Music Therapy Intervention in Parkinson’s Disease Patients: Comparison
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音乐疗法是治疗帕金森病引起的步态障碍的有效方法。节奏音乐刺激、治疗性歌唱和治疗性乐器演奏常用于临床实践。音乐疗法对帕金森病患者步态的机制包括小脑募集的补偿机制、节律夹带、运动学习的加速、神经连贯性的刺激和皮质活动的增加。各机制共同完成音乐疗法对患者步态的干预，帮助患者更好地康复。

Music therapy (MT) is an effective way to treat the gait disorders caused by Parkinson's disease. Rhythm music stimulation, therapeutic singing, and therapeutic instrument performance are often used in clinical practice. The mechanisms of music therapy on the gait of patients with Parkinson's disease include compensation mechanism of cerebellum recruitment, rhythm entrainment, acceleration of motor learning, stimulation of neural coherence, and increase of cortical activity. All mechanisms work together to complete the intervention of MTon patients' gait and help patients to recover better. In this paper, the effect of music therapy on gait disorders in Parkinson's disease patients was reviewed, and some suggestions were put forward.

  • Parkinson’s disease
  • music therapy
  • intervention therapy

一、简介

1. Current status of music therapy

Music is a sound wave composed of elements such as melody, rhythm, and harmony and is defined as a tone or sound arranged in time through a continuous combination of notes [1]. Music activates the "auditory-motor pathway," activating motor neurons through the rhythms contained in the music itself, causing muscles to contract and synchronize body movements with the beat [2]. For example, music with a strong rhythm makes people want to be in sync with it, and the listener's fingers or feet will automatically tap the beat. The main reason for this is that the auditory processing area of the cerebral cortex is adjacent to the motor area. Due to the interaction between the auditory and motor systems, the human body will show corresponding motor performance when stimulated by music [3]. This motor response of the brain to auditory stimuli is called thalamus response. Based on this principle, more and more scholars have applied music to clinical therapy, resulting in Music Therapy. MT plays a role through the cross-activity of the hypothalamic-pituitary-adrenal axis, nervous system, cardiovascular system and digestive system to regulate the psychological and physiological functions of the human body, so it is widely used in the field of medicine and psychotherapy [4]. MT is also used as a special rehabilitation tool for gait abnormalities caused by neurological diseases.

2. Forms of music therapy conducted

MT can be divided into active and passive treatments, depending on the treatment method. Active therapy involves patients playing musical instruments and participating in singing and opera performances under the guidance of a music therapist in a self-fulfilling form. It is a process involving all the sensory organs. The melody and rhythm of music are used as specific stimuli to obtain certain motor and emotional responses, thus combining the movement and stimulation of different sensory pathways, i.e., auditory and tactile (multisensory stimulation). Passive therapy does not require the patient to actively participate in music performance or singing activities, just to listen to music [5]. Passive music therapy is most vital in the treatment effect of PD patients with gait disorders, while active therapy is mainly in the form of teamwork, focusing more on improving PD patients' cognition, mood, quality of life, and other aspects.

3. Modalities of MT to improve gait in PD patients

Current clinical treatment of gait disorders in PD patients consists mainly of Rhythmic Auditory Stimulation (RAS), Therapeutic Singing (TS), and Therapeutic Instrumental Music Playing (TIMP). Treating patients by synchronizing or asynchronizing their walking rhythms with music to adjust walking parameters in this way [6].

3.1 RAS

RAS is a Neurological Music Therapy (NMT) technology that refers to auditory rhythm cues to promote the synchronization of gait movement [7] and is the main method for the intervention of gait disorders in PD patients. A large number of experiments have found that RAS can reshape sensorimotor rhythm and frontal-central parietal lobe/time connection and restore the brain mechanism that generates regular walking rhythm through the intervention of RAS in PD patients with gait disorders. In addition, other studies have shown that RAS has a good therapeutic effect on abnormal gait in PD patients. After treatment, bilateral ankle dorsiflexion and all gait parameters are signifi-cantly improved, and fall index decreases. Spatio-temporal gait parameters, such as stride speed and stride length, are significantly improved [8,9].

3.2 TS

TS is spontaneous behavior, is a kind of internal clue, different from the external clues, such as listening to music rhythm, patients can sing loudly (loud, soft) and in the heart silent in two ways, to synchronize their walk with the pace of the singing, has large variability, can at any time according to the adjustment of the state of patients, and the synchronized rhythm. Compared with external cues, singing does not require any equipment to play music, nor does it require the difficult task of consistently synchronizing with the music rhythm. It can be controlled according to the patient's personal rhythm, reducing spatial and temporal variability [10] and making it easier for patients to complete. Therefore, TS has been regarded as an important method to improve gait disorders in PD patients in recent years.

3.3 TIMP

TIMP has been used in several neurological disorders, including PD, in which patients actively play rhythmic melodies or beats to improve overall and fine motor skills through rhythmic entrainment. Playing Musical Instruments can provide immediate auditory feedback [11]. The instruments used here are mainly percussion instruments that can emphasize obvious beats, such as drums. Such instant auditory feedback can coordinate rhythm and movement, and percussive rhythm can stimulate the movement of patients to synchronize with it, and the movement of playing Musical Instruments can reduce the amplitude of involuntary movement of PD patients. TIMP is mostly used in group cooperation. Some people play Musical Instruments, while others walk and do other body movements according to the rhythm of the music. This form can treat not only movement disorders but also improve the cognitive and emotional quality of life.

4. Study on gait mechanism of MT intervention in PD patients

4.1 Compensation mechanisms for recruiting cerebellum

Since BG is damaged in the brainstem of PD patients and the cerebellum is capable of processing temporal perception and motor execution, the temporal rhythmic perception of musical rhythms and performing synchronized movements are mainly accomplished by recruiting the cerebellum to compensate for the missing function.

4.2 The rhythm of entrainment

The musical rhythm serves as an activation signal to stimulate the PD patient's motor system to synchronize with the musical rhythm. In practice, this rhythmic entrainment synchronizes the walking movement with the musical rhythm and thus intervenes in the patient's gait.

4.3 Accelerated motor learning

When people listen to the rhythm of music, the motor area in the brain will become active, and the auditory environment and incentive effect of music may lead to the acceleration of motor learning [11].

帕金森病（Parkinson's disease，PD）是一种以死亡率低、致残率高为特点的中枢神经系统疾病，患病率约为0.3%[ 1 ]。老年人患 PD 的风险较高，65 岁以上人群患病率为 1~2%，85 岁以上人群患病率为 3~5% [ 2 ]。受全球老龄化趋势的影响，预计到 2030 年，患有 PD 的老年人口将从 8.7 增加到 930 万 [ 3 ]。

4.4 Stimulate neural coherence

PD 主要由黑质致密部 (SNpc) 中多巴胺 (DA) 神经元的消耗和丢失以及路易体 (LB) 神经元中细胞质包涵体的积累引发。PD患者通常有步态障碍和认知问题。步态障碍会对他们的日常生活产生严重的负面影响，其特点是步幅较短、步态较慢和重心不稳定 [ 4 ]，在疾病的后期阶段更为明显 [ 5 ]。步态障碍可能导致日常行动不便，增加跌倒的风险 [ [1]。目前，药物治疗和深部脑刺激主要用于缓解PD患者的步态障碍，但人体的耐药性限制了药物治疗的有效性，副作用如肢体运动异常，会影响患者的日常生活质量[ 7 ]。因此，寻求一种有效且持续的干预措施来缓解 PD 患者的步态障碍是当前临床研究的重点。

When listening to music, music stimulates the nerve to produce excitement. These neural networks are coherent and orderly, and work together to play a role in the coordination of the human body's motor system in the synchronous walking movement with rhythm music, and intervene in gait.

音乐是由旋律、节奏、和声等元素组成的声波，被定义为由音调的连续组合、周期性排列组成的旋律[ 8 ]。音乐激活“听觉-运动通路”，通过音乐本身包含的节奏激活运动神经元，导致肌肉收缩并使身体运动与节拍同步 [ [2]。例如，节奏感很强的音乐让人想要与之同步，听者的手指或脚会自动敲击节拍。其主要原因是大脑皮层的听觉处理区与运动区（MA）相邻。由于听觉和运动系统之间的相互作用，人体在受到音乐刺激时会表现出相应的运动表现[ [3]。大脑对听觉刺激的这种运动反应称为丘脑反应。基于这一原理，越来越多的学者将音乐应用于临床治疗，产生了音乐疗法。MT通过下丘脑-垂体-肾上腺轴、神经系统、心血管系统和消化系统的交叉活动来调节人体的心理和生理功能，因此在医学和医学领域有着广泛的应用。心理治疗[ 11 ]。MT 还被用作一种特殊的康复工具，通过一系列机制干预 PD 引起的步态障碍的治疗，例如小脑补偿机制、节律性夹带、加速运动学习、刺激神经连贯性和增加皮质活动。

4.5 Increased cortical activity

2. MT 的形式

根据治疗方法的不同，MT可分为主动治疗和接受治疗。主动治疗是指患者在音乐治疗师的指导下以自我实现的形式演奏乐器并参与歌唱和歌剧表演。这是一个涉及所有感觉器官的过程。以音乐的旋律和节奏作为特定的刺激，以获得一定的运动和情绪反应，从而将不同感觉通路即听觉和触觉（多感官刺激）的运动和刺激结合起来。接受治疗不需要患者积极参与音乐表演或歌唱活动，只需要听音乐[ [4]。接受性音乐疗法对PD步态障碍患者的治疗效果更为显着，而主动疗法则以团队合作为主，更侧重于PD患者认知、情绪、生活质量等方面的改善。

3. MT 改善 PD 患者步态的方式和临床结果

目前对PD患者步态障碍的临床治疗主要包括节奏听觉刺激（RAS）、治疗性歌唱（TS）和治疗性器乐演奏（TIMP），通过使患者的步行节奏与音乐同步或不同步来调整步行参数来治疗患者。这样[ 13 ]。

3.1。RAS

RAS 是一种神经音乐疗法 (NMT) 技术，它指的是听觉节律提示，以促进步态运动的同步 [ [5]，是干预PD患者步态障碍的主要方法。大量实验发现，RAS可以通过RAS对步态障碍患者的干预，重塑感觉运动节律和额-中央顶叶/时间连接，恢复产生规律步行节律的大脑机制。此外，其他研究表明，RAS对PD患者步态异常有良好的治疗作用。治疗后双侧踝关节背屈及所有步态参数均有明显改善，跌倒指数下降。时空步态参数，例如步幅速度和步幅长度，得到显着改善 [ 15 , 16 ]。西蒙娜 [ 17 ] 和麦金托什等人。[ [6] 进一步发现 PD 患者按照音乐节奏同步行走，步速、步频、步幅均有明显改善，证明 MT 结合步态训练对 PD 的步行功能有更明显的积极影响。患者。在 Thaut 等人的一项研究中。[ 19 ] 在 PD 患者的 RAS 训练中，步态速度和步幅频率的显着增加与胫骨前肌和股骨外侧肌肌电图模式的时间显着变化有关。此外，RAS 可以与其他培训相结合，以获得额外的治疗效果。李等人。[ [7]采用跑步机训练结合音乐干预干预PD患者的冰冻步态，研究结果表明跑步机训练结合音乐干预能显着缓解PD患者的冰冻步态，减少跌倒次数。因此，RAS不仅可以作为主要疗法，也可以作为辅助疗法。

3.2. TS

TS 是一种自发行为，患者主动完成发声，这是一种不同于外部线索的内部线索，例如听有节奏的音乐。患者可以大声唱歌或在脑海中唱歌，并根据歌声的节奏，随时根据患者的状态调整，同步节奏，使自己的步伐与歌唱的节奏同步，变异性大。与外部提示相比，唱歌不需要任何设备来播放音乐，也不需要与音乐节奏一致同步的艰巨任务。它可以根据患者的个人节奏进行控制，从而减少空间和时间的可变性 [ [8] 并且更容易让患者完成。因此，TS被认为是近年来改善PD患者步态障碍的重要方法。埃莉诺等人。[ 21 ]在包括歌唱在内的集中条件下对23名PD患者进行了干预研究，发现歌唱过程中步态变异性降低，提示TS有望成为一种新颖有效的提示技术。佐藤等人。[ 22 ] 有 8 名 PD 患者接受了与歌唱同步进行步行锻炼的训练，他们在训练后表现出步态稳定性、肢体协调性和转向流畅性的改善迹象。哈里森等人。[ [9] 对 60 名 PD 患者进行唱歌或在脑海中唱歌的研究发现，相对于听音乐节奏，在脑海中唱歌和唱歌的步态变异性明显减少，在脑海中唱歌表现出明显的步态变异性。更显着的步态变异性降低。因此，大声唱歌或在心里唱歌可以在一定程度上改善PD患者的步态障碍，这种利用内部线索的新技术为PD康复治疗提供了可靠的指导。

3.3. TIMP

TIMP 已用于多种神经系统疾病，包括 PD，其中患者积极演奏有节奏的旋律或节拍，以通过有节奏的夹带来提高整体和精细运动技能。演奏乐器可以提供即时的听觉反馈 [ [10]。这里使用的乐器主要是可以强调明显节拍的打击乐器，例如鼓。这种即时的听觉反馈可以协调节奏和运动，敲击节奏可以刺激患者的运动与之同步，演奏乐器的运动可以降低PD患者不自主运动的幅度。TIMP主要用于团体合作。有些人演奏乐器，而有些人则根据音乐的节奏走路和做其他身体动作。这不仅可以治疗运动障碍，还可以改善生活的认知和情感质量。帕切蒂等人。[ [4] 进行了一项演奏乐器治疗 PD 的实验，其中 16 名 PD 患者被选择选择自己喜欢的乐器进行打击乐或演奏，而其他人则根据节奏走路。所有患者在TIMP治疗前均接受专业音乐治疗师的指导，在确保患者基本掌握乐器演奏要领后才开始正式治疗。患者每周接受一次 TIMP 干预培训，为期三个月。结果显示提高了运动速度，改善了运动迟缓，改善了沟通与合作，改善了认知。这不仅仅是PD患者之间的互动，更是PD患者自己用来同步行走的鼓点。潘特利亚特等人。[ [11] 要求 PD 患者敲打西非鼓环，以使他们的动作与敲鼓的节奏同步。所有患者在干预前都参加了西非鼓圈课程，以训练西非鼓圈演奏。掌握西非鼓圈演奏技巧后，患者每周接受两次西非鼓圈干预训练，为期六周。干预后，PD患者的步行速度均有不同程度的提高，运动迟缓得到有效缓解。

Perceiving musical rhythms is a process of perceiving time, and walking in sync with it is a process of integrating the timing and sequence of movements that work through the relevant areas of the cerebral cortex. Rhythm music combines the sensory cortex and motor cortex regions.

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