[Original Voices: Report]
Music Therapy Advances in Neuro-disability - Innovations in Research and Practice: Summary Report and Reflections on a Two-Day International Conference
By Julian O'Kelly, Wendy L. Magee, Alex Street, Jörg Fachner, Adele Drake, Joel Cahen, Teppo Särkämö, Hanne Mette Ridder, Monika Jungblut, Ruth Melhuish, & Dale Taylor
Abstract
This article provides a summary of the oral papers presented during a two day international conference, which took place on 7th & 8th June 2013, at the Royal Hospital for Neuro-disability (RHN) in London. The summary texts detail innovative research projects and clinical developments across music therapy, music neuroscience and music psychology addressing the needs of those with acquired and degenerative neurological conditions. The diverse and evolving work in this field is reflected in the topics covered, including disorders of consciousness, dementia, stroke, and the use of modern neuro-imaging methods to measure the effects of music therapy at a cortical level. A discussion of the implications of these converging foci highlights the benefits of the cross-disciplinary dialogue that characterised the conference.
Keywords: music therapy, neuro-disability, neuro-imaging, neuro-plasticity, dementia, stroke, brain injury.
Background and Introduction - Julian O’Kelly
In what is planned as a series of conferences, clinicians and researchers were brought together from 16 different countries to share their work at the first Music Therapy Advances in Neuro-disability two-day conference. As one of the organisers, I was struck by the richness and diversity of material presented, and how this clinical field was so well served by dialogue with related disciplines such as music psychology and neuroscience. I felt a paper drawing in material from speakers might provide a perfect format to continue this cross-disciplinary discourse. Following the conference, I invited all keynote and oral presenters to contribute summaries of their presentations to this paper, with a view to recording this event for a wider audience, and fostering further discussion. What follows is a personal introduction on the themes of this event followed by these contributions. In conclusion I have reflected in the implications of the material brought together for the development of the music therapy profession.
The expanding field of music neuroscience or neuro-musicology has uncovered a plethora of ways in which musical activity can support neuroplasticity (for overviews see Koelsch, 2009; Särkämö, Tervaniemi, & Huotilainen, 2013). Here, changes within brain structures themselves occur where healthy brain regions compensate for damaged neighbouring areas, taking on the functions for which those damaged areas were formerly responsible. In parallel with these advances, the music therapy profession has developed specific interventions to target deficits such as aphasia and gait disturbances arising from acquired and neurodegenerative conditions (e.g. Jungblut, 2009; Thaut et al., 1996). However, in comparison to more established allied health professions such as physiotherapy, music therapy at an international level comprises a relatively small and heterogeneous mix of clinicians in terms of approaches, trainings and levels of integration within medical and healthcare settings. Perhaps this partly accounts for the lack of clinical research utilising the sensitive neuroimaging methods currently used in the evolving field of music neuroscience. There is a need for greater dialogue between both fields, with the potential for mutually beneficial outcomes in research and clinical practice (O'Kelly & Magee, 2013a).
It was with the need for this dialogue in mind that the first Music Therapy Advances in Neuro-disability conference was conceived. The conference was designed to be on a small enough scale to encourage group attendance for all papers and poster sessions, thus encouraging cross-disciplinary discussions throughout the event. What was particularly exciting was the diversity of approaches and clinical populations covered by speakers, combined with the mix of music therapists, psychologists and researchers presenting. Shorter Pechakucha presentations covered subjects as varied as Latin ballroom dancing, rarer conditions such as Rhett’s syndrome and Huntington’s disease, and iPad applications for therapists. Whilst considerable media and research attention has recently focused on aphasia and gait work in particular (e.g. Schlaug, Marchina, & Norton, 2009) the richness of clinical work in this field was given a timely voice at the conference.
Day one of the conference began with keynote Associate Professor Wendy Magee exploring the challenges and opportunities for our profession in work with disorders of consciousness, with an overview of the newly standardised Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (Magee, Siegert, Daveson, Lenton-Smith, & Taylor, 2013). This was complemented by my overview of a neurophysiological and behavioural study designed to develop the evidence base in this field (O’Kelly et al., 2013), which I have led on as a PhD Mobility Fellow at the RHN with Aalborg University. Another PhD study exploring upper limb rehabilitation with stroke patients was outlined by Alex Street, from Anglia Ruskin University. Also from Anglia, Professor Jörg Fachner introduced delegates to the potential of neurophysiological measurement of music therapy using EEG methods, detailing his large scale study of psychodynamic music therapy with depression (Fachner, Gold, & Erkkilä, 2013). The theme of neuro-imaging applications was developed in the second keynote Dr Teppo Särkämö, who presented his research on musical leisure activities in stroke and dementia rehabilitation (Särkämö et al., 2008; 2010; Särkemo, Tervaniemi & Huotilainen, 2013; Särkemo, Tervaniemi & Laitinen et al., 2013). The day also included a presentation on a novel therapeutic use of music played underwater to individuals with special needs by Adele Drake and Joel Cahen of Liquid Vibrations.
On day two Keynote Professor Hanne Mette Ridder from Aalborg University began with an overview of music therapy advances in dementia care, including her recent randomised control trial, demonstrating how music therapy can decrease agitation, disruptiveness and prevent medication increases (Ridder, Stige, Qvale, & Gold, 2013). Using qualitative methods, Ruth Melhuish explored music therapy and dementia further from the perspectives of nursing and health care assistants. Monika Jungblut added to day one’s introduction to neuro-imaging methods, by outlining her research investigating rhythmic-melodic voice training (‘SIPARI’®) (Jungblut, 2009) with those with non-fluent aphasia using fMRI methods. The concluding presentation by Professor Dale Taylor drew together many of the themes from the conference, in his overview of research on musically stimulated neuroplasticity, and Music Re-instruction work with head injured musicians.
To provide Voices readers with a more detailed overview of the conference, keynote and oral presenters have each summarised their papers, presented here in chronological order.
Summary of Papers
Day One Keynote: Music Therapy with Disorders of Consciousness: Challenges, Opportunities and Realities - Wendy L. Magee
Music therapy with disorders of consciousness (DOC) populations has a long history, from the late Professor Mary Boyle's pioneering work in 1983 (Boyle & Greer, 1983) to current developments in diagnosis, assessment and evidence-based interventions (see O’Kelly & Magee, 2013a for overview). Despite the longevity of this enquiry and the breadth of approaches explored, literature on the use of music therapy to address clinical needs with these populations and improve empirical evidence remains sparse. The published literature suggests that three main approaches prevail in clinical applications: first, where music is used as a reward in contingent behaviour training employing assistive technology; second, as a stimulus within sensory or environmental stimulation interventions; and lastly, musicokinetic music therapy (Noda, Maeda, & Yoshino, 2004). Some authors have defined their methods as "active" music therapy (Formisano et al., 2001; Jochims, 1995) however this definition is perhaps a little arbitrary as, when people have such complex needs, the methods employed are receptive only until the person starts to regain some capacity to participate and can engage in more active methods.
It should always be remembered that musical stimuli alone will not necessarily improve consciousness, but that the existing evidence suggests that music therapy in conjunction with multimodal stimulation may improve awareness in comatose ABI patients (Meyer et al., 2010). One of the preventative factors in demonstrating music’s effectiveness has been the lack of measures that are sensitive enough to show behavioural changes in such a complex population. This has been the challenge that prompted the development and standardization of the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness, or MATADOC (Magee et al., 2013). This measure can demonstrate behavioural signs of responsiveness to auditory stimuli in the person with DOC. Possibly most importantly, the MATADOC has diagnostic value thus having relevance for interdisciplinary care of these patients.
There is increasing recognition from the neuroscience community that music provides a useful medium for assessment with this complex population (Jones, Vaz Pato, Sprague, Stokes, & Hague, 2000; Verville et al., 2012). This presents opportunities to the music therapy profession for clinical and research collaborations as never before. However, the challenges are to ensure that music therapy clinicians are adequately trained to a competent level for working with such a complex patient group and that music therapists are using evidence based clinical methods, with standardized measures in order to communicate outcomes using language that can be understood by medical and rehabilitation professionals.
Music Therapy for the Rehabilitation of Upper Limb Function in Stroke Patients - Alex Street
Recent research (Schneider, Schonle, Altenmüller, & Munte 2007; Altenmüller, Marco-Pallares, Munte, & Schneider, 2009; Rojo et al., 2011) has shown that playing set musical patterns using electronic drum pads and keyboards has significantly improved gross and fine upper limb motor movements in stroke patients; electroencephalogram (EEG) and functional magnetic resonance imaging (fMRI) methods have also shown neural reorganization takes place as a result of this treatment and through a process of ‘audio-motor coupling’. A smaller study (Malcolm, Massie, & Thaut, 2009) compared changes in upper limb function between two groups who performed tapping exercises with their paretic hand either at a self-paced rate or to a metronome, and found that the latter significantly improved elbow flexion and extension and reduced compensatory movements.
In my current PhD research I will be recruiting two groups of six stroke patients; a wait list and treatment group, who have reached the end of their acute community physiotherapy and been discharged. Patients who are able to lift their paretic hand up onto a table surface and also have some finger movement will be invited to participate and receive twice weekly music therapy treatment for six weeks, using Therapeutic Instrumental Music Performance (TIMP) in their home. TIMP is a neurologic music therapy technique, which combines the use of rhythm and pulse to support the priming and timing of movements; the harmonic, melodic and dynamic intensity of the music to provide muscle force cues, and the selection and spatial arrangement of instruments that will best facilitate movements targeted for treatment (Thaut, 2005).
The main outcome measure will be the Action Research Arm Test and a semi structured interview, which includes pre and post treatment self-rating. It is hoped that in a follow up study participants will also be invited to the university pre and post treatment for more accurate measurement of movement trajectories using 3D motion capture and EEG to investigate any changes in electrical activity in the motor areas of the brain that could be linked to the music used to support the exercises (audio-motor coupling).
Improvisation and Verbal Reflection: Music Therapy and Its Effects on Depression and Anxiety - Jörg Fachner
In this study an active music therapy approach based on a psychodynamic framework was utilised for the therapy, which means in practice that one third of the therapy is concerned with improvisation while the other two may be talking with the therapist (Erkkilä et al., 2011). Fronto-temporal (FT) areas are discussed to process shared elements of speech and music (Koelsch, 2012). Improvisational psychodynamic music therapy (MT) utilizes verbal reflection on emotions and images arising in clinical improvisation. Does talking and improvising in MT induce neural reorganization in FT areas?
Research on stroke and TBI indicate music therapy interventions targeting co-occurring mood disorder and depression in neurorehabilitation. Explanations why music therapy may change emotional states often refer to neuroscientific research on music appreciation i.e. results based on healthy subjects. Emotion processing while listening to music shows immediate effects on the EEG, in terms of alpha and theta manifestations (Field et al.,1998; Sammler, Grigutsch, Fritz, & Koelsch, 2007).
Fachner, Gold, & Erkkilä’s (2013) aim was to find out whether these effects are lasting, and can be observed in an additional resting EEG recording, i.e., one not taken during or directly after listening but after a course of active music therapy. Therefore in a two-armed randomized controlled trial (RCT) with 79 clients, they compared standard care (SC) with MT added to SC at intake and after 3 months. Correlations between anterior EEG, Montgomery-Åsberg Depression Rating Scale (MADRS) and the Hospital Anxiety and Depression Scale - Anxiety Subscale (HADS-A), power spectral analysis (topography, means, and asymmetry) and normative EEG database comparisons were explored (Fachner et al., 2013). Normative EEG comparisons allow to distinct excessive or abnormal EEG patterns against a database of age, gender, and condition-matched controls (Thatcher, 2010).
After 3 months of MT added to SC, MADRS and HADS-A scores were significantly decreased. Further, lasting changes in resting EEG were observed, in short lateral differences in fronto-temporal areas, measured with Frontal Alpha Asymmetry (FAA) and Frontal Midline Theta (FMT), as well as in significant FT power changes of alpha and theta topography. FMT changes were also significantly correlated to anxiety score reduction. At intake all clients exhibited a correlation of anxiety scores and FT areas, but only the MT group exhibited pre/post changes in FT areas and this difference was significant when compared to the group receiving SC only (Fachner, et al., 2013).
This research indicates that verbal reflection and improvising on emotions in MT added to SC may induce neural reorganization in FT areas. Alpha and theta changes in FT areas indicate MT action and treatment effects on cortical activity in depression, suggesting an impact of MT on anxiety reduction. Results indicate FT areas as regions of interest for high-resolution neuroimaging studies of MT treatment in depression. Further research on the connection of FT processing, emotional expression and prosody changes in MT depression treatment is needed.
A Neurophysiological Study of Receptive Music Therapy with Healthy Adults and Individuals with Disorders of Consciousness: Implications for Practice - Julian O'Kelly
Disorders of consciousness (DOC) comprise a continuum of predominantly acquired conditions. Distinguishing between DOC categories of vegetative state (VS), where there are no indications of consciousness despite evidence of wakefulness, and minimally conscious state (MCS) where consciousness is limited, is a challenging process where misdiagnosis rates remain high (Andrews, 2005). Music therapists from diverse approaches have been involved in the assessment and rehabilitation of those with DOC for the last 30 years. However differences in paradigms persist in thinking about and describing clinical work with this population (O'Kelly & Magee, 2013a). Whilst standardised behavioural assessment techniques have been established (Magee et al., 2013, O'Kelly & Magee, 2013b), evidence based research to underpin the development of the profession in this area is lacking.
To address the need for evidence, a multiple baseline within subjects study comparing EEG, heart rate variability, respiration and behavioural responses of 20 healthy controls with 12 patients diagnosed as VS and 9 as MCS was conducted (O’Kelly et al., 2013). Controls and patients were presented with music therapy (live preferred music & improvised music entrained to respiration), recordings of disliked music, white noise and silence. Post hoc ANOVA tests indicated that preferred music produced the widest range of significant responses (p ≤ 0.05) across healthy controls, with widespread cortical activation observed in EEG measures, and significant increases in respiration rate unrelated to music tempo. Whilst physiological responses were heterogeneous across patient cohorts, behavioural data showed a significantly increased blink rate for preferred music across the VS cohort [post hoc contrast with baseline silence F (1,6) = 8.9, p = 0.03]. Significant post hoc EEG amplitude peaks for music therapy methods were found in frontal areas across patient cohorts (p = 0.05 - 0.0001). The use of music therapy for increasing arousal levels to optimise conditions for accurate assessment is supported by these findings. Furthermore, these selective responses call into question assumptions as to the unresponsive nature of VS, indicating need for research to explore the rehabilitation potential of music therapy with DOC.
Liquid Vibrations - Sound and Music in Water for Children with Complex Needs - Adele Drake and Joel Cahen
Liquid Vibrations is a project that engages the participants in listening through music in water and through facilitating movement in water with Watsu treatment. Underwater, the perception of sound is incredibly detailed and immediate. The lack of spatial signature in the sound gives the impression of a very personal and intimate experience. Despite being in a public space, underwater, the listener is in a very private space, in a womb like environment, which they perceive either by intending and choosing to place their head in the water, or by being held correctly by their carer.
We approach listening as an active and creative process, one that engages the imagination. Listening, attention to the environment is the basis to understanding a physical, social and musical environment. It is the basis to any meaningful communication and expression as it adds clarity to the context within which this expression is made.
We see our work on the continuum of musical therapy and education. We value considerations that determine the listening experience and approach music therapy with emphasis on music and listening as a shared experience with aims to:
- Develop a sense of individuality, sense of self, sense of order and general well being.
- Develop an awareness of sound as a distinct perceptual entity
- Present the variety possible within sound within or without the traditional framework of musical progression.
- Enhance social interaction by creating a shared listening space in the playful environment of the pool.
We are in the process of exploring further opportunities, within music therapy and special needs, whether it is to help bring those in need to consciousness or to a conscious appreciation of sound and music. Further details on Liquid Vibrations are available at: http://www.liquidvibrations.org.uk
Keynote Presentation: Music for the Ageing Brain: Benefits of Musical Leisure Activities in Stroke and Dementia Rehabilitation - Teppo Särkämö
During the past 20 years, neuroimaging and clinical studies have greatly increased our knowledge about how music is processed in the brain and how it can be used in neurological rehabilitation. Owing to the growing incidence of stroke and dementia, there is now a need to develop music interventions that are widely available and easily accessible to the patients and their caregivers. This paper aimed to:
- resent an overview of the neural basis of music processing
- Discuss the neural mechanisms potentially underlying the rehabilitative efficacy of music
- Report evidence from two studies on the effects of everyday musical activities in stroke patients and in persons with dementia (PWD) and their caregivers.
Based on the current evidence from neuroimaging studies of healthy subjects and clinical studies of persons with amusia, music is a complex and versatile stimulus for the human brain (Koelsch, 2011; Stewart, von Kriegstein, Warren, & Griffiths, 2006). Musical activities, such as music listening, singing and playing, engage a highly wide-spread bilateral network of temporal, frontal, parietal, cerebellar, and limbic brain areas, which are involved not just in auditory perception but also control many cognitive, motor, and emotional functions, thus making music a promising and viable tool in neurological rehabilitation (Särkämö, Tervaniemi, & Huotilainen, 2013). The rehabilitative efficacy of music may be due to a number of neural mechanisms, such as improved mood and arousal through the modulation of the dopaminergic mesolimbic system, reduced stress through hormonal changes along the hypothalamic-pituitary-adrenal (HPA) pathway, or enhanced neuroplasticity induced by the musically enriched environment or long-term experience with music.
Data were reported from two randomized controlled trials performed in Finland. In the first study of 60 patients with acute middle cerebral artery stroke, daily listening to one’s favourite music was found to be more effective in improving the cognitive recovery memory and attention than listening to audio books or receiving standard care only over a 6-month post-stroke follow-up (Särkämö et al., 2008). Music listening also reduced depression and confusion and enhanced early auditory encoding in the brain after stroke, as indicated by magneto encephalography (MEG) (Särkämö et al., 2010). Based on patient interviews, music listening was experienced as a leisure activity that could especially help to relax, increase motor activity, and improve mood during the first post-stroke months (Forsblom, Särkämö, Laitinen, & Tervaniemi, 2010). In the second study of 89 PWD-caregiver dyads, both regular singing and listening of familiar songs were found to improve mood and help maintain cognitive functioning in the domains of attention and executive functioning, orientation, and episodic memory during a 9-month follow-up (Särkämö, Tervaniemi, & Laitinen et al., 2013). In addition, singing also had a positive effect on working memory and caregiver well-being, whereas music listening enhanced the quality of life of the PWDs. Collectively, these results suggest that regular musical leisure activities can have long-term cognitive, emotional and social benefits in persons recovering from stroke as well as in persons with mild/moderate dementia and their caregivers.
Day Two Keynote: Music Therapy in Dementia Care: Late Stage Dementia and Social Engagement - Hanne Mette Ridder
Suffering from dementia means facing the disruption of relationships, leading to agitation, anxiety, apathy and depression. Music applied in various forms with persons with dementia reduces these negative symptoms and increases cognitive and social skills. This positive effect of music is shown in a large number of small-scale research studies as well as in a number of randomized controlled studies with music as the independent variable; ranging from music applied in nursing care, in interdisciplinary team work, in community settings and in individual music therapy treatment (for reviews of the literature, see McDermott, Crellin, Ridder, & Orrell, 2012; Ueda, Suzukamo, Sato, & Izumi , 2013).
For people in later stages of dementia, agitation is the main symptom causing patient distress and caregiver burden. According to a Person-Centred Dementia Care, agitation is reactions to unmet psychosocial needs, and attempts to communicate these needs and cope (Kitwood, 1997; Woods, 2001). Agitation is predicted by the culture of care and is not only caused by a lack of social engagement but also leads to social isolation (Stein-Parbury et al., 2012). It is hypothesized that facilitating social engagement and thereby enabling the fulfilment of psychosocial needs leads to a decrease in agitation, and an exploratory cross-over RCT (n = 42) was carried out (Ridder, Stige, Qvale, & Gold, 2013). Data collection took place in 14 nursing homes in Norway and Denmark with the inclusion of residents who were referred to music therapy and who showed symptoms of agitation. Residents were randomized to either six weeks of individual music therapy or standard care. After seven weeks the groups were switched. The primary outcomes were agitation (Cohen-Mansfield Agitation Inventory, CMAI) (Cohen-Mansfield, 1991), quality of life (Alzheimer’s Disease-Related Quality of Life, ADRQL) (Rabins, Kasper, Kleinman, & Black, 1999) and the use of psychotropic medication, collected at baseline, in week 7 and in week 14.
Results showed that the participants received an average of 10 music therapy sessions (SD = 2.82, range 0-13), with a total of 414 music therapy sessions conducted. The sessions lasted on average 33.80 minutes (SD = 9.91) and with 77% of the sessions taking place in the participants’ own living room. The music therapists had a MA degree in music therapy and the majority were experienced or highly experienced. The study showed that six weeks of individual music therapy reduces agitation disruptiveness and prevents medication increases. It was concluded that music therapy allows for a person- centred approach and can be recommended as a valid treatment of agitation and as a possibility to reduce psychotropic medication as well as to prevent caregiver burnout. A larger study is called for in order to measure an effect on agitation frequency and quality of life.
Therapy-Induced Plasticity in Patients with Chronic Non-fluent Aphasia and Apraxia of Speech - Monika Jungblut
This therapy study, which combined cognitive and neural methods (fMRI) of examination, was conducted in order to further investigate the effects of rhythmic-melodic voice training SIPARI® (Jungblut, 2005; Jungblut 2009; Jungblut, Suchanek, & Gerhard, 2009). This evidence-based treatment (Bradt, Magee, Dileo, Wheeler, & McGilloway, 2010) focuses on improving language and speech-motor capabilities especially in patients suffering from chronic nonfluent aphasia.
Difficulties with temporal coordination or sequencing of speech movements are frequently reported in aphasia patients with concomitant apraxia of speech (AOS), a deficit in motor planning or programming of speech movements. Since the SIPARI® treatment specifically trains these functions the objective was to investigate if potential improvements in language and speech-motor performance correlate with changes in brain activation.
Three patients with severe chronic non-fluent aphasia and AOS (1 Broca’s, 2 global aphasia patients) underwent the same fMRI-procedure as 30 healthy control subjects in our pre-study (Jungblut, Huber, Pustelniak, & Schnitker, 2012). For all patients, therapy was started 18 months post onset. Each patient received 50 individual therapy sessions (60 minutes, twice a week) over a period of 25 weeks. During this period neither speech therapy nor any cognitive training took place.
For all patients clinically significant improvements could be assessed in final language and motor-speech tests. A main finding was that post-minus pre-treatment imaging data yielded peri-lesional activations in all patients e.g. in the left superior temporal gyrus, whereas the reverse subtraction revealed either no significant activation or right hemisphere activation. This is the first time that functional reintegration of language and speech relevant areas could be demonstrated due to a specific music therapy intervention. Especially in the treatment of severely impaired chronic aphasia patients with concomitant AOS the applied rhythmic-melodic voice training SIPARI® is very effective because it targets specific language deficits but also cognitive function.
Let Them Bring Their Own Song - Ruth Melhuish
The National Dementia Strategy (DoH, 2009) highlights the need for “an informed and effective workforce for people with dementia.” This project investigated the role of music therapy and dance movement therapy in supporting staff development in a nursing home for people with dementia. The project aimed to explore the experience and perceptions of nurses and healthcare assistants who participated regularly in music therapy or dance movement therapy groups for the residents.
Staff who volunteered to participate in the project were allocated to work with either the music therapist or the dance movement therapist, and they took part in therapy groups with the residents for six weeks. Individual in-depth interviews with the staff were then conducted by the therapists; the interviews were transcribed and analysed using qualitative methods. The project findings identified two main themes which describe significant aspects of staff learning and development. These were:
- Discovering the Person
- Staff witnessed different aspects of residents’ engagement and participation in groups
- This allowed them to discover and understand more about the residents as people.
- Learning from Experience
- They identified key elements of the therapists’ approach
- They adopted a more reflective approach to their work
- They applied their learning to inform their own practice, reporting improved communication and relationships with residents, increased confidence in their skills and greater commitment to supporting autonomy and choice for residents on a day-to- day basis.
The project findings suggest that involving care home staff in music therapy or dance movement therapy groups may be an effective means of helping to develop their communication and relationship skills, thus fulfilling an important aim of the government drive to improve dementia services in the UK.
Musically Stimulated Neuroplasticity: The Science Behind Recovery from Acquired Brain Trauma - Dale B. Taylor
Various treatment teams, each consisting of a music therapist and an applied music instructor working in consultation with medical and neurological experts, have had great success using a Music Re-instruction format with musicians who have suffered severe head injuries. The cases have included a clarinettist and music educator who was hit broadside by a semi-trailer truck, was thought to be deceased, spent days in a coma, suffered memory loss and multiple pelvic fractures. Doctors thought she might remain in a vegetative state, that she would never walk, and that she had only a 50% chance of being able to return to work in six to seven years. By relearning the clarinet using the music re-instruction procedure, she overcame severe losses in physical, cognitive, communication, and musical skills and returned to work in just nine months. She also went on to earn a masters degree, married and gave birth to a healthy daughter. A second case is that of a surgeon who played jazz piano. He had a golf ball sized brain tumour removed from his parietal lobe resulting in physical, musical, and memory losses, along with loss of his operating room privileges. Through music re-instruction, he regained physical skills, piano playing ability, and regained operating room privileges when he was cleared to resume performing surgery. A third case was that of a French horn player, atmospheric physicist and horseback riding instructor who was kicked in the face by a horse. The right side of her face was shattered and paralyzed. All right facial bone including teeth had to be rebuilt. She suffered a TBI with severe episodic and procedural memory losses, vision deficits, post-traumatic stress, 31 reconstructive surgeries, long hospitalizations, and a very low prognosis for horn playing. Ten years later, she began to receive re-instruction on horn in an attempt to remediate pain while playing by using repetition and facial exercises to strengthen facial muscles and rewire synaptic connections in her brain to change the brain’s pain perception. She has now resumed her physics research, horseback riding, and she plays horn in a Los Angeles wind ensemble.
All three subjects lost cognitive, physical, and music skills but rebuilt these capacities while receiving instruction to re-learn music playing skills. A scientific explanation for these advances is rooted in an understanding of the brain’s ability to change in response to the needs of the individual as determined by one’s interaction with environmental stimuli. During brain repair following injury, plastic changes are geared toward maximizing function in spite of the damaged brain. In studies involving rats in which one area of the brain was damaged, brain cells surrounding the damaged area underwent changes in their function and shape that allowed them to take on the functions of the damaged cells (Drubach, 2000). The formation of neuronal connections takes place through neural plasticity, a process that depends on neural activity resulting from stimulation through environmental interaction. New connections form and the internal structure of existing synapses can change. The brain compensates for damage by reorganizing and forming new connections between intact neurons. In order to reconnect, however, the neurons need to be stimulated through active interaction with the environment. The shape and connectivity of individual neurons and their dendrites result from interaction with the environment, exactly as a tree and its branches are shaped by available light (Castren, 2005).
A critical factor in brain metabolism is the selection and development of useful, active neuronal connections and elimination of those that are inactive. In cases of brain injury, it becomes necessary for the brain to compensate for lost functions and maximize remaining functions. A result of neuroplasticity in the injured brain is that brain activity associated with a given function can move to a different location as a consequence of normal experience, brain damage or recovery. For example, if the brain is damaged in one or more of the specialized speech structures, corresponding language processing skills are lost until the brain is able to create new connections in new areas to take over those skills (Taylor, 1989, 2008). This process has been shown to be effectively facilitated by using music (Schlaug, et al 2009). The most viable explanation for the effectiveness of music in this regard lies in its ability to activate large areas of brain tissue and incorporate related skills to help the brain form new synaptic connections, thereby enhancing the recovery of language skills following brain damage. What this often observed process demonstrates is that neural activity in sensory areas reflects environmental stimulation, and that activity-dependent neural plasticity eventually tunes the networks for optimal coding of environmental information such as music (Castren, 2005).
Discussion - Julian O’Kelly
Whether in relation to acquired or degenerative conditions, music therapists offer those with neuro-disabilities support with both functional issues such as gait disturbances and aphasia, and the secondary impact of physical, perceptual and cognitive deficits on mental health, significant for a large proportion of individuals (Andelic et al., 2010; Ouellet, Sirois, & Lavoie 2009). This expansive potential for the profession has some way to go to being fulfilled, where for example in the UK, access to music therapy for those with neuro-disabilities has historically been far from uniform across the country (Magee & Andrews, 2007). Neuro-disability may become an important proving ground for music therapy with implications for the profession as a whole. However, according to Cochrane reviews of music therapy with acquired brain injury (Bradt et al., 2010) and dementia (Vink, Birks, Bruinsma, & Scholten 2003), with a few exceptions, robust evidence is lacking. In common with other fields of practice, evidencing the creative, aesthetic, experiential and spiritual strengths of music therapy is an on-going challenge in the context of influential biomedical evidence based models, where "objective" scientific approaches and randomized control trials are favored.
The post conference discussions, and indeed this paper itself, provide an exciting glimpse into the possibilities afforded by a future exchange of ideas, research and practice collaborations across the disciplines present. For example, the evolving field of music neuroscience has the potential to lend empirical weight and greater understanding to music therapy approaches. Furthermore, the multidimensional nature of music therapy in relational, aesthetic and creative realms may provide neuroscience with new insights into the functioning of the brain, and challenge scientists to develop ways to capture these qualities with neuro-imaging technology. Greater collaboration with psychology with its long tradition of behavioral assessment and measurement may serve encourage more robust music therapy research to evidence clinical practice. Caution is needed in relation to the demands of research paradigms calling for strictly protocolised and standardised techniques, which may fall outside more holistic, improvisational approaches. However, as several presenters illustrated, EEG methods in particular offer a means of objectively capturing clinical effects and neural activity related to a range of practices with diverse populations. When combined with qualitative investigations such as detailed in Ruth Melhuish’s presentation, a comprehensive understanding of the work can evolve, amenable to a wide range of stakeholders important for the development of the profession.
Conclusion
This conference report highlights the dynamic and diverse nature of music therapy in the field of neuro-disability, and the concurrent developments in psychology and neuroscience which may inform clinical practice. Feedback from delegates and speakers at the conference highlighted how much music therapy could benefit from further cross-disciplinary dialogue. Clinicians are gaining new, exciting insights into the biomedical mechanisms underpinning music therapy, and learning about new ways of evidencing their work. At the same time, neuroscientists are discovering more about how the brain functions through the multi-dimensional effects observed when individuals experience or perform music in therapy and everyday settings. The organisers look forward to building on the success of this event with regular series of conferences bringing together researchers and practitioners in the future.
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