singapore General Hospital, SingHealth Duke-NUS Graduate Medical School, Singapore
Ulrica Nilsson, RNA, PhD, School of Health and Medical Sciences, Örebro University, Sweden
Monika Nöcker-Ribaupierre, PhD, Freies Musikzentrum München, Germany
Paul Nolan, MMT, Drexel University, Philadelphia, PA, United States
Kana Okazaki-Sakaue, PhD, Associate Professor Graduate School of Human Development and Environment Kobe University, Japan
Aiko Onuma, MT-BC, Kakehashi Music, Boston, Mass, USA
Hanne Mette Ochsner Ridder, PhD, Department of Communication and Psychology, Aalborg University, Denmark
Phillip L. Pearl, MD, Harvard Medical School, United States
Isabelle Peretz, PhD, University of Montreal, Quebec, Canada
Alexia Ratazzi, MD, Child * Adolescent Psychiatry, PANACEAA, Argentina
Antoni Rodriguez-Fornells, PhD, Universitat de Barcelona, Spain
David Sahar, MD FACC FAHA, College of Physicians and Surgeons of Columbia University, United States
Benedikte Scheiby, MA, MT, Institute for Music and Neurologic Function, CenterLight, United States
Fred Schwartz, MD, Piedmont Hospital Atlanta, Georgia, United States
Helen Shoemark, PhD, Murdoch Children's Research Institute, Melbourne, Australia
Amanda Soebadi, MD, Child Neuro Division, Dept of Child Health, Univ Indonesia Medical School,
Cipto Mangunkusumo Hospital, Jakarta, Indonesia
Thomas Stegemann, MD, MT, University of Music and Performing Arts, Vienna, Austria
Mohan Sundararaj, Global Forum on MSM & HIV (MSMGF), United States
Sumathy Sundar, PhD, Chennai School of Music Therapy, India
Patsy Tan, PhD, Singapore General Hospital, Singapore
Julian F Thayer, PhD, Department of Psychology, The Ohio State University, Ohio, United States
Alan Turry, DA, MT-BC, LCAT Nordoff Robbins Center for Music Therapy, New York University, United States
Patravoot Vatanasapt, MD, Faculty of Medicine, Khon Kaen University, Thailand
Juri Yun, MT-DMtG, KCMT, Ewha Music Wellness Center, Korea
Barbara L Wheeler, PhD, MT-BC, Visiting Professor Temple University, United State
Music & Medicine | 2017 | Volume 9 | Issue 3 | Page 148 | Table of Contents

Table of Contents

Guest Editorial
149-150 Multidisciplinary Applications of Vibroacoustics – from Clinical Practice and Research to Future Directions
Esa Ala-Ruona & Marko Punkanen

Commentary
151-152 The Beginnings of Vibroacoustic Therapy
Olav Skille

Full Length Articles

153-166 Vibroacoustic Stimulation and Brain Oscillation: From Basic Research to Clinical Application
Lee R. Bartel, Robert E.W. Chen, Claude Alain, Bernhard Ross

167-173 The Potential of Rhythmic Sensory Stimulation Treatments for Persons with Alzheimer’s Disease
Amy Clements-Cortes, Heidi Ahonen, Morris Freedman, Lee Bartel

174-177 Can Rhythmic Sensory Stimulation Decrease Cognitive Decline in Alzheimer's Disease? A Clinical Case Study
Amy Clements-Cortes, Heidi Ahonen, Michael Evans, David Tang-Wai, Morris Freedman, Lee Bartel

178-183 Feeling Vibrations from a Hearing and Dual-Sensory Impaired Perspective

Russ Palmer, Olav Skille, Riitta Lahtinen, Stina Ojala

184-186 Vibroacoustic Treatment Protocol at Seinäjoki Central Hospital

Jouko Hynynen, Virpi Aralinna, Maire Räty, Esa Ala-Ruona

187-197 Vibroacoustic Treatment for Chronic Pain and Mood Disorders in a Specialised Healthcare Setting
Elsa A. Campbell, Jouko Hynynen, Esa Ala-Ruona

198-201 Vibroacoustic Therapy in the Treatment of Developmental Trauma: Developing Safety through Vibrations
Marko Punkanen, Marjo Nyberg, Tiinapriitta Savela

202-208 The Effect of Short-Term Vibroacoustic Treatment on Spasticity and Perceived Health Condition of Patients with
Spinal Cord and Brain Injuries
Eha Rüütel, Ivar Vinkel, Priit Eelmäe

Book Review
209-210 Music Therapy Research: Third Edition (2016). Edited by Barbara L. Wheeler; Associate Editor: Kathleen M. Murphy
Grace Anne Thompson
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 149 – 150
Guest Editorial
Multidisciplinary Applications of Vibroacoustics – from Clinical Practice and Research to Future
Directions
Esa Ala-Ruona1,2 & Marko Punkanen1,3
1
VIBRAC Skille-Lehikoinen Centre for Vibroacoustic Therapy and Research, Jyväskylä, Finland
2
Music Therapy Clinic for Research and Training, Finnish Centre for Interdisciplinary Music Research, Department of Music, Art and Culture
Studies, University of Jyväskylä, Finland
3
Nyanssi Therapy Centre, Lahti, Finland
Within the pages of this special issue, are articles that
represent over 30 years of clinical practice, research,
discussion, and development in the field of vibroacoustic
therapy. It comprises submissions based on pioneering work
that began in the 1980s and has been continued and further
conceptualized as part of music therapy practice, music
medicine applications, along with various other therapeutic
applications within the fields of healthcare, rehabilitation, and
wellbeing. We are proud of the collection represented here as
it reflects how much that has been achieved over the years and
furthermore provides a clear indication of that which may
follow. This special issue marks an encouraging and inspiring
step towards the application of low frequency sound vibration
as a treatment and therapy application option in a plethora of
contexts.
Vibroacoustic therapy (VAT) is traditionally considered
to be a physical and receptive form of music therapy that
incorporates pulsed, sinusoidal, low frequency sound from a
specially designed device. Sinusoidal sound is the simplest
sound information representing only a single frequency with
no harmonics. Low frequency sound vibrates between 20 and
100 Hz (20-100 times per second). [1, 2]
The various forms of vibroacoustic applications can be
defined in 3 ways: according to the special needs of a clinical
target group, by the elements included, and according to the
competencies and formal training of the practitioner. In sum,
these applications are referred to either as vibroacoustic
therapy or vibroacoustic treatment. Vibroacoustic therapy
uses the combination of low frequency sinusoidal sound
vibration, music listening, and therapeutic interaction. It is
conducted by a trained therapist (e.g. music therapist,
psychotherapist, physiotherapist, occupational therapist), who
PRODUCTION NOTES: Address correspondence to:
Esa Ala-Ruona, Ph.D. Email: esa.ala-ruona@jyu.fi | COI
statement: The authors declared that no financial support was
given for the writing of this article. The authors have no conflict
of interest to declare.
Copyright © 2017 All rights reserved.
International Association for Music & Medicine (IAMM).
Ala-Ruona & Punkanen | Guest Editorial
also has appropriate training (e.g. VIBRAC-practitioner
training) in using the parameters of vibroacoustic stimuli for
the purpose of achieving individually set therapeutic goals.
Vibroacoustic therapy is always process-oriented and it has
been used through the years with various client groups.
Vibroacoustic stimuli can be provided through various kinds
of technical devices. Such devices have been developed for
example in Norway, Finland, and the USA.
In comparison to vibroacoustic therapy, vibroacoustic
treatment is conducted by a trained clinician (e.g. VIBRAC-
practitioner) in either a hospital or other institutional context,
or in private practice. It is also goal-oriented work, meaning
that it starts through conducting an appropriate initial
assessment, creating an individual treatment plan, carrying
out the treatment protocol, evaluating the outcomes of the
treatment, and finally, through writing the clinical report.
There are a variety of terms related to vibroacoustic
stimuli. Such terms that can be found in literature and/or
research articles include, for example, vibroacoustic
stimulation, vibrotactile stimulation, low frequency sound
stimulation, low frequency sinusoidal sound stimulation, and
rhythmic sensory stimulation. Despite the different terms
used, the core element of vibroacoustic stimuli is the low
frequency, sinusoidal sound vibration, which can basically be
used for either relaxation or activation. The main parameters
that control the stimuli are the used frequency of sound (Hz),
amplitude, pulsation, and scanning. When combined, these
adjustable sound parameters provide diverse possibilities in
designing and editing vibroacoustic stimuli to meet individual
therapeutic needs.
This Special Issue on the Multidisciplinary Applications
of Vibroacoustics is based on some of the authors’
contributions at the first international VIBRAC-conference
held October 14th-15th 2016 in Lahti, Finland. The event
gathered presenters and participants from 16 countries that
attended from all over the world. Keynote addresses were
given by Dr. Heidi Ahonen, Dr. Ana Katušić, Dr. Lee Bartel,
and Dr. Esa Ala-Ruona, some of whom have contributed to
this special issue, as well. The conclusion made in the
conference was that there is an evident need for collecting all
the available information on the best practices both in clinical
MMD | 2017 | 9 | 3 | Page 149
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 149 – 150
work and in research, and to aim towards reaching consensus
on more formalized procedures that will lead toward
standardization. These also are the main goals and objectives
of the VIBRAC Skille-Lehikoinen Centre for Vibroacoustic
Therapy and Research, and furthermore, our hope is that this
issue will formulate as an international hub for all of this
information-so that it can be a focal point in sharing it. The
impression from the conference was that it is the time to take a
step further in development and we have a very nice growing
body of knowledge to be shared. A concrete example of this is
the composition of the articles within this special issue.
This special edition of Music and Medicine starts with a
commentary from Olav Skille. He is the pioneer of
vibroacoustic therapy with over 40 years of clinical experience
in the field. This is followed by Lee Bartel, Robert Chen,
Claude Alain, and Bernhard Ross’ discussion about A
Foundation for Sound as Brain Stimulant with Application to
Possible Treatments. Following this are two contributions
related to Alzheimer’s disease, which is a very interesting
target group for which vibroacoustic treatment shows great
potential. First, is a clinical report on The Potential of
Rhythmic Sensory Stimulation Treatments for Persons with
Alzheimer’s Disease by Amy Clements-Cortes, Lee Bartel,
Heidi Ahonen, and Morris Freedman. The second is a case
study by Amy Clements-Cortes, Lee Bartel, Heidi Ahonen,
Morris Freedman, Michael Evans, and David Tang-Wai
entitled Can Rhythmic Sensory Stimulation Decrease Cognitive
Decline in Alzheimer’s Disease?: A Clinical Case Study. Next, a
unique paper by Russ Palmer, Olav Skille, Riitta Lahtinen, and
Stina Ojala discussing and presenting Feeling Vibrations from
a Hearing and Dual-Sensory Impaired Perspective.
Vibroacoustic Treatment Protocol at Seinäjoki Central
Hospital is presented by Jouko Hynynen, Virpi Aralinna,
Marie Räty, and Esa Ala-Ruona. Furthermore, from the same
clinical context, the paper by Elsa Campbell, Jouko Hynynen,
and Esa Ala-Ruona presents clinical experiences and
outcomes in Vibroacoustic Treatment for Chronic Pain and
Mood Disorders in a Specialised Healthcare Setting. Marko
Punkanen, Marjo Nyberg, and Tiinapriitta Savela illustrate the
use of vibroacoustic therapy in a music therapy context
presented as a clinical report entitled Vibroacoustic Therapy in
Ala-Ruona & Punkanen | Guest Editorial
the Treatment of Developmental Trauma: Developing Safety
through Vibrations. Finally, we conclude with a research
article by Eha Rüütel, Ivar Vinkel, and Priit Eelmäe about The
Effect of Short-term Vibroacoustic Treatment on Spasticity and
Perceived Health Condition of Patients with Spinal Cord and
Brain Injuries.
Vibroacoustic therapy already has a long history in
clinical practice, and there is lot of anecdotal practice-based
evidence available. Recent years have also shown that research
activities are increasing, and new approaches in investigating
this multifaceted treatment and therapy are emerging.
Systematic clinical work, high quality research, and
continuous development of formal training are the
cornerstones of favorable future development. All carefully
conducted reporting is crucial, and the VIBRAC Centre will
provide more formal guidelines for both clinicians and
researchers for enabling reliable and succinct communication
within the field and with closely related professions. [3]
See the VIBRAC website for more details on training,
research, and upcoming events (www.vibrac.fi), and "like" our
Facebook page "Vibrac Skille-Lehikoinen Centre for
Vibroacoustic Therapy and Research" to find out more about
our activities".
References
1. Punkanen, M. & Ala-Ruona, E. Making my body a safe place to
stay: a psychotherapeutically oriented approach to vibroacoustic
therapy in drug rehabilitation. In: Meadows A, ed. Developments
in Music Therapy Practice: Case Study Perspectives. Gilsum, NH:
Barcelona Publishers; 2011:350-367.
2. Punkanen, M. & Ala-Ruona, E. Contemporary Vibroacoustic
Therapy: Perspectives on Clinical Practice, Research, and
Training. Music Med. 2012;4(3):128-135.
3. Ala-Ruona, E., Punkanen, M. & Campbell, E. Vibroacoustic
Therapy: Conception, Development, and Future Directions.
Finnish Journal of Music Therapy, 2015, 1-2: 48-71.
MMD | 2017 | 9 | 3 | Page 150
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 151 – 152
Commentary
The Beginnings of Vibroacoustic Therapy
Olav Skille
1
Core Group Member of the VIBRAC Skille-Lehikoinen Centre for Vibroacustic Therapy and Research, Finland
When I started to work as music teacher at a special
educational needs school in Norway in 1966, I observed
coherence between the pupils’ learning and behavior
problems, and the way they behaved in the music activity
settings. I received a scholarship from the Nordic Council in
order to test a musical behavior observation procedure.
Norway, Sweden, Denmark, and Finland were represented in
the research group, and, after 3 years of work, the result was
presented at the Department of Special Education at
University of Jyväskylä as the Musical Behavior Scale MuBS.
In the early 1970s, no Music Therapy education in any of the
Nordic countries existed. Finnish psychologist and music
teacher Petri Lehikoinen was the first person to have Music
Therapy accepted as an academic discipline in this region, and
music therapy developed in Finland from his teaching. I met
Petri for the first time in Denmark in 1969, and we found that
there were many self-educated “music therapists” working in
institutions for mentally handicapped persons in all Nordic
countries. I was also a music therapy autodidact. Sixteen years
later I served as headmaster of a small institution for multi-
handicapped children. The staff was almost helpless in
educating or training the children - especially children
suffering from Cerebral Palsy. I then remembered a meeting
with Juliette Alvin in 1968 when we agreed that relaxation was
one of the most general effects of Music Therapy. I needed to
understand this relaxation effect, and so I started to collect
equipment that was on hand in my institution.
At that time, basic questions were: if people can relax
through music they perceive auditorily, what would happen if
we would try transferring music directly to the childrens’
body surface? Would the effect be stronger if the affected
limbs were set in direct contact with the sound source?
Thinking about those questions lead to the first concept of
the so-called Music Bath. Children were laid on a beanbag
PRODUCTION NOTES: Address correspondence to:
Olav Skille, E-mail: olav@skille.org | COI statement: The author
declared that no financial support was given for the writing of this
article. The author has no conflict of interest to declare.
Copyright © 2017 All rights reserved.
International Association for Music & Medicine (IAMM).
Skille | The Beginnings of Vibroacoustic Therapy
between two loudspeakers. Our hypothesis was that the
mattress would transfer sound vibrations from loudspeakers
to as large a body surface as possible. Beginning in 1980, I
promised to myself that I would use 10 years of my life to
pursue this idea and realize it – I am still in the process of
further developing my idea.
Developing Vibroacoustic Therapy Hardware
The development of Vibroacoustic Therapy has mostly been
concentrated toward the hardware used for transmitting
sound directly to the human body. If we now search for
Vibroacoustic Therapy on the Internet, we find thousands of
hits and over 100 different sound furniture systems including
several schools or systems for composing music for body
transfer. Time has shown that direct transfer of sound
vibrations to any living organism seems to be effective, and
mostly positive. Developing sound furniture depends mainly
on defining the best transfer mechanism. When Teirich and
Pontvik described the effect of sound transmission via cushion
loudspeakers in the 1950s, perception of sound was limited to
auditory perception. In discussing this with Juliette Alvin, we
agreed that universal elements of all music are: pitch, volume,
rhythm, and timbre. In fact, these are also the physical
elements of verbal communication. But, are these elements of
music the only parameters through which we perceive sound?
Issues of Definitions, Vocabulary, First Trials, and Quality
There are some things we cannot think because we do not know
the words…
I’ve always felt that words and definitions in music theory
and harmonics were not precise enough to describe physical
elements of music and sound. A couple of questions came to
my mind: when pupils in my school relaxed whilst lying in the
Music Bath, what were the exact physical descriptions of
sound elements that were used?
Music seemed to be much too complex in and of itself. To
what extent could we reduce “music” and still observe
physical effects? In that particular context, physical elements
in acoustics seemed to satisfy our need of exact knowledge.
In the 1970s I met Petri Lehikoinen, Tony Wigram, and
physiotherapist Lyn Weekes. We tried to construct several
models of sound transfer furniture. At the same time I
designed model tapes combining music with frequencies.
MMD | 2017 | 9 | 3 | Page 151
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 151 – 152
Collaborating with SEAS loudspeaker factory based in Moss,
Norway, we conducted experiments about transmission of
sound from loudspeaker surface to and through my body. We
found the most powerful effect appearing at 60 Hz and 80 Hz.
80 Hz was too unpleasant, but one octave below we found
optimal combination of pitch and penetrating effect. The 40,
60, and 80 Hz frequencies were used to observe effects in
children, staff, and parents. Together we found effects of
sound transfer on spasticity (40 and 60 Hz), Asthma (50 Hz),
menstrual cramps (52 Hz), neck and shoulder pains (68 Hz)
and migraine headache (86 Hz).
I distributed tapes with these frequencies, both alone and
combined with music on C60 tapes. My colleagues and I
participated in several congresses and symposia, and in 1985
the wooden loudspeaker box was presented at the 5th World
Congress of Music Therapy in Genova, Italy. In 1989 the first
Vibroacoustic Chair appeared in Norway and was later re-
copyrighted under the name Physioacoustic chair in Finland.
It seemed that we had come toward the way’s end.
However, I was dissatisfied with quality of equipment
produced. There was too much sound pollution within the
room during therapy sessions, disturbing other patients on the
wards. Loudspeakers transferred sound from both sides of the
diaphragm. In addition to sound “pollution” physical data
from the Swedish Institute of Defense explained that the
penetration effect of sound frequencies decreased by the
square if distance between loudspeaker and receptor was
doubled. Furthermore, loudspeakers were and still are
constructed for best possible transfer of sound via air.
Therefore, auditory transfer of sound was ineffective for
massage purposes! I had yet to find the best way of
transferring sound vibrations to the body.
At that time I was invited to present a paper at the
Scandinavian Vibration Society meeting in Sweden and there I
learned about transducers. They were designed to transfer
vibrations through water and solid material with a minimum
of sound dispersion to air. I contacted the ACOUVE factory’s
president Imamura from Japan and he sent me some
transducers of different sizes for testing purposes. Stephen
Deuel in the USA built for me a padded cushion, inside which
we put a single transducer. This cushion could be placed
directly on the skin surface anywhere on the body. I started to
use this vibration cushion for personal use, but also lending it
to therapists who wanted to test its effects. Based on such
therapists’ experiences from around the world, I asked Mr.
Imamura to design a 10-transducer model for whole body
vibration transfer. Transducers used were effective between 30
Hz and 100 Hz covering the 40–80 Hz octave. Now it was
possible to construct Vibroacoustic Therapy equipment with
as many transducers as desired.
One element of VAT equipment has not yet been
described: the amplifier. For the VAT Chair we assembled a
Skille | The Beginnings of Vibroacoustic Therapy
six-channel loudspeaker/tape recorder. Over the course of
time while using our equipment we found that we did not
need hi-fi equipment. We just needed amplifiers that could
keep a stable 30 Hz frequency for at least 30 minutes without
melting down the transducers. The present day amplifiers are
effective even when attached to an iPhone.
Outlook
I feel that visualizing and conceptualizing the effects of direct
sound transfer should make it possible to conduct research on
the effects of different frequencies, as well as on the amount of
power needed to access the musculoskeletal and nervous
systems leading us to a better understanding of how to design
safe programmes for different therapeutic purposes.
In physics, sound can be described either as a wave or as
particles, just as there are light waves and photons. Light can
move through a vacuum, but sound waves do need an
atmosphere or solid material as a transport element. Imagine
that some day we could use instruments that could “shoot”
sound particles into and through the body, affecting the
interior of both cells and molecules.
To arrive at that point we need more knowledge.
Acquiring the vocabulary to describe such events might be a
first step. At present we do not even know what we do not
know, i.e. we don’t even know the right questions - as in so
many fields of life sciences.
Let’s go for it!
Start by reading this special issue and enjoy…
Biographical Statements
Olav Skille, Born 1939 in Norway. Studied at
Bergen Lærerhøgskole 1959 - 1962 to be music teacher.
Specialty studies at University of Trondheim 1972 with brain
injuries AS specialty.
Primary school teacher and head master at several schools
and institutions in Norway. Pensioned in 2002. Scholarship
from Norwegian dept. of education to find therapeutic effects
of music education in Norwegian special schools. Grant from
Nordic Council 1972 to find the prognostic possibilities of The
Music Behavior Scale (MUBS) - a Nordic research team that
included Sweden, Denmark and Finland education ministries.
Created the Music Bath which was renamed
Vibroacoustic therapy (VAT). Participated in several
international congresses. Engaged to lecture on VAT in
Singapore, Colcata, Rome, London, Tallinn, Pescara, Zagreb,
Ljubljana and he Nordic countries.
He is a member of the VIBRAC core group.
MMD | 2017 | 9 | 3 | Page 152
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 153 – 166 Bartel, Chen, Alain & Ross | Vibroacoustic Stimulation and Brain Oscillation

Full-Length Article

Vibroacoustic Stimulation and Brain Oscillation: From Basic Research to Clinical Application
Lee R. Bartel1, Robert E.W. Chen2, Claude Alain3, Bernhard Ross3
1
University of Toronto, Toronto, Canada
2
Krembil Research Institute, University Health Network, University of Toronto, Toronto, Canada
3
Rotman Research Institute, Baycrest Centre, University of Toronto, Toronto, Canada

Abstract
This paper addresses the importance of steady-state brain oscillation for brain connectivity and cognition. Given that a healthy
brain maintains particular levels of oscillatory activity, we argue that disturbances or dysrhythmias of this oscillatory activity
coincide with common health conditions including Alzheimer’s disease (AD), Parkinson’s disease (PD), pain, and depression.
This review shows that electric brain stimulation contributes to regulation of neural oscillatory activity and the alleviation of
related health conditions. It is then argued that specific sound frequencies in their vibratory nature can serve as a means to brain
stimulation through auditory and vibrotactile means and as such can entrain and regulate oscillatory activity. The frequencies
employed and found effective in electric stimulation are reviewed with the intent of guiding the selection of sound frequencies for
vibroacoustic stimulation in the treatment of AD, PD, pain, and depression.

Keywords: neural oscillation, vibroacoustic therapy, brain stimulation, music
medicine, thalamocortical dysrhythmia
Rhythmic Oscillatory Coherence and Connectivity
The origin and function of neural rhythmic oscillatory activity
in the brain remains a central research question in
neuroscience. Although several explanations have been
proposed [1], recent work has raised important issues related
to clinical application of oscillatory brain activity in
neurodegenerative diseases and neurorehabilitation [2]. Can
oscillatory brain activity be used as diagnostic biomarker for
conditions like Parkinson’s disease (PD), Alzheimer’s disease
(AD), and depression? And can oscillatory brain activity be
modulated in support of therapeutic interventions?
The healthy human brain has intrinsic and constant
rhythmic oscillation. Popular psychology explained the
oscillatory rhythms of “brain waves” as neural indices of
specific mental states, e.g., delta with sleep (0.1–4Hz), theta
with deep relaxation and creative insight (4–8Hz), alpha with
relaxation (8–12Hz), and beta with problem solving (12–
20Hz). Although generally true, scientific interest is moving
toward understanding the role that oscillatory rhythms may
PRODUCTION NOTES: Address correspondence to:
Lee R. Bartel, E-mail: lbartel2@gmail.com | COI statement: The
authors declared that no financial support was given for the
writing of this article. The authors have no conflict of interest to
declare.
multilingual abstract | mmd.iammonline.com
play in coordinating neural activity supporting perceptual,
cognitive, and motor functions [3]. Oscillatory activity may
index local neural networks from modality-specific brain
areas as well as long-range neural systems that engage sensory
and supra-modal brain regions (e.g., prefrontal and parietal
cortices) [4]. Ward [5] proposed that consciousness is related
to synchronous neural rhythms in general, but that memory
processes are related to gamma (30–50Hz) and theta
oscillatory rhythms, whereas attention is dependent on alpha
and gamma activity. His review of the literature points toward
an increased connectivity between frontal and parietal cortex
during memory recall from larger spectral power in gamma
and theta frequency bands, with the magnitude of gamma
activity modulated by the theta rhythm. This intra-brain
communication through neuronal oscillatory coherence is
thought to index healthy functioning of specific circuits – like
memory, or movement. Although it is well accepted that brain
activity related to perceptual, cognitive, and motor functions
depends on widely distributed neural networks, the functional
connectivity between the nodes of the networks is less well
understood. Fries [6] proposed that the mechanism of
neuronal communication depends on similar neuronal
oscillatory activity and that communication within a local
network (e.g., sensory cortex) happens mainly with coherent
oscillation in the gamma frequency range (30–100 Hz). For
communication between distant brain areas, the amount of
local gamma oscillations is controlled by slower rhythm in the
theta frequency range (4–8 Hz) [7].

Copyright © 2017 All rights reserved.

International Association for Music & Medicine (IAMM).

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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 153 – 166
Dysregulation of Connectivity within Brain Circuits
Using a musical metaphor, we premise that the healthy brain
function depends on a “harmonious symphony” of neuronal
groups oscillating at particular frequencies, which leads to the
supposition, that when one group plays out of tune, too fast or
too slow, or too high or too low, the “symphony” quickly
turns to “cacophony.” Evidence from using Deep Brain
Stimulation (DBS – see Electro-stimulation section that
follows) as a probe or as a treatment suggests that “circuit”
dysfunction is common to many neurological and psychiatric
conditions [8,9]. Essentially, the circuit dysregulations
underlying these conditions are either (1) a lack of coherence
due to inadequate excitation or disturbances to that
coherence, or (2) overly strong coherence in inappropriate
neural populations.
Llinas was among the first to identify that recurrent
connections between the cortex and the thalamus serve as a
mechanism for interconnecting cortical areas and controlling
the flow of information [9,10,11,12,13]. Using a technical
metaphor, thalamocortical loops provide a mechanism for
communication within the brain like a major hub does for the
internet. According to Llinas, the interconnectivity of
thalamocortical loops depends strongly on their rhythmic
oscillatory activity. Optimally functioning thalamocortical
loops show rhythmic activity in the alpha (~10 Hz) and
gamma (~40 Hz) bands. Thalamocortical dysrhythmia (TCD)
is characterized by slowing of alpha oscillatory activity toward
the theta band at 4–8 Hz and a reduction in gamma band
activity. TCD has been revealed in neurological and
psychiatric conditions related to motor, mood, auditory, and
cognitive functions, and has been linked to conditions
including PD, depression, neurogenic pain, schizophrenia,
and tinnitus [10].
With the development of DBS, Lozano and others
identified neural circuits that are dysfunctional and include
the wide range of motor, limbic, auditory, executive function,
cognitive, reward, memory, sensory, mood, and interoceptive
awareness [8]. TCD is thought to be one of the putative
mechanisms underlying several of these dysfunctions.
However, other circuits/systems likely play a role in these
dysfunctions including, but not limited to, globus pallidus
internus over-activity, beta and theta oscillation disturbance,
subthalmic nucleus over-activity, orbitofrontal cortex
hyperactivity, and default mode network dysfunction [8]. The
etiologies of “circuit disturbances vary widely and include
damage to neural pathways, loss of neural elements and
populations, as well as disturbances in the functional activity
of neural circuits, through disordered firing and pathological
oscillatory activity in neuron ensembles” [8, p. 406].
According to Lozano and Lipsman [8], circuit dysregulation
and its treatment is best illustrated with the “prototypical
conditions” affecting motor, mood, and cognitive circuits: PD,
major depressive disorder, and AD. The approach to
Bartel, Chen, Alain & Ross | Vibroacoustic Stimulation and Brain Oscillation
treatment entails regulation of neural oscillations to their
normal level by either entraining coherent neuronal activity in
under-activated circuits or attenuating activity in over-
activated circuits.
Electric Stimulation of the Brain
If we accept that the healthy brain requires an array of
optimally functioning neuronal circuits that exist through
coherent rhythmic brain oscillation and that disease
conditions arise related to a dysfunction of these neural
circuits, then brain stimulation that regulates these
dysfunctional circuits could become a crucial part of
neurorehabilitation strategies. Electrostimulation is currently
the dominant approach being pursued within medical
research and clinical treatment [14].
Principles of Electric Stimulation
Electroconvulsive therapy (ECT) involves passing an electrical
current through the brain, is applied under anesthesia, and
often triggers a seizure. Magnetic Seizure Therapy (MST) is an
experimental treatment that can also induce seizures through
stimulation with magnetic fields. Two other types of electrical
stimulation include Vagus Nerve Stimulation used for
treatment of seizures and depression, and Transcutaneous
Electrical Nerve Stimulation (TENS) used to control nerve
pain. Recently developed brain stimulation methods are more
focal by limiting the stimulation to a specific target area. For
instance, Transcranial Magnetic Stimulation (TMS) and
repetitive TMS (rTMS) use an electromagnetic coil to
stimulate specific areas of the brain such as the motor cortex.
Transcranial Direct-Current Stimulation (tDCS) [15] uses
electrodes placed on specific scalp locations to stimulate the
brain with a constant low amplitude direct current. tDCS
modulates the neuron’s membrane potential. It is divided into
positive “anodal” stimulation that increases neural excitability
and negative “cathodal” stimulation, which decreases
excitability. Deep Brain Stimulation (DBS) requires surgery
and the insertion of electrodes, but offers precise targeting of a
brain area, which is a limitation of the non-invasive methods
[16]. These electrodes deliver electric pulses from a surgically
implanted device. Because of this precise targeting DBS is able
to address specific dysregulated neurological circuits to either
inhibit excessive destructive neural coherence or to excite
greater positive coherence [8], although the specific
mechanisms of DBS are not known [17]. See Table 1 for
references for the positive effects of electric stimulation.
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 153 – 166 Bartel, Chen, Alain & Ross | Vibroacoustic Stimulation and Brain Oscillation

ECT TMS/rTMS tDCS DBS stimulation, either using more global features of music, for
Parkinson’s Popeo Zanjani et Benninger Lozano & example for inducing mood changes, or employing specific
& al. 2015 et al. 2010 Lipsman rhythms of music at various scales. Both NMT and MSR cross
Kellner [19] [21] 2013 [8],
2009 Gonzalez- Mehanna
over into sound-based stimulation when employing musical
[18] Garcıa et al & Lai 2013 rhythm for interaction between sound and movement. A
2011[20] [22] direct sound stimulation approach is Rhythmic Auditory
Alzheimer’s Burgut Cotelli et al. Hansen Lozano & Stimulation (RAS) [39,40,41], which is used to facilitate
& 2011 [24] 2012 [25] Lipsman movement in Parkinson’s or as rehabilitation with stroke. In
Popeo 2013 [8],
2010 Kaplan
this case, the sounds consist merely of rhythmic clicks or
[23] 2012 [26] claps.
Depression Kellner Weiduschat Ferrucci et Lozano & Auditory stimulation, that is not musical, includes
et al. & Dubin al. 2009 Lipsman Peripheral Ultrasonic Neurostimulation (PUNS), using pulsed
2012 2013 [28] [29] 2013 [8] low frequency ultrasound [42,43,44], and its related
[27]
Pain Mowla Short et al. Lefaucheur Lozano &
application of Transcranial focused ultrasound (tFUS) [45]. The
et al. 2011 [31] et al. 2008 Lipsman latter employs beams of ultrasound most often pulsed at 70–100 Hz
2007 [32] 2013 [8], to target specific areas in the brain with “mechanical” stimulation of
[30] Kaplan the brain tissue. One application is to stimulate brain activity while
2012 [26] another is to change brain function by causing a focal lesion. tFUS
Table 1. Positive Effects of Electric Stimulation has the ability to target specific areas deep in the brain, similar to
DBS. Our interest here is in the stimulation aspect, for which
Underlying Mechanism beneficial effects have been shown with psychiatric disorders
Electric brain stimulation does not interact directly with including depression, chronic pain, and PD.
neural activity in the sense of eliciting neural firing. Instead, A reset is a brief interaction with the dynamics of ongoing
brain stimulation modulates excitability in neural networks oscillation, which effectively reduces the magnitude of the
through a variety of interactions, including (1) blocking oscillation. Acoustic Coordinated Reset (ACR) is a
depolarization, (2) inhibiting synaptic responses, (3) neuromodulation of dysregulated brain circuits, which is
depressing synaptic activity, (4) stimulus-induced modulation based on the concept of Coordinated Reset (CR) in DBS, to
of pathological network activity [33], (5) modulation of reset the firing phase of those neurons that are assumed to
plasticity, and (6) activation of remote but connected areas create the dysregulation [46]. As an intervention for tinnitus,
[1,33]. For rTMS at rates between 10 and 20 Hz, an increase of Tass developed ACR for emulating the effect of CR on the
gamma oscillations in the 30 to 50 Hz range has been found, auditory cortex, and possibly the thalamocortical circuit, using
which is interpreted as indexing perceptual and cognitive audible sounds at the frequency of sound perceived in tinnitus
function. Chen and his associates found significant gamma [47]. The approach was based on the assumption that tinnitus
effects from rTMS and speculated that such stimulation is is a dysregulation of brain circuitry, possibly a thalamocortical
useful as a cognitive enhancing strategy [34]. The stimulant dysrhythmia [9,10] also implicated in PD, depression, and
effect in the 30–50Hz gamma range offers most potential for pain. In tinnitus, ACR was used to “reset” a circuit assumed to
sound stimulation because low frequency sound reaches to be too rhythmically synchronized in its firing. Further
that level but is ineffective for the 10–20Hz range. research is required for testing the possibly easier task of using
pulsed audible sound or reinforcement of rhythmic coherence
Music/Sound Stimulation of the Brain at a particular frequency.
Thaut [35] proposed at least 4 mechanisms at work with
Music, as a multi-faceted cultural product, can be seen as a sound and music: (1) affective-aesthetic response focused on
brain stimulant as it engages several cognitive functions, arousal, motivation, and emotion; (2) patterned information
including associative memory. The importance of music in processing – essentially “thinking music” – music engaging
memory functions has been highlighted by social worker Dan the brain as a language on its own; (3) differential neural
Cohen’s “Music & Memory” organization and their “iPod processing, e.g., language with music and language alone use
Project” (musicandmemory.org) which provides access to different brain pathways; and (4) rhythmic stimulation and
recorded music for the elderly. Treatment approaches that are entrainment. Thaut applied the latter to the rhythm of walking
accompanied by scientific validation include Thaut’s [35]. We argue that rhythmic sound stimulation and
Neurologic Music Therapy (NMT) [35] and Altenmüller’s entrainment can be extended to an even wider frequency
Music Supported Rehabilitation (MSR) [36,37, 38] that use range with steady-state brain stimulation at the rate of
specific music-making tasks to engage a muscular and neural targeted brain activity, ranging from sleep states at delta to the
response. The distinction between music and sound is highly whole sweep of gamma frequencies. We are proposing,
relevant for differentiating the approaches of music therefore, that music/sound is a potential analog to electro-

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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 153 – 166
stimulation of the brain in the way that sound stimulates
neural activity and contributes to rhythmic neuronal
coherence at particular frequencies.
Olav Skille in Norway and Petri Lehikoinen in Finland
performed pioneering work in sound stimulation. Lehikoinen
[48] developed Physio Acoustic Therapy (PAT) using low
frequency sound to stimulate the body by means of
loudspeakers mounted inside a chair. The underlying concept
is that sound in the range of 27–113 Hz resonates with muscle
fibers, and massages the lymphatic system [49]. The stimulus
frequency in PAT is continuously varied through the spectral
range, along with slow pulsation in amplitude, to avoid
adaptation of the mechanoreceptors. PAT and Lehikoinen’s
chair device was FDA approved in 1996 for three claims:
increased circulation, decreased pain, and increased mobility.
Although Lehikoinen never connected the whole-body
somatosensory stimulation of PAT to an effect on neural
coherence, it may well contribute to such an effect, despite the
continuously changing stimulus frequency. Recent research
demonstrated a driving effect in the auditory modality using
binaurally detuned pitch pulsation with continuous variation
over a frequency range similar to PAT [50].
Olav Skille [51] developed Vibroacoustic Therapy (VAT)
using an approach similar to PAT but stimulating with static
low frequency (e.g., at 40, 52, 68 or 86 Hz) instead of
continuously varying the stimulus frequency [52,53].
Although a possible interaction with brain activity had been
considered [54,55], research and clinical efforts primarily
assumed an effect on muscle and tissue. The devices designed
for VAT and PAT can be used potentially to deliver stimuli at
gamma rhythms to the brain through the somatosensory
system. A recent pilot study by Clements-Cortes et al. [56]
used a VAT device to deliver 40 Hz brain stimulation to
Alzheimer’s patients through vibrotactile and auditory means.
Since both PAT and VAT as low frequency sound
stimulation (LFSS) generated by special subwoofer-type
loudspeakers or vibrotactile transducers [57] is experienced
through mechanoreceptors as somatosensory vibration rather
than – or in addition to – through hearing as audible sound,
research on the effects of tactile stimulation applies. Research
of Rhythmic Sensory Stimulation (RSS) in somatosensory,
auditory, and potentially visual modality, currently being
pursued by the authors, builds on recent research showing
that vibrotactile stimulation has a strong neural driving effect
[58,59,60]. In this previous research we induced effects
observed in magnetoencephalography (MEG) from localized
mechanical stimulation, using a pneumatic stimulator,
because current sound-driven stimulation on the whole body
involves the use of magnetic transducers, which are
incompatible with MEG sensors. From previous studies it is
known that stimulation of a finger, the hand, or the median
nerve results in an oscillatory response in primary and
secondary sensorimotor cortices [57,61,62] and depends only
little on attention [63].
Bartel, Chen, Alain & Ross | Vibroacoustic Stimulation and Brain Oscillation
Compared to the research using vibrotactile stimulation,
considerably more research has used auditory stimulation for
eliciting steady-state or spontaneous oscillatory responses.
Steady-state response to rhythmic auditory stimuli can be
elicited using clicks, amplitude-modulated isochronous
sounds [64], or pure tones; for example, a 40 Hz amplitude
modulated tone [65,66], or even the rhythms of binaural beats,
that are created through binaurally detuned tones [50].
Common to those methods is that vibrotactile stimulation
with sound, as well as auditory stimulation, can be used to
drive a neural response.
Parkinson’s Disease - Music/Sound Stimulation
Considerable research investigated the concept of rhythmic
pulses to stimulate a brain response and to initiate movement
in PD. Results showed significant improvement in gait
performance with rhythmic auditory stimulation (RAS)
[39,40,41,67,68]. This applied even when medication had been
withdrawn [69,70]. Rhythmic auditory stimulation produced
greater improvement in cadence and stride length compared
to visual cueing [71]. Improvements through rhythmic cuing
have also been observed for arm movements [72,73].
The effect of whole body vibration on PD symptoms has
been considered since Charcot’s 19th century discovery that
PD symptoms subsided during a carriage ride [74]. In two
recent reviews, Pinto et al. [75] and Lau et al. [76] reported
that vibration at 6–25 Hz or vibrotactile sound at 30 Hz
consistently provided the most positive results.
Three studies have used RSS to address PD symptoms
beyond gait: San Vicente et al. [77] studied 60 PD patients; 30
received 25 sessions each 25 minutes long over six months of
“relaxing” music plus 40 Hz sine waves applied
simultaneously through a bed with integrated vibrotactile
stimulation; 30 patients received only the music. Both groups
showed significant improvements on the Unified Parkinson’s
Disease Rating Scale (UPDRS), while the 40 Hz group showed
a larger gain in the “activities of daily living” scale. The
researcher acknowledged that the music-only treatment also
resulted in a vibration effect since it was played through the
bed speakers. King et al. [78] studied 40 PD patients (20
slow/rigid, 20 tremor dominant) not withdrawn from their
medication. All participants received RSS stimulation at 30 Hz
in five series lasting one minute each separated by one-minute
rest periods. UPDRS scores improved significantly in all major
symptom categories. Kapur et al. [74] studied 20 patients
treated with recordings of nature sounds and the inherent low
frequency sounds ranging from 30–500 Hz. One group of ten
participants listened to the recording through headphones
only, and ten listened to the same headphone sounds but also
received the low frequency sound through a set of transducers
in the reclining lounge. Participants received 30 minute
treatments each day for four weeks in their home with self-
reported compliance (93.5%). Results showed significant
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 153 – 166
improvement in both groups on the UPDRS Part 1 and Part 3.
While the stimulation targeted the somatosensory system,
partial transmission of the 30–500 Hz content through the
earphones cannot be excluded.
Finding the Optimum RSS Frequency for Parkinson’s Disease.
The oscillation model of PD places great attention on the
subthalmic nucleus (STN) and related motor circuit. Normal
motor functions are associated with rhythmic STN activity in
the 31–100 Hz range with activity between 60–80 Hz being
associated with improved motor performance [79]. The
typical DBS stimulation frequency that improves symptoms in
PD is 130–185 Hz, and the frequency that decreases motor
function is below 30 Hz [79,80]. Some research showed DBS
in the 30–90 Hz range as effective at improving motor
performance as in the 130–185 Hz range [79]. Given that
stimulation at one frequency also produces a resonant
stimulant response at mathematical multiples (e.g.,
stimulation at 20 Hz increases response at 40, 60, and 80 Hz
[58]), a good frequency to emulate DBS stimulation would be
about 70–80 Hz, with its first partial resonance being 140–160
Hz [81]. This is also a frequency used by pulsed low frequency
ultrasound [82]. The 160 Hz resonance would be close to 167
Hz, identified as having a crucial role in restoring thalamic
relay function [80].
An STN rhythm detected in conjunction with dopamine
and apomorphine (peak at about 319 Hz plus or minus 33 Hz)
is believed to support the basal ganglia circuit’s information
transmission [83,84]. Other research points to 235 Hz [85].
Activity in the 300 Hz range seems also to be correlated with
activity in 60–90 Hz. A reduction of oscillatory activity near
300 Hz may be a potential biomarker for PD [83,84]. The
concern that this effect may be related to advanced state of PD
and medication is countered by research showing that 300 Hz
is also observed in other conditions [86].
If 300 Hz is an essential oscillatory frequency, and DBS at
130 Hz proves effective with PD, the question is whether the
DBS stimulus is only inhibitory, disrupting activity in the
<30Hz area, or is also excitatory, driving activity in the 300 Hz
range through resonance. This is debated with positive
argument for a direct driving effect [83,84,87] and counter
evidence of no overtone effect [88]. One issue is that the
currently approved DBS devices cannot stimulate above 185
Hz but sound-based RSS can do so easily, and so may have a
potent role in treatment. Another good frequency for brain
stimulation with PD then may be 300 Hz.
Three other types of stimulation are worth including.
Electrical Stimulation of the motor cortex [89] is another form
of brain stimulation, however less effective than DBS. The
stimulus frequencies ranged between 10–30 Hz in one study
and 130 Hz in another and were typically varied across a range
instead of using a single constant frequency. Although the
whole body vibration research does not seem to monitor brain
response and so is not developed based on the oscillatory
Bartel, Chen, Alain & Ross | Vibroacoustic Stimulation and Brain Oscillation
model of PD, body vibration has considerable history as
treatment. There is a known effect from muscular movement
on gamma activity and so potentially might act as a stimulant.
Two reviews of whole body vibration research recently show 6
Hz as the most common stimulus with only one using 25 Hz
[75,76]. Studies with rTMS on patients with PD [20,60] use a
range of frequencies below 25 Hz because of technical
limitations and safety considerations, but the mechanism is
not generally considered one of excitation and neural driving.
Low frequency sound stimulation through vibrotactile
devices is limited to above 27 Hz because transducers are less
efficient at lower rate. Two previous RSS studies with PD used
30 Hz [78] and 40 Hz [77]. Assuming neural resonance
response up to four multiples, the stimulus frequency [58] for
optimal sound stimulation of PD could be 40 Hz, eliciting
responses at 40, 80, 120, and 160 Hz, or 80 Hz with responses
at 80, 160, 240, and 320 Hz. Because a reduction of STN
activity in the 300 Hz range has been observed, and because
320 Hz specifically may be a potential biomarker for PD
[83,84], sound stimulation at 320 Hz could be a possible
target.
Music and Sound Stimulation in Alzheimer’s Disease
The effects of music on AD patients have been observed for
years and inspired a broad range of research. Thaut’s
postulated mechanisms for the effect of music [35] are in
essence all forms of brain stimulation: (1) arousal, motivation,
and emotion (2) information processing, and (3) differential
neural processing. Although in one systematic review of music
therapy studies authors determined there was inadequate
scientific quality [91], other studies have shown the
effectiveness of music therapy in AD [92,93,94] but possible
brain mechanisms or even neurophysiological changes have
rarely been shown. Neuroimaging studies found that older
adults with AD were able to learn new and unfamiliar music
and that music memory training and familiar melodies
enhanced long-term memory for unconnected texts [95,96].
There appears to be a shift in the functional neuroanatomical
network activated for memory with dementia, i.e., greater use
of prefrontal-amygdala connections instead of prefrontal-
hippocampal networks [97,98]. That may make music-based
encoding more resilient in people with AD [35].
However, little research has attempted to use vibratory
sound frequency as a means to stimulate the oscillatory
rhythm of the brain or neural cells. Koike et al. [99] postulated
that music may have a role in AD as a catalyst to neural
regeneration, although they admitted that the mechanisms are
not well understood and proposed that stimulating neural
outgrowth with sound may point to a mechanism. The study
used PC12m3 cells cultured in single-cell suspension and
stimulated with nerve growth factor. These cells were then
subjected to direct contact vibration with speakers or at a
distance of 12 cm from the speaker. Cells were treated to a
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 153 – 166
range of frequencies from 10 Hz to 200 Hz for seven days.
Results showed that all frequencies produced greater
outgrowth than the non-vibration control but the greatest
outgrowth occurred when treated with direct vibratory sound
at 40 Hz.
Clements-Cortes et al. [56] premised their study on
evidence that cognitive deficits in AD are related to reduced
gamma power around 40 Hz and that vibrotactile and
auditory stimulation can drive oscillatory power and
potentially improve cognitive function [12]. The treatment
was 40 Hz vibrotactile and auditory stimulation two times a
week for three weeks. Results showed that there was an
average effect size of .58 for each session and qualitative
results that showed some improvements in cognitive clarity
and memory.
RSS Frequency for Alzheimer’s Disease
A scientific foundation for oscillatory mechanisms in AD is
not as well developed as that for PD. Also, less research with
brain stimulation including electro-stimulation has been done
and work with DBS is just beginning. Potential stimulation
frequencies will be inferred from possible dysrhythmias.
Findings of thalamocortical dysrhythmia in AD included
increased power at delta and theta frequencies [100] and a
power decrease at alpha, beta, and gamma frequencies
[100,101,102,103]. Research points to a relationship between
gamma oscillatory activity and cognitive functions [104].
Specifically, research in AD showed decreased spectral power
around 40 Hz [12,105], although brain activity in this
frequency range seems to decrease generally with cognitive
decline and aging [106,107]. Other research reported an
increase in 30–100 Hz gamma band power in AD [101,108]
without specifically studying 40 Hz activity, yet considering
only evoked instead of studying spontaneous activity. The
research supported the potential role of theta and gamma
rhythms for biomarkers of early stages of AD [109].
Brain stimulation for AD is at an early exploratory stage.
High frequency of 130 Hz has been used in DBS [8] and 20 Hz
in an rTMS study [24]. Gamma-band oscillation can be
modulated with low frequency sound or vibrotactile sensory
stimulation [104]. 40 Hz, which is decreased in AD, appears to
be a critical frequency for brain stimulation in AD since 40 Hz
seems generally implicated in brain communication [5,6]. It
appears to stimulate neural outgrowth [99], and the potential
to drive gamma response with auditory or somatosensory
stimulation has been demonstrated [58,60,64].
Pain - Music/Sound Stimulation
Advances in medical technology, including imaging and non-
invasive recording of brain activity, have opened new
windows on the structural and physiological dimensions of
pain, i.e., a network of brain regions linked to pain in a “pain
matrix” [110,111]. Pain pathways are not simple “one-way
Bartel, Chen, Alain & Ross | Vibroacoustic Stimulation and Brain Oscillation
streets” carrying traffic to consciousness; pain is subject to
modulation by the central nervous system. Emotional state,
anxiety, distraction, past experiences and memories, are
among the factors influencing the experience of pain [112].
A meta-analysis of 48 studies involving music and pain
found that in studies where patients were allowed to select
preferred music, the effect size was slightly higher (r=.20) than
in studies where they were not (r=.18) [94]. Particularly
noteworthy, the effect in patients with cancer/terminal
illness/AIDS was considerably higher (r=.45) than in those
post-surgery (r=.15). This points to different effects based on
the nature of the pain.
Although there have been numerous studies of music and
pain [94], few have been adequately theorized to explain why
music reduces pain. Gate Control Theory (GCT) [113]
postulated that pain receptors send information along a
pathway of interconnected nerves to the brain and that at the
point where the nerve enters the spinal cord a “gateway”
exists that can be open to let the signal through or closed. The
gate can be closed by sensory stimulation, like massaging the
area of the pain, or possibly by vibration along the spine. GCT
also maintained that affective and cognitive responses, such as
music-responsive attention and psychological states,
influenced the gate through efferent descending fibers.
Although research has shown that GCT oversimplified neural
systems [114] and the efferent system is not effective, GCT
does help explain why stimulation of touch fibers can reduce
pain perception as is demonstrated with certain applications
of low frequency sound stimulation (LFSS) that induces
mechanical vibrotactile stimulation of mechanoreceptors and
spinal cord functioning not unlike electrical skin and spinal
cord stimulation [115]. Melzack [116] proposed a more
adequate pain theory that would explain the effects of music as
a unified brain mechanism-based body-self neuromatrix
(NM). Sensory, cognitive, and affective dimensions are fully
credited with affecting pain perception and these dimensions
are subject to cognitive-evaluative (attention, expectation,
anxiety, valence) and motivational-affective
(neurotransmitter, hormonal, limbic) inputs. Although exact
mechanisms are not yet understood, NM provides a
framework to understand why functions of music such as
distraction, stress, and anxiety reduction, and aesthetic
pleasure reduce pain perception. Neither GCT nor NM
explains pain associated with rhythmic oscillatory coherence
[117,118]. The correlation of thalamocortical oscillatory
dysrhythmia (TCD) with pain has been demonstrated
[10,119] but no definitive theory has been established.
Effects of Music on Pain
Given the role that neurotransmitters, hormones, and the
limbic system play in pain according to the Neuromatrix
theory, it is highly relevant that music has been shown to
affect the release of endorphins [120,121,122,123,124,
125,126,127,128], dopamine [129,130], serotonin [131, 132],
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 153 – 166
and decrease in cortisol [130,133,134,135,136,137,138]. A
recent review of 400 published scientific papers found strong
evidence that music has effects on brain chemistry and has
mental and physical health benefits on management of mood
and stress reduction, and that it is the rhythmic stimulation of
music, rather than the melody, that has the greatest anti-pain
effect in the brain [136]. Specific brain correlates can now also
be identified with strong emotional response to music [139].
Brain imaging shows that “music can modulate activity in
brain structures that are known to be crucially involved in
emotion, such as the amygdala, nucleus accumbens,
hypothalamus, hippocampus, insula, cingulate cortex and
orbitofrontal cortex. The potential of music to modulate
activity in these structures has important implications for the
use of music in the treatment of psychiatric and neurological
disorders” [139, p.170].
Effects of Sound Stimulation on Pain
LFSS stimulates the mechanoreceptors in the body and
cellular structures, thereby serving to potentially block pain
transmission according to the GCT. In addition to the general
effects of LFSS, which include improved mobility [140],
increased circulation [141], decreased low-density lipoprotein
and blood pressure [142], and reduced muscle strain and
stiffness [141], LFSS helps decrease pain [141,142]. Studies
with LFSS have examined specific pain conditions:
rheumatoid arthritis [143] and polyarthritis in hands and
chest with 40 Hz [144,145], low-back pain, menstrual pain,
and dysmenorrhea with 52 Hz [144,145], knee replacement
pain [146], post-operative gynecological pain [147], and
sports injuries [144,145,148]. Despite this research on specific
pain, the assumption has primarily been that the effect is
mechanical cell stimulation and not neurological rhythmic
driving of oscillatory coherence to affect pain circuits.
Music and Fibromyalgia
Few studies have focused specifically on music or LFSS on
fibromyalgia (FM). Chesky et al. [149] found that musically
fluctuating vibration (60–300 Hz) failed to alter pain
perception in patients with fibromyalgia. Onieva-Zafra et al.
[150] examined the effect of 4 weeks daily music listening to
unspecified “classical” music mixed with salsa music. The
music listening group showed significant reduction in pain as
measured by the McGill Pain scale. The control group
received no treatment and showed no significant change.
Müller-Busch and Hoffmann [151] studied chronic pain
patients including fibromyalgia with a treatment of active MT
using unspecified performed music. The results showed
significant reduction in reported pain intensity but no change
in depression and anxiety scores. Leão and da Silva [152]
showed that women with chronic pain had less pain (p<.001)
after listening to classical music. The few studies of sound and
fibromyalgia that exist primarily draw on cognitive and
affective effects of music. LFSS and fibromyalgia research has
Bartel, Chen, Alain & Ross | Vibroacoustic Stimulation and Brain Oscillation
not been previously theorized and conducted as in the present
study.
Deriving an RSS Frequency for Pain
There is relatively little research that looks at pain as an
oscillatory dysregulation except for TCD research and for
electro-stimulation research that, to some extent, is premised
on dysregulated sensory system circuits [8]. TCD is implicated
in chronic and neuropathic pain with the typical shift of
oscillatory power toward lower frequencies [153,154] and the
edge effect as increased beta activity instead of the more usual
gamma activity. In the case of neuropathic pain the thalamus
appears to be more seriously affected to the point of atrophy
[155]. DBS addresses this with stimulation at the typical 130
Hz frequency. The change in alpha power identified in TCD
research is consistent with observations of alpha power related
to placebo analgesia [156]. The hypothesis is that changes in
alpha activity may be related to expectation of pain relief, with
the change in alpha resulting from either the generation of
expectation, maintenance of expectation, or expression of it.
Since this is assumed to be a top-down process, manipulation
of alpha activity with stimulation might then be a way to
control pain [156]. Since alpha stimulation is possible with
music and sound, this would be a possible direction for
treatment. Although not placed in conjunction with TCD or
alpha power, research on “mind wandering away” [157] may
involve the same mechanism by changing coherence and
alpha power.
Considerable research has been conducted on the
application of rTMS in relation to pain. One assumption about
rTMS is that stimulation above 5 Hz is excitatory and
stimulation below 1 Hz is inhibitory. In relation to chronic
pain, studies have found 10 Hz and 20 Hz to relieve pain but
not 0.5, 1, or 5 Hz [87]. This is in agreement with a meta-
analysis of rTMS pain studies showing that, with repeated
sessions, treatment around 10 Hz was more effective than
using low frequency stimulation (<1 Hz) or higher frequency
stimulation >10 Hz [158]. An evidence-based guideline
considered that high frequency rTMS applied to the motor
cortex is effective in the treatment of pain [159]. Specifically
with fibromyalgia, 10 Hz was found to be effective [160]. Both
rTMS and TCD research point to theta and low beta over-
activations that can be ameliorated with stimulation of high
alpha (10 Hz) [161]. Moreover, motor cortex stimulation
(MCS) shows some effect at reducing chronic pain (phantom
pain) with stimulation in the 15–25 Hz range [162].
Sound stimulation for pain was applied in several
noteworthy studies. Chesky and colleagues [149] used a range
of frequencies with fibromyalgia in a moving manner rather
than at fixed frequency and found little effect. Barnes et al.
[163] reported decreased pain in a single case with
fibromyalgia using 25 Hz stimulation with whole body sound
vibration. Naghdi et al. [164] found significant pain reduction
(Fibromyalgia Impact Questionnaire p<.0001) using 40 Hz
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 153 – 166
stimulation and pointing to TCD as the probable mechanism
underlying the effect. Given the findings of oscillatory states
with pain, effects from electro-stimulation, and assuming
downward oscillatory resonance [165], sound stimulation at
10, 20, or 40 Hz should target the frequencies with greatest
treatment potential.
Depression - Music/Sound Stimulation
Music has for many years been regarded as a means to both
engage emotions and to “cheer up.” A classic story in the Old
Testament has King Saul bothered by “an evil spirit” and
requests David to play his harp and when David plays, the
“evil spirit” leaves him. Recently neuroscience is revealing the
hormonal basis for some of these positive affective
correlations with music [121,128,129,130,136,139], as well as
detailing specific brain components involved in processing
emotion with music [139]. Greater detail was already
described in the section on “Pain.”
Music Therapy and Listening
Scientific studies examining the clinical effect of music on
depression are rare. A 2008 Cochrane Review [166] only
found five studies that met inclusion criteria requiring
therapist-mediated “music therapy” and were too varied to
allow a meta-analysis. Findings in four of those studies
showed a greater reduction in depression symptoms in
participants treated with music therapy than those receiving
standard care. What “music” was used in the therapy was not
detailed. Since 2008, a number of studies in both music
therapy and music medicine have been done with important
findings [131,132,167,168,169]. Of these, Brandes et al.
[131,169] used specifically prepared music that may have
featured an entrainment device for brain stimulation, but
details of the proprietary music have not been published.
Sound Stimulation of the Brain
A few music studies have addressed the extensive EEG
asymmetry research [170]. This research observed alpha level
coherent rhythmic oscillatory brain activity and compared left
frontal with right frontal activity or activation. There is
considerable evidence that this asymmetry is related to mood
disorders and may even have a role as a biomarker for
depression [171]. Field et al. [172] used frontal EEG
asymmetry as an observable outcome in a study with 28
depressed adolescent females. One group listened for 23
minutes to pop/rock music selected for the study by similar
aged girls and the other group was asked to sit and relax their
mind and muscles. Three minute EEG readings were done
before, during, and after the sessions. No changes were
observed in behavior or mood as a result of the treatment, but
the music group showed decreased frontal asymmetry (p=.05)
and decreased cortisol levels (p=.02). A rating of preference
for the music was done and the basic finding supported
Bartel, Chen, Alain & Ross | Vibroacoustic Stimulation and Brain Oscillation
greater shift to symmetry with preferred music. Jones and
Field [173] looked at the effect of massage therapy and 23
minutes of rock/pop music listening on frontal EEG
asymmetry. Except for the addition of massage, this study was
a basic replication of Field et al. [172]. Results showed a
similar effect of reduced asymmetry. Im [174] studied frontal
EEG asymmetry in postpartum depressed mothers (n=9)
compared to non-depressed mothers who recently gave birth
(n=9) and 10 non-depressed women who had not given birth.
EEG was recorded for 5 minutes before and after the
treatment. The length and content of the music session were
not reported. All three groups showed a shift to greater
symmetry after the music session but only for the postpartum
depressed group was the shift significant (p=.021).
Petchkovsky et al. [175] used QEEG data to examine the
effects of depressed adults participating in a choir (1week 8
weeks) as well as practicing with a prepared practice CD that
included physical and singing exercises, meditation dialogue,
and accompaniments. QEEG results are based on a random
sample (9 from a group of 21), who were tested before and
after the intervention. Pre- and post-intervention data from
the BDI and a mental state examination showed significant
improvement (p<.001). The resting QEEG data revealed
greater left-right hemispheric activity symmetry, reduced
hyperactivity in the right prefrontal area, and reduced
hypercoherence.
The only study that recognizes the potential of low
frequency stimulation on brain response is Koike et al. [176].
In this study 15 elderly adults, who had symptoms of
depression assessed with the Dementia Mood Assessment
Scale (DMAS), were given 30 minutes (five days/week, two
weeks) of unspecified “classical” music while resting on a
lounge chair with two speakers close to the head and
frequency crossover at 150 Hz sending the low frequency
component of the sound to transducers in the body area. A
cognitive assessment was done with the Mini-Mental State
Exam. The before and after results showed significant
improvement (p<.05) in the DMAS with significance in the
mood and depression scales but not in the overall dementia
severity scales. No brain imaging was done.
Deriving an RSS Frequency for Depression
Research about oscillatory mechanisms underlying depression
found extensive frontal hemispheric asymmetry in EEG [177].
Typically this involves a comparison of frontal alpha power in
left side versus right side. Although the phenomenon had been
described extensively, underlying mechanisms are not clear
[171], and research on whether frontal asymmetry is a
mediator or moderator of emotions is not clear [170]. If there
were a “causal” role for alpha asymmetry to depression, then
regulation of the asymmetry would be a treatment, and that
might be done by stimulating at 10 Hz. Drug treatments for
depression do seem to restore greater symmetry [177], but
without knowledge of specific mechanisms it cannot be a firm
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 153 – 166
biomarker. Music therapy has been shown to have a positive
effect on frontal asymmetry in several studies
[172,173,174,175,178]. However, vibratory-based rhythmic
stimulation was not a variable in any study.
Another oscillatory theory that applies to depression is
TCD [9,10]. Not unlike the asymmetry theory, it identifies a
dysregulation of alpha and theta bands (increasing power in
lower frequencies) accompanied by gamma frequency effects
[179,180]. No regulatory stimulation frequency is commonly
identified but speculation might point to 10–14 Hz and 40 Hz
as a possible starting point. Since music in general has a
regulatory effect on frontal asymmetry, higher alpha seems to
deteriorate with TCD, and gamma dysregulation is reset with
auditory stimulation [104], a potential brain stimulation for
depression could be 10–14 Hz within music and low
frequency stimulation in the 30–70 Hz range. A possible
experimental response to the lack of research precedent and
evidence could be to use a series of progressive frequencies
between 10–130 Hz, as has been done in DBS research [181].
Summary
This paper has presented a discussion premised on the
importance of steady-state brain oscillation for brain
connectivity and cognition. Given that a healthy brain
maintains particular levels of oscillatory activity, it was argued
that disturbances or dysrhythmia of this oscillatory activity
can be implicated in several health conditions including AD,
PD, pain, and depression. Literature was reviewed that shows
that electro-stimulation can contribute to oscillatory
regulation and the alleviation of certain health conditions. It
was then argued that specific frequencies of sound in its
vibratory nature can serve as a means to brain stimulation
through auditory and vibrotactile means and as such can
contribute to regulation of oscillatory activity. The frequencies
employed and found effective in electric stimulation were
reviewed with the intent of guiding the selection of sound
frequencies for vibroacoustic stimulation in the treatment of
AD, PD, pain, and depression.
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Biographical Statements
Lee Bartel, PhD is Professor in the Faculty of Music with
Appointments in the Rehabilitation Sciences Institute and the
Institute of Life Course and Aging at the University of
Toronto and was the Founding Director of the Music and
Health Research Collaboratory.
Robert E W Chen, MA, MSc. is Senior Scientist in the Krembil
Research Institute in the University Health Network and
Professor in the Division of Neurology, Department of
Medicine, at the University of Toronto with special interest in
the organization of cortical inhibitory and excitatory pathways
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 153 – 166
in the human motor cortex, pathophysiology of movement
disorders, the mechanisms of action of deep brain stimulation
as a treatment of movement disorders.
Claude Alain, PhD is Assistant Director and Senior Scientist at
the Rotman Research Institute, Baycrest Centre, and Professor
in the Department of Psychology and in the Institute of
Medical Sciences, University of Toronto with a specialization
in cognitive neuroscience and focus on the brain processes
that mediate perception and cognition of auditory patterns
Bartel, Chen, Alain & Ross | Vibroacoustic Stimulation and Brain Oscillation
and events, specifically short-term memory and selective
attention.
Bernhard Ross, PhD, is Senior Scientist at the Rotman
Research Institute at the Baycrest Centre, Associate Professor
in the Department of Medical Biophysics at the University of
Toronto, and heads the MEG laboratory with special interest
in neuromagnetic studies of auditory-motor functions and
music-supported rehabilitation of stoke patients.
MMD | 2017 | 9 | 3 | Page 166
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 167 – 173 Clements-Cortes, Ahonen, Freedman & Bartel | Potential of RSS for AD

Full-Length Article
The Potential of Rhythmic Sensory Stimulation Treatments for Persons with Alzheimer’s Disease
Amy Clements-Cortes1,2,3, Heidi Ahonen2, Morris Freedman1,3,4,5, Lee Bartel1
1
University of Toronto, Music and Health Research Collaboratory, Toronto, Canada.
2
Wilfrid Laurier University, Ontario, Canada.
3
Baycrest Health Sciences, University of Toronto
4
Department of Medicine, Division of Neurology, Baycrest Health Sciences, University of Toronto
5
Mount Sinai Hospital, Rotman Research Institute, Baycrest Health Sciences, Sam and Ida Ross Memory Clinic, Baycrest Health Sciences

Abstract
Background: Rhythmic Sensory Stimulation (RSS) is a treatment being implemented for persons diagnosed with a variety of
disorders such as fibromyalgia and Alzheimer’s disease (AD). This paper provides qualitative results of observations and
interactions of AD study participants who received both RSS and visual stimulation sessions for 6 weeks. A case vignette is also
provided.
Objective: The study proposed that RSS could stimulate the auditory and somatosensory system at 40Hz with the potential for
improvements in cognition for persons with AD.
Method: 18 participants at three stages of AD participated: mild, moderate and severe. Participants received a total of 13 sessions
in this AB cross-over design study. Qualitative content analysis was used to analyze the qualitative data.
Results: Qualitative findings from the study support RSS as a potential treatment for persons with AD to increase alertness,
stimulate discussion, and increase interaction and awareness of surroundings.
Conclusion: Further research is needed to explore the effect of the frequency within the sessions provided, the duration of effects,
and whether AD severity interacts with the RSS treatment. Further investigations could also study the effect of auditory 40Hz
stimulation alone, as well as the inclusion of music listening during the RSS sessions.

Keywords: alzheimer’s disease, sound stimulation, cognition, alertness multilingual abstract | mmd.iammonline.com

Introduction slows progression of disease. With such a dramatic increase in

A projected 35.6 million people live with dementia worldwide
and by 2050 estimations predict this number will increase to
115 million [1]. Dementia is characterized as the gradual loss
of higher cognitive functioning. There is behavioral and
psychological symptomology common to individuals living
with dementia such as: dysphoria, anxiety, apathy, psychosis,
aberrant motor behavior, irritability, aggression, eating
disturbance and sleep disorders [2]. The management of
dementia varies. However for persons living with Alzheimer’s
disease (AD) there is no identified cure, and no treatment that
PRODUCTION NOTES: Address correspondence to:
Amy Clements-Cortés, PhD, RP, MTA, MT-BC, FAMI. 56
Destino Crescent, Woodbridge, Ontario, L4H 3E1, Canada;
Email: notesbyamy2@yahoo.ca | COI statement: Bartel receives
royalties for the VST1000 – Somerset Group for sound and
Headwaters Corporation for design and consulting. Freedman
received honoraria from Eli Lilly Canada Inc. for participating in
consultancy and advisory board meetings. He is also listed on a
provisional patent related to methods and kits for differential
diagnosis of AD vs. frontotemporal dementia using blood
biomarkers and may be listed on the planned patent application.
prevalence of persons with AD and other forms of dementia, it
is essential to develop treatments that may reduce the
debilitating symptoms associated with these diseases.
Rhythmic Sensory Stimulation (RSS) is one such new
treatment that is being utilized with persons diagnosed with a
variety of disorders such as fibromyalgia, tinnitus, and AD [3].
RSS can involve vibro tactile stimulation of
mechanoreceptors, auditory stimulation of the auditory
system, or visual stimulation of the optic system. This is done
with regular pulses at a target frequency such as 10 times a
second (10Hz) or 40 times a second (40Hz). The stimulus
results in a neural response – like a nerve firing into the brain
– at the frequency of the stimulus. Therefore if sound and
vibration stimulate the neurons 40 times a second, there is an
increase in coherent neural oscillation, or electro-potential
power at the stimulus frequency. Research shows that steady-
state 40Hz neural activity is normal in healthy brains and is
related to brain connectivity [4,5,6] making it essential in
cognition. Persons with AD have less electro-potential power
at the 40Hz level than those with age-matched ‘normal’ brains
[4], but there is evidence that 40Hz oscillatory power can be
“driven” with vibration [7]. This study proposes that RSS can

Copyright © 2017 All rights reserved.

International Association for Music & Medicine (IAMM). MMD | 2017 | 9 | 3 | Page 167
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 167 – 173
stimulate the auditory and somatosensory system at 40 Hz,
increasing the functional prominence of the steady-state 40
Hz oscillation, which could lead to improvements in cognitive
performance in AD patients.
This report provides descriptive and qualitative results,
including observations and interactions, of the experiences of
AD study participants receiving RSS and visual stimulation
sessions. All 18 participants are described along with the
presentation of one case vignette. A scientific report that
focused on the quantitative results of this study was previously
published, containing the hypothesis, methodology,
quantitative, and minimal qualitative results and implications
for future studies [8]. While quantitative results indicated
statistically significant results for RSS treatment to improve
cognition in as few as six sessions, the qualitative results allow
examination in greater detail of important themes and
interactions to further a clinical understanding of how this
stimulation supports improved cognition.
Treatment and Methods
This pilot investigation sought to assess whether applying RSS
(sound driven vibrotactile stimulation to the somatosensory
system) at 40 Hz in persons diagnosed with AD would
improve alertness, clarity, and/or short-term memory. This
study hypothesized that: repetitive RSS at 40Hz would
produce an increase in neural rhythmic oscillatory coherence
which would subsequently contribute to improved cognition
in patients at 3 stages of AD when compared with repetitive
non-rhythmic visual stimulation sessions.
The substitute decision makers for all participants
provided written consent to participate in the study, and
participants were read an assent letter and asked for their
assent to participate. Participants received six (40 minute)
sessions of both treatments in this AB cross-over study:
Treatment A: 40Hz sound stimulation and Treatment B:
visual stimulation using DVDs. RSS stimulation was provided
for 30 minutes administered through the Next Wave chair [9]
and the visual stimulation consisted of watching 30 minutes of
a DVD [10] specifically designed for persons with AD.
The outcome measures that were described in a previous
report [8] included: the St. Louis University Mental Status
Test [11], Observed Emotion Rating Scale [12], and behavioral
observation by the researcher. During the intake session the
Mini Mental State Exam (MMSE) [13] was collected from the
participant’s chart. The SLUMS test has a maximum score of
30 and any score lower than 20, indicates dementia [11]. The
qualitative data consisted of: (a) dialogue that took place
between the participants and the therapist who provided the
treatment sessions. The therapist sat beside each participant
while he/she received treatment and recorded the verbal
discussion (if any) that took place on the Stimulation session
observation form (Appendix A). (b) Comments recorded by
the therapist on the observed emotion rating scale, regarding
Clements-Cortes, Ahonen, Freedman & Bartel | Potential of RSS for AD
participant comments, affect and behavior [12]. (c) Dialogue
or comments and behaviors of the participants as they walked
with the therapist to and from the treatment sessions from the
pick up or waiting area, which were documented by the
therapist in the participant’s notes on the session date.
Examples of observed behaviors included: eyes open and
looking around the room, fidgeting, body movements or
gestures, facial affect and expressions, increased
verbalizations, etcetera. Eighteen participants completed the
treatment, 10 male and 8 female, and there was an equal
breakdown of persons with mild, moderate, and severe AD.
All participants were recruited from the research database
and/or healthcare facility in a large metropolitan city.
Participants whose names were on the database and who fit
the inclusion criteria were invited to participate. Additional
participants were invited from the community day program.
As explained above, analysis in this paper focuses only on
qualitative results.
Data Analysis
The therapist who delivered the treatment sessions analyzed
the research observation notes (including a, b and c noted
above) alongside two research assistants (RAs). These RAs
were certified music therapists holding the MTA credential
and were blinded to the treatment interventions. Both had
worked previously with this client population, and had also
coded qualitative data in prior studies. The therapist and RAs
studied the data sources and acknowledged important
behaviors, accounts, or statements. Qualitative content
analysis was used to analyze the data and implemented to
create the descriptive codes (conventional content analysis) to
identify the principal significance. Following this, codes were
arranged into comprehensive themes identifying responses,
dialogue, and behaviours during the treatment sessions [14].
The final list of themes was reviewed by the therapist, and the
RA’s. We sought to confirm the interpretational accuracy of
the results. The assistance of the RAs was included to ensure
objective analysis of the results via inter-coder reliability [15].
This analysis team met to discuss the results and the final
list of themes was determined by the therapist who provided
treatment sessions.
Results
To characterize the qualitative observations and ratings of the
participants in this study, a single case study typical of the
study results is presented. A pseudonym (“Louis”) will be
used. A summary of the treatment effects on the three
subgroups based on AD diagnosis is also presented for both
the RSS and the video treatments. As previously noted above
the quantitative results of the study have been published [8]
and indicate that data submitted to regression analysis
produced positive slopes for 40 Hz treatment, demonstrating
MMD | 2017 | 9 | 3 | Page 168
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 167 – 173
an increasing SLUMS score over time (an increase of about .5
for each treatment), and a virtual 0 or negative slope with
DVD treatment.
Case Vignette: Louis
Louis is a 68-year-old male diagnosed with moderate AD.
When treatments began, his MMSE score was 16 out of 30. Six
months prior to the beginning of treatment, his MMSE was 21
out of 30. He was on a variety of medications at the time of
treatment sessions including: donepezil, atorvastatin,
citalopram and a variety of vitamins. He received six sessions
of RSS followed by six sessions of visual stimulation. During
the first RSS session, he asked, “What am I doing here?”. Five
minutes into the treatment, he had his arms folded over his
chest, and presented a neutral affect with his eyes open. At 10
minutes his breathing appeared to be in synchronization with
the amplitude modulation of the vibration. At 15 minutes he
was actively looking around the room, fidgeting, and
commenting on the items. His eyes were fully open at 20
minutes and the arousal appeared to be strongest at the 15-
minute mark, and at the end of the treatment.
Session two of the RSS treatment was similar to session
one, but there was a noticeable change in session three.
During session three, Louis made jokes, talked about his
career and work as an architect, school colors, and on the walk
back from the treatment room to the waiting area he discussed
the art on the wall with the therapist. In session four, he
questioned “Why am I here? Can I talk?” and made some
short ponderings or expressions: “A chair is still a chair”, “A
house is not a home”, “Have you heard of Burt Bacharach? He
composed a lot of songs”. Louis began singing songs and
tapping his hands at 10 minutes, and then started whistling.
When the treatment was finished he talked to the therapist
about his marriage, and his challenges with his partner to have
children. At the beginning of session five, Louis recognized
that he had been to the treatment room before. After five
minutes into the RSS treatment, he shared stories about
growing up in his country, what languages they spoke, and
gave examples of typical names of persons from that country.
At 15 minutes he asked, “Is this a hospital? My wife is a nurse.
The hospital is nice, they help you”. At 20 minutes he asked:
“Have you been to my country? Do you speak another
language? What’s my first language?”. He then began to speak
in Spanish, and at the end of the session he wanted to share
politics of his country with the therapist. He talked about
famous politicians and asked if the therapist knew these
persons. He appeared to be very alert. Session six was similar
to session five, in that there was a lot of discussion on
languages, and he began to share examples of phrases in
Spanish, Italian and French.
The overall trend in sessions suggested that the RSS
treatments were effective in stimulating discussion. One
external factor causing the increase in discussion could be that
Clements-Cortes, Ahonen, Freedman & Bartel | Potential of RSS for AD
he was more comfortable with the therapist over time. Louis
generally began sessions indicating signs of pleasure, smiling,
laughing, alongside small signs of anxiety (uncertainty or
nervousness) about what he was going to have to do. After the
40 Hz stimulation sessions there was no real change in these
indicators; he still demonstrated signs of pleasure and
alertness, and some anxiety when asked the questions on the
SLUMS.
For the visual stimulation sessions, Louis generally began
in an alert state, but alertness declined from a rating of 4 at the
beginning of the session to a rating of 2 by the end of sessions
(as assessed by the observed emotion rating scale). Affect was
high at the beginning of the session, generally rated at a 4 or 5,
but dropped to 2 or 3 and appeared to be flatter and dull
throughout the visual stimulation. Overall Louis was much
less talkative during the DVD sessions. After approximately 10
minutes during all six sessions he frequently tapped his
fingers, and several discussions demonstrated that he
appeared confused and bored by the videos. During one
session, he said “This will put you to sleep. Where is this beach?
I don’t swim. Are we supposed to sleep or what?”. During
session three after 15 minutes he said, “I forget why I am here,
is this a test?”. In session five after 10 minutes he appeared
bored of the video, looking around tapping his hands and
moving his thumbs and said “Why are we watching this? You
call this a movie?”.
Louis displayed pleasure and alertness at the beginning of
each session. From sessions three to six of the videos, there
was some anxiety (restlessness, desiring to be done the
session). The SLUMS test appeared to cause some of the
anxiety but there was also anxiety from the boredom of
watching the video and questioning why he was watching it.
Overall, after the visual stimulation session, Louis was able to
answer the SLUMS question about naming animals and the
city he was in, and could identify the triangle and the largest
object. After the RSS sessions he was able to answer these
questions with an improved ability to name animals and was
also able to answer questions from the story, and recite
numbers backwards. He never was able to correctly answer
the year or day of the week, or the math questions post either
treatment sessions.
Themes found for Mild, Moderate, and Severe AD
participants
Table 1 provides a summary of the qualitative themes found
when participants received RSS and visual stimulation
sessions. A list of participants that each theme corresponds
with is provided. Note that participants are numbered from 1
– 20, but participants 8 and 11 withdrew from the study, and
are not included in analysis below.
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 Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 167 – 173 Clements-Cortes, Ahonen, Freedman & Bartel | Potential of RSS for AD

communication (P7, P9, P13, P19), alertness (P9), relaxing

DVD Total & (List 40HZ THEMES Total & (List
THEMES of of behavior (P12) and greater awareness of context (P13).
Participants Participants During video sessions participants showed greater signs of
Who Shared Who Shared being bored and tired (P9, P13), agitated or restless (P9, P12),
This Theme) This Theme) or producing outbursts (P19).
Boredom 15 (1- 5, 6, 9, Increased 11 (5, 6, 9, 10,
10, 13-17, 18, alertness 13, 14, 16, 17, DVD Stimulation Themes
20) 18, 19, 20)
Increased 7 (1-3, 9, 10, Increased 13 (1,2,4, 5-7,
agitation/ 16, 19) awareness of 9, 12-14, 17, Boredom, increased agitation and increased anxiety.
anxiety surroundings 18, 20) Boredom was a theme for 15 out of the 18 participants. Direct
Increased 3 (13, 14, 19) Increased clarity 4 (1, 6, 10, quotes such as,“I am bored. When is this going to be over?”
suspicion/ 16) and behaviours such as twitting thumbs is evidence that
confusion
Quiet 7 (6, 7, 12, 15, Increased 13 (1, 2, 4, 5- supported this theme. While not as prominent as boredom,
17, 18, 20) interaction 7, 9, 10, 14, seven participants still contributed to the emergence of the
16, 17, 19, 20) increase agitation and anxiety theme (four females and three
Restlessness 3 (1, 2, 19) Reminiscence 6 (1 ,2, 4, 5, 6, males). This theme was evenly spread out among the three
20) classifications of AD.
Sleep 7 (4, 5, 7, 9, Stimulation of 13 (1-7, 9, 10,
16, 17, 20) discussion/story- 14, 16, 17, 20)
telling Increased suspicion/confusion. This theme surfaced for three
participants, two severe AD and one moderate AD.
Table 1: Qualitative Themes Participant 19 for example appeared to be the most impaired
according to the therapist administering sessions. It is
Mild AD participants. During RSS Sessions, mild AD therefore not surprising that she experienced increased
participants appeared to become more alert (P1, P2, P10) and confusion, especially with attempting to answer questions on
recounted interesting stories from the past (P1, P2, P5, P10, the SLUMS test of which she rarely could complete, resulting
P17). They also became more aware of their surroundings and in her scores only ranging between 3 and 4 during both the
commented on what they saw (P1, P2, P5, P17, P18). Several RSS and visual stimulation sessions.
participants seemed to find the treatment relaxing or
commented that they enjoyed it, or appreciated it (P5, P10, Quiet. The “quiet” theme was evident from seven participants
P17). During the video sessions mild AD participants and occurred fairly evenly among male and female
commonly appeared to be bored and even stated that they participants as well as the three levels of AD. It appeared
were (P1, P2, P10, P17). There were some signs of increased logical that persons with severe AD might be quieter in the
anxiety as well as restless and fidgety behaviour (P2, P10). DVD sessions, but for the two persons for whom this theme
Several found it made them tired and sleepy (P5, P17), and surfaced and who were “mild” AD it is curious. Participant 17
some showed signs of confusion (P2, P5). for example was very talkative in the 40 Hz sessions, yet did
not seem to find anything stimulating to comment on with
Moderate AD participants. During RSS Sessions, moderate respect to the DVD. The results are also interesting for
AD participants showed signs of increased arousal that participant six who was overly talkative and animated in the
manifested through increased verbal output like telling stories 40 Hz sessions but quiet during the DVD, confirming the
of the past (P4, P6, P14. P16), increased energy and physical observation that the DVD did not provide substantial
action like moving in the chair, slamming arms while telling stimulation of cognitive function.
stories, and even jumping up (P6, P14), increased voice
volume (P6), singing (P3), and, general alertness (P20). Restlessness. This is a “small” theme as it was only evident in
During the video sessions moderate AD participants 3 participants but interestingly it was for two mild participants
demonstrated some confusion (P3), boredom (P4, P6, P14, and one participant with severe AD. For the participants with
P16), sleepiness (P4), anxiety and restlessness (P4), and were mild AD, it seemed that the DVD was not engaging which
less talkative (P6, P14, P16). caused them to become fidgety and wonder why they were
there. For participant 19, the restlessness corresponded with
Severe AD participants. Generally the severe AD participants her overall level of agitation and physical comfort.
showed less engagement in both treatments, less coherent
verbal communication, and several participants with Sleep. Sleep was a theme that emerged from 7 participants
particularly severe cognitive impairment showed little representing each level of AD. It is not uncommon for an
observable difference between the two treatments. During older adult to potentially close their eyes and drift off,
RSS sessions there was more evidence of interactive verbal especially if they are not sleeping well and/or are

MMD | 2017 | 9 | 3 | Page 170

Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 167 – 173
unstimulated. Sleep in these sessions appeared to be related to
a lack of being engaged in the DVD. The DVDs were created
to assist in relaxation, so sleep is also a natural outcome of that
type of intervention.
40 Hz Stimulation Themes
Increased alertness, stimulation of discussion/storytelling,
increased awareness of surroundings. The theme of increased
alertness surfaced for 11 participants (five mild, three
moderate and three severe). Of these 11, 8 participants also
showed evidence of the theme of stimulation of
discussion/storytelling, and nine participants showed
increased awareness of surroundings. It appeared as though
participants told stories and became more alert regarding their
surrounding or vice-versa: they became more alert and it
sparked storytelling and discussion. These factors seemed to
feed into an increased awareness of surroundings.
Increased interaction and clarity. This was a large theme, and
also corresponded with those participants who showed
evidence of increased alertness, awareness of surrounding,
and stimulation of discussion/storytelling. Increased clarity
was a theme that was evenly split between males and females
in the mild and moderate stages of dementia. It is not
surprising that this theme did not surface for any persons with
severe AD. While not a strong theme in this study for severe
AD participants, it is an important observation and potentially
requires a study with a larger group of participants to emerge
more convincingly.
Reminiscence. The theme of reminiscence was present for 6
participants: Three participants with mild AD and three
participants with moderate AD. Again, it is not surprising this
theme did not emerge for participants with severe AD due to
their impairment.
Discussion
Results support the hypothesis that repeated RSS sessions
would produce an increase in neural rhythmic oscillatory
coherence and that the visual stimulation sessions would not.
Overall visual stimulation sessions did not appear to provide
stimulation for these 18 participants, but rather induced quiet
or sleepy states, perhaps because it did not produce any
further connections in brain activity. The DVDs used in the
study were designed to reduce agitation in persons with AD,
and while the participants were quieter or more inclined to
sleep during treatment sessions, the images did not seem to
reduce anxiety; but rather added to anxious feelings as
participants wondered why they were watching it. It
materialized that 40 Hz treatments were successful at
Clements-Cortes, Ahonen, Freedman & Bartel | Potential of RSS for AD
stimulating increased alertness, interaction, discussion and
storytelling, and awareness of surroundings.
Limitations and Future Research
While the results are very promising, the researchers ideally
would have had the participants receive the 40Hz treatments
three times a week instead of just two. This was not possible in
this study since many participants lived a long distance from
the treatment facility and were unable to travel three times a
week for this study. Further research is required to determine
if there is a particular stage of AD (mild, moderate, severe)
that would best respond to 40 Hz treatments. In addition the
examination of individual case studies over a longer period
would help further the understanding of whether there is an
increase and/or maintenance of SLUMS scores. It is quite
exceptional that the SLUMS scores on average increased 0.5
points on the SLUMS test after each RSS treatment. The
reason it is exceptional is that AD is a degenerative disease and
in only 6 sessions of RSS, participant’s scores were steadily
increasing. Further adding an imaging component to future
studies alongside observation tools would provide additional
evidence. Future research could also look into the use of a
home device, which would enable greater frequency of the
sessions, perhaps from five-seven times per week. For
example, Sound Oasis VTS1000, is a device which produces
very effective low frequency stimulation (RSS) and has
available for download tracks that are very much like the
stimulation used in this study (http://www. soundoasis.
com/sounds/vibroacoustic-therapy/).
Conclusion
Descriptive and qualitative data support the potential of RSS
treatment to promote increased alertness, stimulation of
discussion/storytelling, awareness of surroundings and
increased interaction in persons with AD. In a very short
trajectory of treatments (six sessions of 40 Hz treatment)
participants’ SLUMS scores indicated statistically significant
results for this treatment. Further research is indicated to
further understand of the impact of such treatments,
especially in the cases where there were increased duration of
positive effects.
Acknowledgements
This project was funded with a gift to the Music and Health
Research Collaboratory (MaHRC), University of Toronto by
Mr. Jerry Heffernan. Morris Freedman receives support from
the Saul A. Silverman Family Foundation as a Canada
International Scientific Exchange Program and Morris
Kerzner Memorial Fund.
MMD | 2017 | 9 | 3 | Page 171
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 167 – 173
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3. Bartel L. Music Medicine in Neuro- Rehabilitation: Foundations and
Applications of Sound Stimulation. 2014(Unpublished grant
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coherent thalamocortical 40-Hz oscillations in humans. Proc Natl Acad
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Short term effects of rhythmic sensory stimulation in Alzheimer’s
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doi:10.3233/JAD-160081
https://tspace.library.utoronto.ca/handle/1807/72411 Next Wave
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9. Voevodsky G. The best caribbean beaches [Motion Picture]. 2003.
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the Saint Louis University mental status examination and the mini-
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scale. 1999. Available at www. abramsoncenter. org/PRI. Accessed May
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12. Folstein M, Folstein S, McHugh P. Mini-mental state: A practical
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Psychiatr Res. 1975;12:189-198. http://dx.doi.org/10.1016/0022-
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13. Cho, Y.I. (2008). Intercoder reliability. In P.J. Lavrakas (Ed.),
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Biographical Statements
Amy Clements-Cortés, PhD, RP, MTA, MT-BC, FAMI is
Assistant Professor, Music and Health Research
Collaboratory, University of Toronto; Academic Coordinator,
Ryerson Chang School; Contract Academic Staff and
Supervisor, Wilfrid Laurier University, Toronto, Canada.
Heidi Ahonen, PhD, RP, MTA, FAMI, Professor of Music
Therapy, Wilfrid Laurier University. Director, Manfred and
Penny Conrad Institute for Music Therapy Research. Heidi
has been been using and researching the use of low frequency
sounds in her clinical work since 1991.
Morris Freedman, MD, Head of Neurology at Baycrest Health
Sciences and Professor, Division of Neurology, Department of
Medicine, University of Toronto. His research focuses on
cognitive mechanisms underlying dementia.
Lee Bartel, PhD, Professor Emeritus at University of Toronto.
Founding director of the Music and Health Collaboratory. His
research focuses on sound as cellular stimulant in body, blood,
and brain.
MMD | 2017 | 9 | 3 | Page 172
 Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 167 – 173 Clements-Cortes, Ahonen, Freedman & Bartel | Potential of RSS for AD

1 Appendix A
2 Stimulation Session Observation
3 SID:
4 Date:
5 Time:
Time of Program Corresponding Researcher Participant
Computer Program Observations Comments
Aspects

Opening Comments
Once Seated on Chair

1-5 Mins

6-10 Mins

11-15 Mins

16-20 Mins

20-25 Mins

Closing Comments
While Seated on
Chair

MMD | 2017 | 9 | 3 | Page 173

Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 174 – 177 Clements-Cortes, Ahonen, Evans, Tang-Wai, Freedman, & Bartel | RSS & AD Clinical Case

Full-Length Article
Can Rhythmic Sensory Stimulation Decrease Cognitive Decline in Alzheimer's Disease?
A Clinical Case Study
Amy Clements-Cortes1,2,3, Heidi Ahonen2, Michael Evans1, David Tang-Wai4, Morris Freedman1,3,5,6, Lee Bartel1,
1
University of Toronto, Music and Health Research Collaboratory, Toronto, Canada.
2
Wilfrid Laurier University, Ontario, Canada.
3
Baycrest Health Sciences, University of Toronto
4
Department of Medicine, Division of Neurology, University of Toronto, University Health Network Memory Clinic, Toronto, Canada
5
Department of Medicine, Division of Neurology, Baycrest Health Sciences, University of Toronto
6
Mount Sinai Hospital, Rotman Research Institute, Baycrest Health Sciences, Sam and Ida Ross Memory Clinic, Baycrest Health Sciences

Abstract
Background/Objectives: To present Rhythmic Sensory Stimulation (RSS) as a potential new treatment of Alzheimer’s disease
(AD).
Design: Longitudinal case study over a 3-year period.
Setting: RSS was provided both in a long-term care/research facility and in-home.
Participant: A 92 year old female with AD.
Intervention: Treatments consisted of RSS resulting in gamma frequency entrainment, provided with two different treatment
devices over 3 years.
Measurements: Quantitative and qualitative measures were used including: MMSE, SLUMS, interviews, observation notes and a
participant question sheet.
Results: MMSE scores since diagnosis 3 years earlier, as well as cognition, clarity, and awareness were reported by the subject’s
husband, to have remained unchanged.
Conclusion: Although further research is warranted, this case suggests that RSS has potential to help maintain cognition in AD.

Keywords: alzheimer’s disease, cognition, clarity, gamma frequency entrainment multilingual abstract | mmd.iammonline.com

Introduction Background/ client information

A 92 year-old woman diagnosed with Alzheimer’s disease
(AD) was treated with sound-driven vibrotactile and auditory
stimulation referred to as Rhythmic Sensory Stimulation
(RSS). Mini Mental State Examination (MMSE) [1] remained
stable over the following 3 years. This case demonstrates the
potential of RSS treatments to maintain cognition in patients
with AD.
PRODUCTION NOTES: Address correspondence to:
Amy Clements-Cortés, PhD, RP, MTA, MT-BC, FAMI. 56
Destino Crescent, Woodbridge, Ontario, L4H 3E1, Canada;
Email: notesbyamy2@yahoo.ca | COI statement: Bartel receives
royalties for the VTS1000 –Somerset Group for sound and
Headwaters Corporation for design consulting. Freedman
received honoraria from Eli Lilly Canada Inc. for participating in
consultancy and advisory board meetings. He is also listed on a
provisional patent related to methods and kits for differential
diagnosis of AD vs. frontotemporal dementia using blood
biomarkers and may be listed on the planned patent application.
Copyright © 2017 All rights reserved.
International Association for Music & Medicine (IAMM).
The patient (89 years) was diagnosed with an MMSE score of
22/30 indicating probable AD with mild impairment. MMSE
subscores were: 6/10 on orientation, 3/5 on world backwards,
and 1/3 on delayed recall. Visuospatial skills on clock drawing
and intersecting pentagons were intact. However, drawing of
the Necker Cube was impaired. On CERAD learning and
recall, she learned 2, 4, and 5 words on the first 3 trials. After a
delay, she recalled 1 word and recognized 17/20 words. She
scored 18/30 on the Boston Naming Test. Verbal fluency was
average for the letters C (n=14), F (n=8), and L (n=11).
Semantic fluency for animals was impaired at 10. Digit span
was 6 forwards and 4 backwards. She completed Trails A in 94
seconds. She could not complete the Trails B sample. She
demonstrated some preservative behaviour issues on drawing
alternating Ms and Ns, as well as ramparts. She was on a stable
dose of Donepezil.
She was treated with gamma entraining RSS with 12
sessions at a long-term care facility. Subsequently, she
acquired a consumer device that provided RSS embedded
within relaxing music and she continued to use daily. The
MMD | 2017 | 9 | 1 | Page 174
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 174 – 177 Clements-Cortes, Ahonen, Evans, Tang-Wai, Freedman, & Bartel | RSS & AD Clinical Case

study was approved by the Research Ethics Board at Baycrest direct words the patient stated. The patient’s husband was
Health Sciences. interviewed 4 times - at the end of each week of treatments.
(See Table 2 for open-ended interview questions). The SLUMS
Foundational concept of sound as brain stimulation was administered by the music therapist who conducted the
treatment, however, the husband’s interviews were conducted
RSS uses rhythmic pulsation to stimulate the brain through by another researcher.
the tactile, auditory, or visual system [2] at regular intervals. In
this study RSS was only tactile and auditory. RSS can function Possible
as a specific singular frequency (as was used in the first part of Questions Points
the intervention), or it can be embedded with conventional What is the name of your husband? 1
music, or it can be embedded with conventional music
What year did you get married? 1
(second part of the intervention-at-home). RSS is premised on
the following: (1) Oscillatory brain circuits can become How many children do you have? 1
dysregulated,[3] Dysregulation and connectivity problems What are their names? 8
result in medical conditions.[4] (2) Intra-brain connectivity is Who is the eldest? 1
associated with 40Hz gamma oscillation. [5] (3) External Who is the youngest? 1
rhythmic stimulus can regulate dysregulated circuits and
connectivity. The central premise for the role of RSS in AD is How many grandchildren do you have? 1
the observed decrease in 40Hz gamma activity [2, 6] and that What are their names? 8
auditory and vibrotactile stimulation can increase 40Hz Who is your youngest grandchild? 1
activity and brain connectivity.
How old is he/she? 1
METHODS Who is your first grandchild? 1
Table 1: 11 Questions for Patient about Family
Intervention

During initial treatment, the patient received 12 RSS sessions Since the patient’s treatment started, have you noticed
in four weeks on a Next Wave Physioacoustic Chair [7] that any changes in…
delivers full-body vibrotactile stimulation with computer- 1. How she sleeps?
generated, sinusoidal sound waves transmitted through the 2. Short-term memory function.
chair’s six low-frequency speakers. It is classified as a low-risk 3. Mood?
device approved by the Canadian Standards Association, The 4. Mental clarity during conversations?
United States’ Food and Drug Administration, and British 5. Interest in going places?
Standards Institution.
6. Appetite?
Treatment consisted of a sinusoidal 40 Hz tone (although
7. How she looks after herself?
we call it RSS because of our theoretical frame, it is also known
as vibroacoustic therapy), amplitude modulated on a 4 second 8. Interest in recreation?
cycle, with sound moving progressively through the six 9. Social Relationships?
speakers from legs to head and back again with a peak 10. Ability to solve problems?
amplitude in the range of 104 – 109 dBc (Decibels relative to 11. Level of worry or contentment? Anxiety?
carrier). This RSS treatment was applied for 45 minutes per 12. How safe she feels?
session. Because the patient was experiencing some boredom, 13. Anything else?
during sessions 7–12, relaxing music was played in the
treatment room as ambient sound in addition to the 40Hz Table 2: Interview Questions with Husband
RSS.
The patient was administered the Saint Louis University Following 12 treatments, the patient was advised to use an
Mental Status (SLUMS)[8] cognitive assessment before and in-home consumer device (Sound Oasis VTS1000 [9]) for 30
after treatment, plus a short (25 point) set of 11 questions to 60 minutes a day, five days a week with the “Energize”
about her family (e.g., her children’s and grandchildren’s program. The Energize program features pleasant
names and birthdates) to assess her long-term memory (See instrumental music with a sine-wave bass line that activates
Table 1). Observations and reflective notes recorded by the vibrotactile gamma stimulation with 40Hz as the most
music therapist during and after the session documented prominent frequency. Using the device for 60 minutes
patient’s alertness, ability to focus, drowsiness, confusion, resulted in 20 minutes of 40Hz stimulation. She used the
distraction, inattention and preoccupation, in addition to any

MMD | 2017 | 9 | 1 | Page 175

Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 174 – 177
device almost daily for 30 to 60 minutes for the three years
prior to current reassessment.
RESULTS
Initial RSS Treatments
The SLUMS scores ranged between 13 and 22 pre- RSS
treatment, and between 13 and 23 post-treatment (mean
scores 17.67 and 18.17). Scores for the 11 questions post-test
ranged between 11 and 16, with an average of 13.2. For both
the post-test SLUMS scores and the post-test 11 questions,
data were analyzed to determine the effect of treatment using
a linear regression analysis. In both cases, the scores were
modeled as linear functions of number of treatments. The
estimated slopes and standard errors are given by 0.476(0.197)
and 0.567(0.122), respectively. The p-values, for testing that
the slopes are zero; (and thus there is no effect due to number
of treatments), are 0.036 and 0.002, respectively. There is an
effect of approximately 0.5 of a scale point per treatment. It is
evident from the RSS post-test scores that there is an upward
linear trend in the SLUMS scores.
The following are qualitative observations from the first
12 RSS sessions. The patient typically reported she was
comfortable and described the treatment as: “Very gentle,
hardly noticeable, very comfortable.” She tended to close her
eyes, rest, and sometimes fall asleep for the first 15-18 minutes
of the treatment but then opened her eyes, looked around the
room, and commented on items in the room and sometimes
began conversation.
In the weekly interview, her husband reported he noticed
little change during initial sessions in short-term memory, and
stated her mental clarity fluctuated. She continued to try to
complete crossword puzzles, but this was becoming more
challenging, however her math skills remained strong. Prior to
session 9, her husband noted that during the previous week
she had wandered off, went to three stores, and called home,
remembering her phone number, which she had not been able
to remember in the past few months prior. After the last
session, her husband reported a slight improvement in her
short term memory and sleep. Generally she was content, but
had some moments of irritability.
Three years post diagnosis
Three years after the initial RSS treatment sessions, the patient
was re-assessed. In the initial 12 RSS treatment sessions she
scored an average of 17.7 on SLUMS tests administered at the
start of each treatment. On the 11 questions, she scored an
average of 13.2. Three years later she scored 13 on the SLUMS
test, and 10 on the set of 11 questions test. MMSE score at 3
years post-onset was the same as when she was diagnosed, i.e.
22/30 vs 22/30. This score is noteworthy since the typical
Clements-Cortes, Ahonen, Evans, Tang-Wai, Freedman, & Bartel | RSS & AD Clinical Case
annual decline in the MMSE score is about 3.3 (95% CI 2.9 –
3.7) [9,10].
The patient’s husband was interviewed approximately 3
years after the initial 12 RSS treatments. He reported that after
she was diagnosed with AD he noted an increase in frustration
and “having tantrums”. But, two years after initial RSS
treatment sessions this behavior had subsided without
medications. She was still able to name her 8 children, but not
her grandchildren or great grandchildren. She also exhibited a
few other new behaviors such as hiding her purse and
worrying that she does not have any money in her wallet. She
no longer reads and does not do crossword puzzles. When
she wakes up she is typically disoriented as to where she is,
and sometimes asks her husband who he is.
DISCUSSION
The increase in SLUMS scores during the first 12 RSS scores is
consistent with the findings of a recent RSS and AD pilot
study showing an increase in SLUMS scores with an effect size
close to 3.5 (.58 for each session) in just 6 sessions of RSS
treatment.[10] Three years after continued RSS treatments
with the use of the home device, [11] there was little change
from the patient’s initial SLUMS scores. Furthermore, the
MMSE scores and comments in her medical record indicated
that her cognitive function remained fairly consistent.
Although music used with the RSS may be a contributor to the
results observed, the consistency of these results with the RSS
only study [12] points to the conclusion that it is the
frequency specific RSS that contributed the primary effect.
As a single case study, limitations include the reliability of
the statistical conclusions and potential subjectivity of the
therapists and their observations and assessments of the
patient’s condition pre-, during, and post-treatment.
Furthermore, the set of 11 questions and the interview
questions were not standardized and therefore did not provide
validated measures.
This case supports the use of RSS as a potential new
treatment that may help reduce cognitive decline in AD.
Research is being planned to include neuroimaging of AD
patients at the mild and moderate levels to determine whether
the mechanism involved is possibly the power of the gamma
frequency oscillation and whether this may serve as a
biomarker for AD.
Acknowledgment
This project was funded with a gift to the Music and Health
Research Collaboratory, University of Toronto MaHRC by
Mr. Jerry Heffernan. Morris Freedman receives support from
the Saul A. Silverman Family Foundation as a Canada
International Scientific Exchange Program and Morris
Kerzner Memorial Fund.
MMD | 2017 | 9 | 1 | Page 176
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 174 – 177 Clements-Cortes, Ahonen, Evans, Tang-Wai, Freedman, & Bartel | RSS & AD Clinical Case
References
1. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: A practical
method for grading the cognitive state of patients for the clinician. J
Psychiat Res. 1975; 12(3): 189-98.
2. Iaccarino HF, Singer AC, Martorell AJ, et al. Gamma frequency
entrainment attenuates amyloid load and modifies microglia. Nature.
2016; 540: 230-251. doi:10.1038/nature20587.
3. Llinas R, Urbano FJ, Leznik E, et al. Rhythmic and dysrhythmic
thalamocortical dynamics: GABA systems and the edge effect. Trends
Neurosci. 2005; 28(6): 325-33.
4. Llinás R, Ribary U, Jeanmonod D, et al. Thalamocortical dysrhythmia I:
Functional and imaging aspects. Thalamus Relat Syst. 2001; 3(1): 237–
44.
5. Llinnás R, Ribary U. Coherent 40-Hz oscillation characterizes dream
state in humans. Proc Natl Acad Sci USA. 1993; 90(5): 2078-81.
6. Ribary U, Ionannides AA, Signh KD, et al. Magnetic field tomography
of coherent thalamocortical 40-Hz oscillations in humans. Proc Natl
Acad Sci USA. 1991; 88(24): 11037-41.
7. Next Wave Headquarters. Next Wave Physioacoustic MX therapy chair.
[Next Wave Headquarters web site]. Available at:
http://www.nextwaveworldwide.com/products/physioacoustic-mx-
therapy-chair/. Accessed May 22, 2015.
8. Tariq SH, Tumosa N, Chibnall JT, et al. The Saint Louis University
mental status (SLUMS) examination for detecting mild cognitive
impairment and dementia is more sensitive than the mini-mental status
examination (MMSE) – A pilot study. Am J Geriatr Psych. 2006 14(11):
900-10.
9. Clark CM, Sheppard L, Fillenbaum GG, et al. Variability in Annual
Mini-Mental State Examination Score in Patients With Probable
Alzheimer DiseaseA Clinical Perspective of Data From the Consortium
to Establish a Registry for Alzheimer's Disease. Arch
Neurol. 1999;56(7):857-862. doi:10.1001/archneur.56.7.857
10. Han L, Cole M, Bellavance F, McCusker J, Primeau F. Tracking
cognitive decline in Alzheimer's disease using the mini-mental state
examination: a meta-analysis. Int Psychogeriatr. 2000 Jun;12(2):231-47.
PMID:10937543
11. Sound Oasis.Vibroacoustic Therapy Systems. [Headwaters Inc. web
site]. Available at: http://www.soundoasis.com/product-
category/vibroacoustic-therapy-systems/. Accessed November 7, 2016.
12. Clements-Cortes A, Ahonen H, Evan M, Freedman M. & Bartel L.
Short term effects of rhythmic sensory stimulation in Alzheimer’s
disease: An exploratory pilot study. J Alzheimers Dis. 52(2), 651-660.
DOI 10.3233/JAD-160081
https://tspace.library.utoronto.ca/handle/1807/72411
Biographical Statements
Amy Clements-Cortés, PhD, RP, MTA, MT-BC, FAMI is
Assistant Professor, Music and Health Research
Collaboratory, University of Toronto; Academic Coordinator,
Ryerson Chang School, Toronto, Canada; Contract Academic
Staff and Supervisor, Wilfrid Laurier University.
Heidi Ahonen, PhD, RP, MTA, FAMI, Professor of Music
Therapy, Wilfrid Laurier University. Director, Manfred and
Penny Conrad Institute for Music Therapy Research. Heidi
has been been using and researching the use of low frequency
sounds in her clinical work since 1991.
Michael Evans, PhD, is a Professor of Statistics. His research is
concerned with developing a method for the measurement of
statistical evidence as a foundation for a theory of statistical
inference.
David Tang-Wai, MD, is an associate professor in neurology
and geriatric medicine at the University of Toronto. He is the
co-director of the University Health Network Memory Clinic
and his research is focused on the neurodegenerative
dementias.
Morris Freedman, MD, Head of Neurology at Baycrest Health
Sciences and Professor, Division of Neurology, Department of
Medicine, University of Toronto. His research focuses on
cognitive mechanisms underlying dementia.
Lee Bartel, PhD, Professor Emeritus at University of Toronto.
Founding director of the Music and Health Collaboratory. His
research focuses on sound as cellular stimulant in body, blood,
and brain.
MMD | 2017 | 9 | 1 | Page 177
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 178 – 183 Palmer, Skille, Lahtinen & Ojala | Vibrations & Sensory Impairment

Full-Length Article
Feeling Vibrations from a Hearing and Dual-Sensory Impaired Perspective
Russ Palmer1, Olav Skille2, Riitta Lahtinen1, Stina Ojala3
1
ISE Research Group, University of Helsinki, Finland
2
Core Group Member of the VIBRAC Skille-Lehikoinen Centre for Vibroacustic Therapy and Research, Finland
3
Department of Future Technologies, University of Turku, Finland

Abstract
Working with hearing and dual-sensory impaired clients presents challenges for music therapy professionals. Feeling and
experiencing the vibrations produced by music help to understand what the concept of music is. Music and vibroacoustic
therapies have overlapping effects. Music is for listening while vibroacoustic therapy is mainly similar to physiotherapy. Where
vibroacoustic (VA) facilities are not available, some flexible methods could be adapted. One can use a music centre with two
separate, moveable speakers positioned on a wooden floor to enhance music vibrations. In conjunction inflatable balloons can be
manipulated by the clients. Balloons can be held towards the sound source and used to test the variations of the intensity and
dynamics of the vibrations in the room. The choice of music styles plays an important role to amplify the vibrations and
introduce music to the clients. Clients’ feedback was very positive indicating they were able to feel some musical tones from low,
middle and high levels. These methods appeared to enhance musical vibrations and give some therapeutic experiences, i.e.
relaxation and awareness of musical tones. This approach has been tested over 25 years and the individual feedback supports
notions on how tones are felt through the body.

Keywords: vibroacoustic therapy, vibrosensoric experience, hearing multilingual abstract | mmd.iammonline.com

impairment, dual-sensory impairment, music therapy

Introduction residual hearing in addition to feeling the vibrations. The

Working with clients with a sensory impairment, the
professional may use a multi- or cross-disciplinary approach
adapting various methods or models. This overview presents
practical solutions to working with clients with hearing
impairments deriving from vibroacoustics (VA) as well as
multisensory vibrosensoric experiences. Skille’s pioneering
work involved “bathing” the body in a low frequency sound
bath to relieve pain [1:25]. The original idea was to have a
spasmolytic or pain relieving effect for children with celebral
palsy. Music bath referred to the concept of using bean bags
filled with polystyrene balls supporting the client. As the low
tone frequency is played, the sound is transferred via the
polystyrene balls thus giving a vibrosensoric experience [2].
Vibrosensoric experience refers to the combination of using
PRODUCTION NOTES: Address correspondence to:
Russ Palmer, E-mail: rcpalmer4a12@icloud.com | COI statement:
The authors declared that no financial support was given for the
writing of this article. The authors have no conflict of interest to
declare.
Copyright © 2017 All rights reserved.
International Association for Music & Medicine (IAMM).
music played contains pitch, melody, duration and intensity
variations. These produce different sensations of tones. The
low, middle and high tones are defined by octaves on a piano.
Low tones here are the two lowest octaves on a piano, middle
range is three octaves around middle C (440Hz) and high
tones consist of the two highest octaves on a piano. [3:14].
Furthermore, when a client has a dual-sensory impairment,
i.e. both visual and hearing impairment, some of these musical
elements may have to be presented using hands-on methods,
e.g. touch messages called haptices connected to music
[4,5,6:142-3].
Some researchers have expressed a concern about using
music and low tone frequencies together [7]. Possible clashes
between musical and low tone frequencies depend on the
music style being applied. In the case of matching low tone
frequencies, there is no musical disturbance, but it creates a
vibrosensoric experience for the client [2]. Romanian
researchers define VA treatment as “the conversion of musical
melodies and rhythms into waves that can be felt within the
patient’s body” [8]. Similar remarks can be found in various
works of Skille and Wigram [1, 9, 10]. This appears to
confirm that the combination of music and vibrations
provided by vibroacoustic (VA) techniques allows hearing
impaired clients to benefit from this approach of music
therapy (MT) more so than other approaches.
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 178 – 183
Multimodal refers to the application of low tone
frequency, e.g. 40 Hz and music played simultaneously
through headphones. Multiple stimuli refers to the
application of low tone frequency, and simultaneous music
through a VA device. When applying low tone frequency
through a VA device, there is a pulsating frequency, which
may be aimed towards a specific area on the body for pain
management. At the same time the therapist is able to control
the volume and sensation of the stimulus. Even when the
sound source is stable on the body, the client feels that the
sound is travelling across the body. This is due to the cells in
the body containing liquid which is a good conductor of
sound waves, so any external stimuli will be dispersed all the
way through the body. This allows the client to become
relaxed and prepares him/her for an additional music stimulus
to be possibly applied and listened to. The music controlled
by a CD player begins with volume control at zero, then it is
gradually increased depending on the style of music being
used. For example, if the music is very rhythmical, one does
not want to have overstimulation as this can cause the client to
become restless [11:109]. However, when applying calming
music as defined by Wigram [10:226-7] as well as New Age
music (relaxation music), the music vibrations in the lower
range may be amplified, because of the summation of
frequency peaks [12]. Thus, it may be necessary to adjust the
volume level somewhat. The therapist may place their hand
onto the chair or the VA device. If the vibrations feel too
strong it is necessary to decrease the volume.
Techniques used in a music therapy session can be
applied depending on the device you are using for 15-40
minutes but the most common duration is 23 minutes [13].
This is due to the intensity of the low tone frequencies being
received from the devices. In some cases VA may incorporate
music listening into the equipment and this needs to be
carefully balanced against the low tone frequencies so there is
no danger of overstimulation as this could cause nauseating
aftereffects for the client. It is important for the therapist to
monitor the client’s responses during the treatment
programme (e.g. body language, smiling, breathing rate). For
further discussion on facial expression and body language
reliability on treatment responses, please see [14].
The therapist might use their hands or a small balloon to
feel the device to enable to check and adjust volume and
frequency levels [10]. Sometimes the audio/listening methods
may not be as precise or as accurate as following the vibrations
produced by the VA devices with the hand using the sense of
touch.
Clients with Hearing Impairment
When working with hearing and dual-sensory impaired
clients, there are some challenges for the music therapist [15].
The communication during the session is affected by the fact
of whether or not the client wears hearing aid devices, for
Palmer, Skille, Lahtinen & Ojala | Vibrations & Sensory Impairment
example, sign language users tend not to use hearing aid
devices. Some of these devices may be set up to amplify all
sound sources causing disturbance or disorientation if the
music created or played is too loud. This will make it more
difficult to differentiate musical elements and tones. To
correct for this, it may be advisable to ask the client to adjust
their devices accordingly using their preferred
communication method. If headphones are used, sometimes
the user experiences whistle-like feedback. Some digital
devices may have automatic volume settings. Cochlear
implant (CI) users may require a specific time period for
adjustments to the new soundscapes within the programming
sequence of CIs in the rehabilitation process.
If a hearing impaired client does not use hearing aid
devices, another approach will be necessary in order to
introduce musical elements to the client. In this case, the
client may experience the rhythms and vibrations only
through the sense of touch. Experiencing and feeling musical
vibrations is individual. Therefore, it is necessary merely to
adjust the quality of the sound through the equalizer settings,
not to increase volume levels.
Practical clinical approaches
Vibroacoustic and Physioacoustic Therapy Devices
Basic electronics incorporated into VA devices may include
transducers for low tone frequencies and/or speakers for
music [16]. Some VA devices may be low tone frequency
based using a series of pre-recorded CDs [13, 17]. These are
specially designed programmes covering a broad range of low
tone frequencies [30-120Hz][1]. Skille mentions [40-80Hz] as
being the most effective to be used during a VA session in a
therapeutic process. Lehikoinen specifies using the
Physioacoustic (PA) chair with [27-113Hz] in treating pain
and stress-related symptoms in health and educational
settings [18]. For example SoundOasis or a PA chair allow
both low tone frequencies and music to be played together,
either of which can be adjusted according to the treatment
given. The most widely spread VA devices to date are the
Norwegian Multivib (hand-held transducer, cushion,
mattress), the Finnish Nextwave PA chair, and the American
Somatron. Other devices, such as the Taikofon cushion can
also be used in music therapy.
Sensations of Tones - A Practical Approach
Using balloons enables people with a hearing impairment to
understand how they can feel musical tones through their
bodies. If one holds a balloon between the hands when
prerecorded music is played, it is possible to feel different
tones from the music [3]. Bass tones can be very strong and
be felt in the lower part of the body. Similarly, the middle and
upper ranges can be felt in the middle and upper parts of the
MMD | 2017 | 9 | 3 | Page 179
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 178 – 183
body, depending on the intensity of the vibrational source.
These can also be felt through the balloon. With the upper
register one can also feel the tones from the fingertips and feel
the vibration through the scalp [3, 10:154]. Sound waves
travel through air and water, as defined by several studies and
research groups [19, 12]. The way sound travels through
media can also be used in vibro- and physioacoustics. In this
way we enable the hearing impaired clients to experience
music through different vibro- and physioacoustic devices and
to experience music-induced relaxation.
Balloon Exercise
Sometimes there are no VA or PA devices available. In this
case, it is possible to recreate this “tone sensation” experience
using balloons where there is a wooden floor with a good
quality music Hi-fi system. For example, if one holds the
balloon in front of the chest standing in front of the music
speakers, the vibrations will feel very strong. If one moves
away, the vibrations will be weaker, but the client will still be
able to feel the sound waves via the balloon. That is because of
the power of sound is diminished by the square as the distance
doubles. One can also study different material and texture
resonances using balloons. In addition, beanbags act as a
conductor to enhance the rhythms and vibrations from the
music. This idea is similar to the one Skille refers to as a music
bath [9,17].
It is not necessary to have the music very loud and the
same experiment can also be accomplished using different
types of configurations. This can be a very good way for all
people to understand how we are able to feel the music
through our bodies and to explore the different kinds of tonal
elements (low, middle, and high tones). “In music, vibrations
producing low tones can be felt by body in the feet, legs and
hips. The middle tones can be felt in the stomach, chest and
arms, similarly the *high tones* can be felt in the fingers, head
and hair” [3:14](highlighting original, spelling corrected to
the current use, NB: felt in the hair should be felt through the
vibrations in the scalp). When singing, vibrations from the
nasal cavity travel to the lateral ventricles causing them to
vibrate (Jindrak postulate), see [16]. In their research, Skille
and Wigram outlined the body areas which respond to
different frequency ranges [1:54-5, 10:154].
Feeling Music - A Vibrosensoric Experience
The approach of feeling music encompasses the vibrosensoric
experiences [2] within a relaxing environment especially for
clients with a hearing impairment, as well as those with
multiple disabilities. Skille focused on a wide range of issues
and treatments [9, 20] that can be obtained with VA. The
approach presented here focuses on a vibrosensoric
experience for people with impaired hearing. One aspect that
differs from someone with hearing is that the client with a
Palmer, Skille, Lahtinen & Ojala | Vibrations & Sensory Impairment
hearing impairment is perhaps able to feel greater sensation
through the body. Does this indicate that dual-sensory
impaired people are even more sensitive to the information
gained through touch compared to others?
During a music therapy project in Norway at a residential
school for children who were deaf and had profound learning
disabilities in Andebu (1992-3) using a dedicated vibrating
music floor with prerecorded music (popular to New Age)
appeared to improve some individuals’ wellbeing. Similarly to
Skille, different frequencies appeared to help with different
issues. To mention one example, similar relief was noticed for
one of the clients about digestion problems. These results are,
however, anecdotal but do indicate some baselines for future
research projects.
Selection of Music Styles
For clients with a hearing impairment to feel and gain a
holistic expression of music it may be appropriate to select
certain prerecorded music styles that are instrumental, and
have a good, constant rhythm or clear melody. This may be
due to the way the music is orchestrally arranged or otherwise
making the rhythm or melody easier to follow from a hearing
impaired perspective. Furthermore, the range of tones and
vibrations produced via VA devices enables the client to relax
more during a session. Repetitive music can be therapeutic
for clients who are visually impaired and have multiple
disabilities. This was found during a project in Norway (see
above chapter Feeling Music - A Vibrosensoric Experience).
The suggestions above do not mean that classical music
cannot be used, but from a hearing impaired perspective the
tonal levels within the various music styles may not be strong
enough or consistent enough for the client to experience the
vibrations.
Some New Age music can be very therapeutic due to the
way it is arranged, mainly in a slow, repetitive manner along
with ascending or descending tonal soundscapes. Music like
this has a positive role to play in a therapeutic process. Skille
refered to the use of prerecorded, commercialised music in
particular to enhance the bass frequencies of jazz and other
styles [17:237]. Furthermore, Wigram indicated during his
work with clients with profound learning disabilities that he
used classical music in the sessions [21,22].
There has been some specially recorded music produced
in the 1990s by the composers Otto Romanowski, Matti Kärki
and others, which encompasses low tone frequencies with
music added on top in order to create a relaxing environment
[17]. These are specifically aimed at some of the VA and PA
devices, such as a sound massage bed or a PA chair, which are
more pure tone-related and penetrate to a person’s body more
easily [9, 18]. These may not be so suitable for some very
hypersensitive people. In the case of hearing aid or cochlear
implant users, these deep tones can cause distortion and
disorientation. Of course, it depends on an individual’s taste
MMD | 2017 | 9 | 3 | Page 180
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 178 – 183
on what they want to experience and experiment with. The
music may also relate to some significant past experiences.
Portrayal of Music to the Front and Back of a Person’s Body
In a therapy session with a hearing or dual sensory impaired
client, two exercises can be used to enhance understanding of
how to feel musical rhythms and elements through the body.
The client might want to close their eyes during the session.
This will enable the client to concentrate on the vibrations of
the music and to experience switching of senses. The
switching of senses refers to when a hearing impaired person
may switch off their hearing aid devices and just focus on the
pure sensations from the musical vibrations flowing through
their body. This also allows the client to switch off the
auditory channel and the other senses sharpen as a result [23].
During this exercise, the client receives the rhythm
portrayed by the therapist tapping the structure of the music
used during the session on the client’s upper back. In the case
of rhythmical elements, one can tap the rhythm on the client’s
shoulder and where there is a melody going through the tonal
ranges, it can be expressed using the hands spread out on the
client’s upper back. If there are low tones, the hand is brought
down lower on the back, and the upper register is higher up
on the shoulder level; the hands are used as if drawing a
picture following the rhythm and melody of the music.
Furthermore, if the music is dramatic it can be expressed by
mimicking a fireworks pattern on the back.
A second exercise would include working face to face.
Here the therapist uses hand-to-hand contact and moves
his/her hands to the flow of the music as the client follows the
movements. During this exercise the pair is standing still and
not moving around the floor. They can, however, sway to the
music. This is one more example of how one may feel the
rhythm of the music.
Feedback and observations
For more than 25 years, the methods outlined here have
enabled hearing impaired and dual-sensory impaired clients
to find a new way of how to feel and experience music through
their bodies according to the clients’ feedback. For those with
multiple disabilities, the results have also been positive
through video analysis - recording reactions, expressions of
joy, laughter, and additional movement they would not have
done before. For example, a 13 year-old hearing impaired
female client loved male voices, such as Don Williams,
country music and a soundtrack with East Asian instruments.
When the therapist held up the tambourine, the only way she
communicated with him was to tap the tambourine as the
music was being played through a VA floor. This particular
client had very limited mobility and suffered from spinal
sclerosis, which required external support, but her hands were
mobile and she had vision.
Palmer, Skille, Lahtinen & Ojala | Vibrations & Sensory Impairment
In a group session for five adult dual sensory impaired
clients, they were able to create music together as a group
using the African drums, tambourines, and shakers. This was
a very positive result, making creative music together made
them forget their own disabilities just for this brief moment.
This is an illustration of a socialising effect. Some clients with
multiple disabilities have problems with daily living skills such
as concentration, a weak bladder, or tension. These methods -
feeling music through the body using either VA music floors
or other means - have enabled them to take more control of
these daily living problems by sound massage of the organs.
Summary and Conclusions
This article has focused on clients with hearing or dual-
sensory impairment and the techniques outlined can be
applied with this client group. Perhaps one needs to consider
a new approach to the way we can feel and experience music -
instead of listening to the music auditively, we need to learn
how we can feel the vibrations and musical elements through
our bodies. This knowledge has taken over 25 years to reach
through using different types of VA/PA devices. However, it
is appreciated that not all venues have these facilities available.
That is why it is needed to take one step back to consider how
one is able to feel the musical tones using balloons or smaller
types of music equipment. To achieve this understanding it
may be appropriate for therapists themselves to carry out
some practical exercises as mentioned in the article, either
individually or as a group, and to share their experiences of
feeling music and how they felt. This is the only way we
appreciate how hearing impaired clients respond to music
through vibrosensoric experience.
It should be noted that sometimes hearing impaired
clients may need to use interpreting services in order to
communicate before, during, and after the therapy session.
Communication may not always be simple between client and
therapist for those with hearing impairments, so interpreting
services may be needed. Furthermore, if the client chooses to
use an interpreter, the therapist will get more positive results if
the interpreters are such that the client feels confident and
comfortable working with. Particularly in the case of dual
sensory impairment, the client needs time to get to know the
interpreters due to the different communication methods
appropriate in the therapeutic process.
Vibrational sensitivity can be particularly useful for client
with a dual-sensory impairment in relieving stress, reducing
leg pain, shoulder tension, increasing confidence, and general
wellbeing. The same effects have been found by other authors
[8, 10]. These effects can also be seen in the rehabilitation
process.
Furthermore, clients with multiple disabilities with a
hearing impairment would also benefit from VAT. This can
be provided as a part of their daily living skills programme.
MMD | 2017 | 9 | 3 | Page 181
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 178 – 183
The application of synchronised rhythms, movements, and
relaxation using different styles of music enables special needs
clients to improve their mobility, concentration, and general
coordination skills. This is due to certain musical styles and
the frequencies used producing constant rhythms and
vibrations to the body.
Acknowledgements
We would like to thank Petri Lehikoinen and Tony Wigram
posthumously for their comments and support during the
1990s.
References
1. Skille, O. & Wigram, T. (1995). The effects of music, vocalisation and
vibration on brain and muscle tissue: Studies in vibroacoustic therapy.
In Wigram, T., Saperston, B., & West, R. (1995). The Art and Science of
Music Therapy: A Handbook. Harwood Academic Publishers, UK.
2. Palmer, R. & Ojala, S. (2016). Feeling music vibrations - a vibrosensoric
experience. Proceedings of BNAM2016, paper53.
3. Lahtinen, R. & Palmer, R. (2005). Body Story. Creating Musical Images
through Touch (CMIT). Cityoffset, Tampere.
4. Palmer, R. & Ojala, S. (2011). Basic musical haptices. Retrieved May 26,
2017, from
https://matskut.helsinki.fi/bitstream/handle/123456789/176/MfA%202
011%20Stina%20Ojala.pdf?sequence=6
5. Palmer, R., Lahtinen, R. & Ojala, S. (2012). Musical Experience and
Sharing Musical Haptices. Procedia - Social and Behavioral Sciences 45,
351-358.
6. Lahtinen, R. (2008). Haptices and haptemes. A case study of
developmental process in social-haptic communication of acquired
deafblind people. Academic dissertation, University of Helsinki,
Finland.
7. Punkanen, M. & Ala-Ruona, E. (2012). Contemporary vibroacoustic
therapy: Perspectives on clinical practice, research and training. Music
and Medicine 4(3), 128-135.
8. Ailioaie, L. M., Ailioaie, C., Ancuta, C. & Chirieac, R. (2011). Effects of
physical and vibroacoustic therapy in chronic pain in juvenile arthritis.
Revista Română de Reumatologie, 10(3), 198-202.
9. Skille, O. (1997a). Potential applications of vibroacoustic therapy. In
Wigram & Dileo (1997). Music Vibration and Health. Jeffrey Books,
Cherry Hill, NJ, 49-57.
10. Wigram, T. (1996). The effects of vibroacoustic therapy on clinical and
non-clinical populations. Academic dissertation, St. George's Medical
School London University.
11. Dewhurst-Maddock, O. (1997). Healing with Sound - self-help
techniques using music and your voice. Gaia Books Limited.
12. Ladefoged, P. (1996). Elements of Acoustic Phonetics. University of
Chicago Press. 2nd edition.
13. Skille, O. (1989). Vibroacoustic Therapy. Music Therapy 8, 61-77.
14. Bergström-Isacsson, M., Lagerkvist, B., Holck, U., & Gold, C. (2014).
Neurophysiological responses to music and vibroacoustic stimuli in
Rett syndrome. Research in Developmental Disabilities, 35, 1281-1291.
15. Kerem, D. (2009). The effect of music therapy on spontaneous
communicative interactions of young children with cochlear implants.
InDiMedia, Department of Communication, Aalborg University.
Palmer, Skille, Lahtinen & Ojala | Vibrations & Sensory Impairment
16. Boyd-Brewer, C. & McCaffrey, R. (2004). Vibroacoustic sound therapy
improves pain management and more. Holistic Nursing Practice 18(3),
111-118.
17. Skille, O. (1997b). Making music for vibroacoustic therapy. In Wigram
& Dileo (1997). Music Vibration and Health. Jeffrey Books, Cherry Hill,
NJ, 235-241.
18. Lehikoinen, P. (1997). The physioacoustic method. In Wigram & Dileo
(1997). Music Vibration and Health. Jeffrey Books, Cherry Hill, NJ.
19. Helmholtz, H. L. F. (1877/1954). On the sensations of tone. Translated
into English 1954. Dover, New York.
20. Skille, O., Wigram, T. & Weekes, L. (1989). Vibroacoustic therapy: The
therapeutic effect of low frequency sound on specific physical
disorders and disabilities. Journal of British Music Therapy 3(2), 6-10.
21. Wigram, T. (1997a). The effect of vibroacoustic therapy compared with
music and movement based physiotherapy on multiply handicapped
patients with high muscle tone and spasticity. In Wigram & Dileo
(1997). Music Vibration and Health. Jeffrey Books, Cherry Hill, NJ, 69-
87.
22. Wigram, T. (1997b). The effect of VA therapy on multiply handicapped
adults with high muscle tone and spasticity. In Wigram & Dileo
(1997). Music Vibration and Health. Jeffrey Books, Cherry Hill, NJ, 57-
69.
23. Kandel, E. R., Schwartz, J. H. & Jessell, T. M. (2000). Principles of Neural
Sciences. Elsevier. 4th edition.
Biographical Statements
Russ Palmer Born 1959 in the UK. SRAT(M) music therapist,
vibroacoustic therapy practitioner, singer/ songwriter.
Researcher in Intensive Special Education (ISE) group in
University of Helsinki, Finland. Research interests include:
hearing and dual-sensory impairment, cochlear implant (CI)
music perception, vibrosensoric experience.
Olav Skille Born 1939 in Norway. Studied at Bergen
Lærerhøgskole 1959 - 1962 to be music teacher. Speciality
studies at University of Trondheim 1972 with brain injuries
AS speciality. Primary school reacher and head master at
several schools and institutions in Norway. Retired in 2002.
Scholarship from Norwegian dept. of education to find
therapeutic effects of music education in Norwegian special
schools. Grant from Nordic Council 1972 to find the
prognostic possibilities of The Music Behaviour Scale (MUBS)
- a Nordic research team that included Sweden, Denmark and
Finland education ministries. Created the Music Bath which
was renamed Vibroacoustic therapy (VAT). Participated in
several international congresses. Engaged to lecture on VAT
in Singapore, Colcata, Rome, London, Tallinn Pescara, and
the Nordic countries. Member of the VIBRAC core group
and a honorary member of the ISFMIM.
MMD | 2017 | 9 | 3 | Page 182
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 178 – 183
Riitta Lahtinen Born 1962 in Finland. PhD in Special
Education 2008, Lic. Phil. in Special Education 2004.
Researcher in Intensive Special Education (ISE) group in
University of Helsinki, Finland. Research interests include:
social-haptic communication, haptices, haptemes, dual-
sensory impairment, low- vision and mobility, audio
description.
Palmer, Skille, Lahtinen & Ojala | Vibrations & Sensory Impairment
Stina Ojala Born 1974 in Finland. PhD in Bioinformatics
2011, Lic Phil in Phonetics 2004. Speech scientist at
Department of Future Technologies, University of Turku,
Finland. Research interests include: language, speech,
acoustics, music, sensory impairments, enhanced
environment.
MMD | 2017 | 9 | 3 | Page 183
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 184 – 186 Hynynen, Aralinna, Räty & Ala-Ruona | Vibroacoustic Treatment Protocol

Clinical Report
Vibroacoustic Treatment Protocol at Seinäjoki Central Hospital
Jouko Hynynen1, Virpi Aralinna1, Maire Räty1, Esa Ala-Ruona2,3
1
South Ostrobothnia Healthcare District, Seinäjoki, Finland
2
Music Therapy Clinic for Research and Training, Finnish Centre for Interdisciplinary Music Research, Department of Music, Art and Culture
Studies, University of Jysväskylä, Finland
3
VIBRAC Skille-Lehikoinen Centre for Vibroacoustic Therapy and Research, Finland

Abstract
Vibroacoustic (VA) treatment is offered at the Department of Rehabilitation as part of specialized healthcare in the South
Ostrobothnia healthcare district. This clinical report describes VA protocol used at Seinäjoki Central Hospital, where VA has
been used since 1992, and the protocol is based on the extensive development project on VA from 1996-1999 [1]. According to
our clinical experience, the results are encouraging when VA is used as an additional treatment for patients with chronic pain,
musculoskeletal problems, specific neurological problems such as spasticity, and sleep disturbances. Also, comorbidity with
depression and anxiety is an additional indication for VA to be used with the patients. Systematic collection of clinical data and
continuous development of clinical practice have been essential in establishing and maintaining the high-quality services [2].
Still, no randomized controlled trials have been conducted at this facility.

Keywords: vibroacoustics treatment, specialized healthcare, rehabilitation multilingual abstract | mmd.iammonline.com

Introduction from a physiatrist (at the outpatient clinic), 22% from a

The Department of Rehabilitation in the South Ostrobothnia
hospital district consists of a rehabilitation unit (since 2012),
and outpatient clinics for occupational medicine and severe
pain. Multidisciplinary rehabilitation consists of
Vibroacoustic treatment (VA), physio-, occupational-,
speech-, neuropsychological, and active music therapy
services to all suitable patients on central hospital wards as
well as in the hospital outpatient clinics. Rehabilitation
services are mostly needed in neurological, psychiatric,
orthopedic, and pediatric clinics. There are 124 professionals
working at the rehabilitation unit. One VIBRAC-practitioner
works full-time serving approximately 85-95 patients
(approximately 870-940 visits) per year. 16% of the patients
receive their referral from a physician at the healthcare center,
occupational healthcare unit, or from a private practitioner,
24% from the rehabilitation ward at the central hospital, 21%
PRODUCTION NOTES: Address correspondence to:
Esa Ala-Ruona, E-mail: esa.ala-ruona@jyu.fi | COI statement: The
authors declared that no financial support was given for the
writing of this article. The authors have no conflict of interest to
declare.
Copyright © 2017 All rights reserved.
International Association for Music & Medicine (IAMM).
psychiatrist (at the outpatient clinic), and 17% from other
clinics within the central hospital. The VIBRAC-practitioner
has undergone certification training offered by the VIBRAC
Skille-Lehikoinen Centre for Vibroacoustic Therapy and
Research. In the hospital, the other trained practitioners
include one psychiatric nurse, one pain psychologist, and one
music therapist.
Patients are referred to VA by their physicians. Usually,
those with chronic pain or musculoskeletal or neurological
problems have already met a physiotherapist or other
therapists before receiving VA. Before the VA is begun, the
referring physician rules out any contraindications for
initiating this treatment, e.g. acute inflammation, early
pregnancy, general weakness, and low level of functioning;
however, conditions will be always individually assessed. The
VIBRAC-practitioner is responsible for planning the
treatment protocol for each individual patient.
Typical treatment periods consist of 10-20 appointments,
1-2 times per week. The sessions take place in a specially
equipped, soundproofed room. A “Next Wave Physioacoustic
Therapy Chair” is the main device used for treatment. This
recliner chair includes 6 audio speakers, one each at the neck
and back, 2 at the thighs, and 2 at the calves, through which
the patient is exposed to low frequency sound within the range
of 27-113 Hz. The computer generates and controls the low
frequency sinusoidal sound waves through the speakers.
Another pillow-like device, the Taikofon FeelSound Player, is
also in use. The sound stimulation is experienced as a
MMD | 2017 | 9 | 3 | Page 184
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 184 – 186
massage-like sensation by eliciting sympathetic resonance in
the muscles and other tissues, and side effects are rare. In the
beginning and at the end of each session of the treatment
period, the VIBRAC-practitioner and the patient have a
therapeutic conversation about the patient’s experience of the
treatment and the effects thereof on daily living and on the
patient’s functionality.
Treatment Protocol and Standards
Referral and treatment structure
When a patient is referred for VAT, the VIBRAC-practitioner
first becomes familiar with the patient’s disease and symptoms
through the medical report. Usually, a patient is referred for
10-20 sessions once a week but this may be increased to bi-
weekly sessions or follow an intervallic structure, with sessions
grouped into 2-3 phases throughout the year, depending on
the patient’s needs. The structure is assessed by the VIBRAC-
practitioner upon arrival and according to his/her experiences
of treatment processes.
During the first visit, the patient is interviewed and
asked to fill in VAS (Visual Analog Scale) forms measuring 9
characteristics: general arousal, vitality, mood, relaxation,
pain, quality of sleep, range of movement, limb temperature,
and quality of life. Despite the reason for referral, these areas
will be evaluated and the procedure has been proven to give
valuable information on possible changes and improvement
during the treatment process. The treatment program and
suitable intensity (volume) are individually chosen according
to the patient’s symptoms and current state. Music may be
listened to during the treatment, and can be either preferred
music chosen by the patient, or recommended by the VAT-
practitioner. The role of music is to support the nature of
treatment program (aiming for relaxation, activation, or
working with images), and also supporting the transfer effect
to everyday life (using the same music at home). An extensive
collection of music is available, and individual playlists may be
compiled. Music can be listened to either via headphones or
through speakers. The ideal position for the patient is then
tested; some patients cannot lie on their backs, so they must
receive the treatment in a seated position. The patient may
also use a weight blanket, placed over them during the
treatment – or alternatively a lighter blanket – thus helping
the patient to relax and feel protected and warm. The
treatment room itself has adjustable lighting and it can be
dimmed for the patient’s comfort during the treatment.
Treatment programs
The treatment programs usually last between 20-40 minutes.
The practitioner designs the program based on the symptoms
registered in the patient referral; the most common program
used is a general relaxation program that centers around
40Hz. The general principle is that the programs start at lower
frequencies and volume, so the patient can become
Hynynen, Aralinna, Räty & Ala-Ruona | Vibroacoustic Treatment Protocol
accustomed to the sensation, thus reducing the risk of
negative outcomes. The intensity of the program may be
adjusted during the treatment if needed. Each aspect of the
treatment program can be designed to suit the patient; the
frequency, the nature of the program (activating or relaxing),
the phasic and cumulative durations, and the strength of the
stimulation on the neck, back, thighs, and calves. The
practitioner stays in the room during the treatment to be able
to immediately react to the patient’s needs, to make any
necessary changes, and to observe the patient’s behavior.
After the sessions
After the treatment, the patient has the opportunity to recover
or reactivate little by little. Also at this point, the practitioner
will lead a reflective discussion on the patient’s sensations and
feelings, as well as the immediate effects that the patient
experienced such as whether there were certain pain points
that dissipated or were aggravated by the stimulation, or how
the patient experienced the state of relaxation and music
listening. Close relatives or a physiotherapist, with whom the
patient is familiar, often communicate about possible changes
in functionality. A new treatment program or intensity may be
chosen based on these experiences and the feedback collected.
Assessment, evaluation, and reporting
Each visit is recorded using an electronic medical record
system; for example, while treating insomnia, the program
used, along with the changes made to the program, changes in
functional capacity, and the music used, are recorded in this
system. During the last sessions, the patient completes the
final VAS measurements. These completed scales are then
discussed with the patient as well as the treatment as a whole
(over the 2-3 month period). Possible follow-up is also
planned in the hospital or via private practice, if needed. The
VIBRAC-practitioner then writes the final assessment,
including whether the patient should be referred for further
treatments, and returns this to the referring physician.
Concluding Remarks
Even though only a few randomized controlled trials (RCTs)
have been published during the last decades of VAT, it is
commonly used as an additional treatment for patients with
spasticity, pain, sleeping disorders, depression, and anxiety.
The active and systematic development of VAT-practices,
follow-up procedures, and reporting has shown the
possibilities of VAT as part of specialized health care and
rehabilitation. According to our clinical experience, VAT can
be safely given to patients with post-stroke pain and spasticity,
as well as stable traumatic brain injury patients, and patients
with certain musculoskeletal problems. VAT may play some
role in achieving rehabilitation goals by reducing the
symptoms from which patients are suffering. For more details
on the clinical results of chronic pain patients with co-
morbidities of depression and anxiety, see pages (187-197) of
MMD | 2017 | 9 | 3 | Page 185
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 184 – 186 Hynynen, Aralinna, Räty & Ala-Ruona | Vibroacoustic Treatment Protocol

this issue. Despite these reports and anecdotal practice-based Biographical Statements
evidence, more large-scale, well-designed, and high-quality
studies (series of exploratory case studies, clinical trials, and Jouko Hynynen is a VIBRAC-practitioner at Seinäjoki Central
RCTs) are needed [3]. Hospital in South Ostrobothnia, Finland.

Virpi Aralinna, MSc, OT, is the Chief Occupational therapist

References at Seinäjoki Central Hospital in South Ostrobothnia, Finland.

1. Ala-Ruona E. Fysioakustisen hoidon kehittämisprojekti Seinäjoen Maire Räty, M.D., Ph.D., is the Head of the Rehabilitation
sairaalassa [Project for developing the physioacoustic treatment in Ward at Seinäjoki Central Hospital in South Ostrobothnia,
Seinäjoki Central Hospital]. Seinäjoki: South Ostrobothnia Health Care
District, Physiatrics and Rehabilitation/Music Therapy; 1999.
Finland.
2. Ala-Ruona E. Fysioakustinen hoito osana erikoissairaanhoitoa ja
kuntoutustutkimusta [Physioacoustic treatment as a part of specialized Esa Ala-Ruona, Ph.D., is a music therapist, psychotherapist,
health care and rehabilitation assessment]. In: Ala-Ruona E, Erkkilä J, and senior researcher at the Finnish Centre for
Jukkola R, Lehtonen K, (eds.) Muistoissa Petri Lehikoinen. Jyväskylä: Interdisciplinary Music Research at the University of
Suomen musiikkiterapiayhdistys ry; 2003: 173-193.
3. Punkanen M, Ala-Ruona E. Contemporary vibroacoustic therapy:
Jyväskylä, Finland. Corresponding author: esa.ala-
Perspectives on clinical practice, research, and training [published ruona@jyu.fi
online May 17, 2012]. Music Med doi: 10.1177/1943862112445324.

MMD | 2017 | 9 | 3 | Page 186

Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 187 – 197 Campbell, Hynynen, Ala-Ruona | VA for Pain and Mood

Full-Length Article
Vibroacoustic Treatment for Chronic Pain and Mood Disorders in a Specialized Healthcare Setting
Elsa A. Campbell1, Jouko Hynynen2, Esa Ala-Ruona1
1
Music Therapy Clinic for Research and Training, Finnish Center for Interdisciplinary Music Research, Department of Music, Art and Culture
Studies, University of Jyväskylä, Finland
2
South Ostrobothnia Healthcare District, Seinäjoki, Finland

Abstract
Much of what we know about vibroacoustic (VA) treatment and its efficacy has been published in case reports. Recent clinical
trials have increased awareness of this treatment for target groups such as those with Parkinson’s Disease and Fibromyalgia
Syndrome. Protocols for using VA treatment have not been concreticized although there has been a focus on using 40Hz.
Seinäjoki Central Hospital has used VA treatment for more than two decades, with patient reports on Visual Analogue Scales
being systematically recorded and showing positive outcomes on several measures including pain and mood. This treatment is
offered on the rehabilitation unit as part of specialized heathcare in the South Ostrobothnia healthcare district in Finland. This
paper describes VA treatment utilized within this unit, with a focus on pain and mood outcomes as reported by subjective patient
reports, and practitioner and patient comments.

Keywords: vibroacoustic treatment, chronic pain, mood, music listening multilingual abstract | mmd.iammonline.com

Introduction (PAT), and Rhythmic Sensory Stimulation (RSS) – is low

According to the World Health Organization, 1 in every 15
Europeans suffers from major depression, whilst anxiety
affects nearly 4 out of 15 people, with rates in women
significantly higher than in men [1]. Furthermore,
musculoskeletal pain is prevalent, with one fifth of adult
populations reporting widespread pain, one third
experiencing shoulder pain, and up to one half suffering from
lower back pain [2]. Musculoskeletal conditions are the most
common reason for chronic pain and disability in the EU and
lead to significant healthcare and social costs. Interest in using
music interventions within medical settings has been growing
in the past decades. Vibroacoustic treatment is an example of
such an intervention, yet an exploration of this used within a
multidisciplinary team has been sparsely reported.
Vibroacoustic (VA) treatment – otherwise known as
Vibroacoustic Therapy (VAT), Physioacoustic Therapy
PRODUCTION NOTES: Address correspondence to:
Elsa A. Campbell, E-mail: elsa.campbell@vibrac.fi
| COI statement: The authors declared that this work was
supported by the Faculty of Humanities, University of Jyväskylä,
Finland. The authors have no conflict of interest to declare.
Copyright © 2017 All rights reserved.
International Association for Music & Medicine (IAMM).
frequency (30–120Hz) sound vibration, with music listening,
applied for therapeutic purposes [3]. It has been shown to
increase pressure-to-pain thresholds [4], to increase ability to
work, improve quality of sleep, and help in reducing or
discontinuing analgesic consumption [5] in people with
fibromyalgia. VA treatment has also been shown to improve
cognition in Alzheimer’s patients [6], and decrease pain [7]
and improve functional capacity, and increase blood
circulation in the elderly [8]. Improved passive range of
motion during physical therapy [9], and improved mood,
coping skills, and concentration have also been reported [10],
among others. The range of applications indicates VA
treatment could be a useful addition to multidisciplinary
healthcare practice.
Mechanisms
Pain mechanisms are not well understood. Continued
nociception can lead to dysfunction in the messages conveyed
to the central nervous system. These changes indicate
plasticity in the nervous system, perhaps leading to neural
sensitization. The Neuromatrix Theory proposes the
importance of learned responses to persistent pain. It is
suggested that pain may be suppressed by sensory and
evaluative processes, as well as by the activation of our
endogenous opioid system [11]. The cumulative negative
effects of stress are argued to account for individuality in pain
responses, thereby highlighting a person’s personal pain
history as a factor in their present-day pain responses.
MMD | 2017 | 9 | 3 | Page 187
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 187 – 197
Chronic pain has been shown to alter thalamocortical
connections resulting in disrupted thalamic neuronal behavior
[12]. VA treatment may drive neural rhythmic oscillatory
activity, thereby resetting this dysrhythmia [5]. Relaxation is
one of the effects reported by patients and is described as
resonant oscillation achieved by the targeted area’s specific
frequency matching that of the low frequency sound [13].
Increasing relaxation and decreasing stress may help to
regulate or reset pain responses that have been learned over
time.
Rehabilitation within Specialized Healthcare at Seinäjoki
Central Hospital
VA treatment is offered as part of specialized healthcare at the
rehabilitation unit of Seinäjoki Central Hospital in
Ostrobothnia, Finland, by a full-time VIBRAC-practitioner.1
(Although the general protocol for these patients will be
discussed in this paper, further information on the treatment
protocol used at this facility can be found in a clinical report
on pages 184-186 of this issue.) This multi-modal treatment
setting is used to treat either in- or outpatients whose multiple
symptoms have been especially difficult to treat. These
patients may have received previous treatments, yet their
symptoms persisted. Patients referred to this unit suffer from
various physical, psychological, and emotional symptoms.
Multidisciplinary rehabilitation programmes are beneficial in
addressing sensory, physiological, emotional, and social
issues, and can be a catalyst for patients’ discharge after
intensive multidisciplinary rehabilitation [14]. Such outcomes
work towards increasing patient autonomy; Bettger and
Stineman [ibid.] also explained that measures of depression,
anxiety, or stress could be important elements to consider in
understanding how patients react to an intervention.
This paper presents the use of VA treatment for pain and
mood disorders within the specialized healthcare
rehabilitation unit at Seinäjoki Central Hospital. These cases
are extracted from a naturalistic setting, meaning there was no
control group for comparison. These rich data afford a unique
opportunity to examine VA treatment use within a medical
setting.
2. Method and Materials
Case reports and VAS measurements from 29 chronic
musculoskeletal pain patients with comorbidities of mood
disorders treated within specialised rehabilitation during
2014-2015 were selected. As per standard protocol, the
patients’ pre- and post-treatment outcomes were recorded
using Visual Analogue Scales (VAS) assessing general arousal,
vitality, mood, relaxation, pain, sleep quality, range of
movement, limb temperature, and quality of life. A VAS is a
1
The VIBRAC-practitioner has been trained by the VIBRAC Skille-
Lehikoinen Centre for Vibroacoustic Therapy and Research.
Campbell, Hynynen, Ala-Ruona | VA for Pain and Mood
single-item continuous scale consisting of a horizontal 100-
millimeter line, which is anchored by two descriptors. These
scales are self-administered, with patients asked to mark a
perpendicular line at the point that best represents their
current state. This is then measured with a ruler to determine
the numerical value [15].
The anchors for the pain VAS were unbearable pain and no
pain, and depressed and happy for mood. The pre- and post-
treatment measurements were recorded as part of standard
hospital protocol, as such that the patient does not see the pre-
treatment measurement when completing the post-treatment
scale. In addition to these VAS outcomes, the VIBRAC-
practitioner took general notes on the patients’ state and
recorded their statements/reactions to the treatment (see
Table 4).
2.1. Treatment Protocol
Patients typically receive 10 weekly sessions. This varies
depending on the patients’ individual needs however and they
may initially receive treatment twice a week. The patient
receives the treatment in a Physioacoustic chair (Next Wave),
a recliner with in-built loudspeakers located at the neck, back,
thighs, and calves. The low frequency sound waves are
computer-generated and controlled, and are transmitted
through loudspeakers built into the chair. The stimulation
software used at this healthcare unit is Sonus Health Editor
v3.26c. In this system, the frequencies range from 27.13–
113.22 Hz. The device is approved by the Food and Drug
Administration (FDA) in the USA, the Canadian Standards
Association (CSA), and the British Standards Institution
(BSI), and is classified as class-II, low risk, and non-invasive.
Three claims are permissible: muscle relaxation, stress and
pain reduction, and increased blood and lymphatic
circulation.
The program parameters include time, frequency, scan,
speed, cycle (or pulsation), strength, and action (direction).
The programme is divided into phases of various lengths
measured in minutes. The frequencies are measured in Hertz
(Hz) and range from 29.15–61.04 Hz. Scan refers to the range
of frequencies above and below the fundamental frequencies
in each phase, which is done so as to avoid numbness. For
example, in phase 1 of this programme, the fundamental
frequency was 40.27 Hz and the scanning action moved from
39.26–41.34 Hz. Speed refers to how fast the frequencies in
this scanning action change. Here, the frequencies modulated
every 16 seconds. Cycle is the speed of the pulsation (volume
change). This varies from silence (amplitude = 0 dB) to the set
maximum (n > 0 dB), then returning to silence. The length of
this pulsation cycle was an average of 11.09 seconds (range
7.76–16.25 seconds). The strength of the program is set for
each speaker location. These values are presented as dBC
(decibels relative to the carrier) and were 53.6–103.1 dBC,
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52.6–103.9 dBC, 56.5–108.2 dBC, and 59.7–103.5 dBC for the The VAS outcomes, the practitioner’s clinical
neck/shoulders, back, thighs, and calves respectively. Finally, observations, patients’ comments, and the music listening
action refers to whether the sound moves from head to toe, or choices are recorded in an electronic medical record system.
vice versa. The direction varied almost every second phase, In interpreting these VAS outcomes, the minimal clinically
except for the last phase in which there was no directional important difference (MCID) was selected. MCIDs are scores
movement. The speed of the direction is also influenced by the that reflect changes that are meaningful for a patient.
cycle: the faster the cycle, the faster the directional movement. Although caution should be used when applying this principle
Music listening is often part of the treatment and patients to group scores, these may nevertheless show a general trend.
listen either by headphones or via speakers. They were asked Accepted changes in numerical rating scales for pain intensity
what kind of music they would like to listen to and instructed are 10mm reduction corresponding to a minimally important
to choose music that relaxes them. If they did not have change, and 20–27mm reduction associated with fewer
anything in particular in mind, the practitioner offered requests for medication and relating to “much” or “some”
suggestions. Usually they decided to listen to improvement [16]. As there is no way to determine group
instrumental/classical music, however client preference also differences in these data (because there is no control
meant that patients chose to listen to more rhythmic music condition), the MCID is applied here only as a means of
such as heavy/symphonic metal. All patients presented here attempting to contextualize the outcomes reported.
listened to music during their treatment sessions; the full
discography of music choices is shown in Appendix A Results
presented according to genre.
Music is used in addition to the low frequency sound to Data on 29 patients treated during 2014–2015 are presented.
encourage relaxation and as a means of offering a multi-modal They received treatment for chronic musculoskeletal pain,
treatment experience. As described by Chesky and Michel [4], depression, anxiety, or a combination. The demographic data
this combination takes a “two-pronged” approach to pain are shown in Table 1. As this was part of multidisciplinary
management, with the music listening working on a rehabilitation, some patients underwent other treatments
psychological level, and the physiology being affected by the simultaneously, which does not allow for efficacy assessment,
transcutaneous- applied sound vibration. The low frequency rather gives a picture of VA treatment protocol within a
sound vibration works on its own, however the experience is specialized healthcare unit. All patients presented in this study
enriched when music listening is also a part of the treatment. listened to music during their treatments.
Patients have the choice whether they would like to listen to
music or not and it may occur that clients wish to listen to Table 1. Demographic data, other treatments,
music through the speakers whilst talking with the and medication intake
practitioner about their illness/situation throughout the Characteristics of n=29 patients
treatment program. Age [Mean (SD)] 49.67(10.92)
A session typically begins with a discussion between the Gender [n (%)]
VIBRAC-practitioner and the patient, followed by the VA Female 19 (65.52)
treatment with music listening, and again ending with a Male 10 (34.48)
discussion on the potential sensations, experiences, and/or
emotions evoked during the treatment. The choice of program Weight in kilograms [Mean (SD)] 86.55 (23.09)
and frequencies administered is also based on the patients’
n (%) undergoing other treatments: 21 (72.41)
diagnoses, but the strength of the program can be varied Physiotherapy 11 (37.93)
during the treatment program if a patient feels the stimulation Psychotherapy 4 (13.79)
to be either too much or too little. The most commonly used Intermittent massage 1 (3.45)
programme is General Relaxation, which centers around 40 Discussions with/support from a 4 (13.79)
Hz, lasting usually between 20–40 minutes. The program used psychiatric nurse
with these patients ranged from 27.13–61.04 Hz and lasted 36 n (%) taking medication 26 (89.66)
minutes. This programme is most often used at this facility as n (%) of these taking:
it tends to elicit a strong relaxation response, and clinical Analgesics & mood regulators 11 (42.31)
practice has shown patients tend to respond better to Analgesics alone 4 (17.39)
frequencies within the lower frequencies of the 27.17–133.22 Mood regulators alone (anti-depressants, 5 (21.74)
anti-psychotics, anti-anxiety)
Hz range. If a patient responds especially well to a particular Other (hypertension, insomnia, muscle 8 (34.78)
frequency, this part may be lengthened. The program is relaxants)
usually started at a lower intensity when a client begins these
sessions to avoid possible side effects and so the client
becomes accustomed to the sensation.

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89.66% of patients were taking medication in addition to VA series of VA treatment sessions after a pause (biphasic). After
treatment, with 42% of these patients taking a combination of preliminary analysis, in order to better understand the
analgesics and mood regulators. 72.41% of patients also patients’ outcomes – and because post-treatment relaxation is
received other treatments before, during, or after VA reported by most patients – the relaxation VAS pre- and post-
treatment. For patients in need of psychotherapy, the waiting treatment measures were also extracted. Table 3 shows the
list is quite long and is separately organised and coordinated mean improvement (in mm) and standard deviations from
by the Finnish Social Insurance Institution, Kela. Data are not baseline to the final pain, mood, and relaxation assessments
available if the patient was undergoing psychotherapy for patients who received treatment in both one and two
elsewhere. As discussed earlier, all patients listened to music phases.
during their sessions, with these choices ranging from heavy
metal to ambient/easy listening. Table 2 outlines these Table 3. Average VAS improvements in mm
patients’ psychological and physical symptoms. Some Groups Mean
VIBRAC-practitioner clinical observations and patients’ (SD)
comments are presented in Table 4. Pain Mood Relaxation
Monophasic patients’ 18.96 16 34.22
scores (n=23) (25.37) (16.45) (26.42)
Table 2. Most common symptoms
Symptom category Descriptor
Psychological Depression, social anxiety disorder, panic
symptoms attacks, somatic symptom disorder, Biphasic patients’ scores
Obsessive Compulsive Disorder, trauma- (n=6)
related symptoms Phase 1 16.83 21.5 37.83
(13.41) (18.81) (21.57)
Physical symptoms Rheumatoid arthritis, spondylitis, Phase 2 10.67 0.67 29.33
osteoarthritis, neck tension, (17.87) (8.40) (14.99)
neck/shoulder pain, upper arm pain,
Degenerative Disc Disease, neck tension,
fibromyalgia, chronic pain syndrome, Monophasic patients’ data are presented as VAS pre- and
whiplash post-treatment scores for pain (Figure 1), mood (Figure 2),
and relaxation (Figure 3).
Of the 29 patients presented, 23 received VA treatment in one
phase (monophasic), whilst 6 patients returned for a second

Monophasic patients

100
90
VAS Measurement (0-100mm)

80
70
60 Pain Pre-
50 Treatment
40
30
20 Pain Post-
Treatment
10
0
1 8 9 12 17 18 23 25 28 30 31 32 39 40 41 44 47 48 50 54 59 60 62
Patient ID Codes
Figure 1. Monophasic patients’ (n=23) pain levels pre- and post-treatment

The majority of patients (n=23) received treatment in one corresponding to a minimal–moderate MCID. Some patients
phase, with a mean mm improvement (and standard reported quite drastic pain improvements, with similar
deviation) of 18.96 (25.37) in pain, and 16 (16.45) in mood, improvements in relaxation (Figure 3), as shown by, for

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example, patient 60. Others presented a worsening in pain and relaxation (Figure 3).
levels (e.g. patient 17) but an improvement in mood (Figure 2)

100
VAS Measurements (0-100mm)

90
80
70 Mood Pre-
60 Treatment
50
40
30 Mood Post-
20 Treatment
10
0
1 8 9 12 17 18 23 25 28 30 31 32 39 40 41 44 47 48 50 54 59 60 62
Patient ID Codes

Figure 2. Monophasic patients’ (n=23) mood levels pre- and post-treatment.

Although patient 23 reported barely any improvement in pain relaxation is a relevant factor. The small sample size prevents
or mood, her relaxation score had very much improved after any in-depth or subgroup analyses.
the treatment. As with many of these patients, it is clear that

100
VAS Measurement (0-100mm)

90
80
70 Relaxation pre-
60 treatment
50
40 Relaxation
30 post-treatment
20
10
0
1 8 9 12 17 18 23 25 28 30 31 32 39 40 41 44 47 48 50 54 59 60 62
Patient ID Codes

Figure 3. Monophasic patients’ (n=23) relaxation levels pre- and post-treatment.

Biphasic patients pain (Figure 4), mood (Figure 5), and relaxation (Figure 6)
For patients who received treatment in two phases (n=6), the outcomes for the first and second treatment periods. Each
results are presented according to the pre- and post-treatment

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grouping of four columns represents one individual patient’s

outcomes.

100
90 Pain Pre 1st
VAS measurements (0-100mm)

80 treatment
70
Pain Post 1st
60
treatment
50
40 Pain Pre 2nd
30 treatment
20
10 Pain Post 2nd
treatment
0
4 5 13 19 20 34
Patient ID Codes

Figure 4. Biphasic patients’ (n=6) pain levels pre- and post- treatment

Again, the scores showed – to some degree – improvement in
pain scores, however, these remain somewhat difficult to
interpret conclusively. Patient 19 shows improved pain post-
phase 1, which then returns to baseline post-phase 2. A slight
decrease is also reported in mood scores. Contextualizing the
pain and mood outcomes within those of relaxation help to
give a clearer picture. This patient appeared much more
relaxed after both phases 1 and 2, leaning towards a positive
outcome for this individual.

100
90
VAS measurements (0-100mm)

Mood Pre 1st

80
treatment
70
60 Mood Post 1st
50 treatment
40
30 Mood Pre 2nd
treatment
20
10 Mood Post 2nd
0 treatment
4 5 13 19 20 34
Patient ID codes

Figure 5. Biphasic patients’ (n=6) mood levels pre- and post- treatment

Again, patient 20 shows that the relaxation outcomes reflect
another dimension to the pain symptoms and mood disorder,
thereby highlighting the importance of appreciating the
patient’s pain story in its entirety.
However, the relaxation outcomes did not consistently
clarify the pain or mood outcomes. Patient 13 reported
deterioration in pain and mood, but relaxation remained
somewhat similar after both phases. This patient presented
with fibromyalgia and comorbid depression; the difficulty in
treating this syndrome is highlighted by this patient’s VAS
scores. She reported feeling much better afterwards, especially
the day of and day after receiving the low frequency sound
stimulation. This improvement, the practitioner noted, was
not reflected in the VAS reports.

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100
VAS Measurements (0-100mm)

90 Relaxation pre
80 1st treament
70
Relaxation post
60 1st treatment
50
40 Relaxation pre
30 2nd treament
20
Relaxation post
10
2nd treatment
0
4 5 13 19 20 34
Patient ID Codes

Figure 6. Biphasic patients’ (n=6) relaxation levels pre- and post- treatment

The pain, mood, and relaxation scores across all patients
(n=29) show quite a lot of individual variation. VAS and
verbal reports made by the same patient were sometimes
antagonistic; even if the VAS outcomes showed very little
improvement, the patients verbally expressed feeling better
after the treatment. Some of these verbal reports are presented
in Table 4.
Table 4. Patient responses and practitioner notes on the treatment.
Pain relief
Significant improvement in the situation; easier to undergo
physiotherapy in the absence of pain.
Relaxation
Easier to fall asleep; surprised at the ability to relax; improved
mood; improvement in neck/shoulder tension.
Reduction in medication
Reduction in Mirzapin – from 30mg to 15mg after only one
month of treatment.
Quality of sleep
“I fell asleep faster and listened to the same music at home when
going to sleep; the treatment forced me to relax.”
Duration of effects
He slept for 15 minutes in the first session. Slept without needing
medication that night, slept through until morning. After the
treatment, his anxiety melted away and stayed away for a few
days. After the third visit, he didn’t need relaxation medication
for three days (normally only one day).
Discussion
The implementation of VA treatment at a rehabilitation unit
as part of specialized healthcare has been presented. Decreased
pain, improved mood and sleep, reduction in analgesic intake,
and increased relaxation are among the effects often reported
after VA treatment [4,6,8,10]. These effects have also been
shown in the 29 patients presented here, although interpreting
results within a multidisciplinary setting is complex.
Zisapel and Nir [17] showed that a statistically significant
change of 10mm in VAS scores is clinically significant for
both pain and mood, corresponding to patient ratings of “a
little better”. Furthermore, a 20-27mm increase corresponds
to ratings of “much” or “some” change [16]. Large
improvements can be seen here in individual patients’ pain,
mood, and relaxation scores, particularly in monophasic
patients. However, Katz, Paillard, and Ekman [18] caution
that relying on the MCID as a determinant of clinical
decisions may not be the best approach; the changes in pain
scores do not tell the whole story. The patient may report
clinically relevant changes in other measures, such as
relaxation, as was shown here. Exploration of the whole
patient’s experience is essential; by focusing only on one
aspect of the pain experience, only a part of the outcomes are
understood. This also recapitulates the complexity of the data
presented here.
Patient comments
An interesting observation of these patients’ experiences is the
incongruent responses between the subjective verbal
comments and the VAS outcomes. Patient 19 reported
sleeping much better after the treatment even though this was
not reflected in the VAS outcomes – rather her condition
appeared to have deteriorated. This discrepancy between

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subjective verbal reports and VAS outcomes has also been
reported earlier [19]. Although the VAS outcomes did not
support the comments this patient made on the process, it is
prudent to remember that pain experiences are unique to the
individual. Practitioners treating a patient with chronic pain
cannot define or understand the subjective experience, further
stressing the importance of multiple outcome measures. The
catalyst for improved wellbeing may be the combination of
factors addressing sensory, physiological, and emotional
needs. Chronic pain is a multi-layered phenomenon, affecting
the patient in many facets of their lives, and the aim should be
to address all of these aspects.
Interpreting outcomes
Relaxation is often an after-effect of VA treatment and the
pre- and post-treatment scores presented here support this.
Increased relaxation may help to reset the learned response of
dysfunctional pain processing associated with the cumulative
negative effects of chronic pain, anxiety, and depression. If
stress is accountable for individual differences in pain
perception – and thereby an agent of chronicity – increasing
relaxation so as to decrease stress may aid in regulating and
resetting learned pain responses. However, as neither the
underlying mechanisms of chronic pain nor those of low
frequency sound stimulation are fully understood, further
research is needed to delve into the multifaceted nature of
chronic pain and comorbid mood-related phenomena and the
effects VA treatment exerts thereafter.
One limitation of the data presented here may be that
only pre- and post-treatment process VAS measurements
were taken. Punkanen and Ala-Ruona [2012] explained that in
recording only the two measurement points, we might not see
the range of a client’s experiences of a process. This indeed
may be the case, as the measurements are simply recorded on
the first and last day of the treatment, rather than throughout
the entire experience. Although patients give a subjective
account of how they perceived VA treatment, this does not
show as much detail as would weekly measurements. Taking a
patient’s final measurements on a day they experience
especially high pain levels, for example, may potentially skew
an effective measurement of the process.
Conclusion
The positive outcomes of the patients at Seinäjoki Central
Hospital support current knowledge on the effective
application of VA treatment and music listening for both
chronic pain and mood disorders. Most patients were
undergoing or had received other treatments around the same
period, such as physiotherapy. Objective markers, such as
cortisol levels, should also be explored in future research.
Although pain is a subjective experience, interpreting patient
experiences according to standardized frames - such as the
Campbell, Hynynen, Ala-Ruona | VA for Pain and Mood
minimal clinically important difference – increases validity
and generalizability in experiential reports.
These data were collected as part of standard hospital
protocol and represent the application of this treatment in a
naturalistic setting. Therefore, it is not possible to ascertain
which treatments – or whether it was their combination –
were the catalysts for change due to the lack of a control
group. However, the narrative presented shows that VA
treatment can be beneficial when used within a
multidisciplinary unit, and that the subjective differences
presented by patients are moderately clinically relevant. This
account affords an interesting insight into the workings of a
multidisciplinary treatment process.
VA treatment is growing but the evidence supporting its
efficacy is relatively sparse. Non-controlled studies cannot
report on the efficacy of a treatment, yet reporting protocols
followed in a naturalistic setting provides information on how
a treatment may function within a larger context. A plurality
of methods and reports is necessary for the future of VA
research. Randomized controlled trials are indeed needed to
discuss the efficacy of the stimulation, yet these should not
detract from qualitative reports of patient experiences.
Acknowledgements
The authors wish to thank Ivar Vinkel, M.A., for his assistance
in the preparation of this manuscript and Dr. Med. Heikki
Suoyrjö for his insights and support.
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Biographical Statements
Elsa Campbell, M.A., is a doctoral student of music therapy at
the Music Therapy Clinic for Research and Training, Finnish
Centre for Interdisciplinary Music Research, Department of
Music, Art and Culture Studies, University of Jyväskylä,
Finland. Coordinator for the VIBRAC Skille-Lehikoinen
Centre.
Jouko Hynynen is a VIBRAC-practitioner at the Seinäjoki
Central Hospital in South Ostrobothnia, Finland.
Esa Ala-Ruona, Ph.D., is a music therapist, psychotherapist,
and senior researcher at the Finnish Center for
Interdisciplinary Music Research at the University of
Jyväskylä, Finland.
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Appendix A

Discography

Classical
Johansson L. Bach for Meditation. [Album]. Naxos. 2004.
Johansson L. Beethoven for Meditation. [Album]. Naxos. 2003.
Johansson L. Mozart for Meditation. [Album]. Naxos. 2004.

Easy Listening/Ambient
Clayderman R. All by myself [Album]. Recall (UK). 2000.
Enya. A day without rain [Album]. WEA. 2000.
Enya. The magic of Enya. [Róisín and Celtic Spirit. Album] Newsound. 2000.
Enya, Ryan R. The very best of Enya. [Enya]. Reprise. 2009.
Gregorian. Masters of Chant. Edel America Records. 1999.
Oldfield M. Voyager [Album]. Voyager. 1996.
Vinkel I. Meri Panga Panga All [The sea below the cliff of Panga]. [Album]. Orbital Vox Records. 1999.

Electronic
Jarre MJ. Chronologie [Album]. Polydor. 1993.

Folk/Country/World
Passenger. All the little lights [Album]. Embassy of Music. 2012.

Metal
Aaltonen R, Häkkinen C, Järvinen A. Get on. Love Records. 1974
Aaltonen R, Järvinen A, Maijanen P. Bourbon Street. Polar studios. 1980.
Bell R, Downey B. Whiskey in the Jar. Karussell. 1996.
Bon Jovi J, Sambora R, Child D. You give love a bad name. Mercury. 1986.
Bon Jovi J, Sambora R. It’s my life. Island. 2000.
Blackmore R. Gillian I, Glover R, Lord J, Paice I. Highway star. EMI. 1972.
Blackmore R, Dio JD. A light in the black. Polydor. 1976.
Blackmore R, Glover R. Lost in Hollywood. Polydor. 1979.
Blackmore R, Coverdale D. Stormbringer. Purple. 1974.
Blackmore R, Lynn Turner J. Street of Dreams. Polydor. 1983.
Blackmore R, Gillan I, Glover R. Perfect Strangers. Polydor. 1984.
Blackmore R, Gillan I, Glover R. Wasted sunsets. Polydor. 1984.
Bryant B. Love Hurts. Warner Bros. 1961.
Cartellone M, Chase C, Medlocke R, Rossington G, Thomasson H, Van Zant J. Still Unbroken. Nashville, Tennessee: The All
Blacks. 2009.
Cooper A, Child D, McCurry J. Poison. Epic. 1989.
Cooper A, Child D, Bon Jovi J, Sambora R. Hell is living without you. Epic. 1989.
Coverdale D. We wish you well. United Artists. 1979.
Coverdale D, Marsden B. Here I go again. Geffen. 1987.
Coverdale D, Aldrich D. Best years. SPV/Steamhammer. 2008.
Dio RJ. Don’t talk to Strangers. Warner Bros. 1983.
Dio RJ. Holy diver. Warner Bros. 1983.
Fogerty J. Lookin’ out my back door. Fantasy. 1970.
Gillan I, Glover R, Lord J, Morse S, Paice I. Don’t make me happy. EMI Switzerland. 1998.
Gillan I, Towns C. Sleeping on the Jon. Virgin. 1980.
Gillan I, Glover R, Morse S, Airey D, Paice I. Things I never said. Eagle Records. 2005.
Harburg EY, Brooker G, Arlen H, Reid K. Weisselklenenacht [The signature]. Eagle Records. 2003.
Henley D, Leadon B. Witchy Woman. Asylum. 1972.
Hensley K. Easy livin’. Bronze. 1972.

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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 187 – 197 Campbell, Hynynen, Ala-Ruona | VA for Pain and Mood

Hetfield J, Hammett K, Ulrich L. The unforgiven. Elektra. 1991.

Holopainen T. Nemo. Nuclear Blast. 2004.
Lynott P. The boys are back in town. Vertigo. 1976.
Mercury F, Deacon J. Friends will be friends. EMI. 1986.
Meine K. Wind of Change. Vertigo. 1991.
Osbourne I, Rhoads R, Daisley B. Mr. Crowley. Epic. 1980. Osbourne O, Frederiksen M, Jones M. Dreamer. Sony. 2001.
Page J, Plant R. Stairway to heaven. Atlantic. 1971.
Perry J, Tyler S. Love in an Elevator. Geffen. 1989.
Tyler S. Dream on. Columbia. 1973.
Tyler S, Supa R. Amazing [Orchestral Version]. Geffen. 1993.
Van Halen E, Van Halen A, Roth DV, Anthony M. Ain’t talkin’ ‘bout love. Sunset Sound Recorders. 1978.
Walsh J, Grey G, Henley D. Life in the fast lane. Asylum. 1977.
Warwick R, Johnson D, Gorham, S, Mendoza, M, Wharton D. All hell breaks loose. Los Angeles: Nuclear Blast. 2013.
Waters R. Hey you. Harvest. 1979.
Waters R. Another brick in the wall, pt 2. Harvest. 1979.
Westerholt R, den Adel S, Spierenburg M. Memories. Roadrunner. 2005.

New Age
Levantis. Stress Release. Dynamic Entertainment Ltd. 2001.

Popular
Clayderman, R. Memories [Album]. Telefunken. 1979.
Il Divo. Il Divo [Album]. Syco Music. 2005.
The Shadows. 20 golden greats. EMI. 1977.
Vartiainen J. Terra [Album]. WEA. 2013.

Rock/Hard Rock/Pop Rock

AC/DC. Highway to hell [Album]. Atlantic. 1979.
Agents & Jorma Kääriäinen. Agents is more! [Album]. Parlophone. 1997.
Knopfler M. Sultans of Swing. Vertigo Records. 1977.
Sonata Arctica. Silence [Album]. Spinefarm Records. 2001.
Neljä Ruusua. Poplaulajan Vapaapäivä. 20 suurinta hittiä [Album]. Ratas Music Group. 2013.

MMD | 2017 | 9 | 3 | Page 197

Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 198 – 201 Punkanen, Nyberg & Savela | Vibroacoustic Therapy & Developmental Trauma

Clinical Report
Vibroacoustic Therapy in the Treatment of Developmental Trauma:
Developing Safety through Vibrations
Marko Punkanen1,2, Marjo Nyberg3, Tiinapriitta Savela1
1
Nyanssi Therapy Centre, Finland
2
VIBRAC Skille-Lehikoinen Centre for Vibroacoustic Therapy and Research, Finland
3
Marjo Nyberg Music Therapy Services, Finland

Abstract
Developmental/attachment trauma may strongly impact a child’s capacity to develop self-regulation skills related to feelings of
safety. The ability to utilize a social engagement system ensures that defensive reactions such as fight, flight, freeze, and/or total
submission will be avoided and replaced with integrative mechanisms of response. Vibroacoustic therapy (VAT) uses pulsed,
sinusoidal, low frequency sound on a specially designed mattress or chair. Based on clinical experience, VAT seems to help
regulate a traumatized child’s autonomic nervous system and may assist in the gradual development of a bodily-related feeling of
safety.

Keywords: Vibroacoustic therapy, child psychiatry, developmental trauma, autonomic multilingual abstract | mmd.iammonline.com
nervous system

Introduction traumatized children can be helped to calm down by

Traumatic experiences, and especially
developmental/attachment trauma, may strongly affect a
child’s developing autonomic nervous system and impede
feelings of safety. Developmental/attachment trauma often
causes strong and overwhelming emotions such as panic, fear,
and depression, and may as well dysregulate arousal reactions.
This can lead a child toward encountering serious problems in
self-regulation that will likely inhibit the development of the
ventral vagus complex, which is essential in keeping the social
engagement system activated and is essential in enhancing
feelings of safety within relationships.1 Insecure attachment
styles might lead to faulty neuroception, which means that a
child’s autonomic nervous system may not be able to
differentiate between safety and danger.2
Based on our clinical experience, vibroacoustic therapy
(VAT), which uses whole body low frequency sound
stimulation,3 when coupled with a music therapy relationship,
PRODUCTION NOTES: Address correspondence to:
Marko Punkanen, E-mail: marko.punkanen@vibrac.fi | COI
statement: The authors declared that no financial support was
given for the writing of this article. The authors have no conflict
of interest to declare.
Copyright © 2017 All rights reserved.
International Association for Music & Medicine (IAMM).
regulating their autonomic nervous system. Sound stimulation
with slow pulsations seems to activate a child’s ventral vagus
complex (vagal brake)1 and helps to regulate dysregulated
arousal states and enhance social engagement between the
child and the therapist. In this paper we will present the
theoretical framework of our clinical music therapy work and
illustrate the clinical use of VAT by describing Matti’s
experiences as a case example.
Case Example: Matti
Matti was a 10-year-old boy when his music therapy process
started. His parents were substance abusers, although Matti’s
mother became sober when she was pregnant and she was
able to sustain this for most of Matti’s early youth. Yet, due to
seemingly unstable social circumstances, Matti was taken into
custody and was placed in a children’s home when he was 5
years old. Matti’s mother went into rehabilitation since their
separation, but has been able to stay in contact with Matti.
When the therapy process was initiated, Matti had lived
in a children’s home for 5 years. Although the safe
environment and boundaries had helped him, he still had
various difficulties in social situations and explicitly with self-
regulation. In school, he had problems with concentration and
had diverse learning difficulties. Matti also had severe
episodes of unexplained rage, both at school and in the
children’s home. In general, Matti’s character was lively and
kind, but he often received negative feedback from adults and
peers, primarily because of his outbursts and hyperactivity.
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 198 – 201
At the beginning of the music therapy process, Matti
presented as quite restless. He also avoided eye contact. Matti
nevertheless seemed to be interested in musical activities
(improvising together with the therapist by using keyboards,
M-Audio Keystation 88 MkII), which seemingly helped him
to stay motivated.
Threats Everywhere - Faulty Neuroception and Problems in
Self-Regulation
Developmental trauma affects the functioning of the
autonomic nervous system. It is typical, that a traumatized
child’s arousal level fluctuates between hyper- and
hypoarousal states. In a state of hyperarousal, a child
experiences excessive bodily, emotional, and cognitive
arousal, while in a hypoarousal state the bodily, emotional,
and cognitive experiences are flat. In both cases, the ability to
integrate experiences is compromised and distorted. At
optimal arousal, inside the window of tolerance, a person can
engage socially, process experiences, and integrate these as a
part of the self 4,5.
Porges coined the concept of neuroception to describe the
way our autonomic nervous system evaluates risk from
perceptual information. Through neuroception, we evaluate
whether people or situations we meet are safe or threatening.
The evaluation activates neurobiologically determined social
or defensive behavior. When we meet a threatening situation,
even if we are not aware of it on a cognitive level, the defensive
behavior model will be activated. These defensive reactions in
threatening situations are to fight, flee, freeze, or submit. If we
then evaluate the situation as safe, the defensive reactions are
deactivated and social engagement will instead be activated.1,2
Matti’s experiences in early childhood had an impact on
his neuroception. He often reacted with fluctuating arousal in
situations when there was no real threat in his environment.
For example, in school he had difficulties in trusting adults,
and his hyperarousal was also overwhelming in therapy. He
was neither able to stay in contact with the therapist nor
concentrate on activities, rather his behavior and playing
represented his chaotic internal world.
Safety first – Mobilizing the Social Engagement System
Through Play and Exploration
The social engagement system controls social gestures like
looking/observing, facial expressions, or the ability to identify
a human voice. Together, these factors make engagement in
social situations possible by regulating the heartbeat and
keeping the optimal arousal level for social interaction. A child
who has grown up with secure interaction has internalized the
experience of safety. This helps him to keep his arousal level
inside the window of tolerance or, if needed, to return his
arousal to the optimal level after defensive behavior.4
Matti’s first experience of the vibroacoustic mattress was
to listen to his favorite music (Finnish pop artists Antti Tuisku
and Robin) through its speakers. First, he was just carefully
Punkanen, Nyberg & Savela | Vibroacoustic Therapy & Developmental Trauma
touching the mattress with his hand and feeling the vibrations
of the music. After a couple of sessions it was also possible to
sit on the mattress and feel the vibrations of the low frequency
sound.
After familiarizing himself with the vibroacoustic
mattress, Matti got the idea to a build fort on it. He planned
different kinds of constructions and he built them with the
therapist. First, it was the act of building that was important,
but little by little Matti also spent more time hanging out in
the fort. He liked to draw inside of it, or play board games
with the therapist, while the soothing low frequencies sang
their relaxing song (40Hz sinusoidal sound with 6,8 seconds
pulsation from MULTIVIB mattress).
The VA method helped Matti to stay in contact by
decreasing his arousal from a state of hyperarousal to within
the window of tolerance. Therapeutic interaction was another
side of the development; the therapist’s aim in terms of
interaction was to help Matti find his optimal level of arousal
and stay there.
Being Taken Care of: The Special Meaning of Touch
As Matti’s therapy process progressed, he became more and
more fond of the vibroacoustic mattress. On the mattress,
Matti’s behavior seemed to be more likened to a younger
child’s behavior – it was as though he had regressed to have
the needs of a younger child and was thirsty for attention and
sensitive interaction.
The deep dimension of the vibroacoustic method can
perhaps be examined through touch. Sound is both movement
and vibration. We can comprehensively track low frequency
sound vibrations within the body. Sound touches us both
physically and psychologically. Sound is like a bridge between
the body and the mind. Sound vibration massages us from the
inside out3.
We sense this touch of sound through our somatosensory
system, which develops before our auditory and sensory
systems6. In addition to the somatosensory system, the
auditory system has a significant role in vibroacoustic
treatment (especially when listening to music).
The auditory system also develops very early. Recent brain
research indicates that everyone senses different elements of
music prior to birth; for example rhythm, melody, and
harmony.7,8 Perhaps this explains why experiencing sound
vibration touches us very deeply, and why the sensation of low
frequency sound during VAT reminds clients of very early
pre-birth experiences.9
Finnish child psychiatrist Jukka Mäkelä has mooted the
significance of touch in child development and has raised the
prospect of using touch in children’s psychiatric treatment.
Touch increases oxytocin levels and vagal tonus hence touch
can repair developmental defects of the brain that have been
caused by insecure attachment10. The special meaning of touch
in traumatized children's music therapy is illustrated in Figure
1.
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 198 – 201
According to the principle of the development of brain
plasticity, repeated touch and, in this case VAT, can provide a
compensatory experience for a juvenile client. Importantly, the
child becomes aware that it is possible to experience inner
safety1.
Over time, Matti learned to relax on the vibroacoustic
mattress. The atmosphere in these situations was very
intimate, warm, and safe. The vibroacoustic mattress was a
safe nest, where it was possible to experience care and sharing.
During the same period, other music therapy methods
were used in Matti’s therapy. It was interesting, that his
Client - Therapist
Figure 1. Touch: Special meaning with traumatized children’s music therapy.
Towards Integration
Sensorimotor reactions and different bodily symptoms can tell
us a story without words. The body knows what we do not
cognitively know.3 VAT can help therapists to discover their
clients’ nonverbal historical narratives. Typically, prior to
commencing therapy, traumatized children are unable to
verbally explain any physical sensations or sensorimotor and
emotional experiences. VAT may increase a child’s awareness
of physical sensations. For example, by listening to a child’s
favorite music on a vibroacoustic mattress or using a low
frequency sound program, a child may be able to describe
sensations in his/her body.
Punkanen, Nyberg & Savela | Vibroacoustic Therapy & Developmental Trauma
concentration skills had developed considerably. This was
visible, for example, in his ability to learn new instruments
(Fender Squier Bronco bass guitar and Roland TD-11KV V-
drum set) and play improvisations with the therapist (therapist
playing keyboard M-Audio Keystation 88 MkII) for longer
periods of time. When Matti had begun to trust the therapist,
and his ability to stay inside his window of tolerance increased,
he also achieved the capacity to develop other skills.
As noted above, it was possible to regulate Matti’s arousal
level in the autonomic nervous system by using VAT. At the
beginning of the therapy process, when the relationship
between Matti and his therapist was in the early stages, Matti
was able to calm on the vibroacoustic mattress, but the deeper
experience of relaxation was not yet possible. As the therapy
process progressed and Matti started to trust the therapist
more, he was also ultimately able to relax during VAT.
VAT stimulates a client’s physical sensations, images,
emotions, associations, and memories.3 These can be
processed with different music therapy methods; for example
by singing, playing, improvising, and through discussion and
so forth. In Matti’s music therapy process, it was eventually
MMD | 2017 | 9 | 3 | Page 200
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 198 – 201
possible to process his emotions, images, and memories by
improvising and then discussing the experience. Hierarchical
information processing related to vibroacoustic method is
presented in Figure 2.
Figure 2. Hierarchical information processing: How the vibroacoustic
method is experienced in music therapy.
Conclusion
Developmental trauma affects a child’s action systems so that
the defensive action system dominates a child’s perception
about himself and the outer world. In Porges’s words, a child’s
neuroception about safety has become biased.2 Matti had
serious problems in feeling safe in relationships, which
resulted in challenges within his social environments. During
his music therapy process VAT helped him to gradually learn
to regulate his autonomic nervous system and become more
competent in self-regulation. Of course, VAT alone is not
sufficient when treating developmental traumas. The music
therapist needs to be an interactive psychobiological regulator
for a traumatized child’s dysregulated bodily and emotional
states. Based on our clinical experience, a therapist’s
therapeutic presence in addition to VAT can be a successful
combination particularly when helping children who have
early developmental trauma.
Punkanen, Nyberg & Savela | Vibroacoustic Therapy & Developmental Trauma
References
1. Porges SW. The polyvagal perspective. Biol. Psychol. 2007; 74: 116-143.
2. Geller SM, Porges SW. Therapeutic Presence: Neurophysiological
Mechanisms Mediating Feeling Safe in Therapeutic Relationships. J
Psychoter Integr. 2014; 24(3): 178-192.
3. Punkanen M, Ala-Ruona E. Contemporary Vibroacoustic Therapy:
Perspectives on Clinicial Practice, Research, and Training. Music Med.
2012; 4(3): 128-135.
4. Ogden, P, Minton, K, Pain, C. Trauma and the Body – A Sensorimotor
Approach to Psychotherapy. New York – London: W. W. Norton &
Company; 2006.
5. Siegel DJ. The Developing Mind - How Relationships and the Brain
Interact to Shape Who We Are. New York, London: Guilford Press;
1999.
6. Nolen-Hoeksema S, Fredrickson BL, Loftus GR, Lutz C. Atkinson &
Hilgard’s Introduction to Psychology. Hampshire: Cengage Learning
EMEA; 2014.
7. Huotilainen M. Kuulojärjestelmä. In J Louhivuori, S Saarikallio, eds.
Musiikkipsykologia. Jyväskylä: Atena; 2010: 47-56.
8. Huotilainen M, Fellman V. Sitä äitiä kuuleminen jonka kohdussa
asunto. Lapsi kuulee ja oppii jo kohdussa. Duodecim 2009; 125: 2573-7.
9. Lehtonen K. Musiikki ja psykoanalyysi. In J Louhivuori, S Saarikallio,
eds. Musiikkipsykologia. Jyväskylä: Atena; 201: 237-258.
10. Mäkelä J. Kosketuksen merkitys lapsen kehityksessä. Suomen
Lääkärilehti. VSK 2005; 60(14) 1543-1549.
Biographical Statements
Marko Punkanen, PhD, is music therapist, dance-movement
therapist, trauma psychotherapist and VIBRAC-trainer and
works in Nyanssi Therapy Centre in Lahti and VIBRAC
Centre in Jyväskylä, Finland.
Marjo Nyberg, M.M, is music therapist and VIBRAC-
practitioner and works in Marjo Nyberg Music Therapy
Services in Lahti, Finland.
Tiinapriitta Savela, MPhil, is music therapist and VIBRAC-
practitioner and works in Nyanssi Therapy Centre in Lahti,
Finland.
MMD | 2017 | 9 | 3 | Page 201
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 202 – 208 Rüütel, Vinkel & Eelmäe | Vibroacoustic Treatment in Case of Spinal Cord and Brain Injuries

Full-Length Article
The Effect of Short-Term Vibroacoustic Treatment on Spasticity and Perceived Health Condition of
Patients with Spinal Cord and Brain Injuries
Eha Rüütel1, Ivar Vinkel2, Priit Eelmäe3
1
Tallinn University, School of Natural Sciences and Health,Tallinn, Estonia
2
Tallinn University, Haapsalu College, Centre of Excellence in Health Promotion and Rehabilitation, Tallinn, Estonia
3
Haapsalu Neurological Rehabilitation Centre, Tallinn, Estonia

Abstract
Vibroacoustic (VA) treatment was applied to patients with chronic spinal cord and brain injuries during rehabilitation. The study
aimed to ascertain the suitability of short-term VA treatment for decreasing spasticity and pain, and improving health conditions
within the rehabilitation program for patients with spinal cord and brain injuries. Hypotheses: 1) indicators of self-perceived
spasticity and pain measured after VA treatment are lower than measurement results before treatment; 2) VA treatment can be
used in rehabilitation programs to support the improvement of self-perceived health condition. 53 patients aged 20-72
participated in the study. VA treatment of 40 Hz was conducted once a day for 23 minutes over 4 or 5 days. Self-report numerical
rating scales were used to measure patients’ condition before and after VA treatment sessions. Research findings revealed
significant change in the levels of spasticity, pain, physical discomfort, general health condition, fatigue, and anxiety after VA
treatment sessions compared to the measurements before the sessions. Reduction in spasticity and physical discomfort was not
statistically significantly different after 4 or 5 days of treatment, however a decrease in pain and an improvement in perceived
health condition were significantly higher after 5 days than after 4 days of treatment.

Keywords: vibroacoustic treatment, spinal cord and brain injuries, adults, multilingual abstract | mmd.iammonline.com
spasticity, pain, self-perceived health condition.

Introduction research and the development of the equipment since the

Vibroacoustic Method and Estonian Experiences
Vibroacoustic (VA) therapy is defined as a treatment method
based on low frequency sound vibrations and music [1, 2].
Depending on the choice of sound vibrations, the effect is
either relaxing or stimulating, which allows using VA therapy
for general relaxation and for the purpose of more specific
physiotherapy and receptive music therapy [2, 3, 4]. In
Estonia, mainly devices affecting the whole body are used: VA
treatment beds produced in Estonia, vibroacoustic mattress
(Multivib, Norway) (both utilizing Olav Skille’s programs),
and physioacoustic chair (Next Wave, Finland). Tallinn
University has contributed to VA therapy practice and
PRODUCTION NOTES: Address correspondence to:
Eha Rüüthel, Tallinn University, School of Natural Sciences and
Health, E-mail: eha@tlu.ee | COI statement: The research was
carried out in the frames of the project of Tallinn University
Haapsalu College TA/112 “Health Promotion and Rehabilitation
Centre (15.09.2011-31.08.2015)”, and was funded by European
Regional Development Fund, Tallinn University, Haapsalu
Neurological Rehabilitation Centre and Haapsalu City
Government. The authors have no conflict of interest to declare.
1980s. The newest device, the prototype for which was
launched by the Centre of Excellence in Health Promotion
and Rehabilitation of Haapsalu College was introduced at the
1st International VIBRAC Conference in Lahti, Finland, in
2016.
In Estonian practice, mainly pulsating sinusoidal sound
waves in the range of 30–88 Hz are used. Throughout the
duration of the procedure, often music1 and/or sounds of
nature suitable to the purpose of the procedure are introduced
in the therapy room as an auditory influence. If necessary,
background music can mask everyday sounds and the audible
component of low frequency sounds and provide musical
support to the therapy goals. The most common length of
sessions is 10 to 45 minutes [5]. In Estonian practice, the
frequency of the sessions is 1-5 times a week (depending on
therapy goals) and usually 10 sessions are recommended as
optimal. The duration of a session is about 30 minutes, of
which exposure to low frequency stimulation for 23 minutes
(if music or nature sounds are used as a background, the
session is slightly longer). Depending on the approach and
health state, a combination with creative arts therapies is
usually utilized, primarily in children.
1
Therapist-selected recorded music appropriate for the client. Therapists
follow the music selection instructions given by Grocke and Wigram [1:
226-227].

Copyright © 2017 All rights reserved. MMD | 2017 | 9 | 3 | Page 202

International Association for Music & Medicine (IAMM).
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 202 – 208 Rüütel, Vinkel & Eelmäe | Vibroacoustic Treatment in Case of Spinal Cord and Brain Injuries
According to Boyd-Brewer and McCaffrey [5], there have
not been any reports of adverse effects of the VA method.
Patrick [6] argues that there does not exist a condition in
which a single VA stimulation could give a negative result.
However, practitioners have observed that during or after the
first sessions of VA therapy some negative side effects may
occur – drowsiness, dizziness, and/or nausea. In such cases we
have reduced the volume of the sound and moved the upper
body of the patient in a more upright position (given the
equipment allows this) or raised the height of the pillow.
Based on their practical experience, Wigram [7] and Grocke,
and Wigram [2, pp. 228-229] have listed contraindications to
the use of the VA method: acute inflammations, pacemakers,
psychoses, pregnancy (for the reason that there is a lack of any
relevant empirical studies), acute physical states (first require
consultation with their doctor), and hypotension (the method
may further reduce blood pressure). We have also taken into
consideration psychological factors [8] – e.g. excessive
sensitivity to vibration or subjective aversion or fear of the
given treatment may block the positive effect of VA therapy.
The Findings of Earlier Research on the VA Method
Studies on the VA method have shown a significant
improvement in many somatic and functional disorders, e.g.
reduction in pain [9-12], decrease in muscle tension and
spasms [13, 1, 4, 14-16], reduction in the parameters of blood
pressure, pulse rate and muscle oscillation [17]. In the
treatment of Parkinson’s disease, experiments with the
method have produced an improvement in motor function
[18, 19]. According to the practice-based evidence of VA
treatment VA treatment, positive changes in indicators of the
perceived health condition and emotional state [20] and an
improvement of physical self-awareness [21,22] can be
expected.
Relatively few studies have been conducted on influencing
muscle tone and spasticity, but the received results are
promising. Wigram’s study [15] of physically disabled adults
(n = 10) revealed a considerably higher muscle tension
reduction and movement facilitating effect of VA stimulation
compared to a session of sedative music2. In another of
Wigram’s [16] study (n = 27) VA stimulation produced an
effect similar to motion physiotherapy. Katušić and Mejaški-
Bošnjak [13] describe an improvement in the therapy
outcomes after vibroacoustic stimulation had been added to
physiotherapy. The researchers studied the effect of a 20-
minute VA stimulation (40 Hz) on the spasticity and motor
performance of children with cerebral paralysis (n = 13). The
sessions took place once a week over a three-month period.
The results showed a considerable improvement in body
rotation, including keeping the body and head in an upright
position, and in a variety of movements. Naghdi, Ahonen,
2 the following:
The music used in both conditions was “Cristal Caverns” by Daniael
Kobialka [15: 60].
Macario & Bartel [23] investigated the impact of low
frequency sound stimulation on patients with fibromyalgia (n
= 19 females) and found that cervical muscle range of motion
increased from 25% to 75% (p = 0.001), while muscle tone
changed from hypertonic to normal (p = 0.0002) after 10
treatments (23 min) twice per week of low frequency sound
stimulation (40 Hz).
Pain reduction through sound stimulation has been
described by Chesky & Michel [24], who have described the
technology of Music Vibation Table. In a randomised trial (n
= 32), Burke [9] found that postoperative application of
intensive VA stimulation could considerably reduce the
perceived pain, anxiety, hostility and depression, and also the
use of narcotic substances. Staud’s research group [25]
discovered that vibrotactile stimulation offered efficient pain
management in chronic musculoskeletal pain, including
fibromyalgia. Naghdi, Ahonen, Macario & Bartel [23] used 3
tools to measure the impact of pain: significantly reduced pain
was measured on the Fibromyalgia Impact Questionnaire,
81%; a 49% before-after treatment reduction was measured on
the Pain Disability Index; subjective assessment of pain
showed decrease by 70% in median. Sleep is strongly affected
by fibromyalgia. An improvement in sleep was 90% (p <
0.0001) on the Jenkins Sleep Scale. Fibromyalgia causes
stiffness, and pain decreases the length of time individuals can
stand or sit. The time of sitting and standing without pain
incidence increased significantly (p < 0.0001).
Based on the findings of earlier studies and practical
experience, in the planning stage of this study it was assumed
that short-term VA treatment can have effect on spasticity,
pain- and self-perceived health condition in patients with
spinal cord and brain injuries. The study aimed to ascertain
the suitability of short-term VA treatment in supporting the
decrease in spasticity and pain and improvement in health
condition in the rehabilitation program for patients with
spinal cord and brain injuries.
Hypotheses: 1) indicators of self-perceived spasticity and
pain measured after VA treatment are lower than the results of
the measurement before the treatment; 2) VA treatment can
be used in the rehabilitation program to support the
improvement in self-perceived health condition.
Material and Methods
VA treatment was included in the rehabilitation program as a
complementary intervention. This study can be viewed as a
pilot study and was designed as intervention-outcome
research comparing the results of the treatment with the
indicators before treatment.
Subjects
Patients were referred to the study by the physicians of a
rehabilitation center. The diagnostic criteria of the study were
MMD | 2017 | 9 | 3 | Page 203
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 202 – 208 Rüütel, Vinkel & Eelmäe | Vibroacoustic Treatment in Case of Spinal Cord and Brain Injuries
1. Lower limb spasticity as assessed by the rehabilitation
physician;
2. Time elapsed since the beginning of the disease at least 1.5
years for spinal cord injury and at least six months for
brain injury.
VA treatment took place during a 15 months on 17 randomly
selected weeks from Monday to Friday. Patients meeting the
diagnostic criteria, that were in rehabilitation on the weeks of
the study and agreed to participate in the study, were referred
to VA treatment. A total of 53 patients aged 20-72, including
34 men and 19 women participated in the study.
Procedure
In this study, a vibroacoustic mattress Multivib 10
Transducers Mattress laid on top of a couch was used for VA
treatment. During the procedure a patient was lying on the
mattress in a position comfortable for him/her (patients
mainly preferred lying on their back). For the duration of the
session the therapist conducting the procedure left the therapy
room to stay in the adjacent room. The original 23 minute
Multivib program (composed by Olav Skille) recorded on a
CD with basic frequency of 40 Hz was used for vibroacoustic
stimulation. The choice of the frequency was based on the
earlier observations by practitioners and previous studies,
which had revealed the muscle tone and spasticity reducing
effect of this frequency [13, 15]. Through headphones,
patients heard relaxing music and/or sounds of nature
(depending on their preference) during the session. Based on
these preferences, patients could listen to relaxing music [25],
relaxing music with nature sounds [26] or sounds of nature
[27]. The reason for adding music or nature sounds was to
mask procedures-related sounds coming from the adjacent
rooms. The volume of the VA and auditory stimulation was
regulated to suit the patient according to his/her subjective
assessment.
The VA treatment sessions were planned on 5
consecutive days (from Monday to Friday) at more-or-less the
same time between 9 am and 4 pm. As some of the subjects
left the rehabilitation center a day earlier or on the morning of
the fifth day, in 24 (55%) cases the process included five VA
treatment sessions and in 20 (45%) cases four treatment
sessions on consecutive days. Measurements of the patients’
condition were carried out 3 times immediately before and
after the treatment session.
Measurements were taken in a position most comfortable
for the patient – depending on his/her condition, either sitting
(both before and after the session) or in some cases lying on
the VA mattress (before and after the session). Measuring was
conducted in a lying position in case the change in body
position – movement from the wheelchair onto the bed and
after the session from the bed into the wheelchair – was
inconvenient and would have significantly influenced the
assessment of the perceived health condition. If a patient was
not able to write, the VA therapist recorded the patient’s
condition on the rating scales according to the patient’s oral
responses.
Measurements
It was planned to measure the patients’ condition through
their subjective assessment of spasticity, pain, physical
discomfort, and general health condition. Based on the
additional changes mentioned by patients, within the course
of the study, fatigue and anxiety were added to the indicators
assessed. Numerical rating scales with 11 divisions were
applied (0 – 10). Numerical rating scales are widely used to
measure pain [29, 30] and are recommended for clinical
studies [31]. Such numerical scales with 11 divisions have also
been used to measure spasticity and a statistically significant
correlation has been obtained with the rating scales used by
physiotherapists (Modified Ashworth Scale and Tardieu Scale)
[32]. Simple numerical rating scales are increasingly more
frequently employed to measure subjectively assessed health
indicators like pain, fatigue, depression, anxiety, sleep,
physical and social functions, irrespective of health condition,
age, or gender [33].
Measurements were conducted 3 times, before and after a
VA treatment session – on the first, third and fifth day of the
treatment; if a patient left the rehabilitation center on the
fourth day of the treatment, the third (last) measurement was
conducted on the fourth treatment day. In this study, it was
also planned to use the Tardieu test simultaneously with
numerical scales. Since it had been planned to conduct the
study in the framework of a usual program of rehabilitation,
carrying out the Tardieu test immediately before the first and
after the last measurement of subjective condition by two
physiotherapists, proved to be too time and work consuming.
Therefore, the Tardieu test was abandoned after the trials
conducted in the first weeks of the study.
Data Analysis
Data were analyzed with statistical data processing program
Statistica for Windows 5.0 using repeated measures analysis of
variance (ANOVA/MANOVA). Correlation analysis and
multiple regression analysis were used for assessing
relationship between spasticity and other indicators of health
condition.
Ethical Aspects
Consent to carry out the study was given by Tallinn Medical
Research Ethics Committee. All patients gave their informed
consent to participate in the study. Patients were informed
that the suitability of VA treatment to their condition was
researched. In the referral to the study, contraindications to
VA treatment were taken into account and the treatment was
immediately interrupted when a negative effect from VA
stimulation occurred. In the research data, each participant
was assigned a code and data analysis was conducted with
coded data.
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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 202 – 208 Rüütel, Vinkel & Eelmäe | Vibroacoustic Treatment in Case of Spinal Cord and Brain Injuries

Results conducted VA therapy; one patient (2%) left the rehabilitation

Out of 53 patients, the data analysis included 44 participants,
30 men (average age 41, youngest 22, oldest 72) and 14
women (average age 54, youngest 20, oldest 72). Nine patients
(17%) discontinued for the following reasons: spasticity
increased in three patients (5%); two patients (4%)
experienced discomfort in the heart area, which may have
been related to the earlier occurring heart arrythmia; one
patient (2%) developed a pre-cramp feeling in one leg (which
was not followed by a cramp); two patients (4%) reported
feeling worse (one had a pain in the neck, the other discomfort
in the back and a leg), which the patients did not link to the
centre for personal reasons immediately after referral to VA
treatment.
Since there were no statistically significant gender
differences in the indicators, the indicators for men and
women have not been presented separately.
1. General Effect of Changes in Condition
Repeated measures ANOVA analyses (measurement x
condition indicator) of three measurements (before and after
VA treatment session) indicated the main effect of changes in
patients’ condition (Table 1).

Main Mean before Standard Mean after Standard Number of

effect treatment deviation treatment deviation patients
F Mbefore SD Mafter SD N

F (1, 126)
Spasticity 18.73 4.60 2.75 3.78 2.72 44
Pain 7.15 1.95 2.60 1.57 2.38 44
Physical discomfort 20.77 2.91 2.61 1.93 2.24 44
General health
condition 22.20 6.74 1.94 7.43 1.83 44
F(1, 42)
Fatigue 11.70 4.36 2.85 3.18 2.86 15
Anxiety 9.52 1.84 2.50 1.04 1.51 15
Table 1. Changes in patients’ condition during VA treatment session (scale from 0 to 10); p < 0.01

VA treatment had the greatest effect on general health
condition, physical discomfort and spasticity.
2. Dynamics of Changes Before VA Sessions
Figure 1 shows a change in spasticity over the three
measurements. The dynamics indicates reduction in spasticity
as measured before therapy sessions. The level of spasticity
before the first (measurement 1) and before the third VA
treatment sessions (measurement 2) differed significantly
(Tukey HSD post hoc test, p < 0.05).
Graph 1. Results of the three measurements of spasticity (scale from 0 to 10).
The decrease in pre-session level of physical discomfort
showed main effect F(2, 126) = 5.82; p < 0.01 (M1 = 3.93, SD =
3.10; M2 = 2.57, SD = 2.29; M3 = 2.17, SD = 2.61). In other
measured indicators – pain, fatigue, anxiety, and general
health condition – the measurements before VA sessions did
not reveal significant changes.
3. Relationship Between Treatment Days and Therapeutic
Effect
Of the patients participating in the study, 24 (55%) attended
VA treatment on five consecutive days and 20 (45%) on four
consecutive days. The effect of the number of treatment days
(four or five days) on general health condition was significant:
F(1, 42) = 4.44; p < 0.05 (M4d_before = 6,80, SD = 2,12; M4d_after =
7.25, SD = 1.48; M5d_before = 6.13, SD = 1.92; M5d_after = 7.67, SD
= 1.95).
Number of treatment days had also significant effect on pain
levels: F(1, 42) = 6.88; p < 0.05 (M4d_before = 1.05, SD = 1.73;
M4d_after = 0.60, SD = 1.46; M5d_before = 3.17, SD = 3.29; M5d_after
= 2.29, SD = 2.87).
The effect of the number of treatment days on spasticity,
fatigue, anxiety, and physical discomfort was not statistically
significant.

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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 202 – 208 Rüütel, Vinkel & Eelmäe | Vibroacoustic Treatment in Case of Spinal Cord and Brain Injuries

4. Relationship Between Condition Indicators measurement results also includes the effect of rehabilitation
Pearson correlations between spasticity and other indicators program in general and refers to the total impact of different
were found to be statistically insignificant, correlation between interventions. The music and/or sounds of nature used during
the levels of spasticity before and after VA session showed a the VA treatment sessions certainly had an effect as well.
moderate relationship r = 0.69 (compared to pain r = 0.80; p < However, auditory music was necessary to mask the everyday
0,001). Thus the regression analysis was conducted to see and procedure-related sounds from rooms adjacent to the VA
whether the other changes in the patient’s condition during a therapy room.
VA treatment session could predict the change in spasticity. This study revealed a significant change in the
Self-reported spasticity level after a single VA treatment subjectively assessed spasticity, pain, physical discomfort,
session was included into multiple regression analysis as a general health condition, fatigue, and anxiety after VA therapy
dependent variable. Pain, physical discomfort, and general sessions compared to the measurement results before the
health condition before and after VA session, and spasticity sessions. The level of physical discomfort and spasticity
before VA session were included as independent variables. measured before VA treatment diminished statistically during
The indicators of fatigue and anxiety were left out of the VA treatment days, which also reflects the broader impact of
analysis because of having too few measurements. the rehabilitation program.
It might be assumed that spasticity is linked to physical
Standard Standard T- discomfort. However, the correlation analysis did not show a
BETA
error of
B
error of statistic P significant relationship between these indicators and the
BETA B t(124) value correlation between the measurements before and after VA
treatment session for spasticity was moderate. In this light the
Intercept 2.05 0.79 2.58 0.011 results of the regression analysis deserve some attention
Spasticity
highlighting the accompanying role of physical discomfort
before
0.73 0.06 0.72 0.06 11.80 0.000 before and after the VA session. The present study did not
Physical consider the components of physical discomfort, thus it would
discomfort -0.27 0.07 -0.29 0.07 -3.95 0.000 be interesting to explore further the moderating role of
before physical discomfort in the context of perceived level and
Physical changes of spasticity. The current results seem to refer to some
discomfort 0.18 0.07 0.22 0.08 2.61 0.010
after similarities with the gate control theory of pain [34], which
General integrates peripheral stimuli with cortical variables in the
health perception of pain. The relationship between physical
-0.11 0.07 -0.16 0.09 -1.72 0.088
condition discomfort and spasticity also brings into focus the patient’s
after physical needs and the convenience of the procedure as a
Table 2. Predictors of self-reported spasticity level after a single VA treatment supporting factor for the treatment effect.
session. R = 0.742; R² = 0.55; adjusted R² = 0.54; F(4, 124) = 37.98, p < 0.001, The study results indicate that in order to achieve a
standard error: 1.85 decrease in spasticity, 4 treatment sessions on consecutive
days may be sufficient. However, to improve general health
Although the correlation analysis did not show a significant condition and reduce pain, the five-day intervention proved to
relationship between spasticity and physical discomfort, the be considerably more efficient, indicating that a longer
results in the Table 2 draw attention to the negative intervention provides a better therapeutic effect. This is
relationship between physical discomfort and spasticity before indirectly also confirmed by strong positive correlation
VA treatment session and positive relationship after the between perceived pain level before and after VA treatment
session referring to the important role of physical discomfort course.
in the context of perceived spasticity. The explanatory power Relying on research and relevant recommendations [31,
of the regression model was 54%. 33], numerical scales subjectively rated by patients were used
for measurement in this study. Beyond a doubt, numerical
rating scales have certain limitations, since they reflect
Discussion and Conclusions patients’ general assessment of spasticity and do not allow any
interpretations of this assessment and analysis of specific
In the conversations taking place after the VA sessions, changes in spasticity. On the other hand, simple numerical
patients highlighted the calming and muscle relaxing effect of scales are timesaving, as they do not require large expenditure
VA treatment and the suitability of the procedure after of time and energy and they are convenient to use. This had
physically active physiotherapy training. At the same time, great relevance for the patients involved in this study. Firstly,
changes in the patients’ condition cannot merely be viewed in taking into consideration the patients’ condition, in order not
the context of VA treatment, but the dynamics of the to cause inconvenience related to carrying out measurements

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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 202 – 208 Rüütel, Vinkel & Eelmäe | Vibroacoustic Treatment in Case of Spinal Cord and Brain Injuries
(which may affect the results). Secondly, due to their
treatment plan, patients’ schedule is relatively tight in the
rehabilitation center and rating scales that can be filled in
quickly enable patients to keep up with the rhythm of
consecutive procedures. Thereby, subjective rating of their
condition attaches importance to patients’ own assessment of
therapeutic results and in a broader context allows better
management of patients’ condition, and potential service
provider’s behavior, enhancing communication between
patient and service provider, and reflects a patient’s health
condition [35]. This study also confirmed that the
measurement method used is suitable for observing patients’
condition and receiving feedback from patients.
The outcomes of this pilot study revealed statistically
significant changes during VA treatment, which suggests the
suitability of short-term VA treatment in the rehabilitation
program of patients with spinal cord and brain injuries.
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31. Committee for Medicinal Products for Human Use (CHMP). EMEA
Guideline: Guideline on clinical medicinal products intended for the
treatment of neuropathic pain. CPMP/EWP/252/03 Rev. 1; London: 24th
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scored numeric rating scale and clinician scored measures of spasticity
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34. Melzack R, Wall PD. Pain mechanisms: A new theory. Science.
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10.1007/s10620-012-2500-1
School of Natural Sciences and Health, Estonia; address: Räägu 49,
11311 Tallinn, Estonia.
Psychotherapist and creative arts therapist, curator of arts
therapies master program in Tallinn University.
Ivar Vinkel, MA (psychology), vibroacoustic expert, Tallinn
University, Haapsalu College, Centre of Excellence in Health
Promotion and Rehabilitation, address: Lihula mnt 12, 90507
Haapsalu, Estonia; Chief Executive Officer, Vinkelheli Ltd,
address: Lehola 23, 11620 Tallinn, Estonia.
Priit Eelmäe, MSc (Exercise and Sports Sciences), Chairman of the
Board, Haapsalu Neurological Rehabilitation Centre, address:
Sadama 16, 90502 Haapsalu, Tallinn, Estonia.

Biographical Statements

Eha Rüütel, PhD (psychology), MSc (psychology), MPH (Master

of Public Health), Professor of Arts Therapies, Tallinn University,

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Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 209 – 210 Thompson | Book Review Wheeler & Murphy 2016

Book Review
Music Therapy Research: Third Edition (2016).
Edited by Barbara L. Wheeler; Associate Editor: Kathleen M. Murphy
Grace Anne Thompson1
1
The University of Melbourne, Melbourne, Australia

Hardcover: 758 pages | Publisher: Barcelona Publishers, U.S.A. | Language: English | ISBN-9781937440886

A greatly expanded, updated, and detailed description of objectivist and interpretivist research in music therapy, guided by the
recommendations of a diverse group of experienced music therapists. The book begins with an introduction to the nature of
music therapy research and its relation to theory and practice. Steps in doing research are then detailed, and the foundations and
principles of objectivist and interpretivist paradigms are outlined. After methodological issues inherent in each paradigm are
examined, individual chapters are provided for every type, method, and design of research that has been used in music therapy,
all using the same outline. Finally, guidelines are given for reading, writing, and evaluating research.

Keywords: music therapy, research multilingual abstract | mmd.iammonline.com

Introduction considerations are particularly notable in the 3rd edition,

The third edition of Music Therapy Research is the next
instalment of inspiring research texts under the expert
editorial direction of Barbara Wheeler. This third edition is
even larger than the substantial second edition released in
2005, and introduces a collaboration with Associate Editor
Kathleen Murphy. The availability of the third edition as an
epublication is a welcome change, allowing more people to
access the text at an affordable price or via online library
subscriptions. Those who still like a hardcopy of textbooks
continue to have access to a printed version, although be
prepared to make room on your bookshelf to accommodate
this large volume.
Reviewing a volume with 758 pages is a daunting task,
and particularly when this 3rd edition is much more than a
simple update of the 2nd edition. Hadley’s [1] review of the 2nd
edition noted that it was “really a completely different text - in
size and content” (p. 137) from the 1st edition, and in the case
of the 3rd edition I echo this sentiment. If you are wondering
how much has changed, a simple glance through the table of
contents will reveal that the material has been completely
reshaped and refreshed. While both the 2nd and 3rd editions
provide valuable introductions to the field of research and
explore how to prepare for undertaking research projects,
important contemporary considerations are added and
expanded in the 3rd edition. Multicultural (Ch. 8, Kim &
Elefant) and Interdisciplinary (Ch. 9, Magee & Heiderscheit)
PRODUCTION NOTES: Address correspondence to:
Dr Grace A. Thompson | E-mail: graceat@unimelb.edu.au
| COI statement: The author declared that no financial support
was given for the writing of this article. The author has no conflict
of interest to declare.
reflecting the growing need for the researcher to consider how
their world view or disciplinary view can be both a help and
hindrance to the research process. These two chapters
particularly reflect the growth and maturity within music
therapy research, with Magee and Heiderscheit highlighting
that “collaborating with people from diverse backgrounds
introduces alternative epistemologies and thus encourages
different ways of seeing the focus of interest" (p.85). In the 2nd
edition, there were 6 preparatory chapters before the text went
on to explore research questions, topics and design. In this 3rd
edition, we are treated to 13 chapters that all discuss
important aspects of preparation for engaging in research.
As a music therapy researcher, research supervisor and
educator, I really enjoy engaging with ideas that explore our
beliefs about knowledge and reality. Hiller’s well-constructed
contribution to the discourse about ontology and
epistemology (Ch. 11) marks perhaps the most important shift
in language that occurs in the 3rd edition. Rather than using
the terms ‘quantitative’ and ‘qualitative’ principles, Wheeler
& Murphy now adopt ‘objectivist’ and ‘interpretivist’ as their
language of choice, with chapters 12 to 68 framed from these
perspectives thereafter. Hiller sets the scene clearly and
comprehensively, with an important and foundational take-
home message captured by his assertion that “depending on a
researcher’s beliefs about what can be known (ontology) and
how to approach coming to know it (epistemology), different
decisions will be made toward designing an effective study.”
(p. 99). A key distinction is then made between methodology
(research design) and methods (procedures for data
collection). The 2nd edition terms of quantitative and
qualitative spoke more to methods, with the methodology
implied. However, this new language in the 3rd edition makes
the epistemological distinction in a much clearer and precise

Copyright © 2017 All rights reserved. MMD | 2017 | 9 | 3 | Page 209

International Association for Music & Medicine (IAMM).
Music & Medicine | 2017 | Volume 9 | Issue 3 | Pages 209 – 210 Thompson | Book Review Wheeler & Murphy 2016

way. However, old habits die hard so they say, and therefore it References
will be interesting to see whether researchers (experienced
and/or novice) adopt this language or not. I hope that 1. Hadley S. Book review: Music therapy research second edition.
researchers will be inspired to be more transparent and Music Therapy Perspectives. 2008; 26(2): 137-138.
2. Stige B. The practice turn in music therapy theory. Music Therapy
articulate about their beliefs and values (and therefore Perspectives. 2015; 33(1): 3-1.
potential biases) rather than the audience having to make 3. Wheeler B, Rickson D. The third edition of ‘Music Therapy
assumptions based on a study’s data collection methods. Research’: An interview with Barbara Wheeler. Approaches: An
Personally, I struggle with the term interpretivist, as I feel it Interdisciplinary Journal of Music Therapy. 2017; Advance online
implies that objectivist research is not interpreted. Hiller publication: 1-5.
explains that “objectivism holds that we may come to know
the truth about reality through repeated observations of it in
highly controlled situations.” (p. 100). However, I feel it is Biographical Statement
potentially dangerous to imply that there isn’t a level of
interpretation that happens in all research which is linked to Grace Thompson, PhD, is a registered music therapist and
our beliefs and worldview. Nonetheless, having epistemology lecturer at The University of Melbourne. Grace has worked in
front and foremost is a welcome change, and I hope that this Early Childhood Intervention, Special Education and Private
3rd edition will inspire lively debate amongst researchers so Practice and currently her research focuses on children with
that we continue to refine our communication and disability in family-centred settings. Grace has presented at
articulation of these important concepts. various National and International conferences and
This 3rd edition deepens and expands on important workshops. In 2014 she was Keynote speaker at the World
considerations for music therapy research. For students and Congress of Music Therapy in Krems, Austria, and at the
novice researchers, the foundations, principles and Australian Music Therapy Association National Conference.
preparatory considerations are clear and comprehensive. The Grace is currently President of the Australian Music Therapy
music therapy research and practice communities will Association and along with Stine Lindahl Jacobsen is co-editor
appreciate the way examples from our own discipline are of the book “Music Therapy with Families: Therapeutic
woven throughout each topic and chapter. This integrated Approaches and Theoretical Perspectives”.
approach serves to provide an important link between what
we actually do in our music therapy practice and how we
might explain, understand, and extend that practice through
research. All disciplines and professions need to be able to
articulate to the broader community the contribution they
make to society, whether that is about explaining the benefits,
or mechanisms, or experiences that occur. The complex
relationship between theory, research and practice in music
therapy, and our beliefs about how each domain may (or
should) influence another, are robustly debated within our
discipline [2]. Wheeler herself identifies that research should
be relevant to practitioners [3] and throughout the chapters
the relationship between theory, research and practice is overt
and thoughtful. Each author has provided practice and/or
research examples to help the reader reflect upon and explore
this relationship, with the diversity of practice across the life
span and spectrum of health and wellbeing well represented.
Music Therapy Research, 3rd edition, is a mature and
comprehensive text that will inspire and enrich researchers at
all levels of experience. There is a wealth of information and
deep reflection shared through chapters from leading music
therapy researchers around the world. The chapter authors
generously share their experiences and knowledge, and
provide an abundance of literature to follow up for those keen
to dig deeper. Congratulations to Barbara Wheeler and
Kathleen Murphy for their high-level editorial skills that have
resulted in an inspiring text for research development in
music therapy.

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