Neurologic music therapy (Thaut)

1. Introduction

Version followed: the Neurologic Music Therapy (NMT)® system as taught by the Robert F. Unkefer Academy for Neurologic Music Therapy (Thaut and Hurt-Thaut) and organised in Thaut & Hoemberg (eds), Handbook of Neurologic Music Therapy, 2nd edn (Oxford University Press; the Academy lists it as 2024, and OUP's online edition is dated 21 March 2025). Three points are confirmed in the sources. The list of 20 techniques and its split by domain (3 sensorimotor, 8 speech/language, 9 cognitive) appears in a published table (Rusowicz et al. 2022). The Musical Neglect Training (MNT) procedure now comes from two open-access case reports, one co-authored by Thaut (Kang & Thaut 2019; Kasuya-Ueba & Maeda 2025). The origin and core components of Melodic Intonation Therapy are confirmed (Merrett et al. 2014). Further reading (not drawn on): the handbook chapters themselves (only its table of contents and the OUP book and chapter pages); any Academy page defining the individual techniques; and Thaut et al. (2009) on NMT for executive function and emotional adjustment after TBI. So 14 of the 20 techniques still have only a name and short gloss from the sources. Their steps are marked [synthesis]: they are general music-therapy practice, not the Academy's standardised protocol. The other technique procedures come from open-access papers that apply NMT, Academy course pages and, where marked, secondary teaching material. [source: Handbook TOC (SIU catalogue); OUP book and chapter pages; Rusowicz et al. 2022; Kang & Thaut 2019; Kasuya-Ueba & Maeda 2025; Merrett et al. 2014; ArtEZ and MacPhail course pages]

What it is. NMT is the therapeutic application of music to cognitive, sensory and motor dysfunction caused by disease of the nervous system. Its authors present it as built on neuroscience models of music perception and production and of how music affects non-musical brain functions; its techniques are standardised in name and application as "therapeutic music interventions" (TMIs) that are adapted to each patient and aimed at non-musical, functional goals (walking, reaching, speaking, attending, remembering). [source: Thaut & McIntosh, Dana Foundation/BrainLine 2011; Street 2012]

How change is thought to happen. Music is treated as a highly structured auditory stimulus that engages perception, cognition and motor control together. The motor techniques rely on rhythmic entrainment: the motor system locks onto an external auditory rhythm, so a beat can serve as a timing template for movement (Bukowska et al. describe the brain's ability to entrain movement to a rhythm even when the music is not to the patient's taste). Repeated, cued practice is assumed to drive neuroplastic change, and the musical cue is then faded so the function transfers to daily life without music. [source: Thaut & McIntosh 2011; Bukowska et al. 2016; Braun Janzen et al. 2022]

Status in care. NMT is a medical/rehabilitation adjunct delivered alongside neurology, physiotherapy, occupational therapy and speech-language therapy; it does not replace medical treatment, medication or other rehabilitation. Evidence status as sources state it: the Cochrane review of music interventions for acquired brain injury (Magee et al. 2017, 29 trials, 775 adults) found moderate-certainty evidence that rhythmic auditory stimulation may improve gait velocity and affected-side stride length after stroke, low-certainty evidence for cadence, very-low-certainty evidence for upper-limb timing and communication, insufficient evidence for memory and attention, and called for more high-quality trials before clinical recommendations. A Wisconsin state review (TIAC, 2019) rated NMT for autism and developmental disabilities "Level 4 – Insufficient Evidence". [source: Cochrane CD006787; Wisconsin DHS TIAC 2019]

Who may deliver it. NMT is a credentialed specialism, mainly for qualified music therapists:

Training is the Academy's NMT Training Institute: a 4-day, 30-hour course led by Michael Thaut and Corene Hurt-Thaut and their team, with a written test. Board-certified music therapists (MT-BC, CBMT, USA) who pass gain the "NMT" credential for three years. Allied professionals (e.g. physiotherapists, OTs, speech therapists) may attend, but per the ArtEZ page the course does not authorise practice beyond their own licence. [source: ArtEZ NMT Training; MacPhail NMT Training]
NMT Fellow: an advanced one-day Fellowship for MT-BCs (or equivalent) who have completed the Institute. Fellows present video of their own clinical work using three NMT techniques, judged by vote. Credits count toward MT-BC recertification. Endorsements listed: WFNR, EFNS (European neurorehabilitation societies) and the International Society for Clinical Neuromusicology. [source: MacPhail]
The Academy began in Fort Collins, Colorado (first certification programme 1999). [source: Wisconsin TIAC 2019] In May 2024 the Academy of Neurologic Music Therapy ran its international Training Institute online, billed as a "University of Toronto Training". [source: Eventbrite listing, May 2024] No source states Thaut's own University of Toronto appointment [uncertain].
National registration also applies, e.g. MT-BC in the USA. In the Netherlands, music therapists are expected to be accredited through the Register Vaktherapie. [source: ArtEZ] In the UK, music therapists are understood to be regulated by the HCPC as arts therapists, with BAMT as the professional association. Check the HCPC register before relying on this. [uncertain]
For a psychotherapist without music-therapy and NMT training: do not deliver NMT techniques. Your role is to recognise when NMT fits, refer to a credentialed NMT practitioner within the client's rehabilitation team, coordinate with them, and work alongside on the psychological sequelae of neurological illness. [synthesis]

2. Framework

NMT is a system of about 20 standardised techniques in three domains (sensorimotor, speech/language, cognitive), selected through a clinical reasoning model, the Transformational Design Model (TDM). It is not a fixed-length programme. [source: Wisconsin TIAC 2019; Genguelou slides; Handbook TOC]

TDM: the six steps (version followed: the six-step form summarised by Wisconsin TIAC 2019; Street 2012 gives a shortened four-step form: assess, set non-musical goals, apply the matching NMT technique, fade the music once goals are met):

Diagnostic and functional/clinical assessment of the patient (with the medical and rehabilitation team; standard measures such as timed walks, gait analysis, speech or cognitive tests).
Therapeutic goals and objectives, written as non-musical functional targets.
Design a functional, non-musical therapeutic exercise (what a physio, OT or speech therapist would ask the patient to do).
Translate that exercise into a functional therapeutic music exercise by choosing the NMT technique and musical parameters that will cue it.
Outcome reassessment with the same measures.
Transfer of learning to daily-life activities (music faded; function practised without cue).

[source: Wisconsin TIAC 2019; Genguelou slides (worked RSC example following these six steps); Street 2012] The handbook has a chapter on TDM and assessment that is not drawn on [uncertain on its exact wording]. One secondary teaching source also names a "Rational Scientific Mediating Model" (R-SMM) as NMT's theory base; not verified in primary text [uncertain].

Typical format and dose (from trials, not a fixed protocol):

Individual sessions of 30–45 min are typical; groups of 3–6 clients in community clinics. [source: Braun Janzen et al. 2022; ORU NMT FAQ]
Parkinson's disease pilot: 4 weeks × 4 individual 45-min sessions, each structured as (1) TIMP warm-up for range of motion, (2) daily-activity movements with PSE and TIMP, (3) pre-gait work with TIMP and PSE, (4) gait training with RAS including advanced walking tasks, (5) breathing exercises with calming music; tested in the medication "on" phase. [source: Bukowska et al. 2016]
Gait programmes reported: 20–40 min, 3–5×/week; e.g. stroke 30 min, 5×/week for 3 weeks; MS 30 min, 3×/week for 3 weeks; Alzheimer's eight 45-min home sessions over 4 weeks; TBI daily 30 min for 2 weeks. Upper-limb PSE 30–60 min at least 3×/week (suggestion cited). Home programmes are common. [source: Braun Janzen et al. 2022]

Criteria for moving on (within a technique and across the TDM):

Begin tempo work only once entrainment at the patient's own cadence is established; change tempo in steps and stabilise each level before the next. [source: Braun Janzen et al. 2022; open-exam-prep (secondary)]
Move from basic to advanced task variants (turns, stops, stairs, obstacles) when the basic pattern is stable. [source: Bukowska et al. 2016; open-exam-prep (secondary)]
Fade the music when the goal is reached, then reassess un-cued performance; that un-cued result, not cued performance, decides transfer. [source: Street 2012; Wisconsin TIAC; open-exam-prep (secondary)]
Early post-stroke gait studies required that the patient could manage five stride cycles with hand-held assistance before RAS. [source: Braun Janzen et al. 2022, citing Thaut et al. 1997]

3. Guiding principles

Non-musical, functional goals. Every exercise exists to improve a function outside music; musical outcome is irrelevant. In practice: write the goal so a physio or speech therapist would recognise it ("walk 10 m in under X seconds"), never "play the drum well". [source: Thaut & McIntosh 2011; Street 2012]
Neuroscience-based selection. Techniques are chosen because a mechanism links the musical element to the target function (rhythm–motor timing; melody–speech; musical structure–attention/memory). In practice: pick the technique from the deficit, not from what the client enjoys. [source: Thaut & McIntosh 2011]
Standardised techniques, individualised parameters. Names and core procedures are fixed; tempo, key, instrument, placement and difficulty are tuned to the person. In practice: document the technique name plus all parameters each session so others can replicate. [source: Thaut & McIntosh 2011; Braun Janzen et al. 2022]
Assessment-driven (TDM). Measure before, during and after. In practice: baseline every target with a standard measure before cueing. [source: Wisconsin TIAC; Street 2012]
Music as cue, then fade. The music is scaffolding; success means doing the task without it. In practice: plan fading from the first session. [source: Street 2012]
Adjust to capacity. Duration, task difficulty and cue frequency are "adjusted according to each individual's cognitive and motor capacity". In practice: shorten or simplify rather than push through fatigue. [source: Braun Janzen et al. 2022]
Rhythm over taste for motor cueing. Entrainment works with clearly pulsed music even if not preferred (Bukowska et al. deliberately used non-preferred African and Indian rhythmic recordings). In practice: clarity of beat comes first; preference can be used for motivation where it does not blur the beat. [source: Bukowska et al. 2016; Street 2012 on preferred style aiding motivation]
Interdisciplinary work. NMT is delivered within the rehab team; physios co-set and attend RAS programmes and carry home programmes. In practice: get medical clearance and co-treat for mobility goals. [source: Street 2012]
Relationship still matters. Even in directive, protocol-driven work the relationship carries motivation; switching between instructor (RAS) and collaborator (songwriting) roles can strain trust. In practice: name role shifts and, if possible, use different spaces for functional and expressive work. [source: Street 2012]
Adjunct, not replacement. NMT supplements medical and rehabilitation care. In practice: never advise reducing other therapy or medication. [synthesis; consistent with Cochrane's caution]

4. Intervention inventory

The handbook (2nd edn) organises 20 techniques. Sensorimotor (3): RAS, PSE, TIMP. Speech/language (8): MIT, MUSTIM, RSC, VIT, TS, OMREX, DSLM, SYCOM. Cognitive (9): MSOT, MNT, APT, MACT, MMT, AMMT, MEFT, MPC, MEM. This split and these names are confirmed by the technique table in Rusowicz et al. (2022), and they match the Genguelou course slides and the Wisconsin review's count. The handbook also has chapters on music technology, clinical improvisation in NMT, PSE with constraint-induced therapy, TDM and assessment, and motivation. The catalogued 2nd-edn contents list chapter 17 as "Developmental Speech and Language Training through Music (SYCOM)" and show no chapter 18. DSLM and SYCOM probably have a chapter each (17 and 18), but this was not confirmed [uncertain]. All techniques below are to be delivered only by a credentialed music therapist with NMT training, within a rehabilitation plan. Where a source gave only the name and a gloss, the steps are marked [synthesis]: they are general music-therapy practice, not the Academy's standardised protocol. [source: Handbook TOC; Rusowicz et al. 2022 (Table 1); Genguelou slides; Wisconsin TIAC]

4.0 Safety frame for all techniques (read first)

Medical screening and co-treatment. Get medical/physio clearance before mobility work (Street checked with the consultant whether gait work could aggravate the client's myositis ossificans and obtained a current physio assessment). Test motor work in the medication "on" phase in Parkinson's disease. [source: Street 2012; Bukowska et al. 2016]
Falls. Gait belts for clients using canes or walkers [source: open-exam-prep (secondary)]; clear, non-slip walkway; a second person (physio) for unsteady clients; chairs placed along the route; stop at signs of fatigue, dizziness or freezing. [synthesis]
Hearing safety. Bukowska et al. adjusted volume to each participant [source]. Further [synthesis]: keep playback at comfortable conversational levels; avoid sustained loud drumming, cymbals and amplified percussion in small hard-walled rooms; position the client away from loud instruments and speakers; check hearing-aid and cochlear-implant comfort (feedback, distortion); screen for hyperacusis, tinnitus and sound sensitivity, which are common after brain injury, and offer softer instruments (shakers, soft mallets, felt beaters) or headphones at low volume; protect your own hearing when running percussion groups.
Fatigue and tolerance. Some stroke patients did not tolerate the extra sessions RAS required; adjust load to capacity. [source: Braun Janzen et al. 2022]
Musical trauma and emotional triggers [synthesis]. Music can evoke grief, loss of pre-injury identity (especially former musicians), memories of the injury, a funeral, a relationship or abuse, or religious associations. Ask before using any personally significant song; keep a "not this music" list; use neutral metronome or unfamiliar rhythmic material for motor work when preferred music overwhelms; stop and attend to the emotion if it surfaces; coordinate with the psychotherapist/psychologist when tears, anger or intrusive memories recur.
Materials. Clean shared instruments and mouthpieces (wind instruments in OMREX) between clients; check mallets and suspended instruments are secure; adaptive cuffs must not restrict circulation or skin. [synthesis]

4.1 Rhythmic Auditory Stimulation (RAS)

Purpose / when: Gait training (and other intrinsically rhythmic movement) in stroke, Parkinson's disease, TBI, MS, cerebral palsy, dementia; aims at velocity, cadence, stride length, symmetry, stability. Used once the person can walk a few strides with assistance. [source: Braun Janzen et al. 2022; Bukowska et al. 2016; Street 2012]
Steps:
1. Baseline: measure un-cued walking over a set course (e.g. 10 m): cadence (steps/min), stride length, velocity; note symmetry, freezing, shuffling, foot drop. Street recorded six baseline walks. [source: open-exam-prep (secondary); Street 2012]
2. Entrain at baseline: set a metronome or strongly accented music (clear downbeat in 2/4 or 4/4; metronome embedded in music is common) to the person's own cadence; ask for one step per beat; check steps actually lock to the beat before changing anything. [source: Braun Janzen et al. 2022; Bukowska et al. 2016; open-exam-prep (secondary)]
3. Modulate tempo in about 5–10% steps toward the goal (often faster for stroke/TBI to raise cadence and speed; trials used +5% and +10%; for Parkinson's festination the secondary source suggests slowing). Stabilise at each level. Cueing exactly at preferred cadence has been linked to more stride variability in some studies, so tempo choice matters. Cited literature places useful cue rates within roughly 60–150 bpm. [source: Braun Janzen et al. 2022; Bukowska et al. 2016; open-exam-prep (secondary) for direction by condition]
4. Advanced tasks with cueing: starting and stopping on musical cues, turns, backward walking, braiding, stairs, obstacles; verbal prompts such as "stop, balance, turn" can be built into the song and later faded. [source: Bukowska et al. 2016; Street 2012]
5. Fade: reduce tempo support and cues gradually (Street reduced from 122 to 116 bpm and faded verbal prompts); a secondary source suggests alternating bars of music and silence and having the client count or sing internally. [source: Street 2012; open-exam-prep (secondary)]
6. Reassess un-cued gait with the baseline measure; set a home programme (Thaut et al. 2019 used folk and classical music with a strong 2/4 pulse for home walking). [source: Braun Janzen et al. 2022]
Example language (illustrative): "Listen for the drum first. When you're ready, let your heel land on each beat." / "I'm going to nudge it a little faster; just keep landing on the beat." / "Now the music will drop out for a few bars; keep the beat in your head."
Watch for / working: steps falling on the beat; faster velocity or longer stride on un-cued retest; fewer freezes. Warning signs: falling behind the beat, loss of balance at faster tempi (stability falls below preferred speed and steps shorten above the range, per Bukowska's cited literature), fatigue, festination being driven by too fast a tempo. If entrainment fails, go back to baseline tempo.

4.2 Patterned Sensory Enhancement (PSE)

Purpose / when: Non-rhythmic functional movements and daily activities (sit-to-stand, reaching forward/overhead/back, turning, stepping up and down, weight shifting, dressing, upper-limb sequences); music organises movement in time, space and force using pitch, dynamics, harmony, meter and rhythm. [source: Bukowska et al. 2016; Braun Janzen et al. 2022]
Steps:
1. Break the functional movement into phases with the physio/OT (e.g. lean forward, rise, stand). [synthesis]
2. Map musical elements onto phases: rhythm/meter for timing (a lead-in/upbeat cues initiation), pitch direction for spatial direction (rising for upward movement, falling for controlled lowering), dynamics for force (crescendo for building effort, decrescendo for controlled release), harmonic tension resolving to the tonic to mark arrival at the target. [source: open-exam-prep (secondary), consistent with the elements named by Bukowska et al.]
3. Play live (keyboard, guitar, voice) so you can follow and then lead the client's timing; repeat many trials. [synthesis]
4. Progress speed, range or complexity (e.g. gradually raising metronome frequency during tasks, as in Tian et al.). [source: Braun Janzen et al. 2022]
5. Fade the musical pattern and test the movement in silence and in real settings. [synthesis, per TDM step 6]
Example language (illustrative): "On the low chords, lean forward; when the music climbs and resolves, you're standing."
Watch for / working: smoother, better-timed movement; fewer phases needing hands-on help. Watch for breath-holding during effort, pain, orthostatic dizziness on sit-to-stand, and over-reliance on the cue.
The handbook also has a chapter combining PSE with constraint-induced therapy for upper limbs; not drawn on [uncertain on its procedure].

4.3 Therapeutic Instrumental Music Performance (TIMP)

Purpose / when: Playing instruments as task-oriented exercise to train range of motion, strength, endurance, limb coordination, dexterity, postural control and body perception. [source: Bukowska et al. 2016; Street 2012; Braun Janzen et al. 2022]
Steps:
1. Choose the target movement with the physio/OT (e.g. shoulder flexion, crossing midline, finger isolation). [synthesis]
2. Choose and place instruments so that playing requires exactly that movement: instruments are positioned at strategic body-relative positions (e.g. drums or chimes raised for shoulder flexion; two drums across the midline for trunk rotation; keyboard or small percussion for fine motor). [source: Braun Janzen et al. 2022; placement examples from open-exam-prep (secondary)]
3. Start cueing at a comfortable rate and adjust toward the goal; Bukowska used cajón, congas, drums, maracas and tambourine in warm-up, daily-activity and pre-gait work. [source: Braun Janzen et al. 2022; Bukowska et al. 2016]
4. Adapt grip: universal cuffs, weighted or modified mallets for poor grasp or tremor. [source: open-exam-prep (secondary)]
5. Grade distance, height, repetitions and tempo; move to home practice where possible (a 6-week home TIMP programme after stroke was reported as well tolerated and not fatiguing). [source: Braun Janzen et al. 2022]
Example language (illustrative): "Reach up and hit the high drum on each beat, then back to your lap."
Watch for / working: larger reach, more repetitions, better quality of movement (less trunk compensation); the sound itself gives immediate feedback. Watch for compensatory movement, shoulder pain in hemiplegia, and loud strikes near the ear.
Related approach (not an NMT technique): Music-Supported Therapy (MST; keyboard/drum pads, graded melodic sequences) is a separate method used in stroke rehabilitation; do not label it NMT. [source: Braun Janzen et al. 2022]

Speech and language techniques (8)

Co-plan all of these with the speech-language therapist, and follow the SLT's swallow and voice precautions. Names and glosses are from the Handbook TOC, the Genguelou slides and Rusowicz et al. (2022). RSC has a worked procedure in a source and MIT's core components are sourced; the other six have glosses only. [source: Handbook TOC; Genguelou slides; Rusowicz et al. 2022; Merrett et al. 2014]

4.4 Melodic Intonation Therapy (MIT)

Purpose / when: Non-fluent aphasia. MIT was introduced for English speakers by Albert, Sparks and Helm (1973, Archives of Neurology). Sparks, Helm and Albert (1974) describe the ideal candidate: poor repetition, little speech output and stereotyped utterances, typically severe aphasia after a large left-hemisphere anterior lesion. MIT has its own chapter in the NMT handbook, but it has its own protocol and literature. See the separate MIT guide. [source: Merrett et al. 2014; Handbook TOC]
Core components (as summarised by Merrett et al. 2014):
- intoning common formulaic phrases and sentences on a minor third or a simple melody
- tapping the patient's left hand once per syllable
- slow, rhythmic delivery at about one syllable per second
- a hierarchy of steps that moves gradually from singing to speech The originators held that every core component was needed. Merrett et al. mention intense daily sessions from their own experience; this is not a stated protocol requirement. [source: Merrett et al. 2014]
Steps: The level-by-level hierarchy is published in Sparks & Holland (1976) and Helm-Estabrooks & Albert (2004), which are not drawn on [uncertain]. Follow the published protocol as trained; do not improvise a version. [synthesis]
Versions: the French Thérapie Mélodique et Rythmique (Van Eeckhout et al. 1982) emphasises word accent. There are also Japanese and Persian adaptations, a modified MIT (Conklyn et al. 2012), and MIT without hand-tapping (Hough 2010). Record which version you use. [source: Merrett et al. 2014]
Example language (illustrative): (intoned on two pitches, tapping the left hand on each syllable) "Good – mor – ning."
Watch for: frustration with failed attempts, and fatigue. Cochrane found very-low-certainty evidence for communication benefits of music interventions after stroke. [source: Cochrane CD006787]

4.5 Musical Speech Stimulation (MUSTIM)

Purpose / when: Stimulating speech through music, e.g. in aphasia, using familiar musical material. [source: Genguelou slides (gloss only)]
Steps [synthesis]: choose songs, chants or phrases the person knows well (ask family); sing them leaving the final word or phrase out for the person to complete; move from song completion to functional phrases (greetings, "I need…") set to the same melodic shape; then to spoken versions.
Example language (illustrative): (singing) "Happy birthday to…" (pause, gesture for the person to finish).
Watch for: automatic completion without transfer to spontaneous speech; emotional reaction to songs from the person's past (see trigger screening in 4.0).

4.6 Rhythmic Speech Cueing (RSC)

Purpose / when: Rate and intelligibility problems (dysarthria, apraxia, fluency and rate disorders): a rhythmic beat paces speech. [source: Genguelou slides]
Steps (worked case in the source, post-stroke dysarthria, following TDM): (1) assess by reading a set text aloud; (2) goal: intelligibility in reading and spontaneous speech; (3) non-musical exercises: oro-facial exercises and free conversation on a theme; (4) music exercise: tap the pulse with a metronome, then read a text with one syllable per beat, then read everyday phrases and questions on the beat, then therapist–patient exchange on the beat; (5) reassess by reading the same text; (6) transfer: carers report understanding in spontaneous conversation. [source: Genguelou slides]
Example language (illustrative): "Tap with the click first. Now one syllable for each click: Good – mor – ning."
Watch for / working: clearer articulation and better-paced speech on un-cued retest; robotic speech that does not transfer means fade sooner and practise in conversation.

4.7 Oral Motor and Respiratory Exercises (OMREX)

Purpose / when: Oral-motor control and breath support for speech (e.g. dysarthria, respiratory weakness). [source: Genguelou slides (gloss only)]
Steps [synthesis]: with SLT/respiratory input, use wind instruments (kazoo, harmonica, recorder, blow toys) and vocal sounds graded for breath length, force and lip/tongue movement; pair with rhythmic or melodic cues for duration.
Watch for: dizziness from over-breathing, fatigue, infection control for mouthpieces (single-person instruments, cleaning), contraindications from the medical team (e.g. respiratory or cardiac limits).

4.8 Vocal Intonation Therapy (VIT)

Purpose / when: Voice control: pitch, loudness, timbre, inflection (e.g. hypophonia in Parkinson's disease). [source: Genguelou slides (gloss only)]
Steps [synthesis]: vocal warm-ups and sung exercises graded in pitch range and loudness, moving to intonation patterns of speech (questions, statements, emphasis).
Watch for: vocal strain or hoarseness (stop, refer to SLT); shouting rather than supported voice.

4.9 Therapeutic Singing (TS)

Purpose / when: Broad use of singing to support speech, breath, voice and participation. [source: Genguelou slides (gloss only)]
Steps [synthesis]: choose singable songs in a comfortable key; target a specific function (breath phrasing, articulation, initiation); groups are common.
Watch for: singing becoming entertainment without a functional target; emotional reactions to songs.

4.10 Developmental Speech and Language Training through Music (DSLM)

Purpose / when: Speech and language development in children with developmental delays, using musical materials. [source: Genguelou slides (gloss only)]
Steps [synthesis]: songs, chants and musical games targeting vocabulary, sound production and turn-taking at the child's developmental level; with parents/carers and SLT.
Children: child assent and parental consent; involve carers for home practice; follow safeguarding and mandatory-reporting duties of your setting; keep volume low for young ears. [synthesis]

4.11 Symbolic Communication Training through Music (SYCOM)

Purpose / when: Training communication behaviours (turn-taking, initiating, responding) through structured musical exchange, typically when spoken language is very limited. Full name: Symbolic Communication Training through Music. It is spelled SYMCOM in the Wisconsin review and SYCOM in the Genguelou slides and in Rusowicz et al. (2022). [source: Genguelou slides (gloss only); Wisconsin TIAC; Rusowicz et al. 2022]
Steps [synthesis]: structured instrumental or vocal dialogues (call–response, question–answer phrases, starting and stopping together) mapped onto conversational rules.
Watch for: whether the skills appear outside music (greeting, waiting, signalling).

Cognitive techniques (9)

The source slides group these as attention/perception (MSOT, MNT, APT, MACT), memory (MMT, MEM, AMMT), executive function (MEFT) and personal expression (MPC). The names are confirmed in Rusowicz et al. (2022). Only MNT (4.13) has a sourced procedure. For the others only glosses were found, so their steps are [synthesis] unless stated. Co-plan with neuropsychology and OT. Cochrane found insufficient evidence for memory and attention outcomes of music interventions after brain injury. [source: Genguelou slides; Handbook TOC; Rusowicz et al. 2022; Cochrane CD006787]

4.12 Musical Sensory Orientation Training (MSOT)

Purpose / when: Music to stimulate arousal and orientation, e.g. disorders of consciousness, advanced dementia, early post-injury confusion. [source: Genguelou slides (gloss)]
Steps [synthesis]: short, predictable musical stimuli (greeting song, name sung, simple live music), observing and recording responses (eye opening, orientation to sound, movement); grade from passive reception toward simple active responses.
Watch for: overstimulation (agitation, rising heart rate, startle); keep sessions brief and volume low.

4.13 Musical Neglect Training (MNT)

Purpose / when: Unilateral (hemispatial) visual neglect, e.g. chronic left neglect after right-hemisphere stroke. MNT uses active instrument playing, not listening. Instruments are placed so that playing musical patterns structured in time, tempo and rhythm draws attention into the neglected field. The person's ability to anticipate and complete a familiar musical pattern is used to build exploration of that side. [source: Kang & Thaut 2019; Kasuya-Ueba & Maeda 2025, citing Abiru 2014 (the MNT handbook chapter, not drawn on)]
Steps (protocol in Kang & Thaut 2019, two case reports):
1. Set tone bars on a desk. Put the first bar at the midline, in line with the middle of the face, and two bars on the non-neglected side so that each pattern starts there. Further bars run into the neglected field, ending at a target instrument (a hi-hat cymbal) at the far end.
2. The person plays with the non-paretic arm, completing ascending patterns they know well (scales, familiar melodies) that travel from the attended side into the neglected field.
3. Sit on the non-neglected side. Give the instructions and play a chordal keyboard accompaniment under each pitch.
4. Repeat each pattern five times before moving on. Progress through five levels, from short ascending patterns (three-note scale steps, triads) to full scales. The paper gives no criteria for moving between levels [uncertain].
5. Dose in that report: two 30-minute individual sessions a week for three weeks, with neglect tests (line cancellation) before and after sessions.
- Variant (Kasuya-Ueba & Maeda 2025, left neglect with right hemiplegia): tone bars and percussion were moved progressively leftward across the midline and played with the unaffected hand, while the therapist played harmonic progressions and melodic cues. Later sessions added a semicircle of drums, alternating paddle-drum strikes and a desk-bell task in the lower-left space. Each session ended with singing, which the patient chose as a reward.
Example language (illustrative): "Start on the bar in front of you and play up the scale until you reach the cymbal."
Watch for / working: It is working if the person finds more targets on the neglected side in un-cued neglect tests (cancellation, shape tests), not just while playing. If they keep missing bars or stop short of the end target, shorten the span or add a sound cue on that side. [synthesis] The published evidence is case reports only. [source: Kasuya-Ueba & Maeda 2025 (reviewing Bodak et al. 2014; Kang & Thaut 2019)]

4.14 Auditory Perception Training (APT)

Purpose / when: Discriminating and identifying sound features (tempo, duration, pitch, timbre, rhythm, direction), and integrating sound with other senses. [source: Genguelou slides (gloss)]
Steps [synthesis]: same/different and identification tasks with instruments and voices, graded from large to small differences; link to visual or tactile cues.
Hearing note: check for hearing loss first; reduced discrimination may be peripheral, not cognitive.

4.15 Musical Attention Control Training (MACT)

Purpose / when: Sustained, selective, divided and alternating attention (e.g. TBI, stroke, dementia, ADHD). Taught explicitly at the Academy Institute. [source: Genguelou slides; MacPhail]
Steps [synthesis]: structured active music-making in which the person must respond to musical cues:
- sustained: play only while the music plays, stop when it stops
- selective: respond to one instrument or motif among others
- alternating: switch instruments when the melody or tempo changes
- divided: keep a pattern going while tracking a second cue Grade by length, number of distractors and how subtle the cue is.
Related programme (not labelled NMT by its authors): A Helsinki TBI trial gave 20 individual 60-minute sessions, twice weekly over 3 months, targeting executive function, attention and working memory. Each session had three 20-minute modules: rhythm sequences and bimanual coordination on djembe and body; structured cognitive-motor exercises on a drum set with varied pad arrangements; and assisted piano playing of favourite songs using simplified notation. Improvisation ran through all modules, and difficulty was raised stepwise. Use this as an example of graded structure, not as the MACT protocol. [source: Martínez-Molina et al. 2021 (medRxiv)]
Example language (illustrative): "Play only when you hear the guitar; freeze when it stops."
Watch for: errors rising late in the task (fatigue). Measure transfer on standard attention tests, not musical accuracy.

4.16 Musical Mnemonics Training (MMT)

Purpose / when: Using songs, chants or rhythms as a memory aid for information (sequences, names, routines, lists). [source: Genguelou slides (gloss)]
Steps [synthesis]: set the target information to a simple, singable melody or rhythmic chant; rehearse with progressive fading of the music to spoken recall; test recall in daily context.
Watch for: recall only possible when singing; fade gradually; check the person finds the song acceptable (not childish).

4.17 Musical Echoic Memory Training (MEM)

Purpose / when: Immediate auditory (echoic) memory. [source: Genguelou slides (gloss)]
Steps [synthesis]: listen to short musical items and recall or reproduce them immediately (sing back, play back, identify), graded by length and delay.

4.18 Associative Mood and Memory Training (AMMT)

Purpose / when: Using mood induced by music to support memory recall or learning (mood-congruent or associative recall). [source: Genguelou slides (gloss); Handbook TOC]
Steps [synthesis]: agree with the person which music and mood are targeted; use music to induce the agreed mood state before encoding or recall tasks.
Watch for (trigger risk): music-evoked memories may be painful; screen and agree boundaries first; stop if distress rises (see 4.0 and 5).

4.19 Musical Executive Function Training (MEFT)

Purpose / when: Planning, organisation, problem-solving, decision-making, reasoning and self-monitoring. [source: Genguelou slides (gloss)] Thaut et al. (2009, Ann N Y Acad Sci), "Neurologic music therapy improves executive function and emotional adjustment in traumatic brain injury rehabilitation", reports an NMT trial on this. The title and year are confirmed from a citing paper, but its techniques and procedure are not drawn on [uncertain]. [source: Martínez-Molina et al. 2021 reference list]
Steps [synthesis]: group or individual improvisation and composition tasks with explicit structure. The person must plan a piece, assign parts, choose the sequence, make decisions and evaluate the result. The therapist then helps link the strategy to a daily-life task.
Example language (illustrative): "You're the conductor: decide who starts, how loud, and when we stop. Afterwards, tell me what you'd change."

4.20 Music in Psychosocial Training and Counselling (MPC)

Purpose / when: Mood control, emotional expression, cognitive coherence, social competence and reality orientation in people with neurological illness; the NMT technique closest to psychotherapy. The handbook titles it "Music in Psychosocial Training and Counselling"; the Genguelou slides call it "Music Psychotherapy and Counseling". [source: Handbook TOC; Genguelou slides]
Steps [synthesis]: guided music listening, songwriting, lyric discussion, improvisation and group music-making used to identify and regulate emotions and practise social behaviour. Street's case combined RAS with songwriting in a psychodynamic frame, in a separate room, to address identity after TBI. [source: Street 2012 for the case]
Psychotherapist's role: this is where joint working is most natural: share formulation, agree who addresses trauma or grief, avoid duplicating or contradicting interventions. [synthesis]

4.21 Related practice elements named in the handbook (not separate techniques)

Clinical improvisation in NMT, music technology (e.g. electronic cueing devices, apps for home RAS) and motivational aspects have chapters; their content is not drawn on [uncertain]. Use technology only as prescribed by the NMT therapist. [source: Handbook TOC]

5. Handling problems

The sources say little about problem-handling; most guidance below is [synthesis], with sourced points tagged.

No entrainment (steps don't lock to the beat). Return to the person's own cadence; make the beat more salient (louder accented downbeat, metronome embedded in music, percussive live playing, no tempo fluctuation); reduce task demands (shorter distance, physio support); in cognitive impairment allow more practice: cueing at baseline cadence initially slowed gait and increased variability in Alzheimer's disease, and more practice may be needed. [source: Braun Janzen et al. 2022 (Wittwer et al.); open-exam-prep (secondary) on stimulus clarity; synthesis]
Gains only while music plays (stuck at cued performance). Fade earlier and more gradually (silent bars, internal counting or singing), practise in real settings, measure un-cued performance each session; agree a home programme. Discontinuing RAS in a Parkinson's trial was followed by more falls in the control group, which suggests ongoing practice may be needed. [source: Braun Janzen et al. 2022 (Thaut et al. 2019); synthesis]
Fatigue, overwhelm, intolerance of extra sessions. Some stroke patients did not tolerate the added RAS sessions [source: Braun Janzen et al. 2022]. Shorten sessions, use rest breaks with calming music (Bukowska ended sessions with breathing to calming music) [source], schedule at the best time of day/medication cycle, cut stimuli in sensory overload (TBI). [synthesis]
Dislike of the music / low motivation. For motor cueing, beat clarity matters more than taste [source: Bukowska et al. 2016]; but preferred style can raise motivation and adherence: in Street's case the client's own songwriting sustained his RAS and home practice [source: Street 2012]. Offer a choice among clearly pulsed options; explain why the beat matters. [synthesis]
Non-adherence to home practice. Simple audio files at prescribed tempo, a written plan from the physio, carer involvement, a log; review barriers (pain, fear of falling, low mood). Home RAS in Alzheimer's and home TIMP after stroke were reported as safe and well accepted. [source: Braun Janzen et al. 2022; synthesis for strategies]
Emotional flooding or musical trauma triggers. Stop the task, lower or stop the music, orient ("you're here, in the clinic, it's Tuesday"), validate, offer a choice to continue with neutral material or pause; note the trigger on the "not this music" list; liaise with the psychotherapist or psychologist; for persistent intrusive memories or grief, refer for trauma-focused or grief work. Former musicians may grieve lost skill when playing; offer non-performance roles or unfamiliar instruments. [synthesis]
Role strain and ruptures. Street describes difficulty moving between directive instructor (RAS) and listening collaborator (songwriting), affecting trust; she used separate rooms for the two kinds of work and concluded the functional and psychological aspects need to be addressed together [source: Street 2012]. Name the role change aloud; repair by asking how the directive work felt; adjust pace. [synthesis]
"Resistance" or refusal. Often reflects fear (of falling, failing), pain, fatigue or depression after neurological illness, not opposition: check those first, reduce difficulty to guarantee early success, and connect the goal to what the person cares about. [synthesis]
Physical risks during sessions. Near-fall, dizziness, chest pain, shortness of breath, new neurological signs or seizure: stop, follow the facility's emergency procedure, inform the medical team. Do not progress tempo beyond what balance allows (stability decreases below preferred speed and step length shortens above the useful range, per literature cited by Bukowska). [source: Bukowska et al. 2016 for tempo; synthesis]
Hearing complaints (tinnitus, discomfort, hearing-aid feedback): lower volume, switch to softer instruments, change room or seating, consider audiology referral. [synthesis]
Scope problems. If a non-NMT clinician is asked to "do some RAS": allied professionals with Academy training may use methods only within their own licence [source: ArtEZ]; a psychotherapist without music therapy registration and NMT training should refer, not deliver. [synthesis]
Conflicting expectations ("music will cure it"). State plainly that NMT is a rehabilitation adjunct with modest, mainly gait-related, evidence (Cochrane 2017) and that medication and other therapies continue. [source: Cochrane CD006787; synthesis]
Children and adults lacking capacity. Obtain parental consent and the child's assent, or follow the jurisdiction's capacity and best-interest procedures; involve carers; follow safeguarding and mandatory-reporting duties; do not interpret a child's musical behaviour as evidence of abuse or disorder. [synthesis]

Sources

Sources:

Books cited (not drawn on beyond catalogue/TOC):

Thaut MH, Hoemberg V (eds) (2024/2025). Handbook of Neurologic Music Therapy, 2nd edn. Oxford University Press. [chapters not drawn on]
Hodges DA, Thaut MH (eds) (2021). The Oxford Handbook of Music and the Brain. Oxford University Press. [listed as recommended reading by ArtEZ; not drawn on]
Albert, Sparks & Helm (1973), Archives of Neurology (introduction of MIT); Sparks, Helm & Albert (1974); Sparks & Holland (1976); Helm-Estabrooks & Albert (2004). [cited via Merrett et al. 2014; not drawn on]
Thaut MH et al. (2009). Neurologic music therapy improves executive function and emotional adjustment in traumatic brain injury rehabilitation. Ann N Y Acad Sci. [cited via Martínez-Molina et al. 2021; not drawn on]
Abiru (2014). Musical Neglect Training chapter, in Thaut & Hoemberg (eds), Handbook of Neurologic Music Therapy, 1st edn. [cited via Kasuya-Ueba & Maeda 2025; not drawn on]

Further reading (not drawn on): the technique table in PMC3970008 and a stroke music-therapy protocol (PMC11345398); the TBI music-intervention review PMC8320542; any open copy of Thaut et al. (2009); any NMT Academy page defining the individual techniques.

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