Theroleoftheartsintreatingneurogenic,cognitivelinguisticdisorders
JamieMayer,Ph.D.,CCC-SLP
NorthernIllinoisUniversity
LearnerOutcomes
Attheconclusionofthispresentation,attendeeswillbeableto:
1. Explaintheneurologicalbasisforarts-basedapproachestomaximizeoutcomesforindividualswithdementia,
aphasia,oralexia
2. Describethecurrentevidencebaseforutilizingtheartstomaximizequalityoflifeandspecificspeech-language
treatmentoutcomesforindividualswithdementia,aphasia,oralexia
3. Listspecificapproachesthatincorporateartand/ormusicforindividualswithdementia,aphasia,oralexia
4. Analyzestrengthsandlimitationsofarts-basedapproachesformanagingneurogeniccognitive-linguistic
disorders.
Neurologicalbasisforart
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Abasicbraintutorial
Whereisart?
Whereisthedamage?
Whatcanbespared/utilized/strengthened?
Review:Brainstructure/localization
Associationbetweenartandlanguage?
“…artandlanguagesharethesamehumancognitiveendowment,namelysymbolicandabstractthinking.Artcanbe
infinitelycombinatorial,too…Bothartandlanguagearemodesofsocialcommunicationthatrelyonabstract
expressions.”(Zaidel,2016,pp.4-5).
Whatisthe“neuro-map”ofart?
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Humansaretheonlyspeciestocreateartspontaneously.
Practiceofartisubiquitoustoallhumansocieties.
Universalcommunicativevalue.
Associationwithsymbolicandabstractthinking–hallmarkofhuman-uniquecognition(Zaidel,2016).
Languageisnotindependentofothercognitiveabilities–thus,neitherisart
Evidenceforneuroanatomicalunderpinningsofcomplexpictorialscenes:simultanagnosia(Lposteriortemporal
damage)
Thusitislogicaltoassumethatthecommunicativenatureofarthasneuroanatomicalunderpinnings!
Neuroanatomicalstructure:
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Isartreallya“right-brain”skill?
Isartnon-verbal?Pre-linguistic?
Ifartandlanguagesharecognitiveapparatus–thenNO.
Artisa“wholebrainproduction”(Zaidal,2016,p.15)
Evidenceforbi-hemisphericcreativity?
o Conventionally,RHàcreativity,LHàlanguage,detailedorganization
o But:EvidenceofartlackingcreativitywithLHdamage(e.g.,autism:Nadia,EC)
o fMRIevidenceofbilateralhemisphericactivationduringimagerytasks
Possiblebraincandidatesfor(visual)artproductioninclude(VanEssenetal.,2014;Zaidal,2016):
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Frontalcortex:planning,workingmemory,decision-making
Pre-centralgyrus,SMA,PMC:Motorcontrol
Visualcortex,parietalareas,FEFs:Hand-eyecoordination
Hippocampus:Memory
Posteriorassociationareas:EpisodicandsemanticLTM
Rangulargyrus(inferiorparietallobule):Spatialcognition,spatialattention,spatialorientation
Limbiccircuitry:Emotionalassociations
Widespreadneuronalnetworks:Sustainedattention,global+detailedperception
Musicandthebrain:
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Foruntrainedmusicians,perceptionofmusicalstimuliactivatessameregionsasimaginingamelodyfollowinga
specificcue(Altenmuller,2001;Halpern,2001;Janataetal.,2002;Janata&Grafton,2003;Trainor,2008):
o Superiorandinferiorparietallobules(left>right)
o VLPFC-bilateral
o Righttemporalareas
o RightSMA(PFC)
o LeftSMA/PFC>Righthomologuewhenmusicaltuneincludedlyrics
o RightrostromedialPFC>Lefthomologuewhensubjectstoldtofocusonpitch/tune
o FamiliarmelodiesrecruitedleftIFG,anteriorSTG
o RhythmrecruitedBroca’sarea,insula(LH)
Generally:
o Lefthemisphere:timing,rhythm,lyrics
o Righthemisphere:pitch,timbre,melody
o Bilateralbrainareas,widelyspread
o Righthemisphereismaximallyinvolvedinuntrainedmusicians
o Lefthemisphereismaximallyinvolvedintrainedmusicians
o Temporalareaspredominateformusicalperception
o Frontalareaspredominateformusicalproduction
**Advantageofutilizingartfollowingbraindamage?
Evidencebaseforutilizingtheartstomaximizequalityoflifeandspecificspeech-languagetreatmentoutcomesfor
individualswithdementia,aphasia,oralexia
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Rankinetal.(2007):Studiedmultipleformsofdementia(AD,FTLD:PPA,SD,NIFID):
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“Noneoftheformsobliteratedtheabilitytocreatepictorialrepresentations.Thisreinforcesthenotion
thatpictorialartrepresentsacommunicativesystemwithoutasinglecircumscribedspecializedregionin
thebrain”(Zaidel,2016).
Evidenceofsparedartisticand/ormusicalabilityinthefaceofbraindamage:
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FTD(Thomas-Anterionetal.,2002)
o Patientwithend-stageFTDandnopreviousartexperiencebegandrawingatage70;abletoconvey
appropriatelifeeventsdespitemutism,apathy,lackofvolition,poorlanguagecomprehension+
“hyperorality,”absentsocialskills
o Whatwasspared?Symboliccommunication(throughdrawing,only),semantic/worldknowledge,
emotion,autobiographicalmemory
Aphasia(Gourevitch,1967;Marinaetal.,2007;Pillonetal.,1980)
o Individualsunabletocommunicateverballydrewcartoonseriesdepictinglifeevents
o IndividualswithBroca’saphasiaoftenretaintheirabilitytosing
Evidencesuggestsartexpressioncanbeviewedasamodeofcommunication–evenwhengeneralcognition,social
behavior,motorabilities,andlanguagefail
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Artengagesnumeroussensory/cognitivesystemsthatappearwidelydistributedneutrally
Individualswithbraindamageaffectinglinguisticfunctionhavebeenshowntoexperience“mentalwell-being”
inbeingabletoexpressconceptsthroughart(Bungay&Clift,2010;Leckey,2011).
Individualswithdementiahavebeenshowntodemonstrateimprovedconcentration,socialbehavior,and
“generalwell-being”followingmusictherapy(e.g.,musiclistening,singing,playinganinstrument;Lietal.,2015;
Raglioetal.,2012).
Doesartormusictherapyimprovecognition?
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Inmany/mostcases–no.
Tapspreservedfunctionssupportedbyrelativelyintactregions(Moss,Donnellan,&O’Neill,2012).
ThereisevidencethatindividualswithbraindamageCANlearnnewartskills,evenifthesedonotgeneralizeto
othercognitivedomains–includingvisualart(Choetal.,2015)andmusicproduction(Midorikawa&
Kawanmura,2014).
“…[Al]thoughsingingisnotpropositionalcommunication,itisaverybasicexistentialcommunication.Itnotonlysays,‘I
amalive,Iamhere,’butmayexpressthoughtsandfeelingsthatcannotbeexpressed,atthispoint,byspeech.Being
abletosingwordscanbeagreatreassurance…showing…thattheirlanguagecapacitiesarenotirretrievablylost,that
thewordsarestill‘in’themsomewhere…”(Sacks,2007,p.234).
Artsapproach:
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Healthversusillnessperspective(i.e.,socialmodelofhealth,Brodzinski,2010).
Dementiaisassociatedwithalossofasenseofautonomy–senseofidentity,purpose
Lossofidentityexacerbatedbylossofautobiographicalmemory(e.g.,continuitytheory,Atchley,1989)
Canincorporationoftheartshelp?e.g.,strategiestoconstruct/anchorlifestories?
Engagementintheartscanprovideasenseofcontrol:i.e.,anactivityinwhichanindividualexperiencesasense
ofaccomplishmentand/ormasteryàempowerment(Cohen,2006)
Formoreseverepatients:Awaytopromotelevelofengagement(Stewart,2004)
Mayreducestress-relatedbehaviors(Mimica&Kalinic,2011)
Dementianeuropathology
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Dementiadefinition:Umbrellaterm;>200progressivebraindiseases
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44.4millionpeoplein2014;1in3individualsoverage65willdevelop;numbersexpectedtotripleby2050
(WHO).
AD:MTLatrophyàlossofepisodicmemory
o Unabletoutilizesynapticconsolidation/newsynapticconnectionstoformnewmemories(Borlikovaet
al.,2013)
o Usingovert/declarativeLTMroutestoteachnewinformationwillNOTwork
o Whatfunctionscanbetappedbyart/music?
o Roleofcognitiveself-efficacy?(e.g.,Westetal.,2008)
Aphasia,Alexia
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Encodingexperiencesthrougharangeofmodalities/sensesàstrongermemorytraces(Haxbyetal.,2001)
Aphasiatreatmentinvolveslistening,speaking,reading,writing:Thesecanbeintegratedinarts-based
approachestoincreasemotivation,“humanization”(Ganzfried&Greenfield,2011)
Choralsingingissuperiortochoralspeakingforelicitingwords/phrases(Racette,Bard,&Peretz,2006)
Importanceofmirrorneuronsintherapeuticprocess(e.g.,Sacks,2007)
Singingfamiliarlyricscanbeseenasequallyautomatictootherformsofautomaticspeech,e.g.,counting,
swearing,repeatingdaysoftheweek(Sacks,2007):
o “Thequestionofwhethersinginghasanyuseintherecoveryofspeech,then,canbeformulated
anotherway:Canlanguageembeddedinunconsciousautomationbe‘released’forconscious,
propositionaluse?”(p.237)
o Cancorticalareasthataremerely“inhibited”ratherthandestroyedbe“kick-started”intoactionbyreexperiencinglanguage–evenifembeddedinmusic?
o Canasimilarprincipalbeappliedtosomecasesofalexia–e.g.,whole-wordreading?(Cherney,2004;
2010)
MelodicIntonationtherapyàrighthemispheretakeover?
o PETstudies:MITàincreasedLEFThemisphereactivityinBroca’sarea(Belinetal.,1996)
§ Levelofactivitydecreasedwhenparticipantsspokeversussangsamewords
§ RighthomologuehyperactivitydecreasedduringMIT
• Singingmayhave“dampeddown”theRHoveractivitybyengagingitinanormalversus
pathologicalstate,thusallowingthe“release”oftheLHfromRHinhibition
o MoreseverecasesmayrelyonprimitiveRHmechanismsforrecovery(e.g.,Jeppson&Mayer,2015;
Schlaugetal.,2006)
NOTE:Despitenumerouscasestudies,theevidencebaseforevaluatingart/musictherapyisgenerallypoorly
documented(Beard,2012;Vinketal.,2003)
o Inadequateexplanationsofstudydesigns,descriptionsofactivities,methodology
o Poororunspecifiedmeasuringtools
o Over-emphasisonclinicaloutcomes(versus,e.g.,self-ratingsofQOL)
o Lackofsystematicdataanalyses
Specificapproachesthatincorporateartand/ormusicforindividualswithdementia,aphasia,oralexia
Cognitivetraining
Cognitivestimulation
Guidedpracticeonastandardsetoftasks,designedtotargetand“exercise”particular
cognitivefunctions
• Increasinglyofferedoncomputerizedplatforms
• Mixedevidence,especiallyforgeneralizationtoreallifetasks(e.g.,Owenet
al.,2010)
Reduceexcessdisability,rebuildconfidenceandself-esteem,enhancegeneralsocialand
cognitivefunctioning
• Typically,deliveredinasocialcontext
Person-centeredvalues
“Useitorloseit”(e.g.,Salthouse,2006)
Generalformat:1-2x/week,45-75min.
Evidence:short-termimprovementsindementiaseverity,naming,word-finding,
andself-ratedQOL(Spectoretal.,2003;2010);QOLratingsmaintainedx6
months(Orrelletal.,2014)
Cognitiverehabilitation
Directlytargetsspecific,real-lifetasksthathavebecomeimpairedorabandoned
secondarytocognitiveimpairment
• Individuallytailoredinterventions
• Personallyrelevantgoals
• Examples?
• Evidence:RCT:goal-orientedcognitiverehabilitationimprovedattention,
memory,qualityoflife,andmoodcomparedtootherapproaches(Clareetal.,
2010;2013)
(Clare,2008;Smith&Oyebode,2016;Woodsetal.,2005)
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Artstherapy
Usingdiagnosisandplannedinterventiontocureorlightensymptoms
ArtsActivity
Usingcreativeskillstogenerateasenseofenjoyment,satisfaction,andcompanionshipthrougha
momentofengagementwithouttryingtochangethepersonorcondition
(Zoutewelle-Morris,2011)
Butifartànon-verbalcommunicationand/orempowerment:Isittherapy?Oranactivity?(cf.Beard,2012)
Artactivitiesfordementia
Notrecommendedforindividualswithsignificant,previousartexperience
o Often,awareofchangesinskillàdissatisfaction/frustration
Artisticproductionispossibleduringearlyandmiddlestagesofthedisease(Halpern,2013;Zaidel,2016)
o Visual/visuospatialissuesbymiddlestagesinmanycases(Cronin-Golumbetal.,1991)
o Endstagesincludelossofmotorcontrolandmotivation,severecognitivedecline,anddisinhibition
o Someindividualsinseverestagewillparticipate;mayproducescribbles,randomcolors(Stewart,2004)
o Individualswithadvanceddementiacancompleteself-portraitsuponrequest(Lev-Weisel&HirshenzonSegev,2003)
Asdiseaseprocessprogresses,paintingstendtobecomemoreandmoreabstract
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Drama
VisualArts
Music
ReminiscenceTheater,Imaginary
Theater
Improvisationalstorytelling
RMDMemoryMattersTheater
company
Timeslips©,Inc.
Basting,2005;Phillipsetal.,2010
MemoriesintheMaking
Alzheimer’sAssociation
Kinney&Rentz,2005
ColorMeaMemory,PAINTexpressions Mayeretal.,inprep
Artontouchscreeninterfaces
Mihailidisetal.,2010
Collage
Woolhiser-Shallings,2010
MusicandMemoryproject
Music&Memory,Inc.
Review:Musictherapyforpeoplewithdementia(Vinketal.,2003)
“IrememberbetterwhenIpaint.”Howcanarttherapytieintoreimbursablespeechtherapy–orcanit?
ASHA,SLPscopeofpractice:“Clinicianscanworkdirectlywiththeindividualwhohasdementiaorindirectlythrough
environmentmodifications,caregivertraining,orthedevelopmentoftherapeuticroutinesandactivities”
(http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935289&section=Treatment).
Whattype(s)ofgoalsmightartsapproachesengender?Long-term?Short-term?
LearnerPerformance
Quality
Criteria
Condition
http://www.asha.org/uploadedFiles/Writing-Measurable-Goals-and-Objectives.pdf
ArtsActivitiesforAphasia,Alexia
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Spanallaphasiatypesandlevelsofseverity
Goalsrangefromindirectlyimprovingqualityoflifetodirectlytargetinglanguageexpression
Drama
TheatreAphasique
VisualArt
Music
NotVoicelessDanceProject
TheAfterWordsProject(TAWP)
AphasiaFilmForum
Artworksbyindividualswithaphasia
MIT
MMIT
ORLA+Music
Croteau,Dorze,Marcouxe-Fourtier,
&Getty,2008
NationalAphasiaAssociation
SpeakingofAphasia,LLC
AphasiaNow(www.aphasianow.org)
Albertetal.,1973;Sparks&Holland,
1976
Baker,2000;Jeppson&Mayer,2015;
Henning&Mayer,2016/inprogress
Mayer&Birmantes,inprogress
MMIT:Henning&Mayer,2016/inprogress
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