Neurology papers by David Aldridge

Neurology papers David Aldridge Collected Papers

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TWO EPISTEMOLOGIES: MUSIC THERAPY AND MEDICINE IN THE TREATMENT OF DEMENTIA DAVID ALDRIDGE, PhD and GUDRUN ALDRIDGE, Dipl, MT*

In earlier papers it has been suggested that it is possible for music therapists, creative arts therapists and medical practitioners to work together so that they may negotiate a common language (Aldridge & Brandt, 1991; Aldridge, Brandt, & Wohler, 1989). This paper extends that debate further into another clinical realm, that of dementia in the elderly. Dementia is an important source of chronic disability leading to both spiralling health care expenditure among the elderly and a progressive disturbance of life quality for the patient and his or her family. In the United States the cost of institutional care for patients with dementia is estimated at over $25 billion a year (Steg, 1990). If 4% to 5% of the US elderly population suffer from dementia, then it can be estimated that 1.25% of the adult population are suffering with the problems of severe dementia. Other estimates of the same population suggest that 15% of those over the age of 65 will have moderate to severe dementia with projections to 45% by the age of 90 years (Odenheimer, 1989). Current estimates are that over 60% of those cases of dementia result from Alzheimer's disease (Kalayam & Shamoian, 1990). Dementing illnesses, or acquired cognitive disorders, have been recognized for centuries, but little progress was made in specific diagnoses until the evolution of the nosologic approach to disease and early clinical descriptions of neurosyphilis and Huntington's chorea in the 1800s. Such descriptions were further supported by concurrent understandings that suggested the influence of the brain on behavior. The

first histopathological characterizations of cognitive disorders were made possible by developments in the optical microscope. Thus, Alzheimer (1907) was able to see the neuronal degeneration and senile plaques in the brain of a 55-year-old woman with progressive memory impairment and identify the disease that today bears his name. Although cognitive impairment is evident from behavior, and neurohistopathology can recognize neuronal degeneration, the diagnosis of Alzheimer's disease is prone to error, and authors differ as to the difficulty of making a precise diagnosis (Odenheimer, 1989; Steg, 1990). In the early stages of the disease the symptoms are difficult to distinguish from those of normal aging, a process that itself is poorly understood. To date, there exist no normative established values of what is cognitive impairment or memory loss, or what neurochemical and neurophysiological changes accompany normal aging. It is, therefore, extremely difficult to establish criteria for determining abnormal changes from a normal population and the researcherlclinician must in part rely upon within-the-subject designs to indicate progressive deterioration. A second source of error in diagnosing Alzheimer's disease is that it is masked by other conditions (see Table 1). Principal among these conditions is that of depression, which itself can cause cognitive and behavioral disorders. In addition, it is estimated that 20% to 30% of patients with Alzheimer's disease will have an accompanying depression (Kalayam & Sha-

*David Aldridge, a frequent contributor, is a research consultant to the medical faculty of Universitat Witten Herdecke, Germany and European Editor of The Arts in Psychotherapy. Gudrun Aldridge is a music therapist.

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Table 1 Differential Diagnosis of Alzheimer's Disease Differential Diagnosis Multi-infarct dementia and other forms of cerebrovascular disease Parkinson's disease Progressive supranuclear palsy Huntington's disease Central nervous system infection Subdural haematoma Normal pressure hydrocephalus Multiple sclerosis Seizure disorder Brain tumor Cerebral trauma Metabolic disturbance Nutritional deficiency Psychiatric disorder Substance abuse or overmedication Taken from Steg, R. 1990, Determining the cause of dementia. Nebraska Medical Journal, 75 (4). 59-63. Reprinted with permission.

moian, 1990) thereby compounding diagnostic problems further. Clinical Descriptions of Dementia The clinical syndrome of dementia is characterized by an acquired decline of cognitive function that is represented by memory and language impairment. Whereas the term dementia itself is used widely throughout the medical literature, and in common usage, to describe cognitive impairment, it is generally applied to two conditions: dementia of the Alzheimer's type (DAT) and multi-infarct dementia. The course of Alzheimer's disease is one of progressive deterioration associated with degenerative changes in the brain. Such deterioration is presented in a clinical picture of episodic changes and a pattern of particular cognitive failings that are variable (Drachman, O'Donnell, Lew, & Swearer, 1990). Mental status testing is one of the primary forms of assessing these cognitive failings, which include short and long-term memory changes, impairment of abstract thinking and judgment, disorders of language (aphasia), and difficulty in finding the names of words (anomia), the loss of ability to interpret what is heard, said and felt (agnosia), and an inability to carry out motor activities, such as manipulating a pen or toothbrush, despite intact motor function (apraxia).

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When such clinical findings are present, then a probable diagnosis can be made; a more definite diagnosis depends upon tissue diagnosis (see Table 2). Although dementia of the Alzheimer's type begins after the age of 40, and is considered to be a disease of the elderly, the influence of age on prognosis is not as significant as the initial degree of severity of the problem when recognized (Drachman et al., 1990). Disease severity, as assessed by intellectual function, appears to be the most consistent predictor of the subsequent course of the disease, particularly when accompanied by a combination of wandering and falling, and behavioral problems (Walsh, Welch, & Larson, 1990). However, the rates of decline between subgroups of patients are variable and a patient's rate of progression in one year may bear little relationship to future rate of decline (Salmon, Thai, Butters, & Heindel, 1990). Some authors (Cooper, Mungas, & Weiler, 1990) suggest that an as yet unproven factor, other than declining cognitive ability, may also play a part in the associated abnormal behaviors of anger, agitation, personality change, wandering, insomnia and depression, which occur in later stages of the disease. Clearly, Alzheimer's disease causes distress for the patient. The loss of memory and the accompanying loss of language, before the onset of motor impairment, means that the daily lives of patients are disturbed. Communication, the fabric of social contact, is interrupted and disordered. The threat of progressive deterioration and behavioral disturbance has ramifications not only for the patients themselves, but also their families, who must take some of the social responsibility for care of the patients and bear the Table 2 Diagnostic Evaluation of Dementia Diagnostic Categories Complete medical history Mental status examination Complete physical and neurological investigation (including investigation for infection of central nervous system if suspected) Complete blood count and blood chemistry tests (including vitamin B 12 levels) Thyroid function tests Serology for syphilis Computerized tomography (CT) or magnetic resonance imaging (MRI), electroencephalography (EEG), or positive emission tomography (PET) scanning

Collected neurology papers

TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA emotional burden of seeing a loved one becoming confused and isolated. Finally, it must also be borne in mind that the elderly depressed can exhibit a pseudodementia (Caine, 1981) whereby Alzheimer's is mimicked (see Table 3). Such patients recover and show no sign of residual intellectual impairment.

Assessment of Dementia A brief cognitive test, the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975), has been developed to screen and monitor the progression of Alzheimer's disease. The test itself is intended for the clinician to assess functions of different areas of the brain, and is based upon questions and activities (see Table 4). As a clinical instrument it is widely used and well validated in practice (Babikian, Wolfe, Linn, Knoefel, & Albert, 1990; Beatty & Goodkin, 1990; Eustache, Cox, Brandt, Lechevalier, & Pons, 1990; Faustman, Moses, & Csemansky, 1990; Gagnon, Letenneur, Dartigues, Commenges, Orgogozo, Gateau, Alperovitch, Decamps, & Salamon, 1990; Jairath & Campbell, 1990; Summers, DeBoynton, Marsh, & Majovski, 1990; Zillmer, Fowler, Gutnick, & Becker, 1990). A bedside test, the MMSE is widely used for testing cognition and is useful as a predictive tool for cognitive impairment and semantic memory (Eustache et al., 1990) without being contaminated by motor and sensory deficits (Beatty & Goodkin, 1990; Jairath & Campbell, 1990). Elderly patients scoring below 24 points out of a

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possible total score of 30 are considered demented. However, this scoring has been questioned on the grounds of its cut-off point of 24 as the lower limit, particularly for early dementia (Galasko, Klauber, Hofstetter, Salmon, Lasker, & Thai, 1990); and, that it is influenced by education (Gagnon et al., 1990). Poorly educated subjects with less than eight years of education may score below 24 without being demented. Further criticisms of the Mini-Mental State Examination (MMSE) have been that it is not sensitive enough to mild deficits, but it could be augmented by the addition of a word fluency task and an improvement in the attention-concentration item (Galasko et al., 1990). In addition, the MMSE seriously underestimates cognitive impairment in psychiatric patients (Faustman, Moses, & Csemansky, 1990). An important feature neglected by the MMSE is that of "intention" or executive control (Odenheimer, 1989), which refers to the ability of the patient to persevere with a set task, to reach a set goal or to change tasks. The items the MMSE fails to discriminate (minor language deficits), or neglects to assess (fluency and intentionality), however, may be elicited in the playing of improvised music. A dynamic musical assessment of patient behavior, linked with the motor coordination and intent required for the playing of musical instruments used in music therapy, and the necessary element of interpersonal communication, may provide a sensitive complementary tool for assessment (Aldridge, 1989a) (see Table 5). This would not make music therapy a diagnostic tool. It would not be possible to say that patients played in a partic-

Table 3 Features Differentiating Pseudodementia From Dementia Pseudodementia

Dementia

Onset can be dated with some precision Symptoms of short duration before medical help is sought History of previous psychiatric dysfunction Patients usually complain much of cognitive loss Patients make little effort to perform even simple tasks Behavior often incongruent with severity of cognitive impairment Nocturnal accentuation of dysfunction uncommon "Don't know" answers typical Marked variability in performance on tasks of similar difficulty

Onset can be dated only within broad limits Symptoms can be of long duration before medical help is sought History of previous psychiatric dysfunction unusual Patients usually complain little of cognitive loss Patients struggle to perform tasks Behavior usually compatible with severity of cognitive impairment Nocturnal accentuation of dysfunction common Near-miss answers frequent Consistently poor performance on tasks of similar difficulty

After Caine (1981). Mental status changes with aging. Seminars in Neurology, I ( l ) , 39, Thieme Medical Publishers. Reprinted with permission.

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Table 4 Mini-Mental State Examination Item Orientation for time Orientation for place Registration Attention for calculation Recall Naming Repetition Three stage verbal command Written command Writing Construction Total

Component

Score

year, season, month, date and day state, county, city, building and floor Subject repeats "rose," "ball" and "key" Serial subtraction of 7 from 100 or spell "world" backward "Rose," "ball" and "key" Pencil and watch No ifs, ands, or buts Take a piece of paper in your right hand, fold it in half, and put it on the floor Close your eyes A spontaneous sentence Two interlocking pentagons

1 3 1 1

Taken from Galasko, D., Klauber, M , , Hofstetter, C . , Salmon, D., Lasker, B. & Thai, L. (1990). The Mini-Mental State Examination in the early diagnosis of Alzheimer's disease. Archives of Neurology 47 (l), 49-52.

ular way before they had the disease, or that their particular performance was a consequence of the disease, but it would provide a useful tool for assessing current ability. From this platform of current ability, linking musical assessment to medical diagnosis, it would be possible to recognize a broad spectrum of therapeutic changes, including improvements or deterioration~,which would not be confined to verbal abilities alone.

Music and Dementia Late in adult life, at the age of 56, and after completing two major concertos for the piano, Maurice Ravel, the composer, began to complain of increased fatigue and lassitude. Following a traffic accident, his condition deteriorated progressively (Henson, 1988). He lost the ability to remember names, to speak spontaneously, and to write (Dalessio, 1984). Although he

Table 5 Features of Medical and Musical Assessment Medical Elements of Assessment

Musical Elements of Assessment

continuing observation of mental and functional status testing of verbal skills, including element of speech fluency cortical disorder testing; visuo-spatial skills and ability to perform complex motor tasks (including grip and right left coordination) testing for progressive memory disintegration motivation to complete tests, to achieve set goals and persevere in set tasks "intention" difficult to assess, but considered important concentration and attention span flexibility in task switching mini-mental state score influenced by educational status insensitive to small changes ability to interpret surroundings

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continuing observation of mental and functional status testing of musical skills; rhythm, melody, harmony, dynamic, phrasing, articulation cortical disorder testing; visuo-spatial skills and ability to perform complex motor tasks (including grip and right left coordination) testing for progressive memory disintegration motivation to sustain playing improvised music, to achieve musical goals and persevere in maintaining musical form "intention" a feature of improvised musical playing concentration on the improvised playing and attention to the instruments flexibility in musical (including instrumental) changes ability to play improvised music influenced by previous musical training sensitive to small changes ability to interpret musical context and assessment of communication in the therapeutic relationship

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could understand speech, he was no longer capable of the coordination required to lead a major orchestra. Whereas his mind, he reported, was full of musical ideas, he could not set them down (Dalessio, 1984). Eventually his intellectual functions and speech deteriorated until he could no longer recognize his own music. However, the responsiveness of patients with Alzheimer's disease to music is a remarkable phenomenon (Swartz, Hantz, Crummer, Walton, & Frisina, 1989). Although language deterioration is a feature of cognitive deficit, musical abilities appear to be preserved. This may be because the fundamentals of language itself are musical and are prior to semantic and lexical functions in language development (Aldridge, 1989a; 1989b; 1991b). Although language processing may be dominant in one hemisphere of the brain, music production involves an understanding of the interaction of both cerebral hemispheres (Altenmiiller, 1986; Brust, 1980; Gates & Bradshaw, 1977). In attempting to understand the perception of music there have been a number of investigations into the hemispheric strategies involved. Much of the literature considering musical perception concentrates on the significance of hemispheric dominance. Gates and Bradshaw (1977) concluded that cerebral hemispheres are concerned with music perception and that no laterality differences are apparent. Other authors (Wagner & Hannon, 1981) suggested that two processing functions develop with training where left and right hemispheres are simultaneously involved, and that musical stimuli are capable of eliciting both right and left ear superiority (Kellar & Bever, 1980). Similarly, when people listen to and perform music they utilize differing hemispheric processing strategies. Evidence of the global strategy of music processing in the brain is found in the clinical literature. In two cases of aphasia (Morgan & Tilluckdharry, 1982), singing was seen as a welcome release from the helplessness of being a patient. The authors hypothesized that singing was a means to communicate thoughts externally. Although the "newer aspect" of speech was lost, the older function of music was retained, possibly because music is a function distributed over both hemispheres. Berman (1981) suggested that recovery from aphasia is not a matter of new learning by the nondominant hemisphere but a taking over of responsibility for language by that hemisphere. The nondominant hemisphere may be a reserve of functions in case of regional failure.

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Little is known about the loss of musical and language abilities in cases of global cortical damage. Any discussion is necessarily limited to hypothesizing as there are no established baselines for musical performance in the adult population (Swartz et al., 1989). Aphasia, which is a feature of cognitive deterioration, is a complicated phenomenon. Although syntactical functions may remain longer, it is the lexical and semantic functions of naming and reference that begin to fail in the early stages. Phrasing and grammatical structures remain, giving an impression of normal speech, yet content becomes increasingly incoherent. These progressive failings appear to be located within the context of semantic and episodic memory loss illustrated by the inability to remember a simple story when tested (Bayles, Boone, Tomoeda, Slauson & Kaszniak, 1989). Musicality and singing are rarely tested as features of cognitive deterioration, yet preservation of these abilities in aphasics has been linked to eventual recovery (Jacome, 1984; Morgan & Tilluckdharry, 1982), and could be significant indicators of hierarchical changes in cognitive functioning. Jacome (1984) found that a musically naive patient with transcortical mixed aphasia exhibited repetitive, spontaneous whistling, and whistling in response to questions. The patient often spontaneously sang without error in pitch, melody, rhythm and lyrics, and spent long periods of time listening to music. Beatty (Beatty, Zavadil & Bailly, 1988) described a woman who had severe impairments in terms of aphasia, memory dysfunction and apraxia yet was able to sight-read an unfamiliar song and perform on the xylophone, which to her was an unconventional instrument. Like Ravel (Dalessio, 1984), and an elderly musician who could play from memory (Crystal, Grober, & Masur, 1989) but no longer recalled the name of the composer, she no longer recalled the name of the music she was playing. Swartz and his colleagues (Swartz et al., 1989, p. 154) proposed a series of perceptual levels at which musical disorders take place: (a) the acoustico-psychological level, which includes changes in intensity, pitch and timbre; (b) the discriminatory level, which includes the discrimination of intervals and chords; (c) the categorical level, which includes the categorical identification of rhythmic patterns and intervals; (d) the configural level, which includes melody

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perception, the recognition of motifs and themes, tonal changes, identification of instruments, and rhythmic discrimination; (e) the level where musical form is recognized, including complex perceptual and executive functions of harmonic, melodic and rhythmical transformations. In Alzheimer's patients it would be expected that while levels (a), (h) and (c) remain unaffected, the complexities of levels (d) and (e), when requiring no naming, may be preserved but are susceptible to deterioration. It is perhaps important to point out that these disorders are not themselves musical; they are disorders of audition. Only when disorders of musical production take place can we begin to suggest that a musical disorder is present. Improvised musical playing is in a unique position to demonstrate this hypothetical link between perception and production. Rhythm is the key to the integrative process underlying both musical perception and physiological coherence. Barfeld's (1978) approach suggested that when musical form as tonal shape meets the rhythm of breathing there is the musical experience. External auditory activity is mediated by internal perceptual shaping in the context of a personal rhythm. When considering communication, rhythm is also fundamental to the organization and coordination of internal processes, and externally between persons (Aldridge, 1989a). Rhythm offers a frame of reference for perception (Povel, 1984). Musical tones played in sequence are seen as having a dual function. They are characterized by pitch, volume, timbre and duration. They also mark points in time. These tones then produce both structure in time and of time. When tones are used in sequence only as temporal concepts they can be thought of as providing a temporal grid, which is a time scale on which the tone sequences can be mapped for duration and location. It might profitably be asked what the isomorphic events in terms of physiology are that would meet such a dual function. There may be regular sequential pulses of metabolic, cardiac, or respiratory activity within the body that also have qualities of pitch, timbre and duration. Rhythm too plays a role in the perception of melody. The perceptions of speech and music are formidable tasks of pattern perception. The listener has to extract meaning from lengthy sequences of rapidly changing elements distributed by time (Morrongiello,

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Trehub, Thorpe, & Podilupo, 1985). Temporal predictability is important for tracking melody lines (Jones, Kidd, & Wetzel, l98 1; Kidd, Boltz, & Jones, 1984). Kidd et al. also refer to melody as having a structure in time and that a regular rhythm facilitates the detection of a musical interval and its subsequent integration into a cognitive representation of the serial structure of the musical pattern. Adults identify familiar melodies on the basis of relational information about intervals between tones rather than the absolute information of particular tones. In the recognition of unfamiliar melodies, less precise information is gathered about the tone itself. The primary concern is with successive frequency changes or melodic contour. The rhythmical context prepares the listener in advance for the onset of certain musical intervals and therefore a structure from which to discern, or predict, change. One may not be aware of certain changes and become either out of tune or out of time; such a loss of rhythmical structure, which appears outwardly as confusion, may be a hidden factoiin the understanding of Alzheimer's disease. What is important in these descriptions of musical perception is the emphasis on context where there are different levels of attention occurring simultaneously against a background temporal structure (Jones, Kidd, & Wetzel, 1981; Kidd, Boltz, & Jones, 1984). Musical improvisation with a therapist, which emphasizes attention to the environment (Sandman, 1984; Walker & Sandman, 1979, 1982) utilizing changes in tempo and volitional response (Safranek, Koshland, & Raymond, 1982), without regard for lexical content, may be an ideal medium for treatment initiatives with Alzheimer's patients. The playing of simple rhythmic patterns and melodic phrases by the therapist, and the expectation that the patient will copy those patterns or phrases, is similar to the element of "registration" in the mental state examination. Although improvised musical playing is a useful tool for the assessment of musical abilities, it is also used within a therapeutic context. In this way, assessment and therapy are interlinked, assessment providing the criteria from which to identify therapeutic goals and develop therapeutic strategies. Music Therapy With an Alzheimer's Patient Nordoff-Robbins music therapy is based upon the improvisation of music between therapist and patient (Nordoff & Robbins, 1977). The music therapist plays the piano, improvising with the patient who uses a range of instruments. his work often begins

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TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA with an exploratory session using rhythmic instruments, in particular the drum and cymbal, progressing to the use of rhythmiclmelodic instruments such as the chime bars, glockenspiel or xylophone, developing into work with melodic instruments (including the piano) and the voice. In this way of working, the emphasis is on a series of musical improvisations during each session, and music is the vehicle for the therapy. Each session is audiotaped, with the consent of the patient, and later analyzed and indexed as to musical content. In the case example below, music therapy is used as one modality of a comprehensive treatment package. The patient is seen on an outpatient basis for 10 weekly sessions. Each session lasts for 40 minutes. She is unable to find her way on public transport and is brought to the hospital by her son. Frau X was a 55-year-old woman who came to the hospital for treatment. Her sister, now dead, had Alzheimer's disease, and the family was concerned that she was repeating her sister's demise as her memory became increasingly disturbed. She began playing the piano for family, friends and acquaintances at the age of 40, although without any formal studies. Given this interest, music therapy appeared to have potential as an intervention adjuvant to medical treatment. Initially the patient was referred to the hospital when she and her son became aware of her deteriorating condition, although the disease was in its early stages. At home she was experiencing difficulties in finding clothing and other things necessary for everyday life. She could not cook for herself anymore and was unable to write her own signature. When wanting to speak, she experienced difficulty in finding words. It may be assumed, given the family background, and her own understanding of her failings, that the cognitive problems were exacerbated by depression and likely to be a pseudodementia.

Rhythmic Playing In all 10 sessions Frau X demonstrated her ability to play, without the influence of her music therapist, a singular ordered rhythmic pattern in 414 time using two sticks on a single drum. This rhythmical pattern appeared in various forms and can be portrayed as seen in Example 1. A feature of her rhythmical playing was that in nearly all the sessions, during the progress of an improvisation, the patient would let control of the rhythmic pattern slip so that it became progressively im-

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Example l . Rhythmic playing by the patient on a drum using a beater in her right hand.

precise, losing both its form and liveliness. The initial impulse of her rhythmical playing, which was clear and precise, gradually deteriorated as she lost concentration and ability to persevere with the task in hand. However, when the therapist offered an overall musical structure during the course of the improvisation, the patient could regain her precision of rhythm. As suggested earlier, to sustain perception an overall rhythmical structure is necessary, and it is this musical gestalt (i.e., the ability to provide an overall organizing structure of time) that fails in Alzheimer's disease. The patient reacted quickly to changes in time and different rhythmic forms, and incorporated these within her playing. Significantly, she reacted fluently in her playing to changes from 414 time to 314 time, often remarking " . . . now it's a waltz. . . ." With typical well-known rhythmical forms (e.g., the Habaner rhythm) in combination with characteristic melodic phrases, she laughed, breathed deeply, and played with intent. These rhythmical improvisations, using different drums and cymbals, were played in later sessions on two instruments together. The patient had no difficulty in controlling and maintaining her grip of the beaters. Similarly, she showed no difficulty in coordinating parallel or alternate-handed playing on a single instrument although she played mostly with a quick tempo (120 beats per minute). However, the introduction of two instruments brought a major difficulty for the patient. She stood disoriented before the instruments, unable to integrate them both in the playing. It was only with instructions and direction from the therapist that the patient was able to coordinate right-left playing on two instruments, and changes in the pattern of the playing were also difficult to realize (see Examples 2 and 3). What did remain throughout the improvisations was the inherent musical ability of the patient, in terms of tempo (ritardando, accelerando, rubato) and

Example 2 . Dialogic playing on the drum.

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ALDRIDGE AND ALDRIDGE difficulty in playing them, which may have been compounded by visuo-spatial difficulties (e.g., it is easier to strike the surface of a drum than the limited precise surfaces of adjacent chime bars). Example 3. A change in the pattern of playing.

Harmonic Playing dynamic (loud and soft), which she expressed whenever she had the opportunity. This would also accord with Swartz et al. series of perceptual levels at which musical disorders take place (i.e., levels-(a) the acoustico-psychological level, (b) the discriminatory level, which includes the discrimination of intervals and chords, and (c) the categorical level, which includes the categorical identification of rhythmic patterns and intervals).

Melodic Playing Melody is a natural expression of motion that arises and decays from moment to moment. In this motion, the size of the intervals provides an enormous melodic tension that itself has a dynamic power. The experience of melody is itself an experience of form. As a melody begins, there is the possibility to grasp a sense of the immediacy of the whole form and prepare for the aesthetic pleasure of deviations from what is expected. This element of tension between the expected and the unpredictable has been at the heart of musical composition for the last 200 years. In addition, it is melody that leads the music from the rhythmical world of feeling into the cognitive world of imagination. When Frau X played, her melodies were always lively. She knew many folk songs from earlier times and was able to sing them alone. After only a few notes played by the therapist on the piano, she could associate those notes with a well-known tune. However, when the patient tried to play a complete melody on the piano, or other melody instrument alone, it proved impossible. Although beginning spontaneously and fluently, she had difficulty in completing a known melody. Melody instruments, like the metallophone and the xylophone, which were previously unknown to the patient, remained forever strange to her. At the introduction of a new melody she would often seek a melody known to her rather than face the insecurity of improvisation. When the therapist sat opposite her and showed her which notes to play she then was able to follow the therapist's finger movements. When presented with a limited range of tones, she also had

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At the beginning of the very first session after entering the therapy room, Frau X set her eyes on the piano and began to play spontaneously "Happy is the Gypsy Life." She easily accompanied this song harmonically with triads and thirds. The second song she attempted to play proved more difficult as she failed to find the subdominant, whereupon she broke off from the playing and remarked ". . . that always catches me out." This pattern of spontaneously striking up a melody, and then breaking off when the harmony failed, was to be repeated whenever she tried other songs like "Happy Birthday" and "Horch was kommt von drauBen rein." She showed a fine musical sensitivity for the appropriate harmony, which she could not always play. In the playing of the drum, her musical sensitivity in her reactions to the contrasting sound qualities of major and minor was reduced, but overall she had a pronounced perception of this harmonic realm of music. As in tests of language functioning, the production of music is impaired while perceptual abilities remain.

Changes in the Musical Playing of the Patient In the rhythmical playing on drum and cymbal, the therapist attempted to increase the patient's attention span through the use of short repeated musical patterns and changes in key, volume and tempo, hoping that the patient would maintain a stable musical form. This technique helped the patient to maintain a rhythmical pattern and brought her to the stage where she could express herself stronger musically. Above the emphasis of the basic beat in the music, the therapist searched for other ways to respond to and develop a variety in rhythmical patterns by moving away from the repetitive pattern played by the patient. In a quick tempo the patient was able to maintain a basic beat for a certain time. As soon as the tempo changed and became slower, or the music varied with the introduction of a semiquaver, the stable element of the music was disturbed and took on a superficial character. A further change in the improvising was shown when the patient recognized, and could repeat, rhyth-

Collected neurology papers

TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA mica1 patterns, which were frequently realized as a musical dialogue and brought into a musical context. In the last session of therapy, the patient was able to change her playing in this way so that she could express more strongly by bringing into line her thoughtful and expressive playing (see Example 4). A crucial point in the music was when she chose to play for a bar on the cymbal. Although after a while she trusted herself to play without help on two instruments, she could not come to grips with a new personal initiative on these instruments. This was also reflected in her continuing difficulty with what were initially strange instruments, like the temple blocks. She also expressed her insecurity about how to proceed and needed instructions. The patient displayed few changes in her dynamic playing. She reacted to dynamic contrasts and transitions, but powerful forte playing was only achieved in the last session. At times her playing had a uniform quality of attack, which gave it a mechanistic and immovable character. It was not possible for her to build a freely improvised melody from a selection of tones. It was as if she was a prisoner of the search for melodies of known fixed songs; therefore, the therapist chose the free form of improvising on rhythm instruments. Intentional Playing From the first session of therapy the patient made quite clear her intent to sit at the piano and play whatever melodies she chose and to find the appropriate accompaniments. This wish, and the corresponding willpower to achieve this end, was shown in all the sessions. It was possible to use this impetus to play as a source for improvisation. In the sixth session, Frau X improvised a rhythmical piece in 414 time, which the therapist then transformed with a melodic phrase. At the end of the phrase the patient laughed with joy at the success of her playing and asked to play it again. The original lapses and slips in the form of the rhythmical playing could be carried by the intent and expression with which she played. Although her overall intention to play was preserved, her attention to that playing, the concentration necessary for musical

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production and the perseverance required for completing a sequence of phrases progressively failed and was dependent on the overall musical structure offered by the therapist. Clinical Changes At the end of the treatment period, which also used homeopathic medicine, she was able to cook for herself and find her own things about the house. The psychiatrist responsible for her therapeutic management reported an overall improvement in her interest in what was going on around her, and, in particular, that she maintained attention to visitors and conversations. The patient regained the ability to write her name, although she could only write slowly. While wanting to speak, she still experienced difficulty in finding words. The medical practitioner with overall responsibility for the patient used no validated clinical assessment procedure for mental state examination. It appears that music therapy had a beneficial effect on the quality of life for this patient, and that some of the therapeutic effect may have been brought about by handling the depression. Indeed, it may be that the patient was suffering from a pseudodementia confounded by her own anxiety and depression regarding the demise of her sister. Although the patient came to the sessions with the intention of playing music, her ability to take initiatives was impaired. This situation reflected the state of her home life, where she wanted to look after herself, yet was unable to take initiatives. This stimulus to take initiatives was seen as an important feature of the music therapy by the therapist, and appears to have a correlation in the way the patient began to take initiatives in her daily life. Active music making also promotes interaction between the persons involved, thereby promoting initiatives in communication that the patient also enjoyed, particularly when she accomplished playing a complete improvisation. A contraindication for music therapy with patients who are aware of their problems is that the awareness of further cognitive abilities as experienced in the playing may exacerbate any underlying depression and demotivate the patient to continue. Conclusion

Example 4. Change in the form of the patient's playing.

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If we are unsure of the normal process of cognitive loss in aging, we are even more in the dark as to the normal improvised musical playing abilities of the

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elderly. Any further activities will depend upon some baseline assessment of musical improvising ability. The literature suggests that musical activities are preserved while other cognitive functions fail. Alzheimer patients, despite aphasia and memory loss, continue to sing old songs and to dance to past tunes when given the chance. However, the production of music and the improvisation of music appear to fail in the same way that language fails. Unfortunately, no established guidelines for the normal range of improvised music playing of adults is available. Improvised music therapy appears to offer the opportunity to supplement mental state examinations in areas where those examinations are lacking (see Table 6), although such a hypothetical claim awaits further investigation. First, it is possible to ascertain the fluency of musical production. Second, intentionality, attention to, concentration on and perseverance with the task in hand are important features of producing musical improvisations and susceptible to being heard in the musical playing. Third, episodic memory can be tested in the ability to repeat short rhythmic and melodic phrases. The inability to build such phrases may be attributed to problems with memory or to a yet unknown factor. This unknown factor is possibly involved with the organization of time structures. If rhythmic structure is an overall context for musical production and the ground structure for perception, it can be hypothesized that it is this overarching structure that begins to fail in Alzheimer's patients. A loss of rhythmical context would explain why patients are able to produce and persevere with rhythmic and melodic playing when offered an overall structure by the therapist. Such a hypothesis would tie in with the musical hierarchy proposed by S w a m (Swartz et al., 1989, p. 154) and would suggest a global failing in cognition while localized lower abilities are retained. However, the hierarchy of musical perceptual levels proposed by Swartz may need to be further subdivided into classifications of music reception and music production. Music therapy also appears to offer a sensitive assessment tool. It tests those prosodic elements of speech production that are not lexically dependent. Furthermore, it can be used to assess those areas of functioning, both receptive and productive, not covered adequately by other test instruments (i.e., fluency, perseverance in context, attention, concentration and intentionality). In addition, it provides a form of therapy that may stimulate cognitive activities so that areas subject to progressive failure are main-

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tained. Certainly the anecdotal evidence suggests that quality of life of Alzheimer's patients is significantly improved with music therapy (Tyson, 1989), accompanied by the overall social benefits of acceptance and sense of belonging gained by communicating with others (Morris, 1986). Prinsley recommended music therapy for geriatric care in that it reduces the individual prescription of tranquilizing medication, reduces the use of hypnotics on the hospital ward and helps overall rehabilitation. He recommended that music therapy be based on treatment objectives, the social goals of interaction cooperation, psychological goals of mood improvement and self-expression, intellectual goals of the stimulation of speech and organization of mental processes, and the physical goals of sensory stimulation and motor integration (Prinsley, 1986). In further research, single-case within-subject designs with Alzheimer's patients appear to be a feasible way forward to assess individual responses to musical interventions in the clinical realm. (These can be extended to include multiple baselines.) Such studies would depend upon careful clinical examinations, mental state examinations and musical assessments. Unfortunately, most of the literature concerning cognition and musical perception is based upon audition and not musical production. The production of music, as is the production of language, is a complex global phenomenon as yet poorly understood. The understanding of musical production may well offer a clue to the ground structure of language and communication in general. It is research in this realm of perception that is urgent not only for the understanding of Alzheimer's patients, but in the general context of cognitive deficit and brain behavior. It may be, as Berman ( 1 98 1) suggested, that the nondominant hemisphere is a reserve of functions in case of regional failure, and this functionality can be stimulated to delay the progression of degenerative disease. Furthermore, it is important to point out that when the overall rhythmic pattern failed for the patient described above, the patient was able to maintain her beating in tempo. A similar situation may apply to coma patients who cannot coordinate basic life pulses within a rhythmic context and thereby regain consciousness (Aldridge, 1991a; Aldridge, Gustorff, & Hannich, 1990). We may need to address in future research the coordinating role of rhythm in human cognition and consciousness, whether it be in persons who are losing cognitive abilities or in persons who are attempting to gain cognitive abilities.

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TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA Table 6 Comparative Elements of Two Therapeutic Epistemologies: Medicine and Music Therapy in the Treatment of Patients With Dementia Medical Elements of Assessment

Musical Elements of Assessment

continuing observation of mental and functional status

testing of verbal skills, including element of speech fluency

testing of musical skills; rhythm, melody, harmony, dynamic, phrasing, articulation

cortical disorder testing; visuospatial skills and ability to perform complex motor tasks (including grip and right left coordination).

testing for progressive memory disintegration

motivation to complete tests, to achieve set goals and persevere in set tasks

motivation to sustain playing improvised music, to achieve musical goals and persevere in maintaining musical form

"intention" difficult to assess, but considered important

"intention" a feature of improvised musical playing

concentration and attention span

concentration on the improvised playing and attention to the instruments

flexibility in task switching

flexibility in musical (including instrumental) changes

mini-mental state score influenced by educational status

ability to play improvised music influenced by previous musical training

insensitive to small changes

sensitive to small changes

ability to interpret surroundings

ability to interpret musical context and assessment of communication in the therapeutic relationship

We had set out to negotiate a common language between practitioners, and this was achieved. Although the clinical benefits of music therapy for patients with dementia or pseudodementia remain speculative, a common language to discuss and compare

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Music Therapy Examples improvisations using rhythmic instruments (drum and cymbal) singly or in combination improvisations using melodic instruments singing and playing folk songs with harmonic accompaniment playing tuned percussion (metallophone, xylophone, chime bars) demanding precise movements alternate playing of cymbal and drum using a beater in each hand coordinated playing of cymbal and drum using a beater in each hand coordinated playing of tuned percussion the playing of short rhythmic and melodic phrases within the session, and in successive sessions the playing of a rhythmic pattern deteriorates when unaccompanied by the therapist, as does the ability to complete a known melody, although tempo remains the patient exhibits the intention to play the piano from the onset of therapy and maintains this intent throughout the course of treatment the patient loses concentration when playing, with qualitative loss in the musical playing and lack of precision in the beating of rhythmical instruments initially the musical playing is limited to a tempo of 120 bpm and a characteristic pattern but this is responsive to change although the patient has a musical background this is only of help when she perceives the musical playing, it is little influence in the improvised playing musical changes in tempo, dynamic, timbre and articulation, which at first are missing, are gradually developed the patient develops the ability to play in a musical dialogue with the therapist demanding both a refined musical perception and the ability of musical production

therapeutic changes has been developed, which is the first step in a continuing program of research dialogues. The next step is for other therapists to attempt correlations with their elderly patients to see if our hypotheses stand up to practical clinical investigation.

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Our experiences suggest that it is important to consider a period of active assessment separate from therapy, and that assessment must also incorporate time for orientation to the music therapy setting, the relationship, the instruments and the activity of improvising. References Aldridge, D. (1989a). Music, communication and medicine: Discussion paper. Journal of the Royal Society of Medicine, 82 (12), 743-746. Aldridge, D. (1989b). A phenomenological comparison of the organization of music and the self. The Arts in Psychotherapy, 16, 91-97. Aldridge, D. (1991a). Creativity and consciousness. The Arts in Psychotherapy, 18 (4), 359-362. Aldridge, D. (199 1b). Physiological change, communication, and the playing of improvised music: Some proposals for research. The Arts in Psychotherapy, 18 (l), 59-64. Aldridge, D., & Brandt, G. (1991). Music therapy and inflammatory bowel disease. The Arts in Psychotherapy, 18 (2), 1 13121. Aldridge, D., Brandt, G., & Wohler, D. (1989). Towards a common language among the creative art therapies. The Arts in Psychotherapy, 17, 189-195. Aldridge, D., Gustorff, D., & Hannich, H. (1990). Where am I? Music therapy applied to coma patients [editorial]. Journal of the Royal Society of Medicine, 83 (6), 345-346. Altenmiiller, E. (1986). Brain correlates of cerebral music processing. European Archives of Psychiatry, 235, 342-354. Alzheimer, A. (1907). Uber eine einartige Erkrankung der Himrinde. Allgemeine Zeitschrijt fur Psychiatric und PsychischGerichtliche Medizin, 64. 146-148. Babikian, V., Wolfe, N., Linn, R., Knoefel, J., & Albert, M. (1990). Cognitive changes in patients with multiple cerebral infarcts. Stroke, 21 (7), 1013-1018. Barfeld, 0 . (1978). The case for anthroposophy. London: Rudolf Steiner Press. Bayles, K. A., Boone, D. R., Tomoeda, C. K., Slauson, T. J., & Kaszniak, A. W. (1989). Differentiating Alzheimer's patients from the normal elderly and stroke patients with aphasia. Journal of Speech and Hearing Disorders, 54, 74-87. Beatty, W., & Goodkin, D. (1990). Screening for cognitive impairment in multiple sclerosis. An evaluation of the MiniMental State Examination. Archives ofNeurology, 47 (3), 297301. Beatty, W. W., Zavadil, K. D., & Bailly, R. C. (1988). Preserved musical skills in a severely demented patient. International Journal of Clinical Neuropsychology, 10, 158-164. Berman, I. (1981). Musical functioning, speech lateralization and the amusias. South African Medical Journal, 59, 78-81. Bmst, J. (1980). Music and language: Musical alexia and agraphia. Brain, 103, 367-392. Caine, E. (1981). Mental status changes with aging. Seminars in Neurology. 1 (l), 36-42. Cooper, J., Mungas, D., & Weiler, P. (1990). Relation of cognitive status and abnormal behaviors in Alzheimer's disease. Journal of the American Geriatrics Society, 38 (g), 867-870. Crystal, H., Groher, E., & Masur, D. (1989). Preservation of

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musical memory in Alzheimer's disease. Journal of Neurology, Neurosurgery and Psychiatry, 52 (12), 1415-1416. Dalessio, D. (1984). Maurice Ravel and Alzheimer's disease. Journal of the American Medical Association, 252 (24), 34123413. Drachman, D., O'Donnell, B., Lew, R., & Swearer, J. (1990). The prognosis in Alzheimer's disease. Archives of Neurology, 47, 851-856. Eustache, F., Cox, C . , Brandt, J., Lechevalier, B., & Pons, L. (1990). Word-association responses and severity of dementia in Alzheimer disease. Psychological Reports, 66 (3 Pt 2), 13151322. Faustman, W., Moses, J. J., & Csemansky, J. (1990). Limitations of the Mini-Mental State Examination in predicting neuropsychological functioning in a psychiatric sample. Acta Psychiatrica Scandinavica, 81 (2), 126-131. Folstein, M. F . , Folstein, S. E., & McHugh, P. (1975). MiniMental State: A practical guide for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. Gagnon, M,, Letenneur, L., Dartigues, J., Commenges, D., Orgogozo, J . , Barberger Gateau, P,, Alperovitch, A., Decamps, A., & Salamon, R. (1990). Validity of the Mini-Mental State Examination as a screening instrument for cognitive impairment and dementia in French elderly community residents. Neuroepidemiology, 9 (3), 143-1 50. Galasko, D., Klauber, M., Hofstetter, C., Salmon, D., Lasker, B., & Thai, L. (1990). The Mini-Mental State Examination in the early diagnosis of Alzheimer's disease. Archives of Neurology, 47 ( l ) , 49-52. Gates, A., & Bradshaw, J . (1977). The role of the cerebral hemispheres in music. Brain and Language, 4 , 403431. Henson, R. (1988). Maurice Ravel's illness: A tragedy of lost creativity. British Medical Journal of Clinical Research, 296 (6636), 1585-1588. Jacome, D. (1984). Aphasia with elation, hypermusia, musicophilia and compulsive whistling. Journal of Neurology, Neurosurgery and Psychiatry, 47 (3), 308-310. Jairath, N., & Campbell, H. (1990). Two mental status assessment methods: An evaluation. Journal of Ophthalmic Nursing Technology, 9 (3), 102-105. Jones, M,, Kidd, G., & Wetzel, R. (1981). Evidence for rhythmic attention. Journal of Experimental Psychology, 7 , 1059-1073. Kalayam, B., & Shamoian, C. (1990). Geriatric psychiatry: An update. Journal of Clinical Psychiatry, 51 (S), 177-1 83. Kellar, L., & Bever, T. (1980). Hemispheric asymmetries in the perception of musical intervals as a function of musical experience. Brain and Language, 10, 24-38. Kidd, G . , Boltz, M , , & Jones, M. (1984). Some effects of rhythmic content on melody recognition. American Journal of Psychology, 97, 153-173. Morgan, O . , & Tilluckdharry, R. (1982). Presentation of singing function in severe aphasia. West Indian Medical Journal, 31, 159-161. Morris, M. (1986). Music and movement for the elderly. Nursing Times, 82 (g), 44-45. Morrongiello, B., Trehub, S . , Thorpe, L., & Podilupo, S. (1985). Children's perception of melodies: The role of contour, frequency and rate of presentation. Journal of Experimental Child Psychology. 40, 279-292. Nordoff, P., & Robbins, C. (1977). Creative music therapy. New York: John Day.

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TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA Odenheimer, G. (1989). Acquired cognitive disorders of the elderly. Medical Clinics of North America. 72 (6), 1373-141 1. Povel, D. (1984). A theoretical framework for rhythm perception. Psychological Research, 45, 315-337. Prinsley, D. (1986). Music therapy in geriatric care. Australian Nurses Journal, 15 (9), 48-49. Safranek, M., Koshland, G . , & Raymond, G . (1982). Effect of auditory rhythm on muscle activity. Physical Therapy, 62, 161-168. Salmon, D., Thai, L., Butters, N., & Heindel, W. (1990). Longitudinal evaluation of dementia of the Alzheimer type: A comparison of 3 standardized mental status examinations. Neurology, 40 (g), 1225-1230. Sandman, C. (1984). Afferent influences on the cortical evoked response. In M. Coles, L. Jennings, & J. Stein (Eds.), Psychological perspectives (Festschrift for Beatrice and John Lacey). Stroudberg, PA: Hutchinson & Ross. Steg, R. (1990). Determining the cause of dementia. Nebraska Medical Journal, 75 (4), 59-63. Summers, W., DeBoynton, V., Marsh, G., & Majovski, L. (1990). Comparison of seven psychometric instruments used for evaluation of treatment effect in Alzheimer's dementia. Neuroepidemiology, 9 (4), 193-207.

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Swartz, K., Hantz, E., Cmmmer, G., Walton, J., & Frisina, R. (1989). Does the melody linger on? Music cognition in Alzheimer's disease. Seminars in Neurology, 9 (2), 152-158. Tyson, J. (1989). Meeting the needs of dementia. Nursing Elderly, 1 ( 5 ) , 18-19. Wagner, M., & Hannon, R. (1981). Hemispheric asymmetries in faculty and student musicians and nonmusicians during melody recognition tasks. Brain and Language, 13, 379-388. Walker, B., & Sandman, C. (1979). Human visual evoked responses are related to heart rate. Journal of Comparative and Physiological Psychology, 93, 7 17-729. Walker. B., & Sandman, C. (1982). Visual evoked potentials change as heart rate and carotid pressure change. Psychophysiology, 19, 520-527. Walsh, J., Welch, H., & Larson, E. (1990). Survival of outpatients with Alzheimer-type dementia. Annals of Internal Medicine, 113 (6), 429-434. Zillmer, E., Fowler, P,, Gutnick, H., & Becker, E. (1990). Comparison of two cognitive bedside screening instruments in nursing home residents: A factor analytic study. Journal of Gerontology, 45 (2), 69-74.

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International Tinnitus Journal, Vol. 11, No. 2, 163–169 (2005)

Auditive Stimulation Therapy as an Intervention in Subacute and Chronic Tinnitus: A Prospective Observational Study Martin Kusatz,1 Thomas Ostermann,2 and David Aldridge3 1 Tinnitus

Therapy Center, Krefeld and Dusseldorf; 2 Department of Medical Theory and Complementary Medicine and 2,3 Faculty of Medicine, University of Witten Herdecke, Germany

Abstract: Tinnitus is a noise, a ringing, or a roaring sound in the affected ear and is becoming an increasingly serious problem for health care systems. Integrative treatment concepts are currently regarded as promising therapeutic approaches for managing tinnitus. The aim of this study was to present the results of auditive stimulation therapy, a program of music therapy developed specifically for tinnitus treatment. We collected data on outpatient treatment results from 155 tinnitus patients and evaluated them in a prospective observational study with three defined times of measurement (start, end, and 6 months after the end of treatment). Apart from anamnestic data and subjective evaluation of treatment, the major outcome parameter was the score of the tinnitus questionnaire. To evaluate effectiveness of the therapy, we calculated effect sizes (according to Cohen). Fifty-one percent of the patients were male, and the mean patient age was 49 years. Of the 155 patients, 137 (88%) were capable of gainful employment, which means that they fell in the age range between 18 and 65 years. The duration of tinnitus was more than 6 months for 80% of patients, and 43% had been suffering from tinnitus for more than 3 years. In general, all subscales of the tinnitus questionnaire showed highly significant changes (t-test, p .01) between the measurement points “start of therapy” and “end of therapy,” whereas no significant difference was found between the measurement points “end of therapy” and “follow-up.” At follow-up, the values of the subscales were stabilized at a level recorded at the end of the therapy; we did not observe a reduction to the level prior to treatment. The values for the effect sizes mostly ranged between medium ( 0.5) and high ( 0.8). Closer investigations indicated that a combination of music therapy and psychological training rendered the best effect sizes. This study demonstrated that music therapy is an effective integrated treatment approach and offers a way to make progress in tinnitus treatment. Key Words: effectiveness; music therapy; outcome research; tinnitus

he term tinnitus is derived from the Latin tinnire (“ringing”) and is defined as the perception of sound in the absence of any appropriate external stimulation. A basic difference separates objective and subjective tinnitus. The term objective tinnitus is used for ear sounds based on genuine physical vibrations-oscillations that may be perceived by others or even measured [1]. This type of tinnitus is rather rare, whereas subjective tinnitus is far more frequent. In

Reprint requests: Prof. Dr. David Aldridge, Universität Witten Herdecke, Alfred Herrhausen Strasse 50, 58448, Witten, Germany. E-mail: davida@uni-wh.de

such cases, only the person afflicted perceives the sounds. These may occur as rustling, whistling, whirring, ringing, or droning sounds. High-frequency sounds are perceived far more often than are low-frequency sounds [2], and a hearing impairment is detectable in more than 50% of all cases. The incidence of patients experiencing tinnitus in Germany and the Western world is approximately 10%. Some 1–2% of the population is severely disturbed by tinnitus, which may disrupt everyday activities and sleep [3]. If the symptoms continue for 6 months, we consider the condition to be chronic, the degree of which differs considerably from person to person and

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affects patients in different ways [4]. A decompensated tinnitus is accompanied in most cases by other complaints (e.g., depression, anxiety, impaired sleep and concentration, sensitivity to noises, and the like) [5–7]; consequently, intervention is required. Several treatments of chronic tinnitus have been proposed and implemented [8]. Among complementary therapies, homeopathy and acupuncture are proposed [9–11]. Although several case studies reported efficacy of these treatments, the empirical support in well-controlled studies is still weak [12,13]. Today, such integrative therapy concepts as cognitive-behavioral treatment compiled from counseling, relaxation therapy, music therapy, and pharmacological preparations (lidocaine, neurotransmitters) are regarded as promising therapeutic approaches for managing tinnitus [7]. In particular, music therapy offers the chance of a global treatment approach for tinnitus patients [14]. Harmony, for instance, as a connecting link between rhythm and melody also has a social function. Rhythm may also influence biological parameters via tempo accentuation and meter [15]. These components form the theoretical background for auditive stimulation therapy (AST), the music therapy (MT) program evaluated in this study.

THERAPY AST is a complex program of MT originally employed in the treatment of chronic pain and developed specifically for tinnitus treatment. It consists of a total of 10 therapy sessions and employs specifically developed receptive music programs in combination with an education program. Musical self-control (MSC) training is a music program designed on the basis of music psychology and MT, the effectiveness of which was demonstrated in a clinical study [16]. The objective of MSC training is to improve patients’ control of ear sounds and to relieve their feelings of helplessness. Ringing in the ear or strange sounds bring about alterations in perception. If we encourage the ability of selective hearing, we can promote some sounds in the hierarchy of perception and ignore other sounds or regulate them until they become hardly perceptible. Such training improves (i.e., lowers) the level of sensitivity to sounds. Finally, the objective of AST is to bring about a change in sound perception that induces relaxation, reduces anxiety, and stimulates changes in unfavorable behavior patterns, thus improving the emotional state. The education program is aimed at alterations on a cognitive level. The outpatient therapy (duration, 2 weeks) with AST consisted of a total of 38 hours of therapy (20-hr psychological training, 10-hr MT [AST], 8-hr kinesi-

Figure 1. Complete 2-week program of auditive stimulation therapy (AST) as a function of hours of therapy per day. (A admission; PT psychological therapy; MO motor therapy.)

therapy) and also included counseling by ear, nose, and throat experts, orthopedists, and dentists. Figure 1 shows the complete 2-week program of AST with its different modules.

METHODS At the Tinnitus Therapie Zentrum Krefeld (Germany), we performed an observational study on a multimodal treatment concept (Krefelder-Modell) being applied on an outpatient basis for subacute and chronic tinnitus over a projected period of 2 years. Data on treatment were collected and evaluated in a prospective observational study using several standardized questionnaires immediately before and after therapy and at follow-up after 6 months. Apart from anamnestic data, the questionnaires asked for a subjective evaluation of treatment results. The tinnitus questionnaire designed by Goebel and Hiller [17], now the recommended standard tool throughout Germany, was used at all times for measurement. Included in the evaluation were only those questionnaires in which more than 90% of the questions were answered properly. We included a total of 155 patients in this evaluation. Sufficient follow-up documentation for assessment was available for 111 patients (71.6%). Figure 2 shows the questionnaire instruments used and the patient flow in this study. For an evaluation of the efficiency and sustained success of the therapy, we applied the t-test to show significant differences of tinnitus questionnaire scales after therapy. We carried out subgroup analysis of outcome measures according to the degree of tinnitus severity. Therefore, the tinnitus questionnaire results were grouped in the following clinically relevant groups: minor tinnitus (0–30 points); medium tinnitus (31–46 points); serious tinnitus (47–59 points); and very serious tinnitus (60–84 points). As the treatment concept presented in this study (Krefelder-Modell) is a multimodal concept, the differ-

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Figure 2. Patients and questionnaire instruments. (AST auditive stimulation therapy.)

ent elements of treatment can be compared to achieve more detailed results on the efficiency of the MT training program (AST). Kinesitherapy having received a distinctly lower rating by patients, only the two treatment elements rated as most successful were compared with respect to their effectiveness: psychological training (PT) and music therapy (MT). To evaluate effectiveness of the therapy and to render the results comparable with each other and also with other treatment facilities in the health care sector, we calculated effect sizes according to Cohen [18] and corrected according to McGaw and Glass [19].

PATIENTS One hundred thirty-seven patients (88.38%) were of wage-earning age (i.e., between 18 and 65 years). Table 1 shows that the duration of tinnitus was longer than 6 months for 80% of patients. A total of 43.3% had been suffering from tinnitus for more than 3 years; 33.5% of those interviewed reported that tinnitus developed gradually. Every second patient (50.3%) said tinnitus set in suddenly; 16.1% did not answer this question; 76.8% said tinnitus occurred continuously; and 21.3% reported that tinnitus occurred with interruption. Three patients (1.9%) had no comment. Almost all patients (94.8%) reported times at which tinnitus was particularly intense. In contrast, only 75.5% said that at times tinnitus was barely perceptible. Patients were also asked how often they resorted to seeking assistance through the health care system over 6 months before treatment, and they had the option of

several possible answers. Seventy-four patients answering this question (47.74%) reported 111 individual consultations (main consultation with ear, nose, and throat specialists), which means an average of 1.5 consultations per patient approximately. Before treatment, patients were also asked about previous treatment; 137 patients reported a total of 304 instances (i.e., an average of 2.2 treatments per patient). The major treatments were infusions (78.8%).

RESULTS The total score of the tinnitus questionnaire (Tinnitus Fragebogen [TF]) at the different measurement points is shown in Figure 2. The follow-up sample with regard to the TF total score did not differ significantly from that of the general population, which has been demonstrated [16]. Therefore, Figure 3 shows the mean scale values of the tinnitus questionnaire before and after outpatient tinnitus therapy (n 146) and also at follow-up after 6 months (n 106). In general, all subscales showed highly significant changes (t-test, p .01) between the measurement points “start of therapy” and “end of therapy,” whereas we found no significant difference between the measurement points “end of therapy” and “follow-up.” At follow-up, the values of the subscales were stabilized at a level recorded at the end of the therapy; we did not observe a reduction to the level before treatment. Approximately 80% of the patients with a disease severity of medium to very serious at least moved to a clinically improved stage (e.g., from very serious to serious). The

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Table 1. Sociodemographic and Anamnestic Data Characteristic

Male

Female

Total

Gender

51%

49%

100%

Age Mean Standard deviation Median

48.9 yr 12.1 yr 52 yr

48.7 yr 15.5 yr 50 yr

48.8 yr 13.9 yr 51.5 yr

Marital status Single Married or established partner Divorced or living separated Widowed

16% 74% 10% —

17% 64% 9% 9%

17% 69% 10% 5%

Graduation Secondary school Secondary modern school High school, A-levels University or college

55% 25% 7% 13%

43% 29% 18% 9%

49% 27% 13% 11%

Profession Laborer Clerk Self-employed Unemployed

33% 40% 4% 24%

13% 48% 3% 37%

23% 44% 3% 30%

Duration of tinnitus 6 mo 6–12 mo 1–3 yr 3–5 yr 5 yr

20% 16% 20% 14% 30%

20% 16% 22% 10% 32%

20% 16% 21% 12% 31%

Loudness, ear-ringing: 0 (not at all) to 10 (maximum) Mean (95% CI) Standard deviation Median

6.5 (6.0–7.0) 2.2 6

5.5 (4.9–6.1) 2.8 5.5

6.1 (5.7–6.5) 2.5 6

Disruption, ear-ringing: 0 (not at all) to 10 (maximum) Mean (95% CI) Standard deviation Median

7.0 (6.4–7.6) 2.6 7

6.4 (5.7–7.1) 3.0 6

6.7 (6.3–7.1) 2.8 7

Restrictions, ear-ringing: 0 (not at all) to 10 (maximum) Mean (95% CI) Standard deviation Median

5.8 (5.1–6.5) 3.0 6

4.5 (3.8–5.2) 3.2 4

5.2 (4.7–5.7) 3.2 5

Figure 3. Total score on the tinnitus questionnaire (TF) at the different measurement points, according to degree of disease severity.

details of this transition process will, however, be the subject of a following evaluation using Marcov-chains methods. We determined the values of effect sizes for individual subscales and for the total score. The values for the effect sizes were all in the range of medium ( 0.5) to high ( 0.8), with the exception of the scale somatic disorders, and are illustrated in Figure 4. In a comparison of the individual therapies, AST was responsible for a surprisingly high percentage of the positive total result and clearly was preferred by patients, despite the fact that psychological training was twice as long (20 therapy session hours as compared to 10 for MT). For further analysis of these findings, we

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helped them to cope better with ringing in the ear, 40% of patients described the success as excellent, 29% as good, and 16.8% as satisfactory. At a follow-up 6 months after the end of the therapy, the question was whether any ear ringing was still perceivable; 3.2% of patients reported none at all; 30.8% had a temporary absence of ear ringing; some two-thirds of patients continued to perceive noises during the 6 months after the therapy ended, but these had noise that had been clearly reduced. In summary, 52.3% indicated further positive changes after the therapy was concluded.

Figure 4. Changes (on the tinnitus questionnaire) of scale values in effect sizes. (E emotional distress; C cognitive distress; I intrusiveness; A hearing problems; SI sleeping problems; SO somatic complaints.)

calculated effect sizes at measurement times and related to the patients’ subjective evaluation. Figure 5 illustrates the calculation of effect sizes. A combination of MT and PT renders the best therapeutic effect. MT alone ranked in second place, and PT was third. The combination of MT-PT comprises the partial therapies MT and PT, and this suggests that the share of MT in this result is higher than that of PT. In addition, MT shows excellent effect sizes over longer periods, a clear indication of the quality of the concept of AST as to contents and didactic implementation. The results appear to confirm in particular the intention of enabling patients to continue independently with MT and to make autonomous use of receptive music programs. The most expressive results in this context certainly are those of the follow-up, as the data from these particular patients are available for all measurement times. In retrospect, they were able to come to a conclusive evaluation for themselves. In answer to the question of whether the therapy

Figure 5. Changes in effect sizes (total, n 143; follow-up, n 105) depending on patients’ preferred therapy. (MT subgroup of patients favoring music therapeutic elements; MT PT subgroup of patients who were indecisive between music therapy and psychotherapy; PT subgroup of patients favoring psychotherapeutic elements.)

CONCLUSION An analysis of the tinnitus problem, particularly from a traditional perspective, suggests a general confusion among most experts, although many scientists have explored the problem. A great variety of models and treatment approaches are available, the effectiveness of which is still inconclusive. The standard therapies in Germany include medication to improve blood circulation or, with increasing frequency, infusions as part of a hospitalization period, with disproportionate side effects as compared to the severity of the complaints [20]. In this study, we were able to demonstrate that the multimodal concept achieves highly significant changes. The calculation of effect size, according to the tinnitus questionnaire results, illustrates that the most significant effect sizes occurred in the area of psychological stress and total score changes. In comparison with effect sizes of other studies with hospitalized patients and outpatients summarized in a meta-analysis by Schilter [21], the advantages of this treatment concept become evident. With an overall effect size of 0.63 from pretherapy to follow-up, other multimodal therapeutic strategies range far behind the results of the therapeutic approach described in this study. Medical treatments (e.g., tocainide, lidocaine, carbamazepine) or other remedies have effect sizes in the same magnitude; however, these therapies have side effects, such as tremor, vertigo, giddiness, and nausea [21]. Therefore, our nonpharmacological intervention achieves the high effect sizes of the drug-based therapies without their concomitant side effects. The Krefelder-Modell treatment concept alone uses an MT training program embedded within a complex treatment approach, indicating that the advantage— compared to other treatment forms—is principally the influence of the specific MT intervention. If we assume that tinnitus is not a disease but a symptom of an underlying process, singular symptom– oriented approaches will fail [2]. Sixty-one percent of patients state that professional medical help was not of much use—a shockingly high figure in view of the numerous medical interventions. Much suggests a holistic

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treatment approach, in which ringing in the ear is viewed as a sign of particularly high stress. The question of whether the symptom is of a somatic or a psychosomatic nature seems to be of no importance in the treatment of subacute and chronic tinnitus. An analysis not only of the biological but of the psychological and social needs of patients [22] provides a more comprehensive insight into and understanding of their situation. MT AST is seen as salient to their problems among patients and as highly effective, perhaps because we are not making a direct, singular psychological intervention but an intervention in the same modality as that in which the symptom is experienced. By accommodating sound control within an ecology of other sounds, itself within a stressreduction context, we are offering a form of self-control that is adapted to a personal environment [23–25]. On this extended basis of our knowledge about hearing, we should be able to develop for affected patients coping strategies that address the causes of the problem directly and thus render the symptom superfluous. Our follow-up interview of patients after 6 months showed a high degree of sustained therapeutic success. Furthermore, these interviews provide important feedback for therapists and show longer-term positive treatment results, specifically in the areas of well-being and reintegration of patients in their family environment, as amply demonstrated in our study. We hear frequently that therapy success in most cases becomes evident over time. If a reorientation in terms of perception takes place, the consequences of this reorientation, as therapeutic effects, are best seen in follow-up assessments. The subjective symptom of tinnitus is a phenomenon that the unaffected cannot easily understand, as defining a cause is difficult in most cases. Hearing of sounds that are normally located externally is suddenly directed internally and, therefore, is difficult for others to imagine. The affected individual suffers from a personal noise problem that is inaudible to others; consequently, others lack understanding. Musicians, however, understand this concept as part of their daily practice [26]. “Only inner anticipatory hearing makes musical interpretation possible. This phenomenon is most obvious in Ludwig van Beethoven who composed without being able to hear. Accordingly, listening must also be seen as an internal process of perception” [14]. Neugebauer reminded us that a sensory stimulation must not necessarily result in a conscious perception, nor must a sensory experience necessarily be caused by a physical stimulus. The specific way in which music therapists or musicians hear may indeed be helpful or suitable in understanding tinnitus patients and also in explaining—taking a composer as an example—how such experiences of internal hearing may also be observed in different settings in which they are absolutely

normal and by no means pathological. Aldridge [25] suggested that the purpose of MT is that patients are enabled to generate expressive potentials that reveal new possibilities for becoming healthy. In the context of ear ringing, MT might help to create a context of meanings that integrates the sounds or noises into the music and thus removes them from conscious perception, which would clearly promote recovery. Sounds no longer perceived as disturbing, once brought under control, are perceived as musical. This study demonstrates that MT is an effective treatment approach and offers a way to make progress in tinnitus treatment. Music has an esthetic aspect; it is part of our cultural heritage. How we integrate sounds into our daily life and how they become perceived as noise or music is a complex activity involving the physiological, the psychological, and the social. A therapeutic intervention that incorporates these understandings appears to offer considerable benefits, not as a cure but as a healthy adaptation.

REFERENCES 1. Feldmann H. Pathophysiologie des Tinnitus. In H Feldmann (ed), Tinnitus. Stuttgart: Thieme, 1992:33–70. 2. Pilgramm M, Rychlik R, Lebisch H, et al. Tinnitus in der Bundesrepublik. HNO Aktuell 7:261–265, 1999. 3. Rosanowski F, Hoppe U, Kollner V, et al. Interdisciplinary management of chronic tinnitus: II. Versicherungsmedizin 53(2):60–66, 2001. 4. Wilhelm T, Ruh S, Bock K, Lenarz T. Standardisierung und Qualitätssicherung am Beispiel Tinnitus. Laryngorhinootologie 74:300–306, 1995. 5. Duckro PN, Pollard CA, Bray HD, Scheiter L. Comprehensive behavioural management of complex tinnitus: A case Illustration. Biofeedback Self-Reg 9(4):459–469, 1984. 6. Goebel G, Keeser W, Fichter M, Rief W. Neue Aspekte des komplexen chronischen Tinnitus: II. Die verlorene Stille: Auswirkungen und psychotherapeutische Möglichkeiten beim komplexen chronischen Tinnitus. Psychother Psychosom Med Psychol 41:123–133, 1991. 7. Goebel G. Studien zur Wirksamkeit psychologischer Therapien beim chronischen Tinnitus. In G Goebel (ed), Ohrgeräusche–psychosomatische Aspekte des komplexen chronischen Tinnitus. München: Quintessenz, 1992:87–102. 8. Kröner-Herwig B. Psychologische Behandlung des chronischen Tinnitus. Weinheim: Psychologie Verlags Union, 1997. 9. Park J, White AR, Ernst E. Efficacy of acupuncture as a treatment for tinnitus: A systematic review. Arch Otolaryngol Head Neck Surg 126(4):489–492, 2000. 10. Simpson JJ, Donaldson I, Davies WE. Use of homeopathy in the treatment of tinnitus. Br J Audiol 32(4):227–233, 1998. 11. Weihmayr T. Managing tinnitus with natural healing. When

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it whistles and rings in the ear. Natural Healing Series: 18. Tinnitus. Fortschr Med 116(10):48–49, 1998.

19. McGaw B, Glass GV. Choice of metric for effect size in meta analysis. Am Educ Res J 17:325–337, 1980.

12. Biesinger E. Die Behandlung von Ohrgeräuschen. Stuttgart: Georg Thieme Verlag, 1999.

20. Bork K. Juchreiz nach Hydroxiethystärke: Auch bei Intensivepatienten häufig. Arznei-telegramm. 31(6):53, 2000.

13. Ernst E. Complementary and alternative medicine in the practice of otolaryngology. Curr Opin Otolaryngol Head Neck Surg 8(3):211–216, 2000. 14. Neugebauer L. Schöpferische Musiktherapie bei Patienten mit chronischem Tinnitus. In D Aldridge (ed), Kairos III: Beiträge zur Musiktherapie in der Medizin. Göttingen: Hans Huber Verlag, 1999:42–50. 15. Mosonyi D. Psychologie der Musik. Darmstadt: TonosEdition, 1975. 16. Kusatz M. Auditive Stimulation Therapy AST—Intervention in Subacute and Chronic Tinnitus. Hanover: Proceedings of the Fifth Triennial Conference of the ESCOM, 2003:45–49. 17. Goebel G, Hiller W. Qualitatsmanagement in der Therapie des chronischen Tinnitus. OtorhinolaryngologiaNova 10(6):260–268, 2000. 18. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Erlbaum, 1988.

21. Schilter B. Metaanalyse zur Effektivität medikamentöser und psychologischer Therapien bei chronischem subjektivem Tinnitus. Frankfurt: VAS-Verlag, 2000. 22. Aldridge D. Leben als Jazz. In D Aldridge (ed), Kairos II, Beiträge zur Musiktherapie. Göttingen: Verlag Hans Huber 1998:5–6. 23. Aldridge D, Gustdorff D, Neugebauer L. A preliminary study of creative music therapy in the treatment of children with developmental delay. Complementary Ther Med 3:197–205, 1995. 24. Aldridge D. Music Therapy Research and Practice in Medicine. London: Jessica Kingsley, 1996. 25. Aldridge D. Musiktherapie in der Medizin. Göttingen: Verlag Hans Huber, 1999. 26. Neugebauer L. Das Pfeifen nervt nicht mehr so. Musiktherapeutische Umschau 4:326–335, 2001.

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The Music of the Body: Music Therapy in Medical Settings What strikes me is the fact that in our society, art has become something which is related only to objects and not to individuals, or to life. That art is something which is specialized or done by experts who are artists. But couldn't everyone's life become a work of art? Why should the lamp or the house be an art object, but not our life?

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If w e consider our human biology in terms of musical form rather than mechanical construction and our response to biological challenges as a repertoire of improvisations, w e may find that disease restricts our ability t o improvise new solutions to challenges-in musical terms, restricts our ability to play improvised music.

David Aldridge, Ph.D., is associate professor of clinical research in the Faculty of Medicine at the University of Witten Herdecke in Germany, and the European editor for the journal The Arts in Psychotherapy. He is the coeditor (with George Lewith) of a handbook of clinical research methods for complementary medicine (Hodder and Stoughton 1992).

-Michael Foucault (in Rabinow 1986)

The use of music as a healing agent appears to be common to many cultures. Since David first played to soothe King Saul, there has been the recognition that music can bring relief to the afflicted. That the affliction in Saul's case is usually presented as depression, though it might well have been an acute episode of asthma, only serves to emphasize both the difficulty of historical interpretation and the generalness of reports about music as therapy. An earlier article in Advances, Robert Omstein and David Sobel's "Coming to Our Senses" (19891, reminds the reader of the necessity of enjoying the senses for the promotion of health. This paper goes one step further and presents the use of music as therapy, as it appears in the medical literature during the last decade. (References to psychiatric settings have been excluded.) T h e medical and nursing press contains a series of overviews about music therapy, ranging from letters to full-scale articles. The principle emphasis in this material is on the soothing ability of music and on the value of music as an antidote to an overly technological medical approach (Bailey 1985; Brody 1988; Carlisle 1990; Fischer 1990; Harcourt 1988; Harvey & Rapp 1988; Kartman 1984; McDermit 1984; Morris 1985; Olivier 1986; Ornstein & Sobel 1989; Paren t-Bender 1986; Pouget 1986; Rowden 1984; Stem 1989; Thomas 1986; Wein 1987; Ziporyn 1984). Most of these articles are concerned with what is called passive music therapy-the playing of

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Music therapy has been studied as an aid in treating specific medical problems, including coronary care, cancer pain management, and neurological disorders.

usually prerecorded music to patients-and they emphasize the necessity of healthy pleasures like music, fragrance, and beautiful sights in reducing stress and enhancing well-being. Music therapy is actually more varied and more complex. In some methods the patient is indeed a "passive" listener, and live, or recorded music, is played at the discretion of the therapist. But even in this situation, some therapists challenge the term "passive," insisting that listening is an active process. This is supported, for example, by an approach that uses imagery stimulated by selected musical passages (Bonny 1978; Bonny 1975; Ornstein & Sobel1989). Other methods of music therapy consist of or include active playing of musical instruments and singing, individually or in groups. Some of these approaches incorporate musical improvisation as the key component of the therapeutic activity. There is growing evidence to support the claims of music therapists that music can contribute to healing, although the research methodologies used to substantiate such claims often lack scientific rigor or are unconventional in their approach. It is important to emphasize that some music therapists reject quantitative research outright. They believe that such methods discount the important individual and qualitative aspects of their work as artists working in medical settings, and seek to find alternative forms of research suitable to the arts in clinical practice. Some believe that the study of music therapy provides an opportunity to develop expressive quality-of-life measures for people with serious illnesses, measures that are not solely based on verbal reporting (Aldridge 1989c; Aldridge 1991a).

Readers may be surprised to learn that music therapy has been studied as an aid in treating a variety of medical problems, including coronary care, cancer pain management, and neurological disorders. In this article, we shall move from general considerations to specific observations. We begin with the general use of music in hospital settings, and then turn to detailing the use of music therapy to treat particular problems.

Music Therapy in General Medicine For a while after World War I1 music therapy was intensively used in American hospitals in the rehabilitation of the wounded, with the aim of raising their morale and as a relief from the tedium of hospital life (Schullian & Schoen 1948).Psychiatrists were quick to see the benefits of music for enhancing mood and promoting relaxation in their patients. Since then some hospitals, in mainland Europe particularly, have incorporated music therapy within their practice (Aldridge & Verney 1988; Goloff 1981; Jedlicka & Kocourek 1986; McCluskey 19831, carrying on a tradition of European hospital-based research into the use of music as therapy (Leonidas 1981). The postwar European initiatives were concerned with rehabilitation and psychiatry. However, with the development of the perspectives of psychosomatics, and with a growing tolerance of alternative and complementary medical initiatives, music therapy in Europe has been applied to a wide range of medical problems, including cancer care, the treatment of patients with severely compromised immune systems, the management of pain, and the relief of anxiety. The nursing profession in particular has promoted the general value of music therapy, especially in the United States, and, even when music therapists are not available (Cook 1981), has championed its use as an important nursing intervention (Cook 1986; Fletcher 1986; Frandsen 1989; Frank 1985; Glynn 1986; Grimm & Pefley 1990; Keegan 1989; Kolkmeier 1989; Marchette, Main & Redick 1989; Moss 1987; Mullooly, Levin &

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Feldman 1988; Prinsley 1986; Rice 1989; Sammons 1984; Updike 1990; Walter 1983). At the same time little work has been published about the benefits of music therapy in general medicine. The overall expectation is that the recreational, emotional, and physical health of the patient is improved (Goloff 1981).

Music, t h e H e a r t , and Respiration To explore the specific physiological effects of music, we begin with the effects of music on heart rate and blood pressure in healthy people. If music can influence such physiological parameters in healthy individuals, the findings would support the possibility that music can be used therapeutically for patients who have problems with heart disease or hypertension. As we consider studies in this area, we shall be led to examine the different conceptualizations of time and their possible relation to health and disease. The effects of music on the heart and blood pressure have been a favorite theme throughout history. We can trace the medical study of such effects to an early issue of The Lancet. In 1929, two researchers (Vincent & Thompson 1929) made an attempt to discover the effect on blood pressure of listening to music on the gramophone and radio. Subjects were divided into "musical," "moderately musical," and "nonmusical" groups. The criteria for musicality were not defined, except to mention that the ideal "musical" group were "interested amateurs of good taste and emotional susceptibility, who can, and habitually do, enjoy music in a naive manner without the exercise of too much critical f.iculty." People with varying degrees of musical competence responded differently to volume, melody, rhythm, pitch, and type of music. Melody produced the most marked effect. When the music began, a rapid fall in blood pressure occurred in the "musical" subjects. However, during the music, a change in melody, particularly if the music was soft, resulted in a rise in blood pressure. Volume also produced an apparent, although less ADVANCES, The]ournal of Mind-Body Health

David Aldridge

If music can influence physiological conditions like heart rate or blood pressure in healthy people, then perhaps i t can be used therapeutically t o help patients with heart disease or hypertension.

marked, effect in the least musical groups. In general, listening to music was accompanied by a fall in blood pressure when the music began. However, during the music, blood pressure rose slightly in correlation with changes in melody, rhythm, pitch, and volume, according to the musical susceptibility of the listener. . M o r e recently, in 1972, a valuable paper by Bason and Celler (1972) found that the human heart rate could be varied over a certain range by synchronizing the sinus rhythm-that is, the normal heart rhythmwith an external auditory stimulus. An audible click was played to the subject at a precise time in the cardiac cycle. When the click occurred within a certain range of the cycle, the heart rate could be increased or decreased up to 12 percent in a period of 3 minutes or less. Fluctuations in heart rate caused by breathing remained, but these tended to be less when the heart was entrained with the audible stimulus. When the click was not within the appropriate range of the cardiac cycle, no change would occur. Bason's paper is important for supporting the proposition often made by music therapists that meeting the tempo of the patient is the initial key to therapeutic change. An extension of this premise, that musical rhythm is a pacemaker, was investigated by Haas and her colleagues (Haas, Distenfeld & Axen 1986). In this study, the researchers examined the effects of musical rhythm on the respiratory pattern, a pattern that serves both metabolic and behavioral functions. Metabolic respiratory pathways are located in the lower pons and medulla, whereas the behavioral respiratory pathways are located mainly

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in the limbic forebrain structures which lead to vocalization and complex behavior. There appear to be so-called pattern generators in the brain and spinal cord capable of synchronizing metabolic and locomotor activity, thereby reinforcing an underlying unconscious rhythmic relationship between the two. Because there are metabolic consequences of active music making inseparable from neural activity, the researchers chose listening to music as the stimulus condition. Haas hypothesized that the external musical activity would have a direct influence as a pacemaker on respiratory patterns but would have only minimal effect in itself on metabolic changes and afferent stimuli-that is, would not induce any gross motor movements. Twenty subjects were involved in this experiment. Four were experienced and practicing musicians, six had formal musical training but no longer played a musical instrument, and the remaining ten had no musical training. The subjects first listened to a metronome set at 60 beats per minute and tapped to that beat on a microphone after a baseline period. The subjects were then randomly presented five stimulus conditions: four musical excerpts to which they also t a p ped along, and one period of silence. Respiratory data, including respiration frequency and airflow volume, were collected, along with heart rate and carbon dioxide released at the end of the breath, to measure gross metabolic changes and chemical respiratory drive. The researchers found no appreciable changes in heart rate during the experiment indicating metabolic changes. But they also found that breathing was coordinated with the musical rhythm, expressed in the finger tapping. For nonmusically trained subjects there was little coordination between breathing and musical rhythm, while for trained musicians there was a tighter coupling of breathing and rhythm. The Haas study, then, suggests that motor activity-finger tapping here-and respiration can be synchronized by an external musical rhythm. This finding fits related findings in other studies-that muscle activity decreases when one performs a motor task accompa20

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nied by a musical rhythm similar to the rhythm of the subjects' normal heart rate (Safranek, Koshland & Raymond 1982); that respiratory rhythm follows the rhythm of music within certain limits of variability (Diserens 1920); and that, perhaps most intriguingly, there is a relationship between disturbed functional cardiac a r r h y t h m i a s with disturbed respiration-and musical rhythmic ability (Richter & Kayser 1991). I n the last study, the researchers Kayser and Richter hypothesized that patients with cardiac arrhythmias perform worse in perceiving and producing rhythm than do healthy controls. Thirty-one patients with functional cardiac arrhythmias were compared with 31 control subjects. Subjects were required to mark on a sheet of paper rhythmic patterns played for them on a tape recorder, and to tap synchronously with repeating patterns on the tape recorder. Patients with dysrhythmias had significantly poorer abilities in musical perception and rhythmic anticipation than healthy controls. Patients with a rapidly beating heart (tachycardia) showed a particularly poor sense of rhythm perception and synchronization.

Time and the Musical Expression of Disease Studies such as this support the hypothesis that people with disease may perceive, and respond to, music differently than do healthy people. It may be that different diseases differently affect the responses we have to music. If we consider our human biology in terms of musical form rather than mechanical construction and our response to biological challenge as a repertoire of improvisations, we can view disease as a restriction of our abilities to improvise new solutions to challenges-in musical terms, a restriction of our abilities to play improvised music (Aldridge 1989a, Aldridge 1991~). In regard to heart disease, for example, it is entirely possible to describe the differences in Type A and Type B behavior in musical language, suggesting that the Type A behavior, said to constitute a risk factor for

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Table 1 Musical Elements in Contrasting Characteristics of Type A and B Behavior Type A Behavior

Type B Behavior

Musical Components

increased voice volume fast speech rate short response latency emphatic voice hard metallic voice less mutuality trying to keep control increased reactivity increased heart rate higher cardiovascular arousal maintained

voice quieter slower speech rate longer response latency less emphasis melodic voice increased mutuality less need for control moderate reactivity decreased heart rate cardiovascular arousal returns to lower level

volume tempo phrasing expression/articulation timbre musical relationship musical relationship responsive tempo dynamic

The table lists the contrasting characteristics of Type A and B behavior end then identifies the musical element that one could ascribe to such characteristics. Is the behavioral disturbance of heart disease something like a disruption of musical patterns? Could music therapy be used to help regulate such disturbances?

heart disease, may express a repertoire of body response which is "musically limited." Table 1 identifies the musical components in the contrasting traits that distinguish Type A and B behavior. The Type A behavior pattern has been characterized as an expression of the way in which an individual responds to, and provokes, environmental demands. Helman (1987) refers to this view of the cause of heart disease as a cultural construction that involves the "unique social and symbolic characteristics of Western time." In this view, we are "the embodiment (both literally and figuratively) of the values o f . . . Western society." The individual is caught in the contradictions of selfdemand and societal demand, which for some people may become pathogenic. At the center of this cultural construction is the notion of time. The predominant form of Western time is monochronic. Time is conceived as an external order imposed on the individual. Such a view developed from the need of a modem industrialized society to have a universal public order by which the means of production could be coordinated

and the actions of many individuals regulated. In this form, deadlines have to be met, the passage of time is linear, and its measurement is quantitative. This is time as chronos, and the concept is contained in the idea of chronic illness. However, there is an alternative conccptualization of time that is personal rather than public. This is time as hiros. It is polychronic, and closer to the emerging biological understanding of physiological times that are rhythmically entrained (Johnson 19861, not to an external clock, but to the person as a whole organism. In this conceptualization, time is in a state of flux; it is concerned with flexibility and the convergence of multiple tasks. Time is seen as springing from the self. We may have to consider the idea of heart disease as a kairotic illness where personal biological time is out of step with external imposed time. Some authors do indeed suggest that when we try to impose a fusion between external clock time and personal physiological time, our physiology is affected (Dossey 1982, Helman 1987). Helman writes:

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Western society is unique in trying to impose a fusion between clock time and individual physiology-between rates of bodily movement, speech, gestures, heartbeat, and respiration-and the small machine strapped to the wrist or hung on the wall. "Rush hour," deadlines, diaries, appointments, and timetables all affect the physiology of modem [people], and help construct hidher world view and sense of identity.

In music therapy there are possibilities to experience these varying aspects of time as they converge in their seamless reality. The tension between personal and public time may be heard when improvised music is played in music therapy. Apart from stimulating experiences that differentiate and develop those conceptualizations, music therapy may promote an experience of a timeless qualitative reality essential in particular to the recovery of patients with heart disease.

Relieving Anxiety and Stress in Cardiac Patients Now we turn to the direct use of music in coronary care.* Several authors have investigated the relationship between heart rate and anxiety in the settings both of hospital care (Bolwerk 1990; Bonny 1983; Davis-Rollans & Cunningham 1987; Gross & Swartz 1982; Guzzetta 1989; Philip 1989; Wein 1987; Zimmerman, Pierson & Marker 1988) and of dentistry (Lehnen 1988).The intent usually has been to reduce anxiety in chronically ill patients or to treat anxiety in general (Chetta 1981; Daub & Kirschner-Hermanns 1988; Fagen 1982; Gross & Swartz 1982; Heyde & von Langsdorff

*The relationshipbetween listening to music and changes in respiration has been investigated in various situations other than coronary carewith college-student subjects (Formby et al. 19871, psychotherapy patients (Fried 19901, various chronic illness groups undergoing group psychotherapy (Gross & Swartz 1982), orthopaedic and abdominal surgery patients (Lehmann, Horrichs & Hoeckle 1985), chronic lung disease patients (Tiep et al. 1986), and in a study of mental stress and exercise (Brody 1988). 22

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1983; Lengdobler & Kiessling 1989; Schmuttermayer 1983; Standley 1986; Zimmerrnan et al. 1989). A hospital situation fraught with anxiety for the patient is the intensive care unit. For patients who have suffered a heart attack, and whose heart rhythms are potentially unstable, the setting of the coronary care unit is itself likely to be anxiety provoking, an experience that may reinforce the physiological and psychological reactions that initially led to the cardiac distress of the patient. Several authors have assessed the use of tape-recorded music delivered through headphones to reduce anxiety and so reduce stress (Updike 1990) in patients in intensive or coronary care clinics. Bonny has identified a series of musical selections for tape recordings that she believes has sedative effects (Bonny 1983; Bonny & McCarron 1984; Bonny 1975) and also selections that can induce relaxation and help the patient engage in imagery (Bonny 1978),but none of these assertions has been empirically confirmed. However, Updike (19901, in an observational study, supports Bonny's impression that there is a decreased systolic blood pressure, and a beneficial mood change from anxiety to relaxed calm, when sedative music is played. Davis-~ollans(Davis-Rollans & Cunningham 1987) describes the effect of a 37minute tape of selected classical music on the heart rate and rhythm of 24 coronary care unit patients. (The selections consisted of the first movement of Beethoven's Symphony No. 6, the first and fourth movements of Mozart's Eine klein Nachtmusik, and Smetana's The Moldau.) Twelve of the patients had had heart attacks and another 12 had a chronic heart condition. Patients were exposed to two randomly varied &?-minuteperiods of continuous monitoring, one period with music delivered through headphones, the other a control period without music during which the background noise of the unit was heard through the headphones. The heart-attack and chronic-heart-condition patients showed no differences. Eight patients reported a significant change to a happier emotional state after listening to the music (a result replicated in

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Figure 1 Emotional State of 24 Cardiac Patients Before and After Listening to Music Selections (12 patients with heart attacks, 12 with chronic heart conditions)

tranquil

happy satisfied

worried

sentimental romantic

sad depressed

both happy, satisfied and tranquil

other

The shifts in feelings occurred from listening to music over headphones. There were no significant differences between the responses of the patients who had heart attacks and the patients who had chronic heart conditions. No changes in feelings were produced by the control intervention of listening to the background noise of the coronary care unit over headphones.

Updike's observational study [Updike 1990]), although there were no significant changes in specific physiological variables during the music periods. Relevant here is the argument bv Cassem and Hackett (1971) that relieving depression is beneficial to the overall status of coronary care patients. Figure 1 displays the various emotional shifts in the patients that appeared after listening to the music. A study by Guzzetta (1989) sought to determine whether relaxation and music were effective in reducing stress in patients admitted to a coronary care unit with the presumptive diagnosis of acute myocardial infarction. In this experimental study, 80 patients were randomly assigned to a relaxation, music therapy, or control group. The relaxation and music therapy groups participated in three sessions over a two-day period. The relaxation group received a tape-recorded relaxation induction. The music therapy group received the relaxation induction and a 20minute musical tape selected from three alternative musical styles (soothing classical music, soothing popular music, and nontradi-

tional music defined as "compositions having no vocalization or meter, periods of silence, and an asymmetric rhythm"). Stress was evaluated by peak (apical) heart rates, peripheral temperatures (low in cardiac patients), cardiac complications, and qualitative data. T h e data revealed that lower apical heart rates and raised peripheral temperatures occurred more often in the relaxation and music therapy groups than in the control group. The incidence of cardiac complications was also lower in the intervention groups. Finally, most intervention subjects believed that such therapy was helpful. Thus, both relaxation and music therapy were found to be effective modalities of reducing stress in these patients, with the combination of relaxation and music listening more effective than relaxation alone. It should be noted further that apical heart rates were lowered in response to music over a series of sessions, thus supporting the argument that the effect of music therapy on physiological parameters occurs over time, and is therefore adaptive.

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The positive finding of this study is in contrast to the failure of Zimmerman and colleagues (Zimmennan, Pierson & Marker 1988) to find an influence of music on heart rate, peripheral temperature, blood pressure, or anxiety. However, Zimmerrnan's study allowed for only one intervention of music.

reasons for this overall reduction in anxiety may have been that after four days the I situation had become less acute, the setting had become more familiar, and the fact that by then a diagnosis had been confirmed. , In all these studies patients listened to , music (or other sounds), and in thiscontext it is relevant to recall the different possibilities suggested by earlier-noted studies in which Zimmennan examined the effects of people in effect become the music makers. listening to relaxation-type music and focused on self-reported anxiety and on selected phys- , In the study by Bason and Celler (1972), the researchers influenced heart rate by first iologic indices of relaxation in patients with suspected myocardial infarction. Seventy-five , matching the heart rates of their subjects with a musical rhythm. This finding suggests that patients were randomly assigned to one of in studies on the influences of music on heart two experimental groups-one group listened to taped music over headphones, the other to ' rate, the music should match the individual patient. Matching also makes psychological "white noisef'*-or to a control group. The sense, since different people have varied reacSpielberger State Anxiety Inventory (Spieltions to the same music. Further, because berger 1983) was administered before and improvised music necessarily "meets" the after each testing session, and blood pressure, tempo of the patient, it may be that such heart rate, and digital skin temperatures were playing will have a larger impact than does measured at baseline and at 10-minute inter"passive" listening to music. vals for the 30-minute session. The study The finding of Haas and colleagues revealed no significant difference among the three groups in state anxiety scores or phys(19861, that listening coupled with tapping synchronizes respiration pattern with music iologic parameters. Analyses were then conrhythm, additionally suggests that active ducted of the combined experimental groups music playing can be used to influence and showed that significant improvement physiological parameters and that this synoccurred in all of the physiologic parameters. This finding reinforces the benefit of rest and chronization can easily be developed (Aldcareful monitoring of patients in the coronary ridge 1989a). care unit, but adds little to the understanding of music interventions. Bolwerk (1990) set out to relieve the Cancer Therapy, Pain state anxiety of patients in a myocardial inManagement, farction ward using recorded classical music and Hospice Care (Bach's Largo, Beethoven's Largo, Debussy's Prelude to the Afternoon of a Faun). Forty adults Cancer and chronic pain can require comwere randomly assigned to two equal groups, plex coordinated resources that are not only one of which listened to relaxing music medical but also psychological, social, and during the first four days of hospitalization, communal (Aldridge 1988; Coyle 1987; Fagen the other of which received no music. There 1982; Frampton 1986; Frampton 1989; Gilbert was no controlled "silent condition." While , & von Langsdorff 1983; Walter 1977; Heyde there was a significant reduction in state anxi- I 1983). Hospice care in the United States and ety in the treatment group, state anxiety also England has similarly attempted to meet the fell comparably in the control group. The need for the varied palliative and supportive services that provide physical, psychological, "White noise" or "synthetic silence" is an attempt and spiritual care for dying persons and their to block out environmental noise. In this case it was families (Aldridge 1988; Coyle 1987; Frampa tape recording of sea sounds, which themselves ton 1986; Heyde & von Langsdorff 1983; Jacob were rhythmic (Philip 1989; Zimmennan 1989). l

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1986). In all these settings, supportive services In a study of chronic pain, patients are based upon an interdisciplinary team of playing self-selected tape-recorded health care professionals and volunteers. music reported not only a reduction Music therapy is sometimes included in the emotional experience of in such services. In the Supportive Care Program of the suffering but also a reduction in Pain Service to the Neurology Department the actual sensation of pain. of Sloan-Kettering Cancer Center, New York, a music therapist was part of the supportive team along with a psychiatrist, nurse-cliniaan, neuro-oncologist, chaplain, and social actual physical sensation of pain, according to worker (Bailey 1983; Coyle 1987). Music the patients, was also reduced. This would therapy was used to promote relaxation, to reduce anxiety, to supplement other pain appear to confound the common belief that control methods, and to enhance commumusic therapy primarily induces qualitative nication between patient and family (Bailey emotional experiences and to support the 1983,1984,1985). Depression was a common contention that music therapy can have a feature of the patients in the program, and direct influence upon sensory parameters. music therapy was thought to relieve this In addition to reducing pain, particustate and enhance the patient's quality of life. , larly in pain clinics (Godley 1987; Locsin 1981; A better researched phenomenon is Wolfe 19781, music has been offered during the use of music to control chronic cancer chemotherapy as a form of relaxation and pain, in studies that usually favor tapedistraction (Kammrath 1989) to bring overall recorded interventions rather than the element of live performance. Combinations of 1 relief (Kerkvliet 1990) and to reduce nausea and vomiting (Frank 1985). Using taped pharmacological and nonpharmacological music and guided imagery in combination pain management are acceptable in modem with pharmacological antiemetics, Frank medicine (McCaffery 1990), with nonphar(1985) found that state anxiety was signifimacological interventions generally being cantly reduced, resulting in less vomiting used as a form of distraction. even though the experience of nausea re, mained the same. Although Frank's study This is the approach of a study by Zimmerman and colleagues (Zimmerman, was not controlled, leading to the possibility 8 that the reduced anxiety may have been due Pozehl, Duncan & Schmitz 1989) who investo the natural fall in anxiety levels at the end tigated whether playing self-selected taped 1 of a chemotherapy treatment, the study music combined with suggestions of relaxconsisted of patients who had previously ation, affected patients suffering with chronic pain. The study sought to determine from , experienced chemotherapy and who were self-reports whether the music provided 1 conditioned to experience nausea or vomiting additional relief to patients receiving pain 1 in conjunction with chemotherapy. That the subjects of the study felt relief and vomited medication. In both the experimental and the less is an encouraging sign in the use of music control groups, the blood level of analgesic was controlled. Music was found to decrease 1 therapy in minimizing the distressing effects 1 of chemotherapy. the overall level of the pain experience as In the control of pain, time to listen, reported by patients randomly assigned to the l ,l separated from the surrounding influence of music treatment group. Furthermore, there I the hospital unit by the use of headphones, was a significant reduction in the sensory, as may itself be an important intervention. This well as the affective, component of the pain as may be the underlying import of a study by measured by the McGill Pain Questionnaire Rider (1985) who found that perceived pain (Melzack 1975)-that is, not only was sufferl ing as an emotional experience reduced, the 1 was reduced in a hospital situation in reI

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Music appears t o be a key in helping patients w i t h seemingly hopeless neurological devastation regain their "lost" language capabilities.

In infants the ability to reciprocate the communication of another person is an important I element in communicative competence (Murray & Trevarthen 1986; Street & Cappella 19891and is vital in acquiring speech (Glenn & Cunningham 1984). Music therapy strate1 gies for neurologically damaged adults I attempt to utilize the same processes of reciprocation with the expectation that they will stimulate those brain functions that support, precede, and extend functional speech recovery, for these brain functions are essentially musical and rely upon brain plasticity. Combined with the ability to enhance word retrieval, music can be used to improve breath capacity, encourage respiration-phonation patterns, correct articulation errors caused by inappropriate rhythm or speed, and prepare the patient for articulatory movements. In this sense music offers a sense of time which is not chronological, which is not accessible to measurement, and which is vital in the coordination of human communication (Aldridge 1989a; Aldridge 1991~). Jacome (1984) tells of a stroke patient who was dysfluent and had difficulty finding words. Yet, he writes, the patient I

sponse to classical music delivered through headphones. It could be concluded from his work that isolation from environmental sounds, canceling out external noise, has a positive benefit for the patient regardless of inner content, whether the alternative is music, relaxation induction, or silence.

Neurological Problems Neurological diseases often result in physical and/or mental impairment, and in many cases their abrupt appearance are traumatic for the patient and his or her family (Jochims 1990). Music appears to be a key in recovering former capabilities, language capabilities especially, in what at first can seem like hopeless neurological devastation (Aldridge 1991b; Jones 1990; Sacks 1986). For some patients with brain damage following head trauma, the problem may be the temporary loss of speech (aphasia). Music therapy can play a valuable role helping a person regain his or her speech (Lucia 1987). Melodic Intonation Therapy has been developed to fulfil1 such a rehabilitative role (Naeser & Helm-Estabrooks 1985; 0'Boyle & Sanford 1988).This therapy involves embedding short propositional sentences into simple, often repeated, melody patterns to which patients tap their fingers. Changes of inflection, pitch, and rhythm in the melodies are selected to parallel what would be the natural speech prosody of the chosen sentence. The therapy stimulates articulation, fluency, and the shaping procedures of language, all of which are akin to musical phrasing, and this encourages the singing of familiar songs. Singing within a context of communication motivates a patient to communicate and thus promotes, it is hypothesized, the act of intentional verbal behavior.

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frequently whistled instead of attempting to answer with phonemes.. . he spontaneously sang Spanish songs without prompting with excellent pitch, melody, rhythm, lyrics, and emotional intonation. He could tap, hum, whistle, and sing along. . . . Emotional intonation of speech [prosody], spontaneous facial emotional expression, gesturing, and pantomirnia were exaggerated.

From this case study Jacome goes on to recommend that singing and musicality in aphasics be tested by clinicians, which Morgan recommended in a case of aphasia 1 following stroke (Morgan & Tilluckdharry 1982) Evidence of the possible global strategy of music processing in the brain-the possibility that both brain hemispheres are involved in this processing-is found in the clinical literature. For example, in reporting i I on two cases of aphasia, Morgan and ~ i l l u c k i dharry (1982) describe spontaneous singing by the patients as a welcome release from the 1 helplessness of being a patient. The authors l

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hypothesized that singing was a means to communicate thoughts externally which could not be articulated vocally in speech. Although the "newer aspect" of speech was lost in the damage of the dominant hemisphere for language, the older function of music was retained, possibly because music is a function distributed over both hemispheres. Berman (1981) suggests that recovery from aphasia is not a matter of new learning by the nondominant hemisphere but a taking over of responsibility for language by that hemisphere. The nondominant hemisphere may be a "reserve" of functions available in case of regional failure, indicating an overall brain plasticity (Naeser & Helm-Estabrooks 1985).Similarly, language functions may shift across hemispheres with multilinguals as compared with monolinguals (Karanth & Rangamani 1988), or as a result of learning and cultural exposure where music and language share common properties (Tsunoda 1983). That singing is an activity correlated with certain creative productive aspects of language may be an important point in this context. An example is the case of a 2-year-old boy of above-average intelligence who experienced seizures, manifested by tic-like turning movements of the head (Herskowitz, Rosman & Geschwind 1984). He induced seizures, consistently, by his own singing but not by listening to or imagining music, and also induced them by his recitation and by his use of silly or witty language such as punning. (Seizure activity as registered on an electroencephalogram correlated with clinical attacks and was present in both temporocentral regions, especially on the right side.) Aphasia is also found in elderly stroke patients, and music therapy, as reported in case studies, has been used effectively in combination with speech therapy to restore speech (Lehmann & Kirchner 1986). Gustorff and colleagues (Aldridge, Gustorff & Hannich 1990) describe the application of creative music therapy to coma patients who were otherwise unresponsive. By matching her singing with the breathing patterns of the patient, Gustorff stimulated

The responsiveness t o music of patients w i t h Alzheimer's disease is a remarkable phenomenon.

changes in consciousness which are both measurable on a coma rating scale and apparent to the eye of the clinician.

Problems of the Elderly The psychosocial rehabilitation of older persons is one of the main problems in health policy (Haag 1985).About onequarter of the over 65-year-olds face psychic problems, and are without adequate treatment and rehabilitative care. The development of ambulatory, community-based services as well as intensive support for existing self-help efforts are clearly necessary. Music therapy has been suggested as a valuable part of a combined treatment for the elderly (Dcllmann-Jenkins, Papalia Finlay & Hennon 1984; Fenton & McRae 1989; Gilchrist & Calucy 1983; Gross & Swartz 1982; Lehmann & Kirchner 1986; Morris 1986; Prinsley 1986; Rcnner 1986).

Music and Dementia in the Elderly At the age of 56 Maurice Ravel, the composer, began to complain of increased fatigue and lassitude. His condition deteriorated progressively (Henson 1988);and he lost the ability to remember names, to speak spontaneously, and to write. While his mind, he reports, was full of musical ideas, he could not set them down (Dalessio 1984). Eventually his intellectual functions and speech deteriorated until he could no longer recognize his music. In other words, he showed many of the features now associated with the condition known as Alzheimer's disease. The responsiveness of patients with Alzheimer's disease to music is a remarkable phenomenon (Swartz et al. 1989). Despite the language deterioration of such patients musical abilities appear to be preserved. Beatty and colleagues describe a woman who had severe aphasia, memory dysfunction, and

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apraxia (an inability to perform intentional movements), yet was able to read an unfamiliar song and perform on the xylophone, which to her was an unconventional instrument (Beatty et al. 1988). In a case study Aldridge and Brandt (1991a) suggest that music therapy is an important diagnostic tool in recognizing cognitive and motor impairment in the elderly, and a useful therapeutic adjunct in patient care. Even though the patient they describe may have been suffering from a pseudodementia, the discussion further articulates the value of using music therapy for the treatment of the elderly, demented or depressed. Table 2, which draws on this discussion, compares the medical assessment of Alzheimer's disease with an assessment based on music therapy. Certainly the anecdotal evidence suggests that the quality of life of Alzheimer's patients is significantly improved with music therapy (Tyson 19891, accompanied by the overall social benefits of acceptance and sense of belonging gained by communicating with others (Morris 1986). Prinsley (1986) recommends music therapy for geriatric care, maintaining that it reduces the use of tranquilizing medication and reduces the use of hypnotics on the hospital ward and helps overall rehabilitation. He recommends that music therapy aim at specific treatment objectives: the social goals of interaction and cooperation; the psychological goals of mood improvement and self-expression; the intellectual goals of the stimulation of speech and organization of mental processes; and the physical goals of sensory stimulation and motor integration. Such approaches also emphasize the benefit of music programs for the professional carers (Kartman 1984)and the families (Tyson 1989) of elderly patients.

Assorted Findings and Possibilities A full examination of the possible use of music therapy would cover a variety of only partially explored areas. The following seem to be the most important:

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Breathing Training Fried (1990) presents a general overview of the use of music in breathing training and relaxation. Breathing training in itself is believed to have a physical benefit for anxious patients by enabling them to increase tidal volume-the amount of air moved in a single breath-without excessive loss of carbon dioxide (hypocapnia). Typically, anxious patients have relatively rapid shallow chest breathing and may hyperventilate. Music and breathing have been used to induce alternate states of consciousness, and Fried's paper correlates the characteristics of consciousness and the role of music in altering those states, reinforcing the findings of McLellan (19881, who identifies the qualities of music which can be used to invoke calm and inner peace. Nursing approaches have also utilized the anxiety-relieving effect of music in combination with massage and breathing exercises to relax patients, and to facilitate postoperative recovery (Keegan 1989).

Anesthesia The ability of music to induce calm and wellbeing has also been used in general anesthesia (Keegan 1989; McCluskey 1983). Patients express their pleasure at awakening to music in the operating suite, the music having been played "openly" before the beginning of the operation, and then through earphones during the operation (Bonny & McCarron 1984). In certain instances, it appears that surgical patients are aware of the music being played during an operation. In a study by Lehmann and colleagues (Lehmann, Homchs & Hoeckle 19851, patients undergoing elective orthopaedic or lower abdominal surgery were given either a placebo infusion (.9 percent sodium chloride) or the analgesic tramadol in a randomized and double-blind manner, to evaluate the efficacy of tramadol as one component of balanced anesthesia. Postoperative analgesic requirement and awareness of intraoperative events-tape-recorded music offered via earphones-were further used to

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Table 2 Comparison of Medical and Musical Assessments of Alzheirner's Disease Medical Elements of Assessment

Musical Elements of Assessment

continuing observation of mental and functional status

testing of verbal skills, including speech fluency

testing of musical skills, including rhythm, melody, harmony, dynamic, phrasing, articulation

cortical disorder testing: visuo-spatial skills and ability to perform complex motor tasks (including grip and right/left coordination)

testing for progressive memory disintegration

motivation to complete tests, to achieve set goals and persevere in set tasks

motivation to sustain playing improvised music, to achieve musical goals and persevere in maintaining musical form

"intention" difficult to assess; but considered important

"intention" a feature of improvised musical playing

concentration and attention span

concentration on improvised playing and attention to the instruments

flexibility in task switching

flexibility in musical (including instrumental) changes

mini-mental state score influenced by educational status

ability to play improvised music influenced by previous musical training

insensitive to small changes

sensitive to small changes

ability to interpret surroundings

ability to interpret musical context and assessment of communication in the therapeutic relationship

assess the effects of tramadol. Although anesthesia proved to be quite comparable in both groups, striking differences occurred with respect to intraoperative awareness: while patients receiving placebo proved to be amnesic, 65 percent of tramadol patients were aware of intraoperative music. The ability to hear music during an operation is also reported by Bonny (Bonny & McCarron 1984).

Musical Hallucinations l

1 1

Hallucinations may occur in any of our senses, and auditory hallucinations take various forms-as voices, cries, noises, and, rarely, music. However, the appearance of musical hallucinations, often in elderly patients, has generated interest in the medical literature (Aizenberg, Schwartz & Modai 1986; Berries 1990; Fenton & McRae 1989;

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How music therapy can be i n c o v o rated into medical practice requires extensive research studies. Unfortunately, music therapists and their medical colleagues have created something of an impasse whereby each side demands a style of research unacceptable t o the other.

of-the-ordinary experiences of women are more often labeled pathologically.) Age, deafness, and brain disease affecting the nondominant hemisphere played an important role in the development of hallucinations; on the other hand, psychiatric illness and personality factors were found to be unimportant. For these patients, the application of music therapy to raise the ambient noise level, to organize aural sensory input by giving it a musical sense and thereby countering sensory deprivation, and to stimulate and motivate the patient seems a reasonable approach.

Gilchrist & Kalucy 1983; Hammere, McQuillen & Cohen 1983; McLoughlin 1990; Patel, Keshavan & Martin 1987; Wengel, Burke & Holemon 1989). When such hallucinations do occur they are described as highly organized vocal or instrumental music. In contrast, the ringing or other noises in the ears known as tinnitus is characterized by unformed sounds which sometimes may possess musical qualities (Wengel, Burke & Holemon 1989).

Immune Effects

T o some, case histories of patients with musical hallucinations suggest an underlying psychiatric disorder (Aizenberg, Schwartz & Modai 1986; Wengel, Burke & Holemon 1989). The hallucinations may be exacerbated by dementia occurring with brain deterioration (Gilchrist & Kalucy 1983). Fenton and McRae (1989) maintain that patients with musical hallucinations and hearing loss become anxious and depressed. Fenton challenges the association of musical hallucination with psychosis and previous mental illness. His explanation points to the degeneration of the aural end-organ whereby sensory input, which ordinarily suppresses much nonessential information, fails to inhibit information from other perception-bearing circuits. Other investigators argue for a central brain dysfunction as evidenced by measures of brain function (Gilchrist & Kalucy 1983). In a study of 46 subjects with musical hallucinations (Berrios 19901, the hallucinations were far more common in females. (The attribution of hallucinations to women in particular should be regarded with a degree of caution. As compared to men, out-

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Work referring to the influence of music therapy on immunological parameters is slim. Lee (19911, who has written of the necessity for working with HIV and AIDS patients, emphasizes the value of music therapy. However, Lee fails to be clear about clinical objectives. There remains the possibility that immunological parameters may be influenced by creatively improvising music. Research on this possibility should aim at linking musical analyses with clinical information about immune reactions such that therapeutic correlations could be attempted (Aldridge 1991b&c; Aldridge & Brandt 1991b; Aldridge, Brandt & Wohler 1989) and the results could be related to the current initiatives being made in psychoneuroimmunology.

Conclusion Music has the power to stimulate and to calm, to soothe and to inspire. Playing music undoubtedly benefits people. The elderly are stimulated, the depressed are encouraged, and the tired are invigorated. How music therapy can be incorporated into medical practice requires extensive research studies. Unfortunately, music therapists and their medical colleagues have created something of an impasse whereby each side demands a style of research unacceptable to the other. We can hope that in our general search for methods suitable for researching the human condition (Aldridge 1991a1, we can find ways

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Table 3 Comparison of Medical and Musical Assessments of Bowel Disease Medical Elements of Assessment

Musical Elements of Assessment

separation of self and "nonself"

not tuned to oneself, uncoordinated

lack of gut motility

lack of rhythmic flexibility, unresponsive to tempo changes, lack of rhythmical phrasing

increasingly introverted

quiet playing with no personal contact within the playing

restricted in relationships

difficult to contact in the musical relationship

rigid

repetitive playing, returning to the same tempo and rhythmic pattern, unresponsive to tempo changes

difficulty expressing feelings

intolerant of particular harmonies

appears to be coping well with life in the face of internal turmoil

appears to be going along with the music but an underlying chaotic structure

dependent

no initiatives within the music; dependent upon the therapist

intractable to change

difficult to treat, requiring many sessions

of working together in the future that will generate some flexibility in clinical research. As we have seen, some recent approaches have shown that the two vocabularies of medicine and music have areas of commonality (Aldridge 1989a, 1991b&c; Aldridge & Brandt 1991a&b; Aldridge, Brandt & Wohler 1989). One example of such commonality was illustrated earlier in Table 2, which compares the medical and musical assessments of Alzheimer's disease. Table 3, which compares the medical and musical assessments of bowel disease, provides another example. Gregory Bateson (1972) has reminded us of the need for the arts to accompany the science of modem medicine: The point which I am trying to make in this paper is not an attack on medical science but a demonstration of an inevitable fact: that merely purposive rationality unaided by such phenomena

as art, religion, dream and the like, is necessarily pathogenic and destructive of life; and that its virulence springs specifically from the circumstances that life depends upon interlocking circuits of contingency, while consciousness can only sec such short arcs of such circuits as human purpose may direct. What we may have to consider is that the human being is composed not as a machine but rather as a piece of music which is improvised in the moment (Aldridge 1989b). From such a perspective we may search for common themes among groups of individuals and identify particular repertoires of healthy activities, but each person will have his or her own song. For those of us who are doctors, our task is to encourage our patients in the articulation of their individual singing. Perhaps in the future we will be encouraged to 1 understand how each one of us as a person l 1 can become our own work of art. I

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REFERENCES: Aizenberg, D., B. Schwartz & T. Modai. 1986. 'Musical Hallucinations, Acquired Deafness, and Depression." Journal of Nervous and Mental Disorders. 174:309-11.

Beatty, W., K. Zavadil, R. Bailly & et al. 1988. "Preserved Musical Skills in a Severely Demented Patient." International Journal of Clinical Neuropsychology. 10:158-164.

Aldridge, D. 1988. "Families, Cancer and Dying.'' ]ournal of the Institute of Religion and Medicine. 3:312-322.

Berman, 1.1981. "Musical Functioning, Speech Lateralization and the Amusias." South African Medical Journal. 59:78-81.

Aldridge, D. 1989a. "Music, Communication and Medicine: Discussion Paper." Journal of the Royal Society of Medicine. 82:743-746.

Berrios, G. 1990. "Musical Hallucinations. A Historical and Clinical Study." British Journal of Psychiatry. 156:188-194.

Aldridge, D. 1989b. "A Phenomenological Comparison of the Organization of Music and the Self." The Arts in Psychotherapy. 16:91-97.

Bolwerk, C. 1990. "Effects of Relaxing Music on State Therapy in Myocardial Infarction Patients." Critical Care Nurse Quarterly. 13:63-72.

Aldridge, D. 1989c. "Research Strategies in a Hospital Setting." Complementary Medical Research. 3:20-24.

Bonny, H. 1978. GlM Monograph U2. The Role of Taped Music Programs in the GIM Process. Baltimore: ICM Press.

Aldridge, D. 1991a. "Anesthetics and the Individual in the Practice of Medical Research: A Discussion Paper." Journal of the Royal Society of Medicine. 84:147-150. Aldridge, D. 1991b. "Creativity and Consciousness: Music Therapy in Intensive Care." The Arts in Psychotherapy. 18:359-362. Ald ridge, D. 1991c. "Physiological Change, Communication, and the Playing of Improvised Music: Some Proposals for Research." The Arts in Psychotherapy. 18:59-64. Aldridge, D. & G. Brandt. 1991a. "Music Therapy and Alzheimefs Disease." Journal of Bntish Music Therapy. 5(2):28-63. Aldridge, D. & G . Brandt. 1991b. "Music Therapy and Inflammatory Bowel Disease." The Arts in Psychotherapy. 18:113-121. Aldridge, D., G. Brandt & D. Wohler. 1989. 'Towards a Common Language Among the Creative Art Therapies." The Arts in Psychotherapy. 17:189-195. Aldridge, D., D. Gustorff & H. Hannich. 1990. 'Where Am I? Music Therapy Applied to Coma Patients [editorial]." Journal of the Royal Society of Medicine. 83:345-346. Aldridge, D. & R. Verney. 1988. "Research in a Hospital Setting." Holistic Health. 18:9-10. Bailey, L. 1984. "The Use of Songs with Cancer Patients and Their Families." Music Therapy. 415-7. Bailey, L. 1985. "Music's Soothing Charms." American Journal of Nursing. 85:1280. Bailey, L.M. 1983. 'The Effects of Live Music Versus Tape-Recorded Music on Hospitalised Cancer Patients." Music Therapy. 3:17-28. Bason, B. & B. Celler. 1972. "Control of the Heart Rate by External Stimuli." Nature. 4:279-280. Bateson, G. 1972. Steps to an Ecology of Mind. New York: Ballantine.

Bonny, H. 1983. "Music Listening for Intensive Coronary Care Units: A Pilot Project." Music Therapy. 3:4-16. Bonny, H. & N. McCarron. 1984. "Music as an Adjunct to Anesthesia in Operative Procedures." Journal of the American Association of Nurse Anesthetists. Feb:55-57. Bonny, H. 1975. "Music and Consciousness." Journal of Music Therapy. 12:121-135. Brody, R. 1988. "Which Music Helps Your Muscles." American Health. 7:80-84. Carlisle, D. 1990. "Art and Health. A Creative Approach to Patient Care. The Soothing Arts." Nursing Times. 86:27-30. Cassem, N. & T. Hackett. 1971. "Psychiatric Consultation in a Coronary Care Unit." Annals of Internal Medicine. 75:9. Chetta, H. 1981. 'The Effect of Music and Desensitization on Preoperative Anxiety in Children." Journal of Music Therapy. 18:74-87. Cook, J. 1986. "Music as an Intervention in the Oncology Setting." Cancer Nursing. 9:23-28. Cook, J.D. 1981. 'The Therapeutic Use of Music." Nursing Forum. 20:252-266. Coyle, N. 1987. "A Model of Continuity of Care for Cancer Patients with Chronic Pain." Medical Clinics of North America. 71:259-270. Dalessio, D. 1984. "Maurice Favel and Alzheimefs Disease. The Journal of the American Medical Association. 252:3412-3413. Daub, D. & R. Kirschner-Hermanns. 1988. "Reduction of Preoperative Anxiety. A Study Comparing Music, Thalomonal and No Premedication." Anaestetist. 37:594-597. Davis-Rollans, C. & S. Cunningham. 1987. "Physiologic Responses of Coronary Care Patients to Selected Music." Heart-Lung. 16:370-378.

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Dellmann-Jenkins,M. D.Papalia Finlay, & C. Hennon. 1984. "Continuing Education in Later Adulthood: Implications for Program Development for Elderly Guest Students." InternationalJournal of Aging &Human Development. 20:93-102. Diserens, C.M. 1920. "Reaction to Musical Stimuli." Psychological Bulletin. 20:173-199. Dossey, L 1982.Space, Time and Medicine. Boulder, CO: Shambala. Fagen, T.S. 1982."Music Therapy in the Treatment of Anxiety and Fear in Terminal Pediatric Patients." Music Therepy. 213-23. Fenton. G. & D.McRae. 1989."Musical Hallucinations in a Deaf Elderly Woman." British Journal of Psychiaty. 155:401-403. F i h e r , M. 1990."Music as Therapy." Nursing Times. 66:3W 1. Fletcher, V. 1986.'The Mobile Accident Team: When the Music Stopped." Nursing Times. 8230-32. Fonnby, C, R Thomas, W.J. Brown & J.J. Halsey. 1987. T h e Effectsof Continuous Phonation of 133xenonInhalation Air Curves (Of the Kind Used in Deriving Regional Cerebral Blood Flow)." Brain and Language. 31:346-363. Frarnpton, D.1986. "Restoring Creativity to the Dying Patient." British Medical Journal of Clinical Research. 293:1593-1595. Frarnpton, D. 1989."Arts Activities in United Kingdom Hospices. A Report." Journal of Palliative Care. 5:25-32. Frandscn, J. 1989. "Nursing Approaches in Local Anwthcsia for Ophthalmic Surgery." Jovrnal of Ophthalmic Nursing & Technology. 8:135-138. Frank. J. 1985."The Effects of Music Therapy and Guided Visual Imagery on Chemotherapy Induced Nausea and Vomiting." Oncology Nursing Forum. 12:4752. Fried. R. 1990."Integrating Music in Breathing Training and Relaxation: I. Background, Rationale, and Relevant Elements." Biofredback-Self-Regulator. 15:161-169.

Medical Patients to Music Therapy." Music Therapy. 1:51-56. Grimm, D. & P. Pefley. 1990."Opening Doors for the Child Inside'." Journal of Pediatric Nursing. 16:368-369. Gross, J.L. & R. Swartz. 1982."The Effects of Music Therapy on Anxiety in Chronically 111 Patients." Music Therapy. 243-52. Guzzetta, C. 1989."Effects of Relaxation and Music Therapy on Patients in a Coronary Care Unit with Presumptive Acute Myocardial Infarction." Heart Lung. 18:609-616. Haag, G. 1985. "Psychosocial Rehabilitation in Advanced Age." Rehabilitation-Stuttg. 24:6-8. Haas, F., S. Distenfeld & K. h e n . 1986."Effects of Perceived Musical Rhythm on Respiratory Pattern." Journal of Applied Physiology. 61:1185-91. Hammeke, T., M. McQuillen & B. Cohen. 1983. 'Musical Hallucinations Associated with Acquired Deafness." Journal of Neurology, Neurosurgery, and Psychiatry. 46:570-572. Harcourt,L. 1988."Music for Health." h1wZealand Nursing Journal.81:24-26. Harvey, A. & L. Rapp. 1968."Music Soothes the Troubled Soul." AD-Nurse. 3:19-22. Helman, C. 1987."Heart Disease and the Cultural Construction of Time: The Type A Behaviour Pattern as a Western Culture-Bound Syndrome." Social Science and Medicine. 25:969-979. Henson, R. 1988. "Maurice Ravel's Illness: A Tragedy of Lost Creativity." British Medical Journal of Clinical Research. 296:1585-1588. Herskowitz, J,, N. Rosman & N., Geschwind. 1984. "Seizures Induced by Singing and Recitation. A Unique Form of Reflex Epilepsy in Childhood." Archives of Neurology. 41:1102-1103. Heyde, W. & P. von Langsdorff. 1983."Rehabilitation of Cancer Patients Including Creative Therapies." Rehabilitation Stuttg. 22:25-27.

Gilbert, J. 1977."Music Therapy Perspectives on Death and Dying." Journal of Music Therapy. 14:165-171.

Jacob, S. 1986. "Soothing the Ragged Edge of Pain. Bring on the Music." American Journal of Nursing. 86:1034.

Cilchr~st,P. & R. Kalucy. 1983."Musical Hallucinations in the Elderly: A Variation on the Theme." Australian and New Zealand Journal of Psychiatry. 17:286-287.

Jacome, D. 1984."Aphasia with Elation, Hypermusia, Musiophilia and Compulsive Whistling." Journal of Neurology, Neurosurgery and Psychiatry. 47308-310.

Glenn, S. & C. Cunningham. 1984."Nursery Rhymes and Early Language Acquisition by Mentally Handicapped Children." Exceptional Child. 51:72-74.

Jochims, S. 1990."Coping with Illness in the Early Phase of Severe Neurologic Diseases. A Contribution of Music Therapy to Psychological Management in Selected Neurologic Disease Pictures." Psychotherapy and Psychosomatic Medical Psychology. 40:115-122.

Glynn, N. 1986.'The Therapy of Music." Journal of Ccrontolo{;ical Nursing. 125-10. GodIvy, C. 1987.'The Use of Music Therapy in Pain Clinics." Music Therapy Perspectives. 4:24-27.

Johnson, C. & J. Woodland-Hastings. 1986. 'The Elusive Mechanism of the Circadian Clock." American Scientist. 74:29-36.

Goloff, M. 1981. 'The Responses of Hospitalised ADVANCES, The Journal of Mind-Body Health Vol. 9,No. 1 Winter 1993

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Collected neurology papers

ALDRIDGE Jones, C. 1990. "Spark of Life." Geriatric Nursing of New York. 1 I:l94-196. Kamrnrath, L. 1989."Music Therapy during Chemotherapy. Report on the Beginning of a study." Krakenpflege-Frankfurt. 43:282-283. Karanth, P. & G. Rangamani. 1988."Crossed Aphasia in Multilinguals." Brain-Long. 341 69-180. Kartman, L. 1984. "Music Hath Charms." journal of Gerontological Nursing. 10:20-24. Keegan, L. 1989."Holistic Nursing." Journal of Post Anesthesia Nursing. 4:17-21. Kerkvliet, G. 1990."Music Therapy May Help Control Cancer Pain." Journal of the National Cancer Institute. 82:350-352. Keshavan, M., E. Kahn & j. Brar. 1988."Musical Hallucinations Following Removal of a Right Frontal Meningiorna." Journal of Neurology, Neurosurgery and Psychiat y. 51:1235-1236.

Journal of Nursing Studies. 221-5. McCluskey, F. 1983."Music in the Operating Suite." National Association of Theatre Nurses. 20:33-40. McDermit, R. 1984."Music Therapy: Let's Tune In." Dimensions in Health Service. 61:33-34. McLellan, R. 1988.The Healing Forces of Music. New York: Amity House. McLoughlin, 1. 1990."Musical Hallucinations." British Journal of Psychiatry. 156:452. Melzack, R. 1975. "The McGill Pain Questionnaire: Major Properties and Scoring Methods." Pain. 1:227299. Morgan, 0. & R. Tilluckdharry. 1982. "Presentation of Singing Function in Severe Aphasia." West Indian Medical Journal. 31:159-161. Morris, K. 1985. "Music Therapy." Nursing Times. 81:18. Morris, M. 1986."Music and Movement for the Elderly." Nursing Times. 824-45.

Kolkmeier, L. 1989."Clinical Application of Relaxation, Imagery, and Music in Contemporary Nursing." J-AdvMed-Surg-Nun. 1 :73-80.

Moss, V. 1987. 'The Effect of Music on Anxiety in the Surgical Patient." Perioper-Nurs-Q. 3:9-16.

Lee, C. 1991."Foreword: Endings." Journal of British Music Therapy. 5:3-4.

Mullooly, V., R. Levin & H. Feldman. 1988. "Music for Postoperative Pain and Anxiety." Journal of New York State Nurses Association. 19:4-7.

Lehmann, K., G. Homchs & W. Hoecklc. 1 9 s . "The Significance of Tramadol as an lntraoperative Analygesic. A Randomized Double-Blind Study in Comparison with Placebo." Anaesthesist. 34:ll-19. Lehmann, W. & D. Kirchner. 1986."Initial Experiences in the Combined Treatment of Aphasia Patients Following Cerebrovascular Insult by Spcvch Therapists and Music Therapists." ZeitschnftAltmfcrsthung. 41:123128. Lehnen, R. 1988. "Does Music dunng Dental Treatment Have an Influence on Heart and Circulation Parameters?" Zahnar-tl-Prax. 39:297-300.

Murray, L. & C. Trevarthen. 1986.'The Infant's Role in Mother-Infant Communications." Journal of Child Language. 13:15-29. Naeser, M. & N. Helm-Estabrooks. 1985."CT Scan Lesion Localization and Response to Melodic Intonation Therapy with Nonfluent Aphasia Cases." Cortex. 21:203-223. O'Boyle, M. & M. Sanford. 1988."Hemispheric Asymmetry in the Matching of Melodies to Rhythm Sequences Tapped in the Right and Left Palms." Cortex. 24:211-221. Olivier, L. 1986."Education in Music Therapy." Soins-Psychiatr. 6637-38.

Lengdobler, H. & W.Kiessling. 1989."Group Music Therapy in Multiple Sclerosis: Initial Report of Experience." Psychotherapy & Psychosomatic Medical Psychology. 39:369-373.

Ornstein, R. & D. Sobel. 1989."Coming to Our Senses." Advances. 6:49-56.

Leonidas, 1.1981."Healing Power of Chants." New York State journal of Medicine. 81:966-968.

Parent-Bender, D. 1986."La Therapie Par La Musique." Canadian Nurse. 82:26-28.

Locsin, R. 1981."The Effect of Music on the Pain of Selected Post-Operative Patients." journal of Advanced Nursing. 6:19-25. Lucia, C.M. 1987.'Toward Developing a Model of Music Therapy Intervention in the Rehabilitation of Head Trauma Patients." Music Therapy Perspectives. 4:34-39. Marchette, L., R. Main & E. Rcdick. 1989."Pain Reduction during Neona tal Circumcision." Pediatn'c Nursing. 15:207-208,210. McCaffery, M. 1990."Nursing Approaches to Nonpharmacological Pain Control." International

David Aldridge

Patel, I.I., M. Keshavan & S. Martin. 1987. "A Case of Charles Bonnet Syndrome with Musical Hallucinations." Canadian Journal of Psychiatry. 32:303-304. Philip, Y. 1989."Effects of Music on Patient Anxiety in Coronary Care Units [Letter]." Heart-Lung. 18:322. Pouget, R. 1986. 'What Is Music Therapy?" SoinsPsychiatr. 66:s-8. Prinsley, D. 1986."Music Therapy in Geriatric Care." Australian Nurses Journal. 15:48-49. Rabinow, P. 1986.The Foucault Reader. London: Penguin.

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Collected neurology papers

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Renner, M. 1986. "Means for the Activation of the Elderly. Music for Fun." Krankenpf-Soins-Infirm. 79:85-86. Rice, T. 1989. "Music in Hospitals: 'It Seemed Like Heaven'." Nursing Standard. 4:18-19. Richter, R. & M. Kayser. 1991. "Rhythmic Abilities in Patients with Functional Cardiac Arrythmias." 7th Meeting of the European Society for Chronobiology. Marburg May 30-June 2. Rider, M.S. 1985. "Entertainment Mechanisms Are Involved in Pain Reduction, Muscle Relaxation, and Music-Mediated Imagery." Journal of Music Therapy. 22:183-192. Rowden, R. 1984. "Music Pulled Them Through." Nurs-Mirror. 159:32-34. Sacks, 0.1986. The Man Who Mistook His Wifefor a Hat. London: Pan. Safranek, M., G. Koshland, & G. Raymond. 1982. "Effect of Auditory Rhythm on Muscle Activity." Physical Therapy. 62:161-168. Sarnrnons, L. 1984. "The Use of Music by Women during Childbirth." Journal of Nurse Midwifery. 29:266-270. Schmuttermayer, R. 1983. "Possibilities for Inclusion of Group Music Therapeutic Methods in the Treatment of Psychotic Patients." Psychiatr-Neurol-Med-Psychol-Leip:. 35:49-53. Schullian, D. & M. Schoen. 1948. Music and Medicine. New York: Henry Schuman. Spielberger, C. 1983.Manual for State Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press, Inc. Standley, ).M. 1986. "Music Research in Medical/ Dental Treatment: Meta Analysis and Clinical Applications." journal of Music Therapy. 23:56-122. Stem, R. 1989. "Many Ways to Grow: Creative Art Therapies." Pediatric Annals. 18:645, 649-52. Street, R.J. & J. Cappella. 1989. "Social and Linguistic Factors Influencing Adaptation in Children's Speech." Journalof Psycholinguist Research. 18:497-519.

Swartz, K., E. Hantz, G. Crummer, J. Walton & R. Frisina. 1989. "Does the Melody Linger On? Music Cognition in Alzheimer's Disease." Seminars in Neurology. 9:152-158. Thornas, E. 1986. "Music Therapy." South African Medical Journal. 70:717-718. Tiep, B., M. Bums, D. Kao, R. Madison & J. Herrera. 1986. "Pursed Lips Breathing Training Using Ear Oximetry." Chest. 90:218-221. Tsunoda, T. 1983. "The Difference in the Cerebral Processing Mechanism for Musical Sounds Between Japanese and Non-Japanese and Its Relation to Mother Tongue." In Musik in der Medizin. Edited by R Spintge and R. Droh. Berlin: Springer Verlag. Tyson, J. 1989. "Meeting the Needs of Dementia." Nurs Elder. 1:18-19. Updike, P. 1990. "Music Therapy Results for ICU Patients." Dimension in Critical Care Nursing. 9:39-45. Vincent, S. & J. Thornpson. 1929. "The Effects of Music on theHuman Blood Pressure." The Lancet. 1:534-537. Walter, B. 1983. "A Little Music Why the Dying Aren't Allowed to Die." Nursing Life. 3:52-57. Wein, B. 1987. "Body and Soul Music." American Health. 6:66-75. Wengel, S., W. Burke & D. Holemon. 1989. 'Musical Hallucinations. The Sounds of Silence?" Journal of the American Geriatric Society. 37:163-166. Wolfe, D. 1978. "Pain Rehabilitation and Music Therapy." Journal of Music Therapy. 15:162-178. Zirnmerman, L. M. Pierson & J. Marker. 1988. "Effects of Music on Patient Anxiety in Coronary Care Units.'' Heart-Lung. 17:560-566. Zimmerman, L., B. Pozehl, K. Duncan & R Schmitz. 1989. "Effects of Music in Patients Who Had Chronic Cancer Pain." Western Journal of Nursing Resfirch. 11:298-309. Ziporyn, R. 1984. "Music Therapy Accompanies Medical Care." The Journal of the American Medical Association. 252:986-987.

ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993

David Aldridge

Collected neurology papers

Music Therapy and Intensive Care Keywords: MUSIC, COMA, INTENSIVE CARE

Patients in intensive care often suffer through insufficient communication, inadequate sleep, sensory deprivation"2 and lack of empathy between patient and medical staff. Many activities in intensive care appear to be simply between unit staff and objects, and to a certain extent patients become a part of this object world. We propose that improvised music therapy can prove valuable in this context both for the patient a i d the staff. At the suggestion of a hospital neurologist a music therapist began working with patients in intensive care. Five patients, between the ages of 15 and 40 years, and with severe coma (a Glasgow Coma Scale score between 4 and 7*) were treated. All had been involved in some sort of trauma and had sustained brain damage, and four had undergone neurosur@ry. Music therapy is based on the principle that we are organized as human beings not in a mechanical, chronobiological way but in a musical fashion i.e. a harmonic complex of interacting rhythms and melodic contour^."^"' To maintain our coherence as beings it seems we must creatively maintain our identity. Music therapy is the medium by which coherent organization is regained, linking brain, body and mind. In this perspective the self is more than simply a corporeal being. Each music therapy contact lasts between eight and twelve minutes. The therapist~mprovisesher wordless singing based upon the tempo of the patient's pulse, and more importantly, the patient's breathing pattern, pitching her singing to a tuning fork. The character of the patient's breathing determines the nature of the singing which is clearly phrased so that when any reaction is seen the phrase can be repeated. Before the first session the music therapist meets the family to gain some idea of what the patient is like as a person. O n meeting the comatose patient she introduces herself and tells him she will sing in the tempo of his or her pulse and rhythm of breathing. The Unit staff are asked to be quiet during this period and to avoid invasive procedures for ten minutes after the contact. There is a range of reactions including a change in breathing (it becomes slower and deeper), fine motor "Normal score 15, worst score 3

movements, grasping movements of the hand, turning of the head and eye opcning. When the therapist first begins to sing heart rate slows. Then it rises rapidly and sustains an elevated level until the end of the contact. This may indicate an attempt at orientation and cognitive processing.6" The EEG shows a desynchronization from theta rhythm, to alpha rhythm or beta rhythm in former synchronized areas. This effect, indicating arousal and perceptual activity, fades out after the music therapy stops. Neurones linked to cardiac rhythm have been identified in the medulla and there is a synchronous relationship betwccn the contraction of the heart and the 'ascending' wave of the EEG alpha rhythm.' It is possible that the rhythmic co-ordination of the cardiovascular system with cortical rhythmic firing is of primary importance for cognition. Furthermore, sleep disturbance is a major problem in intensive care units and the effect of a disturbed waking1 sleeping rhythm upon other metabolic cycles may be critical. The rhythmic entrainment of cardiovascular and somatic activities may be a key clement in recovery. This means that we must consider activity of the the total 'behavio~ral'~ patient including rhythmical integration of independent systems with major tidal rhythms of the body. A patient's response to quiet singing highlights a difficulty of noisy, busy, often brightly lit units where communication is hindered by continuous background noise. Shouted commands to an unconscious patient include formal injunctions, i.e. "Show me your tongue", "Tell me your name", "Open your eyes". There may be few attempts made at normal h u m a n communication where the patient cannot speak or where there is restricted physiological access. It is as if he were isolated in a landscape of noise, and deprived of human contact. One benefit of music therapy is t o of the remind the staff of the imnortance ' quality and intensity of human contact. Whilst life support and monitoring devices are essential they encourage a mechanistic approach which sees the patient simply as a biological complex. A period of calm may also benefit the patient. What some staff may fail to recognize is that communication depends on rhythm, not simply upon volu m e . Such unconscious patients, struggling to orient themselves in time and space, are further confused by an environment of continuing loud, disorientating random noise and bright light. For these patients the basic rhythmic context of their own breathing may provide the required focus for orientation.

This raises the problem of intention in human behaviour even when consciousness appears to be absent. It is also vital that staff do not confuse "not responding" with "not receiving". We can further speculate that the various body rhythms become disassociated in comatose states and following major surgery. The question remains then of how rhythms can be integrated and where is the seat of such integration. It is very likely that it is a property of the whole organism. The environment of the patient includes the vital component of human contact and there is reason to believe that the essential basis of this contact too is rhythmiImprovised singing appears to offer a number of possible benefits for intensive care both in terms of human contact and promoting perceptual responses. Better responses to singing, rather than speaking, suggests that the fundamentals of human communication are musical in form. In this way we have the art of m e d i c i n e w i t h i n t h e science of medicine.

1. Wilson L. Intrnsivr ciiri* ik-lirium. A r h w tifhitfrwl h<rilic h r 1972; 130: 225-h. 2. Ulrich R. View 111rtiui;h<i wiiulunv in.iy i n f l ~ n ~ i irfoivery i~t~ from surgrry. Srii-iirr 1QM.224: 420-1. 3. Aldndge D. A plienon~.'ii~~Iugit'al annparistin of the orpni?.ationof music.ind tin-self An'. in Piyhllit'riily I'W*; ll>.'ll-

!+c also Yingling CD, liosobuchi V, llarrington M (1990) I'.KX asa prcilirtor of rortm'ry from coma. laurel 336: 873and Siwtr R (1990) Effectsof auditory stimuli on comatose pitients wilt head injury. Heart 1111d l.un{ I t : 37.3-H.-Kilitur

INTENSIVE & CRITICAL CARE DIGEST Vol. 10 No. 1 MARCH 1991

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Collected neurology papers

Complementary Therapies in Medicine (2005) 13, 25-33

8 9 10 11 12 13

Functionality or aesthetics? A pilot study of music therapy in the treatment of multiple sclerosis patients夽 D. Aldridge a, ∗, W. Schmid b, M. Kaeder c, C. Schmidt a, T. Ostermann d a

Chair for Qualitative Research in Medicine, University of Witten Herdecke, Alfred-Herrhausen-Str. 50, D-58448, Germany b Institute for Music Therapy, Faculty of Medicine, University of Witten Herdecke, Germany c Gemeinschaftskrankenhaus, Herdecke, Germany d Department of Medical Theory and Complementary Medicine, Faculty of Medicine, University of Witten Herdecke, Germany

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Summary Introduction: Neuro-degenerative diseases are, and will remain, an enormous public health problem. Interventions that could delay disease onset even modestly will have a major public health impact. The aim of this study is to see which components of the illness are responsive to change when treated with music therapy in contrast to a group of patients receiving standard medical treatment alone. Material and methods: Twenty multiple sclerosis patients (14 female, 6 male) were involved in the study, their ages ranging from 29 to 47 years. Ten participants formed the therapy group, and 10 the matched control group matched by age, gender and the standard neurological classification scheme Expanded Disability Status Scale (EDSS). Exclusion criteria were pregnancy and mental disorders requiring medication. Patients in the therapy group received three blocks of music therapy in single sessions over the course of the one-year project (8—10 sessions, respectively). Measurements were taken before therapy began (U1), and subsequently every three months (U2—U4) and within a 6-month follow-up without music therapy (U5) after the last consultation. Test battery included indicators of clinical depression and anxiety (Beck Depression Inventory and Hospital Anxiety and Depression Scale), a self-acceptance scale (SESA) and a life quality assessment (Hamburg Quality of Life Questionnaire in Multiple Sclerosis). In addition, data were collected on cognitive (MSFC) and functional (EDSS) parameters. Results: There was no significant difference between the music-therapy treatment group and the control group. However, the effect size statistics comparing both groups show a medium effect size on the scales measuring self-esteem (d, 0.5423), depression HAD-D (d, 0.63) and anxiety HAD-A (d, 0.63). Significant improvements

KEYWORDS

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Music therapy; Matched control group; Self-acceptance; Self-esteem; Depression; Anxiety; Functional scores; Aesthetic

夽 This project was supported by Schering gmbH.

* Corresponding author. Tel.: +49 2302 926 780; fax: +49 2302 926 783.

E-mail address: davida@uni-wh.de (D. Aldridge).

David Aldridge

Collected neurology papers

YCTIM 751 1—9

D. Aldridge et al. were found for the therapy group over time (U1—U4) in the scale values of selfesteem, depression and anxiety. In the follow-up, scale values for fatigue, anxiety and self-esteem worsen within the group treated with music therapy. Discussion: A therapeutic concept for multiple sclerosis, which includes music therapy, brings an improvement in mood, fatigue and self-acceptance. When music therapy is removed, then scale scores worsen and this appears to intimate that msuic therapy has an inﬂuence. © 2005 Elsevier Ltd. All rights reserved.

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sures by which therapeutics are evaluated, and adopt a pragmatic approach to living as well as possible in the context of a chronic condition.10 Although complementary and alternative medicine approaches are being asked for by patients suffering with multiple sclerosis, only a limited number of studies have explored arts and music therapy recently. O’Callaghan,11 for example, encourages patients to write songs using expressive elements related to positive feelings for other people, memories of relationships and expressions of the adverse experiences resulting from living with the illnesses. In a controlled pilot study Wiens et al.12 demonstrated a potential strengthening effect of music therapy—–with a focus on breathing and speech—– on the respiratory musculature of multiple sclerosis patients. Respiratory muscle weakness is characteristic of individuals with advanced multiple sclerosis and can result in repeated infections of the lung. Based on experiences with a music-therapy group of 225 hospital inpatients with multiple sclerosis who participated in a 6-week group musictherapy program,13 music therapy appeared to offer psychological support, relieve anxiety and depression and possibly help with the difﬁcult process of coping with the disease individually. Magee,14—17 also makes use of well-known, precomposed songs and spontaneous improvisation on instruments and their attitudes change from a “disabled self-concept” to a more ‘‘able self-concept’’. In a further study,18 the authors showed improvements in mood state following music therapy, although depression was not directly affected. Studies into factors governing the quality of life for multiple sclerosis patients are interesting in this context. They reveal that patients and their physicians have different perspectives. Physicians determine quality of life mainly with physical and functional parameters, while patients themselves see psychosocial well-being, emotional stability and ways to cope with multiple sclerosis-induced stress as the most important factors.19 High levels of depression and anxiety are associated with people with MS who seek complementary approaches, al-

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Neuro-degenerative diseases are, and will remain, an enormous public health problem. Interventions that could delay disease onset even modestly will have a major public health impact. These diseases are disabling to the sufferers, there is a loss of normal motor functioning, a change in mood, and a gradual loss of cognitive abilities1,2 including auditory problems3 and memory changes,4 and sensory processing.5 These multifarious problems worsen during the course and stages of the disease.1 Furthermore, the patient does not suffer alone; these losses have an impact upon family and social life. Multiple sclerosis is the most frequent inﬂammable disease of the central nervous system among young adults. It is an autoimmune disease with additional genetic and environmental factors6 and considered to be one disease in the general class of neurodegenerative diseases. Disease progression differs considerably from patient to patient, so that while we may talk about stages of the diseases there is no typical multiple sclerosis patient but rather a heterogeneous group of patients where generalizations do not really apply.7 As there are no curative therapeutic interventions, we are reliant upon a palliative intervention. While medical approaches will undoubtedly focus on a functional strategy for treatment, we cannot ignore that these diseases have implications for the performance and appearance of the person in everyday life. Therefore, we need therapeutic approaches that include aesthetic performance as well as functional performance.8 Multiple sclerosis patients show increasing interest in complementary and alternative therapies.9 One reason is their general disappointment with conventional medicine, since causal treatment is not possible; another is a wish to play a more active role in coping with the disease and a demand for a wider range of therapies to meet psychosocial needs as well. Patients say that by using a complementary medical approach then they take personal responsibility for health, reframe the mea-

Introduction

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Collected neurology papers

YCTIM 751 1—9

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Functionality or aesthetics?

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Patients Twenty multiple sclerosis patients (14 female, 6 male) were involved in the study, their ages ranging from 29 to 47 years, with episodic, secondary chronic and primary chronic progression and an average disease duration of 11 years. Ten participants formed the therapy group, and 10 the control group. The groups were comparable in the standard neurological classiﬁcation scheme Expanded Disability Status Scale (EDSS).21 The EDSS of both groups was 2.6 on average, which means that the participants were between normal functions (score: 0) and disability that precludes full daily activities (score: 5.5). Exclusion criteria were pregnancy and mental disorders requiring medication. All participants were informed of the content and details of the study and gave their written consent to publish the material, especially the video sequences from the music-therapy sessions. The Ethical Committee of University of Witten Herdecke examined the protection of data privacy and the ethical aspects. Patients were matched by the researcher administering the trial for age, gender, stage of disease and the standard neurological classiﬁcation scheme EDSS. The basis for the recruitment population was from patients coming for their regular check-ups to the general hospital. A patient was allocated to the treatment group. The next consecutive patient, if matching the previous patient, would be allocated to the control group. If not, that patient would be allocated to the treatment group until the treatment group was complete. Subsequently, 10 matching control patients were allocated. The patients in the therapy group received three blocks of music therapy in single sessions over the course of the project (8—10 sessions, respectively). Patients in the matched control group were promised music therapy after the waiting period. The music-therapy approach used for this study is based on the Nordoff Robbins approach.22 Both patient and therapist are active. Music-making on instruments, or singing, and the music itself that emerges, all are potential possibilities for activity,

Methods

David Aldridge

A matched control trial was implemented using a battery of indices before therapy began (U1), and subsequently every three months (U2—U4) and within a 6-month follow-up without music therapy (U5) after the last consultation. The test battery included the following instruments.

Indicators of clinical depression and anxiety (Beck Depression Inventory and Hospital Anxiety and Depression Scale) The Beck Depression Inventory (BDI) is an established and reliable questionnaire for assessing the severity of depression and offers an instrument suitable to compare this study with other clinical studies.23 Patients with multiple sclerosis are considered to be impaired in identifying emotional states from prosodic cues,24 so it makes sense to use such an inventory. The Hospital Anxiety and Depression Scale (HAD) is a self-administered, bidimensional instrument developed to screen for clinically signiﬁcant depression and anxiety in medical populations (Zigmond, 1983, p. 657). Somatic items are excluded to avoid the confounding effect of physical illness. While it is recognised that patients with multiple sclerosis have a high lifetime risk for major depression, less is known about affective instability and how symptoms like irritability, sadness and tearfulness affect a subject’s overall degree of psychological distress.25 Clinically signiﬁcant anxiety, either with or without depression, was endorsed by 25% of patients, three times the rate for depression.26

Collected neurology papers

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encounter and experience. Individual themes and musical developments emerged for each individual patient; some wanted to sing and dance, others wanted to be sung to, and others wanted to play an instrument or brought their own instruments with them. There were no expectations of previous musical education. The patients wanted recordings of their sessions and their individual selections were recorded onto compact discs. They played them to their partners or friends or just listened to some pieces and remembered the condition and feelings of the situation. There was a high degree of willingness on the part of all patients to take part in the study, so that all rounds of interviews were completed, and 85% of all music-therapy sessions took place.

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though this may be an underlying factor of chronic illness.20 The aim of this study is to see which components of the illness are responsive to change when treated with music therapy in contrast to a group of patients receiving standard medical treatment alone.

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Hamburg Quality of Life Questionnaire in Multiple Sclerosis The Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS) is a disease-specific quality of life instrument for MS. There are 38 items about physical, psychological and social functions and questions about symptoms, progression of the disease and general impairment.29 People suffering with multiple sclerosis identify depression and social function as important components of quality of life (Somerset, 2003, p. 608) and including preferences for health states and treatment alternatives in the decision to initiate treatment for individual patients is seen as an important treatment consideration.30 In addition, data were collected on cognitive (MSFC) and functional (EDSS) parameters. The EDSS describes the state of disability of an MS-patient and ranges from 0 (normal) to 10 (death due to MS). It is a classification scheme that insures all participants in clinical trials are in the same class, type or phase of MS.21 It is also used by neurologists to follow the progression of MS disability and evaluate treatment results. Because of its strong emphasis on ambulation, the EDSS is insensitive to changes in other neurological functions and to cognitive dysfunction in MS. The Multiple Sclerosis Functional Composite (MSFC) is a multidimensional instrument to assess disability of MS-patients. It has three parts, testing the function of legs and walking-ability, the functions of arms and hands and the cognitive functions.31 The IFSS is a scale that assesses incapacity and fatigue. For an evaluation of the efficiency and sustained success of music therapy, Wilcoxon-test statistics of outcome-measures differences from U1 to U4 between the groups were applied to show significant differences. Additionally, effect-sizes were calculated according to Cohen18 and corrected according to McGaw and Glass19 .

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Fig. 1 shows the development of the outcomemeasures in the course of time with therapy from U1 to U4 and up to U5 in the follow-up. At the start of the study (U1) there was no significant difference between therapy group and control group on the varying scale measures. Significant improvements were found within the therapy group over time (U1—U4) in the scale values of SESA (p = 0.012) for depression (BDI, p = 0.036; HADS-D, p = 0.035) and anxiety (HADS-D subscale anxiety, p = 0.13). Significant differences were found for the control group in regard to the subscale anxiety (HADS-A, p = 0.031), while the values for depression and self-acceptance did not show any significant differences over time (U1—U4). No differences were found for the functional and physiological values (MSFC, EDSS) and quality of life (HAQUAMS). The latter is probably because the HAQUAMs quality of life is mainly assessed from statements of physical well-being and mobility thus reflecting scores on the functional scales. However, there was no significant difference in the improvement from U1 to U4 between the musictherapy treatment group and the control group (see Table 1), although effect size statistics comparing both groups show a medium effect size on the scales measuring self-esteem (d, 0.5423), depression HADD (d, 0.63) and anxiety HAD-A (d, 0.63). In the follow-up, scale values for fatigue, anxiety and selfesteem worsen within the group treated with music therapy. The use of p-values and effect size are used as guides in this study as to what may be interesting as hypotheses for further studies, or if further studies are warranted. They are intended as exploratory statistics rather than confirmatory. This is a pilot study and there are considerable limitations both in terms of the sample size and a bias in terms of matching in that there was no random allocation to the treatment group. Considering the correlations between the scale scores differences between T1 and T4, we found correlations between the HAD depression index and self-acceptance, and depression on the BDI and HAD anxiety and depression (see Table 2). We could, therefore, reduce our battery of tests to the Hospital Anxiety and Depression scale in any future trial.

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The Scale for the Evaluation of Self-Acceptance (SESA) is a 35-question scale translated from an original scale that assesses the acceptance of self and others.27 Social support, and coping behaviours, are important for persons afﬂicted with multiple sclerosis. A healthy conception of oneself is central to coping effectively with the day-to-day stresses of modern living. The onset of any neurological disease, with either actual visible deﬁcits or potential future disability, threatens the integrity of that concept.28

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Figure 1 Outcome measures over time. U1—U4: treatment phase, U5: follow-up. Dashed line: control-group, full-line: music-therapy group. BDI: Beck Depression Inventory, HADS-A: Hospital Anxiety and Depression Scale—–anxiety, HADSD: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: Hamburg Quality of Life Questionnaire in Multiple Sclerosis, EDSS describes the state of disability, MSFC: Multiple Sclerosis Functional Composite, IFFS: Incapacity and Fatigue Scale, MSFC: Multiple Sclerosis Functional Composite.

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Table 1

Wilcoxon signed rank test comparing therapy and matched control group.

EDSS MSFC IFFS SESA BDI HADS-A HADS-D HAQUAMS

Music-therapy group, median [25%ile, 75%ile]

Control group, median [25%ile, 75%ile]

Wilcoxon signed rank test, p signiﬁcance (two-tailed)

2.3 [1.4; 3.5] 0.23 [−0.21; 0.47] 34.0 [24.3; 45.0] 115 [79; 125] 13.0 [6.5; 19.0] 9.0 [4.8; 11.8] 5.5 [3.8; 7.0] 2.3 [2.1; 2.5]

2.5 [1.5; 3.6] 0.14 [−0.45; 0.34] 22.5 [12.8; 47.5] 110 [99; 128] 7.0 [3.0; 20.0] 8.0 [3.75;13.25] 6.0 [1.5; 9.5] 2.0 [1.8; 2.4]

0.76 0.61 0.22 0.59 0.33 0.54 0.84 0.07

Difference between intake and end of treatment scores (Wilcoxon signed rank test) z Asymptotic signiﬁcance (two-tailed)

EDSS

MSFC

IFSS

−.303 .762

−.507 .612

−1.224 .221

SESA

BDI

HADS-A

HADS-D

−.533 .594

−.972 .331

−.613 .540

−.205 .837

HAQUAMS −1.837 .066

314 315 316 317 318 319 320 321 322 323 324 325

there is no cure. This frequently life-long process for patients starting when multiple sclerosis is diagnosed obviously demands a range of therapeutic possibilities which must also consider and encourage a patient’s creative abilities.33 What we need to establish is which of the varying parameters is subject to inﬂuence by music therapy, which was the aim of this study. In this study various outcome-parameters were evaluated for their possible appropriateness for showing effects of music therapy. These were both functional and affective. We included many parameters because although the clinicians involved knew that something positive was happening, there was no clear indication of what this was and how to measure it. Through this study we now have an idea of what changes and from this basis can develop hypotheses for a controlled study.

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Correlation of the differences in scales between T1 and T4. SESA

SESA BDI HAD-A HAD-D

BDI

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can be considered as a part of a treatment strategy for two reasons. One, it offers a means to improve communicative performance.18 Second, it promotes the presentation of a self that may be considered as handicapped or degenerating but can be performed as satisfying and whole—–and that is a matter of aesthetics.8,32 We know from the limited, principally anecdotal, music-therapy literature that there are potential benefits from music therapy in terms of enhancing mood and improving self-identity. While there are numerous projects aimed at finding medical relief for suffering and the treatment of disease, we are reminded that disease-related problems influence patient’s mental behaviour and this has ramifications for relationships. A major confrontation for those offering treatment, as it is for the patient, is that the problem worsens and

−0.37 (0.11)

HAD-A −0.33 (0.15) 0.57** (0.01)

HAD-D **

−0.61 (0.04) 0.49* (0.03) 0.41 (0.07)

HAQUAMS 0.03 (0.89) 0.13 (0.59) 0.12 (0.62) 0.01 (0.96)

Levels of significance are printed in parentheses. BDI: Beck Depression Inventory, HAD-AS: Hospital Anxiety and Depression Scale—–anxiety, HAD-D: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: Hamburg Quality of Life Questionnaire in Multiple Sclerosis. ∗∗ Correlation is significant at the level 0.01 (two-tailed). ∗ Correlation is significant at the level 0.05 (two-tailed).

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BDI: Beck Depression Inventory, HADS-A: Hospital Anxiety and Depression Scale—–anxiety, HADS-D: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: Hamburg Quality of Life Questionnaire in Multiple Sclerosis, EDSS describes the state of disability MSFC: Multiple Sclerosis Functional Composite, IFFS: Incapacity and Fatigue Scale, MSFC: Multiple Sclerosis Functional Composite.

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In a final interview, 9 out of 10 music-therapy participants in the study described how important it was to become personally active in their treatment. All 10 participants reported an immediate improvement in their well-being during sessions. In eight participants, this improved state continued for some time and was confirmed by partners or friends. This is also confirmed by improvements in the self-acceptance and depression scales but not by quality of life scores. Differences over time in the depression scores and self-acceptance scores are highly correlated with each other that may reflect their common conceptual background. Seven participants described an enhanced perception of themselves with an increasing self-confidence over the course of the therapy. They were increasingly able to let themselves be surprised by the music as it emerged and by their own previously undiscovered musical skills. Music and music therapy are experienced by patients as ‘‘something moving’’ that shifts negative thoughts about the disease into the background and offers a means of expression for feelings of security, freedom and pleasure.38 One participant relates how she met a friend in the University that she had not seen in a long time, after treatment. They talked for a while and it was only on parting that she told her friend that she has multiple sclerosis. This was a shift in her perception of herself as first and foremost ‘‘a sick person’’ to a normal person with other priorities in life. What is evident from this study is that in assessing music therapy in terms of meeting patients’ needs then we cannot simply take a functional approach alone. Multiple sclerosis patients have a variety of needs, some of these are psychosocial and some of these are also aesthetic. An aesthetic therapy offers the opportunity to experience the self not as solely degenerative but also as creative. This is a major turn around in selfunderstanding and is reflected in both self-esteem and an improvement in mood. We are not denying that these patients have a degenerative disease, simply that these patients are not themselves degenerate. In the face of pathology, even in sickness, we have the potential to be active creative agents. Music therapy emphases creative dialogue as an remedy in the face of a dialogic degenerative disease.35

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recognition of their abilities rather than pathologies, and a possibility for them to exercise their own agency.

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Positive changes are shown in patients’ depressed mood, which are also reflected in the self-acceptance scale. Given that patients with a chronic disease are also stigmatised,34 and this spoiled identity is further exacerbated by the concept of degeneration,35 then any intervention that improves mood and enhances selfacceptance is valuable in mitigating stigma. We know from the anecdotal literature that music therapy is important for establishing and recreating self identity.15,32,36 Perhaps we should not simply consider these diseases as neurodegenerative but as dialogue-degenerative diseases, where there is a breakdown in dialogue between the sufferer and the community. There were no recognizable changes in motor and functional abilities. The form of creative music therapy used here is efficacious for promoting a positive self-identity and relieving the emotional burden on a patient but not for improving functional abilities. Improvements in patients of the therapy group with regard to relieving anxiety and depression, and above all with regard to improved self-acceptance, are a consequence of the qualitative changes brought about in music-therapy encounters. The change in the subscale anxiety of the HADS-D in both groups may be an indication that regular professional patient care helps reduce depression in multiple sclerosis sufferers. Standard therapeutic practice is that patients only attend for contact with a practitioner or treatment when there is a flare up in symptoms. Being recruited into a trial and being regularly assessed is also perhaps an important variable for therapeutic contact. There is a worsening of the music-therapy group scale scores at follow-up when music-therapy treatment is withdrawn, particularly with regard to selfesteem. This may be argued as evidence of the temporary effect of music therapy or that music therapy does indeed have an effect and we see how the patient responds when the therapy is withdrawn. The importance of therapeutic contact is reflected in a qualitative analysis of the data. Two hundred and twenty-six music-therapy sessions were documented on video and evaluated with the help of episodes and generation of categories.37 What emerged from the qualitative aspects of the study were parameters concerning contact between therapist and patient, coping with the situation, the sharing of musical roles, and an ability to structure time and the possibility to initiate changes in play. These factors reflect the needs of these patients for a deeper personal contact, a

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References 1. Amato MP, Zipoli V. Cognitive dysfunction in multiple sclerosis: current approaches to clinical management. Expert Rev Neurotherapeut 2002;2(5):731—42. 2. Mahler M, Benson D. Cognitive dysfunction in multiple sclerosis: a subcortical dementia? In: Rao S, editor. Neurobehavioural aspects of multiple sclerosis. Oxford: Oxford University Press; 1990. 3. Armstrong C. Selective versus sustained attention: a continuous performance test revisited. Clin Neuropsychol 1997;11(1):18—33. 4. Johnson SK, Deluca J, Diamond BJ, Natelson BH. Selective impairment of auditory processing in chronic fatigue syndrome: a comparison with multiple sclerosis and healthy controls. Percept Mot Skills 1996;83(1):51— 62. 5. Schurmann M, BasarEroglu C, Basar E. A possible role of evoked alpha in primary sensory processing: common properties of cat intracranial recordings and human EEG and MEG. Int J Psychophysiol 1997;26(1—3):149—70. 6. Gold R, Rieckmann R. Pathogenese und Therapie der Multiplen Sklerose. Bremen: UNI-MED Verlag Bremen; 2000. 7. Evers KJ, Karnilowicz W. Patient attitude as a function of disease state in multiple sclerosis. Social Sci Med 1996;43(8):S1245—51. 8. Aldridge D. Aesthetics and the individual in the practice of medical research: a discussion paper. J R Soc Med 1991;84:147—50. 9. Alcock G, Chambers B, Christopheson J, Heiser D, Groetzinger D. Complementary and alternative therapies for multiple sclerosis. In: Halper J, editor. Advanced concepts in multiple sclerosis nursing care. New York: Demos Medical Publishing; 2001. p. 239—66. 10. Thorne S, Paterson B, Russell C, Schultz A. Complementary/alternative medicine in chronic illness as informed self-care decision making. Int J Nurs Stud 2002;39(7):671—83. 11. O’Callaghan C. Lyrical themes in songs written by palliative care patients. J Music Ther 1996;33(2):74—92. 12. Wiens ME, Reimer MA, Guyn HL. Music therapy as a treatment method for improving respiratory muscle strength in patients with advanced multiple sclerosis: a pilot study. Rehabil Nurs 1999;24(2):74—80. 13. Lengdobler H, Kiessling WR. Group music therapy in multiple sclerosis: ﬁrst report. Psychotherapie, Psychosomatik, Medizinische Psychologie 1989;39(9/10):369—73. 14. Magee W. A comparative study of familiar pre-composed music and unfamiliar improvised music in clinical music therapy with adults with multiple sclerosis. London: Royal Hospital for Neuro-disability; 1998. 15. Magee W. Music therapy in chronic degenerative illness: reﬂecting the dynamic sense of self. In: Aldridge D, editor. Music therapy in palliative care: new voices. London: Jessica Kingsley; 1999. p. 82—94.

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16. Magee W. ‘‘Singing my life, playing myself’’: music therapy in the treatment of chronic neurological illness. In: Wigram T, Backer JDe, editors. Clinical applications of music therapy in developmental disability, paediatrics and neurology. London and Philadelphia: Jessica Kingsley Publishers; 1999. p. 201—23. 17. Magee W. Identity in clinical music therapy: shifting selfcontsructs through the therapeutic process. In: Miell D, editor. Musical identities. Oxford: Oxford University Press; 2002. p. 179—97. 18. Magee W, Davidson J. The effect of music therapy on mood states in neurological patients: a pilot study. J Music Ther 2002;39(1):20—9. 19. Rothwell PM, Dowell, Mc Z, Wong CK, Dorman PJ. Doctors and patients donˇıt agree: cross sectional study of patients’ and doctors’ perceptions and assessments of disability in multiple sclerosis. Br Med J 1997;314:1580— 3. 20. Sparber A, Wootton JC. Surveys of complementary and alternative medicine: part V. Use of alternative and complementary therapies for psychiatric and neurologic diseases. J Altern Complement Med 2002;8(1):93— 6. 21. Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an Expanded Disability Status Scale (EDSS). Neurology 1983;33:1444—52. 22. Nordoff P, Robbins C. Creative music therapy. New York: John Day; 1977. 23. Aikens JE, Reinecke MA, Pliskin NH, Fischer JS, Wiebe JS, McCracken LM, et al. Assessing depressive symptoms in multiple sclerosis: is it necessary to omit items from the original Beck Depression Inventory? J Behav Med 1999;22(2):127—42. 24. Beatty WW, Orbelo DM, Sorocco KH, Ross ED. Comprehension of affective prosody in multiple sclerosis. Mult Scler 2003;9(2):148—53. 25. Feinstein A, Feinstein K. Depression associated with multiple sclerosis. Looking beyond diagnosis to symptom expression. J Affect Disord 2001;66(2/3):193—8. 26. Feinstein A, O’Connor P, Gray T, Feinstein K. The effects of anxiety on psychiatric morbidity in patients with multiple sclerosis. Mult Scler 1999;5(5):323—6. 27. Berger EM. The relationship between expressed acceptance of self and expressed acceptance of others. J Abnorm Psychol 1952;47:778—82. 28. Jiwa TI. Multiple sclerosis and self esteem. Axone 1995;16(4):87—90. 29. Gold SM, Heesen C, Schulz H, Schulz K-H. Disease speciﬁc quality of life instruments in multiple sclerosis: validation of the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS). Mult Scler 2001;7:119—30. 30. Prosser LA, Kuntz KM, Bar-Or A, Weinstein MC. Patient and community preferences for treatments and health states in multiple sclerosis. Mult Scler 2003;9(3):311—9. 31. Fischer JS, Rudick RA, Cutter GR, Reingold SC. For the National MS Society Clinical Outcomes Assessment Task Force (1999). The multiple sclerosis composite measure (MSFC): an integrated approach to MS clinical outcomes assessment. Mult Scler 1999;5:244—50. 32. Aldridge D. Music therapy research and practice in medicine. London: Jessica Kingsley; 1996. 33. Kriz J. Grundkonzepte der Psychotherapie. Weinheim: Psychologie Verlags Union; 1994. 34. Goffman E. Stigma. Notes on the management of a spoiled identity. Englewood Cliffs, NJ: Prentice-Hall; 1963. 35. Aldridge D. The creative arts therapies in the treatment of neurodegenerative illness. In: Trias G, editor. Music therapy

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We have used effect sizes here, although modest, to provide a platform for other studies that will no doubt improve on what we have attempted. This exploratory study has indicated the potential beneﬁts of music therapy as an aesthetic intervention concerned with the performance of self in everyday life. At some stage we will also need to consider multi centre trials.

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therapy traces. Music Ther Today (online). Available at http://musictherapyworld.net; 2002, December. 38. Schmid W. Music therapy with people suffering from multiple sclerosis. In: Trias G, editor. Music therapy and art therapy in neurodegenrative diseases. Barcelona: Fundaci´ on ‘‘la Caixa’’; 2003.

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and art therapy in neurodegenerative diseases. Barcelona: la Caixa; 2003. p. 37—46. 36. Aldridge D. A phenomenological comparison of the organization of music and the self. Arts Psychother 1989;16:91—7. 37. Aldridge D, Aldridge G. Therapeutic narrative analysis: a methodological proposal for the interpretation of music

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rhythm of breathing. The unit staff were asked to be quiet during this period and not to carry out any invasive procedures for 10 min after the contact. There were a range of reactions from a change in breathing (it became slower and deeper), fine motor movements, grabbing movements of the hand and Intensive care treatment is a highly technological turning of the head, eyes opening to the regaining of branch of medicine. Even in what may appear to be hopeless cases, i t can save lives1 through consciousness. When the therapist first began to sing the application of this modern technology. Howthere was a slowing down of the heart rate. Then the heart rate rose rapidly and sustained an elevated level ever, albeit in the context of undoubted success, until the end of the contact. This may indicate a n intensive care treatment has fallen into disreattempt at orientation and cognitive processing within pute. Patients are seen to suffer from a wide range of problems resulting from insufficient com* ~ . measurement the communicational c o n t e ~ t ~EEG showed a desynchronization from theta rhythm, to munication, sleep and sensory deprivation2s3 and alpha rhythm or beta rhythm in former synchronized lack of empathy between patient and medical staff. areas. This effect, indicating arousal and perceptual Many activities in an intensive care situation appear activity, faded out after the music therapy stopped. to be between the unit staff and the essential Some of the ward staff were astonished that a patient machines, ie subjects and objects. To a certain extent patients become a part of this object world. We propose could respond to such quiet singing. This highlights a difficulty of noisy units such as these. All communithat improvised music therapy can be a useful cation is made above a high level of machine noise. adjunctive therapy in such situations both for the patient and the staff. Furthermore commands to an 'unconscious'. patient In these situations of intensive monitoring and are made by shouting formal injunctions, ie 'Show me machine support, particularly in the case of comatose your tongue', 'Tell me your name', 'Open your eyes'. patients, we may ask of ourselves 'Where is the self Few attempts are made a t normal human communiof the patient?'. Needleman4 reminds us that the cation with a patient who cannot speak or with whom staff can have any psychological contact. It is as if power of scientific thought has been to organize our perceptions i n such a manner that we can survive in these patients were isolated in a landscape of noise, ! the world. Hence the value of scientific medicine and and deprived of human contact. instrumentation. However, he goes on to say that A benefit of the music therapy was that the staff science has also neglected the human body as an were made aware of the quality and intensity of the instrument of knowledge and a s a vehicle for senhuman contact. In the intensive care unit environsations as direct as ordinary sensory experience, but ment of seemingly non-responding patients, depena s subtle as consciousness. dent upon machines to maintain vital functions and At the suggestion of a hospital neurologist a music anxiety provoking in terms of possible patient death, then it is a human reaction to withdraw personal therapist began working with coma patients. To investigate this approach further the work was contact and interact with the machines. This is monitored i n an intensive treatment unit. Five further exacerbated by a scientific epistemology which patients, between the ages of 15 and 40 years, and emphasizes the person only as a material being and which equates mind with brain. with severe coma (a Glasgow Coma Scale score A period of calm was also recognized as having between 4 and 7) were treated. All the patients had been involved in some sort of accident, had sustained potential benefit for the patient. What some staff fail to realize is that communication is dependent upon brain damage and most had undergone neurosurgery. rhythm, not upon volume. We might argue that such The form of music therapy used here is based on the unconscious patients, struggling to orient themselves principle that we are organized as human beings not in time and space, are further confused by an in a mechanical way but i n a musical form; ie a atmosphere of continuing loud and disorienting ranharmonic complex of interacting rhythms and melodic contour^^-^. To maintain our coherence as beings in dom noise. For patients seeking to orient themselves the world then we must creatively improvise our then the basic rhythmic context of their own breathing identity. Rather than search for a master clock which may provide the focus for that orientation. This raises coordinates us chronobiologically, we argue that we the problem of intentionality in human behaviour, are better served by the non-mechanistic concept of even when consciousness appears to be absent. It is musical organization. Music therapy is the medium also vital that staff in such situations do not confuse by which a coherent organization is regained, ie 'not acting' with 'not perceiving'. linking brain, body and mind. In this perspective the We can speculate that the various body rhythms self is more than a corporeal being. have become disassociated in such comatose states. Each music therapy contact lasted between 8 and The question remains then of how those behaviours 12 min. The therapist improvised her wordless singing can be integrated and where is the seat of such based upon the tempo of the patient's pulse, and more integration. Improvised singing appears to offer a number of importantly, the patient's breathing pattern. She pitched her singing to a tuning fork. The character of possible benefits for working with coma patients in the patient's breathing determined the nature of the terms of human contact and promoting perceptual singing. The singing was clearly phrased so that when responses. Human contact through singing, rather than speaking, also suggests that the fundamentals any reaction was seen then the phrase could be repeated. of human communication are musical in form. In this Before the first session the music therapist had met way we have the a r t of medicine within the science the family to gain some idea of what the patient was of medicine. Perhaps the skills of human communilike a s a person. On contacting the comatose patient she would say who she was, that she would sing for cation may become part of medical and nursing David Aldridge Collected papersparticularly in the context of intensive 50 education5, the patient in the tempo of his or her pulse and theneurology

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care. Although what we know from machines is valuable, there are other important subtle forms of knowledge that are best gleaned through personal contact with the patient. The question still remains for us as clinicians and scientists when faced with a patient in coma, or a persistent vegetative state, 'Where is the person and how can I reach her?, and then for ourselves as fellow human beings, 'Where am I?' This raises further the ethical issues of decisions about terminating life support when the brain and the person are no longer seen as one and the same entitylO.

D Aldridge Medical Faculty, Universitat Witten Herdecke Beckwig 4,D5804 Herdecke, FRG

D Gustorff Znstitut fur Musiktherapie, Medical Faculty, Universitat Witten Herdecke

H J Hannich Wilhelms-Universitat Klinic fur Aniisthesiologie und operatiu Intensivmedizin Albert-Schweitzer-Strasse 33, D4400 Miinster, FRG

References 1 Hannich H. Uberlegen m m Handlungsprimat in der Intensivmedizin. Medizin Mensch Gesellschaft 1988;13:238-44 2 Wilson L. Intensive care delirium. Arch Intern fed 1972;130:225-6 3 Ulrich R. View through a window may influence recovery from surgery. Science 1984;224:420-1 4 Needleman J. A sense of the cosmos. New York:Arkana, 1988 5 Aldridge D. A phenomenological comparison of the organization of music and the self. Arts in Psychotherapy 1989;16:91-7 6 Aldridge D. Music, communication and medicine. J R Soc Med 1989;82:743-6 7 NordoffP, Robbins C. Creative music therapy. New York, John Day, 1977 8 Sandman C . Afferent influences on the cortical evoked response. In: Coles M, Jennings JR,Stern JA eds. Psychological perspectives (festscrift for Beatrice and John Lacey). Stroudberg, PA: Hutchinson and Ross, 1984 9 Sandman C. Augmentation of the auditory event related to potentials of the brain during diastole. Znt J Physiology 1984;2:111-19 10 Mindell A. Coma: key to awakening. Boston: Shambala, 1989

regarding HIV infection, but also of general medicine in preparation for Finals. Fortunately, a gynaecologist friend of my parents had trained in Sydney and introduced me to a consultant immunologist there, Professor Ronal Penny. Thus I came to Barts students are no different from most final year spend my elective a t St Vincent's Hospital, Sydney. medics in the need to choose a destination for the I was extremely fortunate in being funded by elective period. This need occasionally encompasses the Guildchrist Foundation, the Clothworkers Trust a desire to journey to a warm and exotic part of the and my Medical College, all in the City of London. world yet a t the same time is concerned with gaining some medical experience. It is surprisingly difficult It was interesting that none of the London-based to combine these two intentions especially since hot AIDS organizations were able to provide any assistance despite my protocol covering the very serious climates are often associated with many outdoor temptations which can divert thought away from negative social aspect of neuropsychiatric complications of HIV infection. study and learning. The public image of the AIDS victim has been the My elective months were spent in Sydney, Australia, a choice governed by my previous special infected homosexual or drug addict. Sydney, with its studies in HIV and AIDS. This interest began in 1985 large population of both these sources of patients, also has people from every walk of life professing beliefs when I joined St Mary's hospital for one year to study 'Infection and Immunity'. From that time, the subject and carrying out behaviour that, as in all cosmoof AIDS and the management of the immunopolitan society, has no norm. AIDS is making its grim inroad, indifferent to stereotyping. During compromised patient began to appear more frequently my time in Sydney, I saw many aspects of inpatient, in medical journals. The neuropsychiatric complications of HIV infection were of particular interest outpatient, community and laboratory care of HIV infection. It is a sad game of numbers that the since they demonstrated links between the immune system, opportunistic infection and psychological Australian population is not much more than a symptoms in patients who practised diverse lifestyles. quarter that of the UK, but contains as many recorded cases of AIDS. The field of neuropsychiatric compliThe extent to which the AIDS epidemic will domications was too vast for deep investigation in nate current medical practice in the UK is still unclear. the limited time of the elective period. My work covered a broad overview of the illness and gave me My concern was to use my particular academic knowledge to support the clinical experience obtained a deep understanding of compassion. 'AIDS patients? Did you wear a mask. I hope on elective. However, I had not had any direct you wore rubber gloves!' This was the reaction personal involvement in the management of HIV of several of my fellow students on my return infection and for that reason alone was keen to London. I must say that, to an extent, these to spend some time attached to a unit where intimations there a possibility of some teaching, not onlyneurology Davidwas Aldridge Collected papersof fear and caution echoed my own 51

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REFLECTIONS CREATIVITY AND CONSCIOUSNESS: MUSIC THERAPY IN INTENSIVE CARE DAVID ALDRIDGE, PhD*

' . . however great the organic damage . . . there remains the undiminished possibility of reintegration by art, by communion, by blocking the human spirit; and this can be presented in what at first seems at first a hopeless state of neurological devastation." (Sacks, 1986, p. 37)

sidered. It raises questions about the location of the self in patients who are comatose, about the nature of communication with patients who are unconscious, and challenges medicine to realize the human body as an instrument of knowledge. Some aspects of modem medicine have become increasingly technological. Such is the case of intensive care treatment. Even in what may appear to be hopeless cases, it can save lives (Hannich, 1988) through the application of this modem technology. However, albeit in the context of undoubted success, intensive care treatment has fallen into disrepute. Patients are seen to suffer from a wide range of problems resulting from insufficient communication, sleep and sensory deprivation (Hannich, 1988; Ulrich, 1984), and lack of empathy between patient and medical staff. Many activities in an intensive care situation appear to be between the unit staff and the essential machines (i.e., subjects and objects). To a certain extent, patients become a part of this object world. Improvised music therapy can be a useful adjunctive therapy in such situations both for the patient and the staff.

The neurologist Oliver Sacks reminds us of the necessary balance we must bring to our work with patients in the field of medicine. All too often we are concerned with testing the patient for deficits, for measuring and for assessing problem-solving capacities. As a balance he urges us to consider the narrative and symbolic organization of the patients, so that we consider their possibilities and abilities. In this way what seems to be damaged, ill-organized, and chaotic becomes composed and fluent. This is the function of the creative arts; through art and play we realize other selves elusive to measurement and fugitive to assessment. Furthermore, there is a quality of time that is apparent in arts activities that is "intentional7' and involves the will of the patients where their spirits are set free. When we consider the situation of intensive care, where patients are often damaged, disorganized, intubated, machine-regulated, often unconscious, and unable to communicate, then we must consider a way of introducing activities that will stimulate communion with those patients. In this paper the ground of consciousness is con-

The Music Therapy Sessions At the suggestion of a hospital neurologist, a music therapist began working with patients in intensive

*David Aldridge is a research consultant to the medical faculty of Universit'at Witten Herdecke, Germany. He thanks Dr. Wilhelm Rimpau for the initiation of this work, Dagmar Gustorff for her pioneering of these skills in difficult conditions, and Professor H.J. Hannich for his providing the circumstances for the further exploration of this work. 359

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care (Gustorff, 1990). To investigate this approach further, the work was monitored in the intensive treatment unit of a large university clinic. Five patients, between the ages of 15 and 40 years, and with severe coma (a Glasgow Coma Scale score between 4 and 7) were treated. All the patients had been involved in some sort of accident, had sustained brain damage, and most had undergone neurosurgery. The form of music therapy used here was based on the principle that we are organized as human beings not in a mechanical way but in a musical form (i.e., a harmonic complex of interacting rhythms and melodic contours) (Aldridge, 1989a, 1989b; Nordoff & Robbins, 1977). To maintain our coherence as beings in the world we must creatively improvise our identity. Rather than search for a master clock that coordinates us chronobiologically, we argue that we are better served by the non-mechanistic concept of musical organization. Music therapy is the medium by which a coherent organization is regained (i.e., linking brain, body, and mind). In this perspective, the self is more than a corporeal being. As Sacks (1986) wrote, "the power of music or narrative form is to organize" (p. 177). What music and narrative structure organizes is the recognition of relationships between elements, not in an intellectual way, but direct and unmediated. With coma patients we see signs of activity, albeit often machine supported, but totally disorganized. The person exists, sometimes in what is described as a vegetative state, but hardly ''lives. " Each music therapy contact lasted between eight and twelve minutes. The therapist improvised her wordless singing based on the tempo of the patient's pulse and, more importantly, the patient's breathing pattern. She pitched her singing to a tuning fork. The character of the patient's breathing determined the nature of the singing. The singing was clearly phrased so that when any reaction was seen the phrase could be repeated. Before the first session the music therapist met the family to gain some idea of what the patient was like. On contacting the comatose patient, she said who she was, that she would sing for the patient in the tempo of his or her pulse and the rhythm of breathing. The unit staff were asked to be quiet during this period and not to carry out any invasive procedures for ten minutes after the contact. There was a range of reactions from a change in breathing (it became slower and deeper), fine motor

David Aldridge

movements, grabbing movements of the hand, and turning of the head, eyes opening to the regaining of consciousness. When the therapist first began to sing there was a slowing down of the heart rate. Then the heart rate rose rapidly and sustained an elevated level until the end of the contact. This may have indicated an attempt at orientation and cognitive processing within the communicational context (Nordoff & Robbins, 1977; Sandman, 1984a, 1984b). Electroencephalogram (EEG) measurement of brain activity showed a desynchronization from theta rhythm, to alpha rhythm or beta rhythm in former synchronized areas. This effect, indicating arousal and perceptual activity, fades out after the music therapy stops. If we consider that cells firing with a cardiac rhythm have been recorded in the medullary area of the brain, and that there is a synchronous relationship between the contraction of the heart and the "ascending" wave of alpha rhythm (Sandman, 1986) of brain activity, then it is possible to hypothesize that the rhythmic coordination of the cardiovascular system with cortical rhythmic firings is of primary importance for cognition. What we have is a weaving together of basic primitive human rhythms, which produce an interference pattern that itself may be that of cognition. It is proposed here that the rhythmic coordination of basic functions in the human body (Jones, Kidd, & Wetzel, 1981; Kempton, 1980; Kidd, Boltz, & Jones, 1984; Lester, Hoffman, & Brazelton, 1985;Longuet-Higgins, 1982; Povel, 1984; Rozzano & Locsin, 1981; Safranek, Koshland, & Raymond, 1982; Steedman, 1977) is a fundamental healing activity. The Ward Situation Sleep disturbance is a major problem in intensive care units and the effect of a disturbed waking1 sleeping rhythm upon other metabolic cycles is critical (Johnson & Woodland-Hastings, 1986; MooreEde, Czeisler, & Richardson, 1983; Reinberg & Halberg, 1971). The rhythmic entrainment of cardiovascular and somatic activities may be the key ground for recovery. This means that we must consider the total "behavioral" (Engel, 1986) activity of the patient so that seemingly independent systems are integrated. The context (i.e., Latin, con textere = weaving together) of this integration is rhythmical involving the coordination of the major tidal rhythms of the body and timing mechanisms within the hypothalamus in the brain.

Collected neurology papers

MUSIC THERAPY IN INTENSIVE CARE As an organizational problem, we must look to the ways in which staff are employed in work shifts. It can occur that patients throughout 24 hours are constantly in contact with nursing staff who are in their own activity cycle, no matter what time of day or night. For rhythmically disoriented patients, no wonder that there are sleep problems when they must respond to constant activity with caregivers who themselves are physically unsynchronized with the patient. Nursing staff, although synchronized with management needs and hospital routine, may need to attend to the sleeplactivity rhythm of the patient. In response to the music therapy, some ward staff are astonished that patients can respond to quiet singing. This highlights a difficulty of noisy, busy, often brightly lit units. All communication is made above a high level of machine noise. Furthermore, commands to an "unconscious" patient are made by shouting formal injunctions (i.e., "Show me your tongue," "Tell me your name," "Open your eyes"). Few attempts are made at normal human communication with a patient who cannot speak or with whom staff can not have any psychological contact. It is as if these patients were isolated in a landscape of noise, and deprived of human contact. A benefit of music therapy is that the staff are made aware of the quality and intensity of the human contact. In the intensive care unit environment of seemingly non-responding patients, dependent on machines to maintain vital functions and anxiety provoking in terms of possible patient death, then it is a human reaction to withdraw personal contact and interact with the machines. Although the machines themselves are of vital importance, they present data that are independent one from another, and that are often considered in isolation, whereas the integration of the systems being measured is the clue to recovery. This is further exacerbated by a scientific epistemology that emphasizes the person only as a material being and that equates mind with brain. At yet another level, we must consider the fixed chronological pulses of machines. If human activity is based on pulse, the nature of those pulses is that they are variable within a range of reactivity. Those pulses are lively and accommodate other pulses to form interacting rhythms. This is not so with machines; they are fixed in their range. Therefore, what is a variable in human activity (the tempo of varying pulses) becomes a constant in these patients. The task then is to introduce coordinated variety with the intention to heal, something that as yet machines

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cannot do. Perhaps the key lies in the fact that it is the consciousness of the therapist that stimulates the consciousness of the patient, and this consciousness is not divorced from the living rhythmic reality of our physiology. A period of calm is also recognized as having potential benefit for the patient. What some staff fail to realize is that communication is dependent on rhythm, not on volume. We might argue that such unconscious patients, struggling to orient themselves in time and space, are further confused by an atmosphere of continuing loud, disorienting random noise, and bright light. For patients seeking to orient themselves, the basic rhythmic context of their own breathing may provide the focus for that orientation. This raises the problem of intentionality in human behavior even when consciousness appears to be absent. Reflexes do not occur in a vacuum; they are conditional occurring in a context of other behavioral activity. If bodily systems are proactive, as well as reactive, then purposive behavior and consciousness may require the context of human communication to function. It is also vital that staff in such situations do not confuse "not acting" on the behalf of the patient with "not perceiving. " We can further speculate that the various body rhythms have become disassociated in comatose states and following major surgery. The question remains of how those behaviors can be integrated and where the seat of such integration is. It is quite clear that integration is an organizational property of the whole organization in relationship with the environment and not located in any cell or any one organ. The environment of the patient includes the vital component of human contact and there is reason to believe that the essential ground of this contact too is rhythmical. Communication, Contact, and Consciousness Improvised singing appears to offer a number of possible benefits for working in intensive care both in terms of human contact and promoting perceptual responses. Human contact as communication is a creative art form. Although what we know from machines is valuable, there are other important subtle forms of knowledge that are best gleaned through personal contact with the patient. Mindell (1989) took the courageous step of attempting process-oriented psychology with comatose patients, accompanying them on their great symbolic journey. The drama of

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our contact with such patients at a time of existential crisis points to a fundamental aesthetic of living systems creatively realized so that we, as artist therapists, can go beyond the confines of a soulless technology. This is not to deny that technology and its benefits, simply to remind us of our human intention as it is realized in art, play, drama, music. What we may also need to consider in future is not how to observe more, but how to question the quality of what we are observing and the premises on which this observation is based. In such situations of intensive monitoring and machine support, particularly in the case of comatose patients, we may ask of ourselves, "Where is the self of the patient?" Needleman (1988) reminds us that the power of scientific thought has been to organize our perceptions in such a manner that we can survive in the world. Hence the value of scientific medicine and instrumentation. However, he goes on to say that science has also neglected the human body as an instrument of knowledge and as a vehicle for sensations as direct as ordinary sensory experience, but as subtle as consciousness. He writes ". . . it is not simply the intellect which science underestimates, it is the human body as an instrument of knowledge-the human body as a vehicle for sensations as direct as ordinary sensory experience, but far more subtle and requiring for their reception a specific degree of collected attention and self-sincerity" (p. 169). The question still remains for us as clinicians and scientists when faced with a patient in coma or a persistent vegetative state, "Where is the person and how can I reach him or her?" and then for ourselves as fellow human beings, "Where am I?" What part of the therapist is contacting the unconscious patient? Could it be that if the musical form of our communication touches our patients, as singing, we can also attend to how we speak with the patients in their breathing patterns, and then attend to them with the very form of our own bodies. This ability to communicate with unconscious patients raises further the ethical issues of decisions about terminating life support when the brain and the person are no longer seen as one and the same entity (Mindell, 1989). When patients are not responding it may be that we are not providing them with the human conditions in which, and with which, they can respond. We as therapists are those conditions that are the context for healing to take place.

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References Aldridge, D. (1989a). Music, communication and medicine. Journal of the Royal Society of Medicine, 82, 743-745. Aldridge, D. (1989b). A phenomenological comparison of the organization of music and the self. The Arts in Psychotherapy, 16, 91-97. Engel, B.T. (1986). An essay on the circulation as behavior. The Behavioral and Brain Sciences, 9 , 285-3 18. Gustorff, D. (1990). Lieder ohne Worte. Musiktherapeutische Umschau, 11, 120-126. Hannich, H.J. (1988). Uberlegen zum Handlungsprimat in der Intensivmedizin. Medizin Mensch Gesellschaft, 13, 238-244. Johnson, C., & Woodland-Hastings, J. (1986). The elusive mechanism of the circadian clock. American Scientist, 74, 29-36. Jones, M,, Kidd, G., & Wetzel, R. (1981). Evidence for rhythmic attention. Journal of Eqerirnental Psychology, 7 , 1059-1073. Kempton, W. (1980). The rhythmic basis of interactional microsynchrony. In M. Key (Ed.), The relationship of verbal and non-verbal communication (pp. 68-75). The Hague: Mouton. Kidd, G., Boltz, M,,& Jones, M. (1984). Some effects of rhythmic content on melody recognition. American Journal of Psychology, 97, 153-173. Lester, B. M., Hoffman, J., & Brazelton, T. (1985). The rhythmic structure of mother-infant interaction in term and proterm infants. Child Development, 56, 15-27. Longuet-Higgins, H. (1982). The perception of musical rhythms. Perception, 11, 115-128. Mindell, A. (1989). Coma: Key to awakening. Boston: Shambala. Moore-Ede, M. C., Czeisler, C. A., & Richardson. G. S. (1983). Circadian timekeeping in health and disease. New England Journal of Medicine, 309, 469-479. Needleman, J. (1988). A sense of the cosmos. New York: Arkana. Nordoff, P., & Robbins, C. (1977). Creative music therapy. New York: John Day. Povel, D. (1984). A theoretical framework for rhythm perception. Psychological Research, 45, 315-337. Reinberg, A., & Halberg, F. (1971). Circadian chronopharmacology. Annual Review of Pharmacology, 11, 455-492. Rozzano, G., & Locsin, R. (1981). The effect of music on the pain of selected post operative patients. Journal of Advanced Nursing, 6 , 19-25. Sacks, 0. (1986). The man who mistook his wife for a hat. London: Pan. Safranek, M., Koshland, G. & Raymond, G. (1982). Effect of auditory rhythm on music activity. Physical Therapy, 62, 161-168. Sandman, C. (1984a). Afferent influences on the cortical evoked response. In M. Coles, J. Jennings, & J. Stem (Eds.), Psychophysiological perspectives: Festschrift for Beatrice and John Lacey. Stroudberg, PA: Hutchinson & Ross. Sandman, C. (1984b). Augmentation of the auditory event related to potentials of the brain during diastole. International Journal of Physiology, 2, 111-1 19. Sandman, C. (1986). Circulation as consciousness. The Behavioural and Brain Sciences, 9, 303-304. Steedman, M. (1977). The perception of musical rhythm and metre. Perception, 6 , 555-569. Ulrich, R. (1984). View through a window may influence recovery from surgery. Science, 224, 420421.

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Journal of Clinical Gempsychologv, Vol. 4, No. l, 1998

Music Therapy and the Treatment of Alzheimer's Disease David ,41dridge1

Ahheimer patients, despite aphasia and memory loss, continue to sing old songs and to dance to past tunes when given the chance. Quality of life expectations become paramount in any management strategy, and music therapy appears to play an important role in enhancing the ability to actively take part in daily life. Improvised music. therapy appears to offer the opportunity to supplement mental state examinations in areas where those examinations are lacking. It is possible to ascertain the fluency of musical production, perseverance with the task in hand, and episodic memory. The inability to build phrases may be attributed to problems with memory or to an yet unknown factor. This unknown factor is possibly involved with the organization of time structures. Thus, music therapy offers an assessment tool sensitive to small changes. Certainly, the anecdotal evidence suggests that quality of life of Ahheimers patients is significantly improved with music therapy accompanied by the overall social benefits of acceptance and sense of belonging gained by communicating with others. KEY WORDS: rhythm; phrasing; intentionality; quality-of-life; music-therapy; memory.

INTRODUCTION

At the age of 56, the composer Maurice Ravel began to complain of increased fatigue and lassitude. Following a traffic accident, his condition deteriorated progressively (Henson, 1988). He lost the ability to remember names, to speak spontaneously, and to write (Dalessio, 1984). Although he could understand speech, he was no longer capable of the coordination required to lead a major orchestra. While his mind, he reports, was full of musical ideas, he could not set them down (Dalessio, 1984). Eventually, his intellectual functions and speech deteriorated until he could no longer recognize his own music. We would speculate now that he had been suffering from Alzheimer's disease. In this paper; the value of music for the sufferers of Alzheimer's disease will be discussed. In particular, there will be a focus on music as therapy. '~edizinische Fakultat, Universitat Witten Herdecke, Alfred Herrhausen Stra. 50, 58448 Witten, Germany.

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MUSIC AS THERAPY There are two principal ways of doing music therapy: "active music therapy" which requires that the patient, or a group of patients play musical instruments, or sing, with the therapist; and, "passive music therapy" whereby the patient, or a group of patients, listen to the therapist who plays live, or recorded, music to them. In active music therapy, the music is often improvised to suit the individual patient. In passive music therapy, the music is often chosen to suit particular patients. Within each of these two main approaches, there are varying schools throughout the Western world, some based on the work of particular teachers, and some are more eclectic and based on psychotherapeutic approaches. Music therapy has been reviewed in the medical and nursing press and the principle emphasis is on the soothing ability of music and the necessity of music as an antidote to an overly technological medical approach. Most of these articles are concerned with passive music therapy and the playing of pre-recorded music to patients emphasizing the necessity of healthy pleasures like music, fragrance, and beautiful sights for the reduction of stress and the enhancement of well-being. The overall expectation is that the recreational, emotional, and physical health of the patient is improved (Aldridge, 1993b). After the Second World War, however, music therapy was intensively developed in American hospitals (Schullian and Schoen, 1948). Since then, some hospitals, particularly in mainland Europe, have incorporated music therapy carrying on a tradition of European hospital-based research and practice (Aldridge, 1990; Aldridge, Brandt, and Wohler, 1989). In recent years, there has been a move to develop an academic tradition of research that attempts to begin a clinical dialogue with other practitioners through research practice (Aldridge, 1989, 1991a,b, 1993a; Aldridge, Gustorff, and Hannich, 1990).

MUSIC, COGNITION AND LANGUAGE As in Ravel's demise above, the responsiveness of patients with Alzheimer's disease to music is a remarkable phenomenon (Swartz, Hantz, Crummer, Walton, and Frisina, 1989). While language deterioration is a feature of cognitive deficit, musical abilities appear to be preserved. This may be because the fundamentals of language, as we have seen in previous chapters, are musical, and prior to semantic and lexical functions in language development. Although language processing may be dominant in one hemisphere of the brain, music production involves an understanding of the interaction of both cerebral hemispheres (Altenmuller, 1986; Brust, 1980; Gates and Bradshaw, 1977). In attempting to understand the perception of music, there have been a number of investigations into the hemispheric strategies involved. Much of the literature considering musical perception concentrates on the significance of hemispheric dominance. Gates and Bradshaw (1977J'conclude that cerebral hemispheres are concerned with music perception and that no laterality differences are apparent. Other investigators (Wagner and Hannon, 1981) suggest that two processing functions develop with training where David Aldridge

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left and right hemispheres are simultaneously involved, and that musical stimuli are capable of eliciting both right and left ear superiority (Kellar and Bever, 1980). Similarly, when people listen to and perform music, they utilize differing hemispheric processing strategies. Evidence of the global strategy of music processing in the brain is found in the clinical literature. In two cases of aphasia (Morgan and Tilluckdhany, 1982), singing was seen as a welcome release from the helplessness of being a patient. The authors hypothesized that singing was a means to communicate thoughts externally. Although the "newer aspect" speech was lost, the older function of music was retained possibly because music is a function distributed over both hemispheres. Berman (1981) suggests that recovery from aphasia is not a matter of new learning by the nondominant hemisphere but a taking over of responsibility for language by that hemisphere. The nondominant hemisphere may be a reserve of functions in case of regional failure. Little is known about the loss of musical and language abilities in cases of global cortical damage, although the quality of response to music in the final stages of dementia is worth noting (Norberg, Melin, and Asplund, 1986). Any discussion is necessarily limited to hypothesizing as there are no established baselines for musical performance in the adult population (Swartz et al., 1989). Aphasia, which is a feature of cognitive deterioration, is a complicated phenomenon. While syntactical functions may remain longer, it is the lexical and semantic functions of naming and reference which begin to fail in the early stages. Phrasing and grammatical structures remain giving an impression of normal speech, yet content becomes increasingly incoherent. These progressive failings appear to be located within the context of semantic and episodic memory loss illustrated by the inability to remember a simple story when tested (Bayles et aL, 1989). Musicality and singing are rarely tested as features of cognitive deterioration, yet preservation of these abilities in aphasics has been linked to eventual recovery (Jacome, 1984; Morgan and Tilluckdhany, 1982), and could be significant indicators of hierarchical changes in cognitive functioning. Jacome (1984) found that a musically naive patient with transcortical mixed aphasia exhibited repetitive, spontaneous whistling and whistling in response to questions. The patient often spontaneously sang without error in pitch, melody, rhythm, and lyrics, and spent long periods of time listening to music. Beatty et al. (1988) describe a woman who had severe impairments in terms of aphasia, memory dysfunction, and apraxia; yet, she was able to sight read an unfamiliar song and perform on the xylophone which to her was an unconventional instrument. Like Ravel (Dalessio, 1984), an elderly musician who could play from memory (Crystal, Grober, and Masur, 1989) no longer recalled the name of the composer, she no longer recalled the name of the music she was playing. Swartz et aL (1989) propose a series of perceptual levels at which musical disorders take place: (1) the acoustico-psychological level, which includes changes in intensity, pitch, and timbre; (2) the discriminatory level, which includes the discrimination of intervals and chords; (3) the categorical level, which includes the categorical identification of rhythmic patterns and intervals; (4) the configural level, which includes melody perception, the recognition of motifs and themes, tonal David Aldridge

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changes, identification of instruments, and rhythmic discrimination; (5) the level where musical form is recognized, including complex perceptual and executive functions of harmonic, melodic, and rhythmical transformation. In Alzheimer's patients, it would be expected that while levels (l), (2), and (3) remain unaffected, the complexities of levels (4) and (5) when requiring no naming, may be preserved but are susceptible to deterioration. It is perhaps important to point out that these disorders are not themselves musical, they are disorders of audition. Only when disorders of musical production take place can we begin to suggest that a musical disorder is present. Improvised musical playing is in an unique position to demonstrate this hypothetical link between perception and production. Rhythm is the key to the integrative process underlying both musical perception and physiological coherence. When considering communication, rhythm is also fundamental to the organization and coordination of internal processes, and externally between persons (Aldridge, 1989). Rhythm offers a frame of reference for perception (Povel, 1984). Rhythm too plays a role in the perception of melody. The perceptions of speech and music are formidable tasks of pattern perception. The listener has to extract meaning from lengthy sequences of rapidly changing elements distributed in time (Morrongiello, Ti-ehub, Thorpe, and Capodilupo, 1985). amporal predictability is important for tracking melody lines (Jones, Kidd, and Wetzel, 1981; Kidd, Boltz, and Jones, 1984). Kidd et a i (1984) also refer to melody as having a structure in time and that a regular rhythm facilitates the detection of a musical interval and its subsequent integration into a cognitive representation of the serial structure of the musical pattern. Adults identify familiar melodies on the basis of relational information about intervals between tones rather than the absolute information of particular tones. In the recognition of unfamiliar melodies, less precise information is gathered about the tone itself. The primary concern is with successive frequency changes or melodic contour. The rhythmical context prepares the listener in advance for the onset of certain musical intervals and therefore a structure from which to discern, or predict, change. One may not be aware of certain changes and become either out of tune or out of time; such a loss of rhythmical structure, which appears outwardly as confusion, may be a hidden factor in the understanding of Alzheimer's disease. What is important in these descriptions of musical perception is the emphasis on context where there are different levels of attention occurring simultaneously against a background temporal structure (Jones et al., 1981; Kidd et a i , 1984). Musical improvisation with a therapist, which emphasizes attention to the environment (Sandman, 1984; Walker and Sandman, 1979; Walker and Sandman, 1982) utilizing changes in tempo and volitional response (Safranek, Koshland, and Raymond, 1982), without regard for lexical content, may be an ideal medium for treatment initiatives with Alzheimer's patients. The playing of simple rhythmic patterns and melodic phrases by the therapist, and the expectation that the patient will copy those patterns or-phrases, is similar to the element of "registration" in the mental state examination. While improvised musical playing is a useful tool for the assessment of musical abilities, it is also used within a therapeutic context. In this way, assessment and

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Music Therapy and Treatment of AJzheimer's Disease

therapy are interlinked; assessment providing the criteria from which to identify therapeutic goals and develop therapeutic strategies.

MUSIC THERAPY AND THE ELDERLY Much of the published work concerning music therapy with the elderly is concerned with group activity (Bryant, 1991; Christie, 1992; Olderog Millard and Smith, 1989) and is generally used to expand socialization and communication skills, with the intention of reducing problems of social isolation and withdrawal, to encourage participants to interact purposefully with others, assist in expressing and communicating feelings and ideas, and to stimulate cognitive processes, thereby sharpening problem-solving skills. Additional goals also focus on sensory and muscular stimulation and gross and fine motor skill development (Segal, 1990). Clair (1990a,b) has worked extensively with tlie elderly and found music therapy a valuable tool for working in groups to promote communicating, watching others, singing, interacting with an instrument, and sitting. Her main conclusions are that although the group members deteriorated markedly in cognitive, physical, and social capacities over an observation period of 15 months, they continued to participate in music activities. During the 30-minute sessions, group members consistently sat in chairs without physical restraints for the duration of each session and interacted with others regardless of their deterioration. This was the only time in the week when they interacted with others (Clair and Bernstein, 1990b). Indeed for one 66-year-old man, it is the sensory stimulation of music therapy that brought him out of his isolation such that he could participate with others, even if for a short while (Clair, 1992). Wandering, confusion and agitation are associated problems common to elderly patients living in hostels or special accommodations for Alzheimers' patients. A music therapist (Cloutier, 1993) has tested singing with the an 81-year-old woman to see if it helped her to remain seated. After 20 singing sessions, the therapist read to the woman to compare the degree of attentiveness. While music therapy and reading sessions redirected the subject from wandering, the total time she sat for the music therapy sessions was double that of the reading sessions (214.3 min vs. 99.1 min), and the time spent seated in the music therapy was more consistent than the sporadic episodes when she was being read to. When agitation occurs in such elderly women, then individualized music therapy appears to have a significantly calming effect (Gerdner and Swanson, 1993). In terms of reducing repetitive behavior, musical activity also reduces disruptive vocalizations (Casby and Holm, 1994). The above conclusions are supported by Groene (1993). Thirty residents (aged 60-91 years) of a special Alzheimer's unit,'who exhibited wandering behavior, were randomly assigned to either mostly music attention or mostly reading attention groups where they received one-to-one attention. Those receiving music therapy remained seated longer than those in the reading sessions. One of the central problem of the elderly is the loss of independence and self-esteem, and Palmer (1977, 1983, 1989) describes a program of music therapy David Aldridge

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at a geriatric home designed to rebuild self-concept. For the 380 residents, ranging from those who were totally functional to those who needed total care, a program was adapted to the capacities and needs of individual patients. Marching and dancing increased the ability of some patients to walk well; and for the nonambulatory, kicking and stamping to music improved circulation and increased tolerance and strength. Sing-along sessions were used to encourage memory recall and promoted social interaction and appropriate social behavior (Palmer, 1983, 1989). It was such social behavior that Pollack and Namazi (1992) report as being accessible to improvement through group music therapy activities. It is the partcipative element, that appears to be valuable for communication, and the intention to participate that is at the core of the music therapy activity which we will see in the following section. Music therapy has also been used to focus on memory recall for songs and the spoken word (Prickett and Moore, 1991). In ten elderly patients, whose diagnosis was probably Alzheimer's disease, words to songs were recalled dramatically better than spoken words or spoken information. Although long-familiar songs were recalled with greater accuracy than a newly presented song, most patients attempted to sing, hum, or keep time while the therapist sang. However, Smith (1991) suggests that it is factors such as tempo, length of seconds per word, and total number of words that might be more closely associated with lyric recall than the relative familiarity of the song selection. In a further study of the effects of three treatment approaches (musically cued reminiscence, verbally cued reminiscence, and music alone) on the cognitive functioning of 12 female nursing home residents with Alzheimer's Disease, changes in cognitive functioning were assessed by the differences between pre- and postsession treatment scores on the Mini-Mental State Examination. Comparisons were made for total scores and subscores for orientation, attention, and language. Musically cued and verbally cued reminiscence significantly increased language subsection scores and musical activity alone significantly increased total scores (Smith, 1986). Prinsley (1986) recommends music therapy for geriatric care as it reduces the individual prescription of tranquilizing medication, reduces the use of hypnotics on the hospital ward, and helps overall rehabilitation. He recommends that music therapy be based on treatment objectives, the social goals of interaction cooperation, psychological goals of mood improvement and self-expression, intellectual goals of the stimulation of speech and organization of mental processes, and the physical goals of sensory stimulation and motor integration. Such goals as stimulation of the individual, promoting involvement in social activity, identifying specific individualized behavioral targets, and emphasizing the maintenance of specific memory functions is repeated throughout the music therapy literature (Prange, 1990; Smith, S., 1990, 1991). Similarly, Smith, D. S. (1990) recommends behavioral interventions targeted at the more common behavioral problems (e.g., disorientation, age-related changes in social activity, sleep disturbances) of institutionalized elderly persons. In a study of mu& therapy in two nursing homes, life satisfaction and self-esteem were significantly improved in the home where the residents participated in the musical activities in comparison with a matched control group that had no music therapy (VanderArk, Newman, and Bell, 1983). David Aldridge

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Music Therapy and Treatment of Alzheimer's Disease

MUSIC THERAPY WITH AN ALZHEIMER'S PATIENT- A CASE STUDY In improvised music therapy, the music therapist plays the piano improvising with the patient who uses a range of instruments and voice. This work often begins with an explanatory session using rhythmic instruments, in particular the drum and cymbal; progressing to the use of rhythmic/melodic instruments such as the chime bars, glockenspiel or xylophone; developing into work with melodic instruments (including the piano); and the voice. An emphasis is placed on a series of musical ,improvisations during each session, and music is the vehicle for the therapy. Each session is audiotape-recorded, with the consent of the patient, and later analyzed andindexed as to the musical content. No musical training is required of the patient although it is essential to discover the musical background of the patient. They are asked about to which music they like to listen, and perhaps more importantly, to which music did they dance when they were younger. A 55-year-old female patient came to outpatient treatment at a general hospital for ten weekly sessions. Each session lasted 40 minutes. Her son drove her to each session as she was unable to find her way alone using public transport. Her sister had died with Alzheimer's disease and the family were concerned that she too was repeating her sister's demise. Her memory had begun to fail and she became increasingly disturbed. The patient was referred initially to the hospital when she, and her son, became aware of her own deteriorating condition. At home, she was experiencing difficulties in finding items of clothing and other things necessary for everyday life. She could not cook for herself anymore and was unable to write her own name. While wanting to speak, she experienced difficulty in finding words. She also appeared to be depressed, and in the light of her sister's death, and her own knowledge regarding her current predicament, it seemed reasonable to make this assumption. As she had previously played the piano for family and friends, although without any formal training, music therapy appeared to have potential as an intervention adjuvant to her medical treatment. In all ten sessions, she demonstrated her ability to play a singular ordered rhythmic pattern in 414 time using two sticks on a drum. However, a feature of her rhythmical playing was that in nearly all the sessions, the patient would let control of the rhythmic pattern slip such that it became progressively imprecise, losing both its form and liveliness. The initial impulse of her rhythmical playing, which was clear and precise, gradually deteriorated as she lost concentration and ability to persevere with the task in hand. However, when the therapist offered an overall musical structure during the course of the improvisation, by playing herself a known piece of music, then the patient could regain her precision of rhythm. In the rhythmical playing on drum and cymbal, the therapist attempted to develop the patient's attention span through the use of short repeated musical patterns and changes in key, volume and tempo. She hoped that through changes in the sound to steer the patient to maintaining a stable musical form. This technique helped the to maintain a rhythmical pattern and brought her to the stage which she could express herself stronger musically. The therapist also searched for other ways to develop variety in rhythm by moving away rom the repetitive pattern played by this patient.

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A change in the patient's ability to improvise was shown when the patient recognized, and could repeat rhythmical patterns in a musical dialogue and thereby brought into a musical context. In the last session of therapy, the patient was able to change her playing in this way such that she could express more strongly by bringing into line her thoughtful and expressive playing. It was this ability to become rhythmically flexible when brought into the form of a dialogue that is a fundamental feature of encouraging communicational competence. From the first session of therapy, the patient made it quite clear her own intent to sit at the piano and play whatever melodies she chose and to find the appropriate accompaniments. This wish and the corresponding willpower to achieve this end, was shown in all the sessions. It was possible to use this impetus to play as a source for improvisation. She laughed with joy at the success of playing and often asked to repeat a successful accomplishment. Lapses and slips in her rhythmical playing could be carried by the intent and expression with which she played. While her overall intention to play was preserved, her attention to that playing, the concentration necessary for musical production and the perseverance required for completing a sequence of phrases progressively failed and was dependent on the overall musical structure offered by the therapist. At the end of the treatment period, she was able to cook for herself and could find her own things about the house. The psychiatrist responsible for her therapeutic management reported an overall improvement in her interest in what was going on around her, and in particular that she maintained attention to visitors and conversations. The patient regained the ability to sign her name, although she could only write slowly. While wanting to speak, she still experienced difficulty in finding words. It appears that music therapy had a beneficial effect on the quality of life for this patient, and that some of the therapeutic effect may have been brought about by handling the depression associated with her failing cognitive abilities and the forebodings of a future reflecting her sister's fate. While the patient came to the sessions with the intention of playing, her ability to take initiatives was impaired, mirroring the state of her home life where she wanted to look after herself, yet was unable to take initiatives. This stimulus to take initiatives in the music was seen as an important feature of the music therapy by the therapist and appears to have a correlate in the way in which the patient began to take initiatives in her daily life. Active music-making promotes interaction between the persons involved, thereby promoting initiatives in communication. Furthermore, the implications for the maintenance of memory by actively making music is significant. As Crystal et al. (1989) found in an 82-year-old musician with Alzheimer's disease, there was a preserved ability to: (1) play previously learned piano compositions from memory, although the man was unable to identify the composer or titles of each work, and (2) learn the new skill of mirror reading while being unable to recall or recognize new information.'This woman could remember some old songs, but also learned new melodies arid retained them from session to session. A contraindication for music therapy with such patients who are aware of their problems is that the awareness of further cognitive abilities as experienced in the

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Music Therapy and Treatment of Alzheimer's Disease

"fable I. Features of Medical and Musical Assessment

Medical elements of assessment

Musical elements of assessment

Continuing observation of mental and functional status

Testing of verbal skills, including element of speech fluency

Testing of musical skills; rhythm, melody, harmony, dynamic, phrasing, articulation

Cortical disorder testing; visuospatial skills and ability to perform complex motor tasks (including grip and right left coordination).

Testing for progressive memory disintegration

Motivation to complete tests, to achieve set goals and persevere in tests

Motivation to. sustain playing improvised music, to achieve musical goals and persevere in maintaining musical form

"Intention" difficult to assess; but considered important

"Intention" a feature of improvised musical playing

Concentration and attention span

Concentration on the improvised playing and attention to the instruments

Flexibility in task switching

Flexibility in musical (including instrumental) changes

Mini-mental state score influenced by educational status

Ability to play improvised music influenced by previous musical training

Insensitive to small changes

Sensitive to small changes

Ability to interpret surroundings

Ability to interpret musical context and assessment of communication in the therapeutic relationship

playing may exacerbate any underlying depression and demotivate the patient to continue. For this patient, she was painfully aware that she could no longer find the harmonies with her left had required for the accompaniment of her favorite songs. This too was another sign of her failing cognitive ability. However, what appeared to be of value from the music therapy sessions (as can be seen in Tables I and 11) is that active musical playing provides a basis from which assessments of varying competencies can be made. Not only is it possible to discern a variety of motor abilities and cognitive competencies, including episodic memory, there is the further advantage of assessing intentionality and perseverance throughout episodes of playing and the session itself. This form of assessment is not based on a verbal competence; and furthermore, the patient is not aware that she is being tested. CONCLUSION

Alzheimer patients, despite aphasia and memory loss, continue to sing old songs and to dance to past tunes when given the chance. Indeed, fun and enter-

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Table 11. Musical Elements of Assessment and Examples of Improvised Playing Examples of improvised playing Musical elements of assessment Improvisations using rhythmic instruments Testing of musical skills; rhythm, melody, (drum and cymbal) singly or in combination harmony, dynamic, phrasing, articulation 0 Improvisations using melodic instruments Singing and playing folk songs with harmonic accompaniment Cortical disorder testing; visuospatial skills

Playing tuned percussion (metallophone, xylophone, chime bars) demanding precise movements

Cortical disorder testing; ability to perform complex motor tasks (including grip and right left coordination)

Alternate playing of cymbal and drum using a beater in each hand Coordinated playing of cymbal and drum using a beater in each hand Coordinated playing of tuned percussion

Testing for progressive memoxy disintegration

The playing of short rhythmic and melodic phrases within the session, and in successive sessions

Motivation to sustain playing improvised music, to achieve musical goals and persevere in maintaining musical form

The playing of a rhythmic pattern deteriorates when unaccompanied by the therapist, as does the ability to complete a known melody, although tempo remains

"Intention" a feature of improvised musical playing

The patient exhibits the intention to play the piano from the onset of therapy and maintains this intent throughout the course of treatment

Concentration on the improvised playing and attention to the instruments

The patient loses concentration when playing, with qualitative loss in the musical playing and lack of precision in the beating of rhythmical instruments

Flexibility in musical (including instrumental) changes

Initially the musical playing is limited to a tempo of 120 Bp and a characteristic pattern but this is responsive to change

Ability to play improvised music influenced by previous musical training

Although the patient has a musical background this is only of help when she perceives the musical playing, it is little influence in the improvised playing

Sensitive to small changes

Musical changes in tempo, dynamic, timbre, and articulation which at first are missing are gradually developed

Ability to interpret musical context and relationship

The patient develops the ability to play in a musical dialogue with the therapist demanding both a refined musical perception and the ability of musical production

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Music Therapy and Treatment of Alzheimer's Disease

tainment are all part and parcel of daily living for the elderly living in special accommodation (Glassman, 1983; Jonas, 1991; Kartman, 1990; Smith, 1992). Quality of life expectations become paramount in any management strategy, and music therapy appears to play and important role in enhancing the ability to actively take part in daily life (Lipe, 1991; Rosling and Kitchen, 1992). However, the production of music, and the improvisation of music, appears to fail in the same way in which language fails. Improvised music therapy appears to offer the opportunity to supplement mental state examinations in areas where those examinations are lacking. First, it is possible to ascertain the fluency of musical production. Second, intentionality, attention to, concentration on, and perseverance with the task in hand are important features of producing musical improvisations and susceptible to being heard in the musical playing. Third, episodic memory can be tested in the ability to repeat short rhythmic and melodic phrases. The inability to build such phrases may be attributed to problems with memory or to an as-yet unknown factor. This unknown factor is possibly involved with the organization of time structures. If rhythmic structure is an overall context for musical production, and the ground structure for perception, it can be hypothesized that it is this overarching structure which begins to fail in Alzheimers patients. A loss of rhythmical context would explain why patients are able to produce and persevere with rhythmic and melodic playing when offered an overall structure by the therapist. Such a hypothesis would tie in with the musical hierarchy proposed by ~wartz'(l989), and would suggest a global failing in cognition while localized lower abilities are retained. However, the hierarchy of musical perceptual levels proposed by Swartz may need to be further subdivided into classifications of music reception and music production. Music therapy offers an assessment tool sensitive to small changes (see Tables I and 11). It tests those prosodic elements of speech production which are not lexically dependent; that is, rhythm, melody, harmony, dynamic, phrasing, articulation. Furthermore, it can be used to assess those areas of functioning, both receptive and productive, not covered adequately by other test instruments (i.e., fluency, perseverance in context, attention, concentration, and intentionality). In addition, it provides a form of therapy which may stimulate cognitive activities such that areas subject to progressive failure, as in progressive memory disintegration, are maintained. There is a possibility to promote both visuo-spatial skills needed in playing instruments and the concentration needed to maintain that playing over a period of time. The playing of instruments apart from its therapeutic value is enables an assessment of grip strength and right-left coordination. Certainly, the anecdotal evidence suggests that quality of life of Alzheimers patients is significantly improved with music therapy (McCloskey, 1985, 1990; Tyson, 1989) accompanied by the overall social benefits of acceptance and sense of belonging gained by communicating with others (Morris, 1986; Segal, 1990). Unfortunately, most of the literature concerning cognition and musical perception is based.On audition and not musical production. Like other authors, we suggest that the production of music, as is the production of language, a complex global phenomenon as yet poorly understood. The understanding of musical production may well offer a clue to the ground structure of language and communi-

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cation in general. It is research in this realm of perception which is urgent not only for the understanding of Alzheimers patients but in the general context of cognitive deficit and brain behavior. It may be as Berman (1981) suggests, that the nondominant hemisphere is a reserve of functions in case of regional failure and this functionality can be stimulated to delay the progression of degenerative disease. We may need to address in future research the coordinating role of rhythm in human cognition and consciousness whether it be in persons who are losing cognitive abilities, or in persons who are attempting to gain cognitive abilities.

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Brust, J. (1980). Music and language: Musical alexia and agraphia. Brain 103: 367-392. Bryant, W (1991). Creative group work with confused elderly people: A development of sensory integration therapy. Brit. J. Occup. Ther. 54(5): 187-192. Casby, J. A., and Holm, M. B. (1994). The effect of music on repetitive disruptive vocalizations of persons with dementia. Am. Occup. Ther. 48(10): 883-889. Christie, M. E. (1992). Music therapy applications in a skilled and intermediate care nursing home facility: A clinical study. Act. Adapt. Aging 16(4): 69-87. Clair, A. (1992). Music therapy for a severely regressed person with a probable diagnosis of Alzheimer's Disease. In Bruscia, K (ed.), Case Studies in Music Therapy, Barcelona Publishers, Phoenixville, PA Clair, A. A. (1990). The need for supervision to manage behavior in the elderly care home resident and the implications for music therapy practice. Music Ther. Perspect. 8: 72-75. Clair, A. A., and Bernstein, B. (1990a). A comparison of singing, vibrotactile and nonvibrotactile instrumental playing responses in severely regressed persons with dementia of the Alzheimer's type. J. Music Thm 27(3): 119-125. Clair, A. A., and Bernstein, B. (1990b). A preliminary study of music therapy programming for severely regressed persons with Alzheimer's-type dementia. J. Appl. Gerontol. 9(3): 299-311. Crystal, H., Grober, E., and Masur, D. (1989). Reservation of musical memory in Alzheimer's disease. J. Neuml. Neuqsury. Psych& 52(12): 1415-1416. Dalessio, D. (1984). Maurice Ravel and Alzheimer's disease. JAMA 252(24): 3412-3413. Fitzgerald Cloutier, M. L (1993). The use of music therapy to decrease wandering: An alternative to restraints. Music Ther. Perspect. ll(1): 32-36. Gates, A., and Bradshaw, J. (1977). The role of the cerebral hemispheres in music. Brain Lung. 4: 403-431.

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Gerdner, L. A., and Swanson, E. A. (1993). Effects of individualized music on confused and agitated elderly patients. Arch. Rychiatr. Nursing 7(5): 284-291. Glassman, L. A (1983). The talent show: Meeting the needs of the healthy elderly. Music The% 3(1): 82-93. .Groene, R. W (1993). Effectiveness of music therapy: Intervention with individuals having Senile Dementia of the Alzheimer's type. 1. Music The% 30(3): 138-157. Henson, R. (1988). Maurice Ravel's illness: A tragedy of lost creativity. Brit. Med. Clin. Res. 296(6636): 1585-1588. Jacome, D. (1984). Aphasia with elation, hypermusia, musicophilia and compulsive whistling. J. Neurol. Neumswg. Psychiat. 47(3): 308-310. Jonas, J. L (1991). Preferences of elderly music listeners residing in nursing homes for art music, traditional jazz, popular music of today, and country music. L Music Ther. 28(3): 149-160. Jones, M,, Kidd, G., and Wetzel, R. (1981). Evidence for rhythmic attention. 1. Exp. Psychol. 7: 1059-1073. Kartman, L L (1990). Fun and entertainment: One aspect of making meaningful music for the elderly. Act. Adapt. Aging 14(4): 39-44. Kellar, L, and Bever, T (1980). Hemispheric asymmetries in the perception of musical intervals as a function of musical experience. Brain Lang. 10: 24-38. Kidd, G., Boltz, M., and Jones, M. (1984). Some effects of rhythmic context on melody recognition. Am. J. PsychoL 97(2): 153-173. Lipe, A W (1991). Using music therapy to enhance the quality of life in a client with Alzheimer's dementia: A case study. Music The%Perspect. 9: 102-105. ~ h ~ l o s kL e ~J., (1985). Music and the frail elderly. Act. Adapt. Aging 7(2): 73-75. McCloskey, L J. (1990). The silent heart sings. Special issue: Counseling and therapy for eiders. Generations 14(1): 63-65. Morgan and Tilluckdharry, R (1982). Presentation of singing function in severe aphasia. West Indian Med. J. 31: 159-161. Morris, M. (1986). Music and movement for the elderly. Nursing Times 82(8): 44-45. Morrongiello, B., Trehub, S., Thorpe, L, and Capodilupo, S. (1985). Children's perception of melodies: The role of contour, frequency, and rate of presentation. J. Exp. Child Psychol. 40(2): 279-292. Norberg, A, Melin, E., and Asplund, K (1986). Reactions to music, touch and object presentation in the final stage of dementia. An exploratory study. Int. Nursing Stud. 23(4): 315-323. Olderog Millard, K A, and Smith, J. M. (1989). The influence of group singing therapy on the behavior of Alzheimer's disease patients. J. Music The%26(2); 58-70. Palmer, M. (1989). Music therapy in gerontology: A review and a projection. National Association for Music Therapy California Symposium on Clinical Practices (1987, Costa Mesa, California). Music T!ier. Perspect. 6: 52-56. Palmer, M. D. (1977). Music therapy in a comprehensive program of treatment and rehabilitation for the geriatric resident. J. Music Thm l4(4): 190-197. Palmer, M. D. (1983). Music therapy in a comprehensive program of treatment and rehabilitation for the geriatric resident. Act& Adapt. Aging 3(3): 53-59. Pollack, N. J., and Namazi, K H. (1992). The effect of music participation on the social behavior of Alzheimer's disease patients. J. Music The%29(1): 54-67. Povel, D. (1984). A theoretical framework for rhythm perception. Psychol. Res. 45: 315-337. Prange, F! (1990). Categories of music therapy at Judson Retirement Community. Music The%Perspect. 8: 88-89. Prickett, C. A, and Moore, R S. (1991). The use of music to aid memory of Alzheimer's patients. J. Music T l m 28(2): 101-110. Prinsley, D. (1986). Music therapy in geriatric care. Aust. Nurses J. 15(9): 48-49. Rosling, L. K, and Kitchen, J. (1992). Music and drawing with institutionalized elderly. Miniconference in Music and Geriatrics (1990, Coquitlam, Canada). Act. Adapt. Aging 17(2): 27-38. Safranek, M., Koshland, G., and Raymond, G. (1982). Effect of auditory rhythm on muscle activity. Phys. The%62: 161-168. Sandman, C. (1984). Afferent influences on the cortical evoked response. In Coles, M., Jennings, L, and Stern, J. (eds.). Psychological Perspectives (Festschrift for Beatrice and John Lacey), Hutchinson and Ross, Stroudberg, PA Schullian, D., and Schoen, M. (1948). Music and Medicine, Henry Schuman, New York. Segal, R. (1990). Helping older mentally retarded persons expand their socialization skills through the use of expressive therapies. Special Issue: Activities with developmentally disabled elderly and older adults. Activ., Adapt. Aging 15(1-2): 99-109. Smith, B. B. (1992). Treatment of dementia: Healing through cultural arts. Pride Inst. 1. Long Term Home Health Care ll(3): 37-45.

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Smith, D. S. (1990). Therapeutic treatment effectiveness as documented in the gerontology literature: Implications for music therapy. Music Thez Perspect. 8: 36-40. Smith, D. S. (1991). A comparison of group performance and song familiarity on cued recall tasks with older adults. L Music Ther. 28(1): 2-13. Smith, G. H. (1986). A comparison of the effects of three treatment interventions on cognitive Functioning of Alzheimer patients. Music Ther. 6a(l): 41-56. Smith, S. (1990). The unique power of music therapy benefits Atzheimer's patients. Activ.,Adapt. Aging 14(4): 59-63. Summer, L (1981). Guided imagery and music with the elderly. Music Ther. l(1): 39-42. Swartz, K.. Hantz, E., Crummer, G., Wilton, J., and Frisina, R (1989). Does the melody linger on? Music cognition in Alzheimer's disease. Semin. Neural. 9(2): 152-158. Tyson, J. (1989). Meeting the needs of dementia Nws. Elder l(5): 18-19. VanderArk, S., Newman, I., and Bell, S. (1983). The effects of music participation on quality of life of the elderly. Music Ther. 3(1): 71-81. Wagner, M., and Hannon, R (1981). Hemispheric asymmetries in faculty and student musicians and nonmusicians during melody recognition tasks. Brain Long. 13: 379-388. Walker. B., and Sandman, C. (1979). Human visual evoked responses are related to heart rate. L Comp. PhysioL Psychol. 93: 717-729. Walker, B., and Sandman, C. (1982). Visual evoked potentials change as heart rate and carotid pressure change. Psychophysiology 19: 520-527.

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Journal of the Royal Society of Medicine Volume 86 February 1993

Music and Alzheimer's disease -assessment and therapy: discussion paper

D Aldridge P ~ D Medizinische Fakultat, Universitat Witten Herdecke, Beckweg 4, D-5804Herdecke BRD, Germany Keywords: dementia; Alzheimer's disease; music psychology; music therapy; mental state examination

Dementia is an important source of chronic disability leading to both spiralling health care expenditure among the elderly and a progressive disturbance of life quality for the patient and his or her family. With anticipated increases in the population of the elderly in Europe, then it is timely to find treatment initiatives in the Western world which will ameliorate the impact of this problem. Music therapy while not offering a cure for such a disease may be in a position to offer amelioration of the impact of the disease and provide a valuable adjunct to diagnosis. The diagnosis of Alzheimer's disease is prone to error and authors differ as to the difficulty of making a precise diagnosis. In the early stages of the disease the symptoms are difficult to distinguish from those of normal aging, a process which itself is poorly understood. A second source of error in diagnosing Alzheimer's disease is that it is masked by other conditions. Principle among these conditions is that of depression which itself can cause cognitive and behavioural disorders. Clearly Alzheimer's disease causes distress for the patient. The loss of memory and the accompanying loss of language, before the onset of motor impairment, means that the daily lives of patients are disturbed. Communication, the fabric of social contact, is interrupted and disordered. The threat of progressive deterioration and behavioural disturbance has ramifications not only for the patients themselves, but also their families who must take some of the social responsibility for the care of the patient, and the emotional burden of seeing a loved one becoming confused and isolated. A brief cognitive test, the Mini-Mental State Examination (MMSE), has been developed to screen and monitor the progression of Alzheimer's disease. As a clinical instrument it is widely used and well validated in practice. As a bed-side test the MMSE is widely used for testing cognition and is useful as a predictive tool for cognitive impairment and semantic memory without being contaminated by motor and sensory deficits. The items which the MMSE fails to discriminate (minor language deficits), or neglects to assess (fluency and intentionality) may be elicited in the playing of improvised music. A dynamic musical assessment of patient behaviour, linked with the motor co-ordination and intent required for the playing of musical instruments used in music therapy, and the necessary element of interpersonal communication,may provide a sensitive complementary tool for assessment1.

Ravel, the composer, began to complain of increased fatigue and lassitude. Following a traffic accident his condition deteriorated progressively. He lost the ability to remember names, to speak spontaneously and to write. Although he could understand speech he was no longer capable of the coordination required to lead a major orchestra. While his mind, he reports, was full of musical ideas, he could not set them down. Eventually his intellectual functions deteriorated until he could no longer recognize his own music. Even in a composer of his standing, with what we may guess was a progressive dementing illness, his active music-making capabilities deteriorated, albeit after speech failed. However, the responsiveness of patients with Alzheimer's disease to music is a remarkable phenomenon. While language deterioration is a feature of cognitive deficit, musical abilities appear to be preserved. This may be because the fundamentals of language itself are musical, and are prior to semantic and lexical functions in language development. Although language processing may be dominant in one hemisphere of the brain, music production involves an understanding of the interaction of both cerebral hemispheres. In attempting to understand the perception of music there have been a number of investigations into the hemispheric strategies involved. Much of the literature considering musical perception concentrates on the significance of hemispheric dominance. Gates and Bradshaw2 conclude that cerebral hemispheres are concerned with music perception and that no laterality differences are apparent. Other authors suggest that two processing functions develop with training where left and right hemispheres are simultaneously involved, and that musical stimuli are capable of eliciting both right and left ear superiority. Similarly, when people listen to and perform music they utilize differing hemispheric processing strategies. Evidence of the global strategy of music processing in the brain is found in the clinical literature. In two cases of aphasia3 singing was seen as a welcome release from the helplessness and a means to communicate thoughts externally. Berman4 suggests that recovery from aphasia is not a matter of new learning by the non-dominant hemisphere but a taking over of responsibility for language by that hemisphere. The non-dominant hemisphere may be a reserve of functions in case of regional failure. Little is known about the loss of musical and language abilities in cases of global cortical damage. Any discussion is necessarily limited to hypothesizing as there are no established baselines for musical Music and dementia performance in the adult population. Aphasia, which Late in adult life, at the age of 56 years, and after is a feature of cognitive deterioration, is a complicated completing two major concertos for the piano Maurice phenomenon. David Aldridge Collected neurology papers While syntactical functions may remain 70

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Table 1. Features of medical assessment and musical assessment Medical elements of assessment

Musical elements of assessment

Examples of improvised playing

Continuing observation of mental and functional status

Â¥Improvisationusing rhythmic instruments (drum and cymbal) singly or in combination, Â¥improvisationusing melodic instruments Â¥singin and playing folk songs with harmonic accompaniment

Testing of verbal skills, including element of speech fluency

Testing of musical skills; rhythm, melody, harmony, dynamic, phrasing, articulation

Â¥playin tuned percussion (metallophone, xylophone, chime bars) demanding precise movements

Cortical disorder testing; visuospatial skills and ability to perform complex motor tasks (including grip and right left co-ordination).

Â¥alternat playing of cymbal and drum using a beater in each hand Â¥co-ordinate playing of cymbal and drum using a beater in each hand Â¥co-ordinate playing of tuned percussion

Testing for progressive memory Testing for progressive memory disintegration disintegration

Â¥th playing of short rhythmic and melodic phrases within the session, and in successive sessions

Motivation to complete tests, to Motivation to sustain playing achieve set goals and persevere improvised music, to achieve in set tasks musical goals and persevere in maintaining musical form 'Intention' difficult to assess; 'Intention' a feature of improvised but considered important musical playing

Â¥th playing of a rhythmic pattern deteriorates when unaccompanied by the therapist, as does the ability to complete a known melody, although tempo remains Â¥th patient exhibits the intention to play the piano from the onset of therapy and maintains this intent throughout the course of treatment

Concentration and attention span

Concentration on the improvised playing and attention to the instruments

Â¥th patient loses concentration when playing, with qualitative losses in the musical playing and lack of precision in the beating of rhythmical instruments

Flexibility in task switching

Flexibility in musical (including instrumental) changes

Â¥initiall the musical playing is limited to a tempo of 120 bpm and a characteristic pattern but this is responsive to change

Mini-mental state score Ability to play improvised music influenced by educational status influenced by previous musical training

malthough the patient has a musical background this is only of help when she perceives the musical playing, it is little influence in the improvised playing

Insensitive to small changes

Sensitive to small changes

Â¥musicachanges in tempo, dynamic, timbre and articulation which a t first are missing are gradually developed

Ability to interpret surroundings

Ability to interpret musical context and assessment of communication i n the therapeutic relationship

Â¥th patient develops the ability to play in a musical dialogue with the therapist demanding both a refined musical perception and the ability of musical production

longer, it is the lexical and semantic functions of The patient often spontaneously sang without error naming and reference which begin to fail in the early in pitch, melody, rhythm and lyrics, and spent long stages. Phrasing and grammatical structures remain periods of time listening to music. Beatty6 describes giving an impression of normal speech, yet content a woman who had severe impairments in terms of becomes increasingly incoherent. These progressive aphasia, memory dysfunction and apraxia yet was failings appear to be located within the context of able to sight read an unfamiliar song and perform on semantic and episodic memory loss illustrated by the the xylophone which to her was an unconventional inability to remember a simple story when tested. instrument. Like Ravel, she no longer recalled the Musicality and singing are rarely tested as features name of the music she was playing. of cognitive deterioration, yet preservation of these Swartz and his colleagues7 propose a series of abilities in aphasics has been linked to eventual perceptual levels at which musical disorders take recovery, and could be significant indicators of hierplace: archical changes in cognitive functioning. Jacome5 (i) the acoustico-psychologicallevel, which includes found that a musically naive patient with transcortical changes in intensity, pitch and timbre. mixed aphasia exhibited repetitive, spontaneous (ii) the discriminatory level, which includes the whistling and whistling in response to questions. discrimination of intervals and chords. David Aldridge Collected neurology papers 71

Journal of the Royal Society of Medicine Volume 86 February 1993

structure which begins to fail in Alzheimer patients. (iii) the categorical level which includes the categorical A loss of rhythmical context would explain why identification of rhythmic patterns and intervals. patients are able to produce and persevere with (iv) the configural level, which includes melody rhythmic and melodic playing when offered an overall perception, the recognition of motifs and themes, tonal structure by the therapist, and would suggest a global changes, identification of instruments, and rhythmic failing in cognition while localized lower abilities are discrimination. retained. (v) the level where musical form is recognized, Music therapy appears to offer a sensitive assessment including complex perceptual and executive functions tool. It tests those prosodic elements of speech producof harmonic, melodic and rhythmical transformations. tion which are not lexically dependent. Furthermore, In Alzheimer's patients it would be expected that it can be used to assess those areas of functioning, while levels (i), (ii) and (iii) remain unaffected, the both receptive and productive, not covered adequately complexities of levels (iv) and (v), when requiring no by other test instruments; ie fluency, perseverance in naming, may be preserved but are susceptible to context, attention, concentration and intentionality. deterioration. In addition it provides a form of therapy which may It is perhaps important to point out that these stimulate cognitive activities such that areas subject disorders are not themselves musical, they are disto progressive failure are maintained. Certainly the orders of audition. Only when disorders of musical anecdotal evidence suggests that quality of life of production take place can we begin to suggest that Alzheimer patients is significantly improved with a musical disorder is present. Improvised musical music therapy accompanied by the overall social playing is in a n unique position to demonstrate this benefits of acceptance and sense of belonging gained hypothetical link between perception and production. by communicating with others. Prinsley recommends Descriptions of musical perception emphasize the music therapy for geriatric care i n that it reduces the importance of context where different levels of individual prescription of tranquilizing medication, attention occurring simultaneously against a backreduces the use of hypnotics on the hospital ward and ground temporal structure. Musical improvisation helps overall rehabilitation. He recommends that with a therapist, which emphasizes attention to the music therapy be based on treatment objectives; the environment utilizing changes in tempo and volitional social goals of interaction co-operation; psychological response, without regard for lexical content, may be goals of mood improvement and self-expression; intelan ideal medium for treatment initiatives with lectual goals of the stimulation of speech and Alzheimer's patients. The playing of simple rhythmic organization of mental processes; and the physical patterns and melodic phrases by the therapist, and goals of sensory stimulation and motor integration8. the expectation that the patient will copy those The understanding of musical production may well patterns or phrases, is similar to the element of 'registration' in the mental state examination. offer a clue to the ground structure of language and While improvised musical playing is a useful tool communication in general. It is research in this realm of perception which is urgent not only for the underfor the assessment of musical abilities, it is also used within a therapeutic context. In this way assessment standing of Alzheimer's patients but in the general and therapy are interlinked; assessment providing the context of cognitive deficit and brain behaviour. criteria from which to identify therapeutic goals and develop therapeutic strategies. Acknowledgment: The author would like to thank the music therapist Gudrun Aldridge for access to the audio-tape If we are unsure as to the normal process of cogrecording of her clinical work, and her clinical insights into nitive loss in aging, we are even more in the dark working with the elderly. as to the normal musical playing abilities of adults. The literature suggests that musical activities are preReferences served while other cognitive functions fail. Alzheimer 1 Aldridge D. Music, communication and medicine: dispatients, despite aphasia and memory loss, continue cussion paper. J R Soc Med 1989;82:743-6 to sing old songs and to dance to past tunes when 2 Gates A, Bradshaw J. The role of the cerebral hemigiven the chance. However, the production of music, spheres in music. Brain Lung 1977;4:403-31 and the improvisation of music appears to fail in the 3 Morgan 0, Tilluckdharry R. Presentation of singing same way in which language fails. Unfortunately no function in severe aphasia. West Indian Med J 1982; established guidelines as to the normal range of 31:159-61 4 Berman I. Musical functioning, speech lateralization and improvised music playing of adults is available. the amusias. S Afi Med J 1981;59:78-81 Improvised music therapy in our experience appears 5 Jacome D. Aphasia with elation, hypermusia, musicophilia to offer the opportunity to supplement mental state and compulsive whistling. J Neurol Neurosurg Psychiatry examinations in areas where those examinations are 1984;47:308-10 lacking (Table 1). First, it is possible to ascertain the 6 Beatty WW, Zavadil KD, Bailly RC, et aL Preserved fluency of musical production. Second, intentionality, musical skills in a severely demented patient. Znt J Clin attention to, concentration on and perseverance with Neuropsychol 1988;10:158-64 the task in hand are important features of producing 7 Swartz K, Hantz E, Crummer G, Walton J, Frisina R. Does musical improvisations and susceptible to being heard the melody linger on? Music cognition in Alzheimer's in the musical playing. Third, episodic memory can disease. Semin Neurol 1989;9:152-8 8 Prinsley D. Music therapy in geriatric care. Aust Nurses be tested in the ability to repeat short rhythmic and J 1986;15(9):48-9 melodic phrases. The inability to build such phrases may be attributed to problems with memory or to a An extended list of references can be obtained from yet unknown factor. This unknown factor is possibly the author. involved with the organization of time structures. If rhythmic structure is a n overall context for musical production, and the ground structure for perception1, (Accepted 30 December 1991) itDavid can be hypothesized that it is this overarching Aldridge Collected neurology papers 72

MISE

POINT

DELA MUSIQUEEN TANT QUE THERAPIE DE LA MALADIE D'ALZHEIMER PARDAVIDALDRIDGE* Il est tout Ã fait Ã©videnque la maladie d'Alzheimer reprÃ©sentun facteur de stress important pour les patients et pour leurs familles. La perte de la mÃ©moiret la perte du langage qui l'accompagne, prÃ©cÃ©da l'installation des troubles moteurs, se traduisent par une perturbation de la vie quotidienne des patients. La communication, vÃ©ritabloutil du contact social, est interrompue et brouillÃ©eLa menace d'une dÃ©tÃ©rioratiprogressive et de problÃ¨me comportementaux a un impact non seulement sur les patients, mais Ã©galemensur les familles qui doivent prendre sur elles une partie de la responsabilitÃsociale de faire soigner le malade, et en mÃªm temps supporter le fardeau Ã©motionnede voir un Ãªtr cher devenir de plus en plus confus et isolÃ©Dans ce contexte, jouer de la musique peut offrir une thÃ©rapiadjuvante susceptible de renforcer les capacitÃ©de communication et de favoriser l'interaction sociale.

Depuis la Seconde Guerre mondiale, la musicothÃ©rapia Ã©tutilisÃ©dans nombre d'hÃ´pi taux d'Europe et des Etats-Unis dans le cadre de la rÃ©Ã©ducati des patients adultes. Il existe deux grandes formes de musicothÃ©rapie La musicothÃ©rapirÃ©ceptive qui consiste Ãjouer de la musique en direct, ou prÃ©-enregistrÃ© L'exercice peut Ãªtr pratiquÃindividuellement ou en groupe. La musicothÃ©rapiactive, elle, implique que le patient joue avec le thÃ©rapeute Quelquefois, cette derniÃ¨r technique fait appel Ã l'improvisation afin d'accorder les besoins individuels du patient avec son tempo et ses capacitÃ©s Lorsque l'on utilise des instruments de percussion, des instruments mÃ©lodiquesimples (comme le mÃ©tallophone par exemple), le patient n'a nul besoin de possÃ©deune expÃ©rienc musicale trÃ¨poussÃ©e Chanter et se servir de la voix joue Ã©galemen un rÃ´l important dans des approches musicothÃ©rapique plus poussÃ©es Tard dans la vie adulte, Ã l'Ã¢g de 56 ans, aprÃ¨ avoir achevÃdeux concertos majeurs pour piano, le compositeur Maurice Ravel commenÃ§Ã se plaindre d'une fatigue et d'une lassitude sans cesse croissantes. A la suite d'un accident de la circulation, son Ã©tase dÃ©tÃ©rio progressivement. Il perdit sa facultÃÃ se souvenir des noms, Ã parler spontanÃ©menet Ã Ã©crire Bien qu'il puisse comprendre les paroles, trÃ¨ vite il n'eut plus la coordination requise pour diriger un grand orchestre. Alors que son esprit Ã©taiplein d'idÃ©ede musiques, raconte-il, il n'Ã©taiplus Ã mÃªm de les exprimer. Finalement, ses fonctions intellectuelles et son langage se dÃ©tÃ©riorÃ¨r au point qu'il devint incapable de reconnaÃ®tr sa propre musique. Pourtant, la capacitÃde rÃ©ponsÃ la musique des patients atteints de maladie d' Alzheidu langage est mer est un phÃ©nomÃ¨ tout Ã fait remarquable. Alors que la dÃ©tÃ©riorati caractÃ©ristiqudu dÃ©ficicognitif, les capacitÃ©musicales semblent en ce cas prÃ©ser vÃ©esCeci peut-Ãªtr parce que les fondements du langage sont de nature musicale, et antÃ©rieurs dans le dÃ©veloppement aux fonctions lexicales et sÃ©mantiques Alors que le traitement du langage peut Ãªtr dominant dans l'un des deux hÃ©misphÃ¨r cÃ©rÃ©brau la production musicale implique une comprÃ©hensiode l'interaction de ces deux hÃ©mi sphÃ¨res On trouve des indices de la stratÃ©giglobale du traitement cÃ©rÃ©br de la musique dans la littÃ©raturclinique. Dans deux cas d'aphasie', le chant a Ã©tconsidÃ©rcomme l'unique

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voie pour Ã©chappe Ã l'incapacitÃ©Les auteurs de l'article pensent que chanter Ã©tai un moyen pour communiquer avec l'extÃ©rieur Alors que le plus rÃ©cenaspect du discours Ã©tai perdu, demeurait la fonction musicale, plus ancienne, peut-Ãªtrparce que la musique est une fonction rÃ©partidans les deux hÃ©misphÃ¨re Berman2suggÃ¨rque la guÃ©riso de l'aphasie ne dÃ©penpas d'un nouvel apprentissage par l'hÃ©misphÃ¨ non dominant, mais d'une Ã§prisen main>>du langage par cet hÃ©misphÃ¨r L'hÃ©misphÃ¨ non dominant pourrait ainsi constituer une rÃ©servde fonctions en cas de dÃ©faillancrÃ©gionale Le chant et la musicalitÃsont rarement testÃ©een tant que caractÃ©ristiquede la dÃ©tÃ rioration cognitive, en dÃ©pi du fait que la prÃ©servatiode ces capacitÃ© chez des aphaet pourrait donc constituer un indicasiques a Ã©tassociÃ©Ã la possibilitÃde guÃ©rison teur significatif des modifications hiÃ©rarchique au niveau du fonctionnement cognitif. Jacome3a rencontrÃun patient n'ayant aucune notion de musique, atteint d'une aphasie mixte transcorticale, qui Ã©mettai spontanÃ©men quantitÃde sifflements en rÃ©pons Ã des questions. Par ailleurs, le patient chantait souvent spontanÃ©ment sans erreurs de ton, de mÃ©lodie de rythme ni de lyrique, et passa une longue pÃ©riodÃ apprendre la musique. Beatty4dÃ©cri le cas d'une femme ayant de sÃ©vÃ¨r difficultÃ© en matiÃ¨rd'aphasie, de dysfonctionnement mnÃ©siquet d'apraxie, encore capable de chercher Ã dÃ©chif frer une partition inconnue et de la jouer sur xylophone - instrument qui pour elle n'Ã©tai pas habituel. Elle ne se rappelait plus jamais le nom de la musique qu'elle jouait. Schwartz et ses collaborateurs5proposent une sÃ©ride niveaux perceptuels oÃ s'intÃ¨ greraient les dÃ©sordremusicaux: (i) le niveau acoustico-physiologique, qui comprend des modifications de l'intensitÃ©du ton et du timbre; (ii) le niveau discriminatoire, qui inclut la distinction des intervalles et des accords; (iii) le niveau catÃ©goriel qui inclut l'identification catÃ©goriell de schÃ©marhytmiques et d'intervalles; (iv) le niveau configurationnel, qui inclut la perception mÃ©lodique la reconnaissance de motifs et de thÃ¨mes les changements de ton, l'identification des instruments et la discrimination rythmique; enfin (v), le niveau oÃ la forme musicale est reconnue, y compris des fonctions d7harmonie exÃ©cutiveet perceptuellement complexes, ainsi que des transformations mÃ©lo diques et rythmiques. Chez les alzheimeriens, on peut s'attendre Ã ce que les niveaux (i), (ii) et (iii) soient intacts, alors que les complexitÃ© des niveaux (iv) et (v) - lorsqu'elles ne nÃ©cessiten aucune dÃ©signatio- peuvent Ãªtr Ã©galemen prÃ©servÃ© mais sont susceptibles de dÃ©tÃ©rioratio Il est peut-Ãªtr important de souligner que ces dÃ©sordrene sont pas en eux-mÃªmede nature musicale, ce sont des dÃ©sordrede l'audition. C'est seulement lorsqu'interviennent des dÃ©sordrede la production musicale, que nous pouvons commencer Ã penser Ã l'existence d'un dÃ©sordrmusical. Jouer de la musique improvisÃ©est, sur ce plan, un moyen privilÃ©gipour dÃ©montrece lien hypothÃ©tiquentre perception et production. Les adultes identifient les mÃ©lodiefamiliÃ¨reen fonction d'informations relationnelles sur les intervalles entre les tons plutÃ´que sur la base d'informations absolues concernant des tons particuliers. Pour ce qui concerne la reconnaissance de mÃ©lodienon familiÃ¨resdes informations moins prÃ©cisesont rÃ©uniesur le ton lui-mÃªmeLa premiÃ¨r prÃ©occupatioest relative aux modifications successives de frÃ©quences ou contour mÃ©lo dique. Le contexte rythmique prÃ©parpar avance celui qui Ã©coutÃ la survenue de certains intervalles musicaux et donc Ã une structure Ã partir de laquelle il est possible de discerner, ou de prÃ©voirune modification. On ne peut pas Ãªtr prÃ©vende certaines modifications et se retrouver hors du ton ou hors du temps; c'est pourquoi une perte de Ã de la confusion - peut reprÃ© la structure rythmique - qui ressemble extÃ©rieuremen

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senter un facteur cachÃdans la comprÃ©hensiode la maladie d'Alzheimer. Ce qui importe dans ces descriptions de perception musicale est l'accentuation du contexte ou se situent les diffÃ©rentniveaux d'attention survenant simultanÃ©ment en toile de fond, dans une structure temporelle. L'improvisation musicale en compagnie d'un thÃ©rapeut - qui renforce l'attention Ã l'environnement en utilisant des modifications du tempo et une rÃ©ponsvolitionnelle indÃ©pendantdu contenu lexical - peut constituer une situation idÃ©alpour des initiatives de traitement de patients atteints de maladie d'Alzheimer. La rÃ©alisatiode phrases mÃ©lodiqueet de schÃ©marythmiques simples par le thÃ© rapeute, et l'attente que le patient reproduisent ces phrases ou ces schÃ©masest tout Ã fait comparable Ãl'Ã©lÃ©me <<enregistrement> du Mini Mental State Examination (MMSE). Si jouer de la musique improvisÃ©constitue un outil trÃ¨utile pour l'Ã©valuatiodes capacitÃ©musicales, la mÃ©thodpeut Ã©galemens'insÃ©redans un contexte thÃ©rapeutiqu destinÃÃ Ã©valueles capacitÃ©cognitives (voir Tableau 1). Dans cette approche, l'Ã©va luation et la thÃ©rapisont interconnectÃ©e- l'Ã©valuatiofournissant les critÃ¨re Ã partir desquels on identifiera des objectifs thÃ©rapeutiqueet on dÃ©velopperdes stratÃ©giede traitement. La plupart des travaux publiÃ©au sujet de la musicothÃ©rapiappliquÃ©aux personnes Ã¢gÃ© Ã©voquenles activitÃ©de groupe6", ce procÃ©dÃ©tangÃ©nÃ©raleme utilisÃ pour accroÃ®tr les capacitÃ©de socialisation et de communication, dans l'intention de rÃ©duir les problÃ¨me de retrait et d'isolement social, de contribuer Ã l'expression et Ã la communication des idÃ©eet des Ã©motions et de stimuler les processus cognitifs, donc d'aiguiser les facultÃ©de rÃ©solutiodes problÃ¨mesD'autres objectifs visent Ã©galemenla stimulation musculaire et sensorielle ainsi que le dÃ©veloppemenÃ plusieurs niveaux des capacitÃ©motrices8. et a constatÃque la musicothÃ© Clair9 a Ã©normÃ©me travaillÃ avec les personnes Ã¢gÃ© rapie Ã©taiun outil trÃ¨ efficace dans le travail de groupe, pour favoriser la communication, regarder les autres, chanter, jouer d'un instrument et s'asseoir. Sa principale conclusion est que, mÃªm si les membres du groupe ont effectivement subit une grave dÃ©tÃ rioration de leurs capacitÃ©cognitives, physiques et sociales au cours des quinze mois de la pÃ©riodd'observation, ils ont tout de mÃªm continuÃ Ã participer aux activitÃ© musicales. Pendant les trente minutes des sessions, les membres du groupe s'asseyaient rÃ©guliÃ¨reme sur leurs chaises - sans aucune restriction physique quant Ã la durÃ©de chacune des sessions - et rÃ©agissaienavec les autres sans se prÃ©occupede leur handicap. L'auteur cite notamment le cas d'un homme de 66 ans, pour lequel la musicothÃ© rapie avait permis de le sortir de son isolation sensorielle au point qu'il devint capable de participer aux sessions avec les autres, mÃªm si ce n'Ã©taiparfois que pour un court instant. Le vagabondage, la confusion et l'agitation sont des problÃ¨me frÃ©quentchez les personnes Ã¢gÃ© rÃ©sidandans des institutions ou dans des Ã©tablissementspÃ©cialemen conÃ§upour les alzheimÃ©riens Un m~sicothÃ©rapeute' a testÃle chant sur une femme de 81 ans afin de voir si ce procÃ©dl'aidait Ã rester assise. Au bout de vingt sÃ©ancede chant, le thÃ©rapeutentrepris de faire de la lecture Ãla patiente pour comparer son niveau d'attention. RÃ©sultat alors que les sessions de musicothÃ©rapiet de lecture amÃ©lioraien Ã©galemenles problÃ¨mede vagabondage, le temps total passÃassis lors des sÃ©ancede musicothÃ©rapiÃ©taiplus de deux fois plus long que celui passÃassis lors des sÃ©ance de lecture (214,3 minutes contre 99,l en moyenne); en outre, le temps passÃassis pendant la musicothÃ©rapiÃ©taiplus important que les Ã©pisodesporadiques ou on lui fai-

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Collected neurology papers

sait la lecture. Lorsque ce type de femme Ã¢gÃmanifeste de l'agitation, la musicothÃ© rapie individuelle semble donc avoir un effet calmant significatif". Pour ce qui concerne la rÃ©ductiode comportements rÃ©pÃ©titif l'activitÃ musicale diminue Ã©galemenles invectives et les vocalisations perturbatrices12. par Groenel'. Trente pensionnaires (Ã¢gÃde 60 Les conclusions ci-dessus sont Ã©tayÃ© Ã 91 ans) d'une unitÃ spÃ©cialpour Alzheimeriens, qui avaient tendance au vagabondage, ont Ã©trÃ©partide maniÃ¨r randomisÃ©soit dans des groupes de musicothÃ©rapie soit dans des groupes de lecture, ou l'on s'occupait d'eux individuellement. Les patients suivant les sÃ©ancede musicothÃ©rapidemeuraient plus longtemps assis que ceux participant aux sÃ©ancede lecture. L'un des principaux problÃ¨mede la vieillesse est la perte d'indÃ©pendancet de l'estime de soi, et PalmerI4 dÃ©criun programme de musicothÃ©rapiedans une rÃ©sidencgÃ©ria trhue, conÃ§pour reconstruire le concept de soi. Pour les 380 rÃ©sident- allant de ceux qui s'avÃ©raientotalement fonctionnels Ã ceux que l'on devait totalement prendre en charge -,un programme a Ã©tconÃ§de maniÃ¨r Ã s'adapter aux capacitÃ©et besoins de chacun. Marcher et danser accroissaient ainsi les facultÃ©de certains patients Ã se mouvoir correctement; et, pour ceux qui ne pouvaient plus se dÃ©placertaper du pied en suivant le rythme de la musique amÃ©lioraila circulation et augmentait la tolÃ©rancet la force. Les sÃ©ancede chant servaient Ã encourager l'Ã©mergencdes souvenirs ainsi qu'Ã favoriser l'interaction et le comportement socialI4.C'est prÃ©cisÃ©me ce comportement susceptible d'amÃ©lioratioau travers d'actisocial que P ~ l l a c kconsidÃ¨r '~ comme Ã©tan vitÃ©de musicothÃ©rapide groupe. Dans ce qui suit, nous Ã©voqueronl'Ã©lÃ©me participatif, qui semble particuliÃ¨remenintÃ©ressan pour ce qui concerne la communication, et l'intention de participer, qui est au centre de l'activitÃ de musicothÃ©rapie

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La rnusicot erapie a ete ega ement uhlisÃ¨ pour &dÃ¨'plÃ¼sp&^i?lq~ie'lâ€¢i~~ a\a ~Ã©nii niscence des chansons et des mots parlÃ©sI6 Chez dix patients alzheimeriens ~robables, il a Ã©tconstatÃque les paroles des chansons revenaient en mÃ©moirinfiniment mieux que les mots parlÃ©ou les informations parlÃ©esMÃªm si les patients se rappelaient les chants familiers avec beaucoup plus de prÃ©cisioqu'une chanson nouvelle, la plupart d'entre eux essayaient tout de mÃªm de chanter, de fredonner ou de battre la mesure pendant que le thÃ©rapeutchantait. Smith suggÃ¨r cependant que ce sont des facteurs comme le tempo, la durÃ©des mots (mesurÃ©en secondes) et le nombre total de mots qui seraient le plus susceptibles d'Ãªtr associÃ©Ã la rÃ©miniscenclyrique, lu tÃ´que le caractÃ¨r plus ou moins familier d'une chanson donnÃ©e" Dans une autre Ã©tudportant sur les effets de trois approches thÃ©rapeutiquediffÃ©rente (rÃ©miniscencinduite musicalement, rÃ©miniscencinduite verbalement et musique seule) sur le fonctionnement cognitif de douze patientes d'une maison de retraite atteintes de maladie d'Alzheimer, les modifications du fonctionnement cognitif ont Ã©tÃ©valuÃ© en fonction des diffÃ©rence- avant et aprÃ¨ sÃ©ancede traitement - des scores obtenus au Mini Mental State Examination. Les comparaisons ont Ã©teffectuÃ©eÃ la fois pour les scores totaux et pour les sous-scores relatifs Ã l'orientation, Ã l'attention et au langage. RÃ©sultatles rÃ©miniscenceinduites verbalement et musicalement augmentaient significativement les sous-scores relatifs au langage, tandis que l'activitÃ musicale seule accroissait, elle, significativement les scores totaux1'. AldridgeIy dÃ©crile traitement d'une femme de 55 ans et les bÃ©nÃ©fic apportÃ©par le jeu de musique improvisÃ©eIl y eut, explique-t-il, des amÃ©liorationsignificatives des capacitÃ©motrices fines. Sa facultÃÃ se souvenir des schÃ©marythmiques, et la capa-

David Aldridge

Collected neurology papers