Development of Regulative Music Therapy guidelines for early to mid-stage Parkinson’s disease

Development of Regulative Music Therapy guidelines for early to mid-stage Parkinson’s disease

In plain language

Idiopathic Parkinson’s disease (PD) is a chronic degenerative neurological disease, the prevalence of which increases with age. Many pharmacological treatments have adverse side-effects and there is a need to explore non-pharmacological treatments that can be tailored to the individual’s requirements. Regulative Music Therapy is a method of becoming aware of oneself by recognising thoughts, feelings and sensations in a non-judgemental way. These are elements central to the technique of mindfulness. Therapies involving mindfulness and music have had some success in treating psychological and physical illnesses. This paper proposes a modified form of Regulative Music Therapy for treating people with Parkinson’s disease. Evidence from the literature together with information collected from an expert interview was used to propose a flexible guideline for further consideration by music therapists in treating people with Parkinson’s disease.


Abstract

Idiopathic Parkinson’s Disease (PD) is a debilitating neurological chronic condition that is more prevalent among older adults. Pharmacological therapies are used with varying success and there are many known adverse side-effects. Studies involving mindfulness-based interventions for PD have reported positive outcomes in alleviating PD-related symptoms, as have music therapy interventions. Regulative Music Therapy is a receptive music therapy method based on the principles of mindfulness, but little is known about its potential as a therapy for treating people with PD. This paper proposes a flexible Regulative Music Therapy guideline for further investigation, adaptation and possible pilot testing by music therapists in the treatment of people with PD. Information from an expert interview was analysed using qualitative content analysis and compared with evidence from the literature on mindfulness as a treatment mode for PD. Key components of this guideline include enabling independent flexible Regulative Music Therapy in the home and facilitating conditions under which participants feel safe, secure and supported in all aspects of the therapy.


Citation

Williams, E.T. (2019). Development of Regulative Music Therapy guidelines for early to mid-stage Parkinson’s disease. Australian Journal of Music Therapy. Advance online publication. Retrieved from https://www.austmta.org.au/journal/article/development-regulative-music-therapy-guidelines-early-mid-stage-parkinson’s-disease


Date published: December 2019

Introduction

     Idiopathic Parkinson’s disease (PD) is a progressive neurodegenerative condition characterised by motor and non-motor symptoms that impact on function to varying extents.  There is no definitive diagnostic test and diagnosis is established through clinical criteria such as rest tremor and loss of postural reflexes. Estimates of incidence and prevalence in published  studies  differ  due  to varying data quality, methodological differences, and lack of consistency in case definitions (Dorsey et al., 2007; Jankovic, 2008). Like other chronic degenerative conditions, PD will place increasing demands on healthcare resources as populations age; people are living longer but not always in good health (World Health Organization, 2015). It is estimated that the number of individuals with PD will increase substantially in coming years due to earlier diagnosis, better case ascertainment and longer survival (Dorsey et al., 2007).

     The neuropathology of PD relates to the loss of dopaminergic neurons in vulnerable neuronal populations within the brain (Dickson, 2018). Deficiency in the quantity of neurotransmitters prevents the normal movement of electrical impulses which are responsible for the planning and execution of movement in the body (Schapira & Jenner, 2011; Thümler, 2006). Disturbances in various regions of the autonomic nervous system are also common. Dominant symptoms include abnormally low muscle tone, dizziness, excessive sweating, gastrointestinal disturbances, drooling, swallowing disorders and obstipation (severe constipation). Neuropsychiatric symptoms, in particular depression, but also irritability, anxiety and panic attacks, are common (Chaudhuri, Healy, & Schapira, 2006).

     In addition to motor, neuropsychiatric and autonomic nervous system disturbances, people with PD incur psychosocial difficulties and deficits in emotional processing and communication, including social awkwardness and unease in social interaction. Evidence of abnormal processing of emotion in people with PD was shown in a meta-analysis from 1,295 individual participants. The authors reported a robust link between PD and specific deficits in recognising emotion from both the face and the voice, and commented that the deficit was particularly acute with respect to negative emotions (Gray & Tickle-Degnen, 2010).

     People with PD seek symptomatic relief through the use of pharmacological medicines. The drug, levodopa, has been commonly used as the main drug of PD treatment for almost fifty years (Tomlinson et al., 2010). However, long-term use of levodopa can result in motor and psychological side-effects about which there has been debate and discussion in the literature. Side-effects include mobility fluctuations (the absence of power to predict sudden ability or lack of ability in terms of movement), hyperkinetic movements, dyskinesia (in which voluntary movement becomes problematic) and dystonia (where muscles are contracted repeatedly causing spasms or postural irregularities) as well as psychological side-disturbances that include disoriented states of mind, hallucinatory psychotic states and depressive moods (Agid et al., 1999; Jankovic, 2002; Thümler, 2006).

     There is wide variation in the characteristics and symptoms of people with PD, making it important to find forms of treatment that are suited to the individual patient’s clinical and psychosocial needs as well as their specific manifestations and symptoms. Evidence suggests that mind-body interventions may reduce disability associated with PD (Bega & Zadikoff, 2014) although more research is needed in this area (McLean, Lawrence, Simpson, & Mercer, 2017).

     Mindfulness. Mindfulness is described as “the awareness that arises by paying attention on purpose, in the present moment, and non-judgementally” (Kabat-Zinn, 2013, p.xxv). The Buddha’s 2500-year-old teachings are generally considered to be the original source of mindfulness, however various facets of mindfulness can also be found in other religious traditions and philosophies (Rappaport & Kalmanowitz, 2014). Mindfulness is now an emerging and complex therapeutic field with commonalities across western psychological and psychotherapeutic practice (Khoury et al., 2013). For example, Freud’s 1912 recommendations regarding the need for skilled attention for effective psychotherapy have been compared with the quality of bare attention or open awareness that is one of the goals of Buddhist Vipassana meditation (Rappaport & Kalmanowitz, 2014).

     Mindfulness therapy. Mindfulness is commonly applied as part of the intervention known as Kabat-Zinn’s Mindfulness-Based Stress Reduction (Kabat-Zinn, 2003; Siegel, Germer, & Olendzki, 2009). In a meta-analysis of 39 mindfulness-based therapy studies Hofmann, Sawyer, Witt, and Oh (2010) reported strong effect sizes for participants with depression and anxiety disorders. Mindfulness-based interventions have also been used to build and strengthen adaptive coping strategies in the treatment of PD (Fitzpatrick, Simpson, & Smith, 2010). Other studies have demonstrated improvement in relation to depressive symptoms, emotional functioning and cognitive functioning (Cash, Ekouevi, Kilbourn, & Lageman, 2016) as well as PD motor symptoms (Pickut et al., 2015). Although there has been considerable research conducted that demonstrates the efficacy of mindfulness-based therapies, little is known about the integration of mindfulness into music therapy (Cairns & Murray, 2015; Medcalf, 2017).

     Music therapy. There is increasing interest in studying the effectiveness of music therapy interventions amongst people with PD. Raglio (2015) reported the outcomes of six randomised controlled trials in which music therapy was used as an intervention for PD. Improvements were found in motor and non-motor symptoms. Most music therapy interventions for PD could be categorised as active music therapy. This term means that the patient is actively involved with an instrument, the voice or both (Eschen, 1996). On the other hand receptive music therapy methods involve hearing, listening to and experiencing various musical genres (Frohne-Hagemann, 1996).

     Although little is known about the potential use of receptive music therapy for people with PD, such methods may be beneficial because they can provide respite from the rigours of more physically demanding forms of therapy. In discussing the relationship between practice and rest in physiotherapy for neuro-rehabilitation, Hauptmann (2008) noted that relaxed, well-spaced practice sessions were more effective than massed practice.

     Regulative Music Therapy. Regulative Music Therapy is a receptive music therapy approach which originated in Germany. The method was developed by Christoph Schwabe during the 1970s. Schwabe et al. (1987) described Regulative Music Therapy as having “practising characteristics” (p.67) in which people learn by practising how to examine their own behaviour and experiences in ways that allow them to alleviate some forms of depression.

     Professional training in Regulative Music Therapy is offered in annual six-month courses under the supervision of Christoph Schwabe at the Academy for Applied Music Therapy in Crossen, Germany. One of the important goals is for the student to achieve personal development through gaining knowledge of one’s self. This is realised by experiencing the therapy from the patient’s perspective. Competence in applying the method is attained by learning from the practical experience of applying the method as a therapist.  See Appendix A for more information.

     Schwabe’s work is still today regarded as important defining research on the topic. Recent scientific evidence on the effectiveness of Regulative Music Therapy is lacking. However, a study in Germany gives evidence in support of Regulative Music Therapy as an intervention for people with psycho-emotional problems. Wosch and Röhrborn (2009) used a pre-post design to test the effectiveness of three psychotherapeutic and three music therapy interventions (including Regulative Music Therapy) on in-patients in the German psychosomatic clinic, Erlabrunn, between 2002 and 2008. The outcomes examined changes in alexithymia[1] (primary outcome) and symptoms of various mental disorders (secondary outcome). The common thread across the therapies being tested was Selbstwahrnehmungsförderung which means that subjects were encouraged to develop awareness of the self. Patients with borderline disorders showed significant follow-up improvement in alexithymia after group music therapy and significant improvements in other psychological symptoms following individual music therapy (Wosch & Röhrborn, 2009). 

     A wide range of symptoms and syndromes can be influenced by the therapeutic application of Regulative Music Therapy. Röhrborn, Schwabe and Unger state that the primary indication for Regulative Music Therapy may be syndrome specific and include anxiety disorders and autonomic nervous system disturbances that are common in people with PD (Schwabe et al., 1987). Other PD relevant symptoms that may be alleviated by Regulative Music Therapy are those relating to hypertension, hypotension, functional psychological disturbances such as sleep disturbances, anxiety and concentration disturbances (Schwabe et al., 1987).

     The regulative aspect of Regulative Music Therapy is achieved through the use of a psychotherapeutic tool referred to as Wahrnehmung. This means perception or sensitive observation (Schwabe et al., 1987), which is very similar to Kabat-Zinn’s definition of mindfulness as “the awareness that arises by paying attention on purpose, in the present moment, and non-judgementally” (Kabat-Zinn, 2013, p. xxxv). However, mindfulness and Wahrnehmung are used in different contexts. For example, mindfulness might be employed simply by learning to establish an awareness of the breath or learning a specific physical awareness called a body scan, whereas Wahrnehmung refers to the awareness that is allowed to drift between perceptions that are either cognitive, emotional, mood-based, physical or acoustic by nature “in the spirit of aiming to accept that which occurs" (Schwabe et al., 1987, p. 71). Although the object of awareness and the context differs, it could be argued that the commonality between mindfulness and Wahrnehmung is the non-judgemental application of awareness in a specific therapeutic situation. In the case of Regulative Music Therapy this awareness is practised while listening to an excerpt of classical music selected by the therapist. Therefore, it is possible to view Regulative Music Therapy as a receptive form of Mindfulness-Based Music Therapy.

     An important principle of Regulative Music Therapy is that participants are kept informed regarding the fact that they can quietly free themselves from their practise posture and leave the room if they so wish. The music used for Regulative Music Therapy has a specific function and hence cannot be randomly chosen but rather selected to suit the current situation and therapeutic needs of the group. Schwabe et al. (1987) state that “calming” (p. 100) classical music can be used to relax the participants whereas music with great contrast, faster tempo and a variety of thematic material (e.g. music in Sonata form) can be used to activate the participants. Schwabe et al. (1987) also note that symphonic music is preferable to chamber music due to the wider spectrum of sounds and colours having a greater potential to “reach the individual” (p. 100). The music also has the function of being an object which participants may voluntarily allow their awareness to rest upon, an object that can be used for the purpose of expanding the ability to perceive a wider variety of cognitive, physical and emotional phenomena (Schwabe et al., 1987).  Further information concerning Regulative Music Therapy is given in Appendix A.

     As in other professions, music therapists need to be kept abreast of new developments and emerging research (Piet, Fjorback, & Santorelli, 2016; Ruijgrok-Lupton, Crane, & Dorjee, 2018). Synthesised data in the form of therapist guidelines can be useful when investigating and trialling new approaches.

     This paper reports a small qualitative study that was undertaken as a first step for gaining insight into the potential application of Regulative Music Therapy as an adjunct treatment for people with PD. The results of this study are used as a basis for a guideline which could be given further consideration for adaptation and possible use by music therapists in treating people with PD.

Methods

     Interview. Primary data was collected through a one-on-one expert interview conducted in German. The key informant interviewed was Ruth Breuer, a music therapist with several years of specialised experience both using Regulative   Music  Therapy   and    working clinically with PD patients. Ruth Breuer has co-authored articles for Musiktherapeutische Umschau with Karen Isaak (concerning integrated awareness) as well as with Helmut Röhrborn, a co-author of the seminal text Regulative Musiktherapie (1987). She was also involved in the planning of a concept for the implementation of Regulative Music Therapy for the university clinic in Erlabrunn, Germany (Schwabe et al., 1987). Ruth Breuer gave written informed consent for the interview and agreed to review the findings.

     The following question was used as a prompt for gathering and assembling data from the interview: “In your opinion as an expert with experience and knowledge of this area, do you think that eight weeks of Regulative Music Therapy could lead to improvements in the mental health of people with early to mid-stage PD?”

     This structured interview was conducted by telephone and was approximately thirty minutes in length. The content comprised eleven predetermined questions, the content of which was checked and cleared by an independent expert in Regulative Music Therapy and music therapy research methods. 

The interview was recorded in its entirety using a dictation application of a Samsung smartphone and then transcribed verbatim. Appendix B includes the interview questions.  

     Data analysis. The first step in the data analysis involved a qualitative content analysis (Mayring, 2015) of the interview data. Key excerpts were extracted from the transcript and generalised into condensed meaning units. Codes were used to describe the salient aspects of each unit. Table 1 gives an example of this process.

     The descriptive codes were labelled with the lower-case letter c and a number. Codes were combined into categories which were assigned with the upper-case letter C and numbers for cross reference. For example, descriptive codes c3, c5 and c6 were merged into the category Specific Planning labelled C3,5,6.

     The next step involved a literature review which was undertaken to assess the extent to which the qualitative content derived from the expert interview was supported by the literature. Given that Regulative Music Therapy is largely confined to German speaking countries, a search of published literature was conducted in German using the terms Parkinson, Krankheit, Regulative and Musiktherapie inter-changeably in the PsychINFO and PSYNDEX databases. Due to the similarity between mindfulness from Mindfulness-Based Stress Reduction (Kabat-Zinn, 2003) and Wahrnehmung (Schwabe et al., 1987) the search also covered studies involving mindfulness-based interventions for PD. For each category derived from the content analysis, the following questions were posed: Was there evidence of support found in the literature? Was there contradictory evidence found in the literature? Categories supported and not contradicted by the literature were then assembled into a draft guideline for review and confirmation by the expert informant, Ruth Breuer.

Results

     Table 2 shows the interview content categories and coded elements which were supported by both the literature and the expert informant.

The categories formed the basis of a flexible guideline for further investigation, adaptation and pilot testing by music therapists in the treatment of people with PD. This guideline is outlined below.

Proposed Guideline

     Session parameters: Specific short and long term objectives for PD participants’ learning of Regulative Music Therapy skills, including an objective for each session, but also over- arching objectives for the duration of course. Therapy sessions should ideally take place twice a week, with each session lasting one hour.

     Specific planning: Regulative Music Therapy for PD can be practised independently and continued privately following completion of the course. The therapist should provide clear explanations regarding informal practice and homework assignments.

     Physical and psychological safety: Therapists must be careful to avoid participants becoming physically, cognitively or emotionally overextended by the demands of Regulative Music Therapy, and the patient’s subjective feeling of being safe is important. Therapists must be aware that due to neuropsychiatric PD symptoms, participants may need the tenets of Regulative Music Therapy to be explained slowly and repeated often. The traditional lying down posture of Regulative Music Therapy practice must be considered as an option only for the able bodied. Those who choose to do this can be offered help in getting to their feet afterwards. Similarly, if a patient has difficulty rising from a chair, support can be offered.

     Physical and psychological safety: An initial reduction in the duration of the musical practice section of Regulative Music Therapy may help prevent the overextension of participants and with the gradual building of confidence with the method, this section could be incrementally increased and adjusted.

     Physical and psychological safety: The Regulative Music Therapy voluntary exit must be clearly explained. This means that the participant may break off the practice session at any time if he/she feels unable to cope with the demands made.

     Physical and psychological safety: Therapists must be very attentive and sensitive towards participants. Due to hypomimia (a reduced degree of facial expression) some participants may not have body language that can be easily interpreted. Others may be uncomfortable discussing their feelings or difficulties they are having with the therapy. In this case, it is recommended that the therapist seeks contact with family members of the patient who may be able to help.

Discussion

     The lack of reporting of receptive music therapy methods for PD indicates the need for investigation and trialling of safe receptive methods that may be suited to the myriad of symptoms associated with PD. The existing body of evidence on the value of Mindfulness-Based Stress Reduction (Kabat-Zinn, 2003) in regard to mental health disorders, such as depression and anxiety, suggest that mindfulness/Wahrnehmung may be an effective technique for neuropsychiatric aspects of PD. However, the implementation and testing of therapies must be handled cautiously, with flexibility and openness to consider new evidence. It is essential to recognise and allow for individual differences in people with PD, not only between stationary and ambulatory treatment groups but in terms of individuals’ backgrounds in relation to, for example, age, sex, ethnicity and socio-economic status (Medcalf, 2017; Ramos & Gonçalves, 2016).           

     In terms of applying the concept of Regulative Music Therapy for PD in a future pilot study, there are many issues to consider. Acknowledging the potential influence of the placebo effect, for example, is of importance for any trials involving PD since there is evidence of the “placebo induced release of endogenous dopamine in the striatum” (Pickut et al., 2015, p. 4). Although a release of dopamine would improve various aspects of health such as motor skills and depression, it would be difficult to accurately ascertain placebo effect induced improvements. Also, trial participants could be asked about their prior knowledge of Regulative Music Therapy because it is possible that prior perception of the method may influence the outcomes.

     Follow-up measurements three months after the completion of a trial would also be recommended. Such an assessment is important as a means of determining whether participants have been able to successfully practise Regulative Music Therapy independently. Successful independent practise hinges largely on the organisation of a structured homework program and also on the motivation of individual participants (Jion, 2014).

     The advantages of Regulative Music Therapy is that it combines a technique of mindful awareness with receptive music therapy in a structured, established framework. Despite the recent interest in mindful music therapy techniques, such therapies have yet to anchor themselves in clinical settings. Medcalf (2017) noted that while an extensive amount of research supports mindfulness-based therapies, research involving mindfulness and music therapy is still in the early stages. Research efforts that focus on building the evidence base for mindfulness and music therapy are, therefore, needed.

     Regulative Music Therapy is not limited to German speaking countries. At the 13th World Congress of Music Therapy in 2011 in Korea, a lecture titled Using Regulative Music Therapy at a college counselling centre in Japan was given by Naoko Moridaira. Subsequently, at the 15th World Congress of Music Therapy in 2017 in Japan, Naoko Moridaira and Issho Fujita delivered a presentation titled Mindfulness-Based Music Therapy and Buddhist Meditation - Dialogue of Regulative Music Therapy and Zen. This highlights not only the connection between Regulative Music Therapy and mindfulness, but also that discussing and comparing similarities and differences between techniques from different cultures is valuable as a potential stimulus for new ideas, and as a means of viewing existing ideas from other perspectives.

     The purpose of this paper is to inform a broader international audience of music therapy teachers and practitioners. Publication in an Australian-based journal will contribute to wider international discussion and provide a foundation for future research into potential applications of Regulative Music Therapy for people with PD.

Limitations

     Having only one interview can be considered a limitation. However, the informant, an expert in the field, provided in-depth insights and confirmed the relevance of the content analysis. This is a legitimate method used in qualitative research (Baškarada, 2014).

     It would have been preferable to have had the opportunity to conduct a follow-up interview. Moreover, a second researcher could have been used to assist with inter-coder reliability by independently analysing the material using the same method. However, these results provide a basis for further work in this area.

Conclusions

     People living with PD are in need of non-pharmacological therapy forms that can treat a wide variety of symptoms. It is necessary to offer a range of therapies to suit the infinitely differing manifestations of PD and the personalities of the individuals involved. The accessible, practical and attractive nature of the musical aspect of Regulative Music Therapy combined with the effectiveness of mindfulness techniques suggest a therapy form that requires further research and investigation for people living with PD.

     The proposed guideline allows for participants to learn how to practise the therapy in their own homes independent of the therapist. Subtle modifications to various aspects of the therapy have been suggested to specifically suit people with PD. There is a need for further investigation and research regarding the use of Regulative Music Therapy to relieve motor, neuropsychiatric and psychosocial symptoms associated with PD.

Acknowledgements

     The author would like to thank the Editor and reviewers for their excellent feedback on the early manuscript. Appreciation is also expressed to Dr Jennifer Stewart Williams who advised on structural and scientific matters. Thanks also go to interviewee Ruth Breuer and Professor Thomas Wosch for their professional and academic advice and assistance in practising and understanding the intricacies of Regulative Music Therapy.

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[1] Alexithymia is a disturbance in the ability to be aware of feelings (Taylor & Bagby, 2004).