Musicoterapia e Reabilitação | Doenças Neurológicas

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Artigo:The Role of Music in the Rehabilitation of Persons with Neurologic Diseases: Gaining Access to `Lost Memory' and Preserved Function Through Music Therapy (Concetta M. Tomaino*)

Abstract

The music therapist must have an understanding of the various disease and neurological processes to adequately assess functional ability and plan appropriate use of music for the course of treatment. We have memories for not only the particulars of a song, such as the melody or lyrics, but also the rich associations that keep the melodies alive for us throughout our life. Memories are not actually lost with dementia or with other brain injuries; rather, the ability to retrieve and gain access to these is damaged. As we possess memories for factual information, we also possess memories or `motor templates' for physical movements. Through music therapy, we have the ability to help patients reintegrate the sense of movement that they have lost. Despite the increased acceptance and understanding of the therapeutic benefits of music therapy in work with persons with neurologic impairments and challenges, more research needs to done to demonstrate it's efficacy in application with a wide range of diagnosis.

The role of music ...

Music therapists working with persons with neurologic diseases, including multi-infarct dementia or Alzheimer s disease, have observed for years the dramatic responses that occur when familiar music is presented to these individuals. Attention is maintained, fragments of memories unfold, and a true connection to the ìself takes place. Even with a specific diagnosis, the range of abilities and disabilities related to a neurological disease can vary greatly with each individual. The music therapist must have an understanding of the various disease and neurological processes to adequately assess functional ability and plan appropriate use of music for the course of treatment.

The medical needs of neurologic patients appropriate for referral to music therapy include: memory deficits, depression, balance/gait problems, fine motor problems, agitation/aggressive behaviors, acute or chronic pain, poor attention, decreased vocal projection, expressive aphasia, poor motivation, reduced muscle strength, Alzheimer's disease, multiple sclerosis, Parkinson's disease, and stroke. The use of music as a therapeutic tool for persons with neurologic disease has tremendous potential because of the many ways the individual properties of music i.e.,rhythm, melody, and harmony, induce sometimes predictable neurologic responses. Some examples of this are auditory cueing for gait (Thaut & Mcintosh, 1992), and the use of music as a retrieval mechanism for those with memory impairment (Tomaino, 1998).
Of the elements of music the two which have the most immediate effects on function are, rhythm and melody (by melody I am referring to the power of a familiar melody to trigger emotional responses and long-term memory retrieval) Various rhythmic stimuli can trigger motor function and help in initiation in persons with stroke and Parkinson s disease. In the book Music and the Brain, by Critchley and Henson (1977), N. Wertheim states: ìThere is no meaning to a rhythm without a message and the impact upon the listener depends on this message carried by the rhythm, or else lent to it by the listener himself.. We know that this particular area of the brain stem, the reticular system, is concerned with a regulation of the cortical electrical rhythms...there are abundant connections between the reticular formation and the auditory pathways. It may be that the rhythmical component of the auditory input has an impact on the whole cerebral cortex and also on large subcortical areas, via the extensive connections of the reticular formation with all these regions.
People's experience with music throughout their lives can influence how they will respond to rhythm and sounds presented during therapy sessions. At times rhythmic cueing can be as simple as a metronomic beat but at other times a person may be more responsive to the more complex rhythms of African drumming. This indicates that rhythmic processing may serve to cue attention as well as initiation, however more research needs to be done to understand how complex rhythms are processed by the cortex as well as subcortical regions. There is a strong connection between the auditory system and the limbic system. This biological link makes it possible for sound to be processed almost immediately by the areas of the brain that are associated with long-term memory and the emotions (Tomaino, 1993). Because processing occurs and/or is mediated at a subcortical level, some information processing is possible despite higher cortical damage. This is evidenced clinically by the strong emotional responses to familiar music we observe in person in persons with memory deficits, such as traumatic brain injury, multi-infarct dementia or Alzheimer's disease. Familiar songs become a tool for connecting to seemingly lost parts of the personality by providing a necessary link to the "self".
We have memories for not only the particulars of a song, such as the melody or lyrics, but also the rich associations that keep the melodies alive for us throughout our life. Memories are not actually lost with dementia or with other brain injuries; rather, the ability to retrieve and gain access to these is damaged. Music, then, can provide access not only to specific moods and memories, but also to the entire thought-structure and personality of the past. In a clinical study (Tomaino, 1998), when personally preferred music was presented to persons with medium to late stage Alzheimer's Disease, each participant demonstrated the ability to spontaneously verbalize fragmented information about their past. One of the participants, Molly, who was non-verbal at the beginning of the music therapy intervention, began to speak after hearing an Irish tune repeated for the third time. Although she only stated "That' s nice". It was the first coherent remark she had made. At that point the therapist asked Molly where she was from and she replied from Ireland and then continued to talk about her family and what a nice town it was. Even though the phrases were fragmented the images and ideas Molly was trying to present were clearly connected.
As we possess memories for factual information, we also possess memories or ìmotor templates" for physical movements. Many adults are institutionalized following a stroke that leaves them with a weakness or paralysis on one side of the body. Even persons with dementia may lose the ability to initiate movements. By stimulating a similar but neurologically different physical activity, music, with a strong rhythmic base, can allow for spontaneous movement, thus keeping limbs and joints free from possible atrophy and contractures. Music, and in particular rhythm, can play a essential role in treatment by providing the necessary cues to reintegrate the sense of movement. The loss of neurologic function can trigger the activation of compensatory mechanisms, which have been lying dormant within the brain, to partially or completely ` take over' the absent function. This phenomenon is known as `neural plasticity'. There are many alternate nerve pathways and connections that can be used to re-establish behaviors. Damasio (1994) indicated that neurologic function includes the recruitment of certain neural pathways, depending on the type of stimulus or the subsequent response. In persons with hemiparesis ( a weakening of one side of the body) it may be possible to stimulate alternate motor pathways with the "right" music/rhythm. For example, walking and dancing, though both physical movements, use different postural schema. Through music therapy, we have the ability to help patients reintegrate the sense of movement that they have lost. The following clinical example illustrates this point:
Sam was a man in his late 60's recovering from a recent stroke. He was on physical therapy and was considered a ìguarded walker --he could walk independently with a quad cane. The discharge team was concerned that Sam's uneven gait might cause him to stumble if he walked on an uneven surface like a typical concrete pavement. His was referred to music therapy in hopes that he could improve his proprioception and regain his ability to lift both legs enough to manage the challenges of walking out-of-doors. Sam was able to communicate well and provided information about his past experiences with music including how, as a teenager, he used to go dancing every week. However, he had not danced in over 40 years. The physical therapist tested Sam's gait and I found some music with a tempo that matched the pace of his stride. The music was familiar to him and he felt comfortable walking to the tempo. As he became more confident of his movements, he began to add dance steps, sliding his feet or clicking his heels. As the sessions progressed, he became more inventive in his movements and within several weeks, of meeting two times a week, he began to lift his left foot off the floor. He was not aware of this but stated that he was able to feel the tempo in his leg and thought that he was able to actually feel the floor with his left foot. Previously he had mentioned that one of the most frustrating things for him was to go to the entertainment programs here and have his right foot tap away, while his left foot remained immobile. He was regaining sensation in that side. We worked together, twice a week for two months. At the same time he continued in physical therapy where the therapist used Sam's internal memory of the music to cue his gait. Sam was soon discharged and moved to an apartment in the community.
Despite the increased acceptance and understanding of the therapeutic benefits of music therapy in work with persons with neurologic impairments and challenges, more research needs to done to demonstrate it's efficacy in application with a wide range of diagnosis. Clinical research in parallel with basic scientific studies which investigate the underlying neural mechanisms stimulated by components of music must continue so that a new understanding of music and the brain will emerge. This knowledge may influence how music can best be applied therapeutically. As technology advances, especially in the area of neuro-imaging, and as clinical research continues, we will be able to fully understand the multiple processes of memory, the complexity of neural networks, and mostly, how music connects to essential neurologic function.

References:

• Damasio, A. R. (1994). Descartes ' error.- Emotion, reason and the human brain. New York: Grosset-Putnam Books.
• Wertheim, N.(1977) Is there a anatomical Localization for Musical Faculties. In Critchley and Henson (eds.)Music and the Brain. London: William Heinemann Medical Books. p.293.
• Thaut, M. H., & Mclntosh, G. C.(1992). Effects of rhythmic auditory cueing on stride and EMG patterns in normal gait. Journal of Neurologic Rehabilitation, 6, 185-190.
• Tomaino, C. M. (1993). Music and the limbic system. In F. J. Bejjani (Ed.), Current research in arts medicine. Chicago: A Cappella Books.
• Tomaino, C. M. (1998). Music on their minds: A qualitative study of the effects of using familiar music to stimulate preserved memory function in persons with dementia. Unpublished doctoral dissertation, New York University. New York.
• Tomaino,C.M. (1998). Music and Memory. In Tomaino (ed.) Clinical Applications of Music in Neurologic Rehabilitation. St. Louis: MMB Music, Inc.
• Tomaino, C.M. (1999). Active Music Therapy. In C.Dileo, (Ed.) Music Therapy and Medicine: Theoretical and Clinical Applications. American Music Therapy Association, Inc.

This article can be cited as: Tomaino, C. (2002) The Role of Music in the Rehabilitation of Persons with Neurologic Diseases. Music Therapy Today (online), August, available at http://musictherapyworld.net

*)D.A., MT-BC Director, The Institute for Music and Neurologic Function, Vice President for Music Therapy at Beth Abraham Health Services 612 Allerton Avenue Bronx, New York 10467 USA (718) 519-4236 ctomaino@bethabe.org http://www.musichaspower.org