Music can be used to help patients talk, walk and be happy!

1. MBS
Music for the Mind
Tutorial
By Dr Madhumita Sen

2. Introduction
 From a Darwinian perspective, music is a
mystery.
 It's unclear whether the human ability to
appreciate a catchy melody conferred some
specific evolutionary advantage or was a by-
product of more general adaptations involving
sound and pattern processing.

3.  But what is known is that evidence of music has
been found in every documented human
culture.
 Nearly all of us have at least some innate
capacity to recognize and process song.
 The human brain houses a staggeringly complex
neuronal network that can integrate rhythm,
pitch, and melody into something far greater
with, it turns out, significant therapeutic
potential.

4.  Research and clinical experience
increasingly support music as medicine.
 Accessing and manipulating our musical
minds can benefit numerous psychiatric,
developmental, and neurologic
conditions, often more effectively than
traditional therapies.

5.  After years of research, two findings stand out as
particularly important for using music in
rehabilitation.
 First, the brain areas activated by music are not
unique to music; the networks that process music
also process other functions.
 Second, music learning changes the brain.
 The brain areas involved in music are also active in
processing language, auditory perception,
attention, memory, executive control, and motor
control.

6.  For example, the same area of the brain is
activated whether a person is processing a
problem in the syntax of a sentence or in a
musical piece, such as a wrong note in a melody.
 This region, called Broca’s area after the French
neurologist from the 19th century who described
it, is also important in processing the sequencing
of physical movement and in tracking musical
rhythms, and it is critical for converting thought
into spoken words.
 Scientists speculate that Broca’s area supports
the appropriate timing, sequencing, and
knowledge of rules that are common and
essential to music, speech, and movement.

7.  A key example of the second finding, that music
learning changes the brain, is research clearly
showing that through musical learning, auditory
and motor areas in the brain grow larger and
interact more efficiently.
 After novice pianists have just a few weeks of
training, for example, the areas in their brain
serving hand control become larger and more
connected.
 It quickly became clear that music can drive
plasticity in the human brain, shaping it through
training and learning.

8. Definition
 Music therapy is an allied health science, consisting
of an interpersonal process in which a trained
music therapist uses music and all of its facets—
physical, emotional, mental, social, aesthetic, and
spiritual—to help clients to improve or maintain
their health.
 Music therapists primarily help clients improve their
health across various domains (e.g., cognitive
functioning, motor skills, emotional and affective
developmental and social skills, and quality of life)
by using music experiences (e.g., singing,
songwriting, listening to music, moving to music) to
achieve treatment goals and objectives.

9. Music Therapy?
 Music therapy rewires the brains of people.
 Scientists are for the first time studying a speech
therapy technique called Melodic Intonation
Therapy to find out what happens in patients’
brains.
 The therapy is used to teach people who have
aphasia (inability to speak) after suffering a
stroke to speak, and makes use of the fact that
many people who cannot talk can still sing.

10.  When patients suffer a stroke on the left
hemisphere of the brain it affects their ability to
speak, but melodic intonation therapy attempts
to tap into the right side of the brain if it is
undamaged.
 Music affects many parts of the brain in both
hemispheres, and it influences motor skills,
emotions and hearing.
 If the affected person is taught to sing sentences,
they can then learn to speak them.

11.  Many patients who have not been able to
speak, in some cases for many years, and who
have tried other speech therapies with no
success, have learned to speak after a few
dozen sessions of melodic intonation therapy.
 Even after a single session most stroke victims
can learn to say a simple phrase by combining a
note in the melody with each syllable, and even
one phrase can make them less dependent and
frustrated.

12.  Schlaug said he thought the reason the therapy is
not used more widely is at least in part because
many people are embarrassed when asked to
sing, and some therapists may feel uncomfortable
singing to their patients.
 Some patients, especially males, can also struggle
with embarrassment.
 Once they start, Schlaug said, they settle in and
the therapy is simple.
 His next goal is to teach the technique to care
givers.
(© 2010 PhysOrg.com)

13.  Spoken language and arm gestures are
controlled by the same motor control system.
 Arm movements can influence language
comprehension much as semantics can
influence arm movement planning.
 Arm movement itself can be used as a linguistic
signal.
 Studies of primate premotor cortex and, in
particular, of the so-called "mirror system",
including humans, suggest the existence of a
dual hand/mouth motor command system
involved in ingestion activities.

14.  This may be the platform on which a combined
manual and vocal communication system was
constructed.
 In humans, speech is typically accompanied by
manual gesture, speech production itself is
influenced by executing or observing transitive
hand actions, and manual actions play an
important role in the development of speech,
from the babbling stage onwards.

15.  Behavioural data also show reciprocal influence
between word and symbolic gestures.
 Neuroimaging and repetitive transcranial
magnetic stimulation (rTMS) data suggest that the
system governing both speech and gesture is
located in Broca's area.
 In general, the presented data support the
hypothesis that the hand motor-control system is
involved in higher order cognition.

16. Melodic Intonation Therapy (MIT)
 Melodic Intonation Therapy (MIT) for Aphasia: is a
therapeutic process used by music therapists and
speech pathologists to help patients with
communication disorders caused by brain damage.
 This method uses a style of singing called
melodic intonation to stimulate activity in the right
hemisphere of the brain in order to assist in speech
production.
 Recent evidence suggests that rhythm may be a
crucial MIT component: rhythmic speech may engage
deeper brain areas known as the basal ganglia.

17.  One study using PET (positron emission
tomography) scans found that areas controlling
speech in the left hemisphere were "reactivated"
by the end of MIT.
 Further work suggests that melodic intonation
therapy can result in significant changes in brain
structure through the brain's own neuroplasticity.

18.  Axon connections in the right hemisphere (in
right handed patients) were found to be
increased in volume after MIT.
 At least theoretically, this could allow for
language processing in right homologous areas,
suggesting that the right hemisphere may
compensate for an impaired left hemisphere by
taking up language processing responsibilities
(Schlaug et al., 2009).

20.  As stroke therapy
 Part of this therapy is the ability of music to affect
emotions and social interactions.
 Research by Nayak et al. showed that music
therapy is associated with a decrease in
depression, improved mood, and a reduction in
state anxiety.
 It is hypothesized that music therapy helps stroke
victims recover faster and with more success by
increasing the patient's positive emotions and
motivation, allowing them to be more successful
and driven to participate in traditional therapies.

21. Wider Scope
 The scope of music therapy has become very
broad.
 It's been studied and shown effective in psychiatric
illness;
 developmental issues; and
 medical conditions, including pre- and
postoperative settings.
 One of the most recognized areas is motor initiation
in patients with neuromuscular and movement
disorders, such as Parkinson disease (PD).

22.  Patients with PD often have a
slowness of movement and a
shuffling gait.
 Music, specifically highly
rhythmic music, has been
shown -- and there's quite a bit
of supporting data here -- to
help them in training and
coordinating their movements
and gait.
 Music also enhances the length
of their stride and improves
balance.

23.  Alzheimer’s disease: Ideally, it's started early to
help prevent memory decline and create new
associative memories early in the disease -- linking
acquaintances, places, and events, for example,
in order to prevent or slow future memory
problems and enhance recall.
 Recent research is really enhancing our
knowledge of neuroplasticity.
 Forming these associations -- these new neuronal
connections -- appears to be neuroprotective.

24. Stroke and Gait disturbances
 When an individual is walking to a familiar song, the
rhythm of the song is processed in the temporal lobe, the
order of the melody is processed in the frontal lobe and
language areas, the lyrics are processed in the language
areas, the personal meaning of the song is processed in
the emotional areas, and so forth.
 With these areas all working together, the individual is
very aware of when he or she is walking unevenly, as this
causes the song to be played with pauses and
hesitation.
 The brain wishes to correct the song, and the other areas
of the brain work together with the motor cortex to
better coordinate the person's movements.

25.  With a modified iPod Touch and a special app
that tracks their steps, patients with Parkinson's
disease (PD) can significantly improve arm-swing
and gait disorders using a musical reward system
designed to rewire their brains, researchers at the
University of Calgary in Alberta, Canada, reported
at the 3rd World Parkinson Congress (WPC).
 The training system, called Ambulosono, designed
by Dr. Hu's team.
3rd World Parkinson Congress (WPC). Abstracts
#P22.31 and #P12.08. October 4, 2013.

26. Mental Illness
 Music therapy is also used to as a
psychotherapeutic application in mental illness
and can help alleviate stress and anxiety.
 This has an impact on neurologic function as well;
for example, multiple sclerosis symptoms can be
exacerbated by stress.
 Preliminary research shows that music can be an
excellent tool for self-relaxation and stress
management in these patients.
 And one of the most fascinating areas in which
music is used is dementia and amnesia.

27.  Music and mood disorders
 According to the Mayo Health Clinic, out of every
100,000 adolescents, two to three thousand will
have mood disorders, out of which 8-10 will commit
suicide.
 Two prevalent mood disorders especially in the
adolescent population are clinical depression
and bipolar disorder.
 Adolescents have identified many benefits of
listening to music, including emotional, social, and
daily life benefits, along with the formation of one’s
own identity.

28.  Music can provide a sense of independence and
individuality, which in turn contributes to one’s own
self-discovery and sense of identity.
 It can also serve as a creative outlet to release or
control emotions and find ways of coping with
difficult situations.
 Music can improve one's mood by reducing stress
and lowering anxiety levels, which can help
counteract or prevent depression.
 Music education programs provide adolescents
with a safe place to express themselves and learn
life skills such as self-discipline, diligence, and
patience.

29.  A person with dementia or amnesia may not
consciously recognize a familiar song, but
something in their subconscious knows it's familiar.
 There are feelings, emotions, or moments of
history in there somewhere.
 And if they listen to those songs, we're realizing
that sometimes these feelings or the emotions are
so strong that they trigger fleeting glimpses of
pieces of memory.
 If we can work with those fleeting moments and
build upon them, maybe stronger connections
can be made and more memories experienced.

30.  Do the memories and recollections last once the
music has stopped?
 In few patients with short-term memory problems in
whom using music, and progressing from older
memories forward, have then been able to recall
recent events.
 In people with Alzheimer-type dementia, who have
seemingly lost the ability to recall past events, music
with strong emotional ties and meaning can lead to
enduring remembrances and recall.
 https://www.youtube.com/watch?v=6KjRD4ttqwM

31.  Initially, it's more reflexive and reactive.
 But if the musical interventions are provided on a
regular basis and for longer periods -- 15 minutes,
20 minutes, an hour -- we find that their short-term
memory and attention improve over time.
 Some studies done by the New York State
Department of Health engaged people with mid-
to late-stage Alzheimer disease in music therapy
sessions for 1 hour, 3 times a week for 10 months.
 Over time, their awareness of other people
improved significantly.

32.  Music-based therapies work via a variety of
musical qualities, with aspects like rhythm, melody,
and emotional familiarity having much different
effects, respectively.

33.  In heart disease
 According to a 2009 Cochrane review of 23
clinical trials, it was found that music may reduce
heart rate, respiratory rate, and blood pressure in
patients with coronary heart disease.
 Benefits included a decrease in blood pressure,
heart rate, and levels of anxiety in heart patients.
 In most studies, patients listened to one 30-minute
music session.
 Only two used a trained music therapist instead of
pre-recorded music.

34.  Depression
 Music therapy has been found to have numerous
significant outcomes for patients with major
depressive disorder.
 One study found that listening to soft, sedative
music for only 30 minutes a day for two weeks led
to significantly improved global depressive scores,
and improved scores on individual depressive sub-
scales.
 Like many of the other studies mentioned, the
effects were seen to be cumulative over the time
period studied – that is, longer treatment led to
increased improvement [Hsu].

35.  Another study showed that ADD patients were able
to better express their emotional states while
listening to sad music than while listening to no
music or happy, angry, or scary music.
 The authors found that this therapy helped patients
to overcome verbal barriers in expressing emotion,
which can assist therapists in successfully guiding
treatment.

36. Stuttering
 Stuttering is typically a developmental
disorder beginning in early childhood and
continuing into adulthood in at least 20% of
affected children.
 The brain functions most optimally when multiple
areas are working together, as areas that work
particularly well can compensate for areas that
work less efficiently, all the while "teaching" the
less developed areas how to rework themselves
to function better.

37.  The benefit of music therapy is that through
musical expression both the primary aspects of
dysfluency (anxiety and motor difficulty) can be
addressed.
 For anxiety, musical expression can be a
confidence builder.
 Most individuals who stutter are able to sing
without dysfluency and if given a composition
exercise where a story is conveyed in the first
person, one gets the experience of fluent self-
expression through song.

38. How does it work?
 Music processing is incredibly complex, and a
complete map of the areas responsible for
music and sound processing doesn't yet exist.
 This complexity is probably why music is so
beneficial as a therapeutic tool.

39. The following are some of effects of music, which
help to explain the effectiveness of music therapy:
 Brain Waves: Research has shown that music with
a strong beat can stimulate brainwaves to
resonate in sync with the beat, with faster beats
bringing sharper concentration and more alert
thinking, and a slower tempo promoting a
calm, meditative state.
 Also, research has found that these changes in
brainwave activity levels can also enable the
brain to shift speeds more easily on its own as
needed, which means that music can bring
lasting benefits to our state of mind, even after
we’ve stopped listening.

40.  Breathing and Heart Rate: With alterations in
brainwaves comes changes in other bodily
functions.
 Those governed by the autonomic nervous
system, such as breathing and heart rate can also
be altered by the changes music can bring.
 This can mean slower breathing, slower heart
rate, and an activation of the relaxation
response, among other things.
 This is why music and music therapy can help
counteract or prevent the damaging effects
of chronic stress, greatly promoting not only
relaxation, but health.

41.  State of Mind: Music can also be used to bring a
more positive state of mind, helping to keep
depression and anxiety at bay.
 This can help prevent the stress response from
wreaking havoc on the body, and can help keep
creativity and optimism levels higher, bringing
many other benefits.

42.  Other Benefits: Music has also been found to
bring many other benefits, such as
1. lowering blood pressure (which can also reduce
the risk of stroke and other health problems over
time),
2. boost immunity,
3. ease muscle tension, and more.
 With so many benefits and such profound
physical effects, it’s no surprise that so many are
seeing music as an important tool to help the
body in staying (or becoming) healthy.

43. Methods

44.  The traditional melodic intonation therapy process
is divided into four progressive stages.
 In the early stages, MIT was used solely for adult
patients, but eventually therapists began to use
MIT with children.
 Therapists found that the traditional procedure did
not work well with children, so a new three level
structure was developed by Helfrich-Miller (Roper
2003).

45. Adult
 As stated above this is a four level process.
 As the patient progresses through the stages the
role of the therapist decreases.
 In the first stage the therapist hums “intoned
phrases” and the patient taps the “rhythm and
stress of each pattern” with his/her hands or feet
(Roper 2003:2).
 In the beginning of the second stage the patient
joins the therapist in humming while continuing to
beat the rhythms

46.  As the patient progresses, the therapist begins to
sing “intoned phrases” and the patient repeats
them.
 The third stage is the same as the final level of
stage two except that now the patient is required
to wait for a designated period of time before
repeating the phrase or sentence.
 This helps to increase the patients ability to
“retrieve” words.

47.  In the fourth and final stage the sentence length
is increases and “sprechgesang” is used to
facilitate the transition to normal speech.
 This technique involves keeping the same
melodic line as the intoned sentence of the
proceeding step, except that the constant pitch
of the intoned words is replaced by the variable
pitch of speech.
 The ultimate goal is to remove the musical
elements entirely so the patient presents normal
speech.

48.  Getting Started
 Seated across a table from the patient, the
therapist shows a visual cue and introduces a
word/phrase (e.g., “Thank you”).
 The accented/stressed syllable(s) will be sung on
the higher of the 2 pitches, unaccented on the
lower.
 The starting pitch should rest comfortably in the
patient’s voice range, and the other pitch should
be a minor 3rd (3 semitones) above or below
(middle C and the A just below it work well for
most people).

49.  For those unfamiliar with this
terminology, think of the
children’s taunt, “Naa-naa -
Naa-naa”.
 These 2 pitches create the
interval of a minor 3rd, which is
universally familiar, requires no
special singing skill, and provides
a good approximation of the
prosody of speech that still falls
into the category of singing.

50.  Inner Rehearsal
 So patients learn to establish their own “target”
phrases, the therapist models the process of inner
rehearsal by slowly tapping the patient’s hand (1
syll/sec) while humming the melody, then softly
singing the words, explaining that s/he is “hearing”
the phrase sung “inside”.
 If the patient has trouble understanding how to do
this, s/he is asked to imagine hearing someone
sing “Happy Birthday” or a parent’s voice saying,
“Do your homework”.

52.  Once the concept is understood, the therapist
taps while softly singing the phrase and indicating
that the patient should hear his/her own voice
singing the phrase “inside”.
 This inner rehearsal (covert production) of the
phrase creates an auditory “target” with which
the overtly produced phrase can be compared.
 Those who master this technique can eventually
transfer the skill from practiced MIT phrases to
expressive speech initiated with little or no
assistance.

53.  Auditory-motor Feedback Training
 Because re-learning to identify and produce
individual speech sounds is essential to patients’
success, training them to hear the difference
between the target phrase and their own speech
is a key aspect of the recovery process.
 In the early phases of treatment, patients listen as
the therapist sings the target, and learn to
compare their own output as they repeat the
words/phrases.
 Sounds identified as incorrect become the focus
of remediation.

54.  Once a problem is corrected, the process of
singing, listening, and repeating begins again.
 As patients learn to create their own target
through inner rehearsal, auditory-motor feedback
training allows them to self-monitor as thoughts
are sung aloud.
 Over time, they learn to use the auditory-motor
feedback “loop” to hear their own speech
objectively, identify problems and adjust to
correct them as they speak, and thereby
decrease dependence on the therapist.

55. Using Music On Your Own
 While music therapy is an important discipline, you
can also achieve many benefits from music on your
own.
 Music can be used in daily life for relaxation, to gain
energy when feeling drained, for catharsis when
dealing with emotional stress, and in other ways as
well.

56. Gait and Balance with the beat!
 Music has proven useful in the recovery of motor
skills.
 Rhythmical auditory stimulation in a musical
context in combination with traditional gait
therapy improved the ability of stroke patients to
walk.
 The study consisted of two treatment conditions,
one which received traditional gait therapy and
another which received the gait therapy in
combination with the rhythmical auditory
stimulation.

57.  During the rhythmical auditory stimulation,
stimulation was played back measure by measure,
and was initiated by the patient's heel-strikes.
 Each condition received fifteen sessions of
therapy.
 The results revealed that the rhythmical auditory
stimulation group showed more improvement in
stride length, symmetry deviation, walking speed
and rollover path length (all indicators for
improved walking gait) than the group that
received traditional therapy alone.

58. Studies
 Researchers in Finland have asked whether music can
benefit people recovering from stroke.
 Their study is notable for its sound methodological
quality, and the results are promising: music does indeed
appear to make a difference to patients' cognitive
recovery.
 Soon after their hospitalisation, 60 stroke patients were
allocated randomly to one of three groups.
 Those in the music group were provided with a portable
CD player and asked to listen to their favourite music for
at least an hour a day for two months.
 Patients in the audio book group spent at least an hour a
day for two months listening to audio books of their
choosing.
 A final control group were not given a listening task.

59.  Compared to the patients who listened to audio
books and the control patients, the patients who
listened to music daily showed superior
performance when tested three months and six
months later on measures of verbal memory and
focused attention.
 Crucially, the psychologists who performed these
neuropsychological assessments were unaware of
which groups the patients had been in - making
this a single-blind, randomised, controlled trial.
 The music and audio book patients also showed
reduced depression and confusion compared with
the control patients.

60.  Neuroimaging studies have shown that listening to
music "naturally recruits bilateral temporal, frontal
and parietal neural circuits underlying multiple
forms of attention, working memory, semantic and
syntactic processing, and imagery," the
researchers said.
 By contrast, the brain activity triggered by speech
without music is less extensive and more focused
on the language-dominant hemisphere (usually
the left).

61.  The new finding is consistent with research on
animals showing that a stimulating environment
can speed recovery after stroke.
 Yet the researchers noted with regret that many
stroke patients are left in their rooms without
much stimulation or interaction.
 "We suggest that everyday music listening
during early stroke recovery offers a valuable
addition to the patients' care," they concluded.

62. Is There a Role for Music in the ICU?
 Among ICU patients receiving acute ventilatory
support for respiratory failure, self-initiated patient-
directed music (PDM) resulted in greater reduction
in anxiety compared with usual care, but not
compared with noise-canceling headphones
(NCH).
 Concurrently, PDM resulted in greater reduction in
sedation frequency compared with usual care or
NCH, and greater reduction in sedation intensity
compared with usual care but not compared with
NCH.
 Crit Care. 2015;19(1)

63. Key Points
 Music understanding networks of the
brain are much more complex compared
to speech networks.
 Music intonation therapy can be used for
speech recovery after stroke.
 Music therapy also helps rewire the brain
in dementias, depression and mental
diseases.

64. Resources
 https://www.youtube.com/results?search_query
 https://www.youtube.com/watch?v=d6SEghlu1Do
 https://www.youtube.com/watch?v=pRqB7V-
G4mM
 https://www.youtube.com/watch?v=X1aToWNevKw
 https://www.youtube.com/watch?v=eBgRI4VdKbE
 https://www.youtube.com/watch?v=6KjRD4ttqwM

65. Q?
Thank you