Mending the Brain Through Music Bret S

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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.

Medscape: Do the memories and recollections last once the music has stopped?

Dr. Tomaino: It depends on the patient. I've had a few patients with short-term memory problems in whom using music, and progressing from older memories forward, have then been able to recall recent events. In people with Alzheimer-type dementia, who have seemingly lost the ability to recall past events, music with strong emotional ties and meaning can lead to enduring remembrances and recall.

Medscape: Several case reports -- including a recent documentary clip that went viral on YouTube -- have demonstrated how effective music can be in helping patients with dementia open up and engage with their environment. How much of this is an actual heightened sense of awareness vs reflexive neurologic activity in response to the music?

Dr. Tomaino: It's both, depending on the individual. Initially, it's more reflexive and reactive. But if the musical interventions are provided on a regular basis and for longer periods -- 15 minutes, 20 minutes, an hour -- we find that their short-term memory and attention improve over time.

We did some studies years ago that were funded by the New York State Department of Health and engaged people with mid- to late-stage Alzheimer disease in music therapy sessions for 1 hour, 3 times a week for 10 months. We found that over time, their awareness of other people improved significantly. Some even recognized those people by name, increased their group interactions, and demonstrated improvement in memory and awareness -- they once again knew when it was lunch time. Page 4 of 6

So yes, in patients with dementia, things that you think are lost forever are retrievable over time with this kind of stimulation. I believe there is now scientific evidence showing this -- that when somebody's engaged in an activity that's meaningful, it involves regions of their frontal cortex that stimulate short term memory and attention. Then if you can hold somebody's attention with something that's meaningful for a long period, the very mechanisms that are breaking down in somebody with dementia are actually being enhanced and activated.

Medscape: Interesting. So, music-based therapies work via a variety of musical qualities, with aspects like rhythm, melody, and emotional familiarity having much different effects, respectively?

Dr. Tomaino: Right. There are totally different mechanisms at work here. The emotional and personal connection is important in dementia, whereas in PD, we're looking at the person's ability to perceive and feel the beat. In patients with PD, rhythm is so important and unique to the patient. Instead of just picking a beat and using a metronome, we experiment with different rhythms and rhythmic styles to see what the person responds best to. They have to feel the pulse in order for that pulse to drive their motor function. So when we talk about "music therapy," we're talking about components of music, such as rhythm, tone, melody, harmony, song -- all of these qualities can be used together or individually to affect the patients with certain conditions.

Who Benefits Most?

Medscape: I'm curious about how an individual's degree of engagement with music before therapy affects the outcome. Does a person's musical skill or appreciation come into play? Does a classical violinist benefit most from music therapy? A music critic? A Deadhead?

Dr. Tomaino: Anybody can benefit from music therapy, but their background in music can help or hurt them. Most humans have an affinity for sound and can process it in highly complex ways. However, in certain diseases people may lose this ability, and in fact sound may get so distorted that they have a negative response to it, even if they'd loved music before their injury. This is especially evident in people with damage to the right temporal lobe: These patients often lose their perception of pitch. In fact, I think in Musicophilia, Dr. Sacks writes about a classically trained, professional musician who, after localized brain damage, is a quarter tone off in his perception of pitch.

Medscape: That's right. And he ended up just tuning his piano up a quarter step!

Dr. Tomaino: Yes! So that's where the music therapist really has to look at what a person is able to perceive. This patient's perceptive problem probably wouldn't have bothered someone who couldn't tell the difference. With a professional musician, you can imagine that their neural connections to sound and perception are greatly enhanced.

For example, we treated a percussionist who'd had a stroke. The traditional therapy would be to work with the nonaffected side to encourage the intact side of the brain to take over function. For example, a right-handed person would be taught to perform tasks with the left hand. But because percussionists and musicians, by nature of their craft, presumably have stronger bilateral neural representation, we convinced the physical therapist to try working with the affected side of the brain and body. The person was able to regain function. By encouraging the patient to use the affected limb, we try to restore as much function as possible to this limb rather than compensate with the other side.

Medscape: We know that certain areas of the brain are highly dedicated to certain aspects of perception and information processing. The left frontal and temporal lobes are highly involved in speech recognition and production. The occipital cortex processes visual information. But music and sound perception and processing seems to involve numerous regions all over the brain. Can you speak about how the brain perceives and processes music, and how this lends itself to therapeutic applications? Page 5 of 6

Dr. Tomaino: There are some areas of the brain that are known to be involved in specific aspects of sound processing, mainly through looking at people who have lost certain abilities through certain brain lesions. As I mentioned earlier, patients with a lesion in the right temporal lobe often experience loss of pitch perception. We know that singing is dominant in the right temporal lobe; however, syntax of both speech and music is left dominant. And there are areas on both sides of the brain that inform and coordinate with each other when it comes to music, because music isn't just one specific skill. That said, music processing is incredibly complex, and as far as I know, a complete map of the areas responsible for music and sound processing doesn't yet exist.

This complexity is probably why music is so beneficial as a therapeutic tool. It's processed bilaterally: in the cortex and subcortically, where it stimulates evolutionarily primitive areas of brain function, such as the cerebellum and the basal ganglia. So when a person does have a deficit, there is still some part of the brain functioning properly that is involved in music processing and can be stimulated through sound.

Another interesting aspect here is that in patients with damage to higher cortical regions -- those with frontal temporal dementia (FTD) -- their appreciation for music may change. Oliver wrote about a classically trained musician who didn't care for any other types of music; after developing FTD, he starting liking rock and roll.

Functional imaging studies, such as those by Dr. Schlaug that I mentioned earlier, are really helping us understand neural plasticity as well as which areas of the brain are involved in what. You can first isolate the components of music, studying where pitch is processed, and beat, and melody. Then you can put them all together, and it becomes very complex. With functional imaging, it became possible to literally watch the brain work in real time while it listens to music.

Acting, Painting, Listening

Medscape: In reading Musicophilia , one of the things that really fascinated me was the idea that our memory for music is far more high-fidelity than it is for nonmusical creative sensory stimuli. Our recollections of visual art and narrative are often distorted or approximated; however, musical memories and dreams have been proven highly accurate in pitch, melody, mood, and rhythm. How does this distinguish music therapy from other forms of creative arts-based interventions, such as art and drama therapy?

Dr. Tomaino: I should admit that I used to be biased when I sat on the board for the creative arts therapy coalition, because I knew that music -- especially the components of music, such as rhythm -- could directly affect brain function rather than requiring the interpretation by the arts therapist. I think the big difference is the other arts therapies tend to work psychotherapeutically. And in fact, many music therapists work psychotherapeutically, which can be very effective.

But myself, Dr. Sacks, and a few of our colleagues became interested in the neurologic underpinnings of music and how sound itself could arouse and stimulate basic brain functioning. Whereas art and drama tend toward the emotions and personal associations -- a sense of self and ego, and all those areas of psychotherapy -- the specific components of music can actually affect brain function in a very measurable, functional way.

Because of this, music therapy is one of the therapies still available to people with devastating diseases, such as Alzheimer disease and neuromuscular conditions, in whom the other creative arts therapies would no longer have a therapeutic benefit. Music can bypass upper-brain processes and higher cognition, as well as stimulate some of the fundamental lower and midbrain areas.

I should say that although we don't treat psychiatric patients at our facility, so often neurologic and psychiatric illnesses -- as well as medical illnesses -- are intertwined. So the psychotherapeutic component of our music-based interventions are very important to our patients too. Page 6 of 6

Medscape: How widely accessible is music therapy, and how many therapists are there in the United States?

Dr. Tomaino: There are close to 6000 music therapists in the United States. It's not that many, when you think about how many people could benefit from it.

Medscape: Short of having access to a music therapy resource for referral, how can clinicians incorporate music therapy techniques into their practice?

Dr. Tomaino: It's really great that something so effective is available to everyone. Although it is always important to seek out a professional music therapist first, there are therapeutic applications of music that others can make use of: for example, using personalized music to help someone with Alzheimer disease feel connected, or using rhythmic cues to help increase stride and gait in someone with PD.

And we haven't even touched on children. Professionals who are working with children with autism-spectrum disorders should really seek out music therapy because it's been very, very successful with this population. It can be so important in developing early language and motor skills, as well as self-identity and social skills.

I could also see a psychiatrist or social worker who's having a hard time having a patient open up asking them to bring their favorite piece of music in; it could be an effective entry point into forming a relationship. Speech therapists who have a patient with aphasia can ask the persons to sing.

Likewise, a physical or occupational therapist can use rhythmic cues to help with motor problems. It's amazing how little rhythm is used in rehabilitation especially in helping people with PD move more effectively. Just remember that each patient responds to different musical cues and rhythms, which requires time to navigate. I've talked to a few neurologists who will put on a Sousa march and expect a patient to immediately get up and walk!

Editor's Note: The American Music Therapy Association's Website maintains a list of music therapists in the United States, many of whom provide Skype services for remote patients.

References

1. Wallin NL, Brown S, Merker B. The Origins of Music . Cambridge, Ma: MIT Press; 2001.

2. Sacks O. Musicophilia: Tales of Music and the Brain, Revised and Expanded Edition. New York, NY: Vintage;2008.

Cite this article: Mending the Brain Through Music. Medscape . Oct 29, 2012.