Reasoning and language, coordination, focus and attention, socialization-these are all major areas in our lives in which timing, or more accurately, planning and sequencing, play a role. The Interactive Metronome has taken the concept of the musical metronome and combined it with modern computer technology to create a training program that can accurately measure and systematically improve a person’s timing. Today, hundreds of clinics, hospitals and schools are training thousands of children and adults with the Interactive Metronome.
HOW DOES IT WORK?
In addition to the IM software program, the IM Package includes two sets of headphones and two contact sensing triggers. One trigger, a special glove with a contact sensor attached to the palm side, senses exactly when the triggered hand makes contact with the other hand while clapping, or when one hand is tapped on the thigh. The other trigger, a flat pad placed on the floor, senses when a toe or heel is tapped upon it. When a user taps a limb in time with the steady metronome reference beat sound heard in the headphones, the trigger sends a signal via a cable to the IM computer program. The IM analyzes exactly when in time the tap occurs in relation to the reference.
The IM program instantaneously transposes the timing information into guidance sounds that the participant hears in the headphones at the same exact time as each tap occurs. The pitch and left to right headphone location of the guidance sounds precisely changes according to each tap’s accuracy. The IM program continually generates accuracy scores (IM scores), displayed in milliseconds on the screen, indicating to the IM Trainer exactly how close in time the user responses are to the reference beat while they are occurring.
ABILITY’S Chet Cooper spoke with Interactive Metronome CEO Tom Eggleston.
Chet Cooper: How did you get involved with Interactive Metronome (IM)?
Tom Eggleston: In 1994, my son Jimmy, as an 8-year old, was being mainstreamed from special education into a regular second grade classroom. My wife, a pediatrician, and I signed him up for piano lessons. The inventor of IM had perfected it for use by professional musicians and he approached Jimmy’s piano teacher to see if it would be useful for students learning music, Jimmy began using the Interactive Metronome and after fifteen one-hour sessions, he demonstrated dramatic improvement including walking without a walker for the first time and never requiring it again. He demonstrated fine motor skill, handwriting and coloring improvement. His attention issues resolved and he caught up with his second-grade classmates academically. That prompted us to become involved with the ongoing medical research that has transpired over the past seven years.
CC: How many people had used the system prior to that?
TE: Good question. The inventor is an acoustical engineer and he had trained a number of musicians. I don’t know the exact number. The happenstance of my son having a disability was unknown to the inventors and certainly we had no expectations other than it would help him with his piano. It was quite a surprise. Subsequently, there have been thousands of patients who have been trained and we’ve discovered through the contributions of a number of leading researchers and physicians what a critical mental process timing. sequencing and planning is. And how foundational it is to the areas that often show deficit like attention deficit disorder and other speech, language and reading disorders as well as for rehabilitation patients with their recovery from either a degenerative condition or a traumatic event.
CC: So, this discovery may not have happened if you didn’t have your son learn piano.
TE: (laughs) You are so right.
CC: What an interesting development for a company. Who was the next person to use the system?
TE: The second case was actually a traumatic brain injury. A young man named Dale was in a head-on car crash on his high school graduation night. Nineteen years later he went through the training that my son did and he went from a, pardon me, a Frankenstein kind of stiff limb, limited motor control and highly garbled speech condition to a rather fluid motion and a large recovery of his speech. Now, to contrast Jimmy’s fif teen sessions. Dale had more than fifty sessions. We have found with many patients subsequently that when you are dealing with a traumatic brain injury (TBI) or a stroke recovery that our standard protocol of fifteen sessions has to be extended. Oftentimes the early sessions have to be simplified because of starting point ability of the patient.
CC: Do you consider this a form of biofeedback?
TE: No, it is different in several respects. Biofeedback is generally passive, where you’re watching a monitor and a series of signals, colors or shapes are appearing on a screen and you react to it. IM is much more energetic. It involves thirteen physical exercises that are done to the metronome beat set consistently at 54 beats per minute. The genius is in the guidance system of additional auditory tones that tell you if you are ahead or behind the beat by left and right ear direction and how far off the beat by both a spatial positioning as well as a tone difference.
CC: Is this technology creating new pathways of learning for people with head trauma or brain damage?
TE: Yes. We have had experts identify that as the case. Our protocol has about 2000-2500 repetitions in each one-hour session. So, part of what you are doing is a series of tasks with this immediate feedback system that is repeated over and over again with a whole variety of activities. So, you have a footpad where you touch your toe and your heel and you have hand triggers both to clap as well as to hit your legs. And then some involve, say, a left hand and a right foot. So, there are bilateral integration elements. It is quite demanding. So, for a serious stroke case, where the patient may only have use of their right side, we wondered, “Is that enough engagement of the limbs to actually capture the improvement in timing sequencing and planning?” We do not have a published study on stroke, but with many case commentaries collected by our practitioners, it does appear that there is no reduction in effectiveness if you only have some of your limbs available for the training.
CC: So, there has been some evidence of improvement in motor skills by stroke patients?
TE: Yes. Motor skills and speech processing have been the most significant functional improvements.
CC: So, after you discovered this incredible system, what went through your mind?
TE: My initial thought was-with Jimmy’s new ability to walk-that this was primarily about gross motor skills. I figured that other kids with mobility problems should have the opportunity to gain the same benefits that Jimmy enjoys. Our first study was actually done under the auspices of the state of Michigan and Dr. Paul Stemmer was the principle investigator. That study was primarily to investigate motor control improvement. We used students out of a Michigan school district. Again, here is another story of this unique unfolding. At the last minute, I said that we should turn on a video camera at the pizza party we had for all the parents (to thank them for transporting their children back and forth) to get their impressions of what had changed in their children. All the expected reports came: “She can now ride a bike for the first time,” “Billy can throw a pass that his broth er can catch. They can actually pass back and forth but before he was so inaccurate,” things that were mobility oriented. But, then they went on to say, “Now Suzy has interest and reads a book for 20 minutes at a time,” “Jane now picks up after herself and can maintain an orderly room.” These things were clearly beyond the realm of motor skills. Although we had observed those additional elements in Jimmy, we hadn’t purposefully researched to capture those. But, that’s what really triggered our theory of additional cognitive benefits being created.
CC: That’s when you started working with ADHD?
TE: Yes. To show you empirically, one nice thing about the system is that we can measure precisely this core capacity of timing. It’s not been measured effectively before. It’s often spoken of as a critical element and there’s been plenty of research, but its been largely subjectively evaluated. Maintaining a consistent interval is the most accepted means of testing it. So, the next step was to get the measure and get enough data that we could show a national scale. What we found is that the normal range is between 40 and 80 milliseconds off the perfect beat. Most people will score in that range. Thanks to Dan Marino, who founded the Dan Marino Center at Miami Children’s Hospital. The hospital director, a pediatric neurologist named Dr. Roberto Tushman, was one of the co-authors of the study. Dan has introduced us to hundreds of pro athletes. So, we tested them and we found that they tested consistently within a range of 20 to 30 milliseconds-substantially closer to perfect beat than the normative range. In Jimmy’s case, he tested at 260 and we find the ADHD population is in that 150-300 range, typically. And we find higher than 300 milliseconds off the beat in more serious cases like cerebral palsy or TBI or stroke. They start much higher and that’s partly why we have to adjust the protocol to accommodate a higher number of sessions.
CC: Does a patient have to, like your son for example, go back in for refresher sessions?
TE: That’s a good question. Jimmy has been re-tested every six months and he’s maintained his score from the end of his training without going back for any further training. We would have restarted the training if he had any deterioration in his improvement. But, we haven’t needed to do so. We’ve also done that with a number of the patients from the mid-1990’s who were the first children trained. We find that they are able to retain their scores, but there has not been a full longitudinal study. Typically, a researcher would like to see ten years of results to establish that permanence claim. We are two or three years short of ten years of data. But, it is pretty uncanny, the ability of the brain. When we ask the experts, they describe it like learning to ride a bike. Training wheels get you to a balance that allows you to ride on two wheels. Our auditory guidance system operates like training wheels to get you to your own perfect beat, which may be normal or it may be somewhat high er than normal if you’ve started with a cognitive disorder. Still, in nearly every case there is a significant improvement from where you began before training.
CC: I know you were previously working for Auto Nation. Did you retire?
TE: I’m still younger than retirement age (laughs). I left a position in January 2001, where I was senior vice president running the technology divisions of Auto Nation. I left in order to start this venture.
CC: So, IM not only changed Jimmy’s life, but your life and several thousands of other people lives just from this discovery.
TE: That’s absolutely right.
CC: What is the inventor’s name?
TE: Jim Cassily.
CC: I’m sure he didn’t expect all of this to occur the way it did.
TE: Indeed. In those days, he literally had a big black box that was the size of a card table and all the adjustment of the guide tones was done manually. So, he had dials that if Jimmy was 260 milliseconds off the beat he would try to dial Jimmy down to 250 and set that as a score that Jimmy was to improve to and then the sounds would adjust. So, one of the first things we said was, “This really needs to be a software product that could operate on any PC and would allow a clinician or therapist to focus on the patient and not worry about trying to adjust the software.” So, the software has been through five versions now. We have a fairly large development team that has been improving it. In those days, we started with only SoundBlaster as the sound card. Today, there are over a hundred different sound cards. So, getting the perfect replication of the tones with all these different sound cards was one of the challenges. But, we’ve been through all of that and it’s a very stable system.
CC: Right now, for someone to go through this, they would be going to an Occupational Therapist?
TE: There are six hundred hospitals and clinics. The two. groups of professionals who are frequently trained are the occupational therapists, you mentioned, and the second would be speech language pathologists with physical therapists being the third. Then we have a group of psychologists and others…pediatricians, etc.
CC: How do you plan to expand IM?
TE: We recently announced a major relationship where we are training their staff now in some selected inpatient and outpatient locations. We will gain experience in both areas of our development. The first is in the areas of disorders where it is a rehabilitation case or a cognitive disorder like ADHD. The second is in the area that we haven’t spoken about yet. In the last year we’ve worked with professional, college and high school athletes and we’ve found that you can take someone who begins in the normal range (the 40-80 score) and move them into the elite athlete range of 20-30-in some cases, even better. We’ve used a standardized academic test to pre and posttest the subjects and we’ve found a one to two grade level improvements both in reading and math as a result of the improved focus and concentration from the IM training. That’s another area of interest to HealthSouth in addition to the core business es that are medical and cognitive.
CC: So, if an athlete wants to expand their athletic ability, there would be some value in it.
TE: Yes. In fact, we have done tests on student athletes. They test at the normal range generally around the 50th percentile at the beginning of the training. We’re consistently achieving 98-99th percentile scores at the end of their protocol. If you’re taking IM training for a performance purpose (not for a disorder), it’s a twelve-session protocol rather than fifteen. It is somewhat abbreviated, because your starting point is so much lower. The IM assessment feature is interesting. In a 20 minute visit to an IM pro, you can be assessed and given a qualitative and quantified measure of your timing. From that compared to a normal range, the IM pro can tell you if you are a candidate for training. So, if you believe you have a disorder, but test in the normal range, you may be advised not to take the training. If you test normal, but you are interested in achieving an elite level of timing, then you could be a good candidate to go through training. So, IM has both an assessment and a training component.
CC: What does an average IM training session cost to the patient?
TE: The therapists generally charge their standard hourly rate. We are not involved in setting up prices.
CC Is this covered under health insurance?
TE: In the majority of cases, patients are securing reimbursement. It depends on the scope of the insurance pol icy, the qualifications of the therapist and the diagnosis of the patient.
CC: What do you see as your next venture with this technology?
TE: Being a partner with HealthSouth in order to expand across their network is really our next major task. Our recent research in Parkinson’s Disease is interesting. The researchers, when we published our fourth study in March of 2001, approached us asking. “Do you realize that the same core mental process that you are improving in these children with cognitive disorders is the process is that deteriorates with the onset of Parkin son’s symptoms?” We would like do to studies both with the early onset of Parkinson’s as well as the advanced stages to see where the IM training could be beneficial. So, that research is ongoing now. There should be some results by fall of 2002..
CC: Do you see something that could be consumer based and used as a form of entertainment?
TE: The role of the therapist is so important in delivering the full benefits. That is the model that we prefer.
CC: Is this patented?
TE: Yes. Patents were applied for and issued-two of them in 1996. It is the only patented system of auditory, brain-based training. There are a number that are visual ly based. You’ve probably seen some where a light changes from red to green and you do some action. But, the brain processes sound-based guidance so much faster than visual. That is one of the features important in its effectiveness. Again, that was not by design. That was just the way the inventor had first designed it because he’s an acoustical engineer by his training. The experts tell us that that is one of the characteristics of the system that makes it is so effective in the medical cases.
CC: How do you feel about your work today compared to what you have done in the past?
TE: It is gratifying to get reports from parents and patients reporting on how their lives have been affected by IM training. I had a visitor this morning whose son had gone through the training first as a serious ADD/ADHD case. The father, a businessman, went through the training on his own and he reports that what psychologists call “the executive functions” improved profoundly for him. It is all very gratifying.