1. Rhythm and
Synchronicity
Metronome as a Modality
By Asha Moonjely, OTS

2. What is the metronome?
• Any device that produces regular, metrical
ticks
• The brain uses the interval of rhythm to
synchronize the execution time of motor
movement required (Thaut, 2002).
• Rhythm functions as a sensory cue to
enhance the temporal organization of
motor control in the nervous
system(Thaut,2002)

3. Role of Neural Synchronization
• The execution of purposeful motor tasks requires
timing and coordination.
• Timing refers to the production of intrinsically
timed motor actions involving complex
spatiotemporal patterns of muscle action.
• The ability to synchronize motor movements with
a steady auditory beat is a measure of neural
efficiency or neural synchronization.

4. Timing Affects Function
– Attention
– Information processing
– Working memory
– Speech & language
– Reading & learning
– Self-regulation & other executive functions
– Sensory processing
– Handwriting
– Motor coordination
– Balance

5. TIMING IN
THE BRAIN
• Dorsolateral pre-frontal cortex (timing, motor
planning, speech)
• Basal ganglia (timing, voluntary motor coordination)
• Cingulate gyrus (timing, executive functioning,
modulation emotions)
• Cerebellum (timing, sense of body position,
production of speech)
• Listening to rhythm activates premotor cortices.

6. TIMING IN THE BRAIN
•  temporal
resolution
• white matter
tract processing
between B/L
parietal frontal
regions
• efficiency of
attentional
control system
• observable
results

7. SUPPORTING RESEARCH
• Motor Relearning is influenced by several key elements:
intensity, task-specificity, active-initiations, motivation
and feedback. (Birgit, 2010)
• Improvements seen in fine motor skills, elbow and
shoulder ROM, functional use in patients with strokes.
• Used to improve gait, balance, coordination in stroke
patients and those with PD
• Colfesh & Conway(2007) found evidence for what is
called the “controlled attention theory of working
memory”, which can be improved by addressing
underlying deficiencies in neural timing.

8. Who can benefit?
• Adult patients with:
– Attention and memory deficits, Stroke, TBI,
Parkinson’s & other neurodegnerative disorders,
Apraxia
– Anyone with mpaired coordination, balance, gait,
posture, functional mobility, handwriting skills,
motor planning and sequencing

9. APPLICATION

10. ACTIVITIES
–Weight bearing and reaching
–Clapping
–Tapping on vertical/horizontal surface
–Reaching/tapping with cognitive
demands
–Utilizing tap lights for upgrade challenge
–Increase proprioception to affected UE
–Supination/pronation
–Pushing/pulling
–Visual integration to improve balance

11. General Facilitation
– Verbal cues to “speed up, slow down, focus”
– Hands on assistance to internalize sense of timing
– Whole body movement vs isolated body part
– Adjust tempo
– Use visual pendulum as an aid
– Repetition is critical (i.e 3 x a week )
– Performance was dictated by the individual’s internal clock
rate (Baudouin, 2006).
• For Hemiplegia:
– Learn with the active hand first before progressing toward
affected hand
– Try to bring affected hand to midline when clapping
– Self assist
– Gravity assisted movement

12. Billing
• It is a treatment modality.
• Customary charges as:
– Cognitive development
– Neuromuscular reeducation
– Therapeutic exercise

13. Case Study
Age: 44 y/o
Gender: Female
PMHx: L MCA Infarct with Right Hemiparesis (admitted
from TBI); HTN
Social History: Mother, Living with family in apartment and
2-3 steps with wide BHR
PLOF: Independent in all ADLs and ambulation
Values/Beliefs: spiritual, states gratitude to God, extremely
motivated to return to PLOF
Leisure: music, reading, socializing with friends outside
Focus of Intervention: Improve independence in self care
and mobility, improve RUE motor control

14. Case Study –Areas of Occupation
3/5/2015 5/3/2015
Sitting Balance S/D G/F+ N/G+
Standing Balance S/D F-/P+ G+/G
Bed Mobility S<->S; sup<->sit Min. A Mod I.
Transfer chair<->bed Min. A Mod I req. SC
Toilet transfer Min. A Mod. I
Tub transfer Min/Mod. A supervision
Grooming Mod. A Mod. I
LBD Mod/Max. A Mod. I
UBD Min/Mod. A Mod. I
PROM WFL for BUE WFL for BUE
AROM RUE no active, LUE WFL 20-110 elbow flexion RUE

15. Project
– Repetition ( to automate skill) is key (1000s of
repetitions)
– More repetitions than encouraged in traditional OT
due to engagement and focus
– Cueing may distract from fatigue due to engagement
– Functional reaching to improve S/D sitting or
standing balance
• Combine with cognitive demands or perform in
isolation such as:
–Number tasks for sequencing
–Categorization with shapes or colors
–Letter tasks for STM or working memory (i.e
ask to spell word)

16. Bibliography
• Baudouin, A., Vanneste, S., Isingrini, M., and Pouthas, V. (2006) Differential involvement of internal clock
and working memory in the production and reproduction of duration: A study on older adults. Acta
Psychologica, 121, 285-296.
• Beckelhimer, S.C., Dalton, A.E., Richter, C.A., Hermann, V., & Page, S.J. (2011) Computer-based rhythm
and timing training in severe, stroke-induced arm hemiparesis. American Journal of Occupational
Therapy, 65, 96-100.
• Bengtsson, S., Ullén, F., Ehrsson, H., Hashimoto, T., Kito, T., Naito, E., . . . Sadato, N. (2008). Listening to
rhythms activates motor and premotor cortices. Cortex, 45, 62-71.
• Colflesh, J.H &C Conway, R.A (2007). Individual differences in working memory capacity and divided
attention in dichotic listening. Bulletin & Review, 14(4), 699-703.
• Hill, V., Dunn, L., Dunning, K., & Page, S. J. (2011). A Pilot Study of Rhythm and Timing Training as a
Supplement to Occupational Therapy in Stroke Rehabilitation. Topics In Stroke Rehabilitation, 18(6), 728-
737.
• Malcolm, M., Massie, C., & Thaut, M. (2009). Rhythmic auditory-motor entertainment improves
hemiparetic arm kinematics during reaching movements: a pilot study. Topics In Stroke
Rehabilitation, 16(1), 69-79.
• Thaut, M. C, G.C.McIntost, R.R.Rice (1997). Rhythmic facilitation of gait training in hemiparetic stroke
rehabilitation Journal of Neurological Sciences, 151, 207-212
• Thaut, M., Kenyon, G., Hurt, C., McIntosh, G., & Hoemburg, V. (2002). Kinematic optimization of
spatiotemporal patterns in paretic arm training with stroke patients. Neuropsychologia, 40(7), 1073-
1081.
• Whitall,J., Waller, S., Silver, K., & Macko, R. (2000). Repetitive Bilateral Arm Training With Rhythmic
Auditory Cueing Improves Motor Function in Chronic Hemiparetic Stroke. Stroke, 2390-2395.