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Active Music Therapy in Parkinson’s Disease: An Integrative Method for Motor
and Emotional Rehabilitation
CLAUDIO PACCHETTI, MD, FRANCESCA MANCINI, MD, ROBERTO AGLIERI, CIRA FUNDAR `O, MD, EMILIA MARTIGNONI, MD,
AND GIUSEPPE NAPPI, MD
Background: Modern management of Parkinson’s disease (PD) aims to obtain symptom control, to reduce clinical
disability, and to improve quality of life. Music acts as a specific stimulus to obtain motor and emotional responses
by combining movement and stimulation of different sensory pathways. We explored the efficacy of active music
therapy (MT) on motor and emotional functions in patients with PD. Methods: This prospective, randomized,
controlled, single-blinded study lasted 3 months. It consisted of weekly sessions of MT and physical therapy (PT).
Thirty-two patients with PD, all stable responders to levodopa and in Hoehn and Yahr stage 2 or 3, were randomly
assigned to two groups of 16 patients each. We assessed severity of PD with the Unified Parkinson’s Disease Rating
Scale, emotional functions with the Happiness Measure, and quality of life using the Parkinson’s Disease Quality
of Life Questionnaire. MT sessions consisted of choral singing, voice exercise, rhythmic and free body movements,
and active music involving collective invention. PT sessions included a series of passive stretching exercises,
specific motor tasks, and strategies to improve balance and gait. Results: MT had a significant overall effect on
bradykinesia as measured by the Unified Parkinson’s Disease Rating Scale (p Ͻ .034). Post–MT session findings
were consistent with motor improvement, especially in bradykinesia items (p Ͻ .0001). Over time, changes on the
Happiness Measure confirmed a beneficial effect of MT on emotional functions (p Ͻ .0001). Improvements in
activities of daily living and in quality of life were also documented in the MT group (p Ͻ .0001). PT improved
rigidity (p Ͻ .0001). Conclusions: MT is effective on motor, affective, and behavioral functions. We propose active
MT as a new method for inclusion in PD rehabilitation programs. Key words: music therapy, Parkinson’s disease,
rehabilitation.
tals, rehabilitation centers, special schools, and hos-pices (8, 9), the literature contains few assessments of ADL ϭ activities of daily living; ANOVA ϭ analysis of MT in medical care. Music has been used as a form of variance; HM ϭ Happiness Measure; MS ϭ motor sub-scale; MT ϭ music therapy; PD ϭ Parkinson’s disease; therapy for many different diseases and, unless hear- PDQL ϭ Parkinson’s Disease Quality of Life Question- ing is totally affected, may indeed be experienced and naire; PT ϭ physical therapy; UPDRS ϭ Unified Par- appreciated by even the most severely physically or cognitively impaired subjects (10). MT has beenwidely used in the rehabilitation of handicapped chil-dren, providing one of the few ways in which thesesubjects can attain self-expression (11). In addition, INTRODUCTION
MT is recommended in geriatric care to improve the Modern management of PD as well as efforts to social, psychological, intellectual, and cognitive per- obtain better symptom control are directed toward re- formance of older people (12, 13). Depressed older covering the patient’s functional status, thus improv- adults, in particular, can experience the effects of pas- ing both clinical disability and quality of life (1– 4). To sive MT (14, 15). MT reduces anxiety in patients un- achieve global improvement in personal well-being, dergoing cardiac procedures throughout the perioper- drugs, in accordance with standard guidelines, as well ative period and in those who have had a myocardial as interdisciplinary measures, such as physical exer- infarction (16, 17); moreover, music seems to relax cise, occupational and speech therapy, and psycholog- patients undergoing surgery (18) or invasive diagnostic ical, nutritional, and social counseling, have been procedures (19). It has also been suggested that music used(5–7). We explored MT as a method for inclusion may modify release of stress hormones and cardiac in PD rehabilitation programs. Even though MT is function (20) as well as the respiratory pattern (21).
widely used in a variety of settings, including hospi- Finally, anecdotal evidence and clinical studies showthat MT improves the cognitive functions and qualityof life of patients with Alzheimer’s disease (22–24).
From the Parkinson’s Disease and Movement Disorders Centre, There are two main branches of MT, active and Istituto di Ricerca e Cura a Carattere Scientifico C. Mondino, Uni-versity of Pavia, Pavia, Italy.
passive. In brief, active MT is based on the improvisa- Address reprint requests to: Dr. C. Pacchetti, Parkinson’s Disease tion of music by the therapist and patients, who play and Movement Disorders Centre, IRCCS C. Mondino, University of an active part by using instruments and voice. The use Pavia, Via Palestro 3, 27100 Pavia, Italy. Email: pacchett@ of instruments is structured to involve all the sensory organs; the rhythmic and melodic components of mu- Received for publication December 3, 1998; revision received sic may be used as specific stimuli to obtain certain Psychosomatic Medicine 62:386 –393 (2000)
0033-3174/00/6203-0386Copyright 2000 by the American Psychosomatic Society MUSIC THERAPY IN PARKINSON؅S DISEASE
motor and emotional responses, thus combining move- Characteristics of Study Population
ment and stimulation of different sensory pathways,that is, auditory and tactile (multiple sensory stimula- tion), with a well-established emotional quality. Pas- sive MT is conducted with the patient at rest. With theaim of producing a state of mental relaxation, the ther- apist plays calming music and invites the patient to PD is a common degenerative disease dominated by a disorder of movement, consisting of bradykinesia (slowness of movement), hypokinesia (reduced move- ments), tremor, rigidity, and postural and gait abnor- malities; mood changes are also a major component of In view of the features of the disease, application of active MT would seem to be appropriate in PD, even though there are, so far, no objective reports on the efficacy of this kind of therapy in patients with PD.
The first aim of this study was to verify the efficacy of MT on motor involvement in patients with PD. More- over, given that PT is the main nonpharmacologic course of intervention in PD (25), we conducted arandomized, controlled, single-blinded, prospective study comparing PT with MT. In addition to measur-ing clinical changes, we evaluated the influence of This prospective, randomized, controlled study lasted 3 months.
these two types of therapy on both the emotional well- Patient examinations were conducted 1 hour before the start of thePT or MT session by a neurologist (C.P.), blinded to the patient’s being and quality of life of PD patients.
study group, after the first morning dose of therapy. Postsessionexaminations were conducted within 1 hour after conclusion of thesession, before the second drug was taken. The UPDRS motor exam- ination (score range, 0 –108) was administered to all patients atweeks 1, 3, 5, 7, 9, and 11 of the study and at the follow-up examination, which was conducted 2 months after completion of thestudy. The patient’s emotional state was assessed at the same time as Thirty-two PD outpatients were invited to participate in the motor function, using the short, self-administered HM, which was study, and informed consent was obtained. To meet our selection filled in by the patient. In brief, the HM consists of two self-report criteria, patients had to have idiopathic PD and had to be responsive questionnaires (parts 1 and 2) that measure emotional well-being.
to levodopa therapy or other dopaminergic treatments. Patients with Part 1 examines the intensity (or quality) of happiness (ie, how secondary parkinsonism (ie, due to vascular disease, drugs, infec- happy or unhappy one feels, with 10 ϭ extremely happy and 0 ϭ tions, toxicity, or other conditions) were excluded. Patients were extremely unhappy) and part 2 measures the frequency (or quantity) stable responders or early fluctuators to levodopa, in Hoehn and of happiness (ie, the percentage of time one feels happy, unhappy, or Yahr stage 2 or 3, and not affected by cognitive deterioration, severe neutral) during the past month. Another parameter considered was sensory (visual or auditory) deficits, or diseases affecting movement.
the combination score, calculated as follows: (Happiness Intensity ϫ Patients were allowed to continue taking their medication, but 10 Ϫ Happiness Frequency)/2, which combines the two scores in the dosage had to have been constant for 1 month before the trial and equal weights. The combination score was assessed at weeks 1, 5, 9, had to remain constant throughout the entire study period. Dopami- and 11 and at the follow-up visit. Validity studies have revealed a nergic therapy consisted of levodopa (standard and slow-release marked inverse relationship between the HM and indices of unhap- formulations) alone or in association with dopamine agonists, such piness usually used to assess mood disorders in patients with PD, as pergolide or bromocriptine. Sixteen patients (12 men and 4 wom- such as the Beck Depression Inventory (27, 28). Each patient com- en; mean age, 62.4 years; mean duration of illness, 4.8 years) took pleted the PDQL at baseline, midway through the study, the end of part in weekly sessions of MT, and 16 patients (11 men and 5 the study, and 2 months after study completion (follow-up visit).
women; mean age, 63.1 years; mean duration of illness, 5.2 years) Items on the PDQL explore the severity of illness in addition to had weekly sessions of traditional PT. Patients were randomly as- systemic, social, and emotional variables (score range, 37–185). At signed to these groups by using a computer-generated number list.
the same time, changes in ADL were evaluated in each patient (score The groups were similar in age, time since diagnosis, drug sched- ules, duration and severity of illness, and motor impairment and The 16 patients of the PT group, divided into two groups of 8, disability, as measured by the MS and ADL subscales of the UPDRS, attended weekly sessions, each lasting about 1.5 hours. PT consisted respectively (26). Furthermore, no significant differences in emo- of a series of passive muscle stretching exercises for rigidity and tional functions, as assessed by the HM (27), or quality of life, as joint mobility, specific motor tasks for hypokinesia, weight shifting measured by the PDQL (4), emerged between the groups (Table 1).
and balance training for posture, plus movement strategies to pre- Psychosomatic Medicine 62:386 –393 (2000)
C. PACCHETTI et al.
vent falls and to initiate and maintain gait (29, 30). During the PT limb bradykinesia (right and left hands and feet; score range, 0 – 68).
sessions, patients performed the exercises concurrently but individ- The rigidity factor (range, 0 –20) was the sum of rigidity scores of all ually, with minimal interaction with one another.
extremities and neck, and the rest tremor factor (range, 0 –20) was The 16 MT patients were divided into two groups of 8, which is the sum of the tremor score for right and left sides and head. The considered the ideal number of subjects to participate in a group postural/action tremor score (range, 0 –16) was the score for postural session. Each group took part in 13 weekly sessions of active MT or action tremor for the upper extremities (32, 33).
lasting about 2 hours each. Active MT involves improvisation by the The Wilcoxon signed-rank test was used to compare every week therapist, who invites patients to play an active role using instru- presession and postsession scores on the following measures: UP- ments and voice. Patients do not require any musical training. Each DRS-MS, UPDRS-MS factors (bradykinesia, rigidity, and postural session was conducted by a music therapist who played an active and resting tremor), and HM part 1. To compare presession and postsession differences between the PT and MT groups every week, Sessions were subdivided into standard sections as follows: en- we performed the Mann-Whitney U test on the following measures: trance and interview, 10 minutes; listening to relaxing music and UPDRS-MS, UPDRS-MS factors (bradykinesia, rigidity, and postural visualization of images, 10 minutes; choral singing and facial ex- and resting tremor), and HM part 1. UPDRS-ADL, PDQL (total and pression, breathing, and voice exercises, 15 to 20 minutes; rhythmic partial), and HM combination scores of the PT and MT groups were movements (eg, involving lower limbs, upper limbs, and gait), 30 compared at weeks 1, 7, and 11 and at the follow-up examination.
minutes; active music involving collective invention and improvi- All statistical tests were two-tailed at the .05 significance level. All sation, 30 to 40 minutes; free body expression to melodic and rhyth- statistical analyses were performed with SPSS/PCϩ, version 4.0.1 mic music, 20 to 30 minutes; and conversation, 10 minutes. Patients used all instruments at their disposal, adopting a free technique. Theequipment consisted of a piano, organ, percussion instruments (eg,metallophones, xylophones, drums, wood blocks, and cymbals), and a high-fidelity system. In MT sessions, exercises were performed by The difference between MT pretest and posttest couples, small groups, or even the group as a whole with a high levelof interaction and communication within the group (eg, patients values demonstrated a significant improvement in performed rhythmic or melodic improvisation using instruments UPDRS-MS scores (Wilcoxon test, p Ͻ .0001; Table 2), and voice freely, or, in another exercise, some of the patients played especially with regard to bradykinesia (Wilcoxon test, the wood blocks with an alternating movement of the arms while the p Ͻ .0001; Table 3). The difference between PT pretest rest of the group marched to the rhythm). Our methods are exten- and posttest UPDRS-MS and bradykinesia values was not significant (Tables 2 and 3). Analysis of changes inbradykinesia revealed that MT had a significant over- all effect (Friedman’s ANOVA, p Ͻ .034; Table 3). This We used Friedman’s to compare paired data emerging from the effect was lacking in the PT group (Table 3). The final evaluation of all presession scores (overall evaluation), within MT evaluation, conducted 2 months after completion of and PT groups, of the following measures: UPDRS-MS, UPDRS-MS the study, demonstrated a lack of motor benefit with factors (ie, bradykinesia, rigidity, and postural and resting tremor) MT. The over-time analysis of rigidity, like the pretest (32, 33), UPDRS-ADL, HM (combination and part 1 scores), and and posttest evaluations, consistently revealed the ef- PDQL (total and partial scores). The bradykinesia factor was thesummation of the following items: speech, facial expression, rising ficacy of PT training on this factor (Table 4).
from a chair, posture, gait, postural stability, body bradykinesia, and A comparison of pretest and posttest differences (⌬) UPDRS-MS Results
a Wilcoxon signed-rank test for presession/postsession analysis. NS ϭ not significant.
b Mann-Whitney U test for comparison of pretest and posttest differences (⌬) in MS scores between the MT and PT groups.
c Friedman’s test for overall evaluation.
Psychosomatic Medicine 62:386 –393 (2000)
MUSIC THERAPY IN PARKINSON؅S DISEASE
UPDRS-MS Bradykinesia Factor Results
a Wilcoxon signed-rank test for presession/postsession analysis. NS ϭ not significant.
b Mann-Whitney U test for comparison of pretest and posttest differences (⌬) in bradykinesia scores between the MT and PT groups.
c Friedman’s test for overall evaluation.
UPDRS-MS Rigidity Factor Results
a Wilcoxon signed-rank test for presession/postsession analysis. NS ϭ not significant.
b Mann-Whitney U test for comparison of pretest and posttest differences (⌬) in rigidity scores between the MT and PT groups.
c Friedman’s test for overall evaluation.
in the UPDRS-MS score (Table 2) and bradykinesia UPDRS-ADL (Total Score) Results
factor (Table 3) values between the MT and PT groups revealed a statistically significant effect of MT on these parameters (Mann-Whitney U test, p Ͻ .0001), whereas analysis of the rigidity factor revealed that PT rather than MT seems to be efficacious on this factor (Mann- Whitney U test, p Ͻ .001; Table 4).
Analysis of the resting and postural tremor scores did not reveal any significant changes (data not Variations in the ADL total score demonstrated that MT induced an overall effect on daily performance of a Mann-Whitney U test. NS ϭ not significant.
activities (Friedman’s ANOVA, p Ͻ .0001; Table 5).
b Friedman’s test for overall evaluation.
Separate analysis of ADL items revealed significantchanges in the following activities: cutting food, dress- ing (Friedman’s ANOVA, p Ͻ .05; data not shown).
ing, falling (Friedman’s ANOVA, p Ͻ .0001), and freez- These results were also confirmed by a comparison of Psychosomatic Medicine 62:386 –393 (2000)
C. PACCHETTI et al.
the influence of MT and PT on ADL score changes, PDQL (Total Score) Results
which revealed that only MT had an effect on the ADLtotal score (Mann-Whitney U test, p Ͻ .0001; Table 5).
Changes in emotional functions, as indicated by HM part 1 and combination scores (data not shown for thelast), showed marked improvement in the MT group throughout the therapy period (overall effect), thus revealing a beneficial effect of MT on emotional well- being (Friedman’s ANOVA, p Ͻ .0001; Table 6). Pre- session and postsession changes in HM part 1 scores revealed the capacity of MT to modify emotional func- tions (Wilcoxon test, p Ͻ .0005; Table 6). Like motor a Mann-Whitney U test. NS ϭ not significant.
changes, emotional changes were no longer evident 2 b Friedman’s test for overall evaluation.
months after completion of MT. Emotional functioningwas not modified in the PT group (Table 6). This result to only four PT patients) reported feelings of well- also emerges from the comparative analysis of the ef- being and dynamism at home, saying that they were fect of MT and PT on HM part 1 and combination more active and keeping themselves busy. In particu- scores. These findings revealed a significant difference lar, they said they appreciated the social contact and in favor of MT both over the study time and after each creative means of communication that MT offered session (Mann-Whitney U test, p Ͻ .0001).
Patients participating in MT sessions displayed a considerable improvement in quality of life, as indi- DISCUSSION
cated by the PDQL total score (Table 7), due particu-larly to variations in the emotional (p Ͻ .0001) and Suggestions that music improves rhythmic limb social (p Ͻ .0001) functioning scores, despite no movements, gait, and freezing in patients with PD are change in parkinsonian and systemic functioning (data not new in the clinical literature, even though they are not shown). As seen with the changes in motor and rather scarce (34 –36). This study is the first to assess emotional functions, the improvement in the quality of objectively the effect of a systematic program of active life was no longer evident 2 months after completion MT on standardized measures of PD severity using a of MT. A comparison of differences in the PDQL total prospective, single-blinded design. Moreover, this ran- and partial scores (data not shown) between the MT domized, controlled clinical study compared the effi- and PT groups revealed a major efficacy of MT on cacy of MT and PT to highlight any eventual difference quality of life (Mann-Whitney U test, p Ͻ .0001; Table between the two methods in their effect on both phys- ical and emotional functions. Our results demonstrate At the final interview, all MT patients (as opposed improvements in motor abilities and emotional status HM Part 1 Results
a Wilcoxon signed-rank test for presession/postsession analysis. NS ϭ not significant.
b Mann-Whitney U test for comparison of pretest and posttest differences (⌬) in HM part 1 scores between the MT and PT groups.
c Friedman’s test for overall evaluation.
Psychosomatic Medicine 62:386 –393 (2000)
MUSIC THERAPY IN PARKINSON؅S DISEASE
related to active MT. The improvement in motor per- assumed to regulate motivational-incentive reinforce- formance was related mainly to changes in bradykine- ments of general behavior (49, 50). Following this sia. Although the MT-related motor response seemed view, the motor facilitation in response to MT could be to decline after each session, a trend of improvement based on emotional reactions momentarily activating was observed in the MT group in the overall evalua- the cortical-basal ganglia motor loop, the circuit pri- tion. Improvement in emotional functions was found marily affected in PD. The behavioral evidence of a both after each MT session and throughout the entire functional interface between the limbic and motor sys- study period, but when measured 2 months after com- tems (51, 52) and the anatomical-functional sensori- pletion of MT, the values returned to baseline levels.
motor integration of basal ganglia and cortical frontal Significant improvements in ADL and quality of life regions (52–59) further support this suggestion.
were also documented in patients undergoing MT. PT, Current knowledge of the cerebral structures in- meanwhile, led to a clear improvement in rigidity but volved in the perception of music is derived from did not induce any major changes in other variables.
clinical-pathological studies and from pioneering Physical rehabilitation has been found to be effec- positron emission tomographic research (60 – 62). Lis- tive in patients with PD, although the evidence is tening to music seems to involve distinct neural pro- questionable in some reports (29, 33, 37–39). Gener- cesses that correspond to the basic components of ally, PT serves as reinforcement of the motor program, music, such as rhythm, pitch, and timbre, or even to but this kind of intervention is usually lacking in the lexicosemantic access to melodic representations (62), motivational and emotional spheres, which could ex- functions that involve one or both hemispheres. Music plain why traditional PT has little influence on mood has been shown to relax and reduce anxiety, modify- state and why it is not easily incorporated into the ing release of stress hormones, cardiac function (20), patient’s lifestyle (33). It is well known, on the other and respiratory pattern (21). These changes induced by hand, that psychosocial variables, such as emotional music could be at the origin of positive findings in state or psychosocial stress, strongly influence abnor- emotional and social items: A clear improvement in malities in gait and posture and other motor perfor- the PDQL scale score demonstrates the efficacy of MT mances (40, 41). In accordance with such observations, on PD patients’ quality of life. This improvement em- occupational and behavioral therapies based on psy- phasizes an important effect of active MT in PD: It chological and motivational aspects can induce im- promotes socialization, involvement with the environ- provements in movement initiation and quality (42).
ment, expression of feelings, awareness, and respon- The beneficial effect on emotional variables mea- siveness. MT, in fact, increases motivation in patients sured in the MT group may be explained by the differ- whose personality is characterized by the absence of ent emotional impact that MT has on patients, which “novelty-seeking” aspects of behavior (63) and by “an- is related to its high level of sensory stimulation and hedonia,” a mood state characterized by the “loss of high degree of personal interaction. In line with this internally generated anticipation, motivation, and view, our study suggests a connection between emo- tions and the facilitation of movement.
In accordance with the clinical literature, it may be This research was supported, in part, by Grant argued that the MT-induced improvement in bradyki- ICS57.2/RC94.10 from the Ministry of Public Health. nesia could be due to the effect of external rhythmic The authors thank K. Wrenn for assistance with trans- cues, which, acting as a timekeeper, may stabilize the lation and A. Citterio for assistance with statistical internal rhythm formation process in patients with PD (43– 45). Indeed, it has been demonstrated that theinitiation and execution times in sequential button- REFERENCES
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