A stroke survivor lost his speech, confidence and the life he knew – then a music therapist stepped in

SINGAPORE: Shortly after being introduced to Mr Soh Sai Moh, music therapist Stephanie Chan admitted to her Mandarin-speaking patient that her command of the language wasn’t great. 

Mr Soh, then 57, was referred to Ms Chan after a stroke in November 2021 left him with aphasia – a language disorder caused by damage to the area of the brain that is responsible for language processing and understanding. 

Even though he had trouble communicating, Mr Soh instantly agreed with Ms Chan’s self-deprecating dig, she recalled with a smile. 

Their rapport, as the pair would learn over the next two years, was crucial for his rehabilitation through music therapy. But it took time to build.

When Ms Chan first met Mr Soh, he was inconsolable, having lost his ability to speak overnight. All she could do at the time was provide him “that therapeutic space to just let him cry”. 

Then she started playing the guitar in her sessions, and quickly learnt of her new patient’s love for music. In his younger days, he was once part of a lion dance troupe, and had been learning to play the erhu (a Chinese string instrument) before his stroke.

Even though he also attended occupational, speech and art therapy, his wife Mrs Soh Ling Fong noticed that music therapy with Ms Chan “calmed him down quite a lot”. Her husband would even try to sing along during her sessions. 

“I think he liked music therapy the most, because music made him feel relaxed. So he always looked forward to music therapy,” she said.

As Mr Soh’s mood improved, Ms Chan decided to try music therapy interventions for his communication. After a joint session with a speech therapist revealed that he was “getting his words out from music”, they felt he would benefit from music therapy even after being discharged, she said. 

Today, Mr Soh continues to see Ms Chan as an outpatient at Outram Community Hospital, located within SGH’s campus.

And with Mrs Soh now being able to catch "at least a few words" from her husband compared with "guessing" what he wanted to tell her in the past, the benefits of music therapy have been two-fold. 

USING MELODY, RHYTHM

At SGH, music therapy is used to help patients like Mr Soh enhance their neuro-rehabilitation goals, such as vocalisation, gait training and endurance. 

It is also used for managing pain, increasing cognition of patients with dementia, increasing arousal of patients with disorders of consciousness, providing psycho-emotional support, and creating “legacy work” for patients in the intensive care unit and palliative care. 

Assessing whether a patient with aphasia may benefit from music therapy depends on their neuroplasticity, said Ms Chan, referring to the ability of the brain’s neural network to reorganise or rewire its functioning in response to stimuli after injuries. 

“I will (first try out) a song with them. It can be a very simple song, like Happy Birthday. You’ll be surprised that they are able to actually sing out the words. That’s when I will come in with an intervention,” she explained.

“For example, with the numbers 1-2-3, I will add a melody and a rhythm and ask the patient to sing 1-2-3. Previously, they might not be able to say the numbers, but when you sing it out with them, it’s easier for them to do that.” 

This intervention, known as Melodic Intonation Therapy, taps on neuroplasticity by “using a different route in the brain to regain the speech”, she added.

Ms Chan demonstrated Melodic Intonation Therapy during a recent session with Mr Soh that CNA observed where he was learning to say the phrase “ni hao ma” (“how are you” in Mandarin). 

Getting him to use his hand to tap along with her rhythm, she then incorporated melody into the words that mimicked the “original” inflection in “ni hao ma” when spoken. 

While one syllable would typically correspond to one tap, Mr Soh needed more than one tap per syllable as he took longer to form his words.

Once he was able to sing “ni hao ma”, he was asked to try saying the phrase without the accompanying rhythm, she added. “So that is how we use music to take out the words in him." 

Aside from helping Mr Soh regain his speech, Ms Chan was also brought in to help him with apraxia as a result of his stroke. The condition is characterised by an inability to carry out familiar movements and gestures, despite the capacity and desire to execute them.   

To work on his coordination, she introduced him to the drums and a hi-hat through an intervention called Therapeutic Instrumental Music Performance. 

“To do one step down onto the pedal, one step up, and then to hit the cymbal, it’s a three-step thing. But with the auditory cues, it becomes a very predictable pattern. So we’re making use of the external auditory stimuli to facilitate that movement of the one, two and three,” she explained. 

“Over time, his brain is able to pick up that it’s actually the same pattern following the melodic line, the harmonics that I was playing on the guitar itself.” 

CREATING SAFE SPACES, “LEGACY WORK”

Despite the benefits of music therapy, misconceptions about the little-known field in the allied health sector persist. Ms Chan, for instance, is still sometimes mistaken for “an entertainer” when she totes her guitar around the hospital. 

Meanwhile, some patients at community hospital, St Luke’s Hospital, often assume the principal music therapist, Dr Tan Xueli, is there to entertain them, help them relax or “make them happy”. But music therapy is not about putting on music to feel better after a long day at work, and neither can anyone who is musically talented practise music therapy, she stressed. 

All music therapists practising in Singapore must be accredited by an approved music therapy programme in their country of training, pointed out Dr Tan, who is also the president of the Association for Music Therapy Singapore, the professional association for music therapists here.

There are fewer than 40 accredited music therapists in the association at the moment, with most of them working in two main areas – healthcare and special education, she said. 

Music therapy is, first and foremost, “goal-oriented” and “it’s never about a musical goal”, Dr Tan highlighted. “It's always a non-musical goal and it's always functional.” 

In stroke patients, like Mr Soh, music therapy covers the physical aspect through gait training and walking. But it also addresses the psychological aspect due to “the loss of the use of their hands, the loss of their jobs, the loss of their identity as the breadwinner of the family”. 

More importantly, to Dr Tan, music therapists “know how to use music safely”. She explained that music evokes memories of events, which aren’t always happy. 

“Who’s there to contain whatever emotions or memories of trauma that could come out? You need a trained professional to sit there and know how to wrap those emotions up or even de-escalate. Music is not always a mood lifter … We could get into some difficult emotions (such as) while people are going through end-of-life stages,” she said.  

With palliative care patients, music therapy can also help their loved ones with the grieving process, said one palliative care consultant at the National Cancer Centre Singapore, who has worked with Ms Chan. 

Dr Jamie Zhou was overseeing a patient in the intensive care unit who had suffered a traumatic brain injury, when a medical social worker recommended she get Ms Chan involved. She admitted that she was initially “a little bit apprehensive” about music therapy, as “it’s not your conventional allied health professional”. 

But Dr Zhou “became an advocate from that day on” when she saw how Ms Chan worked with the family to produce “legacy work” by mixing an audio of the patient’s heartbeat with a song sung by the patient’s child. 

“I think for such a dire situation, to find something very sweet, it’s kind of beautiful. It really touched me,” she told CNA. 

It is not the only time Ms Chan has helped patients leave behind a legacy in their final moments. In one of her more memorable cases, she worked with a 41-year-old patient called Ms Le who was diagnosed with stomach cancer. 

Through music therapy sessions, Ms Le completed two music legacy works for her loved ones – an original song written by her which Ms Chan helped with the melody, and a music recording with her own singing over the sound of her heartbeat. 

“(Music therapy) transcends the conventional way of taking care of our patients as music is a safe vessel to channel a lot of the deepest fears. It's very different from talking to a doctor,” added Dr Zhou. 

“When it comes to a music therapist, they have a way of understanding a person through a therapeutic process and they can design very individualised ways of using music. So I refer (patients) to them quite frequently.”

INSTILLING DIGNITY 

Individualised treatment is ultimately key to recovery, such as in Mr Soh’s case where Ms Chan leaned into his love for Chinese culture. 

Getting patients to say simple phrases, like “ni hao ma”, or their name is about “instilling dignity in patients again” and empowering them, she said.

“When patients hear themselves saying the words, they realise, ‘I actually can say those words.’ And then you realise their mood livens up, and they will get more motivation to do therapy. Then that improves their quality of life.” 

At the end of Mr Soh’s session, Ms Chan told CNA that her patient had come “a very, very long way” by being able to say “hello” and his name. 

“And for him to actually respond in the carryover, where right after the intervention, I asked him, ‘How are you?’ He was able to say, ‘Good.’ And then he was able to ask me back, but of course with some prompts here and there,” she said. 

“If we're talking about one-and-a-half to two years ago, there's no way he was able to do that. So it's these little improvements that I think encourage him to continue to be motivated at therapy.” 

This was extra evident during the session CNA attended, according to Mrs Soh and Ms Chan. The latter noted with surprise that Mr Soh was particularly enthusiastic about attempting the hi-hat and even performed well, despite not having much practice in prior sessions. 

The stroke survivor, his confidence boosted from the hour with his music therapist, smiled and concurred that her Mandarin had improved too.