Music Therapy and Traumatic Brain Injury:  Taking Care of Our Returning Soldiers

In 2006, I took my first training in Neurologic Music Therapy (NMT). Dr. James Gardiner, a neuropsychologist working at the Black Hills VA Healthcare Center and Community Transitions Brain Injury Rehabilitation Center in South Dakota, presented NMT techniques used in working with cognitive rehabilitation. He spoke about the expected number of returning soldiers who would have traumatic brain injury (TBI) because of exposure to the shock waves from roadside bombs. He said it would be important for these soldiers to get treatment. Without treatment, their ability to hold jobs, be in relationships, and make appropriate decisions could all be affected. Areas focusing on attention, executive function and working memory would need to be addressed. Dr. Gardiner elaborated on how difficult these unseen injuries can be for the victims. Families tend to rally when an injury is new or evident and all this focused energy is brought forward to help the patient. As time enfolds, and the issues seem vague, it is more difficult for families to remain patient and understanding because many of the cognitive issues the soldier is facing become more subtle and less easily identified. Dr. Gardiner worked with a music therapist on these cognitive issues through Music Attention Control Training, Music Executive Function Training, and Music Mnemonics Training. Because music shares neural networks for these cognitive processes and music has the ability to create plasticity in the brain through musical exercises, work can be done to help reroute to new pathways.

Recently The Seattle Times published the results of a study supporting Dr. Gardiner’s predictions that many of our veterans would suffer from cognitive issues due to exposure to the bomb blasts. Dr. Elaine Peskind of the Veterans Affairs Puget Health Sound Health System worked with other VA and University of Washington researchers. Comparing 12 returning soldiers from the Iraq War with a control group of adults with no history of concussions and no military service, Dr. Peskind et al. (2010) found evidence of slowed brain activity in areas affecting emotions, focus, language, and sleep in the soldiers compared to their control group counterparts. Tracking a small dose of radioactive glucose injected into the subjects, researchers used PET scans to see how quickly each subjects’ brain metabolized the glucose. This metabolic process indicates brain activity. Behavioral symptoms exhibited by the veteran subjects included poor frustration tolerance, mood swings, disinhibition, and getting into fights. Further research is being done using MRIs to look for possible structural damage in the brain because of the blasts.

ProPublica and NPR have investigated brain injuries in our veterans. Problems with diagnostics and documentation have led to under treatment for many wounded soldiers. In our everyday life, athletes and car accident victims are tested for TBI routinely, leading to some restrictions on activities that might lead to further head injuries. Research with the general public shows that up to 15 percent of people with mild TBI continue to have difficulties cognitively. For our soldiers, lack of documentation of concussion incidents may limit or eliminate treatment at a critical stage. They might not receive treatment at all unless they seek it themselves. Cognitive rehabilitation therapy should be started as soon as possible for patients with persistent symptoms.

What does this have to do with music therapy? Plenty! Cognitive rehabilitation (CR) has grown in its application for victims of TBI through evidence-based standards and guidelines. It has shown benefits for those working on attention, memory, spatial skills, executive function, verbal skills and psychosocial adjustment (Thaut et al. 2009).  Parallel to this, Neurologic Music Therapy has grown as a discipline defined as “the therapeutic application of music to cognitive, sensory, and motor dysfunctions due to neurologic disease of the human nervous system” (Thaut, 2009, p. 406). Music stimulates cognitive, sensorimotor, and affective processes, and this stimulation is “generalizable and transferable to nonmusical brain and behavior function” (Thaut, 2009, p. 406). Recent research shows promise for the use of NMT to CR. Dr. James Gardiner of the Black Hills VA Center, along with Thaut et al. (2009) investigated the use of NMT techniques as part of the cognitive rehabilitation for a treatment group consisting primarily of subjects with TBIs as well as other brain injuries. Treatment focused on attention, memory, executive function, and emotional adjustment. Improvement was seen in executive functioning (mental flexibility) and overall emotional adjustment with a decrease in depression, anxiety and sensation seeking. Sarkamo et al. (2008) studied 60 patients with middle cerebral artery strokes divided into control group, story listening group, and a music listening group for 6 months.  For 8 cognitive tests administered at baseline, 3 months and 6 months, there was no difference except the music group did best on verbal memory and focused attention.  Testing mood measures, there was no difference between groups except the music group was less depressed and less confused. One possible thought is that a better mood improves cognition.  Dopamine was also active, increasing attention. Thaut et al. (2005) also found that a musical mnemonics task for learning word lists induced brain plasticity in neural substrates underlying memory and that musical mnemonics also assisted verbal learning in patients with multiple sclerosis.

Back to our wounded soldiers – early and sustained treatment is vital for the cognitive rehabilitation of our soldiers facing injuries due to such traumatic events as roadside bombs. Neurologic music therapy can work in cognitive rehabilitation to improve the long term health of our veterans. Long term societal costs will be borne by us all if we don’t provide the treatment our soldiers deserve. Failure to hold down a job, failure to support a family and remain in relationships, self-medication, increased fighting and disinhibition are all attributable to TBI's if left untreated or insufficiently treated. The road to recovery should be paved in gold for our returning soldiers through appropriate funding of services. Music therapy should be an integral part of those services because of music’s shared neural networks with cognitive processes and music’s unique ability to engage and arouse the brain, thus optimizing connectivity to areas involving attention, language, perception, motor control and memory.

The Seattle Times, 6.4.2010, http://seattletimes.nwsource.com/html/nationworld/2012110352_brain14m.html

Peskind, E.R., et al. (2010). Cerebrocerebellar hypometabolism associated with repetitive

blast exposure mild traumatic brain injury in 12 Iraq war Veterans with persistent post-concussive symptoms., NeuroImage, doi:10.1016/j.neuroimage.2010.04.008

Miller, T.C. and Zwerdling, D. Brain Injuries Remain Undiagnosed in Thousands of          Soldiers, ProPublica and NPR, 6.7.2010. http://www.propublica.org/feature/brain       injuries-remain-undiagnosed-in-thousands-of-soldiers

Särkämö, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila, S., Mikkonen, M., et al   (2008). Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain: A Journal of Neurology, 131(3), 866-876.          doi:10.1093/brain/awn013.

Thaut, M., Peterson, D., & McIntosh, G. (2005). Temporal Entrainment of CognitiveFunctions: Musical Mnemonics Induce Brain Plasticity and Oscillatory Synchrony in Neural Networks Underlying Memory. The neurosciences and music II: From perception to performance (pp. 243-254). New York, NY US: New York Academy of Sciences. Retrieved from PsycINFO database.

Thaut, M., Gardiner, J., Holmberg, D., Horwitz, J., Kent, L., Andrews, G., Donelan, B., McIntosh, G., (2009). Neurologic Music Therapy Improves Executive Function and Emotional Adjustment in Traumatic Brain Injury Rehabilitation. The Neurosciences and Music III – Disorders and PlasticityNew York, NY US: New York Academy of Sciences. doi: 10.1111/j.1749-6632.2009.04585.x (pp. 406-416).