Research Article :
RGM is based on
principles of neuroplasticity, motor learning, and postural control, and uses
energizing, beat-based music to provide multisensory input (visual, audio,
kinetic, and tactile) in order to stimulate experience-dependent neuroplastic
processes. It aims at stimulating cognitive and motor function (e.g., memory,
concentration, executive function, multitasking, coordination, mobility,
balance, and motor skills). In addition, it may aid body awareness,
self-esteem, and social skills. RGM has been scientifically evaluated as a
means of multimodal sensory stimulation after stroke and as a means of
improving mobility and cognitive function in Parkinsons disease. RGM is a complex
multi-task intervention with the potential to be beneficial in different
settings and in different neurological conditions. It can be performed either
while standing up or sitting down and can be practiced with the advantages
gained as a group activity or individually, which makes it very flexible. It is
currently being used as rehabilitation activity for people with stroke,
Parkinsons disease, multiple sclerosis, dementia, and depression. Furthermore,
RGM is used in programs targeting healthy aging, ADHD, autism, and dyslexia,
and in ordinary school environments. A key issue in neurorehabilitation
is to improve or restore physical and psychosocial abilities, aiming to
maximize activity and participation [1]. In recent years, an innovative rhythm-and-music-based rehabilitation program has
successfully been implemented across Europe, as well as in several non-European
countries. The Ronnie Gardiner Method (RGM) was created in the 1980s by the
Swedish jazz musician Ronnie Gardiner. RGM is now widely used within different
settings such as neurological rehabilitation for people with stroke, Parkinsons disease (PD), and multiple sclerosis, as well as in patients with
dementia and depression. It is also used in programs targeting healthy aging,
ADHD, autism, and dyslexia, and in ordinary school environments. The
combination of music and other augmented sensory information, as well as
multi-tasking movement exercises, makes it a potentially powerful tool in rehabilitation. RGM is described as an exercise
regimen that challenges motor and cognitive-related abilities by its
multi-tasking nature, and is conceptualized as a music-based intervention,
i.e., an experimental protocol that uses music in various forms to aid
therapeutic effects [2]. Because RGM is a physical activity that is planned,
structured, and repetitive, aiming to increase or maintain physical fitness
[3], it also meets the criteria for an exercise intervention. The research on
the efficacy of RGM is still scarce, but a few scientific trials within the
field of neurorehabilitation have thus far shown promising results. A Swedish
randomized controlled study on stroke survivors found that the intervention
facilitated the participants own perception of recovery, as well as
long-lasting improvements concerning balance, grip force, and working memory
[4]. Individual interviews were also
undertaken with participants to explore personal experiences (submitted
manuscript). Another
qualitative study from Sweden found that stroke survivors felt an improved
connection to their unfamiliar bodies, and that they felt an improved ability
to perform complex movements. The music, the practitioner,
and the group were identified as facilitating components [5]. In Parkinsons
disease (PD), a small feasibility study found promising results regarding
mobility and cognitive function, and the adherence was high, suggesting that
the intervention was experienced as enjoyable and motivating [6]. All three
studies evaluated RGRM, a former acronym. Our research group is currently
exploring the efficacy of RGM in PD regarding cognitive function, balance, fear
of falling, and quality of life (ClinicalTrials.gov identification number
NCT02999997). The
present article will outline some of the potential effect mechanisms of RGM,
using PD as an example. PD is a progressive neurological disease resulting from
degeneration of the dopaminergic nigrostriatal pathway of the basal ganglia (Figure 1), and is often accompanied by
deficits in executive functions (e.g., attention, processing speed) in addition
to motor symptoms such as tremors, rigidity, bradykinesia, and gait and
postural difficulties [7]. The number of people with this condition is expected
to increase due to the growing aging population [8]. Current medical management
is only partially effective in controlling the impairments, and therefore,
rehabilitation interventions will play an important role also in the future. Music-based
interventions in general have been found to be beneficial to people with PD
[9]. RGM has the potential to alleviate many symptoms of PD: in addition to
improving quality of life, specific needs areas that RGM might address are:
cognitive function (e.g., attention, spatial cognition, memory, executive
function, anticipation, symbol recognition, and speech), motor skills (e.g.,
gait performance, postural control and body awareness, movement timing, limb
coordination, endurance), emotional impact (e.g., enjoyment, mood regulation,
self-esteem, reducing depression), and social interaction (facilitating group
interaction, reducing social isolation). One
specific problem in PD is an impaired ability of dual-task performance [10], an
executive function that is defined as the simultaneous execution of two tasks
which have separate goals and often involve motor and/or cognitive tasks [11].
Both motor and cognitive factors may contribute to dual-task deficits in PD,
and a number of mechanisms have been suggested to be involved, for example
reduced movement automaticity caused by the basal ganglia dysfunction [10]. It
has been suggested that rehabilitation strategies that are designed to improve
this automatic control of movements have the potential to improve dual-task
performance [10]. Improvement of motor-cognitive dual-task performance in
individuals with neurologic deficits holds potential for improving gait,
balance, and cognition [12]. So far, only few such exercise programs for PD are
music-based [13,14]. Based on the integrated multimodal nature of the program,
RGM is suggested to specifically improve motor-cognitive dual-task performance
in PD. After
a short section describing how RGM is performed, some of the potential effect
mechanisms to improve dual-task performance in PD will be outlined. Three
specific mediators in RGM are hypothesized to work as mechanisms: the music,
external cues, and movement practice (Figure
2). RGM uses four, for this method
unique, blue and red symbols – resembling hands and feet – that are projected
on a screen, mainly within choreoscores, a form of note systems. The colors
blue and red symbolize the right and left side of the body, respectively. The
symbols can be used alone, or often in pairs. In total there are 19 possible
symbols or combinations. Figure 1: Neural circuits
and transmission mechanisms of control in the brains of normal individuals and
those with Parkinson’s disease: direct and indirect pathways. The cerebral
cortex sends input to the striatum. Dopaminergic projections for the substantia
nigra pars compacta (SNc) (red connectors) targets striatal neurons in D1 or D2
receptors. The direct pathway (green connectors): D1 neurons send direct
inhibitory projections to the GPi/SNr. The indirect pathway (green and yellow
connectors): D2 neurons connect indirectly to the GPi/Snr through the GPe and
STN. The SNr inhibits the SC. In Parkinson’s disease, dopaminergic decrease
leads to a reduced inhibitory direct pathway output (thin lines) and increased
excitatory indirect pathway output (thick lines) onto the GPi/Snr and,
consequently, increased SNr inhibition onto the SC as net effect. GPe, external
globus pallidus; STN, subthalamic nucleus; GPi, internal globus pallidus; SNr,
substantia nigra pars reticulata; SC, superior colliculus Figure 2:The main potential processes involved in Ronnie
Gardiner Method with respect to Parkinson’s disease. Each one of the 19 symbols is accompanied by a specific
movement and a certain four-letter word (e.g., BOOM or CHIC) that is to be
pronounced in a loud and clear voice while performing the movement to the sound
of rhythmical music. The music (mainly beat-based popular music) in RGM is
chosen by the certified RGM practitioner, but efforts are also usually made to
use the participants favorite music if possible. The tempo of the performed
exercise is measured by the tempo of the music (beats per minutes, BPM). This
makes it easy to measure improvement in tempo. For progression, the
choreoscores are delivered with increased BPM and with more complex symbols and
patterns. The practitioner wears a shirt that is red and blue to reinforce the
idea of left and right. RGM can be delivered in group
settings, with the potential benefit of the social interaction, or individually
if the participant suffers from fatigue or just needs a quiet environment to
recover. To allow for good group dynamics, a recommended group size of 10 to 12
people is suggested. However, to ensure maximal safety, a group size of 6 to 8
individuals may be more appropriate. RGM can be performed in a seated position
for people who are unable to stand, or standing up, which is suggested to
improve postural stability and stepping ability due to the many weight shifts
that activate anticipatory and reactive postural control mechanisms. RGM can be
varied in many ways by using varied music, different tempo, and choreoscores
with blank spaces to stimulate working memory. There are several short clips
available on the video-sharing website YouTube (www.youtube.com) that show its
usability. The rehabilitative effects of music Music is a powerful tool within
neurorehabilitation for enhancing neuroplastic processes in the brain [2,15].
The effects from musical training on training-related plasticity have been
extensively investigated [16]. In addition, musical activities induce grey and
white matter changes in multiple brain regions, especially in front temporal
areas [2]. Music also activates the dopaminergic mesolimbic system of the
brain, which regulates memory, attention, executive function, mood, and
motivation [2]. Neuroimaging studies have shown that just
listening to pleasurable music stimulates dopaminergic regions of the brain,
including the nucleus accumbens and ventral tegmental area, which have
widespread projections to the cortex [17,18]. This suggests that listening to
music stimulates the same networks at those involved in reward and
reinforcement learning. The combination of music and
exercise therapy has successfully been used in neurological rehabilitation,
especially in PD [19], because music affects many important brain functions.
When combined with procedural skill learning (i.e., learning of tasks to be
performed with automaticity with little attention or conscious thoughts), the
dopaminergic regions responsible for reward, motivation, and learning have the
potential to regulate neuroplasticity mechanisms through dopaminergic release
and neural synchrony [15]. Learning the complex tasks of RGM is a form of
musical training that involves several sensory systems and the motor system,
placing demands on a wide variety of higher-order cognitive processes. RGM
therefore has the potential to activate the same brain areas as when learning
how to play an instrument, although no instruments are involved. For persons
with PD, the use of music as therapy has the potential to yield immediate as
well as long-term effects that are both motor and cognitive related [20]. Immediate effects:
Music-based activities always engage action-related processes in the brain
because areas involving rhythm perception are closely linked to those that
regulate movement (e.g., cerebellum, premotor cortex, supplementary motor area,
and basal ganglia – especially putamen) [17]. People with PD have been shown to
benefit from walking to beat-based music. When walking to music, different
pathways (externally driven) are used than when walking without this external
stimulus (internally driven). For people with PD, the rhythm in music plays a
crucial role, as it activates the neural circuits involved in motor actions,
replacing the impaired internal timing function. Rhythmical use of musical
stimuli thereby enhances audio perception and movement synchronization and
compensates for the loss of control by the extrapyramidal system [2]. Long-term effects: Many
studies have shown that training with musical rhythm for several weeks can
facilitate movement synchronization in persons with PD, improving gait (speed,
frequency, and step length), limb coordination, postural control, and balance
[20]. Long-term effects on neuroplasticity involve structural changes and
remapping of the motor cortex: after several weeks of training (e.g., walking
to music), a cortical remapping occurs [15]. With respect to executive
functions, it has been proposed that musical training engages the
cerebellar-thalamo-cortical network, providing a rerouting to activate
executive functions [21]. A music-based intervention that combines both
cognitive and physical training, such as RGM, thus has the potential to also
improve dual-task performance in people with neurological deficits [22]. Apart from the motor and cognitive
effects, music-based activities may reduce anxiety and depression through their
impact on reward, arousal, and emotion networks in the brain [2]. The
psychological effects and neurobiological mechanisms underlying the effects of
music-based interventions are likely to share common neural systems for reward,
arousal, affect regulation, learning, and activity-driven plasticity [2]. External cues External cues are defined as
external stimuli (temporal or spatial) that generate an increase in sensory and
perceptual sensations to facilitate motor learning and movement initiation
[3,23]. External cues provide augmented sensory information and may be visual,
somatosensory, or auditory. The benefits of external cues in PD are well known
[24,25] and recommended in evidence-based guidelines as a useful rehabilitation
tool in PD, especially to improve gait function [3]. Synchronizing movement to
external cues facilitates movement initiation, speed, amplitude, and cadence
[26,27]. As a result, cues may improve gait during performance of a dual-task
by generating rhythm, even in people with mild cognitive impairment [3]. The exact effect mechanisms
associated with external cues are still not fully understood [25], but several
theories have been brought forward. In PD, the normal internal control of
movement is not functioning sufficiently because of the dopamine loss in the
basal ganglia. External cues are suggested to replace this reduced internal
control [3], supposedly activating cerebellar-thalamic-ventral premotor loops,
thereby bypassing the dysfunctional striatum in the basal ganglia [28]. Cues
may also act to focus attention, particularly during the performance of more
complex tasks [25]. Different external cues work
in slightly different ways: visual cues, for example, are suggested to use
pathways from the visual cortex and reach motor areas via pontine and cerebellar
relays, thereby avoiding the basal ganglia [29]. Auditory cues are suggested to
access cortical circuitry (premotor cortex) via the thalamus or cerebellum
[30,31]. The perception of beat is an important part of rhythm perception,
which has been found to rely on interactions between the auditory and the motor
systems [32]. Auditory cues thereby supposedly train attention focus, by
interacting with attention oscillators (i.e., internal rhythmic processes) via
coupling mechanisms of the brain [33]. Areas involving rhythm perception are
closely related to those that regulate movement (premotor cortex, supplementary
motor area, cerebellum, and the basal ganglia) [20]. Auditory cues seem to be
the most effective cueing strategy [24], and can be delivered by a metronome,
although rhythmical music may be preferred [3,24]. These cues have potential
for enhancing neural plasticity in that multimodal music training involving
senses, movement, and sound has been shown to modulate the auditory cortex
[16]. Externally guided tasks with cues can therefore be seen as both
compensatory (accessing other parts of the brain) and remediating (enhancing
neural plasticity) mechanisms [31,34]. RGM incorporates multiple external
cues: somatosensory through body percussion (e.g., handclaps, stomping with
feet, slapping thighs), visual (in the form of special symbols displayed on
screen), and auditory (beat-based music). This is expected to improve motor
control including dual-task performance in PD by the proposed effect mechanisms.
In addition, rhythmical entrainment (our inherent tendency to time movements to
the regular beat of music) [2] is also trained with RGM. These external cues
also have the potential to enhance affective arousal and motivational activation. Movement practice The role of exercise to enhance
experience-dependent neuroplasticity targeting motor and cognitive
circuitry in PD has been emphasized [35]. Movement practice is conceptualized
as an update of exercise and entails repetitive motor execution to improve the
fluency of motor skills [3]. Two specific areas have been suggested as
important interventions in the European physiotherapy guidelines for PD in
relation to movement practice: optimizing motor learning and dual-task training
[3]. Optimizing motor learning:
Motor learning is defined as a set of processes
associated with practice of experience leading to relatively permanent changes
in the capability for movement [3]. With practice, movement will normally
become more efficient with improved interaction between limbs, and more complex
movements will be controlled with less effort [36]. The ability to carry out
complex motor skills relies much on automaticity [34,37], which depends on
intact basal ganglia function. In addition, learning new motor skills involve interactions of
the fronto-parietal cortices, the cerebellum, and the basal ganglia (especially
the striatum) [3]. In fact, the basal ganglia seem to play a critical role when
learning new movements [38]. Because of the basal ganglia deficits, people with
PD have an impaired ability to achieve, as well as use, automaticity in daily
life [37]. The acquisition of new motor skills
is dependent on neuroplastic processes in the brain, including the
neurotransmitter dopamine. Because of the low levels of dopamine in PD, it was
previously believed that neuroplasticity is diminished in PD. This notion has
since been revised [35], and it is now believed that taking into account
general principles for motor learning, including the use of augmented sensory
information and feedback, will enhance the acquisition of new motor skills and
automaticity of movements in PD [3,34,37]. Motor learning is highly dependent
on cognitive status in PD. In order to optimize motor learning in PD,
treatments should address both the motor deficits and the decreased cortical
plasticity [37]. People with PD may require a higher training dose to achieve
the same positive results as healthy people [3]. In addition, the effectiveness
of motor learning interventions may be improved even further by adding external
sensory stimulation [34], such as music in a pleasant social context in an
environment that increases enjoyment (i.e., multimodal stimulation) [37]. A
frequency of twice weekly sessions for 45 to 50 minutes with a duration of a
minimum of 8 weeks is suggested, with additional home exercises to own favorite
music if possible. RGM incorporates multimodal
stimulation that is expected to enhance experience-dependent neuroplasticity by
targeting both motor and cognitive circuitry. By frequent repetition of the complex
movements in RGM in conjunction with various types of enjoyable music, and by
using a structured learning schedule, motor learning is expected to be enhanced
in PD. Importantly, exercises are typically varied to avoid mental exhaustion
by monotonous repetition of the same movements. When performed in a standing
position, RGM involves complex motor skill elements such as postural stability
with secondary tasks, weight shifting, interlimb coordination, and single leg
stance activities. These exercises are expected to improve postural control
based on the proposed effect mechanisms. Dual-task training:
It was recently suggested that rehabilitation interventions that combine cognitive training with physical exercises may
prove to be the most effective approach to optimize gait in people with PD
[39]. Motor-cognitive interventions combine a cognitive
with a physical rehabilitation task [40]. Such interventions challenge motor
skills, memory, and attention, and are believed to help internally guided task
performance, governed by striatal-thalamo-cortical circuits [39]. Exercise
programs targeting dual-task ability have been developed for people with PD
[41], only few have been music-based. Dual-task interventions may help
participants to automate a task, to focus on other tasks, and consequently, to
free the processing capacity, whereby more attention is available to process
external information [40]. Multi-task exercises (e.g., a combination of motor
skill learning, exercise, socialization, and music) are also hypothesized to
improve mood and cognition in people with neurological deficits [42]. RGM is a multi-tasking
motor-cognitive intervention that targets both cognitive functions such as
executive, attention, and visuo-spatial functions, and adds complex rhythmical
and reciprocal movements. These movements involve internally cued movements
with multi-tasking and attention shifting training with augmented sensory
information from external cues. The demands in RGM shift between
cognitive/perceptual to motor tasks. Multi-tasking requires that the
participants concentrate on and continuously shift attention between the
following elements: the instructions given by the practitioner, the specific
symbols projected on the screen, the music that is being played, performing the
movement that is associated with a certain symbol while pronouncing the correct
symbol name, maintaining ones balance (if standing up), the next step to be
taken, and not bumping into ones neighbor while performing the exercises. By
adding many different tasks, RGM aims at improving the ability to perform a
skilled movement with less conscious or executive control or attention directed
towards the movement itself, i.e., automaticity, and to improve the ability to
switch between tasks. Although this work is largely based
on research concerning PD, RGM is a useful tool in other fields. RGM is an
attractive and enjoyable music-based intervention with many potential benefits.
RGM incorporates several components working as potential effect mechanisms
including rhythmical beat-based music visual and auditory cues sensory
stimulation (body percussion, tactile cues) challenging cognitive tasks and
body movements such as weight shifting. Furthermore, RGM promotes positive
experiences that may enhance functional improvements, mental engagement,
motivation, and well-being. RGM is relatively non-strenuous and does not
require high physical capacity, which makes it a participant-friendly
rehabilitation method. RGM does, however, not specifically target muscle
strength, although movements such as standing up and sitting down are
incorporated during practice. RGM suits many clinical settings, and the
certified practitioners can have various professional backgrounds: music
therapists, physical therapists, occupational therapists,
exercise and movement therapists, speech therapists, or dance instructors. RGM is an innovative music-based
intervention with the potential to improve several aspects in people with
neurological deficits. This article has outlined the theoretical background
with respect to Parkinsons disease however, RGM can be used for any condition.
Because of the novelty of RGM, the evidence for the effectiveness is still
scarce, and there is a need to evaluate RGM in clinical trials in different
settings and in different conditions. The author wishes to thank Mariken
Jaspers, RGM Nederland, for checking the accuracy of the description of RGM.
This work was financially supported by the County Council of Östergötland,
Tornspiran Foundation, Neuro Sweden, Henry and Ella Margareta Ståhls
Foundation, and Research Foundation for Parkinsons disease. The Funders had no
role in study design, data collection, decision to publish, or preparation of
the manuscript. 1.
Khan F, Amatya B, Galea MP,
Gonzenbach R, Kesselring J. Neurorehabilitation: Applied neuroplasticity (2017)
J Neurol 264:603-615. Parkinsons disease, Neuroplasticity, Multiple sclerosis,
Stroke, Autism,Dementia,DyslexiaThe Ronnie Gardiner Method: An Innovative Music-Based Intervention for Neurological Rehabilitation -Theoretical Background and Contemporary Research with Focus on Parkinsons Disease
Petra Pohl
Abstract
The Ronnie Gardiner
Method (RGM) is an innovative, practitioner-led, music-based intervention using
sensorimotor and cognitive integration. RGM was originally developed by the
Swedish musician Ronnie Gardiner. Since 2010, RGM has been successfully
implemented within neurorehabilitation in many countries. The purpose of this
article is to outline some of the theoretical assumptions underpinning the
potential benefits from this intervention, using Parkinsons disease as an
example. Full-Text
How it is performed
Theoretical conceptualizations
Clinical implications
Conclusion
Acknowledgements
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