For Medical Providers and Others:
In 2014, Nuara[1], et. al. reported a single-subject case study involving a 39-year old pianist with multiple sclerosis, with bimanual sensory-motor impairment attributed to 3 cervical relapses in the previous year, who underwent a 3-week treatment program combining repetitive transcranial stimulation (rTMS) with musical keyboard exercises, twice a day, 5 days each week, for 3 weeks. The patient reported improved piano performance and hand function at the end of the trial. The researchers concluded that neurorehabilitation, combined with the simultaneous association of complex hand motor training (piano exercises) and rTMS could improve hand motor performance, specifically, as well as modulate cortical excitability. They recommended a placebo-controlled study in the future.
In 2015, Gatti[2] and colleagues reported a double-blind randomized controlled trial of patients with multiple sclerosis pursuing a treatment for hand function involving musical keyboard exercises alone. Nine patients with either primary or secondary progressive MS completed the experimental group program, and 10 completed the control group program. Both groups played the same exercises on the same keyboards, but the control group played with the power turned off, and therefore had no sound. The shared sensory commonalities between the groups should be noted: tactile sensory feedback, notation system learning using color coding as a learning aid, weighted keyboards facilitated dynamic range feedback to increased or decreased strength of striking the keys for those with audible feedback, and visual learning and feedback. All subjects were non-musicians, could not previously read music, and had not studied music or played piano previously. The primary difference between the groups was the presence of aural feedback of the music being made with the fingers in response to the visual prompt for the experimental group. The researchers found the experimental group reported a 51.1% increase in ABILHAND scores, and the control group reported a 7.6% increase for the same measure. The changes in 9HPT, Jamar and Pinch values was not significantly different between groups, but quality of life reports were significantly increased for the experimental group, attributed to improved hand funciton. It’s important to note that this trial was only conducted for 3 weeks, and significant increases to other measures such as strength would be profound for any treatment measure after so short a period.
This study actually had 4 outcomes: (1) the study of piano or musical keyboard playing improves quality of life and hand function for people living with primary and secondary MS after only 3 weeks of intense and highly regimented therapy, (2) neural reconfiguration is either enhanced, or facilitated by a musical response to movement combining pitch and rhythm, therefore frequency and temporal detection and tracking, as well as coordination of complex motor patterns resulting in musical feedback (this explains why typing on a computer keyboard doesn’t facilitate the same benefit), (3) previous status as a skilled musician was not necessary for gains to be realized, and therefore muscle memory is not necessary to facilitate neural reconfiguration through musical keyboard training, and (4) more research is warranted on the application of this approach over a sustained and continuous period of study, to fingers as well as the rest of the neuromuscular system, including fMRI studies of the brain as proposed below.
These studies do not report the piano exercises used for rehabilitation, but they do prescribe a regimented dosage and high accomplishment standards that are sufficient for a 3-week trial period. However, the rigor of their dosage isn’t necessarily conducive to enjoyment of the practice or the rehabilitation exercise period, and we know that saliency is vital for all learning, including neural reconfiguration in adults with any form of damage to the brain.
Working with a piano student who has relapsing-remitting MS, I developed a program with more flexible standards, based on motor-learning theories as applied to several of the most utilized technique acquisition programs for musical keyboard training. We did not do pre-study assessment of hand function, as we were quite literally just doing…piano lessons. However, I understood that this person’s challenges to hand function were part of a disease course that was, though unique to each patient, inevitably predictable. As such, my training in applying the 3-pronged standard of evidence-based practice guided my research to find what would best suit them as a student, addressing both (1) motor skills acquisition that was logical given the current status of their hand function as applied to the rigors of strength needed, and the taxation of coordination systems inherent to piano playing developed systematically through sound methodologies, and (2) their cognitive and attentional needs as a member of the Neurodiverse community. As someone who enjoys a challenge to my artistic, pedagogical, researcher and therapist identities simultaneously, this work has been a source of great pleasure and discovery. And in truth, I did what any educator would do when presented a student with specific learning needs: I prepared to meet those needs where they were.
Without taking formal assessment measures, this person is enjoying better hand function and associated quality of life. But, the surprise of studying this approach after 8 months was improvements to their hand sensation. The previous two studies did not report this, but each also only studied the approach for 3 weeks; while that is enough time to realize improved hand coordination and agility to some degree, it is not enough time to assess those parameters with any finality, let alone assess the benefits to strength or sensation. My student has eliminated all numbness and tingling in their left hand, and nearly all in their right hand, except for some residual abnormal sensation in the right pinky and ring fingers, itself a very interesting outcome given the innervation of those fingers distinct from the rest of the hand; the student isn’t sure about if the right ring finger is experiencing abnormal sensations around the entire finger or just on the right side, which of course would be further illuminating. Those two fingers continue to experience some numbness and tingling, though it is reduced. And, overall nerve pain is somewhat diminished bilaterally. However, the student continues to practice, and continues to want to learn, and that is what is facilitating the neural reconfiguration. I believe more improvements to hand function and sensation can be achieved with continued application and practice that implements this and a growing body of research, my knowledge as a piano teacher augmented by my training as a speech therapist, and the patient’s goals, most specifically studying the music they want to play, and implementing other goals they bring to the sessions.
At this time, I am prepared to welcome more students who live with MS. I am implementing assessment measures such as measurement of keyboard performance using MIDI[3] data to chart development, and potentially look at the development of individual fingers over time. I am also assessing quality of life pre-study, and at prescribed intervals, using the Arm Function in Multiple Sclerosis Questionnaire (AMSQ). While the scores are indicative of a larger picture, I’m much more interested in the data itself.
FOR MEDICAL PRACTITIONERS:
If your patient is one of my students, and given their permission, I would welcome the opportunity to collaborate with you and your colleagues, and the rest of their healthcare team. If they are pursuing other therapy measures such as occupational or physical therapy, I would be interested in the results of those measures combined with this approach to keyboard training, regardless of any issues of that being a confounding variable. It is my intention to publish a single subject case study on this work, with the possibility of further research, currently planned as a 5-phase study applying the theory of this approach to the rest of the neuromuscular system, and also for those living with more advanced stages of MS. As such, I welcome any data that can illuminate the progress of individual patients, any insight or feedback you’d be willing to share, and any opportunity to discuss this further, including how to build on the knowledge base that exists, and how to make this available to more people living with MS and other forms of brain abnormalities or damage.
Thinking further…Considering the musical “mechanism” of neural reconfiguration in a broader context:
Very recently, several teams led by Dr. Evan M. Gordon from Washington University in St. Louis[4] have produced research explaining a more advanced understanding of the motor cortex, evidencing a network underneath of it, that is responsible for coordinating complex movement patterns, shown through fMRI readings of the brain during instructed physical movement. This research has many implications, including explanations of the truest psychosomatic experiences, including nerve pain associated with heightened emotion. I theorize this network is implicated in the neural reconfiguration facilitated by musical response, essentially hijacking this area responsible for planning or facilitating complex motor patterns into serving to generate motor signals in place of those areas that no longer can. The fMRI studies I propose below may provide insight on this theory about the “mechanism” facilitating neural reconfiguration in this context.
As mentioned, I am preparing a single-subject case study based on my own work applying these theories as a piano instructor, and considering a possible 5-phase study that applies the principle theory of this musical “mechanism” to the rest of the neuromuscular system. The next phases will require more specialized equipment I am developing, and a smart phone app to facilitate this application. I am considering funding in the coming year, but I am also interested in further discussing this, the results of my on-going literature review in this area, the work I’ve done and hope to do, and potential avenues for collaborating with others to broaden the application to more patients, and possibly to others with other forms of either degeneration or CVA/TBI.
Potential areas of future fMRI research should include
The playing of scales, contrary and parallel patterns for beginner and skilled pianists, to compare neural response to the learning of these two basic skills against the neural manifestation of mastery of the same skill set, toward a better understanding of complex fine motor pattern mapping. Contrary scales chosen should represent a pattern with symmetrical motion, and patterns that are highly asymmetrical.
The playing of different forms of polyphony (e.g. Bach vs. Mozart vs. a serialist…) by both novices and masters, to study the neural response to the learning of these more advanced skills against the neural manifestation of mastery of the same skill set, also toward a better understanding of complex fine motor pattern mapping applied to the coordinating of a much more complex motor pattern, as well as the neurological differences between these distinct styles, if any.
Compare the above to the same measures for those living with
CVA/TBI recovery and neural reconfiguration
Degenerative diseases of the brain, including those defined primarily by cognitive decline, to look for areas of unexpected neural reconfiguration and any associated behavioral or physical changes associated with the approach.
These studies would be very interesting when applied to novice keyboard learners living with MS, Parkinson’s Disease, etc.
FOOTNOTES:
[1] Nuara, A., Straffi, L., Spagnolo, F., Rossi, P., Comi, G., Comola, M., Leocani, L. (2014) Poster Session 54. Music and the brain and disorders in musicians: Simultaneous rTMS and piano playing improve hand dexterity and induce changes in cortical excitability in a professional pianist affected by multiple sclerosis, a case report. Abstracts of Poster Presentations, Clinical Neurophysiology, 125(1), S298.
[2] Gatti, R., Tettamanti, A., Lambiase, S., Rossi, P., Comola, M. (2015). Improving hand functional use in subjects with Multiple Sclerosis using a musical keyboard: A randomized controlled trial. Physiotherapy Research International, 20, 100-107.
[3] MIDI: Musical Instrument Digital Interface. This is a computer language specifically for sending musical information from software to digital instruments, with other musical applications. It was developed and implemented in 1983 as a standard for all digital instruments, so that professional musical artists could simultaneously use digital instruments (keyboards, drum machines, etc.) from different manufacturers. Most manufacturers have abided the 1983 agreement and standard faithfully, however one company found a way to require users of their equipment to use only their hardware components, and I do recommend my students not use products from this company, as those products won’t interface well with my tools. This is part of the start-up assistance I provide as part of my on-boarding consultations, which is free of charge.
[4] Gordon, E.M., Nelson, S.M. (2021) Three types of individual variation in brain networks revealed by single-subject functional connectivity analyses. Current Opinion in Behavioral Sciences 40, 79-86. https://doi.org/10.1016/j.cobeha.2021.02.014
Gordon, E.M., Lynch, C.J., Gratton, C., Petersen, S.E., Dosenbach, N.U.F., Nelson, S.M., et. al. (2018) Three distinct sets of connector hubs integrate human brain function. Cell Reports, 24, 1687-1695. https://doi.org/10.1016/j.celrep.2018.07.050.
Gordon, E.M., Laumann, T.O., Gilmore, A.W., Newbold, D.J., Greene, D.J., Berg, J.J., et. al. (2017) Precision functional mapping of individual human brains. Neuron, 95, 791-807. http://dx.doi.org/10.1016/j.neuron.2017.07.011
While my literature review is on-going, a full bibliography is available upon request.