The Use of Rhythmic Auditory Stimulation for Gait

Disturbance in Patients with Neurologic Disorders

KRISTIN LINDAMAN
MUTSUMI ABIRU

Schwab Rehabilitation Hospital, Chicago, IL

Graduate School of Medicine, Kyoto University

The development of modern research technology, such as

brain imaging and motor analysis systems, has led to a greater
understanding of brain processes involved in the perception
and production of music as well as the connectivity between
music and motor, speech, and cognitive networks in the brain.
These findings have revealed that music therapy could
produce stronger and more specific outcomes than merely a
general sense of well-being. This has led to the use of music
for rehabilitation of motor, speech, and cognitive functions
through the systematic application of music for motor
disturbances (Thaut et al., 2005; de lEtoile, 2007). The most
highly researched area has been in regards to gait training
through the use of Rhythmic Auditory Stimulation (RAS). RAS
is defined as:
A technique of rhythmic motor cuing to facilitate training of
movements that is intrinsically and biologically rhythmical.
In humans, the most important type of these movements is
gait. Therefore, RAS is used almost exclusively for gait
rehabilitation. It uses rhythmic cues in 2/4 or 4/4 meter,
presented either as pure metronome beats or as strongly
accentuated beats in complete musical patterns, to cue gait
parameters such as step cadence, stride length, velocity,
symmetry of stride length and stride duration, and double
and single support time of leg stance. (Thaut, 2005, p. 138
139)

The effects of RAS as a treatment intervention for gait

disturbances have been investigated with various patient
populations including stroke, Parkinsons disease and other
neurologic conditions. These interventions will be described
in the following sections.
RAS for Stroke
According to the American Stroke Association (2012),
stroke is the number four cause of death and a leading cause
Ms. Lindaman, MM, MT-BC holds the designation of a Fellow of Neurologic Music
Therapy and has clinical experience with adults and children with neurological
disorders, developmental disabilities, and autism. She works at Schwab
Rehabilitation Hospital in Chicago where she has developed a successful pilot
music therapy program.
Mutsumi Abiru, CBMT, MM, NMT fellow, is studying in Human Health Science, at
the Graduate School of Medicine at Kyoto University, Japan.
2013, by the American Music Therapy Association

35

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of disability in the United States. Deficits following a stroke

are highly variable and are dependent upon the type of stroke
as well as the area of the brain affected. The most common
type of stroke, called an ischemic stroke, occurs when there is
sudden vascular insufficiency. Ischemic strokes are most
commonly caused by a blood clot formed within a vessel, or
a bit of foreign matter, such as part of a blood clot, that is
carried along in the bloodstream (Nolte, 2002). Damage from
an ischemic stroke depends on several factors, such as the size
and distribution of the infarct, as well as the location of the
occlusion along the course of the artery. For example, due to
the high number of autonomic functions controlled there, a
very small lesion in the brainstem can have a much more
devastating effect than damage to some large areas of the
cerebral hemispheres or cerebellum (Nolte, 2002).
The second type of stroke, called a hemorrhagic stroke,
results from the rupture of blood vessels in the brain. Blood is
then released into the surrounding structures of the brain and
blood supply to the area is interrupted. Resulting deficits are
again dependent upon the location of the ruptured vessels as
well as the size of the bleed. It is important to remember that
because axons carrying information from the corticospinal
tract cross midline, damage to one cerebral hemisphere results
in weakness to the contralateral, or opposite, side of the body
(Nolte, 2002).
While stroke related deficits are highly variable, gait
disturbances are prevalent among a wide range of stroke
patients. Common post-stroke gait deficits include reduced
preferred walking speed, cadence and stride length, as well as
reduced symmetry (Roerdink et al., 2007). Stroke patients may
also demonstrate reduced coordination and reduced ability to
adjust their gait to variations in task demands such as turning,
initiation and termination of gait and speed adjustments.
Given that gait disturbances can cause substantial impairment
to the quality of life in stroke patients, it is important to
identify interventions effective in improving gait coordination,
speed and symmetry. RAS is one such intervention that has
been found to be effective in improving gait parameters in
stroke patients.
Thaut and colleagues (1993) investigated the effect of RAS
on gait patterns in ten hemiparetic stroke patients. Participants
were between 4 and 24 weeks post-stroke. Patients walked for
6 meters self-paced in order to determine their baseline
walking speed and ability. During the second walk, researchers added RAS matched to the patients baseline cadence in
order to determine if an immediate entrainment effect existed.
This same trial was repeated three times with each trial spaced
a week apart. A pattern of auditory-motor synchronization
was present for most participants. Significant improvements (p
, .05) for stride time symmetry, stride length symmetry and

ABSTRACT: One of the most highly researched areas in music

therapy is the use of rhythm to provide a timing mechanism for the
rehabilitation of gait. The application of rhythm during gait training
has been developed into a standardized technique in neurologic
music therapy known as Rhythmic Auditory Stimulation (RAS). This
paper will review current research on the effects of RAS for gait
disturbance of stroke, Parkinsons disease and other rehabilitation
populations.

36

of movement in the ankle joint. With this in mind, it is

therefore important to consider the severity of paralysis and
sensory impairment of stroke patients when RAS is implemented.
Finally, in Cochrane review, Bradt et al. (2010) examined
seven studies consisting of 184 participants. The included
studies were randomized and quasi-randomized controlled
trials that compared music therapy interventions and standard
care with standard care alone or combined with other
therapies. Participants were older than 16 years of age and
had acquired brain damage of a non-degenerative nature.
Patients were participating in treatment programs offered in
hospital, outpatient or community settings at the time they
received music therapy. Of the seven studies chosen by the
investigators to be analyzed, two (Thaut, 1997; Thaut, 2007),
with a total of 98 participants, used RAS as the music therapy
intervention for the improvement of gait parameters. Results
were found to be consistent between the two studies, with
significant improvements in velocity, stride length and gait
symmetry for participants receiving RAS training. Participants
receiving RAS also made significant improvements in gait
cadence; however these results were inconsistent between the
two studies (Thaut, 1997; Thaut, 2007) with the larger study
(Thaut, 2007) showing greater cadence improvement. Results
of this review suggest that RAS may be beneficial for
improving gait parameters, such as stride length, gait velocity,
cadence and symmetry. However, due to the limited number
of studies, and small sample size (98) more studies are needed
in order to strengthen the existing evidence.
In summary, research has indicated that including RAS in
conventional physical therapy for gait training of stroke
patients is very effective. When applying RAS, however,
careful consideration must be given to the severity of paralysis
and sensory impairment of stroke patients in order to prevent
unwanted compensations.
RAS with Parkinsons Disease
Although treatment of Parkinsons disease (PD) has advanced with improvements in medication and surgical options
(such as deep brain stimulation), achieving functional
outcomes with these methods alone is difficult. Therefore,
rehabilitation in conjunction with medication is essential for
optimal treatment outcomes. The implementation of RAS is
reported to be effective for rehabilitation of symptoms of PD
including freezing of gait, and akinesia. However, for
continuing effect, each patients individual circumstances
need to be taken into consideration when applying RAS in a
clinical setting.
McIntosh et al., (1997) focused on the entrainment effects of
RAS on gait with PD patients. A total of 41 patients
participated in the study, with 21 PD patients on medication,
10 PD patients not taking medication, and 10 healthy age
matched controls. Results showed significant improvements (p
, 0.5) in mean gait velocity, cadence, and stride length in all
groups while walking with RAS at a pace set 10% faster than
their baseline cadence. Of note, the PD medication group
demonstrated a 36% improvement rate in velocity while the
non-medicated group showed improvements of 25%. These
velocity improvements were the result of large increases in

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weight bearing time on the paretic side were found.

Electromyography (EMG) data showed more balanced muscular activation patterns between the paretic and non-paretic
limbs as well as a decrease in integrated amplitude variability
on the paretic side (p , .05). In addition, a smoother forward
gait trajectory was noted due to a significant increase in center
of mass vertical displacement (shifting of mass in a vertical
direction) and a significant reduction in lateral displacement
(Prassas, Thaut, McIntosh, & Rice, 1997). In subsequent
studies, researchers have investigated the effects of RAS when
used as a training mechanism as well as comparing the effects
of RAS to other treatment interventions.
In a six-week daily training study with 10 stroke patients in
a RAS gait training group and a matched control group of 10
patients receiving conventional therapy gait training, results
showed a significantly stronger (p , .05) improvement in gait
velocity and stride length for the RAS group (Thaut, McIntosh,
& Rice, 1997). No significant differences in stride symmetry
were found. Variability of EMG activation patterns of the
gastrocnemius muscle were significantly reduced at posttest in
the RAS group (69%) as compared to the control group (33%).
A follow-up study investigated 3 weeks of daily gait training in
a group receiving RAS and a control group receiving physical
therapy gait training with traditional physical therapy (NDT or
Bobath) techniques. Again, the RAS group made significant
gains in cadence, stride length, gait velocity, and symmetry
index than the Bobath group (Thaut et al., 2007). Of note, the
magnitude of improvement for all gait parameters was
reduced by approximately 30% when compared to the
previous study (Thaut, McIntosh, & Rice, 1997), where
patients received six weeks of training. This suggests that
while longer-term training produces more improvements,
significant gains can be made in early post-stroke rehabilitation after only three weeks of training.
Schauer and Mauritz (2003) and Schauer, Steingreuber, and
Mauritz (1996) investigated the use of RAS with hemiparetic
stroke patients during treadmill facilitated gait training and
also found significant improvements. In addition, Ford and
colleagues reported improvement in trunk coordination, range
of motion of the shoulder joint, cadence, stride length, and
gait velocity of stroke patients participating in RAS gait
training (Ford et al., 2007) as a result of analysis with threedimensional kinematic equipment. This indicates that the
application of rhythm to gait training not only acts as a
timekeeper, but may also influence and improve positional
and muscular control.
In a related study by Nakano et al. (2010), participants
received conventional gait training with physical therapy (60
min a time, 7 times a week), in addition to RAS (30 min a time,
5 session a week). Cadence, stride length, step length of
paralyzed side and unparalyzed side, velocity, and Symmetry
Index were measured by a 3 dimensional motor analysis
device (VICON612, VMS Ltd). As a result of RAS, all gait
parameters except symmetry index showed significant improvement for all stroke patients (p , .05). The improvements
in Symmetry Index of stroke patients with a thalamic lesion
were different among individuals. Stroke patients with a
thalamic lesion with severe sensory impairment showed
excessive movement of the hip joint to compensate for lack

Music Therapy Perspectives (2013), Vol. 31

The Use of Rhythmic Auditory Stimulation

stride length and not accelerations in cadence. This is an

important finding since shortened stride length is a predominant feature of PD gait patterns. In addition, the ability of both
PD groups to synchronize their steps to the rhythm suggests
that auditory rhythmic input can have an impact on movement
patterns, specifically gait, despite basil ganglia dysfunction.
With evidence demonstrating results within an immediate
entrainment model, other studies began to look at the
effectiveness of RAS and other rhythmic modalities within a
longer-term clinical model.
Setting Tempo to Decrease Freezing of Gait

Effective modality of rhythm in each stage of PD

Lim et al. (2005) completed a systematic review focused on
different modalities of rhythmic rehabilitation, including
auditory, visual, and vibration, and how these varying
modalities influence gait disturbance and activities of daily
living (ADL) of persons with PD. Although Lim et al. reported
that auditory rhythmic stimulation was the most effective
intervention for freezing gait of PD; results indicated different
modalities may be more beneficial for ADLs, especially for
patients in the early stages of PD. For example, when crossing
a noisy outdoor road, auditory rhythmic stimulation was not
successful due to an inability to clearly hear the stimuli. Van
Wegen et al. (2006a, b) reported that visual rhythmic stimulus
(glasses in which a rhythm signal is shown by optical blink)
were more effective for persons with early stage PD in
situations with competing auditory stimuli. In addition, Van

Wegen et al. (2006a, b) have shown that vibrotactile rhythmic

cues (such as a vibrating bracelet) can achieve improved
results. This indicates that patients with early stage PD respond
to several forms of rhythmic stimulation and may need to
adapt and choose the rhythmic modality most suitable to the
situation. However, for severe stages of PD, the auditory
rhythmic cue is the most effective among all modalities of
rhythm (Arias, et al., 2005). Moreover, there is a report that the
auditory rhythmic cue was the most effective of all modalities
for operation of a complicated task, such as walking in a
house while carrying a tray (Rochester, et al., 2005).
Therefore, it is necessary to choose the modality most suitable
to the severity of PD and various ADL scenes of each
individual patient when rhythm is applied for gait training of
patients with PD.
Continuing effect
Positive results have been found when analyzing the
efficacy of RAS for long-term treatment effects with PD
patients. Nieuwboer et al. (2007) reported decreased muscle
rigidity and fall risk, and improvement of gait velocity, stride
length, and balance after 3 weeks of a home program of RAS,
where the participant chose the modality of rhythm delivery
(auditory, visual, or tactile). The researchers also reported that
the effect of RAS continued 3 weeks after ceasing training with
RAS. Similarly, McIntosh, Rice, Hurt and Thaut (1998) found
that improvements made after a 3 week home-based training
program with RAS were maintained for 34 weeks before
gradual decreases in gait performance returned.
Finally, Ito et al. reported that listening to music, with an
emphasized beat in 120 bpm, in daily routine (at least one
hour a day for 34 weeks), improved gait cadence, stride
length and gait velocity. In addition, 70 % of participants
reported decreased depression in addition to improvements in
gait function.
In brief, studies have confirmed RAS as a viable treatment
for PD patients. They have also highlighted the importance of
assessing the needs of individual patients and choosing the
tempo, rhythmic modality and frequency of sessions to best
meet those needs. In addition to improvements in gait
parameters, improvements in mood have also been reported.
RAS with other Neurological Conditions
Researchers have applied Rhythmic Auditory Stimulation
with additional populations, including persons with traumatic
brain injury (TBI), multiple sclerosis (MS), spinal cord injury
and Huntingtons Disease (HD). In an exploratory study with
eight TBI patients, entrainment effects of RAS on TBI gait were
found to be highly variable and dependent upon the patients
initial level of gait ability, with lower level patients demonstrating more difficulty entraining to faster RAS frequencies.
After five weeks of training, significant increases (p , .05) in
gait velocity, cadence, and stride length were found during the
normal walking condition, where patients walked with their
baseline cadence. Two patients who could not entrain to faster
RAS frequencies and had the slowest baseline velocity were
able to improve their walking speed by 35.6% indicating that
they were able to use RAS as a training stimulus (Hurt, Rice,
McIntosh & Thaut, 1998). It is important to note that all

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Freezing of gait is a major factor that leads to falls in

patients with PD. This phenomenon becomes increasingly
more common with the progression of the disease and is
defined as a temporary episode in which gait is halted and the
patient complains that his or her feet are glued to the ground.
The most common form of freezing of gait is start hesitation,
when the patient wants to begin walking, but is seemingly
unable to do so. Turning hesitation is the second most
common form of freezing gait and has become a major factor
leading to disturbances in ADLs for patients with PD.
Researchers have found that RAS, when used as a treatment
intervention for PD patients, is not only effective at improving
gait parameters such as velocity, cadence and stride length,
but can also decrease freezing gait.
Willems et al. (2007) reported that RAS decreased freezing
gait of patients with PD at the time of a turn (U-turn on 180degree left-hand side). Furthermore, these researchers adjusted the tempo of RAS according to the existence of freezing
gait. They found that the PD patients with freezing gait
increased stride lengths by decreasing the tempo; on the other
hand, PD patients without freezing gait increased stride
lengths by increasing the tempo (Willems et al., 2006).
Moreover, when the researchers compared the influence of
two tempos of auditory rhythmic stimuli (100 and 110 bpm)
on gait of patients with early stage PD, results indicated that
there was more decreased variability of gait cadence at 110
bpm but not at 100 bpm (Hausdorff, et al., 2007). Therefore,
the music therapist may need to consider a tempo setting that
is suitable to the severity of PD in order to reduce freezing of
gait and falls.

37

38

Since spinal cord injuries are highly diverse it is important to

thoroughly assess patients in order to identify appropriate
candidates who are most likely to benefit from RAS.
Finally, a study with 27 HD patients showed that
metronome stimuli facilitated significant gait velocity modulation to slower and faster tempos in mild, moderate and
severe stages of the disease (Thaut et al., 1996). Rhythmic cues
provided during gait training resulted in small and nonsignificant speed adaptations and with increasing severity of
the disease became highly ineffective.
Research investigating the use of RAS with other neurological conditions is limited and has often used small sample
sizes. Further research is needed with larger sample sizes in
order to further develop clinical protocols and better inform
clinicians about the best practice for these highly variable
populations.
Conclusions
In conclusion, research investigating the effects of RAS gait
training in several patient groups has demonstrated a strong
facilitating effect. PD and stroke have been the most widely
investigated patient populations. Research investigating the
use of RAS with other neurological conditions is limited and
has often used small sample sizes. Further research is needed
with larger sample sizes in order to further determine the
effectiveness of RAS with populations including traumatic
brain injury, spinal cord injury and multiple sclerosis.
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spinal cord injury. Seventeen incomplete spinal cord patients
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parameters of cadence, velocity and stride length were
measured for each participant across each condition. Participants completed four, 10-meter walks: walk 1, participants
walked at normal pace without rhythm; walk 2, participants
walked to a rhythm set to the tempo of their uncued normal
walk; walk 3, participants walked as fast as safely possible
with no auditory cue; and walk 4, participants walked to an
auditory rhythm set 5% faster than their uncued fast walk.
These walk conditions were paired so that walk 1 always
came before walk 2 and walk 3 always came before walk 4.
Participants were randomly assigned to either walk order A
(walk 1, 2, 3, 4), or walk order B (3, 4, 1, 2). During rhythmic
cueing at the normal tempo, mean scores for cadence and
velocity decreased while average stride length increased. On
average, all parameters decreased at the fast tempo, although
no statistically significant changes were found. However,
small improvements in cadence and velocity indicated that
many participants were able to entrain with a rhythm at the
normal tempo. As discussed previously, research with patients
with traumatic brain injury showed that even when gait
parameters did not improve significantly during entrainment,
participants still benefited from long-term gait training with
rhythmic cueing (Hurt, Rice, McIntosh & Thaut, 1998). This
suggests that although patients with incomplete spinal cord
injuries in this study did not show statistically significant
improvements, they may still benefit from rhythmic cueing.

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