1. Neurological Disorders of Musicians and MusicRandy M. Rosenberg MD FAAN FACPAssistant Adjunct Professor of Neurology Temple School of Medicine Principle Flutist of the Warminster Symphony

2. So what do you hear.? (or What makes something musical?) Rhythm=segmentation of pulsesand their recognition as the beat ofthe music Pitch = a frequency of sound Pitch Contour = variation in intensity, duration and range of pitch=melody Pitches played together=chords Two or more pitch contoursplayed together=harmony Timbre= The same pitch played ontwo instruments sound different(e.g.piano and sax) 3. I like the beat, and you can dance to it. I give it a 85Rock-a-bye BabyYoure a Grand OldFlag 2/4Segments of 3 beatsSegments of 2 beatsto a measureto a measure 4. Anatomical Localization of Music Pitch interval, pattern, tonal structure and timbre Time interval and rhythm Recognition Emotion 5. Musicians Dystonia: Characteristics 6. Musicians Dystonia Widespread abnormalities detected in non-motor brain regions in functional imaging studies of patients with dystonia(Fabbrini et al., 2011; Kuyper et al., 2011) Proposed phenomenology Deranged cortical plasticity leading to abnormalsensorimotor integration Reduced inhibition across several levels of themotor pathway(Chang et al Current Neuropharmacology, Volume 11, Number 1, January2013 , pp. 41-47(7)) 7. Guitarist with Musicians Dystonia 8. Flutist with Embourchure Dystonia 9. Patterns of Musicians Dystonia 10. Musicians Dystonia: Treatment Anticholinergics Baclofen Low dose cabidopa-larodopa Onabotulinium toxin A Sensory Motor Retuning (SMR) 11. Primary Bow Tremor 12. Musculoskeletal and Neuropathic Injury in Musicians 13. Musculoskeletal and Neuropathic Injury in Musicians Carpal Tunnel Syndrome Especially in guitar, violin and viola players Sustained 12th and 13th position on violin Cubital Tunnel Syndrome (Ulnar neuropathy) Left hand of violin, viola and guitar players Thoracic Outlet Bilateral in flutists Left sided in violinists Radial Tunnel Syndrome v lateral epicondylitis 14. Gadgets to Reduce Musculoskeletal Injury 15. Musical Hallucinations 1 Charles Ives, Robert Schumann, Shostakovich Interfere with perception or conversation in amanner that never occurs with normal musicalimagery Usually are a reference from the patients historyof musical exposure or training Characteristics changes over time Increasingly loud More intrusive Expanded repertoire with shorter duration Patient has limited options for control 16. Musical Hallucinations 2 Can be a manifestation of partial seizures usually of right temporalorigin Anatomically widespread when due to structural disease: Temporal lobe,parahippocampal gyrus, dorsal pons Drug induced Anticonvulsants Antidepressants Anesthetics Opiates Amandatine Most common among hearing impaired suspected as a cortical releasephenomenon. Female > male Advanced age NOT earworms Treatment Gabapentin, quintiapine cochlear implant 17. Musicogenic Epilepsy Reflex epilepsy in response to thepsychoacoustic aspects of music Strong correlation to the temporal lobe and aright-sided preponderance Patients often have multiple seizure types Absence and secondary generalization are ofteninfluenced by duration of music Dejavu and other affective seizures are associatedwith music that evokes strong memories andpreference 18. fMRI During an Induced Musicogenic SeizureDuring epileptic aura initiated bythe stimulus, signal increaseswere found in the left anteriortemporal lobe, and the right gyrusrectus. Because fMRI indicated acascade of recruitment of theventral frontal lobes byepileptogenic music, left anteriortemporal lobe activity could besecondary to a right gyrus rectusfocus, possibly triggered byemotional processing of music.Mrocz I.A., Karni A., Haut S., Lantos G., Liu G. fMRI of Triggerable Aurae in Musicogenic Epilepsy.Neurology. 2003 Feb 25;60(4):705-709. PMID: 12601117 19. Williams Syndrome Characteristic facial morphotype Severe cognitive dysfunction Cardiovascular diseaseaccounts for most cases of earlymortality Interest and enthusiasm formusic is almost universalalong with extreme sociabilityand loquaciousness Deletion at chromosome band7q11.23 that involves the elastingene (ELN) Detected through fluorescent in situ hybridization (FISH) 1 per 7,500-20,000 births 20. Decibel (Loudness) Comparison Chart 21. Damaging Sound Exposure Whether Music or NoiseFor every 3dBs over 85,permissable exposuretime is cut in half60/60 rule for CD players80/90 rule for MP3players 22. iPod and Damage to HearingThe Fligor Rule (2006) Maximum settings to obtain 50% maximum dosage iPod volume at 60% for 120 minutes Depends on earphone used Some earphones isolate the ear. Some earphones have different electro-acoustic characteristics. In quiet environment, most people have iPod volumes at 50% but in noisy environments the volume is often 80%. Use isolating headphones! 23. Hearing Loss in Musicians 170,000 professional musicians 60 million+ amateur musicians Percentage with hearing loss Adult musicians age 27-66 years 61% Youth musicians age 18-22 years 22% Child Musicians age 8-12 years 16%Hearing thresholds are generally better in womenProgression is slower in women and in menTHIS IS WHY THE PROBLEMS OF MUSICIANS ARESO IMPORTANT! (ITS THE NUMBERS STUPID!) 24. Five Factors Affecting Hearing Loss in Musicians Intensity Maximum limits for symphony orchestras are achieved at anywhere between 10 and 25 hours per week of playing. Levels in excess of 85 dBA were measured even during a relatively quiet etude at Canadas National Ballet with a peak level of 126 dBA. Duration Liking the music Stapedial reflex (Individual factors) 25. AMUSIA"I know only 2 tunes: one of them isYankee Doodle, and the other one isnt." -Ulysses S. Grant Talking about music is like dancing about architecture 26. Amusia I Inability to recognize musical tones or rhythms orto reproduce them. Congenital Amusia Occurs in 5% of population and is life long Likely some genetic element Inability to recognize or reproduce familiar tunes Impaired ability to judge pitch Variable severity (some individual find musicunpleasant e.g. banging and will avoid wheneverpossible) Generally does not affect prosody or the ability torecognize familiar sounds 27. If You Are Amusic. 28. Amusia II Acquired Amusia Often Coexists with Aphasia Can have isolated deficits in melody and rhythm Expressive Impaired singing Impaired ability to play an instrument Deficit for writing musical notation Receptive Inability to read musical notation Inability to interpret melody Mixed 29. Thank you for yourattention and mayall of your days betuneful ones.