Most days you can find Libby McDermott in front of a piano keyboard practicing. By her own admission, she’s not musical, and she took up tinkling the keys only recently. But practice isn’t a chore; she looks forward to forging through her book of tunes.
“It’s very relaxing,” McDermott said.
Learning to play the piano – she is taking on beginner versions of material ranging from Beethoven’s “Ode to Joy” to Rachel Platten’s “Fight Song” – isn’t a mere avocation for McDermott, 65. It’s an important part of working to slow the progression of her Parkinson’s disease, which was diagnosed in October 2011. In addition to regular practice at home on a digital piano, McDermott also spends 45 minutes a week at Rehabilitative Rhythms, an Aurora-based facility staffed by music therapists who are certified to treat neurologic conditions with evidence-based techniques.
During the Rehabilitative Rhythm sessions, McDermott works with neurologic music therapist Kathleen Marsh, following the time-honored teaching routine of running through scales, on piano keys weighted to provide resistance, led by the measured beats of a metronome. The idea is to use rhythm to strengthen connections in the auditory part of her brain to the region that controls muscle movement – the casualty of Parkinson’s disease.
Following the beat
It’s a well-established idea, said Isabelle Buard, PhD, a neurologist and researcher with the University of Colorado School of Medicine. Buard notes that pioneering studies by Michael Thaut and his colleagues have demonstrated that neurologic music therapy (NMT) can improve gross motor signals vital to maintaining gait and balance in stroke patients and those with Parkinson’s disease and other movement disorders.
Thaut’s work revolves around the concept of “entrainment”: the notion that stimulating the portion of the brain that perceives sound and rhythm can, in turn, synchronize other areas of the brain, including the region responsible for movement. Think of a crowd sitting in a packed stadium that begins clapping their hands or stomping their feet in unison at the sound of a pulsing, rhythmic cue.
Now Buard is principal investigator for the first study to explore using NMT to improve fine-motor skills, which are essential to everyday tasks like writing, eating, and cleaning – not to mention enjoyable activities like playing the piano. Her conceptual framework too rests on using entrainment to find “another switch,” as she puts it, to neurologically light the motor area of the brain, which Parkinson’s disease slowly darkens.
“We think that NMT may benefit movement in patients by going through pathways in the brain that are not affected by Parkinson’s disease,” Buard said.
Rebekah Stewart, MA, MT-BC, a neurologic music therapist at Rehabilitative Rhythms, noted that functional magnetic resonance imaging shows that individuals process music in many areas of the brain.
“Music is a unique tool in treating neurologic injury because it can activate parts of the brain that have not been damaged as much as others,” she said. Music therapy can help improve motor activity in patients with Parkinson’s disease and other movement disorders by attuning them to beats and rhythms that in turn “prime” muscle movement.
Practice to improve the imperfect
Stewart is one of the Rehabilitative Rhythms therapists for Buard’s study; McDermott was one of the early subjects. A control group receives standard occupational therapy to improve their fine-motor skills without rhythmic entrainment. The study group attends thrice-weekly, 45-minute therapy sessions with Rehabilitative Rhythms therapists for five weeks. They use a piano and other musical instruments to practice fine motor movements and patterns with their hands at increasing tempos. They also have short daily home practice sessions that include touching their thumbs in sequence to the other fingers of each hand; extending their arms with palms turned either up or down and curling their fingers into a fist; and reaching for and grasping a cup, dinner utensil or coin in one hand, transferring it to the other and returning it to precisely the same position.
For all the home exercises, patients receive a CD with verbal instructions and cues from a strummed autoharp as well as a steady metronomic beat.
Buard gets baseline measurements of each group’s fine motor skills using a timed test that requires subjects to put small metal pegs into holes in a board. She also records their brain activity with a scanner installed in a compact space in Building 500 on the Anschutz Medical Campus.
For this part of the study, the subject lies on a bed, and Buard attaches leads to specific positions on the head, then slips on a helmet equipped with 248 sensors. With the individual lying perfectly still, Buard plays a series of rhythmic and arrhythmic beats. On hearing them, the subject presses a button positioned at the fingertips. A computer screen in the adjacent room displays the brain activity, showing the connection between the auditory and motor regions. This goes on for an hour. The study participants also get an MRI for a picture of the brain’s anatomy.
After the therapy, the participants in both groups complete pegboard and imaging post-tests to measure the improvement, if any, in their fine motor skills and connectivity between the auditory and motor portions of the brain.
Battling back from a dire diagnosis
The cool clinical setting of Buard’s small lab makes it easy to forget that she’s looking for ways to improve the lives of patients battling a debilitating and isolating disease. McDermott said she was actually relieved when she received diagnostic tests from Dianna Quann, MD, a neuromuscular specialist practicing at the UCHealth Neurosciences Center at University of Colorado Hospital, and a final diagnosis from Maureen Leehey, MD, chief of the Movement Disorders Division at the CU School of Medicine.
If relief sounds like a strange reaction, consider the lengthy, frustrating period that preceded it. McDermott said that only in retrospect did she recognize telltale signs of the disease.
She had little reason to suspect it. She was an avid skier in good physical shape and had for 20 years taught third grade in the Cherry Creek School District – a job that required both physical and mental stamina. In 2010, though, seemingly small problems began to nag at her. Multitasking, an essential skill for every teacher, became increasingly difficult. Her “gorgeous teacher handwriting” got progressively smaller and harder to read. She made puzzling mistakes, like writing “grate” on a student’s paper instead of “great” and at times had trouble with memory and concentration. There were other warning signs, such as a gradual rigidity in her right arm, but “no one thing that seemed worth asking anyone about,” McDermott said.
Her physical challenges increased when she fell while skiing and broke her left shoulder. The recovery required a year of physical therapy. One day during the recovery her husband Mike, medical director at the Diabetes and Endocrinology Clinic at UCH, noticed Libby didn’t swing her right arm at all when she walked. That observation eventually led to the diagnosis of Parkinson’s disease.
At that point she was only 58 but said she felt closer to 85. “I felt I’d aged significantly. I was worried about Alzheimer’s.”
Staying on the move
Medications that maintain and regulate dopamine – the neurotransmitter essential to movement that Parkinson’s disease attacks – in the brain have helped her manage her symptoms, including loosening her right arm. But they can produce side effects, such as involuntary movements, and must be tightly managed. McDermott was determined not to rely on medications alone to slow her disease progression.
She exercises regularly with walking, aerobics and light weightlifting. Last August she pedaled 65 miles on the Copper Triangle to raise awareness for the Davis Phinney Foundation for Parkinson’s, an organization that provides education and support for Parkinson’s patients, families and caregivers. She’s also participated in Pedaling 4 Parkinson’s to garner funds for the Michael J. Fox Foundation for Parkinson’s Research.
Music is now firmly entrenched in McDermott’s therapeutic regimen. She said that after she finished Buard’s study protocol last spring she noticed improvement in her fine motor movements, which is one of her biggest challenges.
“I have trouble with typing and handwriting,” she said. To demonstrate, she picked up a pen from a table with her right hand and turned it into position to write only with difficulty. Pressing the piano’s weighted keys to a regimented beat, she said, has helped to loosen her hands from Parkinson’s rigid grasp.
Other signs of the power of music pop up from time to time, McDermott said. A longtime skier, she recently practiced S turns on the slopes with music playing through one earbud. With music that “best matches the way I ski,” she hit her patterns accurately. When the rhythm of the music stopped, so did the accuracy of her turns.
The experience wasn’t surprising to Buard. “The music is driving the brain to find a functioning level of movement,” she said. McDermott’s experience, she added, shows again the power of rhythm to synchronize the auditory and motor portions of the brain.
Buard makes no claims about the potential long-term effects of NMT, noting that as people age their brains lose plasticity – the ability to change and adapt to stimuli. That presents another challenge for treating people with Parkinson’s, most of whom are middle-age or older (the study is recruiting those from 45 to 85 years of age). Still, Buard added, finding ways to slow the progression of the disease is important to helping patients preserve their quality of life.
“There is depression associated with both fine-motor and cognitive decline,” she said. As that occurs, patients may feel increasingly isolated. The challenges of depression and anxiety can extend to family and loved ones, Buard added – another reason to find readily accessible therapies, like NMT, that ameliorate symptoms.
“When I’m feeling stiff and unfocused, I can sit at the piano and play, and I feel better,” McDermott said. “I like to look for ways to manage my symptoms without increasing medications. There is no risk to this therapy. At worst it may not help you, but in my experience, it has made a significant difference.”
For more information about the NMT for Parkinson’s disease study, contact Isabelle Buard at 303-724-5973 or [email protected].