John was playing the chords to the Doxology for the sixth time when Brian, the transportation aide, knocked on the door of the music therapy office. “Time for physical therapy, Mr. Thomas,” Brian said, poking his head around the door. When John didn’t respond, I put my hand over his, gently, and made eye contact. “Time to go,” I said, while gesturing to my watch and then to the door. I stood up and John slowly pulled his hands from the electronic keyboard. I maneuvered his wheelchair in my small office so that we could open the door completely and then bent down to shake John’s hand and say goodbye. As I took his right hand in mine, he reached up with his left and covered my hand, squeezing it and looking intently at me, tears forming in his eyes. I paused, seeing that he wanted to tell me something.
“My leaf is in your hands,” he said.
***
During the last three years that I worked in physical rehabilitation medicine, my music therapy office was in the same wing as the speech-language pathologists. I think I had moved there from the therapeutic recreation area due to space considerations, but in many ways it made sense from a treatment standpoint; most of the referrals I received were for patients who had difficulties with communication.
I worked in an “acute” rehabilitation facility; patients usually were admitted to our hospital directly from the hospital where they had received care immediately after their stroke, car accident, or other trauma. The chart for my newest patient, John, noted that the cause of his injuries was unknown, that he may have been assaulted but that he had certainly fallen from the rooftop of the business where he was repairing the air conditioning. His most serious injury was to the left hemisphere of his brain, particularly to the temporal and parietal lobes.
The left temporal lobe is, for most people, key to the ability to use and understand language. John had damage to an area called “Wernicke’s” – named for the man who identified its importance – and the speech therapist’s evaluation had confirmed that he had “Wernicke’s aphasia” – an inability to understand language. Normally, this would have been a “contraindication” for music therapy; patients with Wernicke’s aphasia do not tend to respond significantly to music therapy interventions. John, however, had a musical background. He was one of two organists at his small church and at the first staff meeting after his admittance to the rehab hospital, his family had mentioned that music was important to him. These were the days before managed care and severe restrictions on the therapies we could provide, so the physican in charge of John’s care wrote an order for a music therapy evaluation.
As was my custom with new patients, I went to observe John while he participated in another therapy to get an idea of how he performed without the cues and structure he would receive in music therapy. I found him in his room with his occupational therapist, Tim. Tim was working with John on basic grooming skills: combing his hair, brushing his teeth, using an electric shaver. Tim worked on language skills at the same time and this is where John had particular trouble.
Wernicke’s aphasia also is known as “receptive aphasia” because while the patient with Wernicke’s may be able to speak and write, he will have difficulty being able to understand what is said to him, or to read. In addition, he will have problems evaluating his own speech.
The areas that produce, control and evaluate speech and language in the left hemisphere are quite close together. It is not unusual, therefore, for an injury or stroke to cause problems with both expressive (talking, writing) and receptive (listening, reading) language. John’s injuries had affected the receptive areas primarily, but his expressive abilities weren’t perfect. An example of the problems this presented arose when John asked for his comb. Because of the expressive damage he had, he substituted another word for comb, saying “Give me a cat”. Unable to understand what he himself had said, John expected Tim to hand him the comb. When Tim said, “I don’t understand” (another thing John couldn’t comprehend) and failed to follow John’s instructions, John became frustrated. When I arrived at the room, John and Tim were well into their session, and John was well into aggravation. Within a couple of minutes of my arrival, John threw his brush at Tim’s head.
After the session, Tim and I talked. “John’s having trouble with the sequencing of his grooming routine,” Tim said, “so it would be great if he could understand and use language as a cue. So far, though, he‘s just getting more and more frustrated and angry. Repetition will help, of course, so we’ll press on.”
Conversations with Kate, John’s speech therapist, and Phil, his neuropsychologist, confirmed that John was demonstrating a fairly clear picture of Wernicke’s aphasia and that his frustration was affecting his ability to benefit from therapy.
I knew, from case studies and research, that music therapy likely would not have a significant impact on John’s verbal communication abilities; he would be able to repeat things I sang to him and probably be able to sing familiar songs, but without comprehension. I had treated a patient once who had been able to sing, with perfect clarity,
“Yes! We have no bananas! We have no bananas, today!”
and yet, when presented immediately afterwards with a photograph of bananas next to a photograph of a towel, he not only could not pick out the bananas but seemed to have no idea why I’d shown him the pictures. So in John’s case, I didn’t expect that I would be able to help him significantly with functional communication.
Nevertheless, it was obvious that John was discouraged and I wanted to find out if he could participate in music in some way. Perhaps the opportunity to hear his favorite music would provide some relief from the stress and frustration. That was the perspective I had when John came to my office for a music therapy evaluation.
Knowing that John would have a difficult time understanding anything I said to him, I decided to try and start our session non-verbally. I set my electronic piano to reproduce a pipe organ sound and when the transportation aide brought John to my office, I had him rolled right up to the keyboard. I did not greet John with words, but instead smiled at him and gestured to the keys. John did not immediately respond, so placed one of my hands over his right one and gently lifted it to the keys, keeping it elevated so that just one of his fingers pushed down on a key. The instant John heard the “pipe organ,” he lifted his hand from mine, pulled his fingers apart slightly, and using his thumb, index and ring fingers, played a C chord.
The instant that chord sounded, he lifted his index and ring fingers and added his second finger and pinkie to his thumb for an F chord (C – F – A).
John had immediately begun to play the most familiar “progression” of chords, based on the notes C, F, and G. The transition from the C chord to the F chord was a fairly simple one, but the G chord would require him to change all three notes. On his first attempt, he correctly shifted his fingers for the upper two notes, but left his thumb on the C instead of moving it down one note to the B where it belonged.
And then, something interesting happened. John heard his error, and corrected it, moving his thumb down to the B. Where he was unable to hear and correct his speech, he was able to hear and correct his playing.
John continued to repeat this familiar, C, F, G, C progression of chords for a minute or so and then tentatively lifted his left hand to the keys and added lower versions of the same notes to his playing. Within a few minutes, he moved into the Doxology. As before, John demonstrated that he could correct errors of one note. He did get confused when more than one note was wrong, but was able to follow my fingers as I pointed out the correct notes and usually was able to continue on from that point. The latter skill was notable because it meant that he was not playing the entire refrain automatically, but rather with some deliberation.
***
Conscious, deliberate movement is different from the automatic action generated from motor memory; some of the brain activity is the same, but some is different. That is why, after people have a stroke, or other traumatic injury to the brain, they often are able to perform a routine movement or task, like waving, brushing hair or singing. If you interrupt the sequence of their movements, however, or ask them to consciously follow a specific set of instructions, they may have a much more difficult time.
In his music therapy evaluation, John demonstrated that he could be interrupted in the middle of something he probably had committed to motor memory (the Doxology is played in almost every church service) and still was able to continue from that point to the end. He had the ability to play deliberately, a skill which meant that some of his self-evaluation and initiation skills were intact – but obviously much more so for music than for verbal communication.
A week after his first music therapy session, John did something else that was, at first glance, startling. He had started picking out melodies on the keyboard with his right hand – primarily hymns. One day, however, he began to play a fragment of a melody that I recognized, but could not name. John was struggling to get past the first few measures (groups of notes), but he kept getting lost. I felt sure that the printed music for the song would be in one of the many large music books on my shelf, but I needed to know the name of the song. John, of course, couldn’t help. So, I did what I had done occasionally since I’d started working in a hospital without other musicians around: I called my mother. Fortunately, she was used to these long-distance “name that tune” calls and after I quickly explained my dilemma and hummed the first few notes, she said, “Fly Me To The Moon” and “we’ll talk to you on Sunday! Bye!”
“Fly Me To The Moon” was indeed in one of the books on my shelf and I opened the book and placed it on the keyboard stand in front of John. It seemed to me that he recognized that the page was filled with music notation, as he looked from the notes to the keys; but he couldn’t seem to figure out how to translate the printed notes into keyboard keys.
I decided to show him the purpose of the book by playing the melody and I reached across him and started to play the opening notes of “Fly Me To The Moon” – but as soon as I began the first note, he put his hand under mine and continued on his own. Further, he looked at the music as he played and it was evident that he was “reading” it, because he was able to get past the measures he’d played over and over and play through to the end of the song. The grin on his face as he finished was infectious and we laughed together.
It became evident, as I turned to the pages for some other songs I thought he might know, that John couldn’t start any of the songs on his own; but that once I played the first note, he was able to read the rest of the music with minimal assistance. While he was playing, I went around the corner and found his speech therapist, Kate, and had her come and watch John’s playing. We realized together what was happening.
***
Music notation is a symbol system, in many ways like the letters and numbers we write. Once you learn the code, you can read any piece of music. Music notes are named by letters from A to G; and the notes on the page, which appear on a staff, proceed in order as they appear on a line of the staff, then a space, then a line, then a space.
When people first learn to read music, they memorize the placement of the notes. Perhaps you took piano lessons and learned the names of the notes on the lines of the staff with “Every Good Boy Does Fine.” At the very beginning, you read each note and thought, “that’s an A, that’s a C” and so on. After a while, however, you began to recognize the relationships of the notes to one another. You realized that successive notes on lines meant that you should skip one note (the one that would have appeared on the space between the lines). So if the first note was E and it was followed by a note on the line above, you simply “skipped” over F (the space) to G. And after a while longer, you began to hear what that interval sounded like. So every time you saw a similar distance between notes (line to line), you made an equivalent skip on your instrument. You learned the same thing about successive notes on spaces and about lots of other combinations. Quite soon after you learned to read music, you weren’t labeling each note as you played (“A, C, F, D") but rather recognizing the visual patterns -- the intervals – between notes. You learned the association between those visual spaces and the changes in fingering or breathing you needed to make with your instrument to play the notes you were seeing.
Reading words can be a matter of recognizing patterns as well. Many people learn to read by learning the sounds of the letters and the rules of pronunciation, but soon they recognize whole words and don’t stop to “sound them out.” Some children with cognitive impairments, who are not able to learn the rules of phonics, are nevertheless able to read by recognizing whole words on sight, like their names and other familiar words: stop, walk, school, police, food, phone.
***
What Kate and I realized was that John was reading music spatially. He needed help with the first note, because that note had no spatial relationship to a note before it: he had to read it as a symbol, and that was something (due to his receptive aphasia) that he could not do. Once he had his finger on that first note, however, he was able to recognize and interpret the visual intervals between notes and using that, and his memory of what the song should sound like, he was able to play a song from printed music.
John and I tried using printed music for unfamiliar songs, but this was not as successful. He needed a context (the memory of a familiar melody) in which to play. Music is, after all, more than melody and John was not able to concentrate on reading an unfamiliar melody and rhythm and harmony. After all, he wasn’t in a situation in which he wanted to learn something new; he was already spending all his energy trying to regain what he had lost. Despite John’s ability to illustrate for me the ways in which the brain processes music, the purpose of his music therapy wasn’t to provide me with information – it was to improve John’s quality of life and ability to recover all he could after his injuries.
That goal was met. John clearly enjoyed his twice-a-week music therapy sessions and his treatment team (doctor, nurses, therapists) reported that his cooperation improved immediately. While we couldn’t find a way to translate his musical abilities into improved verbal or written communication, his increased enthusiasm gave him the chance to get the most out of his time in our facility. John would always have difficulties with communication and would always need care, but he was more independent when he left us for a long-term care facility in a neighboring state.
When John left, I sent a list of instructions and music with him, hoping that there would be someone among his caregivers who could help keep him involved with music. As with so many of my patients, I was unable to keep track of what happened to John, but knowing and learning from him certainly enhanced my “leaf” – and my ability to treat others.
