and “music therapy”
Transcription
and “music therapy”
Musicoterapia in ambito neurologico Alfredo Raglio Dipartimento di Scienze Biomediche e Chirurgico-Specialistiche Sezione di Clinica Neurologica – Università di Ferrara [email protected] Dr. Alfredo Raglio A.A. 2012-2103 NECESSITA DI DEFINIRE LA MUSICOTERAPIA… Dr. Alfredo Raglio A.A. 2012-2103 9 th WORLD CONGRESS OF MUSIC THERAPY: Music Therapy: a global mosaic many voices, one song WASHINGTON, D.C., 1999 Dr. Alfredo Raglio A.A. 2012-2103 La Musicoterapia è ...l'uso della musica e/o dei suoi elementi (suono, ritmo, melodia e armonia) per opera di un musicoterapeuta qualificato, in un rapporto individuale o di gruppo, all interno di un processo definito, per facilitare e promuovere la comunicazione, le relazioni, l'apprendimento, la mobilizzazione , l'espressione l organizzazione ed altri obiettivi terapeutici degni di rilievo, nella prospettiva di assolvere i bisogni fisici, emotivi, mentali, sociali e cognitivi. La Musicoterapia si pone come scopi di sviluppare potenziali e/o riabilitare funzioni dell'individuo in modo che egli possa ottenere una migliore integrazione sul piano intrapersonale e/o interpersonale e, conseguentemente, una migliore qualità della vita attraverso la prevenzione, la riabilitazione o la terapia . (8 th WORLD CONGRESS OF MUSIC THERAPY, AMBURGO, 1996) Dr. Alfredo Raglio A.A. 2012-2103 Dr. Alfredo Raglio A.A. 2012-2103 Clinical Psychology Review 29 (2009) 193–207 Contents lists available at ScienceDirect Clinical Psychology Review Dose–response relationship in music therapy for people with serious mental disorders: Systematic review and meta-analysis Christian Gold a,⁎, Hans Petter Solli b,c, Viggo Krüger b, Stein Atle Lie a a Unifob Health, Bergen, Norway “…Music therapy is University a special type of psychotherapy where forms of musical interaction and communication are used alongside verbal of Bergen, Norway Diakonale Hospital, Oslo, Norway communication. It Lovisenberg has been defined as “a systematic process of intervention wherein the therapist helps the client to promote health, using music experiences and the relationships developing through them as dynamic forces of change” (Bruscia, 1998). The types of ‘music experiences’ can include a rused t i cin l emusic i n ftherapy o a b s tfree r a acnd t structured improvisation, other types of active music-‐making by patients, and listening to music. Improvisation is perhaps the most prominent form of musical interaction in music therapy. It has been Article history: Serious mental disorders have considerable individual and societal impact, and traditional treatments may Received 30 any June 2008 described as central in m music therapy models. lient(s) and therapist n musical instruments hey have chosen, showClimited effects. Music therapy mayimprovise be beneficial inopsychosis and depression, includingttreatmentReceived in revised form 6 January 2009 resistant cases. Theoaim of this review was t toheme. examine the benefits of music therapy for speople with serious playing together freely o r w ith a g iven s tructure o r a m usical r n on-‐musical M usic t herapists a re pecifically trained to Accepted 12 January 2009 mental disorders. All existing prospective studies were combined using mixed-effects meta-analysis models, intervene therapeutically within the medium, for eallowing xample to support by pofroviding rhythmical or pre-post tonal study), grounding, to clarify, to confront to examine the influence study design (RCT vs. CCT vs. type of disorder Keywords: (psychotic vs. non-psychotic), and number of sessions. Resultsm showed therapy, when added toin music therapy Psychosis or to challenge the client's expression in the music (Bruscia, 1987; Wigram, 2004). Other odes that of music music experiences standard care, has strong and significant effects on global state, general symptoms, negative symptoms, Depression include playing composed singing aanxiety, nd wfunctioning, riting or and improvising songs (Baker dose–effect & Wigram, 2005), and listening to musical engagement. Significant relationships were Psychotherapy music on instruments, depression, identified for general, negative, and depressive symptoms, as well as functioning, with explained variance Dose–effect relationship music (Grocke & W igram, 2006). Songs may be used by clients as a Mixed-effects meta-analysis ranging from 73% to 78%. Small effect sizes for these outcomes are achieved after 3 to 10, large effects after 16 safe, structuring and socially acceptable form in wtohich they The can express hich might be helps too people overwhelming to 51 sessions. findings suggestfeelings that music w therapy is o antherwise effective treatment which with psychotic and non-psychotic severe mental disorders to improve global state, symptoms, and functioning. express. Music listening may be helpful to bring up and make available therapeutically relevant issues (emotions, associations, Slight improvements can be seen with a few therapy sessions, but longer courses or more frequent sessions memories, identity issues). are needed to achieve more substantial benefits. © 2009 o Elsevier Ltd. All rights reserved. All these different modes of ‘music experiences’ become therapeutic by being used in the context f a therapeutic relationship. Verbal discussions, reflections, or interpretations connected to the music are important to help clients explore the potential meaning of an experience, and to Contents relate a new experience within therapy to situations in the client's life. The degree to which the music experience itself, versus the verbal reflection 1. Introduction . . c . onnected . . . . . . . .to . i. t, . i. s . s.een . . . a.s . the . . .active . . . . a . gent . . . . o. f . c.hange . . . . .m . ay . . v . ary . . . b.etween . . . . . .m. odels . . . . o . f m 194usic therapy Music therapy in mentalH health. . . . t . reatments . . . . . . . . t.hat . . .rely . . .solely . . . . o . n . .the . . .d.irect . . . e . ffects . . . . .o.f .m. usic . . . a . lone, . . . 194 (Garred, 2004), as well 1.1. as between clients. owever, which do not 1.2. Music therapy—the evidence to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 “involve or depend upon rocess of intervention nd change 1.3. a p Research questions addressed in thisareview . . . . .w . ithin . . . . a. c . lient–therapist . . . . . . . . . . . .relationship” . . . . . . . . . .(“auxiliary . . . . . . . .level”, . 195 Bruscia, 1998, p. Method T . he . . .term . . . .‘music . . . . .m . edicine’ . . . . . . i. s . s. ometimes . . . . . . . .u.sed . . t . o . d . istinguish . . . . . . . . s. uch . . . t.reatments . . . . . . . .from . . . .m . usic . 196therapy.”… 195), are not music t2.herapy. Dr. Alfredo Raglio A.A. 2012-2103 b c 2.1. Criteria 2.1.1. 2.1.2. 2.1.3. 2.1.4. 2.1.5. for selecting studies Study design . . . Study quality . . . Participants . . . . Interventions . . . Outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 196 196 196 196 196 after initiation of trazodone, and the headache disaped when the the agent agent was was discontinued. discontinued. The The temporal temporal d when onship suggested suggested that that the the headache headache could could be be the the adverse adverse onship t of of trazodone trazodone use. use. The The possibility possibility of of the the headache headache caused caused rotonin syndrome syndrome is is not not likely likely due due to to the the lack lack of of clinically clinically rotonin ciated findings of of mental mental status status change, change, autonomic autonomic hyperhyperiated findings ity or neuromuscular neuromuscular abnormalities. abnormalities. ty or he most common common side-effects side-effects that that lead lead to to discontinuation discontinuation e most azodone for for treatment treatment of of insomnia insomnia are are sedation, sedation, dizzidizziazodone 2 and psychomotor impairment. 2 To our knowledge, and psychomotor impairment. To our knowledge, are few reports of severe headache as an adverse effect are few reports of severe headache as an adverse effect d to trazodone use. In 1992, Workman et al. reported d to trazodone use. In 1992, Workman et al. reported a 35-year-old patient who possessed a genetic predisa 35-year-old patient who possessed a genetic predision toward migraine suffered from severe migraine ion toward migraine suffered from severe migraine ache after trazodone treatment.3 The mechanism of ache after trazodone treatment.3 The mechanism of done-induced headache is not clear. Serotonin-releasing done-induced headache is not clear. Serotonin-releasing r and serum serotonin increase during headache attacks r and serum serotonin increase during headache attacks cerebral vessels are highly innervated by serotonin fibers cerebral vessels4,5are highly innervated by serotonin fibers raphe nuclei. Workman et al. indicated that migraine raphe nuclei.4,5 Workman et al. indicated that migraine ache may be evoked by trazodone through its active ache may be evoked by trazodone through its active bolite, m-chlorophenylpiperazine, which is a potent bolite, is a potent elective m-chlorophenylpiperazine, serotonin receptor agonist.which In addition, this elective serotonin receptor agonist. In addition, this Received 14 June 2011; revised 8 August 2011; accepted 23 23 September September 2011. 2011. accepted Neurology Issue When music music becomes becomes music music therapy therapy When doi:10.1111/j.1440-1819.2011.02273.x doi:10.1111/j.1440-1819.2011.02273.x Psychiatry and Clinical Neurosciences 2011; 65: 679–683 S CIENTIFIC LITERATURE PROVIDES evidence of the CIENTIFIC LITERATURE PROVIDES evidence of the unquestionable effects of music both in pathological coneffects of music boththerapeutic in pathological conIunquestionable personally that music embodies potentialion the texts and uponsee individuals generally speaking.11 Also Also on the texts and upon individuals generally speaking. ties as suggestive – but not scientifically proven. physiological, neurophysiological, biological and neurochemiphysiological, neurophysiological, biological and neurochemiexample, ‘Mozart’s music’ is an concept:22 calFor levels, confirmation of such effects hasinsufficient been forthcoming. cal levels, confirmation of suchoreffects hasfrom beenDon forthcoming. which Mozart? The Requiem an aria Giovanni? Empirically, all individuals can experience well-being and Empirically, all individuals can experience well-being and positive emotions when that has parWhy Mozart and not thelistening Beatles ortoB.music McFerrin? Andsome addresspositive emotions when listening to music that has some particular significance forwhat? them,How? or can derive pleasure from ing whom? Producing ticular significance for them, or can derive pleasure from socializing a musical experience (making or listening tomusicmusic With these queries in mind, the international socializing a musical experience (making or listening to music Psychiatry and Clinical 2011; 65: 679–683 together with others), Neurosciences buthas allintroduced the above, while emphasizing the therapeutic community – as an essential comtogether with others), but all therefers above, while emphasizing the potentialities of music, usually to momentary effects that 3,4 ponent of therapy by music – the concept of ‘relationship’. potentialities of music, elude therapeutic logic.usually refers to momentary effects that Thetherapeutic above thoughts elude logic. can help re-model music-therapeutic I personally see that music potentialipractices by introducing theembodies followingtherapeutic aspects (Evidence Based tiesMusic as suggestive but not scientifically proven. 5,6 musical and Therapy–and Evidence Based Practice): For example, ‘Mozart’s music’ is an insufficient relational training of music therapists, presence of concept: a therapeu011 The Authors which Mozart? The Requiem or an aria from Giovanni? 011 The Authors tic setting, a theoretical/methodological Don background, aims hiatry and Clinical Neurosciences © 2011 Japanese Society of Psychiatry andBeatles Neurology Why Mozart and not the or B. McFerrin? And addressoriented to the achievement of stable and longlasting hiatry and Clinical Neurosciences © 2011 Japanese Society of Psychiatry and Neurology ing whom? Producing what? How? improvements (according to type gravity of pathologies With these queries in mind, theand international musicconsidered), content (active and/or receptive techniques) therapeutic community has introduced – as an essential com3,4 the facilitating intra-by and inter-personal with ponent of therapy music – the conceptrelationships of ‘relationship’. patient/client and rigorous assessment The above thoughts can help re-modelcriteria. music-therapeutic practices by introducing the following aspects Based I believe that neither music nor the(Evidence sonorous-musical 5,6 musical and if Music Therapy andtoEvidence Based Practice): element can fail keep these concepts in due consideration relational of music therapists, presence of aIn therapeuthey aretraining to assume a potential therapeutic value. therapeutic tic applications setting, a theoretical/methodological aims it is of essential importancebackground, that the individual’s oriented to the achievement of stable longmusicality and musical potential shouldand emerge: thislasting can only improvements (according to type and gravity of pathologies happen through the relationship between the music therapist considered), content (active and/or receptive techniques) and the patient/client mediated by the power of music. This is facilitating intra- and inter-personal relationships with the what definesand therigorous therapeutic specificity of music and contextupatient/client assessment criteria. I believe that neither music nor the sonorous-musical element can fail to keep these concepts in due consideration if they are to assume a potential therapeutic value. In therapeutic applications it is of essential importance that the individual’s musicality and musical potential should emerge: this can only happen through the relationship between the music therapist and the patient/client mediated by the power of music. This is what defines the therapeutic specificity of music and contextu- Letters to the Editor 683 alizes the various possible interventions through music. Music can be the source of deep pleasure, it can stimulate relationships and attentive and cognitive functions, but it becomes therapeutic practice only in the presence of the essential components mentioned above. REFERENCES Letters to the Editor 683 Psychiatry and Clinical Neuroscience 1. Sacks O. The power of muisc. Brain 2006; 129: 2528–2532. 2. Koelsch S. Towards a neural basis of music-evoked emotions. Trends Cogn.possible Sci. 2010; 14: 131–137. alizes the various interventions through Music Volume 65,itIssue 7, music. (/doi/10.1111/pcn.2011.65.issue-7/issu C. All those things with music J. Music can 3.beGold the source of deep pleasure, can(Editorial). stimulate Nord. relationTher.attentive 2009; 18:and 1–2.cognitive functions, but it becomes ships and , Kruger et alInformation . Dose-response relationship 4. Gold practice C, Solli HP therapeutic only in theVpresence of the essential com- in Additional muisc therapy above. for people with serious mental disorders: systemponents mentioned atic review and meta-analysis. Clin. Psychol. Rev. 2009; 29: 193– 207. How to Cite REFERENCES 5. Vink A, Bruinsma M. Evidence based music therapy. Music 1. Sacks O. The power of 4: muisc. Brain 2006; 129: Ther. Today 2003; 1–26. Available from2528–2532. URL: http://www. 2. Koelsch S. Towards a neural basis of music-evoked emotions. musictherapyworld.de (last accessed 4 JulyWhen 2004). music becomes music therapy. Psy Raglio, A. (2011), Trends Cogn. Sci. 2010; 14: 131–137. 6. Edwards J. Possibilities and problems for evidence-based prac3. Gold C. All those 683. things with music (Editorial). Nord. J. Music doi: 10.1111/j.1440-1819.2011.02273.x in music therapy. Arts Psychother. 2005; 32: 293–301. Ther.tice 2009; 18: 1–2. 4. Gold C, Solli HP, Kruger V et al. Dose-response relationship in Alfredo Raglio, MA (Music Therapy) muisc therapy for people with serious mental disorders: systemSospiro Foundation, atic review and meta-analysis. Clin. Psychol. Rev. 2009;Cremona, 29: 193– Italy 207. Email: [email protected] M. Evidence based therapy. Music2011; 5. Vink A, BruinsmaReceived 25 July 2011;music revised 22 August Ther. Today 2003; 4: 1–26. Available from URL: http://www. accepted 23 September 2011. musictherapyworld.de (last accessed 4 July 2004). 6. Edwards J. Possibilities and problems for evidence-based practice in music therapy. Arts Psychother. 2005; 32: 293–301. Author Information Sospiro Foundation, Cremona, Italy, Email: raglioa@ Publication History Alfredo Raglio, MA (Music Therapy) Cremona, Italy 19 DEC 2011 1. Sospiro IssueFoundation, published online: Email: [email protected] Article first 22 published online: 19 DEC 2011 Received 2. 25 July 2011; revised August 2011; accepted 23 September 2011. http://onlinelibrary.wiley.com.bibliosan.cilea.it/doi/10.1111/j.1440-1819.2011.02273.x/fu Dr. Alfredo Raglio A.A. 2012-2103 Differences between “music” and “music therapy” interventions in dementia. (Raglio & Gianelli, Current Alzheimer Research, 2009, 6, 293-301). MUSIC MUSIC THERAPY Presence of a professional of the music area Presence of a professional of the musictherapeutic area with specific relational and musical competences Absence of a specific therapeutic setting Presence of a structured therapeutic setting Absence of a specific intervenion model Presence of a music-therapeutic referential model grounded on theoretical and methodological criteria Aims: temporary well-being, improving mood, promoting socialization, memories and stimulation of frames of mind, relaxation, etc. Aims (aspiring to become stable and longlasting over time): attenuation of behavioral and psychiatric symptoms and prevention/ stabilization of complications; increase in communication and relationship skills Contents: structured musical initiatives (rhythmic use of instruments, singing, movement associated to music, etc.) and listening to music (classical music, favourite music, etc.) Contents: sonorous-musical improvisation; listening activities that involve verbal and elaborative competences (preferably at initial stages of dementia) Dr. Alfredo Raglio A.A. 2012-2103 Altri interventi con la musica in ambito clinico… ! ATTIVITA’ DI PRODUZIONE MUSICALE ! ASCOLTO MUSICALE INDIVIDUALIZZATO ! BACKGROUND MUSIC ! MUSICA E MOVIMENTO ! … QUALI OBIETTIVI? IN QUALE AMBITO CLINICO? QUALI CONTENUTI? QUALI PROFESSIONISTI? Dr. Alfredo Raglio QUALI MODALITA’ DI VERIFICA?... A.A. 2012-2103 MUSIC THERAPY MODELS (WORLD FEDERATION OF MUSIC THERAPY, 1999) ! CREATIVE MUSIC THERAPY (NORDOFF- ROBBINS) ! ANALITICAL MUSIC THERAPY (PRIESTLEY) ! BEHAVIORAL APPROACH (MADSEN) ! GUIDED IMAGERY AND MUSIC (BONNY) ! BENENZON MUSIC THERAPY (BENENZON) Dr. Alfredo Raglio A.A. 2012-2103 IN SINTESI… ORIENTAMENTO ORIENTAMENTO UMANISTICO PSICODINAMICO ↓ ↓ VALENZA ESPRESSIVA VALENZA INTROSPETTIVA (enfasi sulla componente estetica) (enfasi sulla componente relazionale) ↓ ↓ LA LIBERTA ESPRESSIVA FACILITA IL FLUSSO EMOTIVO EVITANDO IL BLOCCO DEL PENSIERO E DELLA CREATIVITA L ASTENSIONE DALL AZIONE CONTATTA LE VERE EMOZIONI E SVILUPPA IL PENSIERO Dr. Alfredo Raglio A.A. 2012-2103 Quale musicoterapia? ! Musicoterapia ! musicoTerapia ! MusicoTerapia Dr. Alfredo Raglio A.A. 2012-2103 Altri modelli… ! L’approccio neuroscientifico (ambito neurologico) Dr. Alfredo Raglio A.A. 2012-2103 Le principali tecniche… ! TECNICHE IMPROVVISATIVE ! TECNICHE RECETTIVE Dr. Alfredo Raglio A.A. 2012-2103 Gli ambiti applicativi… ! PSICHIATRICO ! NEUROPSICHIATRICO INFANTILE ! NEUROLOGICO ! GERIATRICO ! ONCOLOGICO/CURE PALLIATIVE ! … Dr. Alfredo Raglio A.A. 2012-2103 LA LETTERATURA SCIENTIFICA… Dr. Alfredo Raglio A.A. 2012-2103 LA RICERCA PUO’ ESSERE INTESA COME SISTEMATIZZAZIONE E VALUTAZIONE DELL’INTERVENTO TERAPEUTICO Dr. Alfredo Raglio A.A. 2012-2103 Necessità di definire i contenuti degli interventi (M o MT)e di utilizzare metodologie di ricerca adeguate Dr. Alfredo Raglio A.A. 2012-2103 EVIDENCE BASED MEDICINE ê EVIDENCE BASED MUSIC THERAPY (Edwards, 2002; 2004; Vink & Bruinsma, 2003; Rolvsjord et al., 2005; Abrams, 2010) Dr. Alfredo Raglio A.A. 2012-2103 “Evidence Based Music Therapy is a method in which the music therapist, in each decision he or she makes, tries to integrate best available scientific evidence with his or her own experience, combined with the values, expectations and wishes of his or her patient. Evidence Based Music Therapy is based on the principles of Evidence Based Medicine”. (Vink & Bruinsma, 2003) Dr. Alfredo Raglio A.A. 2012-2103 LEVEL OF EVIDENCE ! Systematic review that is based on RCT's ! RCT or CCT studies ! Patient-‐series with or without controls ! Case studies ! Expert opinions ! Qualitative research Dr. Alfredo Raglio A.A. 2012-2103 LA RICERCA IN MUSICOTERAPIA … Dr. Alfredo Raglio A.A. 2012-2103 LETTERATURA SCIENTIFICA … Dr. Alfredo Raglio A.A. 2012-2103 igram T W , T e l h TO, Da l a d l e H Gold C, Musicoterapia e… Depressione (Maratos et al., 2009) • Cure di fine vita (Bradt & Dileo, 2010) • Danno cerebrale acquisito (Bradt et al., 2010) • Autismo (Gold et al., 2010) • Demenza (Vink et al., 2011) • Schizofrenia (Mössler et al., 2011) • ibrary Raglio … hed in The CochranDr.e LAlfredo blis n and pu io t a r o b a e Coll Cochran e h T y b ed maintain ared and A.A. 2012-2103 Esempi di RCTs in musicoterapia Dr. Alfredo Raglio A.A. 2012-2103 Efficacy Of Music Therapy In The Treatment Of Behavioral And Psychiatric Symptoms Of Dementia Raglio A, Bellelli G, Traficante D, Ubezio MC, Gianotti M, Villani D, Trabucchi M, Alzheimer Dis Assoc Disor, 2008; 22:158-162 Fondazione Sospiro (CR) Gruppo Ricerca Geriatrica (BS) Unità Valutazione Alzheimer, Ancelle della Carità (CR) RSA Salò (BS) Fondazione Piccinelli (BG) Dr. Alfredo Raglio A.A. 2012-2103 Efficacy of music therapy treatment based on cycles of sessions: a randomized controlled trial. Raglio A, Bellelli G, Traficante D, Gianotti M, Ubezio MC, Gentile S, Villani D, Trabucchi M Aging and Mental Health, 2010, 14, 900-904 Fondazione Sospiro (CR) Gruppo Ricerca Geriatrica (BS) Unità Valutazione Alzheimer, Ancelle della Carità (CR) RSA Salò (BS) Fondazione Piccinelli (BG) Fondazione S. Chiara (BG) IRCCS Don Gnocchi (MI) Dr. Alfredo Raglio A.A. 2012-2103 Background: Music therapy has been proposed as a valid approach for behavioral and psychological symptoms (BPSD) of dementia. Dr. Alfredo Raglio A.A. 2012-2103 Objective: to assess MT effectiveness in reducing BPSD in persons with dementia. Dr. Alfredo Raglio A.A. 2012-2103 Methods: -‐ Sixty persons with moderate-‐severe dementia (CDR 2-‐4) -‐ Experimental group (n=30): 30-‐36 MT sessions (30 min/ session) -‐ Control group (n=30): educational support or entertainment activities. -‐ Subjects were randomly assigned to experimental or control group -‐ multidimensional assessment (MMSE, Barthel Index and NPI) -‐ Improvisational/intersubjective MT approach -‐ Music therapists: 5-‐year training focused on the relational MT approach applied in particular on persons with dementia -‐ MT evaluation: items taken from MTCS (Raglio et al., 2006) Dr. Alfredo Raglio A.A. 2012-2103 Main difference between the two studies: -‐ The first study was based on a continuous treatment: 30 biweekly sessions (16 weeks) -‐ The second study was based on 3 cycles of 12 sessions each, 3 times a week (36 sessions) and each cycle of treatment was followed by 1 month of wash-‐out Dr. Alfredo Raglio A.A. 2012-2103 MAIN RESULTS (first study) Dr. Alfredo Raglio A.A. 2012-2103 RaglioDisord et al Alzheimer Dis Assoc Windows. The cognitive, functional, and behavioral 35 scores were submitted to a mixed analysis of variance, 30 25 with 1 repeated (time: before, after 8wk, after 16wk 20 25 ** 15 and4wkafterendoftreatment)and1independentfactor *** *** 10 (group: experimental and control). Dementia severity 20 ** 5 15 was considered as covariate. *** *** 0 Each NPI item score was submitted to Friedmann’s 10 4 weeks after Before Treatment After 8 weeks After 16 weeks end of analysis of variance for nonparametric data,25 comparing treatment 5 the variations occurred Experimental in the 4 differentGroup surveys (beforeControl Group the treatment, 8wk and 16wk after beginning of 0 Before Treatment After 8 weeks After 16 weeks 4 weeks after FIGURE 1. Average NPI global scores in the experimental and treatment and**P<0.01; also 4wk after end***P<0.001 of treatment) betweenat t test comparison end of control groups between experimental groups.group and control group. The agreement treatment between 2 independent observers of MT sessions was Experimental Group Control Group 30 NPI scores ann’s aring efore g of ween ment was Cohen f NPI miles, Alzheim2, er DiApril–June s Assoc Disord # Volu2008 me 22, Number 2, April–June 2008 Volume 22, Number 35 NPI scores vioral ance, 16 wk actor verity # Dr. Alfredo Raglio A.A. 2012-2103 Raglio et al Alzheimer Dis Assoc Disord " Alzheimer Dis Assoc Disord # Volume 22, Number 2, April–June 2008 Volume 22, Number 2, April–June 2008 Efficacy of Music Therapy TABLE 2. Changes in NPI Items Score Before Treatment After 8 wk Windows. The cognitive, functional, and behavioral scores were submitted to a mixed analysis of variance, with 1 repeated (time: before, after 8wk, after 16wk and4wkafterendoftreatment)and1independentfactor (group: experimental and control). Dementia severity was considered as covariate. Each NPI item score was submitted to Friedmann’s analysis of variance for nonparametric data,25 comparing the variations occurred in the 4 different surveys (before the treatment, 8wk and 16wk after beginning of treatment and also 4wk after end of treatment) between experimental group and control group. The agreement between 2 independent observers of MT sessions was Experimental group Hallucinations Delusions Depression Agitation Euphoria Anxiety Apathy Disinhibition Irritability Aberrant motor activity Appetite and eating Nighttime behavior disturbances Control group Hallucinations Delusions Depression Agitation Euphoria Anxiety Apathy Disinhibition Irritability Aberrant motor activity Appetite and eating Nighttime behavior disturbances 0.28 3.48 2.07 2.90 0.24 3.00 1.97 0.38 3.66 5.59 0.66 3.21 0.21 2.62 1.07 2.38 0.10 1.28 1.21 0.38 2.79 4.17 0.66 1.14 0.10 3.72 2.69 4.93 0.31 3.34 2.03 0.59 4.24 4.93 0.76 1.72 0.34 3.69 2.93 4.34 0.24 2.93 2.69 0.66 4.55 5.14 0.48 1.10 After 16 wk 35 4 wk After End of Trial Test di Friedmann (v2) 0.18 2.93 1.21 1.25 0.04 1.21 0.61 0.18 2.18 3.71 0.07 1.07 0.07 2.68 1.57 1.39 0.00 1.50 1.75 0.46 1.61 3.86 0.57 0.64 2.08 9.70* 6.48 17.03*** 5.67 20.69*** 8.10* 0.83 10.88** 19.60*** 2.54 16.59*** 0.14 3.72 2.34 3.90 0.24 2.93 1.90 0.62 4.24 5.00 0.79 1.38 0.14 3.31 2.28 3.48 0.31 3.10 2.28 0.48 4.55 5.07 0.69 1.10 1.00 2.94 2.72 14.56** 1.70 0.86 4.05 0.84 1.29 1.44 0.69 12.88* 30 NPI scores NPI Test 25 20 ** 15 10 5 0 *** *** Friedmann test average and score (statistical significance: *P<0.05; **P<0.01; ***P<0.001). 18 subjects with Alzheimer disease, comparing listening to preferred music with no music during 10 bathing sessions. This study found out that subjects in the intervention group decreased aggressive behavior, but the results were devoid of statistical significance. Gerdner27 found that listening to preferred music on 39 subjects with dementia had more efficacy in reducing Before Treatment After 8 weeks After 16 weeks 4 weeks after end of treatment reading activities. Patients were evaluated with MMSE, which was not different between the 2 groups at the end of the study. Dr. Alfredo Raglio A.A. 2012-2103 The strength of our study includes the number of patients enrolled, the duration of the treatment, the type of MT approach,21–23 and the use of standardized criteria to assess patient’s behaviors during MT sessions Experimental Group Control Group Raglio et al Alzheimer Dis Assoc Disord # Volume 22, Number 2, April–June 2008 Windows. The cognitive, functional, and behavioral scores were submitted to a mixed analysis of variance, with 1 repeated (time: before, after 8wk, after 16wk and4wkafterendoftreatment)and1independentfactor (group: experimental and control). Dementia severity was considered as covariate. Each NPI item score was submitted to Friedmann’s 25 comparing analysis of variance for nonparametric data, that the assessment for increased communication was done only for the experimental and not for the control the variations occurred in the 4 different surveys (before group. Notwithstanding these limitations, this study supthe treatment, and 16wktreatment after beginning of ports the assertion that MT is8wk an effective for BPSD in demented patients. MT is a low cost approach that NH staff treatment can introduce theirafter everyday and alsoin 4wk end of activities treatment) between with the aim to reduce agitated behaviors, alleviate caregivers’ stress and burden of care and to lead to a experimental groupof and control patients group. Theandagreement global improvement in quality life among relatives. Future studies are needed to definitely confirm our conclusions. between 2 independent observers of MT sessions was Raglio et al 35 Alzheimer Dis Assoc Disord ! Volume 22, Number 2, April–June 2008 30 TABLE 3. Changes in Patient’s Behaviors During the 3 Cycles of MT Treatment First Cycle of MT Sessionsw EB n-EB Smiles Synchronic body movement Singing Mean SD Mean SD 0.30 0.72 0.15 0.11 0.02 0.29 0.31 0.13 0.18 0.04 0.33 0.70 0.15 0.13 0.04 0.27 0.32 0.12 0.17 0.08 NPI scores Observed Behavior 25 Second Cycle of MT Sessionsz 20 15 Third Cycle of MT Sessionsy Mean SD F Cohen d 0.49 0.59 0.25 0.29 0.07 0.33 0.28 0.23 0.37 0.10 10.37*** 5.55** 8.14*** 12.41*** 6.98*** 0.61 1.8 0.53 0.62 0.62 ** Mean and ratings of the F test (**P<0.01; ***P<0.001) on repeated measures (effect inside the subjects) and effect size (Cohen d). wThe first 10 MT sessions. z11th-20th MT sessions. y21st-30th MT sessions. 10 *** *** 5 10. Koger SM, Brotons M. Music therapy for dementia symptoms. Cochrane Database Syst Rev [database online]. 2000;CD001121. 11. Sherratt K, Thornton A, Hatton C. Music interventions for people with dementia: a review of the literature. Aging Ment Health. 2004;8:3–12. 12. Vink AC, Birks JS, Bruinsma MS, et al. Music therapy for people with dementia. Cochrane Database Syst Rev [database online]. 2004;CD003477. 13. Goodall D, Etters L. The therapeutic use of music on agitated behavior in those with dementia. Holist Nurs Pract. 2005;19: Dr. Alfredo Raglio A.A. 2012-2103 258–262. 14. Svansdottir HB, Snaedal J. Music therapy in moderate and severe dementia of Alzheimer’s type: a case-control study. Int Psychogeriatr. 2006;18:613–621. 15. Raglio A, Ubezio MC, Puerari F, et al. The effectiveness of the 0 Before Treatment After 8 weeks After 16 weeks 4 weeks after end of treatment Experimental Group Control Group MAIN RESULTS (second study) Dr. Alfredo Raglio A.A. 2012-2103 Aging & Mental Health Vol. 14, No. 8, November 2010, 900–904 902 Aging & Mental Health Vol. 14, No. 8, November 2010, 900–904 A. Raglio et al. Efficacy35 of music therapy treatment based on cycles of sessions: A randomised controlled trial This stud studies (Rag 30 Sospiro Foundation, Cremona, Italy; Interdem Group (Psycho-Social Interventions in Dementia), EU; Alzheimer’s 2006; Vink e Evaluation Unit, Ancelle della Carità Hospital, Cremona, Italy; Geriatric Research Group, Brescia, Italy; Department of Psychology and Education Technologies Research Centre, Catholic University, Milan, Italy; Department of Neurosciences, Tor Vergata University, Rome, Italy severely deme 25 (Received 6 August 2009; final version received 21 December 2009) in managing We undertook a randomised controlled trial to assess whether a music therapy (MT) scheme of administration, including 20three working cycles of one month spaced out by one month of no treatment, is effective to reduce Ballard et a behavioural disturbances in severely demented patients. Sixty persons with severe dementia (30 in the experimental and 30 in the control group) were enrolled. Baseline multidimensional assessment included Efficacy of music treatment based onInventory cycles randomisedHall con demographics, Mini Mental State Examinationtherapy (MMSE), Barthel Index and Neuropsychiatry (NPI) of sessions: A Murray, for all15 patients. All the patients of the experimental and control groups received standard care (educational and entertainment activities). In addition, the experimental group received three cycles of 12 active MT sessions each, sucha as those a,b c,dEvery cycle of treatment was e followed a three times a week. Each 30-min session included a group of three patients. * ** A. Raglio , D. Traficante , M. Gianotti , M.C. Ubezio , S. Gentile , G. Bellelli by one month of wash-out. At the end of this study, MT treatment resulted to be more effective than standard care to reduce behavioural disorders. We observed a significant reduction over time in the NPI global scores in practical poin 10 (F ¼ 9.06, p50.001) and a significant difference between groups (F ¼ 4.84,a p50.05) due to a d,f both groups D. Villani and M. Trabucchi higher reduction of behavioural disturbances in the experimental group at the end of the treatment (Cohen’s cological ap d ¼ 0.63). The analysis of single NPI items shows that delusions, agitation and apathy significantly improved in the experimental, but not in the control group. This study suggests the effectiveness of MT approach with a reducing behavioural disorders of severely demented patients. working5 cycles in Sospiro Foundation, Cremona, Italy; bInterdem Group (Psycho-Social InterventionsFurthermore in Dementia), EU; Keywords: dementia; behavioural disorders; music therapy treatment d Evaluation Unit, Ancelle della Carità Hospital, Cremona, Italy; Geriatric Research Group, Brescia,MT Italy; s of such 0 f Psychology T0 and Education Technologies Research Centre, Catholic University, Milan, Italy; Department of Introduction MT treatment, the number of patients treated in the sessions. Thi T2 T1 same period could significantly increase and resources A growing body of evidence has recently shown that Vergata University, Rome, Italy could be moreTor correctly allocated. music therapy (MT) is effective in the treatment of ing new inter Experimental group Control group The aim of this randomised controlled study is to Behavioural and Psychological Symptoms of Dementia asses the efficacy of a MT treatment based on three (BPSD) (Casby & Home, 1994; Clark, Lipe, & Bilbrey, had differen (Received August received working6cycles of one2009; month final spacedversion out by one month 21 December 2009) 1998; Clendaniel & Fleishell, 1989; Denney, 1997; Figure 1. Comparison of theof no average global scoresin in treatment onNPI the behavioural disturbances Gerdner & Swanson, 1993; Goddaer & Abraham, lengths of in severely demented patients. 1994;the Kogerexperimental & Brotons, 2000; Raglio et al., 2008; and control group over time. Snowden, Sato, & Roy-Byrne, 2003; Svansdottir & hadscheme a durat We undertook randomised controlled trial to assessDr.whether music therapy (MT) of admi Alfredo a Raglio A.A. 2012-2103 Note: **p50.001. Snaedel, 2006; Vink, Birks, Bruinsma, & aScholten, 2004). Considering these findings, MT is increasingly varying from including three working cycles of one month spaced out by one month of no treatment, is effective Materials and methods proposed as a useful and low-cost non-pharmacological approach in various stages of dementia. However, sample behavioural disturbances Study in severely demented patients. Sixty persons withLee, severe Cheong dementia ( several questions need to be clarified. In particular, a This study took place from March to November 2007. A. Raglioa,b*, G. Bellellic,d, D. Traficantee, M. Gianottia, M.C. Ubezioa, S. Gentilea, D. Villania and M. Trabucchid,f a b c d e NPI global scores f Downloaded At: 22:48 9 November 2010 7,357 1,51 Mean Comparisons of the average NPI global scores in the experimental and control group over time a b c 30 30 30 25 25 25 20 20 20 15 15 15 10 10 10 5 5 5 0 0 0 T0 T1 T1 T2 T3 T4 T5 T5 T6 T7 Time !"#$%&'$()*+,-%./# 0 .()%.+,-%./# Dr. Alfredo Raglio ! A.A. 2012-2103 STRENGTH OF THESE STUDIES: - the general plan of the studies (RCTs) - the number of persons enrolled in the treatments - the duration of the treatments - the description of MT approach - the use of standardized criteria (i.e., blinded raters, clinical scales, fixed camcorder, and MTCS) to assess the clinical outcomes and the MT process Dr. Alfredo Raglio A.A. 2012-2103 THE FUTURE… ! Other RCTs are needed ! Specific and more sensitive tools of assessment are needed ! It is important to define the contents of the music/music therapy interventions ! On which BPSD and in which stages and kinds of dementia is MT more effective? ! Can music and music therapy produce any effect also on cognitive functions? ! Is there a difference between music and music therapy approaches and their effectiveness in the field of dementia? ! It is important to delve into the relationship dose/effect and cost/ Dr. Alfredo Raglio effectiveness A.A. 2012-2103 Esempio di Case Report Dr. Alfredo Raglio A.A. 2012-2103 Raglio A, Bellandi D, Baiardi P, Gianotti M, Ubezio MC, Granieri E. Music therapy in frontal temporal dementia: a case report. J Am Geriatr Soc. 2012 Aug;60(8):1578-‐9. Dr. Alfredo Raglio A.A. 2012-2103 Introduction Music therapy (MT) is a widespread non-‐pharmacological approach in the treatment of Behavioral and Psychological Symptoms of Dementia (BPSD) in dementia. Active MT approach is an important way to communicate with person with dementia also in severe stages of disease. MT has psychological and neuroscientific bases. The sonorous-‐music relationship allows the person to express and modulate/regulate his emotions and behaviors. The frontotemporal dementia (FTD) generally presents several behavioral disturbances (agitation, irritability, depression, disinhibition, etc.) but also difficulties in the emotional perception and regulation, due to the brain lesions. Nevertheless, the person with FTD shows creative aspects and sensibility to the musical patterns. Dr. Alfredo Raglio A.A. 2012-2103 Aim To verify the efficacy of active music therapy approach on behavioural disturbances in a patient with Fronto Temporal Dementia Dr. Alfredo Raglio A.A. 2012-2103 Case Description Mrs. M. is 58 years old and has a diagnosis of FTD (Clinical Dementia Rating=3). An encephalic magnetic resonance imaging scan showed prevalent cortical–subcortical atrophy in the temporal areas, bilaterally; in particular the damage is located in the left frontal region and the temporal pole. The neuropsychological assessment highlighted severe memory and language disturbances (total aphasia). Cognitive evaluation was not possible because Mrs. M. was not able to answer the questions Mini Mental State Examination= n.a.). A behavioral assessment indicted significant disturbances at baseline (Neuropsychiatric Inventory (NPI)=26, Cohen Mansfield Agitation Inventory (CMAI)=40, Cornell Scale for Depression in Dementia (CSDD)=2). In particular, formal caregivers reported agitation, depression, purposeless movements, wandering, and persistent vocalizations. Dr. Alfredo Raglio A.A. 2012-2103 METHODS The MT approach is mainly based on sonorous music relationship between patient and music therapist . They interact using musical instruments but also voice (singing and vocal improvisation). This approach is based on intersubjective psychological theories. Mrs. M. participated in 50 individual MT sessions (30 minutes each) conducted by a trained music therapist twice a week over 6 months. The NPI, CMAI, and CSDD were administered at baseline, before treatment, after 25 sessions, at the end of treatment, and at 1-‐month follow-‐up after treatment to evaluate BPSD, agitation, and depression. Pharmacological therapy was not modified during treatment. During the study, nursing staff monitored the main behavioral disturbances (persistent vocalizations, crying, wandering, purposeless movements) and filled in a chart three times a week reporting absence, partial presence, or presence of the above-‐mentioned disturbances. An independent observer analyzed the MT process from a qualitative point of view through videotapes of each session. Dr. Alfredo Raglio A.A. 2012-2103 tions, crying, wandering, and purposeless @)+('<:C7?-"&(-7! 2/%)/&'(C! ;@52A1! 4'?)/! *"/:=-)$0! R,-&"&-'/! 2/%)/&'(C! ;4*R2A!movements) "/0! 4'(/)$$! severe memory and language disturbances (total aphasia). greatly improved. The effects of MT treatment are summaCognitive evaluation was -/! not 6)8)/&-"! possible because Mrs. M. #7"$)! ='(! 6)<()::-'/! ;4#66A! G)()! "08-/-:&)()0! "&! D":)$-/)1! D)='()! &()"&8)/&1! rized in Table 1. The clinical results were consistent with was not able to answer the questions (Mini Mental State "=&)(! UH! "/0!score HT!not :)::-'/:! P! 8'/&?! "=&)(! &?)! )/0!process. '=! &()"&8)/&E! @+(:-/,! :&"==! 8'/-&'()0! the MT Important changes were observed in Mrs. Examination available)."/0! A behavioral assessment M.’s <+(<':)$)::! vocal productions; 8'%)8)/&:1! she used vocalization to communi- "/0! indicted significant disturbances at baseline (NeuropsychiD)?"%-'("$! 0-:&+(D"/7):! ;",-&"&-'/1! 0)<()::-'/1! G"/0)(-/,! cate, establishing a dialogue with the music therapist and atric Inventory (NPI) = 26, Cohen Mansfield Agitation <)(:-:&)/&!%'7"$-L"&-'/:A!0+(-/,!&?)!:&+0C1!K!&-8):!"!G))VE!F?)!*F!<('7)::!G":!"/"$CL)0!=('8! discharging her emotional and mental stress. Gradually, Inventory (CMAI) = 40, Cornell Scale for Depression in vocalizations and wandering decreased, and interactions Dementia (CSDD) = 2). In particular, formal caregivers "!X+"$-&"&-%)!<'-/&!'=!%-)GE! and communicative behavior toward the music therapist reported agitation, depression, purposeless movements, :&*)4#*' increased (eye and physical contact). wandering, and persistent vocalizations. *"-/!():+$&:!"()!:+88"(-L)0!-/!&?)!F"D$)!PE!! Results Table 1. Results Summary Result Baseline Neuropsychiatric Inventory total score Cohen Mansfield Agitation Inventory total score Cornell Scale for Depression in Dementia total score Observations of nursing staff, mean ± standard deviation, Persistent vocalizations Crying Wandering Purposeless movements a Beginning of Treatment 26 24 40 23 2 3 median (interquartile range)a 1.20 ± 1.01, 2 (2) 0.5 ± 0.83, 0 (1) 1.80 ± 0.62, 2 (0) 1.75 ± 0.72, 2 (1) After 25 Sessions End of Treatment 1-Month Follow-Up 8 10 1 10 10 0 8 7 0 0.93 0.44 1.38 1.26 ± ± ± ± 0.91, 1 (2) 0.73, 0 (1) 0.62, 1 (1) 0.63, 1 (1) 0.39 0.13 0.86 0.88 ± ± ± ± 0.52, 0 (1) 0.08 ± 0.28, 0 (0) 0.37, 0 (0) 0, 0 (0) 0.38, 1 (0) 0.72 ± 0.45, 1 (1) 0.36, 1 (0) 0.69 ± 0.47, 1 (1) Weekly evaluations across periods (three assessments per week): 0 = absence, 1 = partial presence, 2 = presence. ! ! ! ! Dr. Alfredo Raglio A.A. 2012-2103 Discussion It is hypothesized that the above reported results are strongly linked to MT. This approach can be an important nonpharmacological resource in the management of BPSD. A possible explanation is the psychological effects and the effect of MT on the brain. In particular, MT showed its effects on areas involved in emotional processing and regulation, such as the limbic (e.g., amygdala and hippocampus) and paralimbic structures (e.g., orbitofrontal cortex, parahippocampal gyrus, and temporal poles). Music and MT also play an important role in the activation of social cognition areas and in the mirror neurons system. Dr. Alfredo Raglio A.A. 2012-2103 Conclusion These psychological and neuroscientific implications could be part of the underlying mechanisms of MT efficacy on behavioral problems in dementia and in particular in FTD, indicating that MT can be an effective intervention for improving symptoms and quality of life and supporting caregivers in the management of dementia. Dr. Alfredo Raglio A.A. 2012-2103 La ricerca musicoterapeutica in Italia… Dr. Alfredo Raglio A.A. 2012-2103 Punti critici… non riconoscimento della disciplina (a livello formativo e applicativo) - parziale diffusione della disciplina sul piano istituzionale - scarsa presenza e continuità delle esperienze applicative - scarsa formalizzazione/strutturazione degli interventi - scarsa sensibilità scientifica dell’ambito musicoterapeutico - scarsità di pubblicazioni scientifiche Dr. Alfredo Raglio A.A. 2012-2103 IL CONTRIBUTO DELLE NEUROSCIENZE… ! Quali gli effetti prodotti dal suono e dalla musica nel nostro cervello? ! Quali possono essere le potenzialità terapeutiche? ! Perché? ! Tematiche considerate: musica/emozioni, musica/apprendimento, localizzazione delle funzioni cerebrali rispetto alla percezione e produzione dell’elemento sonoro, musica/riabilitazione (neurocognitiva, neuromotoria, etc.) ! Tendenzialmente gli studi non si riferiscono a setting terapeutici Dr. Alfredo Raglio A.A. 2012-2103 who study music cognition often rely on the theorist Leonard Meyer, who defined it as Address for correspondence: Daniel J. Levitin, Ph.D., Department of Current Advances inofthe Cognitive a form emotional communication, or on Psychology, McGill University, 1205 Avenue Dr. Penfield,Neuroscience Montreal, QC of Music H3A 1B1 Canada. [email protected] the definition of the composer Edgar Varése, THE YEAR IN COGNITIVE NEUROSCIENCE 2009 Daniel J. Levitin and Anna K. Tirovolas 212 McGill University, Montreal, QC Canada The Year in Cognitive Neuroscience 2009: Ann. N.Y. Acad. Sci. 1156: 211–231 (2009). ! C 2009 New York Academy of Sciences. doi: 10.1111/j.1749-6632.2009.04417.x The study of music perception and cognition is one of the oldest topics in experimental Annals of the New York Academy of Sciences psychology. The last 20 years have seen an increased interest in understanding the functional neuroanatomy of music processing in humans, using a variety of technologies including fMRI, PET, ERP, MEG, and lesion studies. We review current findings in the context of a rich intellectual history of research, organized by the cognitive systems underlying different aspects of human musical behavior. We pay special attention to the perception of components of musical processing, musical structure, laterality effects, cultural issues, links between music and movement, emotional processing, expertise, and the amusias. Current trends are noted, such as the increased interest in evolutionary origins of music and comparisons of music and language. The review serves to demonstrate the important role that music can play in informing broad theories of higher order cognitive processes such as music in humans. 211 Key words: music; language; emotion; structure; evolutionary psychology; expertise Introduction Figure 1. dress questions about part−whole relationships in music and melody (Ehrenfels 1890/1988). The past decade has seen an exponential The field of music cognition traces its oriincrease in studies of music cognition. Musigins to the 4th century BCE, long before the establishment of experimental psychol- cal behaviors that are typically studied include ogy itself, through the ideas of Aristoxenus, listening, remembering, performing, learning, an Aristotelian philosopher. Contrary to the composing, and, to a lesser extent, movement Pythagoreans of that time, Aristoxenus ar- and dancing. The largest paradigm shift has gued that musical intervals should be classi- been the increased use of neuroimaging and fied by their effects on listeners as opposed neural case studies to inform theories about to merely examining their mathematical ra- the brain basis for musical behaviors. A second tios (Griffiths 2004; Levitin 1999). This notion theme over the past decade has been an inbrought the scientific study of music into the creased interest in the origins of music and its mind, followed by the first psychophysics exper- connection with language, both evolutionarily iments at the dawn of experimental psychology, and functionally. In cognitive neuroscientific studies of lanwhich mapped changes in the physical world guage, mathematical ability, or visual perceponto changes in the psychological world (e.g., Core brain regions associated with musical activity. Based on Tramo 2001 of theand updated in Fechner 1860; Helmholtz 1863/1954). Indeed, tion, one rarely encounters a definition Dr. Alfredo Raglio A.A. 2012-2103 capacity being studied, yet the question of 2006 (from 2006). many of the earliest studies in experimental psy- Levitin chology concerned music, and the Gestalt psy- just what is music (and by implication, what chology movement was formed in part to ad- it is not) is one that emerges more often in this field of inquiry than in the others. Those Strutture limbiche e paralimbiche correlate alle emozioni Review evocate dalla musica (Koelsch, 2010) Dr. Alfredo Raglio Figure 1. Illustration of some structures belonging to the limbic/paralimbic system. The diamonds represent music-evoked activity changes in these A.A. 2012-2103 T Koelsch, 2010 Figure 2. Schematic representation of anatomical connections of some limbic and paralimbic structures involved in the emotional processing of music (Figure 1 and main text). ACC: anterior cingulate cortex; ant Ins: anterior insula; Am (BL): basolateral amygdala; Am (CM) corticomedial amygdala (including the central nucleus), Hipp: hippocampal formation; NAc: nucleus accumbens; OFC: orbitofrontal cortex; PH: parahippocampal gyrus; Temp P: temporal pole. Connectivity is depicted based on Refs. [37,79–81]. Dr. Alfredo Raglio A.A. 2012-2103 I pressuposti neuroscientifici della riabilitazione neuromotoria con la musica e la musicoterapia Dr. Alfredo Raglio A.A. 2012-2103 music as well as psychological, cognitive associations connected with speof defined interventions forway certain diseases. However, even if the corpus of outcom cific musical experiences. In the same the evocation of synaesthetic experiences is often used in music therapy. Musically induced visual imagery contributes to that factor as well as musical imagery itself.29 Music alwaysScientific has a subjective meaning for humans. It is often observed that subPerspectives on Music Therapy Address for correspondence: Prof. Dr. Thomas Hillecke, German Center for Music Thera cultures define themselves by specific musical styles, which are coded as Research, Universitylanguage. of Applied Sciencesmusic Heidelberg, Outpatient Department, Maaßstraße 2 some kind of group-specific Additionally is used to alter THOMAS HILLECKE, ANNE NICKEL, AND HANS VOLKER BOLAY 37 states of consciousness in different nativeVoice: cultures. Music is also fax: known D-68123 Heidelberg, Germany. +49-6221-4154; +49-6221-4152. 38 German Center for Music Therapy Research, and Outpatient Department, to facilitate recall of episodic memories. Cognition modulation is [email protected] University of Appliedsubjective Sciences Heidelberg, D-68123and Heidelberg, Germany cally used to change cognitions meaning patterns, and is 39,40 Some music theralso important in music guided imagery techniques. apists useAnn. musicN.Y. to induce hypnotic and(2005). to alter©states conAcad. aSci. 1060: trance 271–282 2005 ofNew York Academy of Sciences. A BSTRACT: What needs to be done on the long road to evidence-based music 41 sciousness. doi: 10.1196/annals.1360.020 therapy? First of all, an adequate research strategy is required. For this pur(4) The fourthpose factor is called behavior modulation motoric behavioral the general methodology for therapy researchorshould be adopted. Addi- factor: The basic assumption that musicof methods represents a fields useful possibility to tionally, music therapyis needs a variety of allied to contribute 271 without findings, including such mathematics, natural sciences, behavioral and evoke andscientific condition behavior, as movement patterns, the social sciences, as will. well as The the arts. Pluralism seems as welldance as inevi-is well necessity of conscious association of necessary music and table. At least two major research problems can be identified, however, that known. Marching songs are common, and the military offers a great variety make the path stony: the problem of specificity and the problem of eclecticism. of militaryNeuroscientific marches. Neuroscientists, like the team of Michael Thaut, research in music is giving rise to new ideas, perspectives, and point out that rhythmic stimulation influences timing processes in the methods; they seem to be promising prospects for a possible contribution to afrontal andneural empiricalstructures scientific foundation for musicmusic therapy.therapy, Despite theNMT). brain and theoretical associated (neurologic huge heterogeneity of theoretical approaches in music therapy, an integrative This factor is used therapeutically in gait rehabilitation of stroke patients model of working ingredients in music therapy is useful as a starting point for and in theempirical treatment movement problems, for works example, Parkinson studiesofin order to question what specifically in musicin therapy. 42,43 patients. For this Music anda heuristic auditive stimulation—known since working the time of purpose, model, consisting of five music therapy (attention modulation, emotion modulation, in cognition modulation, Pavlov—isfactors a useful tool in behavioral conditioning general. The analysis behavior modulation, and communication has been developed of the behavioral component of patients’modulation) performing music is ofbycentral the Center for Music Therapy Research (Viktor Dulger Institute) in Heidelinterest in berg. active music therapy and important in facilitating the learning of Evidence shows the effectiveness of music therapy for treating certain new behaviors. is the used as aoftheoretical framework in works behavioral diseases,Itbut question what it is in music therapy that remains music 44,45 therapy. largely unanswered. The authors conclude with some questions to neuroscientists, which we hope may help elucidate relevant aspects of a possible link between the two disciplines. KEYWORDS: music therapy; therapy research; multidisciplinary approach; Dr. Alfredo Raglio pluralistic point of view; working ingredients INTRODUCTION A.A. 2012-2103 La musica agisce sulle aree frontali del cervello… Dr. Alfredo Raglio A.A. 2012-2103 mited, thus calling for in- being attributed to neural reorganization.9–11 A different line of studies has shown rapid abilitation approaches.1–4 ted indicating that repeti- plastic adaptation due to music performance, which is not restricted to cortical motor areas butReorganization also involves Underlies auditory and integrative Neural 12–15 Improvement in Stroke-induced Motor auditory–sensorimotor circuits. e: Dr. Sabine Schneider, InstituteDysfunction of by Music-supported Therapy cians’ Medicine, University of Mu-E. Altenm üller, J. Marco-Pallares, T. F. Münte, This suggests that music-making, even in unand S. Schneider Hohenzollernstrasse 47, 30161 Hanskilled patients, might be an effective means 511-3100574; fax: +49-511-3100557. to induce plastic changes in the motor system. r.de THE NEUROSCIENCES AND MUSIC III—DISORDERS AND PLASTICITY a b b a a Institute of Music Physiology and Musicians’ Medicine, University of Music and Drama Hannover, Hannover, Germany b Department of Neuropsychology, Otto von Guericke University, Magdeburg, Germany Motor impairments are common after stroke, but efficacious therapies for these dysfunctions are scarce. By extending an earlier study on the effects of music-supported therapy, behavioral indices of motor function as well as electrophysiological measures were obtained before and after a series of therapy sessions to assess whether this new treatment leads to neural reorganization and motor recovery in patients after stroke. The study group comprised 32 stroke patients in a large rehabilitation hospital; they had moderately impaired motor function and no previous musical experience. Over a period of 3 weeks, these patients received 15 sessions of music-supported therapy using a manualized step-by-step approach. For comparison 30 additional patients received standard rehabilitation procedures. Fine as well as gross motor skills were trained by using either a MIDI-piano or electronic drum pads programmed to emit piano tones. Motor functions were assessed by an extensive test battery. In addition, we studied event-related desynchronization/synchronization and coherences from all 62 patients performing self-paced movements of the index finger (MIDI-piano) and of the whole Dr. significant Alfredo Raglio arm (drum pads). Results showed that music-supported therapy yielded improvement in fine as well as gross motor skills with respect to speed, precision, and smoothness of movements. Neurophysiological data showed a more pronounced eventrelated desynchronization before movement onset and a more pronounced coherence in the music-supported therapy group in the post-training assessment, whereas almost Music III—Disorders and Plasticity: Ann. N.Y. Acad. Sci. 1169: 395–405 (2009). 32.2009.04580.x !c 2009 New York Academy of Sciences. 395 A.A. 2012-2103 Fare musica favorisce cambiamenti plastici del sistema motorio… migliora la connettività corticale e stimola la corteccia motoria … Dr. Alfredo Raglio A.A. 2012-2103 Stretto rapporto tra ritmo e movimento (attivazione aree motorie – corteccia premotoria, aree motoria supplementare, cervelletto, gangli della base – sincronizzazione, modulazione…) Halsband et al., 1993; Janata et al., 2003; Peretz & Zatorre, 2005; Zatorre et al., 2007; Chenn et al., 2008; 2009; Grahn & Brett, 2007; 2009; Schwartze et al., 2011 Dr. Alfredo Raglio A.A. 2012-2103 ctions, this sysg between perry) and motor connecting these regions might underlie effects that outlast the duration of the actual intervention. Nevertheless, the gold standard of proving the efficacy of an intervention will be a randomPart VI Introduction ized clinical trialMusic (RCT), in which participants Listening to and Making Facilitates Brain Recovery Processes are randomly assigned and a new music-based ug, M.D., Ph.D., MuGottfried Schlaug tories, Department of intervention is tested against a gold standard er, 330 Brookline Avor an established intervention. Having a scien7; fax: 617-632-8920. tific basis for the interventions and obtaining n.com Emerging research over the last decade has actions (leg, arm/hand, or vocal/articulatory THE NEUROSCIENCES AND MUSIC III: DISORDERS AND PLASTICITY Department of Neurology; Music, Stroke Recovery, and Neuroimaging Laboratories, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA shown that long-term music training and skill actions). Music might be a special vehicle to can be a strong stimulator for neuro- engage components of this mirror-neuron sysrders and learning Plasticity: Ann. N.Y. Acad. Sci. 1169: 372–373 (2009). plastic changes in the developing as well as adult tem. Furthermore, music might also provide an c 2009 of Sciences. 9.x ! brain.New MakingYork music Academy places unique demands alternative entry point into a “broken” brain on the nervous system, leading to strong cou- system to remediate impaired neural processes pling of perception and action mediated by sen- or neural connections by engaging and linking sory, motor, and multimodal integrative regions up brain centers that would otherwise not be distributed throughout the brain. Furthermore, engaged or linked with each other. listening to music and making music (“musickThe chapters in this section will demonDr. Alfredo Raglio A.A. 2012-2103 ing”) provokes motion, improves and increases strate several music-based experimental interbetween-subject communication and interac- ventions whose effectiveness in clinical popution, and is considered to be and experienced lations is demonstrated and whose underlying 372 La musica è uno stimolo multimodale che attiva varie aree e funzioni facilitando le connessioni… provoca il movimento e stimola l’interazione… Dr. Alfredo Raglio A.A. 2012-2103 L’ascoltare e il fare musica attivano anche le aree del sistema dei Mirror Neurons (Kohler et al., 2002; Keysers et al., 2003; Lahav et al., 2007; Overy & Molnar-Szakacs, 2006; 2009; D’Ausilio, 2009; Koelsch, 2009; 2010; Wan et al., 2010) A.A. 2012-2103 Dr. Alfredo Raglio (Grossman, 1980). the impaired musical domain, damage to this production wereInalso in recreating hierarchically tree structures by Greenfield and Schneider areaorganized of the posterior inferiorused frontal gyrus can lead to the (1977).impairments In contrast, of fluent aphasics, have hierarchically conjoint aphasia and who amusia!a selective organized semanticallyand empty) speech weremusic able to problem with(but perceiving interpreting reproduce the hierarchical structure of the models (Alajouanine, 1948). Recent evidence has also shown that (Grossman, 1980). In the musical domain, damage to this aphasic patients with syntactic comprehension difficulties in area of the posterior inferior frontal gyrus can lead to the language exhibit similar syntactic difficulties in the domain conjoint impairments of aphasia and amusia!a selective of musical 2005). and interpreting music problemharmony with (Patel, perceiving Neuroimaging of language function andshown studiesthat (Alajouanine, studies 1948). Recent evidence has also aphasic patientsintegration with syntactic difficulties of sensory-motor havecomprehension shown evidence of an in language exhibit similar syntactic difficulties in the domain overlap between the brain regions involved in linguistic of musical harmony (Patel, 2005). processing and regions comprising the human mirror neuron Neuroimaging studies of language function and studies system (Rizzolatti and Arbib, 1998; Arbib, 2005). Recent of sensory-motor integration have shown evidence of an neuroimaging studiesthehave alsoregions implicated Broca’s area overlap between brain involved in linguistic andprocessing its right and hemisphere homologue the mirror perception regions comprising the in human neuron andsystem representation human (Rizzolatti ofandhierarchically Arbib, 1998; organized Arbib, 2005). Recent neuroimaging studies have also implicated Broca’s behavior (Koechlin and Jubault, 2006; Molnar-Szakacsarea and2006). its right hemisphere in the perception et al., Furthermore, it hashomologue been proposed that parallel consonant over 2005); dissonant and Siebel, see tonal Figurecombinations 1. In parallel(Trehub, with the developmental literature on action and language, infants 2003). also proposal seem toofshow implicitneural knowledge of for principles The a common substrate music, of hierarchical organization for music, for example language and motor functions is supported by evidence they from are able to distinguish different scales and show preferences studies of language disorders. For example, it has been for consonant over dissonant tonal combinations (Trehub, shown that children with dyslexia exhibit specific timing 2003). difficulties in the domain of music (Overy et al., for 2003), The proposal of a common neural substrate music, motor control and Nicolson, 1995; by Wolff, 2002) language and(Fawcett motor functions is supported evidence from andstudies language et al., 1993; Goswami et al., 2002) of (Tallal language disorders. For example, it hasand been children dyslexia exhibitcan specific thatshown musicthat lessons withwith dyslexic children lead timing to difficulties in the domain music (Overy al., also 2003), improvements in language skillsof (Overy, 2003). Itet has motor control (Fawcett and Nicolson, 1995; Wolff, 2002) been found that patients with severe non-fluent aphasia can and language (Tallal et al., 1993; Goswami et al., 2002) and benefit from Melodic Intonation Therapy (MIT), a highly that music lessons with dyslexic children can lead to imitative speech therapy technique singing. Thealso improvements in language skills based (Overy,on2003). It has technique has been shown towith leadsevere to speech improvements been found that patients non-fluent aphasia can (Sparks et from al., 1974), coupled with changes the neural benefit Melodic Intonation Therapy in(MIT), a highly imitative speech therapy technique based on singing. resources recruited during speech (Belin et al., 1996; OveryThe technique et al., 2005). has been shown to lead to speech improvements The Shared Affective Motion Experience model (SAME) (Overy & Molnar-Szakacs, 2006;2009) and representation of hierarchically organized human behavior (Koechlin and Jubault, 2006; Molnar-Szakacs et al., 2006). Furthermore, it has been proposed that parallel (Sparks et al., 1974), coupled with changes in the neural resources recruited during speech (Belin et al., 1996; Overy et al., 2005). Fig. 1Fig.Model of theofpossible involvement of theofhuman mirrormirror neuron system in representing meaning and affective responses to music. One aspect of theofexperience of music 1 Model the possible involvement the human neuron system in representing meaning and affective responses to music. One aspect the experience of music involves the perception of intentional, hierarchically organized sequences of motor acts with temporally synchronous auditory information. Auditory features of the musical signalsignal involves the perception of intentional, hierarchically organized sequences of motor acts with temporally synchronous auditory information. Auditory features of the musical are processed primarily in theinsuperior temporal gyrusgyrus (STG)(STG) and combined with with synchronous structural features of theof‘motion’ information conveyed by thebymusical signalsignal in thein the are processed primarily the superior temporal and combined synchronous structural features the ‘motion’ information conveyed the musical posterior inferior (BA and 44) adjacent and adjacent premotor The anterior a neural conduit between the mirror neuron system and limbic the limbic system, posterior inferior frontalfrontal gyrusgyrus (BA 44) premotor cortex.cortex. The anterior insulainsula formsforms a neural conduit between the mirror neuron system and the system, allowing this information be evaluated in relation to one’s autonomic and emotional contributing a complex affective response mediated the limbic system. allowing this information to betoevaluated in relation to one’s own own autonomic and emotional state state contributing to a to complex affective response mediated by theby limbic system. Possible feedback mechanisms influence the subsequent processing the musical the immediate and more long-term timescales. The shared recruitment Possible feedback mechanisms may may influence the subsequent processing of theofmusical signalsignal at theatimmediate and more long-term timescales. The shared recruitment of thisof this A.A. 2012-2103 Dr. Alfredo Raglio neural mechanism in both the sender and the perceiver of the musical message allows for co-representation and sharing of the musical experience. Music notes from neural mechanism in both the sender and the perceiver of the musical message allows for co-representation and sharing of the musical experience. Music notes from ‘The ‘The Lady Lady Sings the Blues’ by Billie Holiday and Herbie Nichols. Sings the Blues’ by Billie Holiday and Herbie Nichols. …The Shared Affective Motion Experience model suggests that musical sound is perceived not only in terms of the auditory signal, but also in terms of the intentional, organized sequences of expressive motor acts that are behind the signal. So this model can suggest that properties of the human Mirror Neuron System allow us to consider social communication, and more specifically musical communication, in a new light—less in terms of pitch/timbre/rhythmic patterns—and more in terms of action sequencing, goals/intentions, prediction, and shared representations. In particular I think that this model can be connected to the active music therapy model in which the movements and the gestures behind the sound play an important role. Dr. Alfredo Raglio A.A. 2012-2103 Tutte le funzioni del sistema dei Mirror Neurons sono collegate alla “social cognition” (interazione sociale, comunicazione, empatia,…) (Overy & Molnar-Szakacs, 2009) Dr. Alfredo Raglio A.A. 2012-2103 Ascoltare e fare musica attiva funzioni sociali (Koelsch, 2010) ! Contact ! Social cognition (Steinbeis & Koelsch, 2009; Koelsch, 2009) ! Co-pathy ! Communication (Trehub, 2003; Fitch, 2006) ! Coordination (Overy & Molnar-Szakacs, 2009; Patel, 2009; Kirschner & Tomasello, 2009) ! Cooperation (Rilling et al., 2002; Tomasello, 2005) ! Social cohesion (Baumeister &Leary, 1995; Cross & Morley, 2008) Dr. Alfredo Raglio A.A. 2012-2103 La musica attiva meccanismi gratificanti legati al piacere e alla gratificazione… (Hillecke et al., 2005; Schlaug, 2009; Koelsch 2009; 2010) Dr. Alfredo Raglio A.A. 2012-2103 The neurochemistry of music Mona Lisa Chanda and Daniel J. Levitin Trends in Cognitive Sciences, April 2013, Vol. 17, No. 4 Department of Psychology, McGill University, Montreal, Quebec, QC H3A 1B1, Canada Music is used to regulate mood and arousal in everyday life and to promote physical and psychological health and well-‐being in clinical settings. However, scientific inquiry into the neurochemical effects of music is still in its infancy. In this review, we evaluate the evidence that music improves health and well-‐being through the engagement of neurochemical systems for (i) reward, motivation, and pleasure; (ii) stress and arousal; (iii) immunity; and (iv) social affiliation. We discuss the limitations of these studies and outline novel approaches for integration of conceptual and technological advances from the fields of music cognition and social neuroscience into studies of the neurochemistry of music. Box 2. Relevance for therapy (Koelsch, 2010) Music therapy (MT) can have effects that improve the psychological and physiological health of individuals. A heuristic working factor model for music therapy [72] assumes five factors which contribute to the effects of MT. These factors refer to the modulation of emotion, attention, cognition, behavior and communication. Given that music can change activity in brain structures that function abnormally in patients with depression (such as amygdala, hippocampus and nucleus accumbens; see main text), it seems plausible that music can be used to stimulate and regulate activity in these structures (either by listening to or by making music), and thus ameliorate symptoms of depression. However, so far the scientific evidence for effectiveness of MT on depression is surprisingly weak, because of the lack of high-‐quality studies, and the small number of studies with randomized, controlled trials [73]. Studies on neurological applications of MT have so far mainly dealt with the therapy of stroke patients. Recent evidence suggests that playing melodies either with the hand on a piano, or with the arm on electronic drum pads that emit piano tones, helps stroke patients to train fine as well as gross motor skills with regard to speed, precision and smoothness of movements [74]; it seems likely that an emotional component contributes at least partly to these effects, because this treatment was more effective than a standard rehabilitation. Electrophysiological data suggest that these effects are due to enhanced cortical connectivity and stronger activation of the motor cortex as a result of music-‐supported movement training [75]. Other studies showed that isometric musical stimuli have the capability of regulating gait and arm control in patients with stroke and Parkinson’s disease, presumably as a result of music-‐evoked arousal and priming of the motor system via auditory stimulation, as well as a result of entrainment of the motor system to the beat of the music [75,76]. Moreover, positive emotions elicited by preferred music can decrease visual neglect (possibly by increasing attentional resources) [77], and listening to self-‐selected music after stroke appears to improve recovery in the domains of verbal memory and focused attention (along with less depressed and confused mood) [78]. The neural mechanisms for such effects, however, remain to be specified. Dr. Alfredo Raglio A.A. 2012-2103 INTERVENTIONS WITH MUSIC IN THE NEUROLOGICAL CLINICAL SETTING RELATIONAL MUSIC THERAPY • Trained music therapist • Therapeutic Setting • Psychological models • Relationship as the core of intervention • Specific active or receptive techniques • Aims (aspiring to become stable and long-lasting over time): attenuation of behavioral and psychiatric symptoms and prevention/stabilization of complications; increase in communication and relationship skills (sometimes improvement of cognitive and motor functions) REHABILITATIVE MUSIC THERAPY • Trained professional/music therapist • Rehabilitative setting • Neuroscientific and neurocognitive models • Motor and cognitive exercises using sonorous-musical elements (in particular rhythm) • Specific techniques • Aims (aspiring to become stable and long-lasting over time): cognitive and motor changes (sometimes psychological changes) MUSIC—SUPPORTED MOTOR ACTIVITIES • Absence of a Professional of the music field • Absence of a specific therapeutic setting • Absence of a specific intervention model • Using music to support motor activities • Aims: well-being, improving mood and motivation, promoting socialization, motor and cognitive stimulation Western Michigan University Kalamazoo, MI USA Neurologic Music Therapy A Research-Based System of Standardized Clinical Techniques ! Colorado State University ! Center for Biomedical Research in Music and Neurologic Rehabilitation ! ! ! ! ! Michael Thaut, Ph.D Neuroscience/Music Therapy Gerald McIntosh, M.D. Neurologist Ruth Rice, MS PT PT, Neurologic Rehabilitation Gary Kenyon, MS Biomechanics, Mathematics Corene Thaut, MM MT, Neurologic Rehabilitation Thaut, M.H. (1999). Training Manual for Neurologic Music Therapy Neurologic Basic Definitio ! NMT is de applicatio sensory, a to neurolo nervous sy erapy f Standardized versity al Research in gic Rehabilitation oscience/Music Therapy ologist Neurologic Rehabilitation echanics, Mathematics Neurologic Rehabilitation aining Music Thaut, M.H. (1999). Training Manual for Neurologic Music Therapy Neurologic Music Therapy Basic Definitions ! NMT is defined as the therapeutic application of music to cognitive, sensory, and motor dysfunctions due to neurologic disease of the human nervous system. Thaut, M.H. (1999). 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