Music-supported therapy was shown to induce improvements in motor skills in stroke survivors. Whether all stroke individuals respond similarly to the intervention and whether gains can be maintained over time remain unknown. We estimated the immediate and retention effects of a piano training program on upper extremity function in persons with chronic stroke.
Thirteen stroke participants engaged in a 3-week piano training comprising supervised sessions (9 60 min) and home practice. Fine and gross manual dexterity, movement coordination, and functional use of the upper extremity were assessed at baseline, pre-intervention, post-intervention, and at a 3-week follow-up.
Significant improvements were observed for all outcomes at post-intervention and follow-up compared to pre-intervention scores. Larger magnitudes of change in man- ual dexterity and functional use of the upper extremity were associated with higher initial levels of motor recovery.
Piano training can result in sustainable improvements in upper extremity function in chronic stroke survivors. Individuals with a higher initial level of motor recovery at baseline appear to benefit the most from this intervention.
Keywords: cerebrovascular accident, hand, paresis, learning, music, rehabilitation
Most stroke survivors experience upper extremity impairments (Hendricks et al., 2002) that can result in persistent activity and participation limitations. Existing approaches for upper extrem- ity rehabilitation have been shown to yield modest to moderate improvements (Van Peppen et al., 2004), possibly due to insuffi- cient training intensity and treatment adherence. Current litera- ture on motor learning and recovery indicates that interventions should be meaningful, task-specific, tailored to the person’s capacity and interests, and provide sufficient repetition and challenge to induce training effects (Van Peppen et al., 2004; Hubbard et al., 2009). Rehabilitation interventions can further take advantage of multi-sensory feedback to provide knowledge of results and/or performance (Cirstea and Levin, 2007).
Music-supported therapy (MST) uses a music-learning paradigm to support motor rehabilitation. It is hypothesized that auditory feedback may facilitate learning and performance and that the musical context makes the therapy more engaging and rewarding as compared to conventional approaches. MST was shown to yield improvements in manual dexterity in both acute and chronic stroke survivors (Altenmuller et al., 2009; Amengual
Abbreviations: BBT, Box and Block Test; CMSA, Chedoke McMaster Stroke Assessment; FTN, Finger to Nose Test; FTT, Finger Tapping Test; Jebsen, Jebsen Hand Function Test; MST, Music-supported Therapy; NHPT, Nine Hole Peg Test.
et al., 2013). Electrophysiological measures further demonstrated that MST may build on auditory-motor coupling mechanisms to drive cortical facilitation and brain plasticity (Amengual et al., 2013). Despite the potential of MST for upper extremity rehabilitation, previous studies have not tested whether gains can be maintained on the longer term. Furthermore, as stroke survivors present with a range of severity, there is a need to determine who best responds to this intervention. Finally, existing MST programs consist of mixed-instrument protocols (piano and drum pads) that require daily supervised sessions (Altenmuller et al., 2009; Amengual et al., 2013). Such resource-intensive protocols may be difficult to implement in the clinical setting or at home. Existing protocols also lack details on training parameters and criteria for progression.
In the present study, we have developed an individually tailored piano training program that combines structured and supervised training sessions with home practice. The specific objectives of this study were to estimate the immediate and retention effects of a 3-week piano training program on manual dexterity, finger movement coordination, and functional use of upper extremity in chronic stroke survivors and to establish the relationship between the participants’ characteristics and intervention outcomes. We hypothesized that MST improves upper extremity function and piano-related outcomes. We also hypothesized that participants may respond differently to the intervention depending on their clinical profile, including their age, chronicity, and initial level of motor recovery.
A convenience sample of 13 chronic stroke survivors was recruited among discharged patients of 2 rehabilitation centers in the Mon- treal area. Inclusion criteria were: (1) first supratentorial chronic stroke (>6 months) in the middle cerebral artery territory con- firmed by CT scan or magnetic resonance imaging; (2) a motor deficit of the paretic upper extremity but some capacity for active wrist and finger movements [scores of 3–6 out of 7 on the arm and hand components of the Chedoke McMaster Stroke Assessment (CMSA)] (Gowland et al., 1993; Hubbard et al., 2009) and; (3) corrected to normal vision. Participants were excluded if having moderate to severe cognitive deficits (scores 23 on the Montreal Cognitive Assessment) (Nasreddine et al., 2005), visual field defect (Goldmann perimetry), or visuospatial neglect (Bell’s test), if still receiving therapy for the upper extremity or if having another condition interfering with upper extremity movements. Individ- uals with professional musical experience and/or more than 1 h per week of practice of any musical instrument during the past 10 years were not included in the study. Note that two participants were found a posteriori to have a lesion that involved the brainstem and the cerebellum. The study was approved by the Institutional Ethics Committee and written informed consent was obtained from each participant.
Participants were assessed on clinical outcomes at baseline (week0), pre-intervention (week3), post-intervention (week6), and at follow-up (week9). Training sessions and evaluations were per- formed by the same therapist. The intervention consisted of three individual 1-h sessions per week for three consecutive weeks for a total of nine sessions. Piano performance measures were collected at every session. Supervised sessions were complemented with a biweekly home program (30 min/session).
Musical pieces, created with Harmony Assistant™(Myriad, Toulouse), involved all five digits of the paretic hand. Whether played with the right or left hand, they involved the same num- ber of finger repetitions and similar finger sequences. Pieces were composed by an experienced musician and were designed to be musically pleasant based on simple harmonic rules of composition as well as of relatively short duration and easy to remember (Figure 1). Musical pieces were displayed with Syn- thesia™(Synthesia LLC), a software program adapted for peo- ple with no music reading abilities. A visual display cued the sequence of key presses required to produce each melody by showing a blue dot falling from the upper part of the screen down to the correct key on a virtual keyboard (Figure 2). After each cue, the program paused until the participant pressed the correct key before moving on. During the supervised train- ing sessions, participants played on a touch sensitive Yamaha P-155™ piano keyboard (Yamaha). They received feedback on their performance through Synthesia and through the therapist who provided verbal feedback on the quality of movement and compensatory strategies. Home piano exercises were executed on a roll-up flexible piano (Hand Roll Piano, 61K™), without Synthesia.
Nine musical pieces were introduced in an order of increasing difficulty: level 1 involved movements of consecutive fingers [e.g., digit 1–2–3–4–5]; level 2 involved third, fourth, and fifth inter- vals or movements of non-consecutive fingers [e.g., 1–3–5–2–4] and; level 3 involved chords, that is two fingers played at the same time. Within each level, three musical pieces that involved an increasing number of key presses and changes in melodic direction were introduced (Table 1). In addition, the speed of execution or tempo increased within each musical piece: participants started at a tempo of 30 beats per minute (bpm) and once reaching 80% accuracy [1 (#errors/#key presses) 100] on three con- secutive trials, the tempo was increased by steps of 10% until reaching 60 bpm. After the latter tempo was reached, the next musical piece was introduced. During the home practice sessions, participants were asked to reproduce short digit sequences on the roll-up piano. These sequences comprised short excerpts of the same musical pieces practiced during the supervised sessions and consisted of 30 written exercises where all 5 fingers were repre- sented as a number (1 thumb, 5 pinky). Participants reported on their practice duration and content in a logbook after each practice session.
Piano performance measures included the number of errors (incorrect or early key presses) and duration of the musical pieces recorded with Synthesia as well as the total number of pieces com- pleted after the nine sessions. The following clinical measures were also collected at baseline, pre- and post-intervention, and follow- up. The Box and Block Test (BBT) and Nine Hole Peg Test (NHPT) were used to evaluate gross and fine manual dexterity, respectively. The functional use of the upper extremity was assessed with the six-item version of the Jebsen Hand Function Test (Jebsen). The Finger to Nose Test (FTN) and Finger Tapping Test (FTT) were chosen as measures of arm and finger movement coordination, respectively.
At post-intervention, feedback was collected using a custom- designed questionnaire. The questionnaire included questions where participants rated their interest in the structured piano ses- sions, the home practice exercises, and the musical pieces using a numerical rating scale (score of 0 not interesting and 10 very interesting). Open-ended questions further investigated whether participants had experienced adverse or undesirable effects during the intervention, and whether they had observed changes in upper extremity function after the training. Any additional written and verbal comments were collected.
We conducted a linear mixed model analysis for repeated mea- sures with autoregressive covariance structure, while controlling for baseline measurements (week0), with time [pre (week3), post (week6), and follow-up (week9)] as a within-subject factor to assess the effect of the intervention on the clinical measures. Post hoc pairwise comparisons were used to identify differences
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