Page 1 of 6 www.medscape.com Mending the Brain Through Music Bret S. Stetka, MD, Concetta M. Tomaino, MA, DA, LCAT Oct 29, 2012 Editor's Note: From a Darwinian perspective, music is a mystery. It's unclearwhether the human ability to appreciate a catchy melody conferred some specific evolutionary advantage or was a by-product of more general adaptations involving sound and pattern processing. But what is known is that evidence of music has been found in every documented human culture [1,2] -- and that nearly all of us have at least some innate capacity to recognize and process song. The human brain houses a staggeringly complex neuronal network that can integrate rhythm, pitch, and melody into something far greater with, it turns out, significant therapeutic potential. Research and clinical experience increasingly support music as medicine. Accessing and manipulating our musical minds can benefit numerous psychiatric, developmental, and neurologic conditions, often more effectively than traditional therapies. Dr. Concetta M. Tomaino, along with noted neurologist and author Dr. Oliver Sacks, cofounded the Institute for Music and Neurologic Function to study the effects of music on the brain and neurologic illness in particular. In light of increasing interest in music therapy and accumulating data supporting the approach, Medscape spoke with Dr. Tomaino about how the brain perceives music and the role of the Beatles in treating neurologic disease. Introduction Medscape: Thanks for speaking with us today, Dr. Tomaino. The Institute for Music and Neurologic Function has been integral to our understanding of how the brain processes music, and how music can be used as therapy in certain neurologic conditions. Can you give us some background on the Institute and discuss your role and work there? Dr. Tomaino: The Institute was incorporated in 1995 to bridge the worlds of neuroscience and clinical music therapy. It grew out of the work of both myself and Dr. Oliver Sacks, with support from CenterLight Health System (formerly Beth Abraham Family of Health Services). I'm a music therapist by training, with a master's degree and doctorate in music therapy but also with a strong neuroscience background. Back in the 1970s, I was working in a nursing home and was amazed at how people with end-stage dementia, with little to no cognitive ability or awareness of their surroundings, could still process familiar music. I started wondering whether music could be used as a specific therapy to arouse cognition in patients with severe dementia. When I came to Beth Abraham in 1980, Oliver Sacks was the attending neurologist and had been asking similar questions about the postencephalitic patients he wrote about in Awakenings , wondering how music and arts affected people who'd lost brain function through disease or trauma. And so we sought each other out and became good friends. We worked together, him using music to test patients and me clinically applying music to help people recover or improve function. Both of us realized that there was something important going on here, and in the mid-1980s, we began seeking out scientists who could help us study the effects of music on brain function. In 1985, Oliver's book The Man Who Mistook His Wife for a Hat became popular, and I was president of the American Association for Music Therapy. Our administration took notice of the attention both Oliver and I were receiving from the media and asked whether there was something they could help us do to expand upon our ideas. And so the Institute was formed as a center dedicated to studying music and brain and bridging the clinical and neuroscience communities. Page 2 of 6 Medscape: Can you speak about the origins of music therapy and how it's been used over the years? Dr. Tomaino: The therapeutic aspects of music have been noted in societies for thousands of years; however, interest really grew around the time of World War II, in part because the Works Progress Administration (WPA) program started bringing musicians into veterans hospitals. Doctors and nurses observed that people who seemed to be totally unresponsive would come to life when music was played. The hospital staff wanted to bring more musicians in, but training was needed to prepare them to better understand the conditions and needs of the patients. The approach gained attention, and eventually music therapy came together as a profession in the late 1940s. We now have a certification board, and the American Association for Music Therapy oversees academic and clinical training approaches. The scope of music therapy has become very broad. It's been studied and shown effective in psychiatric illness; developmental issues; and medical conditions, including pre- and postoperative settings. However, Dr. Sacks' and my interests and contributions to the field have been in the area of neurologic function. Medscape: In which neurologic conditions has music therapy shown the greatest effectiveness? Dr. Tomaino: There are so many, but one of the most recognized areas is motor initiation in patients with neuromuscular and movement disorders, such as Parkinson disease (PD). Patients with PD often have a slowness of movement and a shuffling gait. Music, specifically highly rhythmic music, has been shown -- and there's quite a bit of supporting data here -- to help them in training and coordinating their movements and gait. Music also enhances the length of their stride and improves balance. Later in the course of PD, cognitive and short-term memory decline are common; in this case, music has been shown to be an effective mnemonic tool, a memory enhancer for remembering basic information -- phone numbers, people, addresses, things like that (I'll get to other forms of dementia in a second). My work and that of some colleagues has also shown that singing and using music to enhance voice and communication is also beneficial for people with PD. Medscape: Is music therapy used preventatively or symptomatically to address the cognitive component of PD? Dr. Tomaino: Ideally, it's started early to help prevent memory decline and create new associative memories early in the disease -- linking acquaintances, places, and events, for example, in order to prevent or slow future memory problems and enhance recall. Recent research is really enhancing our knowledge of neuroplasticity. Forming these associations -- these new neuronal connections -- appears to be neuroprotective. Recalling Words and Memories Medscape: Another area researched at the Institute is using music therapy to help patients with nonfluent aphasias recover speech -- patients who comprehend language and know what they want to say, but just can't find the words. How successful has this approach been? Dr. Tomaino: These are patients who have had damage, such as a stroke, to the Broca region of the brain, in the left frontal lobe. Some do have mild cognitive impairment, but mostly they fully understand what's being said to them -- at least, that's the case in the patients we work with. We apply several techniques depending on the patient's residual skills: for example, can they sing a simple song and tap their finger along with the rhythm. We cue them to sing along with familiar lyrics from memory and help prompt word retrieval by leaving pauses within the lyrics -- you leave out a few lyrics in a familiar Beatles song and have the patient try to find the words without losing the beat. This helps a great deal. As the person improves, we Page 3 of 6 move toward a more traditional form of melodic intonation therapy (MIT), focusing on the tone and rhythm or normal speech phrases rather than singing lyrics to songs. Traditional MIT, developed by a team at the Boston Veterans Affairs Hospital in 1973, is being studying by such neuroscientists as Gottfried Schlaug at Harvard Medical School. A simple, 2-tone sequence -- a high and a low pitch -- is used to pattern the inflection of speech. It has 4 levels, beginning with humming and tapping short phrases and gradually moving toward a Sprechstimme , or a more normal rhythmic speech with little melodic change. Patients are asked to repeat single words with the beat and tones, gradually increasing to more complex phrases, such as "Good morning, how are you today?" [Editor's Note: Imagine each syllable alternating between 2 tones.] The repetition overlaid on the music helps reinforce the patterns of normal speech and helps patients recover words and fluency. Neuroimaging studies indicate compensatory changes in the right frontal lobe areas. Music therapy is also used to as a psychotherapeutic application in mental illness and can help alleviate stress and anxiety. This has an impact on neurologic function as well; for example, multiple sclerosis symptoms can be exacerbated by stress. Preliminary research shows that music can be an excellent tool for self-relaxation and stress management in these patients. And one of the most fascinating areas in which music is used is dementia and amnesia. Medscape: Dr. Sacks has written about a number of patients who, despite exhibiting severe amnesia, can remember song lyrics perfectly. What does this say about the neuronal pathways involved in musical memory vs say, declarative memory, our ability to consciously recall information? And what is the therapeutic potential here? Dr. Tomaino: They are most likely primarily processed by separate brain systems. So a person with dementia or amnesia may not consciously recognize a familiar song, but something in their subconscious knows it's familiar. There are feelings, emotions, or moments of history in there somewhere. And if they listen to those songs, we're realizing that sometimes these feelings or the emotions are so strong that they trigger fleeting glimpses of pieces of memory. If we can work with those fleeting moments and build upon them, maybe stronger connections can be made and more memories experienced.