Parkinson's Disease and Music

In the United States, over 1.5 million people are afflicted with Parkinson's Disease. Millions are similarly afflicted across the world. Among these millions are musicians and lovers of music whose enjoyment of music and perhaps even their livelihoods as musicians, have been affected by this disease.

Parkinson's Disease, or PD, is a progressive disease and as such it slowly begins to deteriorate musical skills. The first signs of the onset of PD are usually misinterpreted as a need for more practice. PD generally presents unilaterally (on one side) when first noticed. There may be shaking or unusual stiffness of hands and fingers. Since the symptoms are usually on one side there is an unbalance of skills.1

As coordination begins to diminish, and no amount of practice seems to help, the condition becomes alarming. Eventually, the disease becomes bilateral and both sides are affected, though one side will remained pronouncedly noticeable.

Movement restriction of the extremities is not the only manifestation of PD that hinders a musician. Vocal production becomes difficult. Muscle control and coordination of the entire vocal apparatus diminish (breath control, vocal cords, tongue and mouth).2 The operative word is "difficult," not impossible. In fact there is evidence that singing--in particular--is a valuable PD management tool.3

There is no question as to the value of music as a therapy for PD patients. Neurologist Enrico Fazzini, MD, a neurologist at New York University Medical Center, says that music helps reconnect PD patients to what PD takes away: the ability to move automatically. Mechanical music-making that was once so ingrained for performers that it was nearly an unconscious ability must be raised to a very conscious level. But, therapeutically, music--or for that matter, anything--that helps PD patients concentrate and focus on a physical task will help patients move. "Music can do that, Fazzini says--sometimes dramatically."4

But once PD has set in, how difficult is it to raise that consciousness? Is it quantifiable? Perhaps not, but possibly in terms of a gradient scale.

Installment Two: Pianists and Parkinson’s Disease (3/18/04)

There are four important elements of piano playing that are limited by the effects of PD: touch, timing, tone and technique. These elements are adversely affected by either or both of the basic symptomatic manifestations brought on by PD: Tremors and stiffness. Ironically, these two symptoms are opposites. Tremors are uncontrollable episodes of extraneous movement that cannot, with any certainty or reliability, be anticipated nor measured. Artificial tremors, called dyskinesias, are also produced as side effects of PD medicines. Bradykinesia is a slowness or complete lack of (non-responsive) movement. Either of these symptoms would be difficult to overcome, but when both are evident, playing the piano becomes very difficult.

The elements of playing the piano chosen below are not as independent as they look on paper. Each element is at some level, either mentally, physically, musically or cerebrally connected to the others. What influences and affects one element is ultimately bound to affect the others. That being said, for convenience, the following four elements have been chosen as independent topics for discussion as they relate to PD.

Touch
There is a certain suppleness missing in the hands of a PD victim. The feel of the keys is so important for knowing where the hands are in relation to the surrounding keys, especially the black keys since, because of their arrangement in groups of 2’s and 3’s, they hold a special meaning to location.

Though there is no loss of actual tactile sensation, that is, nerve perception of hot/cold, rough/smooth, sharp/dull, etc., there is a lack of feeling of where you are on the keyboard.  This is probably due to the hundreds, perhaps thousands, of minute muscular movements once taken for granted that are no longer available to the same degree as they once were.

Dynamics, or more rightly the range of dynamics, are dependent upon agility. To put this concept into perspective, bear in mind that a beginner may have but two dynamics—loud and soft. A well-trained pianist, however, may be capable of many levels of dynamics from extremely soft (ppppp) to extremely loud (fffff) with a gradient of volume in between that can change from phrase to phrase or even note to note. It is that wide spectrum of dynamics that is no longer available with PD. It is important to note here that common sense says that because of various levels of experience, talent and the stage of PD an individual is currently in, it is impossible to lump together all pianists with PD and predict what they can do or not do.

Accuracy of notes and rhythm relies upon predictable movement, movement learned by thousands of repetitions. Mentally, there is still an expectation of these precise movements but the PD makes motions, once quick and accurate, slow and unreliable. 

Timing
Timing is a crucial element of music making. PD does not affect the mental concept of meter, commonly called a time signature, but coordination and steadiness (or lack thereof) do have a great impact on the execution of timing. Exact synchronization between the fingers and hands (and feet for organists) is a measure of ability. Split-second synchronization is measured in hundredths of a second. That degree of response is no longer available with PD. Even at a slow tempo, or speed, where such rapid synchronization is unnecessary, steadiness of a tempo—especially at slow tempos—is the problem. Imagine a mechanical clock that ticks unevenly or, more realistically, at a random pace and that would be what a pianist with PD might experience.

Tone
Tone is very much related to dynamics insofar as minute muscular movements are concerned. Tone is not strictly volume, though to the uninformed, it may sound the same. A good piano tone has three attributes: character, balance and depth. Character is usually predetermined by the instrument, the type of wood it is made from and the humidity of the environment, so this part of tone has no relation to PD. Balance and depth, however, do. Balance, both between the fingers and the arms is crucial to maintaining an even or balanced (uniform, if you will) tone. Without nimble agility, tone is bound to be uneven and change with every phrase. Depth of tone is rather subjective. It is the amount of full sound (not volume) the fingers and hands can “draw” from the piano through pressure (also see tone) imparted by the weight of the arms and conveyed through the fingers onto the piano keys, thence, mechanically to the strings.

Technique
Technique is the simultaneous application of every element, though the term is usually applied to performance agility with respect to quickness of execution and the manual processes used to accomplish musical passages. There is a long litany of piano technique terms, but a few (not in any order) will make the point.

For a pianist (organist) with PD, trills, or rapid playing of alternate keys (usually adjacent, e.g. CDCDCDCDC…), are quite difficult to execute. First of all, PD and “rapid” never go together. In order to execute a trill, two fingers are required to rapidly alternate evenly, with equal volume, tempo and tone for, perhaps several beats or even several measures. The PD pianist may begin a trill successfully, but he or she is hard pressed to maintain it for long. Shorter trills, often characterized as ornaments, such as mordents and turns, may be accomplished with a little more ease. However, PD frequently causes response delays in certain motor operations, and since an ornament may need to executed in .5 seconds or less, a PD pianist could easily “miss the window of opportunity” because of the delay in response.

Tremolo is a special situation in which the hand(s) rock quickly back and forth between pitches, sometimes between single notes an octave apart and sometimes between notes of a chord. Tremolo uses the wrist more than the fingers and a PD pianist at times cannot keep up the rocking due to general stiffness and cogwheeling or ratcheting in the wrist. Cogwheeling is defined as when “rigidity of a muscle gives way in a series of little jerks upon being passively stretched, analogous to the ratcheting movement when a spring-loaded rod drops into the successive notches of a cog” (“Ratcheting.” Dorland’s Illustrated Medical Dictionary, 10 Mar 2004; www.mercksource.com).

Repeated notes, that is simply playing the same note many times in a row, sounds like a easy task, but as with trills, ornaments and tremolo, response delay and stiffness cause unevenness and early fatigue. The only mitigation is the tempo of the repeated notes, in other words, if the tempo is slow enough, the notes may be played more correctly.

Pianists with PD do not have to give up playing the piano, but they must expect complications. Depending on the progress of the PD, the degree of skill and natural ability, plus medication, a pianist can still enjoy making music.

Parkinson’s Disease is a disease of inconvenience to say the least. Musicians who are PD victims can still find musical fulfillment. Next time, other musical outlets for musicians with PD.

Some examples of musicians or associates of musicians who may have suffered from PD:

French composer "Victor Massé (1822-1884) was suffering from a nervous disease which forced him to give up his position at the Conservatoire in 1876 and which increasingly restricted his movements before eventually confining him to his home." (Grove's Dictionary of Music and Musicians, 6th ed. Vol.11, p. 800)

Julius Allgeyer (1828-1900) was an engraver and photographer. He was a close friend of German pianist and composer Johannes Brahms (1833-1897). The daughter of another German composer, Robert Schumann (1810-1856), Eugenie Schumann described Allgeyer as "painfully slow in speech and movements." (Source: Brahms, Malcolm MacDonald (New York:1990) p. 459

There will be more to this project. For now, if you are a musician with PD (or you are a friend or care-giver of a musician with PD) and would like to make a comment about PD and music, please e-mail us at
parkinson@morrisonfoundation.org.

The Morrison Foundation for Musical Research, Inc. is not a medical institute and we are not doctors. We cannot offer any medical advice. We would, however, like to begin a database of information as it relates specifically to victims of Parkinson's Disease and the art of music. Any information contributed will remain confidential and anonymous.

NOTES
1. This is from the view of a pianist. Bi-dexterous musicians (harpists, organists, percussionists, wind and string players will probably share this view. On the other hand (no pun intended), a brass player (3 valves or slide) may not experience this imbalance as profoundly if his/her right hand is not affected [left hand for horn players].

2. This also applies to wind players (woodwinds and brass) who depend upon proper breath control for good tone production.

3. Levine, Bernie, "Singing and Parkinson's Disease," American Parkinson's Disease Association Newsletter (Winter 1996-97).

4. Morelli, Jim, "Music Helps Movement, Mood in Parkinson's Patients," WebMD Medical News Archive (June 20, 2000) referencing the Journal of Psychosomatic Medicine (no issue, no date).

 

 Revised 3/14/2006

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