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,
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: [email protected]
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 PARKINSONS 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 PARKINSONS 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-
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 PARKINSONS 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-
pressing tasks are positively influenced by acousticcues (46), as are gait velocity, cadence, and stride
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Co-Occurring Disorder-Related Quick Facts: NICOTINE Nicotine: Nicotine, a component of tobacco, is the primary reason that tobacco is addictive, although cigarette smoke contains many other dangerous chemicals, including tar, carbon monoxide, acetaldehyde, nitrosamines, and more.1 In 1988, the Surgeon General concluded that cigarettes and other forms of tobacco (i.e., cigars, pipes
Gwava makes Linux move IT World Canada (24 Mar 2004) SALT LAKE CITY - Montreal-based software vendor Gwava announced at this year’s Novell BrainShare user conference that it is porting its e-mail surveillance solution for Novell’s GroupWise collaboration platform over to Linux. The release of Gwava for Linux comes on the heels of Friday’s announcement at the Cebit trade show in Ha