Kerry Devlin, Kyurim Kang, and Alexander Pantelyat (eds.) 2023. Music Therapy and Music-Based Interventions in Neurology: Perspectives on Research and Practice. Humana Press.
Behind this anthology is a group of music therapists and researchers in music medicine from the Johns Hopkins Center for Music and Medicine in Baltimore, USA. The contributions are gathered in 17 chapters from 40 music therapists, physicians, and others in the field of music and neurology from the USA, Asia, Europe, and Australia.
Medical Music Therapy and Music Medicine
What unites the chapters in this anthology is the use of what they call "music-based interventions." This is broadly defined as "the use of music and rhythms to improve human health." These interventions are delivered by both music therapists and other healthcare workers, or sometimes performed by the clients themselves, such as through individual music listening. This field, neurology, covers a wide range of medical diagnoses. It can involve stroke, traumatic brain injuries, movement challenges such as Parkinson's, language and speech difficulties, memory challenges such as Alzheimer's disease, epilepsy, autoimmune neurological injuries, or medical conditions in the brain or nervous system related to cancer or palliative care. All of these areas are covered in the book, in addition to chapters on music interventions during surgical procedures, the use of approaches in telehealth, technology-based services, a chapter on autism and neurodiversity, and a concluding chapter on psychosocial approaches.
A Mapping of Mechanisms
The anthology initially focuses on describing underlying mechanisms in the brain, nervous system, and cognitive functions that are affected by or related to disease and injuries. An introductory chapter defines 'mechanism' as a system of parts and processes that have a causal relationship with each other and produce one or more effects. The chapter is particularly concerned with "biological or behavioral processes, the disease's pathophysiology, or the mechanisms behind the intervention action," as stated at the beginning of the defining chapter "Mechanisms of Music Therapy and Music-Based Interventions."
Four Mechanisms
Four such mechanisms are first described: the mechanisms behind the rehabilitation of motor functions, mechanisms that regulate interpersonal synchrony, mechanisms behind pain regulation, and mechanisms related to the regulation of affects and emotions.
In terms of rehabilitation of motor difficulties, this is based on the theory of neuroplasticity, which deals with how repeated activation of specific neural pathways leads to the strengthening of these pathways. This means that lasting changes in the brain can develop in response to musical stimuli. This has relevance for conditions such as stroke, traumatic brain injuries, Parkinson's disease, multiple sclerosis (MS), and other conditions.
Several such mechanisms for motor rehabilitation are described, including those for interpersonal synchrony and auditory-motor coupling. Furthermore, mechanisms behind empathy and understanding others, stress reduction, and social bonding are described, as well as neuroendocrine processes such as the production of dopamine and oxytocin. Additionally, there is a review of mechanisms for pain management and affect regulation.
Stroke, Traumatic Brain Injuries, and Parkinson’s
We learn much about the underlying processes in the brain and nervous system for various movement challenges. When it comes to music interventions, many of these are based on the neurological music therapy developed by Michael Thaut, for example, the use of rhythmic auditory stimulation (RAS). In short, this involves using a metronome or music playback/live music while the patient practices walking (or possibly upper body movements). This is a well-documented method, supported by substantial research. The same applies to the method for speech training in aphasia, "Melodic Intonation Therapy" (MIT), where the patient sings syllables while marking the rhythm with their right hand. This is to support auditory-motor interaction and motor functions in the articulation of speech in the damaged left hemisphere.
Medical Research
The chapters are extensively referenced with research articles, primarily from the medical field. Relational, cultural, or other contextual factors are clearly underrepresented in these introductory chapters.
The idea behind the project is likely to provide as much support and evidence as possible for music-based interventions in a field so clearly influenced by biomedical thinking. However, the editors note that there are supplementary perspectives on such treatment, and potentially other "mechanisms" that could influence disease processes. But the causality behind these is not problematized.
Memory Challenges
For me, the contribution from two familiar figures in music therapy, Hanne Mette Ridder and Concetta Tomaino, was an enjoyable read. When they write about "Music for Memory Disorders," they draw on their extensive experience as music therapists and researchers with great expertise in the dementia field. In the chapter, they go through different forms of memory – short-term, long-term, and working memory, as well as semantic and procedural memory, and autobiographical and nostalgic memory.
The authors point out how memory recall can happen unintentionally, such as when nostalgic and autobiographical memories are triggered by music. Memory is linked to processes in the brain. For instance, early memories may change and be reconstructed when recalled in new contexts. The recall of autobiographical memories is an important means of preserving a sense of self and identity. Much of this is familiar knowledge, but here it is placed within a neuropsychological context and given many useful details. The chapter also refers to general research and practice from music therapy with people facing memory challenges.
Music Therapy During Radiation Treatment
Sometimes, cancer affects the brain, and patients must undergo treatments that involve scanning the brain. Having to wear a protective mask and be placed in these machines to remain completely still for five to ten minutes is a significant ordeal for most, causing anxiety and stress. This is particularly challenging for children. As seen in Tidsskriftet Musikkterapi No. 1/23, music therapist Julie Mangersnes at the Rikshospitalet in Oslo works on the MustRa project, which supports children and adolescents during radiation therapy. The music therapists have developed procedures to prepare and calm patients facing such situations. The limited research available is referenced, and there is also mention of research on the use of music during chemotherapy. A 'fun fact' worth noting is that Jan Sverre Knudsen was the first music therapist to use music during chemotherapy. This took place at the Radiumhospitalet in Oslo, in collaboration with other healthcare staff. This was documented in Musikkterapi No. 3-4 in 1987, referencing an article in Aftenposten about how music can reduce nausea in patients undergoing cancer treatment.
Mozart Against Epileptic Seizures?
One chapter is devoted to music listening in cases of epilepsy where medication does not work, known as refractory epilepsy. Here, research is conducted by studying EEG measurements, which can detect irregularities in brain activity between seizures. In this way, it is possible to investigate interventions that might reduce the frequency of seizures. This allows researchers to measure the effect of listening to music.
Studies show that listening to Mozart's music can lead to fewer epileptic seizures. Years ago, there was a claim that a so-called "Mozart effect" had been discovered. An experiment suggested that listening to Mozart's Sonata in D Major for Two Pianos (K448) made people more intelligent. However, this was quickly debunked after a series of follow-up experiments.
But oddly enough, Mozart's music seemed to have an effect in one specific area. Several studies now showed that this piano sonata, other pieces by Mozart, and even Haydn could have positive effects on reducing seizure frequency. They also tried other types of music, including preference-based music, but without the same effect.
This is intriguing, and several theories have been proposed about why Mozart and other classical music forms might have this effect. Some point to the periodicity in Mozart's compositions, the use of repetition and symmetrical forms. Others point to hierarchical structures in the music that correspond to molecular hierarchies in the brain. But all of this remains speculation. A universal effect or procedure for music listening has not been established, but more research in this area is likely. This, by the way, is an example of music medicine research rather than music therapy, as the therapist is absent in this case.
Autoimmune Diseases
There are several diagnoses related to autoimmune diseases, with multiple sclerosis (MS) being the most well-known that affects the nervous system. Some research and documentation exist, including an early article by Wolfgang Schmid, written in collaboration with David Aldridge. The chapter references the use of rhythmic auditory stimulation for training walking functions. Otherwise, there do not appear to be any other specific approaches in this work, and it refers to several common methods in music therapy with broad psychosocial goals.
Autism and Neurodiversity
An American music anthropologist (Michael Bakan), along with a British music therapist (Hilary Davis), has written a clear defense of music therapy for autistic individuals, based on the theory of neurodiversity. They reject a music therapy practice in this field that is built on a medical model, where autism is viewed as a condition or disease with symptoms to be treated. They, therefore, oppose the use of the word "intervention" and advocate for a user-oriented collaboration with autistic individuals who engage with music.
They are particularly critical of a behavioral analytical approach (Applied Behavioral Analysis) and note that in a 2013 survey, 54.2% of American music therapists used behavior therapy as an intervention for autistic individuals. They consider behavior therapy for autistic individuals to be harmful because it does not make these individuals less autistic but instead encourages them to mask their autism by imitating the behavior of allistic (non-autistic) individuals.
I see that the music anthropologist behind this chapter, who has studied neuroatypical individuals, is employed at Florida State University. It is at this very university that the behavioral therapeutic approach to music therapy was developed, with my advisor from 1972, Clifford Madsen, as a leading figure. At that time, this discussion was not on the agenda.
The article is based on a political and "anti-oppressive" stance on the field. It views Brynjulf Stige’s development of community music therapy positively and refers to the somewhat limited literature describing music therapy within the neurodiversity paradigm. There are many good references here for readers who want to learn more about this work.
Telehealth and Therapeutic Technologies
There are several technological solutions to support therapy, data collection, software that controls music, the use of sensors, smartwatches, and more. This is a vast and rapidly evolving field. The chapter contains lists of programs and products, their target groups, research groups, and websites for those seeking more information.
One aspect of this technology is the use of telehealth and telemedicine in music therapy, which saw a significant increase after the COVID-19 pandemic. This can involve live, synchronized interactions between users and therapists, electronic transmission of documents, photos, and videos, user monitoring and data collection, and providing health information to users via smartphones, among other things.
Psychosocial Aspects
When so much emphasis is placed on brain mechanisms to explain why and how music affects neurological injuries, there is a need to highlight factors outside the brain and body that interact with brain processes. One chapter is therefore dedicated to the psychosocial aspects of music-based interventions. This involves influences on all levels, from micro to macro. In dealing with vulnerable individuals, we must always consider factors that affect motivation, sense of mastery, identity, coping resources, grief reactions, and so on. In other words, music-based interventions, or music therapy for this group of patients, must always consider psychological and cultural factors. In a biopsychosocial perspective, not only the body but also emotions and existential dimensions of health, as well as broader social contexts like family and community, must be taken into account—all of which are part of a more holistic approach.
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