-Department of English-
Health Humanities Undergraduate Research
Music Therapy and Neurodegeneration
Overview
Inspired by a lifelong passion for music and a growing interest in neuroscience, this research explores the potential of music therapy as a preventive intervention for neurodegenerative disease. Across four literature reviews, I examine the history and current clinical prevalence of music therapy, its cultural and socioeconomic relevance, and the neuroplastic mechanisms through which music can influence cognition, memory, and brain health. I also investigate the barriers limiting its integration into healthcare settings despite growing evidence supporting its therapeutic value. By combining perspectives from neuroscience and the health humanities, this work seeks to better understand how music can be leveraged to promote cognitive well-being and improve quality of life. Moving forward, I hope to contribute to research that bridges the gap between scientific evidence and clinical implementation, advancing the integration of music therapy into patient care and preventive health strategies.
I. Evolution of Music Therapy within Medical Services Worldwide
Abstract
This work focuses on describing music therapy, reviewing potential clinical uses for music therapy, and summarizing the historical evolution of music therapy across the globe. While the use of music to improve well-being has historical roots dating back to Biblical times, music therapy gained popularity only in the late 1900s. Given its adaptability to various treatment modalities, its likely efficacy in treating a range of psychological and neurological conditions, its ease of administration, its favorable risk:benefit profile, and the universal connection between people and music, music therapy has the potential to benefit patients across the globe. However, due to the lack of published research supporting its use, many clinicians are unaware or uneducated on the true value music therapy can offer. According to a recent survey, most physicians are open to education on this approach (Hense 30). This presents an opportunity for existing music therapy practitioners and advocates, including patients, to raise awareness of its benefits. This specific paper holds significance as it expands music therapy knowledge and seeks to facilitate its development. With more individuals aware of the practice, this safe therapeutic method will become available to more patients.
What is Music Therapy?
Music therapy is the delivery of music by a trained musical professional to address physical, emotional, cognitive, and social needs and to enhance the relationship between therapist and patient. Oftentimes, music therapy is prescribed as a complementary therapy, working alongside another form of medical care. Due to the diversity in clinical applications for music therapy, it can be paired with numerous forms of care, including cognitive functional, physical, pharmacological, psychological, and neurological treatments. Sessions can be either individual or group-based. In individual music therapy sessions, therapists assess the patient’s symptoms and adjust the therapy according to the patient’s preferences. Group music therapy can introduce the concept of “collaborative musicing”. Differing from individual music therapy, collaborative musicing is the act of collaborating to accomplish a collective, group-oriented goal. Music therapy encompasses a variety of activities, including music improvisation, music listening, songwriting, music performance, learning through music, etc. However, there are common music-based interventions used that do not fall under the umbrella of “music therapy.” For instance, other healthcare professionals playing recorded music is not considered music therapy, as music therapy must be delivered by a musically trained clinician. Also, the sheer act of music listening does not incorporate the musical element of intrapersonal relationships. This is one of the key characteristics of music therapy that differentiates it from other clinical or therapeutic techniques.
Clinical Applications for Music Therapy
One major characteristic of music therapy that differentiates it from other commonly practiced treatments is its versatility. With music therapy being relatively new to the healthcare setting, research on music therapy is limited. However, the research that has been completed suggests that music therapy will prove applicable to many disease states. The primary goal of music therapy is typically remediation, with music therapy acting as a “relaxant, therapeutic activity, agent in stress management, comfort, auditory training, modifier of brain wave activity, [and] guide for visual imagery” (Darrow et al. 19). Thus, music therapy has many neurological applications.
Historically, the application of music therapy was limited to motor therapies or speech/language rehabilitation. Prior to this, applications of music therapy to cognitive rehabilitation was not well studied (Thaut 281). Recent research has identified links between music and cognitive functioning, including temporal order learning, spatiotemporal reasoning, attention, and auditory verbal memory (Thaut 281). These functions affect an individual’s ability to perceive, recognize, remember, and comprehend the order of events, objects, a given scenario, or conversation. The element of music that drives improvement in these functions is rhythm. Rhythm has been proven to help tune and modulate attention by using patterns to “entrain attention focus by interacting with attention oscillators via coupling mechanisms” (Thaut 281). Rhythm can also affect temporal structuring and patterning processes in perception and learning (Thaut 282). Music therapy has shown therapeutic potential in these areas, even without a complementary treatment. Following along the lines of neurological pathways, newer research finds that music may help reduce pain intensity (“Music”). Music therapy has shown success in reducing pain associated with childbirth, cancer chemotherapy, retrieval of eggs for in vitro fertilization, broken bones, fractures, sickle cell diseases, multiple sclerosis, osteoarthritis, etc. (“Music”). Introducing music as a non-pharmacological pain treatment may also reduce the need for pain-relieving medications. This may help reduce opioid addiction and abuse.
Parallels have also been found between music memory formation processing and nonmusical memory processes. Specifically, the phrasing, grouping, and isolation of musical patterns strongly correlate with the temporal chunking principles of nonmusical memory processes (Thaut 281). Both musical and nonmusical stimuli drive cognitive processes of attention and memory. This is exceptionally important, given musical memories can survive longer than nonmusical memories (Thaut 282). One of the primary reasons for this outcome is the emotional nature of music. Music oftentimes elicits an emotional response within an individual. Emotional memories are retained longer in an individual because more cortical area of the brain is activated, and the amygdala is highly active (Thaut 283). If using music therapy to condition music as an emotional stimulus, exposure to music can facilitate verbal learning and memory recall in a patient. This association can prove beneficial to patients experiencing memory loss and can aid in memory retrieval for patients with Alzheimer’s disease or dementia, whose symptoms were previously thought to be irreversible.
As music can engage with many areas of the brain, it can strengthen synaptic networks and pathways associated with sensory and motor processes (Edwards 869). Rhythmic auditory stimulation, a specific form of neurological music therapy, presents auditory rhythmic cues to the patient. The outcomes of these sessions have been beneficial for patients with gait disorders, indicating the stimulation of sensory and motor cortices in the brain (Edwards 869). It has also been found that musical stimulation may help combat stroke or traumatic brain injury symptoms. In an experiment conducted by Hommel, Peres, Pollak, and Memin, music stimuli were found to be superior to other sensory and cognitive stimuli, such as verbal instruction or tactile cues (Thaut 283). Such data suggests that music may have the potential to cure some motor and sensory disorders. Both neurological music therapy and melodic innovation therapy proved successful in the rehabilitation of patients with aphasia by “stimulating their cognitive, emotional, and sensorimotor functions” and increasing their overall measured language scores (Edwards 869). Through the activation and strengthening of neuronal circuitry, music therapy can be beneficial to patients indicating sensory or memory dysfunction.
Music therapy application also extends to the psychology domain. Many preliminary research studies provide compelling evidence that music-based interventions can be beneficial in treating anxiety and depressive symptoms. Besides looking at these symptoms strictly from a psychiatric standpoint, it is necessary to note that many individuals battling a fatal condition also experience depression and anxiety, making music therapy applicable to most patients in the healthcare setting. Music therapy is currently being studied in youth mental health services, mostly due to youth engagement with the media (Hense 18). Hense found that younger individuals listen to music for an average of 18 hours per week and many of the individuals identified music as their preferred creative activity (Hense 19). This adds to the comfort associated with music therapy, providing the patient with something they frequently access. By facilitating music listening through a healthcare professional, youth can connect with the health-promoting elements of music. To note, Hense also found that a patient’s existing relationship with a song acts as an emotional agent (Hense 19). Due to the individuality of music therapy sessions, this aspect can be exploited, as each music therapy session can be tailored to the patient’s preferences, maximizing the emotional benefit of the treatment. When planning the music-based invention, therapists should account for the patient’s preferences, while also considering the patient’s economic demographics and cultural history. Music therapy has proven effective regardless of a person’s national identity, socioeconomic status, or cultural background (Rodgers-Melnick et al.). However, every culture engages with music in its own way. It is important for the music therapist to be aware of this in order to prevent the trigger of an insensitive musical genre or method of performance. Similarities among cultural musical tradition may be used as a “melting point” (Bolger 29). In a 10-month study produced by Lucy Bolger, a Norwegian music therapist held musical gatherings for women from rural Bangladesh. The primary goal of the group sessions was to encourage the exploration of different social roles, making the women more comfortable in a role of higher authority. As ‘a foreigner’ Bolger could not communicate with any of the women other than via music. By the end of the study, women who were previously silent were leading the group, and members of the group would meet without instruction to engage with music (Bolger 29). People from different cultural backgrounds relate to music in various ways, thereby engaging with music therapy in different styles. Due to the adaptability and ubiquity of music, this therapy form may be beneficial across the globe.
Unlike most other treatments, there are very few downsides or side effects to music therapy. Some argue that extensive playing of musical instruments can lead to joint injury; listening to music at a loud volume can contribute to noise-induced hearing loss; and emotional music can trigger a traumatized response (“Music”). However, all of these can be prevented with careful consideration of the form of music therapy treatment and a thorough physical evaluation of the recipient. At its core, the risk:benefit ratio of music therapy is favorable. It is extremely collaborative in nature, humanizing the practice and making the patient feel a sense of control. Music therapy is extremely adaptive and can provide benefits to almost any population. It can easily be performed with minimal equipment, destimulating the patient from the common crowded hospital environments. Music therapy presents a calming resort to patients and provides them with a known stimulus to address their individualized needs.
Thayer Gaston’s Motives for Music in a Clinical Setting
Thayer Gaston, known as the “father of music therapy,” is arguably the most important figure in the evolution of music therapy. Throughout his time, Gaston championed the use of music therapy in the medical field and helped to integrate it within the healthcare setting. To fully understand the history of music therapy, it is necessary to understand the mind of the man who introduced the idea. Gaston stated, “Among the several basic drives of man is that of esthetic expression” (Gaston 9). This concept of esthetic expression is the act of communicating and expressing one’s feelings. Among the various modes of esthetic expression, Gaston thought music to be the most popular (Gaston 9). Music can be a means of communicating one’s raw emotions. To Gaston, the wordless meaning of music provides the art with its “potency and value” (Gaston 9). Despite musical influence on behavior, Gaston believed the chief value of music was to work as a modality for establishing relationships with patients (Gaston 21). In this therapeutic strategy, music is working to foster an interpersonal relationship between individuals and groups. Through music, it can foster progress towards a therapeutic goal, as individuals would be more open to expression (Gaston 21). Gaston also highlighted the malleability of music therapy, claiming it to be the most adaptable of the arts. It can be integrated indoors, outdoors, individually, in a small group, or in a large group. Music exists in all cultures, meaning it can be applied globally (Gaston 9). While music may be utilized differently in various global regions, it is always used for the expression of the inner self and group integration (Gaston 9). This proves music to be a “global language”.
Through observation of everyday life and psychotherapy sessions, Gaston proposed multiple applications for music within a healthcare setting. He noted that background music can be “conducive to great conversational interchange”, indicating that it could spark conversation and provide a welcoming space within therapy sessions (Gaston 9). He heavily focused on how music can affect mood, stating it can alleviate loneliness and amplify positive attitudes. Both of these benefits can further strengthen the relationship between patient and therapist or among patients in a group, reducing hostile actions and verbalizations and creating a more peaceful and open therapeutic environment. Oftentimes, music elicits the “tender emotions, such as love of family, religion, … patriotism, loyalty, and similar relationships” (Gaston 19). This can help alleviate the fear of “closeness” typically present in psychotherapy conversations.
Gaston further dissected the main musical elements; patterns, tempo, rhythm, harmony, and form, claiming unique uses for them all. For instance, for a patient whose purpose of treatment is to provide a well-structured activity, the patient must respond promptly to remain rhythmically on tempo (Gaston 20). Additionally, in a group performance setting, the individual must pay close attention to their entrances and rhythm to keep the piece composed and fluid among all the performers. In learning the music and successfully performing it, the patient may feel increased self-gratification, reducing their anxiety. This further proves a healthy therapeutic argument for an individual as the benefits come in a noncompetitive fashion (Gaston 20). Gaston also introduced the concept of “functional music”, in which music would act as a stimulus for a predetermined response rather than being played directly by the individual (de L'Etoile 60). However, no matter the forum in which the music is presented to the patient, Gaston believes that “‘music is always secondary to the improvement of the patient’” (de L'Etoile 60). To this, music therapists ensure that they are having the patient interact with what is appropriate for the patient’s needs (de L'Etoile 60). All in all, Gaston noticed many uses of music in therapy that could be beneficial for facilitating patient improvement.
History of Music Therapy within the United States
The onset of music therapy as a practice was very gradual. Throughout history, references have been made to the potential clinical applications of music. However, it took numerous years before these ideas took root in the United States healthcare system. Literary works discussing music as a therapy precede the times of the Old Testament, suggesting a “mythical origin” for music therapy (Darrow et al. 18). Around these same years, writings of Aristotle and Plato introduced music as a healing source (“History of Music”). The inspiration for music therapy in America grew from Britain. The oldest English-language text on the issue of music and medicine was written by Browne and published in London, England in 1729 (Darrow et al. 18). This novel applied scientific principles to music therapy, as well as presented a case for its use in modern medicine. Browne argued a variety of musical therapeutic applications, stating that music can elicit moods, stimulate extramusical associations, influence psychological processes, and has a purpose in preventative healthcare (Darrow et al. 18). The first direct mention of the term “music therapy” appeared in “Music Physically Considered” within Columbia Magazine in 1789 (“History of Music”). Following this, two medical dissertations were published by Edwin Atlee (1804) and Samuel Mathews (1806). Both individuals were students of Dr. Benjamin Rush, the founder of American psychiatry, and claimed him the inspiration for their findings. Samuel Mathews’s paper especially held a significant case for the efficacy of music therapy in a healthcare setting. The 1800s also recorded the first music therapy intervention, along with the first recorded systematic experiment in music therapy (“History of Music”). After this, music therapy advocates established several institutions to bring together thought leaders in this new field. In 1903, Eva Augusta Vescilius founded the National Society of Music Therapeutics; in 1926, Isa Maud Ilsen founded the National Association for Music in Hospitals; and in 1941, Harriet Ayer Seymour founded the National Foundation of Music Therapy (“History of Music”). While these founders did not directly develop the organized clinical profession of music therapy, they contributed heavily to the first journals and books of that time. These women, along with countless other music therapy proponents, started to shift their efforts to developing a nationally recognized music therapy undergraduate curriculum (de L’Etoile 65). The first college course in music therapy was developed in 1919 at Columbia University titled “Musicotherapy”. Its purpose was to teach the psychophysiological action of music and to provide training for its medical use (de L'Etoile 53). It was first taught by Margaret Anderton, but later by Isa Maud Ilsen. In striving to develop more interest in the field, in September of 1926, the New York Times offered free scholarships to musicians who complete the training at Columbia University (de L’Etoile 53).
Within the United States, music therapists have been practicing within the medical setting since the mid-20th century. Directly after World War I and World War II, community musicians visited thousands of war veterans suffering from physical and psychiatric trauma. The patients experienced significant physical and emotional responses, leading doctors to request the hiring of musicians in the hospital (“History of Music”). While many of these hospital volunteers completed training, there was a need for specialized higher education. Gaston expressed that many of the aspiring workers were not completely aware of the skills and considerations needed in the clinical atmosphere (de L'Etoile 61). In response, in 1944, Roy Underwood established the first official curriculum, leading to a Bachelor’s degree in music therapy. (de L'Etoile 57). Shortly thereafter, Gaston established a Master’s degree of Music Education in Functional Music (de L'Etoile 59). To expand upon the scope of pure musical practice, these students completed coursework in psychopathology, psychiatry, psychotherapy, and various specific therapies, such as lobotomy, and electric and insulin shock therapy (de L’Etoile 56). Training courses became more consistent; the state hospitals of Iowa developed a curriculum in response to the lack of qualified professionals within their hospitals (de L'Etoile 55). From the 1950s to today, training courses have become more rigorous and coherent. The skills required to be a music therapist today vary greatly from clinicians in the past. The original purpose of music in hospitals stood as entertainment for wounded soldiers. Nowadays, it is a clinical tool, providing psychosocial, neurological, and physical therapy, and it is highly recommended that a practicing therapist demonstrate at least a Bachelor level of Music Education degree. The medical professionals in music therapy can now unite on a national level. The American Music Therapy Association (AMTA) formed in 1998 as a merge between the National Association for Music Therapy (NAMT) and the American Association for Music Therapy (AAMT). This association is bringing together music therapists across the United States, as well as other countries.
Currently within the United States, about 64.8% of practicing music therapists work in in-service facilities (Hense 29). These music therapists provided services to around 36,000+ facilities (“A Descriptive” 4). In 2020, the American Music Therapy Association (AMTA) performed a diagnostic test to calculate the current prevalence of the music therapy practice within the United States. In the year 2020, nearly 2 million people received music therapy services (“A Descriptive” 4). Most music therapists work 30+ hours a week and make an average of $58, 973 (“A Descriptive” 11). New job opportunities are readily opening, meaning that the profession is continuing to grow in popularity. More than “twice as many positions were created as were eliminated” in 2020 (“A Descriptive” 29). As more jobs are available and more positions are filled, more patients can get care through music therapy. As of October 1, 2021, 9,483 board-certified music therapists were reported (“A Descriptive” 32). Looking at the trend of expansion, this number can be predicted to be higher today. When breaking down the actual population served, it was found that music therapy was served relatively consistently across all ages (“A Descriptive” 20). As noted before, music therapy is extremely versatile in its use, benefiting a plethora of disorders. Currently, the main populations consist of abused individuals, individuals with AIDS, Alzheimer’s/Dementia, autism, behavior disorders, grief, cancer, chronic pain, eating disorders, learning disabilities, as well as neurologically impaired, terminally ill, and dual-diagnosed individuals (“A Descriptive” 16). The medical professionals were spread across different clinical settings: self-employed and private practice (11%), medical setting (19%), mental health setting (13%), geriatric facilities (13%), children’s facilities/schools (11%), and other (33%). Overall, music therapy can prove beneficial for numerous individuals and continues to expand as its potential efficacy gains awareness.
Current Prevalence of Music Therapy on a Global Scale
As the music therapy field continues to expand, research in this field is shifting from “anecdotal clinical descriptions and position papers to descriptive, experimental, and historical investigations” (Darrow et al. 19). One of the ways to identify the global prevalence of music therapy is to evaluate the frequency of publications across different countries. It is incredibly difficult to locate the exact number of music therapists in many countries, given most countries do not have the technology to maintain this information. In 2021, Kaimili Li, Linman Weng, and Xueqiang Wang studied review and article publication trends of music therapy research in the Web of Science database. In all, 1,004 publications were studied across 2,531 authors from 1,219 institutions (Li et al. 1). The articles and reviews covered 49 different countries or regions (Li et al. 7). In interpreting these results, it is important to consider that music therapy may be just as prevalent in underdeveloped countries, however not as well documented as first-world countries due to lack of resources. However, psychosocial psychology is not as prevalent in some cultures, which would also indicate that some cultures are somewhat resistant to the music therapy practice. For instance, psychosocial counseling “is a relatively new phenomenon in South Asia, and initial studies exploring the use of counseling methods in India, Nepal, and Bangladesh indicate that counseling is a potentially useful method of psychosocial support in this region” (Bolger 32). This further states that music therapy is still widely unknown and developing. But, this data also proves that music therapy can prove efficacious on a global scale.
The study showed a notable increase in music therapy publication percentages from the year 2000 to 2019 (Li et al. 1). The year 2015 was considered a major turning point because it was the first time 80 articles or reviews were published (Li et al. 7). In comparison, 80 global publications is very small compared to scientific publications on other medical topics. This further illustrates the lack of awareness music therapy is still facing. Across all years, the United States had the largest number of publications (362 publications) (Li et al. 1). Following the United States was Germany (96), England (95), Australia (88), Norway (72), China (53), Denmark (45), Italy (39), Canada (30), and Israel (29) (Li et al. 3). All of these countries are first-word countries, meaning they have the resources to medical practices. This does not mean that music therapy is not common in third-world countries. In terms of institutions, The University of Melbourne produced the highest number of publications (45), followed by the University of Minnesota (43), University of Bergen (39), Florida State University (33), and Aalborg University (32). In terms of the collaboration map of institutions, the most productive universities engaged in music therapy were located in the United States, namely, University of Minnesota (43 publications), Florida State University (33 publications), Temple University (27 publications, and University of Kansas (20 publications) (Li et al. 5). One key observation is the spread of these universities across various countries. It is necessary for the expansion of music therapy awareness that research is conducted globally. The volume of research at a university positively correlates with the strength of their music therapy programs. If these are spread across the globe, hopefully more aspiring music therapists will have the opportunity to study in the field.
Of all of the authors, MJ Silverman published the most papers (46) followed by Gold C (41), Magee WL (19), O’Callaghan C (15), and Raglio A (15). Cooperation among authors has also increased remarkably throughout the years, an important development for expansion within the music therapy research field (Li et al. 5). Currently, the most common terms in music therapy studies are “depression”, “autism”, “hospice”, “efficacy”, “health”, and “older adults” (Li et al. 6). These terms indicate future applications of music therapy. These align with the finding that a majority of music therapy practitioners work within the psychiatric setting (Darrow et al. 19).
History of Music Therapy in Australia
To better understand how music therapy developed worldwide, it is necessary to dive into specific global regions. This section describes the history of music therapy within Australia. As stated previously, Australia is predicted to be one of the countries populated with the most professional music therapists. Australia’s national laws for content restrictions are limited, making their research findings accessible to others. Unlike Australia, other countries restricted sharing or translating, making findings unusable or inaccessible for the average researcher. As one will see, Australia’s music therapy history was heavily dependent on other countries, making it a good case study to digest.
One of the pioneers of Australian music therapy was Esther Kahn. In the 1920s, Kahn became aware of music therapy within the United States and set up a group of interested people to form the International Society for Music Therapeutics (“History of the Australian”). Kahn saw music’s potential to uplift the soul and wished to see it used in a psychiatric sense. On August 21, 1926, Kahn spoke at the Lyceum Club in Sydney and expressed the effectiveness of using music to cure depression (“History of the Australian”). Later, on October 16, 1932, she published an article in “The Sun” newspaper titled “Music Healing in Sydney” (“History of the Australian”). In this, Kahn described individual and group musical-based therapy sessions that had occurred over the past two years. While the musical therapy practice was starting to unfold in Australia, it was still not an established profession or well-known by the general public. On April 21, 1938, Kahn published another article in “The Sun”, this time focusing on her individual work as a composer and teacher alongside figures Mirrie Hill, Marjorie Hesse, and Miriam Hyde (“History of the Australian”). In this article, Kahn quoted a few American specialists working in psychiatric hospitals in the United States (“History of the Australian”). By doing so, Kahn was able to show the prevalence of music therapy globally. Besides Kahn, the Australian Red Cross played a crucial role in the beginning of music therapy in Australia (“History of the Australian”). Working for the Red Cross Library, Eleanor Barber wrote music programs and distributed them to hospitals in Victoria for discussion groups (“History of the Australian”). This action exposed many individuals to the therapeutic effects of music. The Red Cross Music Therapy Service was benefited by a visit from Sybil Beresford-Peirse, a graduate from the Guildhall music therapy course in London, in 1968 (“History of the Australian”). Sybil was able to share her personal experiences with music therapy in London and provide guidance on how the practice should be performed and established. Ruth Bright helped facilitate the implication of music therapy by publishing “Music and Mental Health” in 1966, speaking at the Royal ANZ College of Psychiatrists, and completing a survey on how music can be used therapeutically in Australian schools and hospitals (“History of the Australian”). Following the publication of one of Bright’s books in 1972, “Music in Geriatric Care”, music therapy became a recognized profession in the Public Service of NSW (“History of the Australian”). Bright’s actions were key in spreading awareness of the practice and benefits of music therapy.
The first application of music therapy occurred in Victoria for a patient population of 550 individuals (“History of the Australian”). In 1974, a group of advocates for music therapy gathered, which morphed into the Queensland branch of the Australian Music Therapy Association. In 1975, the first music therapy conference was held in Glebe, Sydney, where individuals worked with overseas trained physicians to create a certification process for the music therapy position (“History of the Australian”). By 1984, the Victorian Red Cross Music Therapy had employed four qualified music therapists and provided music therapy to 14 hospitals around Victoria (“History of the Australian”). Originally, music therapy practices focused on treatment in admission wards, acute wards, long-term wards, psychiatric hospitals, and therapeutic communities (“History of the Australian”). By 2016, 37% of Australian registered music therapists reported working in a mental health care setting, 48% of whom worked with younger individuals (“History of the Australian”). This suggests the expansion of music therapy to different applications and patient populations. Since the first music therapy conference in 1975, annual conferences have been organized across major cities in Australia (“History of the Australian”). These annual gatherings allow for the expansion of practice and uniformity of practice across the country.
Current Issues Impeding the Expansion of Music Therapy
The primary reason music therapy is not heavily practiced is due to the lack of documentation supporting its efficacy. While there is preliminary research on this technique, this research is relatively “new and incomplete in many aspects” (Darrow et al. 18). This obstacle exists on a national and international level. As a researcher, I found it difficult to discover information about music therapy; published research is scarce within the United States, let alone in the Global South. In addition, I struggled with several journal articles written in foreign languages that were not in a format available for translation. This does not bode well for the general population to become aware of this treatment mechanism. Thus, many individuals do not comprehend the scope of music therapy potential, and clinicians are hesitant to integrate the treatment within their practice. Nonetheless, there is evidence that clinicians are eager to learn about music therapy applications. In a study comparing clinicians’ exposure to music therapy to their referral rates (for music therapy), the clinicians were asked if they would be interested in attending professional development sessions about music therapy (Hense 26). One hundred percent of the participants answered that they would like to attend these sessions (Hense 26). There was also a strong positive correlation between clinicians’ knowledge of music therapy and their referral rates, indicating that if more clinicians are educated on music therapy, more individuals may be referred to a music therapist.
One of the reasons that robust, large-scale music therapy research studies are so scarce is due to the difficulty of objectively measuring its outcomes. Due to the versatility of music therapy, there are numerous clinical endpoints to consider when evaluating efficacy, such as emotion, cognition, motor, sensory, interoception, behavioral, social, engagement behaviors, functional status, and voice/speech domains (Edwards 875). Not only are many of these endpoints correlated, but objective non-invasive measurement may require technologically advanced equipment. However, advances in brain-wave measurement techniques, such as EEG and MEG, may remedy this, making it easier to quantify music therapy benefits (Thaut 281).
Finally, many individuals stray away from music therapy because of the cost. Oftentimes, music therapy is not funded by third-party payers, such as healthcare insurers (Darrow et al. 19). This makes treatment accessible to only wealthy individuals. However, as awareness is raised, the practice becomes more common, and technology becomes more advanced, one can hope that more insurance companies will pay for the treatment and recognize music therapy as a form of healthcare.
Future Directions
The study of music therapy, especially from a neurological and humanistic viewpoint, is still widely under-researched. Most of the studies completed used convenience surveys and/or small sample sizes. This type of research risks producing inconsistent and unreliable data, which may call into question the true efficacy of music therapy. As individuals within the field of music therapy continue research, it is necessary to make the experiments replicable and with large sample sizes, ensuring the results are statistically significant and irrefutable. New technology should enable measurement of biochemical and neurological changes within the body. Researchers should focus on conducting studies on patients with Alzheimer’s disease, Parkinson’s disease, strokes, and dementia, as well as search for any potential biomarkers of the inflammatory, structural, circuitry, functional, synaptic dynamic, neuroplasticity, neurodegenerative, gene expression, sensory, and motor categories (Edwards 837-876). Additionally, music therapists need to equip themselves with the ability to educate fellow clinicians about their profession. Without these efforts, music therapy will continue to be widely unknown. In future endeavors, I hope to look at music’s effect on the body’s neuroplasticity, potentially applying music therapy to learning disabilities. Moreover, I intend to argue the humanistic characteristics of music therapy and compare patient’s experiences with music therapy to those of pharmacological treatments. In all, I will endeavor to share my findings as widely as possible, as my goal is to educate others on the wide-ranging benefits of music therapy. After all, music therapy is a comfortable, safe, non-invasive, non-pharmacological treatment method that should be readily accessible to everyone.
II. Unheard Potential: Addressing the Gaps, Cultural Relevance, and Educational Barriers in Music Therapy
Abstract
This work focuses on revealing common music therapy techniques, connecting cultural practices to therapeutic settings, and discovering underlying barriers that limit music therapy expansion. It also includes the education pathway to becoming a music therapist and analyzes how this influences the overall frequency of treatment. Music therapy research has proven its effectiveness in curing many neurological and behavioral conditions. However, this research is often overlooked due to its low quality and lack of additional supporting publications. Globally, there is an extreme shortage of knowledge surrounding music therapy. In response, clinicians remain uneducated about music therapy benefits, resulting in low referral rates. Additionally, much of the music therapy practice goes undocumented, decreasing international development and hindering research strides. This paper advocates for the addition of music therapy within the standard medical practice and suggests avenues for future research. It incorporates patient testimonies to display examples of the strong emotional and bodily connections one can make with music. These also help to reveal patterns of effective treatment plans and guide decision-making for future music therapists. As education and research levels rise, music therapy will become an accessible treatment option for individuals worldwide.
Path to Becoming a Music Therapist
While the road to becoming a music therapist is straightforward, it is relatively extensive. This process can vary depending on the residing area; however, it is similar across countries. In the United States, one must start by obtaining a bachelor’s in music therapy (“FAQ”). It is not required that the bachelor’s degree be specifically in music therapy, but it must be in the music, biology, psychology, social sciences, or behavioral sciences realm. This degree must also be accompanied by a demonstration of musical competence (“FAQ”). While it is not expected that a music therapist can play every instrument, they must still be proficient in a couple of instruments to thoroughly provide treatment. Following the bachelor’s degree, the aspiring music therapist would then apply for a master’s degree at an AMTA (American Music Therapy Association) approved program (“FAQ). Currently, 100 universities are AMTA-approved, spanning numerous states across the country (“FAQ”). This largely aids the growth of music therapy studies by being accessible to many people within the United States. While music therapy is still expanding, master’s program opportunities are not a major limitation in the field’s development. After completing a master’s program, one must also complete 1200 hours of fieldwork, including an internship in healthcare and/or an educational facility (“FAQ”). This requirement forces music therapists to be exposed to patient interactions before formally starting their job. It is very different to learn techniques in a classroom versus putting them into practice in real life. Through the fieldwork, upcoming therapists can pose questions to experienced individuals and learn necessary methods for helping a patient. Finally, the individual must pass the national examination by the Certified Board for Music Therapists to be officially Music Therapist-Board Certified (MT-BC). Once the individual has the credentials, they can practice as a music therapist within the United States.
Another popular scene for the music therapy practice is Australia. The pathway to becoming a music therapist in Australia differs slightly from the United States, but their core teachings remain the same. In Australia, the individual must first obtain their bachelor’s degree in music, creative arts, education, allied health, social science, health science, or humanities (“Becoming”). Like the United States, this must also be coupled with a demonstration of musical proficiency. Following, the individual must get a master’s degree from one of 2 accredited programs. These programs consist of a Master of Music Therapy at the University of Melbourne and a Master of Creative Music Therapy at Western Sydney University (“Becoming”). The former of these universities accepts no more than fifty students a year, while the latter accepts about thirty students a year (“Becoming”). These universities are much more prestigious than those in the United States, which limits the total number of music therapists possible in Australia. While making these programs extremely competitive does not help the overall quantity of music therapists, it does ensure the production of quality therapists by providing more one-on-one discussions with experts. Along with the master’s degree, one must also complete a provisional year with professional staff provided by the AMTA (Australian Music Therapy Association) (“Becoming”). Like the United States, this professional development allows for in-field experience before officially starting a job as a music therapist.
The United Kingdom’s system is also a good comparison due to the prevalence of music therapy within the country. Again, the UK requires individuals to complete a bachelor’s and master’s degree in the same fields as the United States and Australia (“Music”). These subjects remain consistent across any country’s music therapy degree. To fully understand the practice, the music therapist must analyze the biological and psychological reasons for a patient’s condition. From here, they must carefully choose proper musical characteristics and expression types to best suit the patient. An expansive background in the health and social fields guides these decisions. Directly after obtaining a master’s degree in the UK, the individual registers with the Health and Care Professions Council (HCPC) and officially begins to practice music therapy (“Music”). The UK also has options to register for an apprentice position if the individual feels the need to gain more exposure to the field before practicing by themselves (“Music”). In all, the UK path is slightly shorter than the American and Australian paths, but it is still comparable. The overall process for becoming a music therapist differs slightly between countries, but the core components—educational background, musical proficiency, and in-field practice—remain the same.
Most Practiced Songs in Music Therapy
One of the reasons why music therapy education is so extensive is due to the large variety of treatment methods that can be offered. Music therapy can be practiced in many different spaces, including hospitals, psychiatric facilities, private practices, rehabilitation centers, schools, nursing homes, etc. Each of these locations differs in the general type of care provided. For instance, hospitals mostly approach care with complementary therapy, pairing music therapy with the injection of a sedative or pain medication. Music therapy may also be used in this scene to reduce muscle tension or to induce sleep (“FAQ”). In nursing homes, music therapy can be used more as a stimulus. Music can promote movement and increase sensory stimulation. Upbeat music also corresponds strongly with enhanced mood and quality of life, which is a focus for hospice settings. For schools, music therapists draw out the educational aspects of music. Music can be played in conjunction with educational material to increase memory processing in students. Additionally, music learning is used to strengthen nonmusical areas such as coordination and communicational skills (“FAQ”). Lastly, psychiatric facilities focus on the interpersonal relationship between one and music. Music therapists carefully pick musical tracks and performance methods that resonate strongly with the individual or group. Through this, individuals can connect with songs and become aware of their inner emotions. Every facility is not bound to adhere strictly to these forms of music therapy, rather, these are commonalities often observed in each given setting.
Along with the therapeutic methods, the songs utilized in therapy sessions also vary greatly. At first, one might assume that softer songs, like classical piano pieces, are popular in therapy sessions; however, this is not necessarily true. A music therapy program logged their most requested songs by adults with intellectual disabilities aged 22-60. They noticed a strong appeal for upbeat songs from famous movies like “Cant Stop the Feeling” from Trolls, “Do Re Mi” from The Sound of Music, “All Star” from Shrek, “Beauty and the Beast” from Beauty and the Beast, “Can You Feel the Love Tonight” from The Lion King, and “A Whole New World” from Aladdin (“Top”). The fast tempo and crescendos present in these pieces make them catchy and bright tunes. These songs are good options for music therapy sessions that are trying to encourage engagement and high spirits. In support, the same patients also enjoyed listening to popular American hits like “Beat It” by Michael Jackson, “Can’t Help Falling in Love” by Elvis, “Country Roads” by John Denver, “Fight Song” by Rachel Platten, and “Firework” by Katy Perry (“Top”). These adults most likely find these numbers and lyrics familiar due to their repeated exposure to these songs. When stressed, the patients can reconnect with memories and the present environment through this music.
Another study, completed by Chroma, surveyed 50 music therapists across the United Kingdom. In combination, the clinicians surveyed had performed 17,500 hours of therapy and had helped over 500 patients. They found a strong use of the songs “We Will Rock You” by Queen, “Three Little Birds” by Bob Marley, “Amazing Grace”, “Another Brick in the Wall” by Pink Floyd, and “You Are My Sunshine” by Johnny Cash (“Study”). Like the previous study, these music therapists mostly used upbeat, popular songs. However, it is important to keep in mind the patient population and global location of both of these studies. Therapy provided to adults with intellectual disabilities varies greatly from music therapy offered to other patients, simply due to the patients’ needs. Additionally, both of these studies originated from primarily English-speaking countries, explaining the high popularity of English songs. It cannot be assumed that the same trends would be observed in other areas of the world, like the Global South. So, while these studies benefit the quality of music therapy practice in specific clinical realms, they do not capture patterns that would apply to every music therapy setting. In truth, there is “not necessarily a ‘most popular’ music genre or music therapy style simply due to the individuality of the practice” (“FAQ”).
Cultural Influences on Music Therapy Treatment
A large chunk of music therapy efficacy is based on the individual’s relationship with music. A song the client is familiar with will be more impactful than one the patient has never heard. Oftentimes, the connection felt with a specific music genre or presentation originates from one’s culture or socioeconomic upbringing. Throughout childhood, individuals are constantly surrounded by music. This presents in various forms, from singing children hymns to simple rhythmic beats being made when completing tasks. After repeated exposure, the body grows familiar with these sounds and forms a sense of comfort. This feeling of naturality does not wane over time and is still present in later years. As this translates to music therapy, the body will automatically react to traditional music because it “knows” this type of music (Park 229). This characteristic emphasizes the individuality of the practice and forces music therapists to understand the patient’s background before properly treating them.
Besides simple song popularity and language barriers, cultures also play a role in one’s relationship with music. Every culture integrates music differently into society. Musical presentation also varies. Each culture holds traditional dances, utilizes specific instruments, and intrinsically unites with music in unique ways. For instance, the Korean culture is based on Confucianism, so individuals do not express their emotions externally (Park 229). When exposed to music, Korean individuals are more likely to internalize their feelings, rather than express them to the group. This trait of Korean culture hinders individuals from connecting to others’ traditional music that incorporates a lot of community involvement and emotional expression. An anonymous woman raised within the Korean culture shares her experiences with other genres of music: “I found it very difficult and strange when I first tried to play the piano in certain rhythms and genres such as Arabic music, blues, and jazz. My body did not accept the feeling of such different rhythms the first time I tried. Even though I could play the scale, it did not sound completely authentic” (Park 229-230). This individual was unable to integrate herself into the Arabic music. Arabic music uses key signatures and rhythmic patterns that differ greatly from Korean music because the music is used to elicit different, unique responses in each culture. Although music notes are heard the same across the world, the combination of notes can be arranged in hundreds of different ways and patterns. Korean music uses a pentatonic scale that follows breathing (Park 230). Instead of matching the music to one’s environment, this music focuses more on connecting one’s inner breathing to the song. Rather than making music a group experience, this becomes more of an individual connection.
Following the exposure to Arabic music, the individual was instructed to practice vocal holding exercises. Conversely to how the individual reacted to Arabic music, she was able to better match her body to this form of music, as it better expressed characteristics of Korean music (Park 230). Besides following breathing patterns, this exercise also repeated two simple chords that overlapped Korean musical structure and mood (Park 230). This musical study holds crucial information for the music therapy practice. The songs chosen in music therapy sessions need to be direct reflections of an individual’s culture. If not, therapy sessions will not be as effective. The individual will feel disconnected and unmotivated, rather than experiencing the therapeutic aspects of the music. When choosing the form of music therapy, such as group or individual therapy, it is also important to consider how cultural background can alter one’s outcomes in the therapy session. In Korean culture, individual connection with music is much more practiced than group connection. So, individuals with Korean backgrounds would most likely feel more comfortable in individual therapy sessions rather than group therapy sessions. Group therapy sessions rely on the expression of emotion and the gathering of a community to draw out and uplift the overall spirit. Someone who is not comfortable expressing their emotions externally would not enjoy this unnatural experience, hindering both their own and the group’s emotional growth.
A similar experience was shared by a Jewish patient who was in a psychiatric setting comprised of mostly black and Hispanic patients (Park 230). The psychiatric facility mostly played jazz and hip-hop music, as most of the patients resonated strongly with these genres. While this music playing helped lift the mood of many patients within the setting, the Jewish patient did not feel the same excitatory effects of the music as the other patients did. Instead, the patient stated that these songs “gave her headaches” (Park 230). Unlike the other patients, the Jewish individual was not as familiar with the quick-paced chord progressions in these genres. Instead, the individual responded much better to Irish folk songs that were like songs within her religion (Park 230). Most Jewish music is written in the minor key, which differs from typical Asian or American songs (Park 232). In America and Asia, the minor key is associated with a “sad” mood, whereas the major key is associated with a “happy” mood. But in the Jewish religion, minor keys are seen as normal and do not facilitate depressing moods. The differences in societal practices between different religions and cultures create significant variations in bodily responses to music listening. Music structure and function “may be related to basic human drives” and biological needs (Park 231). Therefore, music therapists’ decision-making cannot disrupt this natural balance.
Both music therapy studies provide definite evidence that one’s culture strongly affects how one responds to music. Music therapists must consider how different music genres affect a patient before beginning therapy. Music not only reflects cultural society and expresses emotions, but also affects the human body in adverse ways (Park 230). The therapist needs to ensure that the music they are utilizing will not harm the patient physically or emotionally. They must guarantee that their musical choice does not insult the individual or group, but rather uplifts them and supports them on their emotional or physical journey.
Frequency of Music Therapy Prescription
One of the main setbacks of music therapy expansion is the lack of research and the lack of prescription. In the United States, there is no concrete number representing how many individuals receive music therapy every year. However, an estimate can be extrapolated based on a workforce analysis completed by the American Music Therapy Association in 2021. The American Music Therapy Association sent out a survey to every board-certified music therapist in the United States (“A Descriptive” 33). From the survey respondents, 77% indicated that their job involved mainly clinical responsibilities. The 770 respondents saw a total of 202,585 clients within the 2020 year, averaging 263 clients per service provider (“A Descriptive” 33). Using this average and assuming that around 77% of all 9,483 board-certified music therapists work in a clinical setting, it can be estimated that a total of 1,920,426 people received music therapy within the United States in 2020 (“A Descriptive” 33). Again, this number is simply an estimate. Additionally, the year 2020 marks the start of the COVID-19 pandemic, which strongly impacted everyday life within the United States. Many individuals no longer had access to in-person healthcare or the financial support to obtain any form of healthcare. So, this number is not necessarily a strong representation of the number of individuals who receive music therapy within the United States today, however, there is no other research that has captured a more accurate number.
In comparison, the “more common” forms of therapy within the United States are much more researched and can provide an accurate treatment number through an accumulation of data points. More than 50 million Americans seek physical therapy every year (Salamon). Also, 59.2 million adults in the United States received treatment or counseling for mental health in 2023 (Vankar). These therapy prescription rates are much higher than those of music therapy. Not only are mental health therapy and physical therapy practiced over 25 times more than music therapy within the United States, but there is also much more research and knowledge for these therapies than there is for music therapy. Similar to the music therapy practice, around 3 million Americans receive acupuncture each year (Levarda). However, acupuncture is offered in 42% of U.S hospitals, including the top 10 nationally ranked hospitals (Levarda). The exposure to other forms of therapy is much greater than that of music therapy. Music therapy has proven effective for a diverse number of treatments. Its fluidity should make it a common practice within many hospitals, psychiatric facilities, hospice care centers, etc. However, the fact that music therapy is an alternative form of therapy causes many individuals to be wary of its effectiveness and avoid the therapy as a whole. A similar under-researched trend is noticed with art therapy. Like music therapy, art therapy is considered both a complementary therapy and an alternative therapy method. For art therapy, there is no approximation for the number of recipients in the United States every year. However, it is estimated that there are about 5,000 art therapists within the United States, approximately half of the number of board-certified music therapists (“State”). This lack of knowledge is profoundly unacceptable for the growth of the medical field today. Only 15 states within the United States regulate art therapy as a mental health profession, including Connecticut, Delaware, Kentucky, Maryland, Mississippi, New Jersey, New Mexico, Oregon, Tennessee, Virginia, New York, Texas, Pennsylvania, Wisconsin, and Utah (“State”). If these humanistic therapies continue to go unnoticed within the healthcare field, fewer individuals will gain exposure to them and forgo them as treatment options.
In response, doctors need to be educated on the benefits of employing complementary therapies in their practices. Borkan, Neher, Anson, and Smoker completed a study to examine how “allopathic physicians participate in the decision to refer patients for alternative therapies” across multiple locations (Borkan et al. 545). From their results, “Primary care physicians are more likely than other medical specialists to be knowledgeable about, personally subscribe to, and refer patients for alternative therapies” (Borkan et al. 545). In general, physicians who personally use alternative therapies for themselves or their families had a higher referral rate. Similarly, physicians who use complementary therapies or alternative techniques within their practice had higher referral rates (Borkan et al. 545). However, the referral rates and patterns “were similar between sites despite considerable cross-cultural and health system differences” between each researched location (Borkan et al. 545). Music therapy is a “global language” that can be adapted to fit any individual, explaining the similarity of referral rates between physicians of varying backgrounds. This aspect of music therapy proves its use as a complementary therapy. In clinical settings across the globe, patients are treated with predetermined steps proven to be effective for a given disease/disorder. Conversely, music therapy methods can be similar, but they are always reflective of the individual’s wants and background. With music therapy being used alongside standard medical practices, not only will the patient reap the benefits of music therapy, but the patient will also feel heard and somewhat in control of their treatment. However, the overall lack of knowledge among physicians towards the music therapy practice poses a serious limit to its expansion and overall therapeutic frequency.
Along with the under-education of music therapy benefits also comes minimal insurance coverage options. As music therapy is not recognized by many as a common form of treatment, it is often difficult for patients to have therapy sessions covered by insurance. Nevertheless, in recent years there have been positive strides in this economic development. Since 1994, Medicare has made music therapy a reimbursable option, making music therapy accessible to many Americans (“FAQ”). This advancement towards accepting music therapy greatly impacted its expansion. Without any insurance coverage, music therapy is an expensive option. Like any other form of therapy, music therapy utilizes costly tools and requires highly trained individuals, causing therapy sessions to be pricey. Insurances oftentimes cover common forms of therapy, making music therapy less affordable in comparison. With music therapy also being covered by Medicare, this evens out therapeutic costs and allows it to be just as accessible to individuals as other forms of therapy. But, there are still many insurance companies that do not reimburse the practice. With Medicaid, only a few states offer reimbursement: Arizona, Indiana, Maryland, Michigan, Texas, and Wisconsin (“FAQ”). All of these states have programs that acknowledge the music therapy practice. Since music therapy is being ignored by a majority of states, many individuals are unable to afford the treatment. Finally, private insurers usually reimburse on a case-by-case basis. If the treatment was pre-approved or deemed medically or behaviorally necessary, insurance companies are much more likely to cover the cost of music therapy (“FAQ”). It is currently estimated that about 20% of third-party insurance companies within the United States reimburse music therapy (“FAQ”). This number is already quite high, given the previous statistics on music therapy use and acceptance, and it is continuing to climb. Larger utilized insurance companies like Cigna, United Healthcare, Blue Cross Blue Shield, and Aetna have also all paid for music therapy services in the past, indicating that they are not against its expansion in the future (“FAQ”). Requiring social workers and physicians to take a short training course on the benefits of music therapy would alleviate most of the unfamiliarity and misinformation being spread today. If music therapy becomes properly credited, it would become a safe healthcare option for many more patients.
Patient Testimonies
Music therapy is severely underpracticed across the globe. Most individuals avoid music therapy simply because they are unaware of its presence. Of the limited few who are aware of it, many follow a separate recovery path due to the lack of quality research proving its effectiveness and the lack of referral by clinicians. Still, music therapy is beneficial to many. Although the therapy is recognized for its wide range of therapeutic benefits, music therapy is especially beneficial for neurological and behavioral recovery.
Jordan Manco is a U.S Army Veteran formally deployed in combat operations in 2021 to Northeastern Syria (Manco). After returning home, Manco was “broken physically, mentally, [and] emotionally” (Manco). He tried numerous coping methods but was still left feeling empty and hopeless. Manco would constantly experience PTSD symptoms, but was unaware of how to connect and face his underlying emotions. After some time, Manco journeyed on a music therapy retreat filled with many other searching individuals, musicians, and music therapists (Manco). Here, Manco learned that “music is not just an art form; it’s a universal language that can heal, connect, and transform” (Manco). Manco worked with a music therapist who facilitated their songwriting. Jordan Manco expresses that within the song, “facilitators and artists captured me and my story and shared it back to me” (Manco). Having struggled with PTSD, Jordan was consistently holding onto his distressing memories, but was unable to express the deep emotions he had associated with them. Through the song, Jordan was able to “reconnect and anchor into a part of [him]self that [he] had forgotten and was desperately trying to find” (Manco). In all, music therapy helped Jordan Manco get in touch with his feelings and release the stress that was holding him back from completing everyday activities. The music therapy retreat completely transformed Manco’s life, allowing him to move past his trauma. Jordan Manco shares his story to “inspire and encourage” others to consider music therapy as a healing route (Manco).
Songwriting can also be helpful for individuals with autism spectrum disorder. Linus, a six-year-old boy on the autism spectrum, originally came to music therapy with goals to develop movement, communication, and cognitive skills (Fuller 47). Along with music therapy, Linus also participated in other health modalities like speech pathology and occupational therapy (Fuller 47). Although music therapy played an important role in Linus’s developmental path, music therapy effects are heightened when used in unison with other forms of therapy. Throughout Linus’s years of music therapy, the music therapist integrated visual support to mark his cognitive developments and to make the environment less stimulating for Linus (Fuller 47). Over time, the symbolic materials transitioned from photos with text to drawings with text to text only (Fuller 47-48). Once Linus was old enough, the music therapist tasked him with creating a song. This activity challenged Linus’s cognitive and communication skills. It also stimulated slight anxiety towards the idea of starting a new project. However, the music therapist was able to quickly counter this uneasiness through the playing of consistent rhythms and melodies (Fuller 48). This repetition is commonly found in music and is a great tool for reducing anxiety and overstimulation. After a few sessions, Linus successfully created his song (Fuller 49). The music therapist shared a CD copy with Linus, which he showed off to many, proud of his accomplishment (Fuller 49). Linus’s music therapy journey was extremely unique and allowed him to grow in many developmental areas. Many different musical elements proved beneficial for Linus’s treatment, like rhythms and lyrical creations, which are not present in other therapeutic forms.
Music therapy can also be used to improve fine motor skills and alleviate pain. Liz Rodgers underwent a traumatic brain injury, leaving her with cerebral palsy and chronic regional pain syndrome (Smith). After her injury, Rodgers tried various forms of therapy to try to reverse some of the physical damage and release some emotional stress. She found physical therapy unhelpful and felt that the physical therapist was trying to “fit [her] into the standardized goals instead of adapting [her] therapy plan to fit [her] individual needs” (Smith). Liz Rodgers then became a music therapy patient. Over time, she noticed statistically significant changes in self-rating pain on a “10-point” scale. She also improved her breathing support through singing her song recreations and fine motor skills through playing the piano (Smith). Liz Rodgers’ story highlights her positive music therapy experience. The therapy helped her in many physical ways, as well as helped decrease her depression and PTSD symptoms (Smith). Rodgers made it her life’s mission to advocate for other individuals with special needs by showing them that their physical disabilities do not need to stop them from achieving their personal goals (Smith). This advocacy would not be possible without music. Rodgers went on to perform musical numbers in the community with the help of her music therapist (Smith). She displayed the uplifting effects of music and the rejuvenation factors of music therapy as well.
Adding to the list of music therapy effects, music therapy can also facilitate neuroplasticity. Christopher Bailey is a music therapy patient who lost his eyesight due to a damaged optic nerve (Bailey 93). Following this, Bailey could no longer recognize loved ones’ faces. Instead, he just saw blurred light and minimal color (Bailey 93). Bailey shares, “Much of our cognition and pleasure are neurologically centered around sight” (Bailey 94). In Bailey’s recollection, he explains how this negatively impacted his quality of life and the connections he was able to make with loved ones. He began unable to carry out basic human functions, like walking, communicating, cooking, and eating (Bailey 96). In an attempt to combat these disparities, Bailey started a new program at the World Health Organization on Arts and Health (Bailey 94). After research and listening to music himself, Bailey noticed his symptoms waning. Listening to music can help with echolocation, allowing Bailey to imagine his surroundings through sound (Bailey 96). Music can also trigger both the emotional and auditory centers of the brain, helping the brain to adapt to the damage done to the visual cortex (Bailey 99). Again, the soothing principles of music still apply to Bailey. Through music listening, Bailey was able to accept his troubles and emotions, rather than ignoring them (96). Music therapy has many positive effects that can benefit many individuals.
Future Directions
Despite its growing popularity, music therapy is still an under-researched and underdeveloped field, particularly when compared to more common therapeutic practices. Although ground-level research has been completed and has displayed promising results for various fields like neurorehabilitation, pain management, mental health, developmental disorders, etc., these studies often lack validity and reliability. Many music therapy studies include small sample sizes, lack longitudinal data, rely on participant willingness, and vary widely in methodology. This produces varying results that pose a challenge to generalizing music therapy techniques into a standard practice. While the various therapeutic effects are a strength of music therapy, they also limit music therapy findings, as research is stretched thin over numerous different settings. Most research limitations do not stem from the practice of music therapy itself. Music therapy is completely ignored by many physicians and research institutions, leaving music therapy researchers with limited materials and funding. Additionally, the global prevalence of music therapy is completely unknown. While the United States has poor research publications, many countries within the Global South have little to no research published. As previously explained, cultural barriers should not prove a threat in music therapy, as they may in other therapeutic methods. Both poor and rich, both black and white, both secular and religious individuals, all listen to music (Giddens 85).
To ensure the proper treatment of each patient, music therapists should reflect on each therapy session to find areas of improvement. There are many factors to consider when choosing music therapy treatment. For instance, how much engagement should the music therapist have in the session? This answer can vary greatly depending on the patient population. If the patient can perform, create, and understand musical elements on their own, they may want less guidance than patients who cannot. The music therapist must challenge the patient without making the environment too stimulating or challenging. The music therapist must also think about how they would alter therapy sessions to account for physical or mental barriers that a patient may experience. Music therapy is meant to be very inclusive, meaning that any patient should feel welcome and comfortable within the therapeutic setting. Technological instruments may also hinder the music therapist’s decisions. Does the facility have access to instruments? Are there recording devices present? If not, there are still many ways one can emulate music elements. As the music therapist grows within their practice, they should search for ways to improve their therapeutic methods and share their findings with others.
For the expansion of music therapy, it may be beneficial to limit research to specific uses, rather than attempting to capture the whole realm of music therapy at once. This would increase the quality of music therapy research and potentially increase music therapy advocacy. The World Health Organization defines health as “not merely the absence of disease or infirmity, but the attainment of the highest personal level of physical, mental, and social well-being (Bailey 95). To start, music therapy should focus on treating patients who are no longer able to progress in physical aspects. Music therapy can increase these individuals’ quality of life by brightening their moods when they are unable to continue hobbies or other joyous tasks. Additional focus should be on curing neurological diseases/disorders, such as memory loss, motor dysfunction, cognitive development, mental health struggles, neurorehabilitation, etc.
For future research, individuals should focus on these neurological and behavioral topics. Rather than attempting to increase the quantity of research publications, researchers should first focus on creating quality publications. Music therapy effects can be difficult to measure, as they can be subjective to the patient. Researchers should focus on effects that can be quantified, such as capturing brain scans to mark the development of neuroplasticity. Quantifiable data also helps to alleviate skepticism around alternative therapies. Future research should also be conducted with larger sample sizes, longer periods, and repeated methods. This will increase the validity of music therapy research and further prove the outcomes of previous studies. Finally, the music therapy practice needs to be taught. Therapists, clinicians, educators, and social workers should be required to take quick educational courses informing them of the various forms of alternative and complementary therapies. This simple addition would profoundly increase the knowledge of music therapy and allow the benefits to be reaped by many. This education expansion needs to be international. Without knowledge of advancements from other countries, the music therapy development would be prolonged. Music therapy can be beneficial to many individuals worldwide, it just needs to be heard.
III. Observing Potential Benefits of Music for Neurocognitive Diseases
Abstract
Music is a part of everyday life, which often leads us to underestimate its true power. Although it has been used as a treatment for centuries, many still do not consider music a form of “medicine.” In contrast, neuroscience is a relatively new and intimidating field of study. Our understanding of some neurophysiological workings of the body is limited, and the field is stereotyped as overly complex and inaccessible to the average person. Many scientific papers reinforce this perception, using highly specific language that is difficult for non-experts to understand. This work aims to eliminate these stereotypes by showing that music has profound effects on the brain, which can be observed from a neurological perspective. Music therapy engages numerous brain regions and shows promise in alleviating symptoms of neurocognitive diseases.
Neurological Background:
How is sound processed?
Sound originates from sound waves, which are oscillating patterns of high and low pressures. As these waves travel through a medium like air or water, they cause the molecules of the medium to vibrate back and forth, transmitting energy that is ultimately perceived by the ear. First, the vibrations travel through the auditory canal and strike the tympanic membrane, also known as the eardrum (see Fig. 1, component A). The eardrum then causes the ossicles (Fig. 1, component B) to vibrate—three small bones in the middle ear that transmit and amplify sound between the outer and inner ear. The stapes, the last of the ossicles, pushes on the oval window (Fig. 1, component C), creating waves in the fluid of the cochlea (Fig. 1, component D). These waves vibrate the adjacent basilar membrane. Sitting on this membrane is the organ of Corti, which contains hair cells. When the hair cells bend, potassium ion channels open, causing a depolarization. This depolarization causes calcium entry at the base of the hair cell, which triggers the release of neurotransmitters onto the auditory nerve fibers. The auditory nerve fibers then fire action potentials that travel down the cochlear nerve (Fig. 1, component E) to various regions of the brain.
Figure 1. A cross-section of the ear anatomy. Illustration ©Chris Gralapp, used with permission. Letter labels added by Anna Ekstrom.
Figure 2. The central auditory pathway. Illustration ©Chris Gralapp, used with permission. Letter labels added by Anna Ekstrom.
The central auditory pathway passes through the brainstem, midbrain, thalamus, and the auditory cortex in the temporal lobe. Sound does not become a conscious perception until it reaches the auditory cortex, but earlier structures perform essential processing of pitch, dynamics, timing, and spatial location. After leaving the inner ear, the auditory nerve first synapses in the cochlear nuclei (see Fig 2, component A) at the base of the brainstem (“How,” 4:38-4:42)). Here, the brain unconsciously processes basic features like pitch, timing, and loudness (“How,” 4:42-4:51). From the cochlear nuclei, signals advance to the superior olivary complex (Fig 2, component B), which is the first region to receive input from both ears (Peterson et al.). This enables sound localization by monitoring the differences in timing and intensity of stimuli between the two ears (Joris and Van Der Heijden). Signals ascend through the lateral lemniscus nuclei (Fig 2, component C) to the inferior colliculus (Fig 2, component D) in the midbrain through one of two tracts; following the superior olivary complex, the auditory pathway splits into the contralateral and the ipsilateral pathway (Fig 2, component E). The contralateral auditory pathway refers to the opposite side of the brain from the side that the sound entered from. Conversely, the ipsilateral auditory pathway refers to the same side. For instance, if the sound enters the right ear, the contralateral path will bring the sound to the left hemisphere, and the ipsilateral path will bring it to the right hemisphere. These tracts pass through
the same sequence of structures, but on opposite sides of the brain. So, an identical path is taken no matter which pathway brought the signal to the inferior colliculus (Fig 2, component D). The inferior colliculus integrates sound information and helps orient the head and eyes towards the source. Subsequently, the signal travels to the medial geniculate nuclei (Fig 2, component F) of the thalamus, which acts as a “relay station” and filtering center before sending the impulse to the auditory cortex (Peterson et al.). Once the signal arrives in the auditory cortex (Fig 2, component G) of the temporal lobe, it becomes a conscious perception of sound.
The auditory cortex has many functions, like “processing pitch, loudness, harmony, consonance/dissonance, changes in frequency, and … sound localization” (“How”, 5:38-5:53). With this, many areas are tonotopically arranged, meaning that different areas are better at processing certain frequencies than others (“How”, 6:09-6:47). This layout allows the brain to interpret complex sounds, like speech and music, which range in frequency and pitch. However, pure frequency processing does not result in what we perceive as “music”. The auditory cortex is bi-directionally connected to many other brain regions, forming the auditory system. Again, different brain regions are responsible for perceiving distinct musical characteristics. For instance, the temporal and frontal lobes of the brain contribute to the processing of intervals, melodies, and harmonies (“How”, 7:49-8:00). These regions also conduct language processing, helping us understand the structure and syntax of music (8:05-8:25). The prefrontal cortex and inferior frontal areas of the frontal lobes help to maintain attention and focus while perceiving sound (“How”, 8:45-8:56). Attention is crucial for music interpretation because it relies heavily on the individual’s environment. Are they with loved ones or in solitude? Are they dancing or purely listening? This integrates sound with the visual and motor fields in the parietal lobes (“How”, 8:34-8:45). The main motor areas, the basal ganglia and cerebellum, contribute to movement and rhythm processing (“How”, 8:00-8:05). Feelings are modulated by the limbic system, which consists of the amygdala, basal ganglia, hypothalamus, and hippocampus. These structures coordinate emotional responses through the release of neurotransmitters and hormones. Specifically, the mesolimbic system, or the reward pathway, gives the listener pleasure. When listening to music, the brain releases dopamine during buildups and beat drops (“How”, 10:55-11:25). High dopamine levels activate the mesolimbic system, causing the feeling of pleasure. Besides regulating emotion, the limbic system also helps with the formation and retrieval of long-term memories (“How”, 10:40-10:52). This is why individuals may associate music with a memory or why, when listening to music, a memory is triggered. In all, the auditory system is a complex and collaborative network. The specialization and simultaneous activation of multiple brain structures allow for parallel processing of sound. With many brain regions activated, this leads researchers to question whether there is unexplored usage for music in clinical settings.
What is neuroplasticity?
The nervous system is an interconnected web of neurons that communicate with one another through neurotransmitter release and electrical signals. It controls everything from cognition and movement to heart rate and breathing. The nervous system is divided into the central nervous system, containing the brain and spinal cord, and the peripheral nervous system, containing everything but the brain and spinal cord. Neuroplasticity refers to the nervous system’s adaptability and functional changes. In other words, it is “‘the ability of the nervous system to change its activity in response to intrinsic or extrinsic stimuli by reorganizing its structure, functions, or connections’” (Puderbaugh and Prabhu). Neuroplasticity encompasses both neuronal regeneration and, to a limited extent, neuronal reorganization (Puderbaugh and Prabhu).
When a presynaptic neuron repeatedly communicates with a postsynaptic neuron, the synapse strengthens. This phenomenon is termed long-term potentiation (LTP). It is theorized that repeated stimulation of a presynaptic neuron causes the postsynaptic neuron to add receptors. As a result, a lower threshold is required for activation of the postsynaptic neuron (Puderbaugh and Prabhu). Synaptic pruning plays a large role in neuroplasticity. Synaptic pruning refers to the selective weakening and elimination of unused or less active synapses. Neural connections that are more frequently used will be stronger and quicker than those that are rarely used.
Neuronal reorganization is less extensive than neuronal regeneration because it can only occur in the central nervous system. If there is damage to a portion of the brain, the brain can reorganize to regain the lost functions due to damage (Puderbaugh and Prabhu). For example, Graveline, Mikulis, Crawley, and Hwang used functional magnetic resonance imaging (fMRI) to display that after a hemispherectomy, the brain was able to restore the lost function (Puderbaugh and Prabhu). In the patient, half of the cerebral cortex was removed. Over time, supplemental motor and sensory areas reorganized to perform the function of the missing side (Puderbaugh and Prabhu). Jaillard et al. found similar findings in 4 adult patients who experienced an ischemic stroke of their right primary cortex (Puderbaugh and Prabhu). Through a series of fMRI, they initially saw increased activity in the bilateral premotor cortex (Puderbaugh and Prabhu). Later, this activity shifted over to the motor cortex in the right hemisphere, performing the lost function (Puderbaugh and Prabhu).
Neuroscience is an emerging field. The study of neuroplasticity is necessary for advancing knowledge of neurocognitive and neurodegenerative diseases. Many neurological conditions involve disrupted neural circuits. By investigating and understanding the physiological mechanisms of neurogenesis (the creation of new neurons) and refining neuroplasticity mechanisms, researchers will become more informed on how the nervous system responds to changes. From here, clinicians and researchers can propose treatment methods for synaptic recovery and improve the outcomes of neurological diseases.
Alzheimer’s Background:
Dementia is a neurocognitive disorder used to describe the decline of cognitive skills severe enough to affect daily life. In 2010, there were 35.6 million individuals living with dementia worldwide (Matrone and Brattico 1). This number is expected to increase to around 65.7 million individuals by 2030, and 115.4 million by 2050 (Matrone and Brattico 1). Dementia is not a single disease but can be caused by various underlying diseases. The most common cause of dementia is Alzheimer’s disease (AD), accounting for 60-80% of cases (Matrone and Brattico 1). Alzheimer’s disease is a “progressive neurodegenerative disease, characterized by an early stage in which people experience a progressive memory loss and a decrease in thinking ability, such as decision-making” (Matrone and Brattico 1). In later stages of the disease, individuals may be unable to perform daily activities or to recognize loved ones” (Matrone and Brattico 1).
Although the exact cause of Alzheimer’s disease is still debated, AD is considered a multifactorial disorder, caused by biological, genetic, and environmental components. Approximately 2 percent of AD cases are attributed to genetic linkage (Matrone and Brattico 1). These individuals carry mutations in the amyloid precursor protein and presenilin 1 and 2 (Matrone and Brattico 1). Although AD is often found in older adults, when caused by genetics, individuals can start displaying symptoms around age ten (Matrone and Brattico 1). Many social and physiological factors can also contribute to an Alzheimer’s diagnosis. Patients with AD oftentimes have limited education, depression, hypertension, diabetes, high cholesterol, smoking, and previous head trauma (Matrone and Brattico 1). Additionally, patients tend to have an imbalance between their blood and cerebrospinal fluid growth factors, like brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) (Matrone and Brattico 1). Even though factors contribute to an AD diagnosis, the most supported cause is the accumulation of amyloid-B plaques and neurofibrillary tangles in the brain (Matrone and Brattico 1).
The buildup of extracellular amyloid plaques and intraneural neurofibrillary tangles (Koch and Spampinato 474) results from an imbalance in the production and clearance of the precursor amyloid-B and tau proteins (Matrone and Brattico 1). For example, it was found that tau overexpression, the precursor to neurofibrillary tangle formation, can induce synaptic degradation, even in the absence of abundant tangles (Koch and Spampinato 474). These molecules are highly packed and insoluble filaments. Therefore, their accumulation disrupts brain cell communication, leading to neural dysfunction. As neural communication begins to deplete, patients exhibit regional brain atrophy and symptoms of dementia (Matrone and Brattico 1).
Music as Medicine
For centuries, music has been used as a therapeutic tool to address emotional and cognitive issues. In ancient Greek and Roman history, music therapy helped to alleviate stress and enhance emotions in a group environment (Huang and Luo). Ancient Chinese practices used a similar methodology, using the therapy to reduce anxiety, depression, and fear (Huang and Luo). The universality of music enables it to reach a broad patient population. Every individual can experience music, including those who are deaf, hearing, or even in prenatal stages (Agapaki et al.).
Modern technology has enhanced our understanding of how music is processed in the body. As music is perceived, circulating vibrations are transmitted through air, bones, and tissues, activating the auditory system and beyond (Agapaki et al.). Once the auditory system converts these mechanical vibrations into electrical signals, they activate broader neural pathways, including motor, cognitive, and emotional systems. As previously discussed, the activation of these pathways is linked to long-term potentiation. Consequently, listening to music is associated with neuroplastic changes at both the ontogenetic and phylogenetic levels (Agapaki et al.). The cognitive decline seen in Alzheimer’s disease results from synaptic weakening and dysfunction. Since music can strengthen neural connections, researchers should continue to explore its potential as a neurocognitive treatment and prevention option.
Many studies have been conducted to test the benefits of music therapy. Some scientists discredit the data due to inadequate methodology, reproducibility crisis, confounding variables, etc., but there are still many promising studies that have linked music therapy to cognitive benefits (Agapaki et al.). Music therapy is an under-researched field. The studies that are being conducted have small sample sizes and observation bias, causing the research to be ignored. Scientists want data-driven studies that contain numerical measurements, but music therapy outcomes can be difficult to assess. Today, various tools can image brain structure (CAT and MRI scans), brain function (MEGs and EEGs), or both (fMRIs and PET scans). This can provide more tangible data that will increase the accuracy and precision of the results. As technology continues to improve and more education is spread on music therapy, large sample studies can be conducted to effectively measure the benefits of music therapy on neurocognitive improvement.
Dementia-Specific Studies
Case Study: Ms. A
Dementia-focused studies provide hope that music therapy can reduce symptoms of neurocognitive disorders. For instance, a case study following Ms. A, an 88-year-old woman with vascular dementia, saw new learning and potential deceleration of cognitive decline (Kondo et al.). Vascular dementia describes cognitive impairment from damage to the CNS due to cerebrovascular diseases, like ischemic strokes (Kondo et al.). Ms. A attended music therapy twice a week for 15 minutes each session over 18 months (Kondo et al.). Over this time, her cognitive state was monitored using the Mini-Mental State Examination (MMSE), which checks memory, attention, language skills, orientation, etc. (Kondo et al.). Throughout her treatment, Ms. A’s MMSE scores worsened, but she was still able to concentrate on playing digital instruments and performances (Kondo et al.).
Although Ms. A experienced some cognitive decline, this study showed that someone with late-stage vascular dementia can learn to play a new instrument and continue to play it throughout their progression (Kondo et al.). Neurologically, this memory consolidation occurs in the hippocampus, and the procedural aspects occur in the cerebellum. As discussed earlier, these locations are only part of what gets activated when learning to play an instrument. There are auditory components, visual components, emotional connections, and more. The ability to learn a new instrument hints that the brain regions responsible for processing music are some of the last to be affected by dementia (Matrone and Brattico 3). Even so, activation and strengthening of these synapses can aid in slowing the progression of dementia. With Ms. A, her continual ability to concentrate on playing the instruments exhibits this fact (Kondo et al.). However, it is difficult to state that the music therapy slowed her cognitive decline because the speed varies greatly between individuals.
To measure this in future experiments, one could do a twin study. Since identical twins contain 100 percent of the same genome, twins may experience cognitive decline at similar rates. One twin would be repeatedly exposed to music therapy, while the other would not. If the twin receiving the music therapy has a significantly slower decline than their twin, this would indicate that music slows the progression of cognitive decline. To make this experiment possible, there would have to be previous evidence that twins experience the same rate of cognitive decline. Additionally, there are minimal sets of twins that are both diagnosed with a neurocognitive disorder.
Twin study
Twin studies are highly reputable because they alleviate the confounding variable of genetic propensity (Balbag et al.). If studied young enough, most twins are also raised in the same household, eliminating some environmental factors as well. Balbag, Pedersen, and Gatz conducted a twin study with dementia patients to measure whether being a musician impacts cognitive deterioration (Balbag et al.). Patients were diagnosed with dementia according to the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) (Balbag et al.). Following, individuals were sorted based on having dementia, being cognitively impaired, or being cognitively intact (Balbag et al.). After filtering for cognitive impairment and musical history, the study consisted of 157 pairs of twins (Balbag et al.). Musicians were considered participants who played music frequently or occasionally within the last 5 years (Balbag et al.). The study found that individuals who played an instrument later in adulthood had a 64% lower likelihood of developing dementia or cognitive impairment than their cotwin (Balbag et al.). The researchers performed a crude test and found the results statistically significant (Balbag et al.).
Balbag’s, Pedersen’s, and Gatz’s study provides evidence that music exposure can lower the risk of developing a neurocognitive disease. Surprisingly, few studies address the rates of dementia in lifelong musicians versus non-musicians. These rates could indicate whether musical listening or exposure may prevent the onset of neurocognitive disorders. If so, this would be revolutionary to the medical community. Many neurodegenerative disorders, like Alzheimer’s disease, have no cure. People with late-stage dementia often need caregivers because they can no longer perform basic daily functions. They are in a constant state of confusion, not understanding their environment or the people around them. This is mentally draining for patients, as well as their loved ones. By decreasing the rates of dementia through simple preventative measures, like music exposure, this would save many individuals the suffering that comes with the diagnosis.
Musical memory training
Adding to the twin study, Wu and Junhao also found that music therapy interventions helped to delay memory decline (Wu and Junhao 33). The study followed a 16 membered elderly group with mild dementia. The participants were split into a control group and a treatment group (Wu and Junhao 35). Individuals in the treatment group received two music therapy sessions a week (Wu and Junhao 35). Prior to and following the 2 months, the memory state of the participants was documented through various tests (Wu and Junhao 35). At the first session, the social worker focused on forming a relationship with the elder and explained the goals of the experiment (Wu and Junhao 39). They also would play a memorable song for the patient and ask how it made them feel (Wu and Junhao 39). Sometimes, patients were able to recall specific times that they heard the song (Wu and Junhao 39). The following sessions consisted of musical memory training (Wu and Junhao 39). In patients with dementia, short-term memory is lost before long-term memory. One goal of the experiment was to try and improve the short-term memory of the participants. The social workers played a simple song that repeated the lines “What is your name?,” “My name is xxx” (Wu and Junhao 39). In the following sessions, the elders introduced themselves with the song (Wu and Junhao 39).
Over the course of the study, participants in the treatment group rose 4 points on the daily life activity scale (ADL) (Wu and Junhao 41). In contrast, scores among individuals in the control group remained relatively stable or decreased. Two months after the experiment, participants’ ADL scores were reassessed and found comparable to scores recorded right after treatment (Wu and Junhao 40). This indicates that the cognitive improvements remained for a considerable amount of time. Besides the ADL score increase, patients who received music therapy reported higher confidence in their memory abilities and higher overall happiness. This pattern was not witnessed in the control group. Collectively, these findings emphasize the impact of music therapy on memory recall and daily functioning. They support the hypothesis that music listening strengthens neurological pathways, especially within the memory and emotional regions. Beyond cognitive improvement, patients were happier and more self-confident when exposed to music. These emotions heighten livelihood and provide a sense of peace even when facing cortical deterioration. Music exposure is a non-invasive, low-cost remedy that should be further considered in clinical settings.
Recall with and without music
To further assess how auditory stimuli influence cognitive performance, Foster and Valentine observed how environmental noise impacted patients with AD’s task execution (Matrone and Brattico 3). Patients were tasked to complete an autobiographical adaptation of the Mini-Mental State Examination under various conditions—Vivaldi’s Four Seasons, unfamiliar music, cafeteria noise, or silence (Matrone and Brattico 3). After analyzing against the controls, researchers found Alzheimer’s disease patients remembered significantly better in the sound conditions than in silence, and while listening to music than in the cafeteria noise (Matrone and Brattico 3). These outcomes were replicated and confirmed by other studies (Matrone and Brattico 3). This finding suggests that structured auditory input can enhance memory performance in individuals with Alzheimer’s disease.
From a neurological perspective, music listening can be associated with arousal enhancement, anxiety reduction, involuntary recall, and verbal narration enhancement (Matrone and Brattico 3). Music appears to activate neural circuits in the limbic and neocortical regions of the brain, allowing for music to drive emotional responses and memory recollection (Matrone and Brattico 3). This helps explain why music serves as a powerful stimulus for engaging memory and emotion-related networks. To reach the largest patient population, clinical staff need to become aware of musical benefits. By reducing educational barriers between physicians and complementary therapies, like music therapy, greater attention can be given to this genre of research. Thus, more patients will be offered music therapy as comfort care.
Scientists have established that neurogenesis is feasible in certain regions of the adult brain, like the hippocampus, but its function in other brain regions is limited. For this reason, the potential for replacing fully disconnected circuits, especially in neurodegenerative diseases like Alzheimer’s disease, is minimal. On the other hand, neuroplasticity is highly supported and compensates for damaged networks anywhere in the central nervous system. Neuroplasticity can strengthen existing synapses and recruit alternative pathways to support the loss of cognitive function. In Alzheimer’s disease and other neurodegenerative disorders, this means that neither neuroplasticity nor neurogenesis would be able to compensate for the complete loss of neural circuitry. However, weakened synapses can be strengthened through neuroplasticity, meaning that some cognitive dysfunction could be alleviated.
As previously discussed, most data suggest that musical memory remains intact even in later stages of Alzheimer’s disease. This hints that these areas have great potential for rehabilitation. Since brain regions activated by music listening and playing are still relatively functional, continual activation of these circuits would cause these connections to strengthen. So, through structured music therapy, patients with neurodegenerative disorders could relieve some of their symptoms. In doing so, the patient’s quality of life would greatly increase. Even a slight memory enhancement may allow the patient to remember a family member or their favorite movie. Patients would have more meaningful conversations with others since their attention span and concentration could increase. Music therapy can be highly individualized, meaning each patient can receive specialized care that adapts to their cultural background and preferences. This could present as specific songs played, known to bring the person joy. The therapist can utilize instruments that the individual used to play, or cultural songs that spark childhood memories. By triggering weakened neural circuits and tailoring therapies to everyone, music therapy offers a promising and personalized method for enhancing the overall quality of life in patients with neurodegenerative disorders.
Relevant Music-Based Studies
Short-term memory and encoding with music
Studies exploring music and memory correlation can be relevant to our discussion of neurocognitive disorders, even if not directly stated. Like in Foster and Valentine’s study, researchers studied how the auditory environment affects performance on an exam (Matrone and Brattico 4). 3 groups of college students took an intelligence quotient (IQ) test under various conditions (Matrone and Brattico 4). The first group listened to a Mozart sonata, the second listened to a relaxation tape, and the third group did not listen to anything before the test (Matrone and Brattico 4). Individuals in the first group scored the highest on the examination. This phenomenon is termed the “Mozart effect,” referencing the idea that listening to Mozart’s music can temporarily increase cognitive performance.
Many future studies have shown that music increases some cognitive functions, like memory, executive functions, speech, and attention in adults and children (Matrone and Brattico 2). Although AD is commonly associated with older individuals, it can also develop in younger individuals, especially due to genetic factors. In a study with preschool children, researchers found that short-term music training increased verbal intelligence (Matrone and Brattico 2). The researchers proposed that musical training activates prefrontal brain regions (Matrone and Brattico 2), which are responsible for decision-making and problem-solving. Because these same networks are affected in individuals with Alzheimer’s disease, strengthening them through musical training may result in slower cognitive decay. One way to study this is by observing older musicians, since they have been exposed to “long-term” musical training.
Musician-based studies
Musician-based studies are one of the best ways to observe the long-term effects of music on the brain. Musicians undergo years of musical training, and they provide a natural model for extended brain stimulation. Unfortunately, not many studies have considered musicians as their sample population. This may be due to difficulty finding participants, variability in music exposure, or other limiting factors. However, the studies that have been conducted show promising results of reduced cortical atrophy. For instance, in elderly professional musicians, there is preserved “volumes of the neuronal fibers of the arcuate fasciculus, connecting the supratemporal lobe with the inferofrontal regions of the brain, hence halting the apoptosis related to normal aging” (Matrone and Brattico 2). In other words, music practice strengthens neural connections and results in a larger cortical area than that of non-musicians. As cells die and brain connections weaken, the cortical area shrinks. As expected, “increased grey matter volume of the Heschl’s gyrus, primary motor cortex, premotor cortex, cerebellum, and hippocampus have been found in musicians when compared with non-musicians” (Matrone and Brattico 2). Grey matter consists of neural cell bodies, meaning it is where information is learned and processed. So, increased grey matter in music-stimulated areas suggests musicians have stronger neural connections in these regions than non-musicians. Again, strengthened synapses may prevent the onset of neurocognitive disorders.
In support, another study found that the rates of “regular musical activities, such as singing, improve the well-being and cognitive functions” are higher in healthy older persons compared to unhealthy older persons (Matrone and Brattico 3). From a preventative standpoint, music exposure may reduce the risk of developing dementia. Overall, these findings suggest music-based interventions may serve as a valuable therapeutic tool for both enhancing the standard of living of individuals with AD and preventing further progression of the disease.
Treatment Methods
Today, “the most frequently prescribed treatments for AD are Acetylcholinesterase Inhibitors (AchEIs) and memantine” (Koch and Spampinato 473). These treatment options offer short-term improvement of some symptoms (usually a few months), but do not slow the progression of disease decline (Koch and Spampinato 473). These care interventions are estimated to be effective for only half of the patients (Koch and Spampinato 473). Although these treatments provide some relief, patients still experience decline in communication and everyday activities. Once again, Alzheimer’s disease affects individuals and families physiologically and emotionally. Loved ones “lose” the person they used to know. Relationships weaken between the diagnosed individual and others. Individuals with AD are not able to celebrate life milestones or hobbies they used to enjoy. They no longer remember prominent memories that turned them into the person they became. For this, better treatment needs to be discovered to decrease cognitive dysfunction in patients.
BDNF, a protein that helps brain cells grow and survive, may protect neurons against amyloid beta-induced neurotoxicity (Matrone and Brattico 3). Various studies have been done in mouse, rat, and primate models to study the effects of BDNF administration (Matrone and Brattico 3). BDNF administration was found to reverse synaptic damage, partially normalize genetic errors, improve cell signaling, reduce oxidative stress, reduce cell death, and partially rescue learning, memory, and cognitive deficits (Matrone and Brattico 3). However, BDNF is too large a molecule to penetrate the blood-brain barrier (BBB) (Matrone and Brattico 3). The BBB is a selective layer of cells that acts as a gate, determining what can and cannot enter the brain. Since BDNF cannot cross the blood-brain barrier, it would not be able to reach the brain if delivered pharmaceutically. However, mouse studies indicate that music exposure can alter levels of BDNF in the hypothalamus and hippocampus (Matrone and Brattico 3). So, musical training may cause increased BDNF levels, which would reduce the probability of developing a neurocognitive disease. BDNF levels can only be measured in non-human subjects for ethical reasons. BDNF levels must be measured in vivo in humans, which is incredibly invasive. Until technology advances to a point where brain fluid would not be required to assess BDNF levels, studies must continue to evaluate non-human models.
Recent consensus has pointed out that measuring amyloid-beta peptides and tau proteins in the cerebrospinal fluid (CSF) could aid in AD diagnosis and predicting disease progression (Koch and Spampinato 474). The most common way to gather a CSF sample is through a spinal tap. A physician will insert a needle at the bottom of the spinal cord and withdraw the CSF sample. Although this can be performed on older individuals, the procedure carries complications with age. Scientists also have stated that Positron Emission Tomography (PET) imaging can be used to measure amyloid-beta peptides and tau proteins (Koch and Spampinato 473). Like spinal taps, this imaging is somewhat invasive and safer for younger individuals. Also, with both points, we are still limited in our understanding of the AD pathophysiological changes (Koch and Spampinato 473). To maximize patient comfort, a less invasive therapeutic method should be offered, like music therapy.
Future Directions
Many researchers and physicians discredit music therapy studies due to observation bias and experiment reliability. To their point, most music therapy studies are conducted with limited resources and small sample sizes. In the past, it was difficult to non-subjectively measure the effects of music therapy. Most improvements were reported via a survey, such as individuals reporting mood increases or less fatigue. When reevaluating these papers today, critics should consider that almost all research points to the same conclusion: music training can strengthen numerous brain regions, including the auditory cortex, motor cortex, frontal lobe, temporal lobe, hippocampus, amygdala, limbic system, and corpus callosum. This neural strengthening can prevent further cognitive decline in neurodegenerative disorders, like Alzheimer’s disease.
For future experiments, researchers should continue to measure neurophysiological outcomes of music exposure. These measurements, like cortical size, are much more “concrete” than subjective surveys. This would make the studies more reliable and more accepted by the medical community. Additionally, studies should utilize new neurophysiological imaging methods, like Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) scans. These imaging techniques can measure cortical size, which is positively associated with stronger neural circuits. Although these scans do not detect cellular function like PET scans, they provide detailed images of the brain, making them a safer option for older patients. Finally, educators, researchers, and healthcare workers need to become more informed about complementary therapies. By combining objective neurophysiological measurements and increased awareness of music therapy, future research can more effectively demonstrate the benefits of music on neurodegenerative diseases. These findings can then be shared with the healthcare system.
IV. Bridging the Gap from Bench to Bedside: Optimizing Music Therapy for Alzheimer’s Disease Intervention
Abstract
Music therapy has been increasingly recognized for its clinical benefits across a wide range of neurological and psychological conditions, including Alzheimer’s disease. Despite substantial evidence supporting its efficacy, its integration into standard healthcare practice remains limited, highlighting a disconnect between research findings and clinical integration. This paper examines the neurological mechanisms behind music therapy, with a particular focus on neuroplasticity and its dependence on timing and dosage. Concepts such as critical and sensitive periods, as well as the debated role of adult neurogenesis, are considered to understand how therapeutic outcomes may be optimized. Evidence supporting early intervention of music therapy in treating Alzheimer’s disease is discussed, emphasizing the importance of engaging neural circuits before extensive degeneration occurs. Furthermore, research on musicians is considered as a model for experience-dependent brain changes, offering insight into the mechanisms by which music may influence cognition. This paper also addresses limitations in current music therapy research. This includes inaccessibility to current music therapy research papers, methodological challenges, and inconsistent measurement tools, which contribute to the underutilization of music therapy in clinical settings. Finally, recent increases in funding and research initiatives are highlighted as promising steps toward improving study quality and promoting the translation of music therapy into healthcare practice. Together, these findings stress the importance of refining both the scientific understanding and practical implementation of music therapy to maximize its therapeutic potential in Alzheimer’s disease.
Introduction
From past papers, we have found ample evidence suggesting the clinical benefits of music therapy. For instance, music therapy can be advantageous for individuals with cognitive disorders, neurodegenerative diseases, autism-spectrum disorder, brain injuries, gait disorders, motor dysfunctions, mental health disorders, pain, etc. (e.g., Agapaki et al.; Kondo et al.; Wu and Junhao; Matrone and Brattico; Smith). Regardless, the practice rates of music therapy are relatively low in healthcare settings, suggesting a gap between bench data and clinical outcomes. Addressing this gap requires not only demonstrating efficacy but also a deeper understanding of how interventions should be optimally implemented in a real-world setting. Current research supporting a neuroplastic mechanism implies that music therapy benefits are gained through activity-dependent changes in neuronal circuitry. In other words, music therapy activates diverse brain regions and strengthens certain connections, resulting in positive patient outcomes. However, neuroplastic changes are time- and dosage-sensitive, meaning the timing and frequency of therapeutic intervention may significantly impact a patient’s treatment results. This paper considers how factors such as critical periods, sensitive periods, neurogenesis, and treatment dosage shape the clinical benefits of music therapy for treating Alzheimer’s disease.
Sensitive and Critical Periods
To understand the impacts of sensitive and critical periods on neuroplasticity and music-based therapeutic outcomes, we must first understand what sensitive and critical periods are. The term “sensitive period” refers to a limited growth phase during which “the effects of experience on the brain are unusually strong” (Knudsen 1412). During this time, neural circuits are highly malleable. The brain can still adapt outside of sensitive periods, but the rate and efficiency of plasticity are diminished. Conversely, critical periods are discrete developmental windows during which the brain undergoes irreversible changes (Knudsen 1412). Like sensitive periods, critical periods are characterized by heightened neuroplasticity; however, they are more restrictive, as certain environmental inputs are required for normal development. Clinicians must identify these crucial windows to maximize patient neurorehabilitation outcomes and ensure proper growth. For instance, the critical period for the auditory cortex in humans usually ends around age 3-4 years (Miendlarzewska and Trost). Kral and Sharma used this finding to declare an ideal age for cochlear implantation in congenitally deaf children (Kral and Sharma). Their findings revealed that sensory deprivation before age 3-4 years in these individuals resulted in abnormal sensory discrimination and oral language learning (Kral and Sharma). So, for congenitally deaf children to receive the greatest potential outcome, cochlear implants should be inserted prior to the end of the critical period. This example amplifies the importance of timing in clinical intervention. By understanding when the auditory cortex’s critical period occurs, clinicians were able to maximize patient benefits through the timing of their cochlear implant intervention.
There are numerous factors to consider when labeling sensitive and critical periods. The timing and duration of critical periods are not determined solely by age, but also by experience (Hensch). If appropriate neuronal stimulation is not present, developing systems may wait until this stimulus is provided. Additionally, fulfilling environments may lead to prolonged duration of critical periods (Hensch). On top of this, critical periods are different for all brain regions (Miendlarzewska and Trost). Sensitive period commencement is much more gradual than critical periods. Even after a sensitive period has ended, many neuroplastic mechanisms continue to operate (Knudsen 1417). This enables mature circuits to modify their paths based on lifetime experiences (Knudsen 1417). The variability in timing and plasticity illustrates why physicians must consider sensitive and critical periods when designing and implementing therapy interventions. Neural systems differ in their responsiveness across a lifespan and across brain regions, meaning the efficacy of a given treatment depends not only on the intervention itself, but also on how and when it is delivered. By understanding when the brain is especially malleable, clinicians can maximize functional recovery and minimize irreversible deficits.
The framework of critical and sensitive periods is highly relevant to neurodegenerative diseases, such as Alzheimer’s disease. Although the timing of Alzheimer’s disease onset is much later than when critical periods occur, the same principles of optimizing neuroplastic potential are applicable when designing treatment plans. Music therapy slows neurodegenerative decline in Alzheimer’s patients through neuroplastic mechanisms. As an individual engages with music, it preserves the remaining neural connections in the patient’s brain. To achieve the greatest benefits from music therapy intervention, the therapy should be introduced at the beginning stages of Alzheimer’s disease. Here, the individual has the greatest number of functional circuits, meaning they have the greatest chance of responding to external stimulation. Critical period and sensitive period research help inform the optimal timing and dosing of music-based interventions across numerous neurological conditions. As scientists continue to learn more about neuroplasticity mechanisms, we will have a better understanding of how music therapy is beneficial for neurodegenerative diseases. Given that neuroplasticity (the strengthening of neural circuitry) is more strongly supported than neurogenesis (the formation of new neural circuitry) in scientific literature, particularly in older individuals, music therapy intervention should be targeted toward periods of heightened neuroplasticity to enhance cognitive, emotional, and functional outcomes in patients with Alzheimer’s disease.
Neurogenesis Potential
Although neurogenesis is highly debated in the scientific community, it should not be overlooked. In Alzheimer’s disease and other neurodegenerative diseases, neural connections slowly degrade. Music therapy maintains the strength of current synapses, meaning it can only slow the progression of Alzheimer’s disease, not reverse any of the symptoms. However, if neurogenetic potential is preserved in brain regions heavily affected by Alzheimer’s disease, it may contribute to modest improvements or symptom stabilization. The hippocampus plays a central role in memory formation, and many symptoms of Alzheimer’s disease stem from memory impairments. Thus, if older individuals retain neurogenic capacity in the hippocampus, treatments like music therapy can be tailored to stimulate this process, potentially enhancing memory function.
Fortunately, emerging findings confirm the potential for neurogenesis in the hippocampus. Ahmed Disouky and his team observed postmortem human hippocampal tissue from young adults, aging adults with normal cognition, “SuperAgers” (older individuals with exceptional memory), individuals with Alzheimer’s disease, and individuals with preclinical Alzheimer’s pathology (Disouky et al.). They dissected and homogenized the dentate gyrus (a section of the hippocampus) from the samples and isolated individual cell nuclei. They then compared the cell abundance, gene expression patterns, and chromatin accessibility changes across the various experimental groups. Overall, they found neural stem cells, neuroblasts, and immature neurons in post-mortem hippocampus tissue, providing strong evidence that the hippocampus can participate in neurogenesis throughout adulthood (Disouky et al.). More specifically, Disouky and his team identified stem cells, astrocytes, CA1 neurons, epigenetic modifications, and transcriptional regulation as major contributors to hippocampal neurogenesis. As expected, neurogenic possibilities differed across age groups and cognitive diagnoses. Compared to younger adults, cognitively healthy older adults showed age-related changes in gene expression and epigenetic profiles associated with hippocampal neurogenesis, suggesting reduced efficiency of neurogenetic processes (Disouky et al.). Additionally, individuals with Alzheimer’s disease displayed fewer immature neurons and reduced neurogenic activity than both healthy older adults and younger adults. Interestingly, the SuperAgers demonstrated better-preserved neurogenesis, implying that cognitive resilience is associated with enhanced neurogenesis (Disouky et al.). These findings further support the notion that strengthened synapses result in cognitive enrichment.
A supplementary study to investigate why SuperAgers maintain high synaptic strength can reveal how lifestyle and/or genetic factors contribute to cognitive level. If these results indicate a positive correlation between brain stimulation and synaptic strength, music may serve as a preventative measure for neurodegenerative diseases. Music engagement activates numerous interconnected brain circuits. The more an individual interacts with music, the more robust these circuits will become. It is also important to consider the low neurogenetic potential found in individuals with Alzheimer’s disease (Disouky et al.). Even in low amounts, neurogenetic potential may be able to improve symptoms. As expected, the likelihood of symptom reversal decreases as the disease progresses. There must be intact or partially preserved neural pathways for therapeutic interventions to be effective. As neurodegeneration advances, the continual loss of neural connections reduces the brain’s ability to respond to external stimulation. With this, music therapy should be implemented as early as possible to receive the best clinical outcomes. If the hippocampus reserves some neurogenic potential in individuals with early Alzheimer’s disease, as demonstrated by Disouky et al., music therapy can be individualized to the patient to stimulate this process. The adaptability and customization of music therapy emphasize its relevance when creating Alzheimer’s disease treatment plans. Early introduction of music therapy in individuals with Alzheimer’s disease may help preserve existing synapses and potentially promote the formation of new neural connections.
While Disouky et al.’s work serves as evidence that neurogenesis is possible in adult brain structures, other scientists have found the opposite to be true. Namely, a research article by Sorrells et al. argues that the findings on postmortem hippocampal tissue display insignificant amounts of neurogenesis potential (Sorrells et al.). The paper compares cell proliferation in the dentate gyrus across the human lifespan, emphasizing the significant decline in neuroplastic capacity with age. It also highlights the differences in rodents’ and humans’ ability to generate new neurons into adulthood (Sorrells et al.).
In all, it is inconclusive whether adult neurogenesis is possible in humans or not. There is a general consensus that stem cells are present in low amounts in older adults; however, whether these cells retain the capacity for neurogenesis remains controversial. Neuroscience is a relatively new field of study, meaning that many neuronal mechanisms, like neuroplasticity and neurogenesis, are not yet fully understood. As more data emerges about these mechanisms, we will have a clearer understanding of what is truly necessary for neuroplastic and neurogenetic changes to occur in the brain. A deeper mechanistic understanding will also assist in patient care by identifying the optimal timing and dosage of music therapy treatment. Moreover, it will allow therapists to shape music-based interventions around an individual’s physiological presentation to help slow and potentially reduce Alzheimer’s disease symptoms.
Music Engagement and Cognitive Benefits
Studying how music therapy and musical training affect the human brain across different ages provides insight into when and how music-based interventions should be administered. To illustrate, studies indicate that instrument training may accelerate the development of neurofilaments in the upper cortical layers of the auditory cortex between ages 6 and 12 years (Moore and Guan; Hannon and Trainor). Neurofilaments are responsible for fast, synchronized neurotransmission, meaning music engagement may impact how efficiently neural circuits develop during sensitive periods. When providing instrument training during a period of high neuroplasticity, the children may develop more efficient synapses. This discovery stresses the importance of early music-based intervention in Alzheimer’s disease treatment. Like timing instrument training to sensitive development periods, clinicians must time music therapy to periods of high neuroplasticity. With Alzheimer’s disease, the highest rates of neuroplasticity are present at the start of disease onset. This also points out the importance of early diagnosis. If physicians can identify Alzheimer’s disease early and effectively apply music therapy, the individual may experience slower degeneration rates than otherwise predicted.
This potential benefit is supported by evidence that music-induced neural changes can lead to measurable functional improvements. For example, Miendlarzewska and Trost reported that synaptic strengthening can translate into observable cognitive outcomes. They note that “correlational and interventional studies of children undergoing music training consistently show that they perform better in the areas closely associated with music: fine motor skill, rhythm perception and auditory discrimination” (Miendlarzewska and Trost). Music training can improve cognitive and motor functioning in children, domains that are often compromised in individuals with Alzheimer’s disease. Music clearly engages auditory processing networks, motor timing systems, and memory circuits, making it an appropriate therapy for Alzheimer’s disease. Although not directly stated, this finding further supports early intervention as ideal for achieving optimal clinical results. Childhood is a time of rapid growth and development, during which neural circuits are highly dynamic and continuously adapting. This demonstrates that the effectiveness of experience-dependent change depends heavily on levels of neuroplasticity. Early stages of Alzheimer’s disease still retain sufficient neural integrity, making early treatment especially important.
Studies on older individuals also emphasize the value of early treatment for Alzheimer’s disease. In 2014, a group of scientists conducted a randomized controlled trial on 48 patients with Alzheimer’s disease or mixed dementia to measure the effects of music versus cooking interventions (Narme et al.). Each intervention method lasted for four weeks, and outcomes were measured through emotional, cognitive, and behavioral domains, as well as caregiver distress. Although there were no significant changes in cognitive performance, both interventions reduced caregiver burden and enhanced short-term and working memory, particularly in participants with mild dementia (Narme et al.; Sihvonen et al.). The difference in response between individuals with moderate-to-severe dementia and mild dementia is most likely related to the enhanced cognitive reserve in individuals with mild dementia (Sihvonen et al.). Again, music therapy should be implemented as early as possible for the best cognitive outcomes when treating individuals with Alzheimer’s disease.
In addition to the timing of therapy intervention, optimizing the dosage of therapy is also essential. In other words, does greater exposure to music therapy lead to improved outcomes, and is there an optimal spacing between therapy sessions to maximize its effectiveness? A meta-regression assessing music therapy time and improved levels of pain found a positive association between the two variables, but it was not statistically significant (Chow et al.). While we need more quality studies to answer these questions, this positive association indicates that more music exposure leads to decreased pain. Pain is something that can be returned to baseline, meaning treatment is effective if something stops hurting. On the other hand, cognition and memory are very plastic. An individual’s memory and cognition can decline, but they can also get better. Considering these factors, more music therapy exposure may be able to not only return an individual’s cognition and memory levels back to normal, but it may also improve them. As a result, music therapy may be most effective when it is repeatedly applied to an individual for a long period of time.
This experiment and its findings are highly significant for the advancement of music therapy in clinical settings. In addition to reinforcing its therapeutic benefits, the results offer valuable guidance on optimizing music therapy implementation for individuals with Alzheimer’s disease. While the abstract is accessible to everyone, individuals must be affiliated with an approved organization or pay $64 to access the full article (Chow et al.). This includes a detailed description of the methods, the raw data, and the results, which are all key features of the overall review. As a researcher, it is necessary to digest each section of a paper to understand the research limitations. I have access to the full text through the University of Pittsburgh, but the average individual does not have this access. Music therapy data is already extremely scarce. I understand that the paper is intended for healthcare professionals, but in restricting access, this paper is contributing to the music therapy knowledge gap. Regardless of profession, everyone should have access to ethical healthcare options. Furthermore, anyone should be able to explore emerging therapeutic approaches to better understand their options when confronting illness. Limiting access to this research risks reinforcing existing disparities in knowledge and hindering the broader development and application of music therapy in clinical practice.
Musicians as Research Participants
Given that music engagement induces neuroplasticity, researchers have devoted significant attention to studying musicians. Through musicians, researchers can observe how repeated music exposure shapes brain structure and function. While many confounding variables can contribute to a musician’s auditory processing, motor coordination, and neural circuitry, studies of musicians provide a mechanistic foundation for understanding the most effective modes of music-based therapeutic delivery. Musicians may also serve as evidence of the potential protective effects of music engagement against cognitive decline. To begin, significant differences were found in the cognitive levels of elderly musicians and non-musicians (Hanna-Pladdy and MacKay). Hanna-Pladdy and MacKay compared the non-verbal memory, verbal frequency, and executive functions of musicians and non-musicians aged 60-83 years (Hanna-Pladdy and MacKay; Miendlarzewska and Trost). Through several regression analyses, they evaluated how the type of musical training, years of musical engagement, age of musical learning, and other variables predicted cognitive performance. The results indicated “a strong predictive effect of high musical activity throughout the life span on preserved cognitive functioning in advanced age” (Hanna-Pladdy and MacKay). To clarify, musical engagement may help mitigate, to some degree, the deterioration of cognitive functions (Miendlarzewska and Trost). Music is a small and highly accessible addition to daily life. Individuals may play an instrument at home, listen to the radio while driving to work, or sing in the shower. No matter the mode, anyone can interact with music. This accessibility is particularly important when considering preventative strategies for neurodegenerative disorders, like Alzheimer’s disease. Over time, continual music exposure may sustain neural networks through repeatedly activating auditory, motor, and memory-related connections. Simply adding more music to one’s life may prevent excessive cognitive loss. This finding also complements existing music therapy literature, displaying how structured music engagement can support cognitive and emotional functioning in individuals. To retain the greatest cognitive abilities in individuals with and without Alzheimer’s disease, music therapy and music engagement should be utilized early and often.
In addition, physiological recordings have revealed enlarged brain regions in musicians compared to non-musicians. The first study investigating structural differences between musicians and non-musicians found that musicians exhibited a larger anterior corpus callosum (Schlaug et al.). Following this publication, the same finding has been reproduced through different methodological approaches (Hyde et al.; Lee et al.; Oztürk et al.; Schlaug). More specifically, individuals who began music training at ≤ 7 years old are reported to have a significantly larger corpus callosum than musicians who started training at a later age (Schlaug). The anterior corpus callosum primarily connects the prefrontal cortex of both hemispheres. It regulates executive function, coordination of motor tasks, attention, and much more. In this case, a larger brain region indicates stronger synapses, meaning a musician would be expected to perform better in these relative fields than a non-musician. Beyond the anterior corpus callosum, there have also been anatomical differences found in the auditory and motor cortices, somatosensory areas, premotor cortex, inferior temporal and frontal regions, cerebellum, hippocampus, etc., in musicians versus non-musicians (Oechslin et al.; Miendlarzewska and Trost; Barrett et al.; Norton et al.). Overall, these structural difference in musicians displays how music can activate a widespread network of neural systems. These extensive adaptations provide a mechanistic basis for why music therapy may be effective in healthcare settings. Through neuroplasticity, music can simultaneously strengthen motor and cognitive systems, combating the neurodegenerative loss of these symptoms that characterize Alzheimer’s disease.
The findings in musicians provide ample evidence of the efficacy of music engagement; however, many other confounding variables can contribute to the larger cortical sizes found in musicians. For instance, was the individual innately predisposed? Do the sex, age, or type of instrument strongly contribute to cortical structural differences? To answer this nurture versus nature debate, a team compared 5 to 7-year-olds beginning piano or string lessons (n=39) to 5 to 7-year-olds without any instrument training (n=31) (Norton et al.). The participants were evaluated through a series of visual-spatial, non-verbal reasoning, verbal, motor, and musical tests, as well as magnetic resonance imaging scans. The group found no preexisting differences between the participants and no correlations between music perceptual skills and brain or visual-spatial measurements. However, they did report correlations between music perceptual skills and both non-verbal reasoning and phonemic awareness (Norton et al.). More studies need to be performed to examine whether the enhanced motor and cognitive performance of musicians is due to innate factors or experience-induced plasticity changes. This study found no pre-existing differences in the experimental versus the control group but documented a positive correlation between music perception and non-verbal reasoning and phonemic awareness. These results indicate that environmental music stimulation may result in the discrepancies found in musicians’ brains. This discovery, along with others previously provided, highlights how musical experiences alter existing cognitive-linguistic networks. Again, music engagement and music therapy may help forestall cognitive decline, further emphasizing the need for prompt initiation of music therapy in patients with Alzheimer’s disease.
Low Quality of Music Therapy Research
One of the barriers halting the progression of music therapy implementation in healthcare settings is the poor quality of music therapy studies. Music therapy research can be weak for several reasons, including low sample sizes, lack of true control groups, reliance on subjective reports, poor standardization, and lack of randomization/blinding. All of these factors contribute to weaker research studies. They decrease the validity and reliability of the research conducted, meaning the research may not be accurate or genuinely applicable. Historically, there is a severe lack of research funding for music therapy research. With this, it is difficult to create high-quality studies that require resources and funding. Achieving a large sample size, for instance, requires significant resources, including funding to offer incentives for participant recruitment. Overall, music therapy research is often overlooked due to methodological challenges and a lack of quantitative data that is often required for modern evidence-based medicine. As a non-traditional treatment approach, music therapy is often viewed with skepticism, and the low quality of many studies further contributes to its disregard by clinicians.
To understand the translational gap between the large amount of evidence proving music therapy efficacy and the lack of clinical intervention, a group of scientists conducted a narrative review of current music therapy research to test the overall quality and success of music therapy treatment (Raglio et al.). They conducted a search on PubMed and PsychInfo databases and found 25 randomized controlled trials or controlled clinical trials regarding the effect of music therapy and other mood disorders in neurological patients. The Jadad score was used to evaluate the quality of the studies. The Jadad score is based on 7 items that evaluate random assignment, flow of participants, and double-blinding assessments, making it a simple, short, reliable, and valid evaluation (Raglio et al.; Jadad et al.). A research study can score between 0 and 5 points on the Jadad scale, with 2 of those 5 earned through being a double-blind study (Raglio et al.). Of the 25 controlled trials, none of the studies were double-blind, meaning the maximum points a study could score was 3 points. The team found 36% of the studies earned 3 points, 20% of the studies earned 2 points, 12% of the studies earned 1 point, and 32% of the studies earned 0 points on the Jadad Scale (Raglio et al.). In all, the Jadad score evaluation revealed generally poor methodological quality of research protocols. However, the team also found that almost all studies supported the effectiveness of musical interventions in “improving mood, depression, quality of life, functional recovery, and neuromotor performance” (Raglio et al.).
This study further supports our claim that many music therapy studies are of low quality. Specifically, this study revealed that very few to no music therapy research papers utilize a double-blind setup. In drug administration studies, participants may receive identical-looking pills, one containing active treatment and the other serving as a placebo. This type of blinding is difficult to replicate in music-based interventions. Although participants may engage with auditory stimulation for the same duration using similar devices, they will be aware of whether they are listening to music or not. Likewise, individuals will know if they are actively playing an instrument. So, is double-blinding necessary to make strong music therapy research?
While double-blinding is often considered the standard in clinical research because it minimizes expectancy bias, its absence does not automatically invalidate a study, particularly in experiential interventions like music therapy. Instead, it highlights the importance of alternative methodological strategies to ensure research rigor. For example, researchers can use a single-blind design, where the assessors are unaware of the group assignments. Active control groups, like audiobooks or non-musical sounds, can also be used to better isolate the specific effects of music compared to regular auditory stimulation. To make the studies more objective rather than subjective, researchers can rely on neuroimaging, physiological responses, or standardized cognitive assessments. Strong music therapy research may not rely on a strict double-blinding approach, but rather on methodology, appropriate controls, and transparent acknowledgement of limitations.
Strides to Strengthen Music Therapy Research
Clearly, music therapy research requires increased funding and more rigorous methodological approaches to gain recognition among physicians and facilitate its integration into clinical practice. To minimize the subjectivity of assessing an individual’s music engagement during research studies, Turry and his team created the Music Engagement Scale (MES) (Turry et al.). The MES is a restructured version of the Music Interaction Scale (MIS) that allows for more feasible application in both clinical and research settings, thus reducing subjective variability in individual assessments. Before the MES scale, researchers often used the Nordoff-Robbins scales or the MIS to measure an individual’s music engagement, but both scaling guidelines contributed to inaccurate, subjective measurements (Turry et al.).
The Nordoff-Robbins scales are a set of 3 measures that provide a comprehensive assessment of a client’s music engagement (Turry et al.). However, the inter-rater reliability is inconsistent between individuals trained in the Nordoff-Robbins approach and those without training (Mahoney). In other words, a music therapist trained in this framework may evaluate a client’s music engagement differently than a clinician who lacks this specialized training. As a result, the Nordoff-Robbins scales may be considered somewhat subjective. This limits their practicality outside of research settings, as many healthcare professionals are not trained in this approach. Without a reliable and widely applicable method for measuring music engagement in clinical contexts, the translation of music therapy into standard clinical practice remains limited. The Music Interaction Scale (MIS) is more recent than the Nordoff-Robbins Scales (Turry et al.). This scale emphasizes macro-level coding, focusing on overall patterns of music engagement rather than moment-to-moment (micro-level) analysis. Still, the MIS rests on “the assumption of linear progress, [conflating] therapy support with client engagement, [emphasizing] duration over quality of engagement… and [characterizing] music-making behaviors in ways that [requires] raters to judge whether the client’s engagement in music [is] purposeful” (Turry et al.). In all, both scales are beneficial for measuring music engagement, but altering the scales may allow for more accurate and widespread use.
The MES allows for this more accurate and widespread use. This framework consists of four primary tiers, or categories, of engagement. From least musically engaged to most musically engaged, these consist of Attentiveness (levels 0-2), Active Music Making (levels 3-4), Interactive Music Making (levels 5-7), and Reciprocal Music Making (levels 8-9) (Turry et al.). Each category includes at least two levels that distinguish variations in both the quality and duration of music engagement. The overall rating can be completed in a few minutes and results in a single assigned numerical value. When using the MES, researchers found strong inter-rater reliability between therapists with and without Nordoff-Robbins Music Therapy training, indicating that the scale can be effectively utilized by a broad range of clinicians and healthcare professionals (Turry et al.). Although the MES has some limitations, such as the need for further validation, its relatively recent development presents significant potential for expansion. As the scale continues to be tested and improved, it may provide a more standardized and accessible method for assessing music engagement, ultimately supporting the integration of music therapy into clinical practice.
Recent Music Therapy Research Funding
Traditionally, music therapy has been an underfunded field, which has contributed to weaker research outputs that are often overlooked by contemporary healthcare systems. This lack of funding may be a key barrier to the integration of music therapy into clinical settings. As previously discussed, research has consistently demonstrated the efficacy of music therapy across a wide range of clinical conditions, including cognitive, emotional, and motor impairments. Despite this growing body of evidence, rates of music therapy prescription remain low, highlighting the disconnect between research findings and clinical implementation. Several factors likely contribute to this gap, including limited large-scale clinical trials, challenges in standardizing interventions, and difficulties in study design. Together, these barriers suggest that improving research quality, increasing funding, and developing more accessible methodologies are essential steps towards advancing the recognition and adoption of music therapy in modern healthcare.
On a positive note, an increasing number of research grants appear to prioritize the expansion of music therapy. To begin, the Arthur Flagler Fultz Research Award is an annual grant of $20,000 designed to promote and support research towards innovative music therapy treatments (“Arthur”). Established in 1999 alongside the founding of the American Music Therapy Association (AMTA), this award reflects early efforts to advance music therapy research. Although the funding may not be sufficient to support large-scale or high-cost research projects on its own, it nonetheless provides meaningful support for preliminary studies and contributes to the continued development of the field. On a similar scale, the Institute for Therapy through the Arts at Northwestern University was awarded a 3-year $90,000 research grant from the National Endowment for the Arts (ITA). This funding will be dedicated to investigating the impact of music on individuals with dementia and their families (ITA). While all music-based research is valuable, this topic is particularly relevant to our discussion of implementing music therapy as a complementary treatment for individuals with Alzheimer’s disease. Neurological mechanisms explain the fundamental workings of music therapy for various diseases. Contributions to this field of research may help reveal some of these neurological mechanisms, like neuroplasticity and neurogenesis, and allow clinicians to create more humane and effective treatment plans.
In recent years, there have also been large-scale research grants aimed at bringing together music therapy and neuroscience. For instance, the NIH awarded $20 million over five years for the Sound Health initiative (“NIH”). The Sound Health initiative launched in 2017. The main goal of this project is to identify biomarkers and to understand how music tempo can help stabilize the gait of patients with Parkinson’s (“NIH”). While this funding is not directly working with Alzheimer’s disease, Parkinson’s disease is also a progressive neurodegenerative disorder. In understanding how one neurological disorder can interact with music, we may be able to apply similar principles when treating another form. Through this project, we will also gain a better understanding of how music tempo impacts treatment outcomes. By recognizing how different musical elements affect symptom outcome, we can tailor music-based interventions in the future to align with patient needs.
Similarly, the NIH and NEA have released numerous music-based grant opportunities across several of their institutes (“Music”). While the objective of each project is catered towards the institute’s overarching goals, all of the institutes are interested in further comprehending the mechanisms behind music therapy. The institutes that contain music therapy research grants consist of the National Cancer Institute, National Eye Institute, National Institute on Aging, National Institute on Alcohol Abuse and Alcoholism, National Institute of Biomedical Imaging and Bioengineering, National Center of Complementary and Integrative Health, National Institute on Drug Abuse, National Institute of Dental and Craniofacial Research, National Institute of Mental Health, National Institute of Neurological Disorders and Stroke, and the National Institute of Nursing Research (“Music”). Specifically, the National Institute on Aging is looking to support clinical trials investigating the neural pathways and circuits involved in music processing and how they may be altered in Alzheimer’s disease and Alzheimer’s disease-related dementias (“Music”). By providing significant funding, music therapy research will become more recognized and higher quality. Hospitals and other healthcare settings will become more aware of the treatment option and potentially consider its integration.
Correspondingly, the Creative Forces are a part of the NEA Military Healing Arts Network. Over the past few years, the Creative Forces initiative has awarded $900,000 to the Indiana Institute for Medical Research to study music therapy and chronic pain in U.S. Veterans (“Creative Forces: NEA”). Since 2022, it has also distributed more than $2.2 million across 101 projects and has partnered with the Mid-America Arts Alliance to offer matching grants of up to $10,000 for emerging one-year projects and $25,000 for advanced one-year projects (“Creative Forces: Community”). This level of funding is significant for the advancement of music therapy research, as it supports a wider range of studies, including preliminary projects and large-scale clinical investigations. Increased financial support allows researchers to improve study design, expand sample sizes, and include more rigorous methodologies, all of which enhance the credibility of findings. As a result, stronger and more consistent evidence can help build confidence among clinicians and healthcare systems, ultimately facilitating the integration of music therapy into clinical practice.
Future Directions
Future music therapy research should prioritize the development of more rigorous and standardized methodologies to strengthen the validity. Large-scale randomized controlled trials with clearly defined intervention protocols, including timing and dosage, are necessary to establish a more definite relationship between music therapy and clinical outcomes. Additionally, further investigation into the role of neuroplasticity and the potential of neurogenesis in older adults will help clarify the mechanisms through which music therapy exerts its effects, particularly in the early stages of Alzheimer’s disease. There is also a need to refine and validate objective measurement tools, such as standardized engagement scales, to reduce subjectivity and improve reproducibility across studies. Expanding collaboration between neuroscientists, clinicians, and music therapists may further enhance the translational impact of this research. Moreover, continued investment in funding and grand opportunities will be critical for supporting high-quality studies and advancing the field.
Future work should attempt to quantify the current prescription of music therapy in healthcare settings. While current surveys predict the rates of music therapy practice to be low, there is no definite conclusion. More surveys must be conducted to gauge physicians’ opinions of music therapy and to understand the limitations that are preventing doctors from utilizing this therapeutic approach. Additionally, future work should explore personalized approaches to music therapy, tailoring interventions based on individual patient characteristics, disease stages, and responsiveness to treatment. By addressing these gaps, music therapy research can move beyond demonstrating efficacy in research papers and toward establishing its broader integration into healthcare systems for the treatment of Alzheimer’s disease.
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Thank you! :)