The Rhythm of Healthier Aging

a pendulumJohns Hopkins neurologist Alex Pantelyat is developing promising treatments for his aging patients with Parkinson’s disease and other neurodegenerative diseases that involve no costly drugs or unpleasant side effects. These treatments are easy to pursue at home, or together with friends and family. And they appear to improve the health of patients with debilitating chronic illness while also unlocking feelings of joy and well-being.

What is this seeming miracle drug? In a word, it’s music.

Pantelyat, a talented violinist and co-director of the Johns Hopkins Center for Music and Medicine, is passionate in his belief that music could hold a key to better aging. And he has embarked on a range of music-related studies that back up that optimism.

“Music has been an integral part of the human experience as long as humanity has been around,” says Pantelyat, the Alafouzos Family CIM Human Aging Project Scholar. “It’s been intuitively felt to have healing properties, but now we are in a position to study the mechanisms and optimize music-based interventions.”

Quality of life improved over six weeks of drumming and worsened when participants were assessed six weeks later, suggesting that continued drumming is necessary to sustain improvements.

Perhaps his longest-ranging project involves singing and patients with Parkinson’s disease. In a pilot study several years ago, Pantelyat found that those who participated in group singing saw improved quality of life, and voice strength and clarity. And when spouses or caregivers were invited to participate, their quality of life also improved. He has continued the project with ParkinSonics, a choir for patients with Parkinson’s disease and their caregivers. The choir met weekly at Govans Presbyterian Church in north Baltimore before COVID-19 and it continues to meet virtually.

“That’s such an important part of our work. If a study is deemed valuable, we make every effort to roll out the intervention as a community program,” Pantelyat says. “The results are inspiring: People who had never sung before are now singing in four-part harmony. The ParkinZoomSonics choir continues to grow, even during the pandemic. Just last week we had several more people sign up.”

Pantelyat’s work involving West African drumming followed a similar trajectory. In this project, patients with Parkinson’s disease sat in a circle, each straddling a traditional goblet-shaped djembe drum, and they followed the lead of the instructor, who set the rhythm. In a pilot study of patients who participated in the drumming twice a week over six weeks, Pantelyat reported that participants experienced a reduction in their symptoms: Some walked more easily; for others, tremors subsided and they were in a better overall mood. Quality of life improved over six weeks of drumming and worsened when participants were assessed six weeks later, suggesting that continued drumming is necessary to sustain improvements.

To Pantelyat, this points to the importance of establishing sustainable community-based programs. “We have to continue activating these parts of the brain to continue to see results. So, it’s important for programs like group drumming to be continued long term,” he says.

Fortunately, through the Center for Music and Medicine, in February he was able to establish a virtual drumming group for individuals with Parkinson’s disease and their care partners, led by drum therapist and instructor Jason Armstrong Baker. The goal is to add another virtual drumming group for people with Huntington’s disease and their care partners soon.

“There’s evidence that being involved in music may improve your life, and it may even prolong your life.” – Alex Pantelyat

“The big idea behind all of these community-based programs is this concept of ‘social prescribing,’ which originated in the U.K. over 10 years ago,” says Pantelyat. “The idea is to give a patient a ‘prescription’ to enroll in a community-based arts program, or for tickets to museums or concerts, which would be covered by health insurance.” To his mind, the cost-benefit analysis of social prescribing clearly comes down on the side of music. “There’s evidence that being involved in music may improve your life,” he says. “And it 
may even prolong your life.”

In his recent work, Pantelyat is turning to technology to create individualized solutions for his patients with atypical parkinsonism, which encompasses a range of movement and neurological symptoms and can make walking particularly difficult. Pantelyat undertook a pilot study, in which a patient is asked to walk for two minutes, during which time the velocity of his or her gait is measured. Then the patient walks for two minutes again, but this time to a metronome beat of music that is 10% faster than the baseline gait. “So, if a patient took 90 steps per minute the first time, he’s now aiming to take 99 steps per minute, trying to synch each step to a beat on the metronome,” Pantelyat explains. After a 10-minute break, the person is asked to walk the same path again for two minutes, but without the metronome beat.

Many patients in the pilot study showed improved gait with the metronome, and for some the improvement was sustained without the metronome. This is proof of concept for the idea “that you can get people with atypical parkinsonism to walk faster and with more confidence after a very short-term intervention,” says Pantelyat.

He is working now with a Boston-based tech firm to develop an adaptable device that would make it possible for patients to pursue this “treatment” at home. The idea is to use a playlist of songs that the user enjoys (whether Bach or Jimi Hendrix) while they walk. Then, through a sensor attached to the shoe, the tempo of each song continually adjusts to the walker’s gait, encouraging the person to walk at a more regular pace.

“This is an example of moving toward precision medicine, or ‘precision music,’ that would benefit a patient population that is prone to falls and reduced mobility,” says Pantelyat. “If we could get this rhythm-based auditory stimulation approach out into the broader population of patients with parkinsonism, it would be an important step forward.”

April 29th, 2021

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Reversing a ‘Terrible Trade-Off’

opposing arrowsIt’s a Faustian bargain in the world of basic biology. And, crucially, it could have important implications for advancing our understanding of the mechanisms behind human aging.

Cardiologist Mark Anderson, director of the Department of Medicine, explains it this way: An enzyme known as CaMKII developed an oxygen-sensing capability 500 million years ago, at the dawn of vertebrate evolution, that was preserved through all subsequent speciation into humans — an exquisite chain of evolutionary preservation documented recently by molecular biologist Qinchuan Wang, a research associate in Anderson’s lab who is the Karen and Ethan Leder CIM Human Aging Project Scholar.

But why has oxidated CaMKII — prompted by a pair of amino acids known as methionines — been preserved through all these millions of years? And what impact does that have on human aging?

That’s where the Faustian deal comes in. Using fruit flies and genetically engineered mice, the Hopkins scientists have shown, through painstaking work conducted over many years, that CaMKII activation improves physiologic (fight-or-flight) performance by actions in skeletal muscle. That quick burst of movement is a good thing early in life, allowing us to outrun predators and to live to reproduce. But as animals like humans age, CaMKII activation damages many tissues in the heart, brain and skeletal muscle, making us more susceptible to diseases linked to too much oxidation, such as heart disease, cancer and cognitive decline.

“Evolution doesn’t care if you die of heart failure at 60, or get Alzheimer’s in your 50s, because you’ve already done your thing: You’ve reproduced.” – Mark Anderson

It’s quite a trade-off, notes Anderson. “Evolution doesn’t care if you die of heart failure at 60, or get Alzheimer’s in your 50s, because you’ve already done your thing: You’ve reproduced,” he says. “The mutation [oxidized CaMKII] that enabled you to be faster and more fit earlier in life will remain fixated in the species and will prosper.”

Now, using new molecular tools and genetically engineered animal models, Wang and others in Anderson’s lab are focused on finding ways to reverse this terrible trade-off.

“The goal is to find ways to preserve the benefits of oxidized CaMKII and to minimize its damage,” says Anderson, who serves on the executive committee of the Johns Hopkins Human Aging Project. “This could have dramatic implications in the quest to prevent frailty, reduce the burden of diseases related to aging, and to extend our life span.”

April 29th, 2021

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Empathy in Practice

lines radiating from the centerPhysician and author Suzanne Koven, who completed medical school and residency at Johns Hopkins before moving on to a career in primary care at Harvard and Massachusetts General Hospital, is Mass General’s first writer-in-residence and a frequent contributor to publications ranging from The Boston Globe to The New England Journal of Medicine. Her new book, Letter to a Young Female Physician: Notes from a Medical Life, came out on May 4.

Notably, that is the very day that Koven gave CIM’s 18th Annual Miller Lecture. In the Q&A that follows, Koven talks about the influences that have shaped her career and explains how art and literature can hold a key to better doctoring.  

You arrived at Johns Hopkins in July 1980 and left for Harvard almost exactly 10 years later. What memories stand out during your time here?

I started by working in a lab while I took post-baccalaureate coursework so that I could apply for medical school, which I started at Johns Hopkins in 1982. The first two years of medical school, I struggled because I hadn’t been a science major in college and the coursework was so difficult. Then we moved to clinical work the second two years and I discovered that my Yale College background in English — all those novels that I read — served me a lot better than the organic chemistry that I crammed and promptly forgot. 

Reading is like empathy in practice. When you’re reading a novel, you’re being asked to care about a character whose experience and suffering you can only imagine. That imaginative leap is something that we do in clinical medicine every day. I’ve never had a heart attack and I don’t know what chest pain feels like or the fear that comes with it. Reading is very good practice for developing that kind of imagination.

After medical school, you remained at Hopkins for your residency training. How was that experience for you?

I adored my residency! I loved wearing my Osler scarf and running around the hospital and the overwork of it and the excitement of it and the brilliance of the Attendings and being a part of a team that was so defined by excellence. And yet, looking back, there were some darker aspects of medical training in that era, which I get into in my book. One was sexism. 

As a junior resident, I had my first baby. (There was so little precedent that I was invited by Human Resources to write a formal policy for maternity leave.) Looking back, why, as a pregnant woman, was I standing on my feet for hours, a factor that led to my developing preeclampsia? It didn’t occur to me or anyone else at the time to provide accommodations. In retrospect, the hours that we worked were punishing but the feeling was that you can’t be a “real” doctor unless you follow a patient through the first 36 hours of their crisis, for example. But that came at a price, particularly if you were pregnant. 

“The whole idea of narrative medicine is that by reading literature closely, you become better able to elicit and interpret and respond to patient stories.” – Suzanne Koven

The other dark side, and this was invisible to me at the time, was the inherent racism of health care then. Hopkins Hospital was formally segregated until the 1950s, and it was de facto segregated when I was there in the 1980s. The poor Black patients were on the Osler service by the house staff, while the well-off white patients had private rooms and were treated by the attending physicians. Years later, I reconnected with one of my few Black residency mates, and he shared stories of white patients refusing to be seen by him, and of micro- and macro-aggressions he endured. Sadly, all of this was invisible to me at the time.

You left for Harvard in 1990 and have practiced primary care there for the last 30 years. At what point did your interest in narrative medicine and storytelling take root?

For a very long time, I just assumed that once I chose medicine, I would read novels at night and it would be a hobby. I continued to believe that until about 15 years ago. After I earned a master’s degree in nonfiction writing, my division chief — in an example of how good mentoring can be life-altering — suggested I run a monthly reading group at Mass General. That evolved into running writing workshops and hosting events in narrative medicine, and then I became the writer-in-residence, first for my division and then for Mass General. Now that work is a bigger part of my professional life than my medical practice. I’ve become more and more emboldened by the idea that if you get members of the hospital health care team seated around a conference table and talking about literature, something magical happens.

How does that magic play out?

The whole idea of narrative medicine, started at Columbia University 20 years ago by Rita Charon, is that by reading literature closely, you become better able to elicit and interpret and respond to patient stories, which is so foundational to providing excellent clinical care. This isn’t some “squishy” feel-good stuff: Being able to appropriately listen and respond to a patient’s story really affects diagnosis and treatment. And sitting around a table with colleagues allows us to talk about our work and our patients in a much deeper and less guarded way.

As doctors, we are often so worried about whether we’re going to make a mistake in the care we provide. But patients aren’t worried about our competence. They are worried about whether we are listening to them, and caring about them. Patients I’ve talked to about narrative medicine totally get it. When I say to patients that I find that sitting around a conference table talking about a Shakespeare play makes us better at listening to patients and their experiences, my patients light up.

The 18th Annual Miller Lecture, which Koven offered virtually on May 4, is made possible by the generosity of Mrs. Anne G. Miller and her daughters, Sarah Miller Coulson and Leslie Anne Miller, and her husband, Richard Worley.

April 29th, 2021

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Miller Coulson Academy Inducts New Members

This spring, the Miller Coulson Academy of Clinical Excellence at Johns Hopkins inducted nine new clinicians — doctors who are the “best of the best” when it comes to providing patient care. The new class of Academy members joins 80-plus clinician members, from departments across Johns Hopkins Hospital and Bayview Medical Center, who are all committed to establishing initiatives and programs to advance excellence in clinical care.

The 2021 Miller Coulson Academy inductees are:

Gail Berkinblit, M.D./Ph.D.,
Department of Medicine, General Internal Medicine

Ed Bessman, M.D., M.B.A., F.A.A.E.M., F.A.C.E.P.,
Department of Emergency Medicine

Brian Garibaldi, M.D., M.E.H.P., F.A.C.P., F.R.C.P.(E.),
Department of Medicine, Pulmonary and Critical Care Medicine

Neda Gould, Ph.D.,
Department of Psychiatry and Behavioral Sciences

Elisabeth Marsh, M.D., F.A.H.A.,
Department of Neurology, Neurovascular

Leslie Miller, M.D.,
Department of Psychiatry and Behavioral Sciences

Heather Sateia, M.D.,
Department of Medicine, General Internal Medicine

B. Douglas Smith, M.D.,
Department of Oncology, Hematologic Malignancies

Sumeska Thavarajah, M.D.,
Department of Medicine, Nephrology

April 29th, 2021

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