Hot Topic: Music therapy in the rehabilitation of persons with Parkinson's disease

I am very excited to be joined by not one, but two experts in today's topic, which is music therapy in Parkinson's disease rehabilitation. Our first esteemed guest is Cassandra Mulcahy. She received a Bachelor of Music Therapy from Berklee College of Music, and then a Master of Music Therapy from Temple University.

She is a licensed and board-certified music therapist and an accredited neurological music therapist. [00:01:00] Currently, she is based at the Yale New Haven Health Bridgeport Hospital. Thank you so much for joining us today and sharing your wealth of expertise that you quite clearly have.

Mrs. Cassandra Mulcahy: Thank you so much. 

Ms. Nicole Duff: Our second scientific genius to join us is Professor Stefan Mainka. He is a qualified music therapist currently working at the Parkinson's Center, Beelitz-Heilstätten. He is also a university professor, where he is the deputy head of the study program master's degree in music therapy at the University of the Arts Berlin.

He has a host of scientific articles to his name, but most importantly, he is a true gentleman and good samaritan. I met Professor Mainka in 2019 while doing a course at Beelitz-Heilstätten, an incredible facility as an aside. My taxi never arrived to [00:02:00] take me to the airport, and I was going to miss my flight.

However, Professor Mainka went out of his way to drive me to the airport an extra hour, and so I would like to add that to his list of credentials. Thank you so much for being with us here today.

Prof. Stefan Mainka: Thank you for having me, Nicole, and I'm happy that our topic today is not the German public transport. That's a really different affair.

Ms. Nicole Duff: You're right. So the evidence around music therapy in Parkinson's disease is quite extensive, and that makes it a really highly effective treatment which really should be integrated into patients' treatment regimes, but it isn't. And so I hope that today we can discuss the specific symptoms music therapy can be used to treat, as well as how you, our highly trained therapists, go about this. So sometimes in research, music therapy is broken down into two groups as relational music [00:03:00] therapy and rehabilitative therapy. They do say there's some crossover and it's mutually influenced, and I sort of want to try and understand that a little bit more. So I'd like to start with rhythmic auditory stimulation, as this by far has the most quantitative evidence in support of it. Now, Professor Mainka, this is very much within your wheelhouse, so could you try and explain the concept of rhythmic auditory stimulation to us?

Prof. Stefan Mainka: Rhythmic auditory stimulation refers to a training technique for gait, and it's one of the defined clinical techniques of the concept of neurologic music therapy. What is done in the therapy is, first of all, to measure the patient's walk. So we measure the tempo, the walking speed, the stride length and most importantly, we measure the step frequency.

And we eventually also judge qualitative aspects [00:04:00] of gait, like upright posture, swinging of arms, et cetera. And together with the patient, figure out what needs to be improved. So what are the things that perhaps make patients walk unstable or feel unstable while walking.

And those things are specifically addressed and targeted by adjusting the tempo of the music. So at first, having measured and found out about the step frequency, we really adjust the music very closely to the patient's walking pattern. And by this, step by step, we move towards a better and more functional gait pattern to reach the therapeutic goals.

Ms. Nicole Duff: That sounds incredibly technical and something that I couldn't imagine myself ever being able to do that. And so tell me how do you go about becoming someone like a music therapist like you who would then be able to go about doing this kind of treatment?

Prof. Stefan Mainka: Maybe I [00:05:00] have to add something else. At first, I know this sounds very technical, and I know perhaps this is not what you and also the listeners expect at first when we talking about music and therapy. Of course, I had... I could have also just said, we take out music off the shelf, we adjust that to the walking, and magically the patient walks better and more fluently.

And this is what happens most of the time, and this is what patients experience very often in their first session when they come to me or to a music therapist. But what is rather important is actually looking at those functional, structural aspects to make that really a... is also important for your listeners and especially, I think, for people working in the field that it is a very functional and very structured technique.

So yes, it can be fun. So yes, we also address, of course, patient's preferences, patient's likes, patient's mood, of course. It's not just about technique. But first of all, it's functional, and that's what makes the technique so special and so powerful. So I cannot really remember what was your question.

In fact you've been [00:06:00] asking something different.

Ms. Nicole Duff: No, that's okay. I asked how someone could go about becoming a music therapist, but I think what you're really saying is that what makes it effective is that it engages so many different parts of a patient's personality, life, movement. And it brings them as a whole. And when you're saying function, you're not just saying, "Oh, you have poor balance, let's address your balance," or, "You have poor coordination."

It brings so much together, as well as bringing in the music that they like and I think that's something that's really special. A- and Cassandra, maybe you can feed into that a little bit, I'd like to introduce you and what you do properly just now, but maybe speaking to this specific aspect, maybe you can add your point of view.

Mrs. Cassandra Mulcahy: Yeah, absolutely. From a psychodynamic lens, I don't think of rhythm as just helping with movement. I see it as people becoming more organized and grounded [00:07:00] within themselves. Rhythm is actually one of our earliest experience in life before language. It's the heartbeat, the breath, and the sensation of being rocked.

So it's really tied into how we learn to regulate and feel safe. And within Parkinson's, where people often feel out of sync with their bodies, that steady external rhythm gives them something to lean into, something that's predictable and can help build that coherence. So of course, there's also the relational piece, whether you're moving or making music and rhythm or with someone else, it creates a sense of being met and understood without needing words.

And that can be really powerful in reducing the isolation of somebody with Parkinson's or with anyone with a chronic illness. So yes, it's supporting gait and coordination, but also helping to restore a sense of coherence and connection and identity as well.

Ms. Nicole Duff: That's amazing. Thank you. [00:08:00] I think sometimes we can forget that a dysregulated neurological system doesn't absorb or create plasticity or function as well as it should. And when we can get that regulation, we're activating prefrontal cortices and so many pathways in a way that's just so much more beneficial for the patient.

And when you talk about the regulation and tapping into that rhythm that we know and, we've got rhythm here and all the research that I've got in front of me about the cerebrothalamocortical network and then tapping into the putamen, and of course, we know that all happens, but it doesn't happen unless you really are in that space to be able to be regulated and then enjoy and be open to being able to connect.

So Professor Mainka, do you guys include an element of dance into the walking or is it just pure gait?

Prof. Stefan Mainka: The technique rhythmic auditory stimulation, in fact, is [00:09:00] also used and can also be used for movements other than gait. So it's also applicable for movements when being seated. That's what we in my place transferred into a kind of gymnastics program. So it's a bit like dancing then if you want, but again like we do it, it's a bit more functional.

It can be used in standing position for dance-like exercises. I most of the time don't do that and don't include that in the gait training where we really talk about gait, and we want to quickly get into practice which is close to the patient's environment, close to their habits, close to also just getting the idea I can just leave my house, my flat, and walk around the block and do that with the music.

So very quickly getting into the topic. But coming back to the-- these very interesting points Cassandra mentioned about coherence, feeling of [00:10:00] coherence, feeling of being restructured, identity. And Nicole, you also said that as well. The good thing and the amazing thing about the usage of music is that you have all these aspects in one place from the first note and from the first bar.

And this is the amazing thing, it really affects all of our brain, and there are these cognitive structural aspects, functional movement-related aspects, and of course, all that is related to our feelings, our identity, like Cassandra said. And all these aspects are addressed if they fall into place.

And in therapy sometimes it's depends on the setting, I think, where we work. In my hospital the patients are coming. They are used to be addressed very function-orientated, very much talking about their symptoms because that's what we do in the hospital all day.

While I imagine in other settings for instance, in private practices or settings like this it's also, of [00:11:00] course, very appropriate to talk about, yes, experiences, relational aspects about emotions and feelings. And this is possible, and this is sometimes also equally effective when starting this therapeutic journey together.

Ms. Nicole Duff: I think that the two of you see it so much more than those of us who aren't music therapists, but I can hear the passion coming from both of you as you talk. Just saying, from that first moment that patients engage with that music, you can see something already coming alive in them, something that's, that nothing really else but music can bring about.

And I think that's such an exciting moment and part of their rehabilitation that you guys get to witness, and that we really need to understand a little bit more. Because these non-motor symptoms that we talk about, such as the apathy specifically, when patients just are really unable to bring themselves to do anything, but we have [00:12:00] music which helps them to feel like they can come alive again. So maybe Cassandra, I can go to you and say, have you worked specifically with apathy?

Are non-motor symptoms addressed one-on-one? Do you target each non-motor symptom individually with a different treatment modality? Or is it all non-motor symptoms in one?

Mrs. Cassandra Mulcahy: Yeah, that's a great question. Thank you so much for that. I don't think of it personally as having one specific technique for each symptom. It's more that music really becomes this like flexible medium or modality that can meet a lot of these needs at once. So for things like mood and anxiety, I might lean into rhythm or structure.

Like a steady pulse can be very grounding. It gives people something that they can connect to, which can help, again, regulate that nervous system when things feel overwhelming. For things like apathy, I tend to shift towards creative [00:13:00] entry points, things like songwriting or even digital music creation.

And what I've found is that when somebody creates something of their own, it can spark curiosity and even a sense of awe or wonder. And there's a lot more research coming out that looks at depression, and there's some really interesting evidence showing that brief experiences of awe can actually reduce depressive symptoms and improve wellbeing.

So clinically, that's something that we can translate. Those moments of awe can help reengage motivation and a sense of possibility when someone is feeling more apathetic. So it gives them, again, that creative entry point into that motivation. For things like emotional expression, I might use lyric analysis or improvisation or just giving people a way to externalize what they're feeling without needing to have the right words for it. And then for things like social connection or quality of [00:14:00] life group work is really powerful. Music naturally brings people into that shared experience. So if it's like singing or drumming or just listening to music together, that sense of connection can be really meaningful. Cognitively, music also supports attention, memory, sequencing and so simple structured exercises can help with focus and processing or even like learning different musical techniques or instruments.

So overall, it's less about matching one technique with each symptom and more about using music in an integrative, responsive way, meeting the person where they are and in their culture, in their preferences, in their history, and in their experience, and supporting their whole experience, not just one piece of it.

And as Stefan so eloquently shared music has the ability to really encapsulate the whole neurologic experience so we can access many of these outcomes just through a single [00:15:00] intervention.

Ms. Nicole Duff: Thank you so much. I think that word that you say, a sense of awe, is really quite profound because how many of us actually on a day-to-day basis experience a sense of awe? It's something that really is significant. And I think for me having thought through some of the treatments that you guys do, I think together with awe would be a sense of hope that for these patients, when they can see something that fills them with awe, specifically in their own bodies, if they can see themselves achieving something that they never thought they could, that must fill them with something that again helps with anxiety and the depression and makes them want to engage socially, makes them want to try harder within their therapies.

And so I just love that word that you've used, and I think it's such an exciting one that [00:16:00] I've never heard described with other therapies. No one has awe with the amount of pills they have to take or an amount of awe that they have to try and write bigger. You know what I mean? I just think it's such an beautiful concept that you've got attached to your guys' therapy.

It's really amazing.

Prof. Stefan Mainka: It definitely is. And this creative side which Cassandra mentioned is of course additionally, talking about the neurologic impact on cognitive, emotional, motoric aspects is individually, right? But when we look at music as a group activity where people interact and share ideas and share emotions and share their problems and their difficulties and moments of awe this is of course something also extremely powerful and to get people to take part inside the group with activities Cassandra mentioned this could be singing, drumming, songwriting, or just improvising together on easy-to-play [00:17:00] instruments.

This would be very powerful and very effective, I believe. The sad thing about this is in my country, in Germany, we don't have enough music therapists to really provide that on a regular ambulant basis for all the patients. But this would be very good to have.

Ms. Nicole Duff: I can hear absolutely where you're coming from and I think that again, when we're looking at the research and seeing how much there is and then linking it to the amount that's actually happening with the practice it's very difficult. To hear you guys talking about the benefits that you're seeing from patients, it's something that yeah, I think, all of us are saying there's such a shortage of resources, but the power that you guys have within your therapy is certainly something very unique.

So Cassandra, I'm just gonna dip into you a little bit more. And so I've been on your website with regards to The Sound of Wishes and the terminology that you said it's a name that honors [00:18:00] both vulnerability and vibrancy. And that's I must be honest, my brain hasn't quite been able to engage in that completely to really understand that concept, but tell me how you got to that name.

Mrs. Cassandra Mulcahy: Thank you. It's a name quite simply that kind of came to me as I was going on a walk with my dog at the time. But really on a deeper level, The Sound of Wishes did come from thinking about the emotional space that people are in when they're living with a chronic illness, with grief, or with the everyday experience of what it is to be human.

And I think that a lot of what I bring to the table is helping people to externalize what those hopes or dreams or intentions are. So a lot of times, along with the physical symptoms, there's also this quiet layer of longing, wishes for how things used to feel or hopes how people wish to feel again.

And I wanted the name [00:19:00] to hold that vulnerability but also the vibrancy and possibility. In terms of the work itself, it reflects how I approach treatment. With Parkinson's, I'm not only addressing the motor symptoms through rhythm and structured techniques, but also a space for expression, identity, and connection.

So music becomes a way for people to reconnect with parts of themselves that might feel distant, whether that's creativity, voice, or a sense of agency. So the name really represents that balance, honoring the reality of what someone is going through while also making space for meaning, expression, and moments of vitality within that.

Ms. Nicole Duff: Sure. That's really multifaceted. Thank you for going through that. Professor Mainka, now I know that there's many other areas of music therapy that you are involved in. You spoke about your musical gymnastics, and when I was at your facility, I [00:20:00] went through it and performed much worse than some of your patients.

But you have a couple of others as well therapeutic singing, instrumental improvisation, the music-based fine motor skills, and then what I'm particularly curious about is you developed an app called CuraSwing. Could you tell us a bit more about that?

Prof. Stefan Mainka: Yeah. In this project, in fact, we used the options of the technology of the smartphone, where you have accelerometers and you can provide an ongoing measurement of walking parameters, and we choose the arm swing to be the target input. So in our app, we continually use the motor performance of the patients in their arm swing to shape that with an algorithm into a dynamic changing music.

So the music, we don't just shape and, change one piece [00:21:00] of music. We have a full library of different audio small patches, and they are in the app. They are re-reconnected and remixed, you can say, to the full piece. So we're having different patches for bass, hi-hat, snare, accompaniment, and so on.

And these are composed during walking into a new piece of music, and this piece is dynamically linked to the arm swing. So through this, we bridge over the damaged action perception loop in those patients. Because we know Parkinson patients they can actually move fast, they can move big, but they find it very hard to do it, and they find it even harder to keep it up.

So what works very effectively is these external ways of stimulation that can be either visual, it can be tactile or auditory through music. And in our app, we make the music meaningful. So during walking you walk [00:22:00] to a rhythmic constant tempo. You get a meaningful music that's telling you whether you're doing good functional movements or not.

And we find this really effective in first clinical trials. We see that it really helps patients to improve their motor amplitudes in walking in arm swing and also in step frequency. And we believe this is a really innovative technique to improve therapies. And it's done in the end individually in the home environment, and you don't need a therapist, and you don't need a group.

So this is also very attractive and applicable, for instance, for low-income countries.

Ms. Nicole Duff: I think that's incredible, and this algorithm that you guys have devised is amazing. And I think what it almost does, is when you see someone who wants to go for a run and they put their their AirPods in and they go for a run. A- and for example, someone with Parkinson's who can almost replicate that sense of [00:23:00] normality where they too even though they're walking around normally with your app on, but they could also almost replicate the sense of, "I'm gonna go out and go for my walk," and I'm replicating the same sense of athleticism that someone else might do as well, when it's also a sense of therapy the rest of the day.

I'm not sure if maybe I'm just trying to be overly excited about it, but I think it's an app that can have, as you say, in low income countries, it can really extend into many different areas. So I look forward to the publications.

Prof. Stefan Mainka: Thank you, yes.

Ms. Nicole Duff: We running a little bit short on time, but I have, oh, I've got so many more questions for you. But perhaps one last one is, you guys work under the same umbrella but in very different realms. Do you feel that the word music therapist encompasses both of what you do, or do you feel the word or the title music therapist [00:24:00] should be changed to better explain what each of you do? And maybe that's contentious and you can just say skip. 

Prof. Stefan Mainka: It's perfectly legitimate to ask that, to ask this question, and we also ask this question ourselves at the university, would it be good to talk about music psychotherapy specifically or functional therapy? This is helpful in some ways. It is helpful to target specific goals in research to outline studies and to describe clinical and evidence-based applications.

But in general, I would say yes the general term music therapy is still the best term to have, and there all these things can be incorporated. And as we discussed we do have all the emotional aspects, the relational aspects. We do have psychological inner reflective processes being started by this music, e-even perhaps by a [00:25:00] functional gait training musical activity, it could be the case.

So these things they fall together and this is the magic and the potential of music, and we shouldn't take that away or limit that by being, I think, too narrowly in defining our field Do you agree, Cassandra?

Mrs. Cassandra Mulcahy: I absolutely agree. I think of different psychodynamic therapists and how many different ways they practice, or occupational therapists and how many different ways they practice. And I think that music therapy is absolutely the umbrella that captures all of the magnificence and awe and evidence-based research and magic that we create out there with our patients.

Ms. Nicole Duff: I want to thank you both. I have learned so much more about music therapy and therapists during this time, and you have opened my eyes even wider to the beauty of it. And thank you so much for what you are doing for our patients and I hope that I get to meet you guys again [00:26:00] sometime.

Thank you so much.

Mrs. Cassandra Mulcahy: Thank you so much, Nicole, for having us. It's been an honor and a blessing to speak with you today.

Prof. Stefan Mainka: Thank you, Nicole. Thank you, Cassandra.