Sound Medicine

Neurology Now
September/October 2006
Volume 2(5)
p 26–29
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A woman with short reddish-brown hair, in jeans and a blue sweatshirt, slowly shuffles down a hospital hallway. She reaches out haltingly to take the arm of her caregiver, and they turn to walk back down the hall. Suddenly, the air fills with music-a bright, synth-pop version of “New York, New York.” Within seconds, the woman's hesitant shuffle-step speeds up into a brisk, normal walking pace. At the end of the hallway, she turns around again, lets go of her aide's arm, and literally bops back, swinging her arms in time with the music.

A miracle? No, just the power of music. The woman, who has Parkinson's disease, is a resident of Beth Abraham Hospital in the Bronx, N.Y., where an innovative music therapy program has made the silent speak and the lame walk.

Beth Abraham gained fame thanks to the movie Awakenings, which starred Robert De Niro and Robin Williams, and was based on the book of the same name by the hospital's renowned neurologist, Oliver Sacks, M.D. Dr. Sacks has since retired from the hospital, but his legacy lives on. Over the past decade, the theories he and others pioneered about the ability of music therapy to help in the rehabilitation of people with neurological illnesses and injuries have evolved from fringe notions to ideas whose time has come in mainstream medicine.

“Anybody who has worked with these populations, especially people with Alzheimer's disease, has observed that despite severe cognitive impairment, there's something about music that can engage and stimulate people differently than other activities,” says Concetta Tomaino, director of Beth Abraham's Institute for Music and Neurological Function, which integrates neurological, rehabilitative, and music-brain research. “Therapists know that familiar music can calm people who are agitated and spur people to sing who otherwise don't engage with others.”

But when Tomaino first began working at Beth Abraham in the early 1980s, our understanding of the brain and how it worked was still in its infancy. Neurologists saw music therapy as just something pleasant to fill patients' time. “Science told us for years that the brain is fixed: we have a specific number of cells in our brain, and by the time we're 80 or 90, we'll have lost half of them,” Tomaino says. “Now we understand that due to neural plasticity, the brain can change and compensate for damage, if it has the right stimulus.”

It's becoming increasingly apparent that music, for many patients, can be the right stimulus. In fact, research is now showing that the brain itself can be changed by participating in music.

“In the past five years, there's been a real sea change in our understanding of music therapy,” Tomaino says. “Music combined with cognitive neuroscience is an enormous emerging area of research. New knowledge from our growing understanding of the brain-using tools ranging from EEGs to PET scans to functional MRI-is helping us to better understand what happens in the brain as a result of music therapy, and to fine-tune our protocols to best help our patients.”

The dementia unit at Beth Abraham is known as “Club Daisy.” About 20 patients with various types of moderate dementias spend their days in this cheery room, which features a chubby pet bunny rabbit and a collage of garden photos pasted to the walls. When the door opens around 1 p.m., several residents eagerly call out, “Is it music time?”

Figure. No caption available.

Click here to enlarge

Music therapist Marah Bobilin gathers the group in the front of the room around her electronic keyboard, starting them off with a “Hello Daisies” call-and-response song that greets each person by name. Some participate at once, while others sit silently in the back and one woman complains loudly in a tirade spiced with obscenities. But as Bobilin sings, asks questions, and encourages them to swing maracas and tambourines in time with “New York, New York” and other familiar tunes, the agitated woman slowly calms down and some disengaged residents begin to shake their instruments with the beat. A double bill of Harry Belafonte-“Jamaican Farewell” and “The Banana Boat Song (Day-O)”-inspires one man, who had stubbornly remained at his lunch table, to dance in his wheelchair. “I didn't know you had moves like that!” Bobilin calls.

What's happening here? “The higher cortical activity that allows us to quickly pull out information from our memories, relay it, and process it in the moment is damaged in Alzheimer's disease,” Tomaino says. “But those long-term memories and information about past experiences are still in there; they just need to be tapped into. Studies are beginning to show that when we save ‘music memories,’ we're saving symbolic information-not just groups of chords, but all those rich associations. Once you get someone's attention and stimulate them with music, information can be retrieved and associated.”

If you play a familiar lullaby for a woman with dementia, she may not be able to say it's the song she sang to her daughter every night, but she may smile, show a change in manner, and sing along. “At the end of the song, she might say something like, ‘I have to go, the children are coming home from school,’”

Tomaino says. “That doesn't make sense in the present, but it makes absolute sense in terms of the memory fragments that are stimulated.” Studies done at Beth Abraham and elsewhere have found that stimulating memory with music can improve the quality of life for people with dementia.

The power of music operates in a different way for people with Parkinson's. “Studies have found that specifically the rhythm of music can stimulate the organization of motor planning and motor timing,” Tomaino explains. “If you put on a strong beat, even just a metronome, you will often see the person with Parkinson's move from shuffling along to lifting up both legs and walking in time to the music.”

This may happen because an auditory signal-like a metronome, rhythmic drumming, or “New York, New York”-prompts the prefrontal cortex, which organizes our thoughts and movements, into action. “For someone who's had prefrontal damage and can't self-initiate that movement, these external cues appear to stimulate the same networks,” Tomaino says. “They can, in many cases, jump-start our internal generator, improving motor control and coordination.” Several studies have shown that “gait training” using music helps to improve walking speed and coordination for people with Parkinson's.

Just as people with dementia may respond best to a popular song from their teenage years while remaining unmoved by a current song, not all Parkinson's patients will walk more smoothly with just any type of music. One of Tomaino's patients went from a slow shuffle-step to a near-foxtrot with the help of the slow, swaying rhythms of “Ramblin' Rose,” while a younger man with Parkinson's found that the unpredictable beat of African drumming helped him get dressed in the morning.

“How the brain responds to music and sound changes with exposure to it,” says Tomaino. “And some people are more auditory than others.”

Ann Grundy has lived more than 15 years at Beth Abraham. She spent the first three months in a coma, after a severe asthma attack that deprived her brain of oxygen. When she awoke, the brain damage had left her without the ability to speak-a condition called dysarthria, in which the coordination of motor function and breathing is impaired. Today, Grundy serves on the residents' council at Beth Abraham and frequently appears at the music institute's events. She's still in a wheelchair, and her speech is difficult but perfectly understandable.

What happened? Again, it was music. Noticing that Grundy was able to make gurgling sounds in the back of her throat, Tomaino assigned music therapy interns to work intensively with her on making sounds and holding them. Then Grundy went on to a regular music therapy class for people with stroke and other brain injuries. There, instead of trying to speak the words she wanted to say, she learned to sing them.

Figure. Science shows how music therapy helps patients with Alzheimer's, Parkinsons, and brain damage.

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“Often, people with brain injuries and particular types of stroke can sing words when they cannot speak them,” Tomaino says. “It appears that the overstimulation of singing, in many cases, can lead to easier access to word retrieval for speaking. Researchers are now doing imaging studies of the complements between right-brain and left-brain speech processing, and also the similarities between speech and music.” PET studies, for example, have shown that stroke patients undergoing “melodic intonation therapy” begin to reactivate a part of the brain called Broca's area, thought to be critical to the recovery of speech.

“Whe-ere is my pil-low?” Ann Grundy and several other patients take turns singing on an old video, to the tune of the “threefold amen” used in many churches. Patients began a three-month class able to say an average of four syllables intelligibly. At the end of the class, they averaged between nine and nineteen syllables.

Here again, the right music can make all the difference. Where the “amen” song and the “Hallelujah” from Pachelbel's Canon in D resonated with the devout Ann Grundy, a young woman in Beth Abraham's music therapy studio today is looking for something more contemporary. Marah Bobilin and the woman's speech therapist settle on a hip-hop beat, and soon the woman is rocking in time and laughing as she repeats “My head hurts, I have a headache,” sounding like she's doing backup for the Black Eyed Peas.

“When the music starts and a person with Parkinson's disease starts virtually running down the hall, it looks like circus magic,” Tomaino says. “That's why people didn't take all this seriously in the beginning.”

But now, science is catching up with what music therapists like Tomaino have known for decades. And the beat goes on…

INNOVATIVE THERAPIES

This is the first in a series of regular articles covering complementary therapies. Also known as alternative therapies, they are now being accepted by doctors to augment standard medical treatments.

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