Music and The Brain: A Musician Neurologist’s Perspective

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Music and The Brain: A Musician Neurologist’s Perspective

Andrew N. Wilner, MD: Welcome to Medscape. I’m your host, Dr Andrew Wilner. Today, I have the pleasure of speaking with Dr Phillip Pearl. 

Dr Pearl is director of epilepsy and clinical neurophysiology at the Boston Children’s Hospital. He’s also a serious musician and has performed in the Longwood Symphony Orchestra. He’s currently a member of the Music and Health Institute at the Berklee College of Music in Boston.

Today, we’re going to discuss how music affects the brain and the potential for music therapy. Dr Pearl also has a new book that he might tell us about. Welcome, Dr Pearl. Phillip L. Pearl, MD: Thank you, Dr Wilner. It’s really quite an honor. Your name is so well known. I love reading Medscape articles that you’ve done.

Wilner: Well, thanks for that. I was reading your bio, and it took me hours to get through it. Where to start? Neurology? Music? How did you put those two things together at a professional level? 

Combining Music and Neurology

Pearl: I’ve always found that one can do some really creative, interesting things by combining ideas. In fact, every time I think I have an original idea, I find out it’s not original. Somebody, through a PubMed search, or even pre-PubMed days like Index Medicus, had mentioned it. 

In my case, for example, I always wanted to be a pediatrician. My own pediatrician was a role model, but then I fell in love with neuroscience in college as an undergrad at Hopkins where I also was attending the Peabody Conservatory of Music. I combined pediatrics and neuroscience and became a pediatric neurologist. 

I grew up in Baltimore and attended the Peabody Preparatory for music (it’s like a high school of music), got a diploma from there, and I was in the first class at Hopkins that got to audition and also apply to the Peabody Conservatory. Back then, Hopkins bought Peabody or else this music conservatory would’ve gone bankrupt. Even though I was pre-med, I was also a conservatory student. I’m used to living in that combined world.

And they are two different worlds, but there’s a lot of intersection. There are many medical musicians. As you mentioned, I played in the Longwood Symphony Orchestra, which is basically an orchestra of physicians working in the Longwood medical area in Boston and other allied health personnel who are musicians.

Combining ideas has been very helpful. For example, I love the history of medicine and the history of music. I’ve worked on presentations and writings looking at the medical problems of the musical masters, such as Beethoven’s deafness. I mean, what could be more fascinating than what caused deafness in perhaps the greatest composer of all time?

People think maybe it was the lead in his hair or something else, but there’s actually pretty good evidence, if you look at his autopsy findings, that it was Paget disease causing thickening of the bone, short stature, and deafness of the type he had — high-frequency hearing loss starting in his mid-twenties.

I have pictures of Gershwin tumor, his actual histology, and talk about the whole story of Gershwin. By the way, when I do these things, I play Beethoven and I play Gershwin. I have a whole Gershwin set I play. I would love to play the “Rhapsody in Blue,” but there’s not really time, so I do some of the standards and make some points about it. These are really fun things to do. 

Then as you mentioned, there’s this notion of whether music has a role in neurology, in neurologic disease and in medicine in general. Certainly it does, but how much it does, the jury is still out. There are some really interesting aspects. Music therapy, of course, has emerged as a major field in and of itself. 

Physician Musicians and the Brain Center for Music 

Wilner: I think it’s also true that the frequency of physician-musicians is higher than one would expect by chance. Is that correct? 

Pearl: I don’t know the figure, but it’s just got to be correct. There is a large amount of data showing that children who study music have higher academic achievement. Now, is that because of the music or is it because of that population of children who are taking music? Is it because of family demographics or influences that are motivating those children to do all the things they do? 

It makes total sense that there are many medical musicians. Longwood Symphony Orchestra is not unique. I was just down in Houston visiting my residency alma mater, which is Texas Children’s Hospital, Baylor College of Medicine, and there’s an entire orchestra there in Houston of physicians, which I didn’t know about until my visit.

Then there’s a music and medicine study section on which I participated that Francis Collins had initiated, looking at research involving music and medicine. It’s a major field. 

Wilner: Brain mapping has really advanced since Wilder Penfield was stimulating the brain and made the homunculus. Now we have functional MRI and ways to map music. You’re an epileptologist, so you’re used to trying to map the seizure focus so it could be effectively treated and maybe resected. Where is the brain center for music? 

Pearl: This is such a great question, and you framed it perfectly. As you said, neurology has changed from a lesional field to a functional field. In other words, it used to be that someone had a lesion and Dr Broca recognized the expressive language area from that, and Wernicke the receptive language area and so forth. And Phineas Gage with a terrible railroad injury of the pole that went through his brain and the frontal lobe was really better understood because of the effects on him — since he lived with that thing for another decade after that terrible injury.

With functional imaging, we’re able to image what’s happening in a brain while a person functions. That has led to revolutionary discoveries in that the old notion that music is basically in the right hemisphere of the brain for most people. 

I’m left-handed, so I’m a little strange, and I don’t know what my functional MRI shows. It could show bilateral language, or it could show right-sided language. Most people, we talk about as left hemisphere-dominant for language. 

The old theory is the sound/symbol thing. Sounds, like language, are processed by the left hemisphere, or the verbal hemisphere. Symbols, arts, math, and stuff like that are processed by the right hemisphere.

Music was felt to be a right hemispheric phenomenon. There’s a kernel of truth to that because when someone has, say, amusia after a stroke, if you read Musicophilia, Oliver Sacks’s book that we both enjoyed, that kind of event is almost always from a right-sided stroke.

If someone has musicogenic seizures— in other words, a certain song evokes a seizure — it’s often a childhood hymnal or something because it got so implanted in their hippocampus, the memory center where all the glutamate is, that it caused epileptogenesis. It’s almost always the right temporal lobe. 

The functional imaging has shown a couple of really important things: one is the localization of music, and two is the network. Epilepsy is now considered a network disease, not just a zone disease of different zones, but different networks, and the same thing applies to music. 

Let’s start with functionality. It turns out the entire brain is active when it comes to music. I mean, it starts in the ears, the cochlea, and it goes to Heschl gyrus, well basically superior temporal gyrus, primary auditory cortex. Then it has to get processed. 

Now, just like visual information goes to the occipital lobe, there’s a dorsal pathway going to the parietal lobe to say where things are in space, an eventual or lower pathway going through the temporal lobe to say what you’re seeing, it turns out music also has these different streams.

It has a dorsal stream going from the temporal lobe up to the parietal in frontal lobes. The dorsal stream is more of the location, the rhythm, or the pattern, and the ventral stream is telling you more of the content or the melody. It has these different streams.

Also, both sides of the brain are involved in listening to music, and of course, performing music. Music processing on functional MRI involves both temporal lobes, frontal lobes, parietal lobes, the limbic system, the emotional system, such as the insula, and even the cerebellum — which has to do with meter, rhythm, and also language — is active in music.

We’ve learned from functional MRI that music activates widespread bilateral areas of the cerebrum, the brain, as well as the cerebellum. There are streams that are involved whether your brain is handling the content of the music in terms of the pitches and the harmonies vs the rhythm or the pattern.

The next thing is about network. We now understand that the brain works by networks. For example, there’s a default mode network, which means when you’re just chilling out, relaxing, daydreaming, or meditating — which is actually important for highly complex mental tasks such as improvising — the default mode network is very active. There’s an executive function network, which is more about your academics and your learning. There’s a salience network, which tells you what part of the information you know is important, which is the signal vs the noise. 

It turns out that on functional imaging using MRI-compatible keyboards — in other words, keyboards that have been created so a musician can play the piano in the MRI and see what part of their brain lights up — when someone is playing straight classical music, the more executive function lights up and the more lateral prefrontal cortex.

When someone is improvising, it tends to be more medial prefrontal cortex, more default mode network. Improvising is like the zone that the athlete goes into. Same with the musician. That is your default mode network. It has everything to do with creativity. 

The salience network tells you the signal from the noise. That’s an issue with people with autism, right? Autistic people tend to hyperfocus on little things and miss the forest for the trees, so they miss what’s salient.

It turns out autistic children are often said to be musically gifted, and they have a higher rate of absolute pitch, or perfect pitch, as it’s said. I don’t have it, so I don’t call it perfect; I call it absolute. Most musicians like me have relative pitch. 

Functional imaging has shown that in children with autism, their language and music cortex are mixed up in the sense that when they listen to music, their language cortex lights up, Broca area lights up, so they’re actually processing music the way we process language. When they get fed with language, it’s diffuse and not well differentiated, which goes along with why they don’t do very well with language.

The functional imaging, when it applies to music, it’s also teaching us a whole lot about neurologic disease. 

Music Therapy as Rehab

Wilner: It sounds like music therapy might be useful for patients with stroke, for example, to activate the brain, kind of like rehab. Does that make sense? 

Pearl: Absolutely. Music therapy is amazing. It’s fantastic rehabilitation. It’s been used in someone, say, who has a dominant hemisphere stroke affecting basically Broca area and expressive language. Even though a speech therapist may not be able to easily get a person to speak again, a music therapist could get someone to sing and sing after a stroke, to the point that then they can start speaking. The music therapy becomes a bridge to regaining language.

In addition, it doesn’t take many trips to a retirement home, a nursing home, or a memory center, where I’ve played piano enough times to find out the power of music with dementia. It just brings people with dementia back to an incredible state of energy, enjoyment, and they can recall old lyrics that they knew years ago that they hadn’t been shown in days, weeks, months, or even years.

It’s very powerful for dementia, which of course has become the scourge of our time since the population is living longer and aging, and the rates of Alzheimer’s and other dementias are going up. There’s also evidence that it helps patients with Parkinson’s disease with their motor skills. 

There’s also amazing evidence how it contributes to brain plasticity. There’s evidence that, in the neonatal intensive care unit, music can help newborns with their oxygen saturation, their heart rate, and their responses to pain. There was one study showing that, in premature infants who were exposed to music vs non-music in the NICU, 2 years out, they had better social emotional scores. They were better able developmentally to handle social emotional stress. 

On the other end of the spectrum is older adults. There was an amazing study published just a couple years ago in the Annals of the New York Academy of Sciences. They took a group of adults, ages 65-75, who were not musicians. They were musically, you might say, naive. They put half of them in piano lessons for 6 months and they put half of them in a music appreciation course for 6 months where they just sat around, listened to music, and talked about it. 

The group in the piano lessons, after 6 months, had a higher volume to their superior temporal cortex. They actually had increased brain volume in their sixties and seventies from taking piano lessons. It’s never too late to start.

Music, Medicine, and the Neurobiology of Creativity

Wilner: Dr Pearl, I think we’re just hitting the tip of the iceberg here. I understand you have a book coming out: Music, Medicine, and the Neurobiology of Creativity. Do you address what you just talked about? Is that the direction of the book? 

Pearl: Yes, in much more detail. I was giving a grand rounds at McGill, Montreal Neurologic Institute, virtually during the pandemic. I was giving one of my talks on the neurologic problems of great musicians and a medical student started peppering me with questions.

He was a classical pianist. The guy was absolutely brilliant. His name is Saman Arfaie, and the reason I say this is he’s my co-editor on the book. After the grand rounds, he contacted me and he said, “I have to work with you.” 

I have quite a few young physicians who write me similarly. They tend to be medical musicians like me. I said, “Well, this talk I gave, I’ve kind of written it up in various papers, but I’ve always wanted to write a book about this topic.” He has so much energy and brilliance. He said, “Great, let’s do it.”

That was about 3 years ago, and now the book is coming out. Together, we have assembled experts from all over the world on neurology and the brain, musical processing and the brain, the genetics of music, and the anatomical localization of music. We have a section on the historical vignettes or clinicopathologic correlations of medical problems of great musicians. I mentioned a few, but we have many more. 

We also have information on the arts in medicine in general, including using narrative writing in medicine and using art in neurologic diagnosis. A colleague of mine at Johns Hopkins, Carl Stafstrom, has specialized in using art with children to diagnose their headaches vs other neurologic problems, including depression. We have a chapter on poetry by Nina Schor, a very famous neurologist, who is quite a poet. We have all kinds of information. 

I edited this book, I didn’t write it. Editing is much easier than authoring a 25-chapter book like this, but we’re pretty excited about this release. Thanks for mentioning it. 

Wilner: I’m excited to read it. I can’t wait. Dr Pearl, this has been, as I anticipated, a great discussion. Is there anything you’d like to add before we wind up? 

Pearl: I thank you for this opportunity. I really enjoy your columns for Medscape. I love it when I get Medscape emails. This is just a great pleasure to do, and I hope it inspires other physicians. 

Wilner: Thank you. I’m Dr Andrew Wilner, reporting for Medscape.

Andrew Wilner is a professor of neurology at the University of Tennessee Health Science Center, Memphis, and a seasoned neurologist and epilepsy expert who has mastered the less conventional locum career path. He is the author of four books, including Bullets and Brains, and hosts the podcast The Art of Medicine with Dr. Andrew Wilner.