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Abstract

Music is an art form that strongly affects people and can elicit many different emotions at the same time, including happiness, anxiety, sadness, and even ecstasy. What is it about music that causes such a strong reaction from each of us? Music engages many senses, which in turn can produce a multiplicity of responses and help create more extensive neuronal connections, as well as influence behaviour through structural and functional changes in the brain. Music-based interventions as a therapeutic tool in rehabilitation are becoming more common. It is said that the impact of music on the human body is positive. However, what impact does music have on the young nervous system, especially the affected one? This review presents the advantages and disadvantages of the use of music in paediatric neurology to treat dyslexia, cerebral palsy, and stroke, among others. Potential negative impacts such as musicogenic epilepsy and hallucinations will be discussed.

Keywords

Music music therapy brain neuroplasticity children and adolescents neurological disorders

“Music begins where words are powerless to express. Music is made for the inexpressible. I want music to seem to rise from the shadows and indeed sometimes to return to them.”

Claude Debussy

1 Introduction

Many studies show that music, either played or listened to, can affect the plasticity of neuronal connections [1 –3]. Music engages many senses, which in turn can produce a multiplicity of responses (multimodality). This can help create more extensive neuronal connections as well as influence behaviour through structural and functional changes in the brain. Discovering and understanding the influence of music and its therapeutic effect on neurotypical and neuroatypical brains will facilitate the development of effective, maybe even personalized, music-based rehabilitation in the future [4]. Improvisation (free and structured), listening to pre-recorded or live music, vocalization, and singing songs are central music therapy techniques [5]. The use of music therapy (defined as “music-based interventions delivered in a clinical setting by a credentialed music therapist that use various musical elements”) and music-based interventions (the use of music in all experimental forms/protocols to explore its therapeutic effect) [6] as therapeutic tools in the rehabilitation of neurological patients is becoming more common. It is important to add that neither music medicine (which can be offered by medical personnel as pre-recorded music) nor music education involve a systematic therapeutic process, whereas music therapy creates and develops such a process with the help of a trained music therapist [7, 8]. In elderly patients, music therapy is used in diseases such as Parkinson’s disease [9, 10], Alzheimer’s disease, and dementia [11, 12]. In children and adults, it can be used in dyslexia, autism, or attention deficit/hyperactivity disorder (ADHD) [13, 14] as well as others, which will be further expanded upon in this review.

Recognising musical education as an auditory fitness regimen is an interesting concept [15]. The basic terms most related to the concept of human musical responsiveness are pitch, timing, and timbre. Musicians have increased responsiveness to these when compared to non-musicians as shown using imaging at the level of the brainstem [15]. These three elements of musical mastery are honed and practised during many years of musical education, with the best result related to the time of beginning of the learning process – the earlier the start, the better the results.

The vibrating body produces a sound pressure wave which, for many instruments, is of short duration and approximately periodic. The pitch is related to the fundamental frequency, and as frequency increases the perceived pitch is “higher,” while the harmonics are multiples of the fundamental frequencies [16]. The musical transposition is based on 2 categories: pitch distance (number of semitones between notes) and distance between keys (which reflects harmonies’ proximity between keys). The activation of the intraparietal sulcus is a reflection of the degree of temporal and pitch-based transformation of melodic information, which shows a strong resemblance to the visual-spatial transformation [17]. The pitch discrimination depends on cortical and subcortical neural pathways, which differ between musicians and non-musicians [18]. The ability to distinguish the pitch of tones is more accurate and faster in musicians compared to non-musicians, but non-musicians are also able to detect pitch differences [19, 20].

The distinction or identification of the timbre consists of juxtaposing sounds, both of the same volume and pitch, and differences result from the use of a different instrument or voice. In non-musicians, timbre variations can affect the pitch judgment. It is suggested that the differentiation processing of instruments and voice timbre is done within the same neural networks [21, 22].

The definition of rhythm given by the online Oxford Dictionary is “a strong regular repeated pattern of sounds or movements” and “a regular pattern of changes or events,” which may even refer to biological rhythms or the changing rhythms of seasons; currently, much is being learned about the relationship between musical performance and circadian rhythms. Literature data indicate that areas of the brain related to motor output and production (cortico-subcortical networks, basal ganglia, motor cortex, thalamus, insula, and cerebellum) are responsible for the perception of rhythm, hence why humans can synchronize movements with the regular rhythm sequences so easily. Musical rhythm is grouped into a hierarchical structure (meter 2/4, 3/4, etc.) including groups of accented temporal events, where the first beat is considered as strong-accented [16, 23], which gives the listener the expected structure linking the perception of time and salience [24].

Many cortical and subcortical brain structures, which are involved in controlling auditory, emotional, sensory-motor, and cognitive functions [25], are engaged in music processing and production. Those cognitive functions include: emotional networks (emotional perception of music, so also the motivation for listening to or participating in musical activity), the frontal lobe (attention, planning, and coordination of movement, acquisition of musical skills or control, and expression of emotions), the parietal lobe and temporo-occipital areas (integration of sensory inputs), the cerebellum (motor coordination, rhythm processing) and some primary and secondary regions in cerebral cortex responsible for the reception of sensory stimuli [3, 26].

Imaging studies show that musicians have larger gray matter volume in perirolandic regions [27] and wider anterior corpora callosa compared to non-musicians. The age (before age 7) to start music training is critical regarding the size of the corpus callosum but also of the primary motor cortex [2, 28]. Depending on the instrument used and handedness, there also exist differences in brain structure and in the various interactions of the motor, somatosensory, and auditory system. Compared to non-musician controls, lesser interhemispheric asymmetry (in the form of enlargement of the nondominant hemisphere) with a reduced dissymmetry in distal hand and finger movement representation (distal hand/finger motor skills) in right-handed keyboard musicians was observed. It has also been confirmed that bimanual training has a positive effect on the increase of intrasulcular length of the precentral gyrus, especially in the non-dominant hemisphere. Moreover, the earlier bimanual training was started, the more pronounced plasticity effects / structural adaptations were observed (negative correlation between age and plasticity) [29]. For Amunts et al., a negative correlation with age of commencement of musical training in keyboard players supported the hypothesis “that the human motor cortex can exhibit functionally induced and long-lasting structural adaptations”. In string players, increased representation of the left hand was demonstrated in the motor and somatosensory cortex, probably due to use-dependent plasticity [30]. No correlation between duration of musical training and hand performance asymmetry was seen [31]. However, duration can affect left-lateralized activation in Heschl’s gyrus, the ventral supramarginal gyrus [32, 33], and cerebellum (in trumpet player) [34]. The brain, thanks to its complex organization, can adapt or change depending on the conditions. It is suggested that the effect of music has a bigger impact on brain plasticity and connections if the child starts learning sooner rather than later, although positive effects can be obtained at any age [35, 36]. Musical experience probably delays the onset of loss of neuronal connections in the elderly and the appearance of cognitive impairment [37].

There exists a hypothesis that neuroplasticity develops through activation of reward circuitry located in the limbic system. This music-evoked pleasure, mainly induced by preferred music, is related to the release of dopamine in the mesolimbic striatal regions (particularly, activity levels in the nucleus accumbens), just as is seen with primary and secondary rewards. Unfortunately, it is still unclear if dopamine and its circuits are causing or facilitating this pleasure, and whether their appearance is a consequence of that pleasure by engaging dopamine-related learning and motivational systems [38 –40]. Another “reward” is the role of music in interpersonal contacts, such as listening to or making music together. It affects well-being, social attraction, and interpersonal interaction by sharing music-related activities (such as dancing, attending concerts, or cultural events) or music preferences. It must be remembered that responses to music are not only highly specific to personal and cultural preferences, but also place of origin. The experience of music varies from person to person. [41].

There is a model which links individual properties of music to therapeutic mechanisms called the Therapeutic Music Capacities Model (TMCM). In this model, authors try to define the therapeutic benefits of music by identifying the core qualities or capacities of music. They recognized seven capacities of music (and music interventions) that interact together and engage neural mechanisms. Among them are: engaging, emotional, physical, synchronous, personal, social, and persuasive capacities. Different capacities can be used depending on goals, challenges, and symptoms. Unique to music is the ability to use a large number of capacities in a pleasant and accessible manner at the same time, activating mechanisms such as the mirror neuron system, neuroplasticity, and intact shared or compensatory neural networks resulting in cognitive, psychosocial, motor, and behavioral benefits [42, 43].

2 Early childhood and youth

Preterm birth negatively affects the maturation of the child’s nervous system and can lead to neurodevelopmental or behavioural impairments. These can be evident in childhood and include anxiety, socio-emotional problems, or psychiatric disorders [44]. Modifications of brain network or microstructure and early developmental brain anomalies in regions responsible for emotion and socio-emotional processing have been found in preterm infants. It has been proven that the use of music for sensory stimulation, especially in the critical period of auditory maturation, affects activity-dependent brain plasticity, increases functional connectivity, and leads to structural brain development. In particular, the effect of music on amygdala volume can be seen. However, in addition to artificially selected stimulating factors, postnatal environmental and maternal factors such as heartbeat sounds, and singing or speech strongly stimulate the nervous system for further development (based on the stimulation of the primary auditory cortex) [45, 46]. The positive effect of the combination of music therapy and mother singing seems to be even more useful in the case of preterm infants with severe brain injury. Interventions based on sensory stimulation decrease length of hospitalization, improve behavioural state organization, neurobehavioral development, and breastfeeding [47].

Music stimulation can improve language development in neurodevelopmentally normal children. Studies were carried out to compare the impact of music and art education on speech development in school-aged children. The results showed a great advantage of music over art education in terms of its impact on speech amelioration. Music improves general auditory coding capabilities by affecting the brainstem and auditory cortex. It can also affect memory traces by increasing the efficiency of working memory and by sequencing processes integrating pitch and syllabic structures. Additionally, a positive effect on neuropsychological tests, intelligence tests (IQ), and verbal ability was demonstrated, which further motivated children to pursue artistic development [48 –50].

3 Dyslexia

According to the Polish Dyslexia Association, the incidence of dyslexia in Poland is 9–10% of students. In the European population, this percentage accounts for around 10–15%, while for the general population the prevalence of anywhere from 5–10% to 17.5% is assumed [51, 52]. Despite not having a neurological disorder, those with dyslexia can have poor temporal and phonological processing skills such as difficulties in reading, trouble in differentiating similar sounds, difficulty uttering syllables, and impaired coordination of movements. They can have these despite a normal level of intelligence, normal comprehension, and adequate education. These kinds of dysfunctions may lead to school problems, anxiety, and introversion [53, 54]. Research results show the positive impact of music education on phonological awareness and reading skills. The improvement of phonological awareness is due to adequacy of the use of phonological units from larger to smaller, i.e. from a full phrase to a syllable [55].

It is estimated that people with dyslexia have poor perception of rhythm and meter. Temporal processing skills are important in auditory processing. This means that the speed of auditory information processing influences the development of proper listening and language competences. Accurate rhythm reproduction is a predictor of the accuracy of reading pseudowords, while the proper meter perception task is connected with text reading accuracy and word reading speed. The mother’s formal education also plays a role in the accuracy of word reading [56, 57]. The education of the parent, especially the mother, also affects the intellectual achievements of the child, and the development of vocabulary is associated with better later recognition of words [58].

The perception of pitch and rhythm affects the achievement of correct speech prosody, but does not have to strictly affect language skills (it is responsible for only 57% of developed dyslexia). It is assumed that low sensitivity to a change in amplitude and rise time detection can predict the development of this disorder in 100% of cases [57, 59].

“Music rehabilitation” by nonverbal/instrumental music training has the potential to adaptively affect brain plasticity of the same neural network that is involved in speech processing. There is an overlap of neural networks, where music plays a dominant role (higher demands than for speech), and induces positive emotions. This musical activities are repeated and related to focused attention [60]. In the multicenter, open, randomized controlled trial Flaugnacco et al. [53] hypothesized that the improvement of reading skills and phonological awareness in children with dyslexia could be influenced by musical training. Their theory was that the children would be influenced by improving rhythm abilities and temporal processing, because those with dyslexia have temporal processing deficiency (both in music and language). This trial confirmed reading accuracy (including pseudo-word reading) improvement. This result also supports the hypothesis that phonological development and language acquisition are influenced by rhythm-based processing. One can use methods based on music and rhythm (multi-modal) such as playing an instrument, singing (by matching the syllable to the metrical structure), metrical poetry, or rhythmic movement to the music [61].

Group classes performed as rhythmic entertainment in the presence of a positive and playful emotional environment are recommended and can lead to synchronization of abilities among participants. This type of activity should be a dynamic process in order to maximize the demands on the audio-motor loop and predictive processing in a fully active setting with movements and dance, music making, and focusing on rhythm rather than pitch accuracy. The best recommendation for children with dyslexia is likely rehabilitation based on the development of rhythm through the use of percussion instruments and body tapping, e.g. lips and limbs, to create beatboxing or rap. It would help to improve global temporal skills and may facilitate fast temporal processing of speech sounds. Large variation will keep children’s attention and allow them to generalize this process and transfer it to language and reading [56 , 63].

4 Cerebral palsy

Cerebral palsy (CP) is a group of symptoms caused by permanent non-progressive brain damage. Many factors promote the development of this disease, including pregnancy-related factors (e.g. delivery hypoxia, prematurity) and maternal factors such as a mother below 16 and over 40 years of age. In the Polish population the incidence of this disorder is estimated at 2.0–2.5 cases per 1000 live born children [64].

Preliminary research conducted on a group of children with CP showed the potentially positive effect of monthly auditory stimulation based on gamma waves (32–250 Hz) compared to ordinary listening to music [65]. Stimulation for at least 10 minutes four times a week for four weeks (patients with a Gross Motor Functional Classification Scale level of 2 to 5, median 4) improves motor function [rated with Gross Motor Function Measure (GMFM), Goal Attainment Scale, and Quality of Upper Extremity Skills Test (QUEST)], improves communication with the child, and reduces the burden on the guardian (assessed with the use of Care and Comfort Hypertonicity Questionnaire). At the post-intervention assessments (20 weeks after intervention), parents’ reports showed that the child’s body became more relaxed and cognitive functions such as attention, communication, and collaboration were improved. Caregivers did not report side effects regarding sleep, salivation, head control, urination, or bowel movement problems. Significant improvement in the treatment group was seen in walking (p = 0.006) and standing (p = 0.017) on the GMFM scores (p = 0.41) and protective extension (p = 0.001), weight bearing (p = 0.014) and grasps (p = 0.014) on the QUEST scores (p = 0.006). The positive effect of therapy lasted up to 5 months [66].

The speech formation process is delayed in up to 96% of patients with CP. The disorders may be transient or permanent and may vary in severity [67]. It is suggested that around 33–63% of patients with CP have some form of communication difficulty. Furthermore, speech disorder and delay seems to be independent of cognitive ability [68]. Children have a poorer vocabulary and incorrect sentence structure, e.g. sentences are incomplete and short. Intellectual disability is a factor that affects speech abnormalities in half of cases, however the correlation is not proportional. The type of speech disorder, including dysphasia or dysarthria, is related to the location of damage (e.g. damage of the language areas or other structures involved in speech development) and its size [67, 69]. The presented speech disorders also depend on the form of CP. In the pyramidal form of CP, speech disorders of the dysarthria type are caused by damage of the subcortical-cortical tracts with varying severity and extent of damage. Speech disorders caused by pseudobulbar palsy are frequently seen in bilateral hemiplegia. In addition, epilepsy occurring in CP [inhibitory effect on psychomotor development, secondary central nervous system (CNS) changes], visual disturbances (impaired eye contact between the patient and others), and less commonly hearing impairment (perception disturbances) may contribute to speech disorders [70]. Research in children with speech development delay, based on the Nordoff-Robbins method (Creative Music Therapy), confirmed that this method not only effectively improves phonological memory and children’s understanding of sentences, but also ameliorates the relationship between the child and therapist, as well as communication skills. The use of different improvisational techniques [71, 72] and rhythmic structures also seems to play a key role in human perception and action (see dyslexia subsection) [73].

In addition to speech disorders, there are posture and movement disorders which limit the activity of affected children [74]. These patients may also have attention, cognitive, and sensory disabilities. More severe cognitive impairments are observed in epilepsy, brain malformations, or spastic quadriplegia. However, there is no clear consensus on the correlation between the intensity of motor impairments and cognitive disorders [75, 76]. Instrumental training has the potential to influence motor, executive, and cognitive functions (motor and personal development), positively influence brain plasticity, as well as increase a patient’s motivation and relaxation. Among others, piano/keyboard lessons or playing percussion instruments are mentioned (probably due to the fact that those instruments are easily accessible, do not require musical predisposition, and that the sound is produced directly after hitting) as arousing and sustaining positive changes in the CNS. This includes promoting functional and structural changes and effective connectivity between the cerebellum and primary motor area. They are also thought to help the development of sensorimotor skills, as hand movement coordination is required during the use of any instrument [77, 78]. In addition, integration processes occur in many regions of the brain with overlapping visual, auditory, and tactile feedback (multiple demands). Playing instruments involves bidirectional interaction (forward and backward transmission) of information in the central nervous system and peripheral motor structures. Such stimulation can occur at any age and at different timescales [79].

A positive effect of rhythmic auditory stimulation on gait patterns in CP was also investigated [80]. In such stimulation, it is important to emphasize each component of gait and conduct proper physiotherapy, achieving muscle tone stabilization and good body posture alignment. Improvement of functional walking consists of inhibition of abnormal movement patterns and facilitating ordinary components (reflexes, muscle tone) [81]. Improving gait and mobility is a widespread goal in cerebral palsy rehabilitation. The lack of gait treatment can lead to an increase in motor disability and a reduction in physical activity affecting adulthood. Furthermore, gait training seems to have a more significant effect on walking speed than standard physical therapy [82]. In addition to the positive impact on hip and pelvic movement (kinematic parameters), rhythm activates the muscles according to specific timing, synchronizing steps and muscle activation. This increases speed and decreases movement diversity (reduce gait abnormalities) which leads to the improvement of cadence, walking velocity, and stride and step length. Music therapy can further reduce pain (the most common for which are the neck, back, and feet) and fatigue, which are commonly reported symptoms in CP [83 –85].

Considering the diversity of symptoms in cerebral palsy, careful observation of the child is of utmost importance. Caregivers should be careful when making decisions since auditory stimulation may increase the number of epileptic seizures [86] since epilepsy can co-occur with CP with the incidence of epilepsy in CP ranging from 15–60% and has been reported to be as high as 90–94% [87].

Rehabilitation in CP should promote the development of nonacquired skills with early rehabilitation recommended [79].

5 Autism spectrum disorder

The aetiology of autism spectrum disorder (ASD) is not well known (environmental, neurobiological, and genetical factors have been suggested). However, this complex neurodevelopmental condition persists throughout one’s lifespan and has lifelong impacts. ASD prevalence estimates vary, though currently it is assumed to affect 1.5% of the population [88] and affects males 3–4 times more frequently than females [89]. This global developmental disorder is characterized by impaired communication, interpersonal contacts, behaviour, and cognitive function. Intellectual disability and attention deficits occur in about 30 percent of cases [88, 90]. Children with ASD are about 7 times more likely to develop epilepsy than the general population, and the co-occurrence of intellectual disability increases this risk even more (probably by 3–5 times) [91]. Certain sounds can lead to crying, covering of the ears, irritation, or anger and this sensory dysfunction results from improper processing of stimuli by the brain, e.g. hypo- or hyperreactivity to sensory input [92, 93]. Language deficits are not considered a significant feature in ASD (they are instead regarded as co-occurring conditions). However, speech production difficulty and impaired speech fluency or clarity have also been described in the form of motor and oral-motor impairments [94 –96]. In ASD the number of short (cortico-cortical, cortico-subcortical) and long range (different brain regions) connections in the brain are reduced. It is hypothesized that the abnormality of long-range connectivity may lead to social-emotional and communication deficiencies. Correct stimulation (e.g. musicotherapy, music-induced neuroplasticity) affecting those neural networks can lead to an improvement of functions due to structural plasticity. Over-connectivity of sensory networks has also been reported, in which case music can play a modulating role, reduce excessive neural information, and improve the communication process [94, 97].

In ASD, the goals of music therapy focus on better socialization, connection skills, and cognitive and language functions rather than on physiology [98]. Rhythmic entrainment methods can involve large networks of brain connections and structures. These methods together with synchronization, rhythmic vocalization, and bimanual motor actions can stimulate and improve speech, language and motor skills, and restore natural rhythms by reorganization of abnormal circuits. There is also a hypothesis that rhythmic interventions can alleviate anxiety, decrease repetitive behaviour, increase awareness, and improve organization of sensory experiences [94, 99]. Children diagnosed with ASD have problems with synchronization because of a unique rhythmic movement profile. Organization of body rhythm in the form of body attunement within various types of therapy, such as music or dance therapy, helps to improve synchronization and cooperation [100]. Additionally, free musical improvisation, which does not require either antecedent musical skill nor competence in the child, can allow the child to express their feelings and personality artistically. The therapist’s use of structures such musical dialogue or “frameworking” can help to break or disturb the rigid patterns of behaviour and play. However, therapeutic and musical skills are required of the therapist to achieve this goal [101].

Research conducted by Geretsegger et al. [5], suggest that music therapy used in ASD improves social interaction, adaptation, social-emotional reciprocity, verbal and non-verbal communication skills, and behaviour initiation. Furthermore, music therapy can positively influence family interactions and quality of life. This applies in particular to improvement of the (parent-reported) social communication, benefits of disability-related supports, coping, and cohesion [97]. It is also argued that early motor ability delays may be linked with receptive and expressive language development and interpersonal contact disorders. Therefore, there is a possibility that the development of motor skills may improve social and language outcomes [102].

Group training can also be helpful for children with ASD. Working in pairs teaches them to cooperate and open up to the person with whom they are practicing (e.g., using a mirroring exercise to imitate their partner). These exercises often require eye contact, observation ability, and attentiveness which are impaired or often absent in those with ASD. It is possible that music makes it easier to establish social engagement. Additionally, creative exercises improve self-regulation and reduce repetitive behaviours, including stereotyped and compulsive behaviours [103]. Meta-analyses suggest that both group and individual therapy improve social interactions [104] and that group therapy can reduce anxiety symptoms in children with ASD with IQ > 69 [105].

The next positive aspect of music therapy is its effect on body weight. Some classes involve with active participation of the child, which can lead to a decrease in body mass index, greater physical activity, and better body posture. It is documented that children with ASD spend significantly more time in sedentary pursuits like watching television or playing video games than typically developed peers. This lifestyle type can also result from social conditions (as lack of available transportation), poor motor or social skills and community level barriers [106]. Additional difficulties for children with ASD include motor impairment (including problems with postural stability, balance, movement speed, gait, and joint flexibility), poor nutrition, metabolic abnormalities, and polypharmacy [107, 108]. The use of music as a motivating factor during exercises with children affected by ASD can lead to increased engagement, interactive communication, and desired energy expenditure. The tempo used increases willingness to do sports. It should not be too fast, because then it produces an effect similar to the absence of musical stimulation. It may be surprising to note that the best impact on behavioural disorders is observed with the use of slow music which can not only regulate maintenance but also enable focus and extend exercise intensity [107].

It appears that skills such as excellent attention to detail, sensory responsivity, and extended sensory-perceptual processing and discrimination [109] can be successfully used in art therapy, and thus also in music therapy. Although there are many studies on the musical abilities or higher incidence of absolute pitch in children with ASD as compared to typically developing peers [110], the results are inconclusive [111]. These different results may be due to the fact that children suffering from ASD exhibit interest in music at an older age than average. Other factors include the child’s gender, different diagnostic criteria used in research, and the presence of more severe hyperactivity/inattention and lower working memory (the latter two may share a neural substrate with musical deficits). It should also be noted that abilities and preferences are also influenced by the child’s place of residence, cultural background, and language spoken [112].

6 Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in childhood (more than 5% of children and 2.5% of adults). It can have a meaningful impact on the quality of life of the individual and their family, as well as the social and/or educational functioning of an individual [113]. Neural connection disturbances in cerebellar-cortical and fronto-cerebellar pathways are seen in ADHD. These are responsible for distortions in the duration of perception and production of basic linguistic processing, including phonological features, phonemes, and syllables during the auditory input and articulatory output of spoken language; they can therefore result in poor reading, language, and attention skills. Also, basal ganglia anomalies and decreased connectivity with the cortex have been described. These may be related to cognitive and sensorimotor functions. Consequently, children and adults with ADHD suffer from rhythmic deficits. These beat-tracking skills are closely linked to the cognitive functions of inhibition and flexibility [114, 115]. It seems that the presence of impulsivity is also linked to abnormalities in timing skills [116]. It was observed that children who have the ability to synchronize to the beat demonstrate better attentive behaviours. In the presence of cognitive or developmental disorders, simple and easy-to-follow musical activities can be successfully used [117]. Therefore, rhythm-based therapy or sessions with piano or Orff Instruments may have therapeutic potential in improving attention (e.g. by using irregular rhythm or changing nature of the music) and decrease impulsivity and hyperactivity in ADHD [118]. Activities in a group of peers with the creation of structured (especially rhythmic) music or instrumental or vocal improvisation, can lead to increased impulse control and internal organization, improved body awareness, and motor coordination [119, 120].

7 Stroke or acquired brain and spine injury

There is more literature being published about neonates and children suffering from cerebral infarction. The diagnosis is often delayed and may result in epilepsy, sensorimotor deficits, language impairment, or even death. The frequency of stroke in children varies from 1.2 – 13 per 100,000 person-years (it depends on the size of the studied groups) [121]. The aetiology of stroke is significantly different from that of adult patients. However, up to 20–30% of strokes are of unknown origin [122, 123]. In the early post-stroke period, one of the basic elements of neuroplasticity (and functional recovery) is the reorganization of the cerebral cortex, during which the management of different functions migrates from the damaged part of the brain to undamaged areas. For this reason, it is essential to begin rehabilitation as early as possible [124]. Unfortunately, the number of reports on post-stroke rehabilitation in children is limited, so this review focuses on reports in adult patients. Therapeutic effectiveness was proven for neurologic music therapy (NMT), especially using the rhythmic auditory cueing (RAC) technique [125], in the rehabilitation of patients after stroke. Research suggests that the periodicity of a pulsed rhythmic auditory signal (e.g. in rhythmic auditory stimulation RAS) may affect the activity of motor neurons. This leads to more regular and synchronized patterns by obtaining more consistent timing and motor unit recruitment. This results in an improvement of basic gait parameters such as step cadence, velocity, and swing symmetry, which are important in gait rehabilitation and motor deficits [126, 127]. Thaut et al. [128] showed in their research superiority of the RAS method over neurodevelopmental therapy (NDT)/ Bobath training for gait performance in subacute hemiparetic stroke rehabilitation, especially if this method has been used for a longer period of time. The Bobath method is an approach to neurological rehabilitation that promotes motor learning for efficient motor control in various environments, thereby improving participation and function. Enhancement of gait performance and dynamic postural stability can be obtained with a training length of 20–45 minutes session for 3–5 times a week [129]. The RAS method is currently included in the adult stroke guidelines – Evidence level A [130]. The authors found no similar recommendations for the paediatric age group.

Also, playing a musical instrument can enhance motor function, especially of the upper extremity, which can be disturbed by a stroke as well as after an injury. This activity active music-based approach, in addition to helping the child learn motor skills, also strengthens cognitive functions (including the perception and integration of information from different modalities) [3, 131]. Even simply listening to music (passive intervention) can lead to activation of motor and premotor areas and marked improvements of fine motor skills [132, 133]. Research shows that listening to music can positively affect visual awareness in patients with neglect, improving recovery of memory and attention. It also has been shown to have emotional and psychological impact (mood improvement, prevention of depression, stress reduction) [134].

Aphasia is a complication of stroke (or other brain injury) leading to loss of the ability to produce and/or understand language. Its nature and severity are influenced by the size and location of the lesion e.g. fluent aphasia in Wernicke’s area injury or non-fluent in Broca’s area injury. In non-fluent aphasia, Melodic Intonation Therapy (MIT) is applied through melody and contour enhancement and sensorimotor network engagement, resulting in improved propositional speech (the generative and controlled language production). Everyday sentences are produced by a patient in a singing-like manner (with an exaggeration of natural prosody) and while they tap on each syllable with the left hand [135 –137]. In the therapy of fluent aphasia, MIT may be beneficial as well [138].

Songwriting is a process in which the patient (often referred to as the client), alone or with a therapist, creates and/or records lyrics and music within a therapeutic relationship to assuage their needs (emotional, psychosocial, cognitive, or communicative) [139]. This method depends on completing a song in series of sessions (generally one to five), during inpatient stays or a slower stream, insight-oriented work [140]. The structured therapeutic songwriting with lyric analysis can be proposed to patients after spinal cord injury, acquired brain injury, or stroke to think over losses and construct a new perspective or self-concept, e.g. meaning, satisfaction, and quality of life. In order to encode the process in memory, music should be paired with lyrics that coincide with activation of emotions [141, 142]. Healthy reintegration is also supported by identity-focused songwriting, where self-concept is considered to be an important driver in the subacute rehabilitation setting [143].

Music therapy can be a potential method of rehabilitation for children with vascular brain disorders. However, it requires further research since most of the cited literature was related to adult patients.

8 Musicogenic seizures and musical hallucinations

In addition to the positive aspects of music, its negative effects are also described in the literature. An extremely rare type of epilepsy in children is musicogenic epilepsy. Its estimated prevalence is one in ten million [144, 145]. It is a type of epilepsy with a not fully understood pathogenesis. Seizures occur in response to musical stimuli that either emotionally (due to emotional content, mediated through the limbic mesial temporal lobe structures/mesolimbic system) or because of the type of instrument, music, or emotional content affect the occurrence of reflex epilepsy (however, not all cases fulfill the criteria). It should be added that the latency between the occurrence of the stimulus and the seizure is controversial, it can take one to several minutes and during this time tachycardia, excitement, and tachypnea may be observed. This type of epilepsy has strong correlation with the temporal lobe and a right-sided preponderance. It may also depend on the level of musical education with predisposition for this condition growing in direct proportion. There is also a tendency for lateralization of musical hallucinations in electrical brain stimulation with more right over left preponderance [146].

The type of seizure occurring varies depending on the precipitant factors. In addition, there are difficulties in distinguishing reflex seizures from spontaneous epilepsy because patients can experience both phenomena, and the difference is based on the time between the appearance of the stimulus and the occurrence of the seizure. It is important to add that in reflex seizures, there is an identifiable trigger which consistently evokes seizures. Spontaneous seizures precede reflex seizures [147]. In addition to genetic predisposition and acquired lesions, an altered neural network (dysfunction in decisive, associative, and emotional circuits) is also taken into account. Hypersynchrony may lower the threshold for seizure activity or may cause hyperexcitability of certain brain areas (which facilitates and triggers the epileptic seizure) by functional activation for epileptic discharges of a small area by exposure to particular sensory, cognitive, or motor stimuli [148, 149].

Treatment with carbamazepine or, less often, oxcarbazepine can lead to reversible altered pitch perception. Surgery may be associated with impaired music memory and reception (as timbre, pitch, tone) if it affects the right temporal lobe including Heschl’s gyrus. Research shows that the right hemisphere is responsible for pitch processing (frequency resolution) and the left for speech analysis (temporal resolutions). Differences are also seen for the left and right auditory cortices in the processing of temporal and spectral aspects of acoustic stimuli. Imaging tests during musicogenic seizures using functional magnetic resonance imaging and subdural electrodes showed activity within right mesial temporal lobe, lateral temporal lobe, Heschl’s gyrus, insula, and frontal lobe areas. During emotional melodies fronto-occipital and fronto-orbital activation was seen [147, 150]. Up to 16% of patients suffering from epilepsy originating in the frontal lobes also experience hallucinations in the form of ticking, melodies, or others during an epileptic seizure [151].

Sanchez-Carpintero et al. [152] described musicogenic seizures in a child with Dravet syndrome. The boy was born after a normal pregnancy and delivery. The parent’s neurological history was unremarkable. Until 6 months of age his psychomotor development seemed to be normal. However, the interview showed that at the age of 4 months the baby developed fever after a vaccination and had a generalized clonic seizure that lasted 10 minutes. Furthermore, parents noted that the myoclonic jerks had occurred previously during warm baths and under varying light conditions. With time, more and more seizures occurred, and they were caused by various stimuli. At the age of 5 years, only fever and music precipitated his seizures. They usually started 3 to 5 seconds after the beginning of the music – which were melodies from electronic devices and sometimes played on the piano. Certain melodies provoked loss of consciousness accompanied by eyelid and perioral myoclonia and finished as a generalized clonic seizure.

In juvenile myoclonic epilepsy, the impact of stimuli such as auditory precipitation or playing an instrument (in addition to factors such as sleep deprivation, menstruation, and excessive alcohol intake) are classified as triggering factors [153, 154].

Listening to Mozart’s Sonata for two pianos in D major (K448) may have a potential anti-epileptic effect on abnormal epilepsy activity as shown on children’s EEG. This effect may be due to enhanced synchronization in the right frontal and left temporal-parietal areas. However, there are many theories that require further investigation as a possible non-pharmacological supplementary treatment or an additive to antiepileptics [155, 156].

9 Hypersensitivity to sound

In their synthesis, Williams et al. [157] estimated the prevalence of hyperacusis in the ASD population to be 37–45%. Additionally, approximately 50–70% of individuals with ASD may experience these disorders at some point in their life. Less information can be found on the relationship between hyperacusis and ADHD, however the literature prevalence range is noted to be 3.2–17.1% [158, 159]. This is a hearing disorder when an individual has decreased tolerance or increased sensitivity to sound levels that do not bother most individuals. People experiencing hyperacusis find everyday sounds unpleasant or painful and perceive them as more intense and louder than they are [160]. Those sounds can also lead to distress and anxiety. Unfortunately, this disorder can have a profound effect on children’s behaviour and sometimes results in abnormal social interactions, isolation, and educational consequences. Greater emotional or even anxiety responses to sound can be caused by functional alterations in the central nervous system and generalized hyperactivity of auditory and extra-auditory pathways [161]. There exist no current recommendations for behavioural or pharmacological treatment of this disorder [157], but in such cases, music therapy should be applied with extreme caution.

10 Conclusions

Music therapy, like all treatments, has its advantages and disadvantages, as well as recommendations and contraindications. The implementation of music therapy or its components should depend on the level of intellectual and physical development of the child, as well as desired goals, challenges, and symptoms. The benefits of music employment in therapy include increased music-induced neuroplasticity, increased motor, executive, and cognitive skills as well as improved motivation, relaxation, and social outcome. Comorbidities must be considered; in the case of epilepsy, the selected therapy should not increase the excitability of neural circuits or cause an increase in the frequency or discharge leading to seizures. In case of hyperacusis, music therapy should be applied with extreme caution.

Music education and other musical activities give children pleasure and can be a desirable alternative to remaining sedentary. Motivating children to create music, dance, and participate in rhythmic activities can have many positive effects on linguistic, memory, motor, and emotional development. So why, if we have such an easy opportunity on hand, not take advantage of it?

Music-based interventions and music therapy can be conducted individually or in groups. This can be decided based on context, symptoms, and planned goals and depends on triggering neural processes: motor, behavioural, cognitive, and psychosocial. Those music activities may be active (playing, dancing) or passive (listening).

Properly, music therapy should be conducted by a person with completed studies (bachelor’s, master’s, or postgraduate studies, depending on the country). In the case of conducting an intervention that affects motor or other special skills of a participant, such a person should work or co-treat with other allied health professionals depending on the therapy goals. Music therapy is an allied health profession which, in addition to the above-described issues of child neurology, provides assistance for adults and children with psychiatric, cognitive, or developmental disorders, as well as speech and hearing impairments.

It seems that a good solution for therapy in children with neurological diseases would be the inclusion of music therapy in rehabilitation or speech therapy activities. This therapy can be conducted by outpatient and inpatient allied health or rehabilitation teams. Like other non-pharmacological treatments, music therapy takes time and needs consistent administration to produce the tangible intended effects.

Further research should be carried out on children after stroke and vascular diseases of the brain or acquired injuries, as there is still little literature on the subject. Interesting results could likely be obtained from research into neuromuscular diseases and tics, but they remain unexplored.

Conflict of interest

The authors have no conflict of interest to report.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Where words are powerless to express: Use of music in paediatric neurology

Abstract

Keywords

1 Introduction

2 Early childhood and youth

3 Dyslexia

4 Cerebral palsy

5 Autism spectrum disorder

6 Attention-deficit/hyperactivity disorder

7 Stroke or acquired brain and spine injury

8 Musicogenic seizures and musical hallucinations

9 Hypersensitivity to sound

10 Conclusions

Conflict of interest

Funding

References