Dan Keller 0:00
Welcome to this episode of Substantial Matters: Life and Science of Parkinson's. I'm your host, Dan Keller. At the Parkinson's Foundation, we want all people with Parkinson's and their families to get the care and support they need. Better care starts with better research and leads to better lives. In this podcast series, we highlight the fruits of that research, the treatments and techniques that can help you live a better life now, as well as research that can bring a better tomorrow. Music therapy can have multiple benefits for people with Parkinson's disease in terms of movement, mood, speech, and even breathing. It's an established profession provided by academically trained therapists, and people should not shy away from this therapy, even if they can't carry a tune. Taking advantage of music therapy does not require any musical talent. Dr. Concetta Tomaino, the Executive Director of the Institute for Music and Neurologic Function, describes the variety of Parkinson's symptoms that this form of therapy may help alleviate and the scientific underpinnings for many of its benefits.
Dr. Concetta Tomaino 1:26
The use of music to help people with Parkinson's disease has been really well established over the years. It's known that rhythm and rhythmic cueing can help with initiation and also entrainment of movement. So people with Parkinson's who have problems in initiation and freezing do respond really well to a rhythmic pulse that actually generates brain activity that helps them initiate the movement and coordinate movement.
Dan Keller 1:54
So do they have to be doing music at the time, or does it have some lasting effect where they can kind of invoke it when they need to move?
Dr. Concetta Tomaino 2:03
The interesting thing with rhythm, initially, the rhythm has to be present as an external cue. But there's some research, and also I've worked clinically now for 40 years: if the person with PD is able to internalize that beat, for example, if there's a song that has the same rhythmic tempo and they can sing that song to themselves as they're walking, they're able to then generate the pulse on their own. It takes a little training, but once they are able to do it, they can then pull up this song when they need to.
Dan Keller 2:33
This sounds sort of like teaching people to do cardiopulmonary resuscitation, and the beat is to “Stayin’ Alive.”
Dr. Concetta Tomaino 2:40
Right.
Dan Keller 2:41
You know.
Dr. Concetta Tomaino 2:41
Exactly.
Dan Keller 2:41
Which you can't get out of your mind.
Dr. Concetta Tomaino 2:43
Exactly. So those earworms are really good when it comes to cueing walking. And then similarly, music can help with other aspects of some of the challenges people with PD have, so not just movement and coordination and range of motion, but also cognitive function, communication skills, making sure that the voice is strong and loud and there's efficacy into how the person can communicate. So there's lots of potential benefits for music therapy.
Dan Keller 3:12
Does it have any effect on non-motor symptoms like autonomic problems, just temperature regulation and constipation and digestion.
Dr. Concetta Tomaino 3:22
So music can affect things like anxiety, stress reduction. We help our clients with something called mindfulness, but using finding music that helps them reduce their anxiety, reduce their stress, find songs that can help motivate them. It does have a regulatory effect, just certain types of rhythm can down regulate different aspects of internal functional heart rate, respiratory rate, things like that as well. There's been some good science that shows the mechanisms by which these auditory pulses actually drive different types of neurological responses as well.
Dan Keller 3:59
How's it done? How do people get into taking advantage of music therapy?
Dr. Concetta Tomaino 4:03
The field of music therapy is an established profession, so there are music therapists who are academically trained, board certified, and those music therapists do additional training in neurologic music therapy so they know the protocols and techniques. That being said, there's techniques that a person with PD can take advantage of themselves to use music to benefit and enhance their quality of life. So if they can't find a music therapist in their area or at their center of excellence, they can find music that helps them feel the beat, helps them want to move, helps them feel motivated to continue to participate in different exercise regimens. If there's community groups such as choruses or dance programs, they could take advantage of that, because we know that the skills embedded in those music programs then carry over to wellness, overall wellness for the person with PD. In the formal music therapy session, the music therapist will actually assess if the person feels the beat in the music, and if they don't, how that beat can be accentuated through manipulating the music and sound so the person can benefit from this kind of rhythmic cueing. We do know from neuroscience research, just the way the basal ganglia loses some of the dopamine in that cell area, that loss of dopamine also affects perception of rhythm. So some people with PD actually lose perception, or slow their perception of where the beat is. And so a music therapist will actually work with the person and help them figure out what type of music, what type of rhythmic music, will actually help them.
Dan Keller 5:41
In other aspects of movement, for people with Parkinson's novelty matters. I mean, people take up boxing, people take up a musical instrument. So here does the music have to change over time, different beats, that sort of thing.
Dr. Concetta Tomaino 5:58
Not so much with the rhythm itself, because once we establish what beat is going to help them move and initiate function, that beat can be continued no matter what engagement and motivation needs novelty. So if they're listening to a certain type of music, changing up the music, even though the rhythm of the music may be the same, there's different ethnic music that incorporates similar rhythms, but maybe more complex, that may excite them and engage them a little bit more, dancing, sometimes playing the musical instrument. We know that learning a musical instrument enhances cognitive ability and short term memory, so even if they're learning an instrument for the first time, that can have carryover benefits to enhancing cognition. People with PD will complain that with the tremors and stiffness, it's hard to play guitar or some other instrument that has very fine motor skills. But there's other types of electronic instruments where you can tailor the touch to enable the person to be more successful.
Dan Keller 7:01
Are there scientific studies to really show outcomes here?
Dr. Concetta Tomaino 7:05
Sure. So one of the really fascinating things about music perception and music neuroscience is that the neuroscience community has really embraced looking at music in the brain because it allows them to look at complex systems. So even though clinically we've known for years that people with Parkinson's can dance even though they can't walk, there's now neuroscience evidence, in fact a journal which is published in 2016 that highlights all the current research in rhythmic auditory cueing and Parkinson's and movement disorders. So looking at the mechanisms by which this auditory pulse drives multiple areas of brain function, from cerebellum up to the cortex and all the midbrains, and how these areas communicate with each other, that's been pretty well established. The fact that there's a diminishing of auditory perception in people with PD has been studied, and that's been established. There's been clinical studies looking at what's called rhythmic auditory stimulation, RAS in gait studies, not only in initiation of gait, but also in improving stride length and coordination and length of gait. So those have been well established. New areas that are being looked at now are in singing programs to enhance communication skills as well as the psychosocial aspects of being with another person and sharing music with that person in an activity such as singing choir or in the dance ensemble. And so this hasn't been as much research in the psychosocial aspects, but just last year there was a paper published on reduction of anxiety in group music making.
Dan Keller 8:48
Do people have to have any musical ability, or, as my old landlord would say, would it work for someone who can't carry a tune in a bucket?
Dr. Concetta Tomaino 8:57
It's interesting, because you don't have to be a musician to appreciate music. We all know that there's this concept beat inception, and it happens before we're even born. A fetus at five months gestation can already perceive beats and respond to beats, and we need that when we're born, because being able to perceive time in the rhythmic sense allows us to learn language, allows us to interact with other people. So that's a pretty strong neurologic function that's a foundation for all of us. There are people that have something called amusia. It's also something that they're born with where there is a glitch in the brain where they may not perceive pitch, or they may not be able to perceive a rhythmic pulse, but that's a very small piece of the population. In music therapy and then music-based activities, most of the time the person's not a musician. And so we see time and time again where music can still reach somebody and engage them in a very meaningful way, even though they themselves are not musically inclined.
Dan Keller 10:00
Yeah, you've mentioned beat a lot, but does singing also enter into it? Does it help in vocalization, articulation, volume, intonation?
Dr. Concetta Tomaino 10:11
Exactly. So the beat, in and of itself, will help with initiation and coordination of movement, but singing and using your voice exercises the vocal folds, which also start to stiffen up in Parkinson's. So speech therapists will do humming exercises and things like that, but the act of singing actually keeps the vocal folds very flexible. That allows for the normalization of the tone of voice, as opposed to really strained, hyper sound or constrained voice that you see a lot with people with PD. Articulation, being able to enunciate words, can be enhanced through singing exercises and also volume, which is very important, because we know that people with PD lose their perception of how loud they are. And so when they sing, they tend to use more breath support and are able to project their voice to be heard. So without a lot of effort, they're actually getting this very beneficial therapeutic output by singing.
Dan Keller 11:14
Does music therapy have long lasting effects? Does someone have to keep going somewhere? Or can they either do it on their own or not even have to do it on their own.
Dr. Concetta Tomaino 11:25
Once a music therapist has established what types of music and how the music can be beneficial, most music therapists will give a take-home kit. And now, with the advance of technology, you can have a playlist that's created that records and keeps the music that works for you. And so you can take advantage of that 24/7. So if you wake up at two o'clock in the morning and you're restless, you can put on your playlist for either relaxation or for moving around or whatever it is you want to do, and then that can be monitored over time. So what usually happens is the client will come into the clinic, be assessed what type of music will work, be referred to wellness programs in the community, and given some take-home music that they can use on a regular basis to maintain their function. If you're active and if you're using these skills on a regular basis, then it won't cure Parkinson's of course, but it definitely delay the progression of some of the side effects of Parkinson's, such as low voice or dyskinetic movement or slowness of movement in bradykinesia.
Dan Keller 12:30
Who's qualified to do music therapy?
Dr. Concetta Tomaino 12:33
Music therapy in the United States is an academically trained clinician who's attended an approved academic program approved by the American Music Therapy Association. They do 1,200 hours supervised clinical internship after their academic training and then sit for a board exam. So music therapists in the United States have an MT-BC after their name, Music Therapist Board Certified. In several states now it's also a licensed profession state by state, and that's increasing too, because there's a big movement in the arts community. There's a big arts and healthcare movement, where musicians are providing programs for various people for wellness programs, and there's a need to distinguish the clinical treatment of using music as opposed to a wellness program that a local musician is running.
Dr. Concetta Tomaino 13:27
And so it's sort of like buyer beware, that if you need help and you want a rigorous assessment and a program that you can really benefit from, seek out a music therapist in your area.
Dan Keller 13:38
Are most movement disorders physicians aware of music therapy programs around them?
Dr. Concetta Tomaino 13:44
They are, and they're beginning to know more about it. I've been a teacher with the Parkinson's Foundation for close to 12 years now, and the idea that music therapy is an important allied profession within the Parkinson's community is becoming more known.
Dan Keller 14:02
Anything important to add or we've missed?
Dr. Concetta Tomaino 14:02
Well, if people want to learn more about music therapy, they should look at musictherapy.org, which is the American Music Therapy Association. They can also look at the Academy for Neurologic Music Therapists. These are advanced trained music therapists who are specifically aware of the nuances of neuromuscular issues and how music can be used as a protocol and cue to help them. My institute has been doing research in this for many years. I worked with Oliver Sacks, the neurologist for Awakenings renown, and so together we've been looking at the translational aspect of clinical music practice and informing the neuroscience community. And they can reach us through imnf.org.
Dan Keller 14:43
Great, thank you. In addition to the resources that Dr. Tomaino mentioned, you can find more information by searching music therapy on our website at parkinson.org. There's a link to a summary of the presentation that Dr. Tomaino gave at this year's Center Leadership Conference, including a description of what a music therapy class is like and why rhythm is so helpful for symptom control. If you're a music therapist and would like to increase your knowledge about Parkinson's disease and interprofessional care, we encourage you to apply to the Allied Team Training for Parkinson's program coming up in Iowa City. Registration is now open at parkinson.org/attp. You can also call our toll-free help line to speak with our PD information specialists. They can answer questions and provide information about this topic or anything else having to do with Parkinson's. You can reach them toll-free at 1-800-4-PD-INFO. If you have any questions about the topics discussed today, or if you want to leave feedback on this podcast or any other subject, you can do it at parkinson.org/feedback. At the Parkinson's Foundation, our mission is to help every person diagnosed with Parkinson's live the best possible life today. To that end, we'll be bringing you a new episode in this podcast series every other week. Till then, for more information and resources visit parkinson.org or call our toll-free helpline at 1-800-473-4636. Thank you for listening.
