Neurology papers

Neurology papersDavid Aldridge Collected Papers

The Arts in Psychotherapy. Vol. 19, pp. 243-255, 1992 Printed in the USA. All rights reserved.

0197-4556192 $5.00 + .OO Copyright 0 1992 Pergamon Press Ltd.

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 Alz- heimer'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 evo- lution of the nosologic approach to disease and early clinical descriptions of neurosyphilis and Hunting- ton'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 Alzhei- mer'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.

David Aldridge Collected neurology papers 1

244 ALDRIDGE AND ALDRIDGE

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 us- age, to describe cognitive impairment, it is generally applied to two conditions: dementia of the Alzhei- mer'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).

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 fall- ing, and behavioral problems (Walsh, Welch, & Lar- son, 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


TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA 245

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 Ex- amination (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; Gag- non, 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

Table 3 Features Differentiating Pseudodementia From Dementia

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 Exam- ination (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-

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.



Table 4 Mini-Mental State Examination

Item Component Score

Orientation for time year, season, month, date and day 5 Orientation for place Registration Attention for calculation Recall Naming

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

Repetition No ifs, ands, or buts 1 Three stage verbal command Take a piece of paper in your right hand, fold it in half, and put it on the floor 3 Written command Close your eyes 1 Writing A spontaneous sentence 1 Construction Total

Two interlocking pentagons

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.

Table 5 Features of Medical and Musical Assessment

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

Medical Elements of Assessment Musical Elements of Assessment

continuing observation of mental and functional status 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; visuo-spatial skills and ability to cortical disorder testing; visuo-spatial skills and ability to perform complex motor tasks (including grip and right left perform complex motor tasks (including grip and right left coordination) coordination) testing for progressive memory disintegration testing for progressive memory disintegration motivation to complete tests, to achieve set goals and motivation to sustain playing improvised music, to achieve persevere in set tasks 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


TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA

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 Alz- heimer'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 & Han- non, 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.

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 (Be- atty, 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



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 (Ald- ridge, 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,

Trehub, Thorpe, & Podilupo, 1985). Temporal pre- dictability 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 ad- vance 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). Mu- sical improvisation with a therapist, which emphasizes attention to the environment (Sandman, 1984; Walker & Sandman, 1979, 1982) utilizing changes in tempo and volitional response (Safranek, Kosh- land, & 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


TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA 249

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 pack- age. 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 Alz- heimer'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-

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 or- ganizing 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 Ha- baner 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.


ALDRIDGE AND ALDRIDGE

Example 3. A change in the pattern of 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. How- ever, 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

difficulty in playing them, which may have been com- pounded 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).

Harmonic Playing

At the beginning of the very first session after en- tering 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 har- monically 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-


TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA 25 1

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 pro- ceed and needed instructions.

The patient displayed few changes in her dynamic playing. She reacted to dynamic contrasts and transi- tions, 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

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

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 conver- sations. 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 en- joyed, 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

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



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-

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 (Prins- ley, 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. Fur- thermore, 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, 199 1a; 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.



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 Music Therapy Examples

continuing observation of mental and functional status

testing of verbal skills, including element of speech fluency

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

"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


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).


- 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

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

We had set out to negotiate a common language therapeutic changes has been developed, which is the between practitioners, and this was achieved. Al- first step in a continuing program of research dia- though the clinical benefits of music therapy for pa- logues. The next step is for other therapists to attempt tients with dementia or pseudodementia remain spec- correlations with their elderly patients to see if our ulative, a common language to discuss and compare hypotheses stand up to practical clinical investigation.



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.

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163

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 Aldridge

3

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 becomingan increasingly serious problem for health care systems. Integrative treatment concepts arecurrently regarded as promising therapeutic approaches for managing tinnitus. The aim of thisstudy was to present the results of auditive stimulation therapy, a program of music therapydeveloped specifically for tinnitus treatment. We collected data on outpatient treatment resultsfrom 155 tinnitus patients and evaluated them in a prospective observational study with threedefined times of measurement (start, end, and 6 months after the end of treatment). Apart fromanamnestic data and subjective evaluation of treatment, the major outcome parameter was thescore of the tinnitus questionnaire. To evaluate effectiveness of the therapy, we calculated ef-fect sizes (according to Cohen). Fifty-one percent of the patients were male, and the mean pa-tient 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 tinnituswas more than 6 months for 80% of patients, and 43% had been suffering from tinnitus formore than 3 years. In general, all subscales of the tinnitus questionnaire showed highly signif-icant changes (

t

-test,

p

�

.01) between the measurement points “start of therapy” and “end oftherapy,” whereas no significant difference was found between the measurement points “endof therapy” and “follow-up.” At follow-up, the values of the subscales were stabilized at alevel recorded at the end of the therapy; we did not observe a reduction to the level prior totreatment. 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 psycho-logical training rendered the best effect sizes. This study demonstrated that music therapyis an effective integrated treatment approach and offers a way to make progress in tinnitustreatment.

Key Words:

effectiveness; music therapy; outcome research; tinnitus

he term

tinnitus

is derived from the Latin

tinnire

(“ringing”) and is defined as the perception ofsound in the absence of any appropriate exter-

nal stimulation. A basic difference separates objectiveand subjective tinnitus. The term

objective tinnitus

isused for ear sounds based on genuine physical vibra-tions-oscillations that may be perceived by others oreven measured [1]. This type of tinnitus is rather rare,whereas subjective tinnitus is far more frequent. In

Reprint requests: Prof. Dr. David Aldridge, UniversitätWitten Herdecke, Alfred Herrhausen Strasse 50, 58448,Witten, Germany. E-mail: [email protected]

T

such cases, only the person afflicted perceives thesounds. These may occur as rustling, whistling, whir-ring, ringing, or droning sounds. High-frequency soundsare perceived far more often than are low-frequencysounds [2], and a hearing impairment is detectable inmore than 50% of all cases.

The incidence of patients experiencing tinnitus inGermany and the Western world is approximately 10%.Some 1–2% of the population is severely disturbed bytinnitus, which may disrupt everyday activities andsleep [3]. If the symptoms continue for 6 months, weconsider the condition to be chronic, the degree ofwhich differs considerably from person to person and


International Tinnitus Journal, Vol. 11, No. 2, 2005 Kusatz et al.

164

affects patients in different ways [4]. A decompensatedtinnitus is accompanied in most cases by other com-plaints (e.g., depression, anxiety, impaired sleep andconcentration, sensitivity to noises, and the like) [5–7];consequently, intervention is required. Several treat-ments of chronic tinnitus have been proposed and im-plemented [8]. Among complementary therapies, home-opathy and acupuncture are proposed [9–11]. Althoughseveral case studies reported efficacy of these treat-ments, the empirical support in well-controlled studiesis still weak [12,13].

Today, such integrative therapy concepts as cogni-tive-behavioral treatment compiled from counseling,relaxation therapy, music therapy, and pharmacologicalpreparations (lidocaine, neurotransmitters) are regardedas promising therapeutic approaches for managing tin-nitus [7]. In particular, music therapy offers the chanceof a global treatment approach for tinnitus patients[14]. Harmony, for instance, as a connecting link be-tween rhythm and melody also has a social function.Rhythm may also influence biological parameters viatempo accentuation and meter [15]. These componentsform the theoretical background for auditive stimula-tion therapy (AST), the music therapy (MT) programevaluated in this study.

THERAPY

AST is a complex program of MT originally employedin the treatment of chronic pain and developed specifi-cally for tinnitus treatment. It consists of a total of 10therapy sessions and employs specifically developedreceptive music programs in combination with an edu-cation program. Musical self-control (MSC) training isa music program designed on the basis of music psy-chology and MT, the effectiveness of which was dem-onstrated in a clinical study [16]. The objective of MSCtraining is to improve patients’ control of ear soundsand to relieve their feelings of helplessness. Ringing inthe ear or strange sounds bring about alterations in per-ception. If we encourage the ability of selective hear-ing, we can promote some sounds in the hierarchy ofperception and ignore other sounds or regulate themuntil they become hardly perceptible. Such training im-proves (i.e., lowers) the level of sensitivity to sounds.

Finally, the objective of AST is to bring about achange in sound perception that induces relaxation, re-duces anxiety, and stimulates changes in unfavorablebehavior patterns, thus improving the emotional state.The education program is aimed at alterations on a cog-nitive level.

The outpatient therapy (duration, 2 weeks) withAST consisted of a total of 38 hours of therapy (20-hrpsychological training, 10-hr MT [AST], 8-hr kinesi-

therapy) and also included counseling by ear, nose, andthroat experts, orthopedists, and dentists. Figure 1 showsthe complete 2-week program of AST with its differentmodules.

METHODS

At the Tinnitus Therapie Zentrum Krefeld (Germany),we performed an observational study on a multimodaltreatment concept (Krefelder-Modell) being applied onan outpatient basis for subacute and chronic tinnitusover a projected period of 2 years. Data on treatmentwere collected and evaluated in a prospective observa-tional study using several standardized questionnairesimmediately before and after therapy and at follow-upafter 6 months. Apart from anamnestic data, the ques-tionnaires asked for a subjective evaluation of treat-ment results. The tinnitus questionnaire designed byGoebel and Hiller [17], now the recommended standardtool throughout Germany, was used at all times formeasurement. Included in the evaluation were onlythose questionnaires in which more than 90% of thequestions were answered properly.

We included a total of 155 patients in this evalua-tion. Sufficient follow-up documentation for assess-ment was available for 111 patients (71.6%). Figure 2shows the questionnaire instruments used and the pa-tient flow in this study.

For an evaluation of the efficiency and sustainedsuccess of the therapy, we applied the

t

-test to showsignificant differences of tinnitus questionnaire scalesafter therapy. We carried out subgroup analysis of out-come measures according to the degree of tinnitus se-verity. Therefore, the tinnitus questionnaire results weregrouped in the following clinically relevant groups:minor tinnitus (0–30 points); medium tinnitus (31–46points); serious tinnitus (47–59 points); and very serioustinnitus (60–84 points).

As the treatment concept presented in this study(Krefelder-Modell) is a multimodal concept, the differ-

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


Auditive Stimulation Therapy in Tinnitus International Tinnitus Journal, Vol. 11, No. 2, 2005

165

ent elements of treatment can be compared to achievemore detailed results on the efficiency of the MT train-ing program (AST). Kinesitherapy having received adistinctly lower rating by patients, only the two treat-ment elements rated as most successful were comparedwith respect to their effectiveness: psychological train-ing (PT) and music therapy (MT).

To evaluate effectiveness of the therapy and to ren-der the results comparable with each other and alsowith other treatment facilities in the health care sector,we calculated effect sizes according to Cohen [18] andcorrected according to McGaw and Glass [19].

PATIENTS

One hundred thirty-seven patients (88.38%) were ofwage-earning age (i.e., between 18 and 65 years). Table1 shows that the duration of tinnitus was longer than6 months for 80% of patients. A total of 43.3% hadbeen suffering from tinnitus for more than 3 years; 33.5%of those interviewed reported that tinnitus developedgradually. Every second patient (50.3%) said tinnitusset in suddenly; 16.1% did not answer this question;76.8% said tinnitus occurred continuously; and 21.3%reported that tinnitus occurred with interruption. Threepatients (1.9%) had no comment. Almost all patients(94.8%) reported times at which tinnitus was particu-larly intense. In contrast, only 75.5% said that at timestinnitus was barely perceptible.

Patients were also asked how often they resorted toseeking assistance through the health care system over6 months before treatment, and they had the option of

several possible answers. Seventy-four patients answer-ing this question (47.74%) reported 111 individual con-sultations (main consultation with ear, nose, and throatspecialists), which means an average of 1.5 consulta-tions per patient approximately. Before treatment, pa-tients were also asked about previous treatment; 137patients reported a total of 304 instances (i.e., an aver-age of 2.2 treatments per patient). The major treatmentswere infusions (78.8%).

RESULTS

The total score of the tinnitus questionnaire (TinnitusFragebogen [TF]) at the different measurement pointsis shown in Figure 2. The follow-up sample with regardto the TF total score did not differ significantly fromthat of the general population, which has been demon-strated [16]. Therefore, Figure 3 shows the mean scalevalues of the tinnitus questionnaire before and after out-patient tinnitus therapy (n

�

146) and also at follow-upafter 6 months (n

�

106).In general, all subscales showed highly significant

changes (

t

-test,

p

�

.01) between the measurementpoints “start of therapy” and “end of therapy,” whereaswe found no significant difference between the mea-surement points “end of therapy” and “follow-up.” Atfollow-up, the values of the subscales were stabilized ata level recorded at the end of the therapy; we did notobserve a reduction to the level before treatment. Ap-proximately 80% of the patients with a disease severityof

medium

to

very serious

at least moved to a clinicallyimproved stage (e.g., from

very serious

to

serious

). The

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



166

details of this transition process will, however, be thesubject of a following evaluation using Marcov-chainsmethods.

We determined the values of effect sizes for individ-ual subscales and for the total score. The values for theeffect sizes were all in the range of medium (

�

0.5) tohigh (

�

0.8), with the exception of the scale

somaticdisorders

, and are illustrated in Figure 4.In a comparison of the individual therapies, AST

was responsible for a surprisingly high percentage ofthe positive total result and clearly was preferred by pa-tients, despite the fact that psychological training wastwice as long (20 therapy session hours as compared to10 for MT). For further analysis of these findings, we

Table 1.

Sociodemographic and Anamnestic Data

Characteristic Male Female Total

Gender 51% 49% 100%

Age Mean 48.9 yr 48.7 yr 48.8 yrStandard deviation 12.1 yr 15.5 yr 13.9 yrMedian 52 yr 50 yr 51.5 yr

Marital statusSingle 16% 17% 17%Married or established partner 74% 64% 69%Divorced or living separated 10% 9% 10%Widowed — 9% 5%

GraduationSecondary school 55% 43% 49%Secondary modern school 25% 29% 27%High school, A-levels 7% 18% 13%University or college 13% 9% 11%

ProfessionLaborer 33% 13% 23%Clerk 40% 48% 44%Self-employed 4% 3% 3%Unemployed 24% 37% 30%

Duration of tinnitus

�

6 mo 20% 20% 20%6–12 mo 16% 16% 16%1–3 yr 20% 22% 21%3–5 yr 14% 10% 12%

�

5 yr 30% 32% 31%

Loudness, ear-ringing: 0 (not at all) to 10 (maximum)Mean (95% CI) 6.5 (6.0–7.0) 5.5 (4.9–6.1) 6.1 (5.7–6.5)Standard deviation 2.2 2.8 2.5Median 6 5.5 6

Disruption, ear-ringing: 0 (not at all) to 10 (maximum)Mean (95% CI) 7.0 (6.4–7.6) 6.4 (5.7–7.1) 6.7 (6.3–7.1)Standard deviation 2.6 3.0 2.8Median 7 6 7

Restrictions, ear-ringing: 0 (not at all) to 10 (maximum)Mean (95% CI) 5.8 (5.1–6.5) 4.5 (3.8–5.2) 5.2 (4.7–5.7)Standard deviation 3.0 3.2 3.2Median 6 4 5

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



167

calculated effect sizes at measurement times and re-lated to the patients’ subjective evaluation. Figure 5illustrates the calculation of effect sizes.

A combination of MT and PT renders the best thera-peutic effect. MT alone ranked in second place, and PTwas third. The combination of MT-PT comprises thepartial therapies MT and PT, and this suggests that theshare of MT in this result is higher than that of PT. Inaddition, MT shows excellent effect sizes over longerperiods, a clear indication of the quality of the conceptof AST as to contents and didactic implementation. Theresults appear to confirm in particular the intention ofenabling patients to continue independently with MTand to make autonomous use of receptive music pro-grams. The most expressive results in this context cer-tainly are those of the follow-up, as the data from theseparticular patients are available for all measurementtimes. In retrospect, they were able to come to a conclu-sive evaluation for themselves.

In answer to the question of whether the therapy

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

CONCLUSION

An analysis of the tinnitus problem, particularly from atraditional perspective, suggests a general confusionamong most experts, although many scientists have ex-plored the problem. A great variety of models and treat-ment approaches are available, the effectiveness of whichis still inconclusive. The standard therapies in Germanyinclude medication to improve blood circulation or,with increasing frequency, infusions as part of a hospi-talization period, with disproportionate side effects ascompared to the severity of the complaints [20].

In this study, we were able to demonstrate that themultimodal concept achieves highly significant changes.The calculation of effect size, according to the tinnitusquestionnaire results, illustrates that the most signifi-cant effect sizes occurred in the area of psychologicalstress and total score changes. In comparison with ef-fect sizes of other studies with hospitalized patients andoutpatients summarized in a meta-analysis by Schilter[21], the advantages of this treatment concept becomeevident. With an overall effect size of 0.63 from pre-therapy to follow-up, other multimodal therapeuticstrategies range far behind the results of the therapeuticapproach described in this study. Medical treatments(e.g., tocainide, lidocaine, carbamazepine) or other rem-edies have effect sizes in the same magnitude; however,these therapies have side effects, such as tremor, vertigo,giddiness, and nausea [21]. Therefore, our nonpharma-cological intervention achieves the high effect sizes ofthe drug-based therapies without their concomitant sideeffects. The Krefelder-Modell treatment concept aloneuses an MT training program embedded within a com-plex treatment approach, indicating that the advantage—compared to other treatment forms—is principally theinfluence of the specific MT intervention.

If we assume that tinnitus is not a disease but asymptom of an underlying process, singular symptom–oriented approaches will fail [2]. Sixty-one percent ofpatients state that professional medical help was notof much use—a shockingly high figure in view of thenumerous medical interventions. Much suggests a holistic

Figure 4. Changes (on the tinnitus questionnaire) of scalevalues in effect sizes. (E � emotional distress; C � cognitivedistress; I � intrusiveness; A � hearing problems; SI � sleep-ing problems; SO � somatic complaints.)

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 betweenmusic therapy and psychotherapy; PT� � subgroup of pa-tients favoring psychotherapeutic elements.)



168

treatment approach, in which ringing in the ear is viewedas a sign of particularly high stress. The question ofwhether the symptom is of a somatic or a psychosomaticnature seems to be of no importance in the treatmentof subacute and chronic tinnitus. An analysis not only ofthe biological but of the psychological and social needsof patients [22] provides a more comprehensive insightinto and understanding of their situation. MT AST isseen as salient to their problems among patients and ashighly effective, perhaps because we are not making adirect, singular psychological intervention but an inter-vention in the same modality as that in which the symp-tom is experienced. By accommodating sound controlwithin an ecology of other sounds, itself within a stress-reduction context, we are offering a form of self-controlthat is adapted to a personal environment [23–25]. Onthis extended basis of our knowledge about hearing, weshould be able to develop for affected patients copingstrategies that address the causes of the problem directlyand thus render the symptom superfluous.

Our follow-up interview of patients after 6 monthsshowed a high degree of sustained therapeutic success.Furthermore, these interviews provide important feed-back for therapists and show longer-term positive treat-ment results, specifically in the areas of well-being andreintegration of patients in their family environment, asamply demonstrated in our study. We hear frequentlythat therapy success in most cases becomes evidentover time. If a reorientation in terms of perception takesplace, the consequences of this reorientation, as thera-peutic effects, are best seen in follow-up assessments.

The subjective symptom of tinnitus is a phenome-non that the unaffected cannot easily understand, as de-fining a cause is difficult in most cases. Hearing ofsounds that are normally located externally is suddenlydirected internally and, therefore, is difficult for othersto imagine. The affected individual suffers from a per-sonal noise problem that is inaudible to others; conse-quently, others lack understanding. Musicians, how-ever, understand this concept as part of their dailypractice [26]. “Only inner anticipatory hearing makesmusical interpretation possible. This phenomenon ismost obvious in Ludwig van Beethoven who composedwithout being able to hear. Accordingly, listening mustalso be seen as an internal process of perception” [14].Neugebauer reminded us that a sensory stimulationmust not necessarily result in a conscious perception,nor must a sensory experience necessarily be caused bya physical stimulus. The specific way in which musictherapists or musicians hear may indeed be helpful orsuitable in understanding tinnitus patients and also inexplaining—taking a composer as an example—howsuch experiences of internal hearing may also be ob-served 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 en-abled to generate expressive potentials that reveal newpossibilities for becoming healthy. In the context of earringing, MT might help to create a context of meaningsthat integrates the sounds or noises into the music andthus removes them from conscious perception, whichwould clearly promote recovery. Sounds no longer per-ceived as disturbing, once brought under control, areperceived as musical.

This study demonstrates that MT is an effectivetreatment approach and offers a way to make progressin tinnitus treatment. Music has an esthetic aspect; it ispart of our cultural heritage. How we integrate soundsinto our daily life and how they become perceived asnoise or music is a complex activity involving the phys-iological, the psychological, and the social. A therapeu-tic intervention that incorporates these understandingsappears to offer considerable benefits, not as a cure butas a healthy adaptation.

REFERENCES

1. Feldmann H. Pathophysiologie des Tinnitus. In H Feld-mann (ed),

Tinnitus

. Stuttgart: Thieme, 1992:33–70.

2. Pilgramm M, Rychlik R, Lebisch H, et al. Tinnitus in derBundesrepublik.

HNO Aktuell

7:261–265, 1999.

3. Rosanowski F, Hoppe U, Kollner V, et al. Interdiscipli-nary management of chronic tinnitus: II.

Versicherungs-medizin

53(2):60–66, 2001.

4. Wilhelm T, Ruh S, Bock K, Lenarz T. Standardisierungund Qualitätssicherung am Beispiel Tinnitus.

Laryn-gorhinootologie

74:300–306, 1995.

5. Duckro PN, Pollard CA, Bray HD, Scheiter L. Compre-hensive behavioural management of complex tinnitus: Acase Illustration.

Biofeedback Self-Reg

9(4):459–469, 1984.

6. Goebel G, Keeser W, Fichter M, Rief W. Neue Aspektedes komplexen chronischen Tinnitus: II. Die verloreneStille: Auswirkungen und psychotherapeutische Möglich-keiten beim komplexen chronischen Tinnitus.

PsychotherPsychosom Med Psychol

41:123–133, 1991.

7. Goebel G. Studien zur Wirksamkeit psychologischerTherapien beim chronischen Tinnitus. In G Goebel (ed),

Ohrgeräusche–psychosomatische Aspekte des komplexenchronischen Tinnitus.

München: Quintessenz, 1992:87–102.

8. Kröner-Herwig B.

Psychologische Behandlung des chro-nischen Tinnitus.

Weinheim: Psychologie Verlags Union,1997.

9. Park J, White AR, Ernst E. Efficacy of acupuncture as atreatment for tinnitus: A systematic review.

Arch Oto-laryngol Head Neck Surg

126(4):489–492, 2000.

10. Simpson JJ, Donaldson I, Davies WE. Use of homeopathyin 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.

12. Biesinger E.

Die Behandlung von Ohrgeräuschen.

Stutt-gart: Georg Thieme Verlag, 1999.

13. Ernst E. Complementary and alternative medicine in thepractice of otolaryngology.

Curr Opin Otolaryngol HeadNeck Surg

8(3):211–216, 2000.

14. Neugebauer L. Schöpferische Musiktherapie bei Patientenmit 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: Tonos-Edition, 1975.

16. Kusatz M. Auditive Stimulation Therapy AST—Interventionin Subacute and Chronic Tinnitus. Hanover:

Proceedings ofthe Fifth Triennial Conference of the ESCOM

, 2003:45–49.

17. Goebel G, Hiller W. Qualitatsmanagement in der Thera-pie des chronischen Tinnitus.

Otorhinolaryngologia-Nova

10(6):260–268, 2000.

18. Cohen J.

Statistical Power Analysis for the BehavioralSciences

. Hillsdale, NJ: Erlbaum, 1988.

19. McGaw B, Glass GV. Choice of metric for effect size inmeta analysis.

Am Educ Res J

17:325–337, 1980.

20. Bork K. Juchreiz nach Hydroxiethystärke: Auch beiIntensivepatienten häufig.

Arznei-telegramm.

31(6):53,2000.

21. Schilter B.

Metaanalyse zur Effektivität medikamentöserund psychologischer Therapien bei chronischem subjek-tivem Tinnitus.

Frankfurt: VAS-Verlag, 2000.

22. Aldridge D. Leben als Jazz. In D Aldridge (ed),

Kairos II,Beiträge zur Musiktherapie.

Göttingen: Verlag Hans Hu-ber 1998:5–6.

23. Aldridge D, Gustdorff D, Neugebauer L. A preliminarystudy of creative music therapy in the treatment of chil-dren with developmental delay.

Complementary TherMed

3:197–205, 1995.

24. Aldridge D.

Music Therapy Research and Practice inMedicine.

London: Jessica Kingsley, 1996.

25. Aldridge D.

Musiktherapie in der Medizin.

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26. Neugebauer L. Das Pfeifen nervt nicht mehr so.

Musik-therapeutische Umschau

4:326–335, 2001.


ALDRIDGE

The Music of the Body: Music Therapy in Medical Settings

David Aldridge

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, we 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).

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?

I

I -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 ep- isode 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 pro- motion 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; Thom- as 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, the Hear t , and Respirat ion

To explore the specific physiological effects of music, we begin with the effects of music on heart rate and blood pressure in healthy people. I f 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 hab- itually 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

If music can influence physiological conditions like heart rate or blood pressure in healthy people, then perhaps i t can be used therapeutically to help patients wi th 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 rhythm- with 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. Meta- bolic 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. Respira- tory 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 accompa-

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 arrhythmias 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 pro- vokes, 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 figur- atively) of the values of . . . 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 con- ccptualization of time that is personal rather than public. This is time as hiros. It is poly- chronic, 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:



ALDRIDGE

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 time- tables 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 stim- ulating 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 & Cunning- ham 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 relationship between listening to music and changes in respiration has been investigated in various situations other than coronary care- with 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).

1983; Lengdobler & Kiessling 1989; Schmut- termayer 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; Bon- ny 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 & Cun- ningham 1987) describes the effect of a 37- minute 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 &?-minute periods 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 worried sentimental sad both happy, other satisfied romantic depressed satisfied and

tranquil

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 admit- ted 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 20- minute 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.

The 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

I

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. ,

Zimmennan examined the effects of listening to relaxation-type music and focused on self-reported anxiety and on selected phys- , iologic indices of relaxation in patients with suspected myocardial infarction. Seventy-five , patients were randomly assigned to one of two experimental groups-one group listened to taped music over headphones, the other to '

"white noisef'*-or to a control group. The Spielberger State Anxiety Inventory (Spiel- berger 1983) was administered before and after each testing session, and blood pressure, heart rate, and digital skin temperatures were measured at baseline and at 10-minute intervals for the 30-minute session. The study revealed no significant difference among the three groups in state anxiety scores or physiologic parameters. Analyses were then con- ducted of the combined experimental groups and showed that significant improvement occurred in all of the physiologic parameters. This finding reinforces the benefit of rest and careful monitoring of patients in the coronary care unit, but adds little to the understanding of music interventions.

Bolwerk (1990) set out to relieve the state anxiety of patients in a myocardial infarction ward using recorded classical music (Bach's Largo, Beethoven's Largo, Debussy's Prelude to the Afternoon of a Faun). Forty adults were randomly assigned to two equal groups, one of which listened to relaxing music during the first four days of hospitalization, the other of which received no music. There was no controlled "silent condition." While , there was a significant reduction in state anxi- I

ety in the treatment group, state anxiety also fell comparably in the control group. The

"White noise" or "synthetic silence" is an attempt to block out environmental noise. In this case it was a tape recording of sea sounds, which themselves l

were rhythmic (Philip 1989; Zimmennan 1989).

reasons for this overall reduction in anxiety may have been that after four days the 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 people in effect become the music makers. In the study by Bason and Celler (1972), the researchers influenced heart rate by first matching the heart rates of their subjects with a musical rhythm. This finding suggests that in studies on the influences of music on heart rate, the music should match the individual patient. Matching also makes psychological sense, since different people have varied reactions to the same music. Further, because improvised music necessarily "meets" the tempo of the patient, it may be that such playing will have a larger impact than does "passive" listening to music.

The finding of Haas and colleagues (19861, that listening coupled with tapping synchronizes respiration pattern with music rhythm, additionally suggests that active music playing can be used to influence physiological parameters and that this synchronization can easily be developed (Ald- ridge 1989a).

Cancer Therapy, Pain Management, and Hospice Care

Cancer and chronic pain can require complex coordinated resources that are not only medical but also psychological, social, and communal (Aldridge 1988; Coyle 1987; Fagen 1982; Frampton 1986; Frampton 1989; Gilbert 1977; Heyde & von Langsdorff 1983; Walter 1983). Hospice care in the United States and England has similarly attempted to meet the need for the varied palliative and supportive services that provide physical, psychological, and spiritual care for dying persons and their families (Aldridge 1988; Coyle 1987; Framp- ton 1986; Heyde & von Langsdorff 1983; Jacob

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


ALDRIDGE

1986). In all these settings, supportive services are based upon an interdisciplinary team of health care professionals and volunteers.

Music therapy is sometimes included in such services.

In the Supportive Care Program of the Pain Service to the Neurology Department of Sloan-Kettering Cancer Center, New York, a music therapist was part of the supportive team along with a psychiatrist, nurse-clini- aan, neuro-oncologist, chaplain, and social worker (Bailey 1983; Coyle 1987). Music therapy was used to promote relaxation, to reduce anxiety, to supplement other pain control methods, and to enhance communication between patient and family (Bailey 1983,1984,1985). Depression was a common feature of the patients in the program, and music therapy was thought to relieve this state and enhance the patient's quality of life.

A better researched phenomenon is the use of music to control chronic cancer pain, in studies that usually favor tape- recorded interventions rather than the element of live performance. Combinations of pharmacological and nonpharmacological pain management are acceptable in modem medicine (McCaffery 1990), with nonpharmacological interventions generally being used as a form of distraction.

This is the approach of a study by Zimmerman and colleagues (Zimmerman, Pozehl, Duncan & Schmitz 1989) who investigated whether playing self-selected taped music combined with suggestions of relaxation, affected patients suffering with chronic pain. The study sought to determine from self-reports whether the music provided additional relief to patients receiving pain medication. In both the experimental and the control groups, the blood level of analgesic was controlled. Music was found to decrease the overall level of the pain experience as reported by patients randomly assigned to the music treatment group. Furthermore, there was a significant reduction in the sensory, as well as the affective, component of the pain as measured by the McGill Pain Questionnaire (Melzack 1975)-that is, not only was suffering as an emotional experience reduced, the

In a study of chronic pain, patients playing self-selected tape-recorded music reported not only a reduction in the emotional experience of suffering but also a reduction in the actual sensation of pain.

actual physical sensation of pain, according to the patients, was also reduced. This would appear to confound the common belief that music therapy primarily induces qualitative emotional experiences and to support the contention that music therapy can have a direct influence upon sensory parameters.

, In addition to reducing pain, particularly in pain clinics (Godley 1987; Locsin 1981;

I Wolfe 19781, music has been offered during chemotherapy as a form of relaxation and distraction (Kammrath 1989) to bring overall

1 relief (Kerkvliet 1990) and to reduce nausea and vomiting (Frank 1985). Using taped music and guided imagery in combination with pharmacological antiemetics, Frank (1985) found that state anxiety was significantly reduced, resulting in less vomiting

, even though the experience of nausea remained the same. Although Frank's study

I

was not controlled, leading to the possibility 8 that the reduced anxiety may have been due

to the natural fall in anxiety levels at the end 1 of a chemotherapy treatment, the study 1 consisted of patients who had previously , experienced chemotherapy and who were 1 conditioned to experience nausea or vomiting 1 in conjunction with chemotherapy. That the

subjects of the study felt relief and vomited less is an encouraging sign in the use of music

1 therapy in minimizing the distressing effects 1 of chemotherapy. l In the control of pain, time to listen, , separated from the surrounding influence of l I the hospital unit by the use of headphones, ' may itself be an important intervention. This

may be the underlying import of a study by 1 Rider (1985) who found that perceived pain l 1 was reduced in a hospital situation in re-

ADVANCES, The Journal of Mind-Body Health Vol. 9, N o 1 Winter 1993 - - . - . - - - - - . . 25


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Music appears to be a key in helping patients wi th seemingly hopeless neurological devastation regain their "lost" language capabilities.

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 1991 b; 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 embed- ding short propositional sentences into simple, often repeated, melody patterns to which patients tap their fingers. Changes of inflec- tion, 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.

I In infants the ability to reciprocate the communication of another person is an important

I element in communicative competence (Mur- ray & Trevarthen 1986; Street & Cappella 19891 and is vital in acquiring speech (Glenn & Cunningham 1984). Music therapy strate-

1 gies for neurologically damaged adults I

attempt to utilize the same processes of re- ciprocation with the expectation that they will stimulate those brain functions that support, precede, and extend functional speech

I recovery, for these brain functions are essen- tially 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

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)

l Evidence of the possible global strategy

1 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 uck i

, dharry (1982) describe spontaneous singing by the patients as a welcome release from the

1 helplessness of being a patient. The authors

26 ADVANCES, Th ie Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993 - . . . .. .- .--


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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 pun- ning. (Seizure activity as registered on an electroencephalogram correlated with clinical attacks and was present in both temporo- central 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 to music of patients w i th 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



ALDRIDGE

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 Alzhei- mer'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:

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 exer- cises to relax patients, and to facilitate postoperative recovery (Keegan 1989).

Anes thesia

The ability of music to induce calm and well- being 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



ALDRIDGE

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




testing of verbal skills, including speech fluency

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

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

coordination)



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

Hallucinations may occur in any of our senses, and auditory hallucinations take

1 various forms-as voices, cries, noises, and, rarely, music. However, the appearance of 1 musical hallucinations, often in elderly patients, has generated interest in the medical literature (Aizenberg, Schwartz & Modai

1 1986; Berries 1990; Fenton & McRae 1989;



ALDRIDGE

How music therapy can be i n c o v o - rated into medical practice requires extensive research studies. Unfortu- nately, 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.

Gilchrist & Kalucy 1983; Hammere, McQuil- len & 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).

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 nonessen- tial 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-

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.

Immune Effects

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. How- ever, 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



ALDRIDGE

Table 3 Comparison of Medical and Musical Assessments of Bowel Disease


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 vocabu- laries 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 I

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

l

science but a demonstration of an 1

inevitable fact: that merely purposive l rationality unaided by such phenomena 1

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. Per- haps in the future we will be encouraged to understand how each one of us as a person can become our own work of art.

ADVANCES. The loumal of Mind-Body Health Vol. 9, No. l Winter 1993 31


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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." h1w Zealand 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.

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

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

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.

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



ALDRIDGE

Jones, C. 1990. "Spark of Life." Geriatric Nursing of New York. 1 I:l94-196.

Kamrnrath, L. 1989. "Music Therapy during Chemo- therapy. 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.

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

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

Lehmann, K., G. Homchs & W. Hoecklc. 19s. "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. 41:123- 128.

Lehnen, R. 1988. "Does Music dunng Dental Treatment Have an Influence on Heart and Circulation Param- eters?" Zahnar-tl-Prax. 39:297-300.

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

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

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

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. 1:227- 299.

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.

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

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

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 Intona- tion 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.

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

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

Patel, I.I., M. Keshavan & S. Martin. 1987. "A Case of Charles Bonnet Syndrome with Musical Hallucina- tions." 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?" Soins- Psychiatr. 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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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 Wife for 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." Journal of 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: 152-1 58.

Thornas, E. 1986. "Music Therapy." South African Medical Journal. 70:717-718.

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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.

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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.



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 i t 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~mprovises her 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. On 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 opcn- ing. 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 be- twccn 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 the total 'behavio~ral '~ activity of the 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 human 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 remind the staff of the imnortance of the ' quality and intensity of human contact. Whilst life support and monitoring de- vices 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 volume. Such unconscious patients, struggling to orient themselves in time and space, are further confused by an environment of continuing loud, disori- entating 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 i t 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 rhythmi-

Improvised 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 medic ine wi th in t he science of medicine.

1. Wilson L. Intrnsivr ciiri* ik-lirium. A r h w tifhitfrwl h<rili- c h r 1972; 130: 225-h.

2. Ulrich R. View 111rtiui;h <i wiiulunv in.iy inf l~n~i i i~t~ rfoivery 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- 7.

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

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

Functionality or aesthetics?A pilot study of music therapy in the treatmentof multiple sclerosis patients�

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D. Aldridgea, ∗, W. Schmidb, M. Kaederc, C. Schmidta, T. Ostermannd7

a Chair for Qualitative Research in Medicine, University of Witten Herdecke, Alfred-Herrhausen-Str. 50,D-58448, Germany

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c Gemeinschaftskrankenhaus, Herdecke, Germany11

d Department of Medical Theory and Complementary Medicine, Faculty of Medicine,U

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

SummaryIntroduction: Neuro-degenerative diseases are, and will remain, an enormous publichealth problem. Interventions that could delay disease onset evenmodestly will havea major public health impact. The aim of this study is to see which components ofthe illness are responsive to change when treated with music therapy in contrast toa group of patients receiving standard medical treatment alone.Material and methods: Twenty multiple sclerosis patients (14 female, 6 male) wereinvolved in the study, their ages ranging from 29 to 47 years. Ten participants formedthe therapy group, and 10 the matched control group matched by age, gender andthe standard neurological classification scheme Expanded Disability Status Scale(EDSS). Exclusion criteria were pregnancy and mental disorders requiring medica-tion. Patients in the therapy group received three blocks of music therapy in singlesessions over the course of the one-year project (8—10 sessions, respectively). Mea-surements were taken before therapy began (U1), and subsequently every threemonths (U2—U4) and within a 6-month follow-up without music therapy (U5) af-ter the last consultation. Test battery included indicators of clinical depression andanxiety (Beck Depression Inventory and Hospital Anxiety and Depression Scale), aself-acceptance scale (SESA) and a life quality assessment (Hamburg Quality of LifeQuestionnaire 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 treatmentgroup and the control group. However, the effect size statistics comparing bothgroups 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

� This project was supported by Schering gmbH.* Corresponding author. Tel.: +49 2302 926 780; fax: +49 2302 926 783.E-mail address: [email protected] (D. Aldridge).

965-2299/$ — see front matter © 2005 Elsevier Ltd. All rights reserved.oi:10.1016/j.ctim.2005.01.004


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were found for the therapy group over time (U1—U4) in the scale values of self-esteem, depression and anxiety. In the follow-up, scale values for fatigue, anxietyand 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 isremoved, then scale scores worsen and this appears to intimate that msuic therapyhas an influence.© 2005 Elsevier Ltd. All rights reserved.

Introduction14

Neuro-degenerative diseases are, and will remain,15

an enormous public health problem. Interventions16

that could delay disease onset even modestly will17

have a major public health impact. These diseases18

are disabling to the sufferers, there is a loss of nor-19

mal motor functioning, a change in mood, and a20

gradual loss of cognitive abilities1,2 including audi-21

tory problems3 and memory changes,4 and sensory22

processing.5 These multifarious problems worsen23

during the course and stages of the disease.124

Furthermore, the patient does not suffer alone;25

these losses have an impact upon family and social26

life.27

Multiple sclerosis is the most frequent in-28

flammable disease of the central nervous system29

among young adults. It is an autoimmune disease30

with additional genetic and environmental factors631

and considered to be one disease in the general32

class of neurodegenerative diseases. Disease pro-33

gression differs considerably from patient to pa-34

tient, so that while we may talk about stages of35

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sures by which therapeutics are evaluated, and 58

adopt a pragmatic approach to living as well as pos- 59

sible in the context of a chronic condition.10 60

Although complementary and alternative 61

medicine approaches are being asked for by 62

patients suffering with multiple sclerosis, only 63

a limited number of studies have explored arts 64

and music therapy recently. O’Callaghan,11 for 65

example, encourages patients to write songs using 66

expressive elements related to positive feelings 67

for other people, memories of relationships and 68

expressions of the adverse experiences resulting 69

from living with the illnesses. 70

In a controlled pilot study Wiens et al.12 demon- 71

strated a potential strengthening effect of music 72

therapy—–with a focus on breathing and speech—– 73

on the respiratory musculature of multiple sclerosis 74

patients. Respiratory muscle weakness is character- 75

istic of individuals with advanced multiple sclerosis 76

and can result in repeated infections of the lung. 77

Based on experiences with a music-therapy 78

group of 225 hospital inpatients with multiple scle- 79

rosis who participated in a 6-week group music- 80

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the diseases there is no typical multiple sclerosispatient but rather a heterogeneous group of pa-tients 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 fo-cus on a functional strategy for treatment, we can-not ignore that these diseases have implicationsfor the performance and appearance of the personin everyday life. Therefore, we need therapeuticapproaches that include aesthetic performance aswell as functional performance.8

Multiple sclerosis patients show increasing inter-est in complementary and alternative therapies.9

One reason is their general disappointment withconventional medicine, since causal treatment isnot possible; another is a wish to play a more ac-tive role in coping with the disease and a demandfor a wider range of therapies to meet psychosocialneeds as well. Patients say that by using a com-plementary medical approach then they take per-sonal responsibility for health, reframe the mea-

therapy program, music therapy appeared to of-fer psychological support, relieve anxiety and de-pression and possibly help with the difficult processof coping with the disease individually.

Magee,14—17 also makes use of well-known, pre-composed songs and spontaneous improvisation oninstruments and their attitudes change from a “dis-abled self-concept” to amore ‘‘able self-concept’’.In a further study,18 the authors showed improve-ments in mood state following music therapy, al-though depression was not directly affected.

Studies into factors governing the quality of lifefor multiple sclerosis patients are interesting in thiscontext. They reveal that patients and their physi-cians have different perspectives. Physicians deter-mine quality of life mainly with physical and func-tional parameters, while patients themselves seepsychosocial well-being, emotional stability andways to cope with multiple sclerosis-induced stressas the most important factors.19 High levels of de-pression and anxiety are associated with peoplewith MS who seek complementary approaches, al-


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Functionality or aesthetics? 3

though this may be an underlying factor of chronic103

illness.20104

The aim of this study is to see which components105

of the illness are responsive to change when treated106

withmusic therapy in contrast to a group of patients107

receiving standard medical treatment alone.108

Patients109

Twenty multiple sclerosis patients (14 female, 6110

male) were involved in the study, their ages rang-111

ing from 29 to 47 years, with episodic, secondary112

chronic and primary chronic progression and an av-113

erage disease duration of 11 years.114

Ten participants formed the therapy group, and115

10 the control group. The groups were comparable116

in the standard neurological classification scheme117

Expanded Disability Status Scale (EDSS).21 The EDSS118

of both groups was 2.6 on average, which means119

that the participants were between normal func-120

tions (score: 0) and disability that precludes full121

daily activities (score: 5.5).122

Exclusion criteria were pregnancy and mental123

disorders requiring medication.124

All participants were informed of the content125

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encounter and experience. Individual themes and 156

musical developments emerged for each individual 157

patient; some wanted to sing and dance, others 158

wanted to be sung to, and others wanted to play an 159

instrument or brought their own instruments with 160

them. There were no expectations of previous mu- 161

sical education. The patients wanted recordings of 162

their sessions and their individual selections were 163

recorded onto compact discs. They played them to 164

their partners or friends or just listened to some 165

pieces and remembered the condition and feelings 166

of the situation. 167

There was a high degree of willingness on the 168

part of all patients to take part in the study, so that 169

all rounds of interviews were completed, and 85% 170

of all music-therapy sessions took place. 171

Methods 172

A matched control trial was implemented using 173

a battery of indices before therapy began (U1), 174

and subsequently every three months (U2—U4) and 175

within a 6-month follow-up without music therapy 176

(U5) after the last consultation. 177

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nd details of the study and gave their written con-ent to publish the material, especially the videoequences from the music-therapy sessions. Thethical Committee of University of Witten Herdeckexamined the protection of data privacy and thethical aspects.Patients were matched by the researcher ad-inistering the trial for age, gender, stage of dis-ase and the standard neurological classificationcheme EDSS. The basis for the recruitment pop-lation was from patients coming for their regularheck-ups to the general hospital. A patient wasllocated to the treatment group. The next con-ecutive patient, if matching the previous patient,ould be allocated to the control group. If not,hat patient would be allocated to the treatmentroup until the treatment group was complete. Sub-equently, 10 matching control patients were allo-ated.The patients in the therapy group received three

locks of music therapy in single sessions overhe course of the project (8—10 sessions, respec-ively). Patients in the matched control groupere promised music therapy after the waitingeriod.The music-therapy approach used for this study

s based on the Nordoff Robbins approach.22 Bothatient and therapist are active. Music-making onnstruments, or singing, and the music itself thatmerges, all are potential possibilities for activity,

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The test battery included the following instru-ents.

ndicators of clinical depression and anxietyBeck Depression Inventory and Hospitalnxiety and Depression Scale)

he Beck Depression Inventory (BDI) is an estab-ished and reliable questionnaire for assessing theeverity of depression and offers an instrumentuitable to compare this study with other clini-al studies.23 Patients with multiple sclerosis areonsidered to be impaired in identifying emotionaltates from prosodic cues,24 so it makes sense tose such an inventory.The Hospital Anxiety and Depression Scale (HAD)

s a self-administered, bidimensional instrumenteveloped to screen for clinically significant de-ression and anxiety in medical populations (Zig-ond, 1983, p. 657). Somatic items are excludedo avoid the confounding effect of physical illness.hile it is recognised that patients with multi-le sclerosis have a high lifetime risk for majorepression, less is known about affective insta-ility and how symptoms like irritability, sadnessnd tearfulness affect a subject’s overall degree ofsychological distress.25 Clinically significant anx-ety, either with or without depression, was en-orsed by 25% of patients, three times the rate forepression.26

logy papers 43

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Scale for self-acceptance (SESA)205

The Scale for the Evaluation of Self-Acceptance206

(SESA) is a 35-question scale translated from an207

original scale that assesses the acceptance of208

self and others.27 Social support, and coping be-209

haviours, are important for persons afflicted with210

multiple sclerosis. A healthy conception of oneself211

is central to coping effectively with the day-to-day212

stresses of modern living. The onset of any neuro-213

logical disease, with either actual visible deficits or214

potential future disability, threatens the integrity215

of that concept.28216

Hamburg Quality of Life Questionnaire in217

Multiple Sclerosis218

The Hamburg Quality of Life Questionnaire in Multi-219

ple Sclerosis (HAQUAMS) is a disease-specific qual-220

ity of life instrument for MS. There are 38 items221

about physical, psychological and social functions222

and questions about symptoms, progression of the223

disease and general impairment.29224

People suffering with multiple sclerosis identify225

depression and social function as important compo-226

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Results 256

Fig. 1 shows the development of the outcome- 257

measures in the course of time with therapy from 258

U1 to U4 and up to U5 in the follow-up. At the start 259

of the study (U1) there was no significant differ- 260

ence between therapy group and control group on 261

the varying scale measures. 262

Significant improvements were found within the 263

therapy group over time (U1—U4) in the scale 264

values of SESA (p = 0.012) for depression (BDI, 265

p = 0.036; HADS-D, p = 0.035) and anxiety (HADS-D 266

subscale anxiety, p = 0.13). Significant differences 267

were found for the control group in regard to the 268

subscale anxiety (HADS-A, p = 0.031), while the val- 269

ues for depression and self-acceptance did not show 270

any significant differences over time (U1—U4). No 271

differences were found for the functional and phys- 272

iological values (MSFC, EDSS) and quality of life 273

(HAQUAMS). The latter is probably because the 274

HAQUAMs quality of life is mainly assessed from 275

statements of physical well-being and mobility thus 276

reflecting scores on the functional scales. How- 277

ever, there was no significant difference in the 278

improvement from U1 to U4 between the music- 279

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nents of quality of life (Somerset, 2003, p. 608) andincluding preferences for health states and treat-ment alternatives in the decision to initiate treat-ment for individual patients is seen as an importanttreatment consideration.30

In addition, data were collected on cognitive(MSFC) and functional (EDSS) parameters. The EDSSdescribes the state of disability of an MS-patientand ranges from 0 (normal) to 10 (death due toMS). It is a classification scheme that insures allparticipants in clinical trials are in the same class,type or phase of MS.21 It is also used by neurolo-gists to follow the progression of MS disability andevaluate treatment results. Because of its strongemphasis on ambulation, the EDSS is insensitiveto changes in other neurological functions and tocognitive dysfunction in MS. The Multiple SclerosisFunctional Composite (MSFC) is a multidimensionalinstrument to assess disability of MS-patients. Ithas three parts, testing the function of legs andwalking-ability, the functions of arms and hands andthe cognitive functions.31 The IFSS is a scale thatassesses incapacity and fatigue.

For an evaluation of the efficiency and sustainedsuccess of music therapy, Wilcoxon-test statistics ofoutcome-measures differences from U1 to U4 be-tween the groups were applied to show significantdifferences. Additionally, effect-sizes were calcu-lated according to Cohen18 and corrected accordingto McGaw and Glass19.

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herapy treatment group and the control group (seeable 1), although effect size statistics comparingoth groups show amedium effect size on the scaleseasuring self-esteem (d, 0.5423), depression HAD-(d, 0.63) and anxiety HAD-A (d, 0.63). In the

ollow-up, scale values for fatigue, anxiety and self-steem worsen within the group treated with musicherapy.The use of p-values and effect size are used as

uides in this study as to what may be interesting asypotheses for further studies, or if further studiesre warranted. They are intended as exploratorytatistics rather than confirmatory. This is a pilottudy and there are considerable limitations bothn terms of the sample size and a bias in terms ofatching in that there was no random allocation tohe treatment group.Considering the correlations between the scale

cores differences between T1 and T4, we foundorrelations between the HAD depression index andelf-acceptance, and depression on the BDI and HADnxiety and depression (see Table 2). We could,herefore, reduce our battery of tests to the Hospi-al Anxiety and Depression scale in any future trial.

iscussion

his study tried to identify factors to be influ-nced with a music therapeutic approach in treat-ng patients with multiple sclerosis. Music therapy

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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, HADS-D: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: HamburgQuality of Life Questionnaire in Multiple Sclerosis, EDSS describes the state of disability, MSFC: Multiple SclerosisFunctional 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.

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

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

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

EDSS 2.3 [1.4; 3.5] 2.5 [1.5; 3.6] 0.76MSFC 0.23 [−0.21; 0.47] 0.14 [−0.45; 0.34] 0.61IFFS 34.0 [24.3; 45.0] 22.5 [12.8; 47.5] 0.22SESA 115 [79; 125] 110 [99; 128] 0.59BDI 13.0 [6.5; 19.0] 7.0 [3.0; 20.0] 0.33HADS-A 9.0 [4.8; 11.8] 8.0 [3.75;13.25] 0.54HADS-D 5.5 [3.8; 7.0] 6.0 [1.5; 9.5] 0.84HAQUAMS 2.3 [2.1; 2.5] 2.0 [1.8; 2.4] 0.07

Difference between intake and end of treatment scores(Wilcoxon signed rank test)

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

z −.303 −.507 −1.224 −.533 −.972 −.613 −.205 −1.837Asymptotic significance(two-tailed)

.762 .612 .221 .594 .331 .540 .837 .066

BDI: Beck Depression Inventory, HADS-A: Hospital Anxiety and Depression Scale—–anxiety, HADS-D: Hospital Anxiety and DepressionScale—–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.

can be considered as a part of a treatment strat-308

egy for two reasons. One, it offers a means to309

improve communicative performance.18 Second, it310

promotes the presentation of a self that may be311

considered as handicapped or degenerating but can312

be performed as satisfying and whole—–and that is313

a matter of aesthetics.8,32 We know from the lim-314

ited, principally anecdotal, music-therapy litera-315

ture that there are potential benefits from music316

therapy in terms of enhancing mood and improving317

self-identity.318

While there are numerous projects aimed at find-319

ing medical relief for suffering and the treatment320

of disease, we are reminded that disease-related321

problems influence patient’s mental behaviour and322

this has ramifications for relationships. A major323

confrontation for those offering treatment, as it is324

for the patient, is that the problem worsens and325

there is no cure. This frequently life-long process 326

for patients starting when multiple sclerosis is di- 327

agnosed obviously demands a range of therapeutic 328

possibilities which must also consider and encour- 329

age a patient’s creative abilities.33 What we need 330

to establish is which of the varying parameters is 331

subject to influence by music therapy, which was 332

the aim of this study. 333

In this study various outcome-parameters were 334

evaluated for their possible appropriateness for 335

showing effects of music therapy. These were both 336

functional and affective. We included many param- 337

eters because although the clinicians involved knew 338

that something positive was happening, there was 339

no clear indication of what this was and how tomea- 340

sure it. Through this study we now have an idea of 341

what changes and from this basis can develop hy- 342

potheses for a controlled study. 343

Table 2 Correlation of the differences in scales between T1 and T4.

SESA BDI HAD-A HAD-D HAQUAMS

SESA −0.37 (0.11) −0.33 (0.15) −0.61** (0.04) 0.03 (0.89)BDI 0.57** (0.01) 0.49* (0.03) 0.13 (0.59)HAD-A 0.41 (0.07) 0.12 (0.62)

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Levels of significance are printed in parentheses. BDI: BeckScale—–anxiety, HAD-D: Hospital Anxiety and Depression ScaleHamburg 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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ression Inventory, HAD-AS: Hospital Anxiety and Depressionpression, SESA: Scale for self-acceptance (SESA), HAQUAMS:

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Positive changes are shown in patients’ de-344

pressed mood, which are also reflected in the345

self-acceptance scale. Given that patients with346

a chronic disease are also stigmatised,34 and347

this spoiled identity is further exacerbated by348

the concept of degeneration,35 then any inter-349

vention that improves mood and enhances self-350

acceptance is valuable in mitigating stigma. We351

know from the anecdotal literature that music ther-352

apy is important for establishing and recreating self353

identity.15,32,36 Perhaps we should not simply con-354

sider these diseases as neurodegenerative but as355

dialogue-degenerative diseases, where there is a356

breakdown in dialogue between the sufferer and357

the community.358

There were no recognizable changes in motor359

and functional abilities. The form of creative mu-360

sic therapy used here is efficacious for promoting361

a positive self-identity and relieving the emotional362

burden on a patient but not for improving functional363

abilities.364

Improvements in patients of the therapy group365

with regard to relieving anxiety and depression, and366

above all with regard to improved self-acceptance,367

are a consequence of the qualitative changes368

brought about in music-therapy encounters. The369

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recognition of their abilities rather than patholo- 400

gies, and a possibility for them to exercise their 401

own agency. 402

Qualitative considerations 403

In a final interview, 9 out of 10 music-therapy par- 404

ticipants in the study described how important it 405

was to become personally active in their treat- 406

ment. All 10 participants reported an immediate 407

improvement in their well-being during sessions. In 408

eight participants, this improved state continued 409

for some time and was confirmed by partners or 410

friends. This is also confirmed by improvements in 411

the self-acceptance and depression scales but not 412

by quality of life scores. Differences over time in 413

the depression scores and self-acceptance scores 414

are highly correlated with each other that may re- 415

flect their common conceptual background. Seven 416

participants described an enhanced perception of 417

themselves with an increasing self-confidence over 418

the course of the therapy. They were increasingly 419

able to let themselves be surprised by the music as 420

it emerged and by their own previously undiscov- 421

ered musical skills. Music and music therapy are ex- 422

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hange in the subscale anxiety of the HADS-D inoth groups may be an indication that regularrofessional patient care helps reduce depressionn multiple sclerosis sufferers. Standard therapeu-ic practice is that patients only attend for con-act with a practitioner or treatment when theres a flare up in symptoms. Being recruited intotrial and being regularly assessed is also per-aps an important variable for therapeutic con-act.There is a worsening of the music-therapy group

cale scores at follow-up whenmusic-therapy treat-ent is withdrawn, particularly with regard to self-steem. This may be argued as evidence of theemporary effect of music therapy or that musicherapy does indeed have an effect and we seeow the patient responds when the therapy is with-rawn.The importance of therapeutic contact is re-

ected in a qualitative analysis of the data. Twoundred and twenty-six music-therapy sessionsere documented on video and evaluated with theelp of episodes and generation of categories.37

hat emerged from the qualitative aspects ofhe study were parameters concerning contact be-ween therapist and patient, coping with the sit-ation, the sharing of musical roles, and an abil-ty to structure time and the possibility to initi-te changes in play. These factors reflect the needsf these patients for a deeper personal contact, a

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erienced by patients as ‘‘something moving’’ thathifts negative thoughts about the disease into theackground and offers a means of expression foreelings of security, freedom and pleasure.38 Onearticipant relates how she met a friend in the Uni-ersity that she had not seen in a long time, af-er treatment. They talked for a while and it wasnly on parting that she told her friend that she hasultiple sclerosis. This was a shift in her percep-ion of herself as first and foremost ‘‘a sick per-on’’ to a normal person with other priorities inife.What is evident from this study is that in assess-

ng music therapy in terms of meeting patients’eeds then we cannot simply take a functionalpproach alone. Multiple sclerosis patients havevariety of needs, some of these are psychoso-ial and some of these are also aesthetic. An aes-hetic therapy offers the opportunity to experi-nce the self not as solely degenerative but alsos creative. This is a major turn around in self-nderstanding and is reflected in both self-esteemnd an improvement in mood. We are not denyinghat these patients have a degenerative disease,imply that these patients are not themselves de-enerate. In the face of pathology, even in sick-ess, we have the potential to be active creativegents. Music therapy emphases creative dialogues an remedy in the face of a dialogic degenerativeisease.35

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We have used effect sizes here, although mod-453

est, to provide a platform for other studies that will454

no doubt improve on what we have attempted. This455

exploratory study has indicated the potential ben-456

efits of music therapy as an aesthetic intervention457

concerned with the performance of self in everyday458

life. At some stage we will also need to consider459

multi centre trials.460

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Journal of the Royal Society of Medicine Volume 83 June 1990 345

Where am I? Music therapy applied to coma patients

Intensive care treatment is a highly technological branch of medicine. Even in what may appear to be hopeless cases, i t can save lives1 through the application of this modern technology. How- ever, 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 deprivation2s3 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, ie subjects and objects. To a certain extent patients become a part of this object world. We propose that improvised music therapy can be a useful adjunctive therapy in such situations both for the patient and the staff.

In these 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?'. Needleman4 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.

At the suggestion of a hospital neurologist a music therapist began working with coma patients. To investigate this approach further the work was monitored in an intensive treatment unit. 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 is based on the principle that we are organized as human beings not in a mechanical way but in a musical form; ie a harmonic complex of interacting rhythms and melodic contour^^-^. To maintain our coherence as beings in the world then we must creatively improvise our identity. Rather than search for a master clock which 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, ie linking brain, body and mind. In this perspective the self is more than a corporeal being.

Each music therapy contact lasted between 8 and 12 min. The therapist improvised her wordless singing based upon 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 then the phrase could be repeated.

Before the first session the music therapist had met the family to gain some idea of what the patient was like as a person. On contacting the comatose patient she would say 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 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 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 indicate an attempt at orientation and cognitive processing within the communicational c o n t e ~ t ~ * ~ . EEG measurement showed a desynchronization from theta rhythm, to alpha rhythm or beta rhythm in former synchronized areas. This effect, indicating arousal and perceptual activity, faded out after the music therapy stopped.

Some of the ward staff were astonished that a patient could respond to such quiet singing. This highlights a difficulty of noisy units such as these. All communication is made above a high level of machine noise. Furthermore commands to an 'unconscious'. patient are made by shouting formal injunctions, ie 'Show me your tongue', 'Tell me your name', 'Open your eyes'. Few attempts are made a t normal human communication with a patient who cannot speak or with whom staff can have any psychological contact. I t is as if these patients were isolated in a landscape of noise, and deprived of human contact. !

A benefit of the music therapy was that the staff were made aware of the quality and intensity of the human contact. In the intensive care unit environment of seemingly non-responding patients, dependent upon 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. This is further exacerbated by a scientific epistemology which emphasizes the person only as a material being and which equates mind with brain.

A period of calm was also recognized as having potential benefit for the patient. What some staff fail to realize is that communication is dependent upon rhythm, not upon 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 and disorienting random noise. For patients seeking to orient themselves then the basic rhythmic context of their own breathing may provide the focus for that orientation. This raises the problem of intentionality in human behaviour, even when consciousness appears to be absent. I t is also vital that staff in such situations do not confuse 'not acting' with 'not perceiving'.

We can speculate that the various body rhythms have become disassociated in such comatose states. The question remains then of how those behaviours can be integrated and where is the seat of such integration.

Improvised singing appears to offer a number of possible benefits for working with coma patients in terms of human contact and promoting perceptual responses. Human contact through singing, rather than speaking, also suggests that the fundamentals o141~0768190, of human communication are musical in form. In this Mo3542802.,,,,o way we have the ar t of medicine within the science a lgoo of medicine. Perhaps the skills of human communi- ~h~ ~~~~l cation may become part of medical and nursing Society of education5, particularly in the context of intensive Medicine David Aldridge Collected neurology papers 50

346 Journal of the Royal Society of Medicine Volume 83 June 1990

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

AIDS afterthought

Barts students are no different from most final year medics in the need to choose a destination for the elective period. This need occasionally encompasses a desire to journey to a warm and exotic part of the world yet at the same time is concerned with gaining some medical experience. It is surprisingly difficult to combine these two intentions especially since hot climates are often associated with many outdoor temptations which can divert thought away from study and learning.

My elective months were spent in Sydney, Australia, a choice governed by my previous special studies in HIV and AIDS. This interest began in 1985 when I joined St Mary's hospital for one year to study 'Infection and Immunity'. From that time, the subject of AIDS and the management of the immuno- compromised patient began to appear more frequently in medical journals. The neuropsychiatric complications of HIV infection were of particular interest since they demonstrated links between the immune system, opportunistic infection and psychological symptoms in patients who practised diverse lifestyles. The extent to which the AIDS epidemic will domi- nate current medical practice in the UK is still unclear.

My concern was to use my particular academic knowledge to support the clinical experience obtained on elective. However, I had not had any direct personal involvement in the management of HIV infection and for that reason alone was keen to spend some time attached to a unit where there was a possibility of some teaching, not only

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 Nordoff P, 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 gynae- cologist friend of my parents had trained in Sydney and introduced me to a consultant immunologist there, Professor Ronal Penny. Thus I came to spend my elective at St Vincent's Hospital, Sydney. I was extremely fortunate in being funded by the Guildchrist Foundation, the Clothworkers Trust and my Medical College, all in the City of London. It was interesting that none of the London-based AIDS organizations were able to provide any assistance despite my protocol covering the very serious negative social aspect of neuropsychiatric complications of HIV infection.

The public image of the AIDS victim has been the infected homosexual or drug addict. Sydney, with its large population of both these sources of patients, also has people from every walk of life professing beliefs and carrying out behaviour that, as in all cosmo- politan society, has no norm. AIDS is making its grim inroad, indifferent to stereotyping. During my time in Sydney, I saw many aspects of inpatient, outpatient, community and laboratory care of HIV infection. It is a sad game of numbers that the Australian population is not much more than a quarter that of the UK, but contains as many recorded cases of AIDS. The field of neuropsychiatric complications was too vast for deep investigation in the limited time of the elective period. My work covered a broad overview of the illness and gave me a deep understanding of compassion. 0141-07681901

'AIDS patients? Did you wear a mask. I hope 0 6 0 M 6 ~ 0 2 1 ~ 0 2 ~ ~ l o you wore rubber gloves!' This was the reaction Q lggo of several of my fellow students on my return l-he ~~~~l to London. I must say that, to an extent, these Society of intimations of fear and caution echoed my own Medicine David Aldridge Collected neurology papers 51

The Arts in Psychotherapy, Vol. 18, pp. 359-362. Pergamon Press plc, 1991. Printed in the U.S.A. 0197-4556191 $3.00 + .00

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)

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-

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; Ul- rich, 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 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


360 DAVID ALDRIDGE

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

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 & Rob- bins, 1977; Sandman, 1984a, 1984b). Electroenceph- alogram (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; Moore- Ede, Czeisler, & Richardson, 1983; Reinberg & Halberg, 197 1). 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 hypo- thalamus in the brain.


MUSIC THERAPY IN INTENSIVE CARE 361

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 won- der 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

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


362 DAVID ALDRIDGE

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?" Needle- man (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.

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 Psychother- apy, 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 mi- crosynchrony. 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 percep-

tion. Psychological Research, 45, 315-337. Reinberg, A., & Halberg, F. (1971). Circadian chronopharma-

cology. 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. Lon- don: 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.), Psy- chophysiological 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 Jour- nal of Physiology, 2, 11 1-1 19.

Sandman, C. (1986). Circulation as consciousness. The Behav- ioural 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.


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 (Dales- sio, 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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18 Aldridge

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

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Music Therapy and Treatment of Alzheimer's Disease 19

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). Simi- larly, 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

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20 Aldridge

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 predict- ability 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 ad- vance 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). Mu- sical 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 21

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

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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 danc- ing 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).

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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 con- versations. 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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"fable I. Features of Medical and Musical Assessment

Medical elements of assessment Musical elements of assessment

Continuing observation of mental and Continuing observation of mental and functional status functional status

Testing of verbal skills, including element of Testing of musical skills; rhythm, melody, speech fluency harmony, dynamic, phrasing, articulation

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

Testing for progressive memory disintegration Testing for progressive memory disintegration

Motivation to complete tests, to achieve set Motivation to. sustain playing improvised goals and persevere in tests music, to achieve musical goals and

persevere in maintaining musical form

"Intention" difficult to assess; but considered "Intention" a feature of improvised musical important playing

Concentration and attention span

Flexibility in task switching

Concentration on the improvised playing and attention to the instruments

Flexibility in musical (including instrumental) changes

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

Musical elements of assessment Examples of improvised playing

0 Testing of musical skills; rhythm, melody, Improvisations using rhythmic instruments harmony, dynamic, phrasing, articulation (drum and cymbal) singly or in combination

0 Improvisations using melodic instruments Singing and playing folk songs with harmonic accompaniment

0 Cortical disorder testing; visuospatial skills Playing tuned percussion (metallophone, xylophone, chime bars) demanding precise movements

Cortical disorder testing; ability to perform Alternate playing of cymbal and drum using a complex motor tasks (including grip and right beater in each hand left coordination) Coordinated playing of cymbal and drum using

a beater in each hand Coordinated playing of tuned percussion

0 Testing for progressive memoxy disintegration 0 The playing of short rhythmic and melodic phrases within the session, and in successive sessions

Motivation to sustain playing improvised The playing of a rhythmic pattern deteriorates music, to achieve musical goals and persevere when unaccompanied by the therapist, as does in maintaining musical form the ability to complete a known melody,

although tempo remains

"Intention" a feature of improvised musical The patient exhibits the intention to play the playing piano from the onset of therapy and maintains

this intent throughout the course of treatment

Concentration on the improvised playing and The patient loses concentration when playing, attention to the instruments with qualitative loss in the musical playing and

lack of precision in the beating of rhythmical instruments

Flexibility in musical (including instrumental) Initially the musical playing is limited to a changes tempo of 120 Bp and a characteristic pattern

but this is responsive to change

Ability to play improvised music influenced Although the patient has a musical by previous musical training 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 The patient develops the ability to play in a relationship musical dialogue with the therapist demanding

both a refined musical perception and the ability of musical production

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tainment are all part and parcel of daily living for the elderly living in special ac- commodation (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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28 Aldridge

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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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.

Job Title: JCGI Article: M0 Kevboardina: MTW/Nov. 23. 1997

Makeup: MTW/Nw. 23, 1997 Last Revision: MTW/Nov. 23. 1997


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-5804 Herdecke 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.

Music and dementia Late in adult life, at the age of 56 years, 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. 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 performance in the adult population. Aphasia, which is a feature of cognitive deterioration, is a complicated phenomenon. While syntactical functions may remain David Aldridge Collected neurology papers 70

94 Journal of the Royal Society of Medicine Volume 86 February 1993

Table 1. Features of medical assessment and musical assessment

Medical elements of assessment Musical elements of assessment Examples of improvised playing

Continuing observation of Continuing observation of mental Â¥Improvisation using rhythmic instruments mental and functional status and functional status (drum and cymbal) singly or in combination,

Â¥improvisation using melodic instruments Â¥singin and playing folk songs with harmonic

accompaniment

Testing of verbal skills, Testing of musical skills; rhythm, Â¥playin tuned percussion (metallophone, including element of speech melody, harmony, dynamic, xylophone, chime bars) demanding precise fluency phrasing, articulation movements

Cortical disorder testing; visuo- Cortical disorder testing; visuo- Â¥alternat playing of cymbal and drum using a spatial skills and ability to spatial skills and ability to beater in each hand perform complex motor tasks perform complex motor tasks Â¥co-ordinate playing of cymbal and drum using (including grip and right left (including grip and right left a beater in each hand co-ordination). co-ordination). Â¥co-ordinate playing of tuned percussion

Testing for progressive memory Testing for progressive memory Â¥th playing of short rhythmic and melodic disintegration disintegration phrases within the session, and in successive

sessions

Motivation to complete tests, to Motivation to sustain playing Â¥th playing of a rhythmic pattern deteriorates achieve set goals and persevere improvised music, to achieve when unaccompanied by the therapist, as does in set tasks musical goals and persevere in the ability to complete a known melody,

maintaining musical form although tempo remains 'Intention' difficult to assess; 'Intention' a feature of improvised Â¥th patient exhibits the intention to play the but considered important musical playing piano from the onset of therapy and maintains

this intent throughout the course of treatment

Concentration and attention Concentration on the improvised Â¥th patient loses concentration when playing, span playing and attention to the with qualitative losses in the musical playing

instruments and lack of precision in the beating of rhythmical instruments

Flexibility in task switching Flexibility in musical (including Â¥initiall the musical playing is limited to a instrumental) changes tempo of 120 bpm and a characteristic pattern

but this is responsive to change

Mini-mental state score Ability to play improvised music malthough the patient has a musical influenced by educational status influenced by previous musical background this is only of help when she

training perceives the musical playing, it is little influence in the improvised playing

Insensitive to small changes Sensitive to small changes Â¥musica changes in tempo, dynamic, timbre and articulation which a t first are missing are gradually developed

Ability to interpret surroundings

Ability to interpret musical Â¥th patient develops the ability to play in a context and assessment of musical dialogue with the therapist communication in the demanding both a refined musical perception therapeutic relationship and the ability of musical production

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.

Musicality and singing are rarely tested as features of cognitive deterioration, yet preservation of these abilities in aphasics has been linked to eventual recovery, and could be significant indicators of hierarchical changes in cognitive functioning. Jacome5 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. Beatty6 describes 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, she no longer recalled the name of the music she was playing.

Swartz and his colleagues7 propose a series of perceptual levels at which musical disorders take place:

(i) the acoustico-psychological level, which includes changes in intensity, pitch and timbre. (ii) the discriminatory level, which includes the

discrimination of intervals and chords. David Aldridge Collected neurology papers 71

Journal of the Royal Society of Medicine Volume 86 February 1993 95

(iii) the categorical level which includes the categorical identification of rhythmic patterns and intervals. (iv) the configural level, which includes melody perception, the recognition of motifs and themes, tonal changes, identification of instruments, and rhythmic discrimination. (v) 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 (i), (ii) and (iii) remain unaffected, the complexities of levels (iv) and (v), 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.

Descriptions of musical perception emphasize the importance of context where different levels of attention occurring simultaneously against a background temporal structure. Musical improvisation with a therapist, which emphasizes attention to the environment utilizing changes in tempo and volitional response, 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 therapy are interlinked; assessment providing the criteria from which to identify therapeutic goals and develop therapeutic strategies.

If we are unsure as to the normal process of cognitive loss in aging, we are even more in the dark as to the normal musical playing abilities of adults. 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 appears to fail in the same way in which language fails. Unfortunately no established guidelines as to the normal range of improvised music playing of adults is available.

Improvised music therapy in our experience appears to offer the opportunity to supplement mental state examinations in areas where those examinations are lacking (Table 1). 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 perception1, it can be hypothesized that it is this overarching

structure which begins to fail in Alzheimer 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, and would suggest a global failing in cognition while localized lower abilities are retained.

Music therapy appears to offer a sensitive assessment tool. It tests those prosodic elements of speech production which 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; ie 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 are maintained. Certainly the anecdotal evidence suggests that quality of life of Alzheimer patients is significantly improved with music therapy accompanied by the overall social benefits of acceptance and sense of belonging gained by communicating with others. Prinsley recommends 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 recommends that music therapy be based on treatment objectives; the social goals of interaction co-operation; 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 integration8.

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 which is urgent not only for the understanding of Alzheimer's patients but in the general context of cognitive deficit and brain behaviour.

Acknowledgment: The author would like to thank the music therapist Gudrun Aldridge for access to the audio-tape recording of her clinical work, and her clinical insights into working with the elderly.

References 1 Aldridge D. Music, communication and medicine: dis-

cussion paper. J R Soc Med 1989;82:743-6 2 Gates A, Bradshaw J. The role of the cerebral hemi-

spheres in music. Brain Lung 1977;4:403-31 3 Morgan 0, Tilluckdharry R. Presentation of singing

function in severe aphasia. West Indian Med J 1982; 31:159-61

4 Berman I. Musical functioning, speech lateralization and the amusias. S Afi Med J 1981;59:78-81

5 Jacome D. Aphasia with elation, hypermusia, musicophilia and compulsive whistling. J Neurol Neurosurg Psychiatry 1984;47:308-10

6 Beatty WW, Zavadil KD, Bailly RC, et aL Preserved musical skills in a severely demented patient. Znt J Clin Neuropsychol 1988;10:158-64

7 Swartz K, Hantz E, Crummer G, Walton J, Frisina R. Does the melody linger on? Music cognition in Alzheimer's disease. Semin Neurol 1989;9:152-8

8 Prinsley D. Music therapy in geriatric care. Aust Nurses J 1986;15(9):48-9

An extended list of references can be obtained from the author.

(Accepted 30 December 1991) David Aldridge Collected neurology papers 72

MISE P O I N T

DE LA MUSIQUE EN TANT QUE THERAPIE DE LA MALADIE D'ALZHEIMER PAR DAVID ALDRIDGE*

Il est tout Ã fait Ã©viden que la maladie d'Alzheimer reprÃ©sent un facteur de stress important pour les patients et pour leurs familles. La perte de la mÃ©moir et la perte du langage qui l'accompagne, prÃ©cÃ©da l'installation des troubles moteurs, se traduisent par une per- turbation de la vie quotidienne des patients. La communication, vÃ©ritabl outil du contact social, est interrompue et brouillÃ©e La menace d'une dÃ©tÃ©riorati progressive et de pro- blÃ¨me comportementaux a un impact non seulement sur les patients, mais Ã©galemen sur les familles qui doivent prendre sur elles une partie de la responsabilitÃ sociale de faire soi- gner le malade, et en mÃªm temps supporter le fardeau Ã©motionne de voir un Ãªtr cher devenir de plus en plus confus et isolÃ© Dans ce contexte, jouer de la musique peut offrir une thÃ©rapi adjuvante susceptible de renforcer les capacitÃ© de communication et de favoriser l'interaction sociale.

Depuis la Seconde Guerre mondiale, la musicothÃ©rapi a Ã©t utilisÃ© 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©rapi rÃ©ceptive qui consiste Ã jouer de la musique en direct, ou prÃ©-enregistrÃ© L'exercice peut Ãªtr pratiquÃ individuellement ou en groupe. La musicothÃ©rapi active, 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©lodique simples (comme le mÃ©tallophone par exemple), le patient n'a nul besoin de possÃ©de une 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 achevÃ deux 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©ta se dÃ©tÃ©rio progressivement. Il perdit sa facultÃ Ã se souvenir des noms, Ã parler sponta- nÃ©men et 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©tai plein d'idÃ©e de musiques, raconte-il, il n'Ã©tai plus 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 capacitÃ de rÃ©pons Ã la musique des patients atteints de maladie d' Alzhei- mer est un phÃ©nomÃ¨ tout Ã fait remarquable. Alors que la dÃ©tÃ©riorati du langage est caractÃ©ristiqu du dÃ©fici cognitif, les capacitÃ© musicales semblent en ce cas prÃ©ser vÃ©es Ceci 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©hensio de l'interaction de ces deux hÃ©mi sphÃ¨res On trouve des indices de la stratÃ©gi globale du traitement cÃ©rÃ©br de la musique dans la littÃ©ratur clinique. Dans deux cas d'aphasie', le chant a Ã©t considÃ©r comme l'unique


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©cen aspect du discours Ã©tai perdu, demeurait la fonction musicale, plus ancienne, peut-Ãªtr parce que la musique est une fonction rÃ©parti dans les deux hÃ©misphÃ¨re Berman2 suggÃ¨r que la guÃ©riso de l'aphasie ne dÃ©pen pas d'un nouvel apprentissage par l'hÃ©misphÃ¨ non dominant, mais d'une Ã§pris en main>> du langage par cet hÃ©misphÃ¨r L'hÃ©misphÃ¨ non dominant pourrait ainsi constituer une rÃ©serv de fonctions en cas de dÃ©faillanc rÃ©gionale Le chant et la musicalitÃ sont rarement testÃ©e en tant que caractÃ©ristique de la dÃ©tÃ rioration cognitive, en dÃ©pi du fait que la prÃ©servatio de ces capacitÃ© chez des apha- siques a Ã©t associÃ© Ã la possibilitÃ de guÃ©rison et pourrait donc constituer un indica- teur significatif des modifications hiÃ©rarchique au niveau du fonctionnement cognitif. Jacome3 a rencontrÃ un patient n'ayant aucune notion de musique, atteint d'une aphasie mixte transcorticale, qui Ã©mettai spontanÃ©men quantitÃ de 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©riod Ã apprendre la musique. Beatty4 dÃ©cri le cas d'une femme ayant de sÃ©vÃ¨r difficultÃ© en matiÃ¨r d'aphasie, de dysfonctionnement mnÃ©siqu et 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 collaborateurs5 proposent une sÃ©ri de niveaux perceptuels oÃ s'intÃ¨ greraient les dÃ©sordre musicaux: (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©ma rhytmiques et d'intervalles; (iv) le niveau confi- gurationnel, 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 d7har- monie exÃ©cutive et 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©sordre ne sont pas en eux-mÃªme de nature musicale, ce sont des dÃ©sordre de l'audition. C'est seulement lorsqu'intervien- nent des dÃ©sordre de la production musicale, que nous pouvons commencer Ã penser Ã l'existence d'un dÃ©sordr musical. Jouer de la musique improvisÃ© est, sur ce plan, un moyen privilÃ©gi pour dÃ©montre ce lien hypothÃ©tiqu entre perception et production. Les adultes identifient les mÃ©lodie familiÃ¨re en fonction d'informations relationnelles sur les intervalles entre les tons plutÃ´ que sur la base d'informations absolues concer- nant des tons particuliers. Pour ce qui concerne la reconnaissance de mÃ©lodie non fami- liÃ¨res des informations moins prÃ©cise sont rÃ©unie sur le ton lui-mÃªme La premiÃ¨r prÃ©occupatio est relative aux modifications successives de frÃ©quences ou contour mÃ©lo dique. Le contexte rythmique prÃ©par par avance celui qui Ã©cout Ã la survenue de certains intervalles musicaux et donc Ã une structure Ã partir de laquelle il est possible de discerner, ou de prÃ©voir une modification. On ne peut pas Ãªtr prÃ©ven de certaines modifications et se retrouver hors du ton ou hors du temps; c'est pourquoi une perte de la structure rythmique - qui ressemble extÃ©rieuremen Ã de la confusion - peut reprÃ©


senter un facteur cachÃ dans la comprÃ©hensio de la maladie d'Alzheimer. Ce qui importe dans ces descriptions de perception musicale est l'accentuation du contexte ou se situent les diffÃ©rent niveaux 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©pons volitionnelle indÃ©pendant du contenu lexical - peut constituer une situation idÃ©al pour des initiatives de traitement de patients atteints de maladie d'Alzhei- mer. La rÃ©alisatio de phrases mÃ©lodique et de schÃ©ma rythmiques simples par le thÃ© rapeute, et l'attente que le patient reproduisent ces phrases ou ces schÃ©mas est tout Ã fait comparable Ã l'Ã©lÃ©me <<enregistrement> du Mini Mental State Examination (MMSE). Si jouer de la musique improvisÃ© constitue un outil trÃ¨ utile pour l'Ã©valuatio des capa- citÃ© musicales, la mÃ©thod peut Ã©galemen s'insÃ©re dans un contexte thÃ©rapeutiqu destinÃ Ã Ã©value les capacitÃ© cognitives (voir Tableau 1). Dans cette approche, l'Ã©va luation et la thÃ©rapi sont interconnectÃ©e - l'Ã©valuatio fournissant les critÃ¨re Ã partir desquels on identifiera des objectifs thÃ©rapeutique et on dÃ©velopper des stratÃ©gie de traitement. La plupart des travaux publiÃ© au sujet de la musicothÃ©rapi appliquÃ© aux personnes Ã¢gÃ© Ã©voquen les activitÃ© de groupe6", ce procÃ©d Ã©tan gÃ©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©e et des Ã©motions et de stimuler les processus cognitifs, donc d'aigui- ser les facultÃ© de rÃ©solutio des problÃ¨mes D'autres objectifs visent Ã©galemen la stimulation musculaire et sensorielle ainsi que le dÃ©veloppemen Ã plusieurs niveaux des capacitÃ© motrices8. Clair9 a Ã©normÃ©me travaillÃ avec les personnes Ã¢gÃ© et a constatÃ que la musicothÃ© rapie Ã©tai un 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©riod d'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©agissaien avec les autres sans se prÃ©occupe de leur handi- cap. 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©tai parfois que pour un court instant. Le vagabondage, la confusion et l'agitation sont des problÃ¨me frÃ©quent chez les personnes Ã¢gÃ© rÃ©sidan dans des institutions ou dans des Ã©tablissement spÃ©cialemen conÃ§u pour les alzheimÃ©riens Un m~sicothÃ©rapeute' a testÃ le chant sur une femme de 81 ans afin de voir si ce procÃ©d l'aidait Ã rester assise. Au bout de vingt sÃ©ance de chant, le thÃ©rapeut entrepris de faire de la lecture Ã la patiente pour comparer son niveau d'attention. RÃ©sultat alors que les sessions de musicothÃ©rapi et de lecture amÃ©lioraien Ã©galemen les problÃ¨me de vagabondage, le temps total passÃ assis lors des sÃ©ance de musicothÃ©rapi Ã©tai plus de deux fois plus long que celui passÃ assis lors des sÃ©ance de lecture (214,3 minutes contre 99,l en moyenne); en outre, le temps passÃ assis pendant la musicothÃ©rapi Ã©tai plus important que les Ã©pisode sporadiques ou on lui fai-


sait la lecture. Lorsque ce type de femme Ã¢gÃ manifeste de l'agitation, la musicothÃ© rapie individuelle semble donc avoir un effet calmant significatif". Pour ce qui concerne la rÃ©ductio de comportements rÃ©pÃ©titif l'activitÃ musicale diminue Ã©galemen les invectives et les vocalisations perturbatrices12. Les conclusions ci-dessus sont Ã©tayÃ© par Groenel'. Trente pensionnaires (Ã¢gÃ de 60 Ã 91 ans) d'une unitÃ spÃ©cial pour Alzheimeriens, qui avaient tendance au vagabondage, ont Ã©t rÃ©parti de 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©ance de musicothÃ©rapi demeuraient plus longtemps assis que ceux par- ticipant aux sÃ©ance de lecture. L'un des principaux problÃ¨me de la vieillesse est la perte d'indÃ©pendanc et de l'estime de soi, et PalmerI4 dÃ©cri un programme de musicothÃ©rapie dans une rÃ©sidenc gÃ©ria trhue, conÃ§ pour reconstruire le concept de soi. Pour les 380 rÃ©sident - allant de ceux qui s'avÃ©raien totalement fonctionnels Ã ceux que l'on devait totalement prendre en charge -, un programme a Ã©t conÃ§ de maniÃ¨r Ã s'adapter aux capacitÃ© et besoins de chacun. Marcher et danser accroissaient ainsi les facultÃ© de certains patients Ã se mou- voir correctement; et, pour ceux qui ne pouvaient plus se dÃ©placer taper du pied en suivant le rythme de la musique amÃ©liorai la circulation et augmentait la tolÃ©ranc et la force. Les sÃ©ance de chant servaient Ã encourager l'Ã©mergenc des souvenirs ainsi qu'Ã favoriser l'interaction et le comportement socialI4. C'est prÃ©cisÃ©me ce comportement social que P ~ l l a c k ' ~ considÃ¨r comme Ã©tan susceptible d'amÃ©lioratio au travers d'acti- vitÃ© de musicothÃ©rapi de groupe. Dans ce qui suit, nous Ã©voqueron l'Ã©lÃ©me parti- cipatif, qui semble particuliÃ¨remen intÃ©ressan pour ce qui concerne la communication, et l'intention de participer, qui est au centre de l'activitÃ de musicothÃ©rapie 1.3 Ãˆ"â€¢llO..*-** d," " +$ +\-----+ .- : :-i- .----.. La rnusicot erapie a ete ega ement uhlisÃ¨ pour &dÃ¨ 'plÃ¼ sp&^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©t constatÃ que les paroles des chansons revenaient en mÃ©moir infiniment mieux que les mots parlÃ© ou les informations parlÃ©es MÃªm si les patients se rappelaient les chants familiers avec beaucoup plus de prÃ©cisio qu'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©rapeut chantait. 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©miniscenc lyrique, lu tÃ´ que le caractÃ¨r plus ou moins familier d'une chanson donnÃ©e" Dans une autre Ã©tud portant sur les effets de trois approches thÃ©rapeutique diffÃ©rente (rÃ©miniscenc induite musicalement, rÃ©miniscenc induite 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©t Ã©valuÃ© en fonction des diffÃ©rence - avant et aprÃ¨ sÃ©ance de traitement - des scores obtenus au Mini Mental State Examination. Les comparaisons ont Ã©t effectuÃ©e Ã la fois pour les scores totaux et pour les sous-scores relatifs Ã l'orientation, Ã l'attention et au langage. RÃ©sultat les rÃ©miniscence induites 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©cri le traitement d'une femme de 55 ans et les bÃ©nÃ©fic apportÃ© par le jeu de musique improvisÃ©e Il y eut, explique-t-il, des amÃ©lioration significatives des capacitÃ© motrices fines. Sa facultÃ Ã se souvenir des schÃ©ma rythmiques, et la capa-


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