Mending the Brain Through Music
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 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.
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.
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 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.
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.
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