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Widespread for centuries, music therapy took root in the United States in the 1950s. By the early 1970s, most of the work in music therapy on the east coast had been split into two categories: early childhood development-to address pre-educational skills in children with Down syndrome, autism and learning disabilities-and psychotherapy, to help patients deal with mental health issues.
Clinicians also tried to tap into the power of music for a third area: geriatric care. At the time, however, music simply was used to connect with individuals or help them pass the time. "There wasn't any insight or understanding of how and why music was effective as a therapeutic tool," said Concetta Tomaino, DA, MT-BC, executive director and co-founder of the Institute for Music and Neurologic Function (IMNF) and senior vice president of Music Therapy at Beth Abraham Family of Health Services in the Bronx, NY.
She realized the power of music when she worked in a nursing home and received positive reactions to it from people with end-stage dementia who were catatonic or agitated. "When I played a specific song, not only did they respond but they recognized the sound as music, which told me that they still had the ability to cognitively process auditory information specifically related to familiar music," she told ADVANCE.
This discovery led her on a journey parallel to that of other music therapists who were beginning to observe a much stronger connection between music and function that went beyond the psychotherapeutic aspects. "There was something specific about how the brain processed the music or how music gained access to parallel networks," she said. "This was 30-something years ago, so nothing in the scientific literature even hinted at that."
When Dr. Tomaino joined Beth Abraham, she teamed up with Oliver Sacks, MD, now a professor of neurology and psychiatry at the Columbia University Medical Center in New York City and an honorary medical advisor at the IMNF. They started questioning why music seemed to affect people who had lost their ability to speak.
"That's where my initial work in music and speech rehabilitation started to unfold-connecting with neuroscientists who were eager to share ideas, analyze them, and look clinically at where music could help as a restorative therapy for people who had a stroke or traumatic brain injury," she said. It affords patients the opportunity to access the function they lost due to brain injury or a neurological condition like Parkinson's disease.
"Deficits disappear or minimize when the right music, rhythmic cue, or aspect of music is employed that allows that function to be enabled," she said. "The research is only starting to validate the efficacy of music therapy or music as a restorative tool to re-stimulate mobility, language and communication, and memory."
Music therapy is a dynamic, active intervention between a therapist and patient-which is key to understanding how it works. This collaborative process enhances therapy. Clinicians can explore and take advantage of the different aspects of music, such as rhythm and melody, to facilitate increased patient responses to the music. Depending on the outcomes, the music therapist can create an appropriate program for a patient "as opposed to just putting on a recording and expecting something to happen," said Dr. Tomaino.
Sessions do not have a rigid structure, said Darlene Monda, MS, CCC-SLP, on staff at Beth Abraham Family of Health Services' Adult Day Health Care, who collaborates with staff at the institute. "It isn't a question-and-answer type of therapy, where the patient feels on the spot. We're all singing together. There's an elevated mood, and patients are given a voice without the anxiety that can go along with that."
Her role in therapy is to find the basic functional elements that the patient needs to focus on. The role of the music therapist is to sense the musical elements that will stimulate the patient, such as the key or rhythm that is most suitable for eliciting speech. Both can alter rate and other elements as they go along.
A big part of therapy is spontaneous music-making, which is facilitated by the music therapist. Rhythmic cueing benefits individuals with motor, motor initiation or memory problems; and rhythm alone can help strengthen attention spans. "Auditory cueing stimulates some key pathways to brain areas involved in motor initiation and control," she said. "It reinforces and trains those areas into action. The right beat can provide that information and enable somebody to move."
A useful protocol is the Melodic Intonation Technique (MIT), which was created by Robert Sparks, MSc, and Nancy Helm, MEd. Patients with Broca's or non-fluent aphasia have benefitted from this technique, according to Dr. Tomaino. "Many times they could sing a familiar song but could not speak the words independently." While this observed phenomenon was attributed to split brain function, with the right side involved in singing and emphatic speech and the left involved in speech, language and linguistics, "that's not completely true," she said. "There are shared networks and properties on both sides of the brain, especially in the temporal lobes and motor areas."
In recent clinical studies Dr. Tomaino has found that when individuals with non-fluent aphasia sing soon after a stroke, they may get some of the lyrics right even though they cannot speak. The kick is that they initially can sing the song with some ease and recover more of the lyrics with practice and repetition.
"It will come back easier to them because it's not as affected as spontaneous speech, which is the part affected by the stroke," she explained. "As they start recovering the predictable words in lyrics, the recovery of naming tasks is facilitated."
Music therapists at Beth Abraham work with speech-language pathologists to treat individuals with dysarthria. A protocol similar to MIT developed by the IMNF is used to work out songs or jingles that will help patients remember particular phrases, such as requests for help or their phone number. "We've had people who couldn't speak three syllables intelligibly but were speaking up to 19 syllables very clearly at the end of two months," said Dr. Tomaino.
She theorizes that singing a familiar song helps prime the brain, making it easier for patients to say words. The clinician points to an object or picture and asks the patient to name it. After singing the song many times, the patient can get the word out quicker. "We're stimulating word retrieval," she said.
Using the IMNF techniques, an individual may sing "Happy Birthday" while tapping on the tabletop or the floor. The clinician then removes the melody and asks the person to speak the lyrics in a rhythm, effectively turning them into a chant. The goal is to reflect the natural contour of the word by creating an up-and-down movement of sound. Finally, the clinician removes the rhythm to see if the patient can say the words independent of those cues.
The ultimate test is to find out if there is carryover in other aspects of speech. Patients need to internalize the process and understand what the music is enabling them to do. Without initiating the concept and techniques on their own, they will have difficulty generalizing recovered skills.
Dr. Tomaino recalled a patient with a stroke who hadn't spoken for several years. When he started singing every day, however, he was able to verbalize short phrases spontaneously.
Another case involved a person who had endured a major stroke. The former criminologist, who had spoken at trials, couldn't say a word. He got frustrated and depressed as recovery remained out of reach, despite rigorous speech therapy. Finally, his speech-language pathologist tried MIT. The patient sang "Happy Birthday" as part of the assessment. Hearing his voice for the first time in years, he was amazed at how easy it was for him to get the words out.
"He thought to himself, 'How can I do this and not say a word?' He had the wherewithal to realize that there was something about music that enabled him to say the words, even though they were just lyrics to a simple song," said Dr. Tomaino.
Inspired, the patient went home and listened to every piece of classical music he had, searching for repetitive melodic lines. Whenever he found them, he would think about what those melodic lines would sound like if he were to put phrases to them. With consistency and practice, he forced himself to sing everything he wanted to say. Over the years he recovered his speech. "He consciously takes the music away so he is only speaking in a very rhythmic way," Dr. Tomaino said. "He can speak fluently using that technique." (To see this individual's ability to speak using MIT, go to http://www.youtube.com/watch?v=F_5verI-bj8.)
One of the songs that clinicians in the program sang with their first patient, who had severe aphasia, was "Show Me."
"The patient could not understand what people were asking," recalled Monda. "When we taught her this song, we hoped she would be able to say those words so people would realize she wasn't able to answer a question unless she was shown items to choose from, such as three kinds of cereal. It worked and started to happen in all kinds of situations. It's been an amazing thing."
Clinicians help people with aphasia produce purposeful functional language with the support of a melody. Traditional speech therapy exercises can be repetitious, boring and frustrating; but the mood of music therapy eliminates all of that. "Music is fun and relaxing," said Monda. "If people make a mistake, they don't have to worry because there is always another verse and another chance to get it right."
Depression and a lack of motivation are two of the biggest factors that hinder recovery in rehabilitation and make it difficult for individuals to practice as they should. Music therapy can provide an outlet for patients to overcome their depression and poor motivation.
"If somebody is depressed, unmotivated, withdrawn, and not participating fully in rehabilitation, chances are they are not going to recover to their full potential," said Dr. Tomaino. "We often work with patients in music therapy to provide a way for them to express feelings nonverbally and help them to deal with both the psychodynamic issues of recovery and loss and the naturalistic way that music can stimulate other areas to regain function."
Carryover occurs when patients engage in repetitive, ongoing practice to the point where music begins to reconnect or make new networks in the brain, erasing some of the inhibition caused by stroke. Therapists encourage the patients and their caregivers to use these techniques several times a day, 15 to 20 minutes at a time, to help them learn to use their voice again.
Typical materials used in aphasia therapy, such as visual cueing and pictures, are still part of therapy, even when music is involved. The speech-language pathologist needs to figure out what makes sense to work on. That information often comes from the patient. For example, he or she might want to be able to say the names of grandchildren or ask certain questions.
"I use all the things that I would normally use in a session, but the most interesting thing is what's absent," said Monda. "The yes-no questions and the back-and-forth drilling are gone."
What is it about music that breathes new life into people? She believes it's the primal nature of rhythm and its connection to the human heartbeat.
"It's in us all," she said. "It's intact in most of my stroke patients because their language zone is affected but not their melody or rhythm facilities. Using that strength and those fundamental skills facilitates an individual's ability to use something else that used to be natural and automatic. But their language skills do not return spontaneously or naturally. That comes with time, practice and repetition."
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Jason Mosheim is a Senior Associate Editor of ADVANCE. He can be contacted at jmosheim@advanceweb.com.
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