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A Piano Training Program to Improve Manual Dexterity and Upper Extremity Function in Chronic Stroke Survivors

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Frontiers in Human Neuroscience
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Objective: 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. Methods: 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. Results: Significant improvements were observed for all outcomes at post-intervention and follow-up compared to pre-intervention scores. Larger magnitudes of change in manual dexterity and functional use of the upper extremity were associated with higher initial levels of motor recovery. Conclusion: 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.
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HUMAN NEUROSCIENCE
ORIGINAL RESEARCH ARTICLE
published: 22 August 2014
doi: 10.3389/fnhum.2014.00662
A piano training program to improve manual dexterity and
upper extremity function in chronic stroke survivors
Myriam Villeneuve 1,2,Virginia Penhune3and Anouk Lamontagne 1,2*
1School of Physical and OccupationalTherapy, McGill University, Montreal, QC, Canada
2Feil and Oberfeld Research Centre, Jewish Rehabilitation Hospital, Research Site of the Montreal Center for Interdisciplinary Research in Rehabilitation (CRIR),
Laval, QC, Canada
3Laboratory for Motor Learning and Neural Plasticity, Department of Psychology, Concordia University, Montreal, QC, Canada
Edited by:
Rachael D. Seidler, University of
Michigan, USA
Reviewed by:
Patrick Ragert, Max Planck Institute
for Human Cognitive and Brain
Sciences Leipzig, Germany
Eckart Altenmüller, University of
Music and Drama Hannover, Germany
*Correspondence:
Anouk Lamontagne, Feil and Oberfeld
Research Centre, Jewish
Rehabilitation Hospital, McGill
University, 3205 Place
Alton-Goldbloom, Laval, QC H7V 1R2,
Canada
e-mail: anouk.lamontagne@mcgill.ca
Objective: 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.
Methods: 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.
Results: 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.
Conclusion: Piano training can result in sustainable improvements in upper extremity func-
tion 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
INTRODUCTION
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 persons capac-
ity 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 par-
adigm 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 Assess-
ment; 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 reha-
bilitation, 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 respond 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
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Villeneuve et al. Piano playing after stroke
clinical profile, including their age, chronicity, and initial level of
motor recovery.
MATERIALS AND METHODS
PARTICIPANTS
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.
GENERAL PROCEDURE
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.
INTERVENTION
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.
OUTCOME MEASURES
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.
DATA AND STATISTICAL ANALYSIS
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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Villeneuve et al. Piano playing after stroke
FIGURE 1 | Excerpts of musical scores of three pieces, one at each level, with digit number under each note.
Frontiers in Human Neuroscience www.frontiersin.org August 2014 | Volume 8 | Article 662 | 3
Villeneuve et al. Piano playing after stroke
FIGURE 2 | (A) Structured training session setting; (B) screen shot of Synthesia Musical Instrument Digital Interface (MIDI) piano program; (C) Roll-up flexible
piano.
between measurement time-points. Correlations were carried out
between change scores on the clinical measures and characteris-
tics of the participants at baseline [age, time since stroke, motor
recovery (CMSA), and manual dexterity (BBT)]. Pearson corre-
lation coefficients were used for all outcomes, except for the level
of motor recovery for which Spearman’s rank correlation coef-
ficients were used. Statistical analyses were performed in SPSS
V20. The level of significance was set to p<0.05. For each family
of outcome measures, we controlled for family-wise error using
modified Bonferroni correction.
RESULTS
Participants’ characteristics are presented in Table 2. Based on
the arm and hand components of the CMSA, participants were
classified as mildly affected (score of 6), moderately affected (scores
of 4 or 5), or severely affected (score of 3). Seven participants suf-
fered from a subcortical stroke, four had a cortical stroke, while
two participants were found post-priori to have pontine or cere-
bellar lesions. Six participants had a right hemisphere lesion, six
had a left lesion, and one participant showed bilateral lesions. Out
of the 13 participants, only 5 had prior musical training, which
included 1–5 years of non-professional piano experience before
the age of 18, with the exception of one participant (#11) who
played occasionally (<1 h/week) in the 2 years preceding stroke
onset but had no formal musical training. Participants were free
of cognitive deficits as indicated by MoCA scores ranging from
28 to 30. All were living in the community and average school
attendance was 14 ±3.7 years (mean ±1 SD).
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Villeneuve et al. Piano playing after stroke
All participants completed the nine training sessions over
3 weeks, except participants #3 and #6 who, due to personal
constraints, completed the program over 4weeks. Two to nine
musical pieces were completed, with some participants reach-
ing level 1 (n=4) and others reaching level 2 (n=5) and level
3(n=4) at post-intervention (Table 3). Each piece was prac-
ticed on average 25 times before reaching 80% accuracy at
60 bpm. At 60 bpm, average durations of musical pieces ranged
Table 1 | Musical piece’s progression.
Song # Piece
duration (s)a
Number of
notes
Number of
changes in
melodic
direction
LEVEL 1: CONSECUTIVE NOTES
1 32 52 11
2 38 69 32
3 48 87 38
LEVEL 2: INTERVALS
4 32 40 18
5 32 59 34
6 48 90 40
LEVEL 3: CHORDS
7 32 53 16
8 32 82 26
9 48 136 31
aPiece duration at 60 bpm.
from 32 to 48 s. Mean home practice time was 28 min/session,
with seven participants meeting/exceeding practice time
requirement. All participants performed the home exercises
independently.
Participants completed all the evaluations. Some, however,
were unable to complete specific tests [NHPT (n=4), FTN
(n=1), and Jebsen (n=1)] at any of the evaluation time-
points due to their low level of motor recovery. No significant
differences were found between baseline and pre-intervention
scores for any of the clinical tests, including the BBT, NHPT,
FTN, FTT, and Jebsen (t-tests, p>0.05). The linear mixed
model showed significant effects of the intervention (p<0.0001)
on the BBT [F(2,24) =38.70], NHPT [F(2,16) =17.50], FTN
[F(2,22) =101.59], FTT [F(2,24) =14.74], and the Jebsen
[F(2,21) =24.02]. Post hoc analyses revealed that scores for all
clinical outcomes were significantly higher at post-intervention
compared to pre-intervention (p<0.0001), while there was no
significant difference between post-intervention and follow-up
(p>0.5).
Although every participant showed improvements on all clini-
cal tests, a large variability in initial scores as well as change scores
was observed across participants (Table 3;Figure 3). In general,
larger changes on the BBT were observed in the mildly affected
participants, whereas larger changes on the NHPT and Jebsen
were seen in the moderately and/or severely affected participants.
Among the seven participants classified as mildly affected, many
scored within the norms (mean ±1 SD) at post-intervention on
the BBT (n=2), NHPT (n=5), and on all subtests of the Jeb-
sen (n=6) (see norms, Mathiowetz et al., 1985;Hackel et al.,
1992;Oxford Grice et al., 2003). None of these participants scored
within the norms prior to the intervention.
Table 2 | Participant characteristics at baseline.
Participant Age Gender Lesion localization Etiology Time since
stroke
CMSA
arm/hand
Spasticity
(MAS)
Musical
experience
MoCA
score
1 62 F Right basal ganglia I 118 3/3 3 5 30
2 71 F Left pontine medullary I 112 3/3 3 0 30
3 52 M Right basal ganglia I 40 3/3 3 1 30
4 54 M Bilateral cerebellum (L >R) and left
thalamus
I 14 4/4 0 0 30
5 49 M Left sub-arachnoids and left sylvian
fissure
H 32 5/4 1 0 30
6 41 M Right frontal cortex, right basal ganglia,
right head of caudate, and right corona
radiata
I 44 5/4 2 0 30
7 75 M Left fronto-parietal region I 18 6/6 0 0 30
8 75 M Right thalamus and internal capsule H 6 6/6 0 0 29
9 74 M Left thalamus I 12 6/6 0 0 29
10 79 F Right sylvian para-central gyrus I 15 6/6 0 1 30
11 60 F Right intraparenchymal frontal region H 61 6/6 0 2 30
12 32 F Left intraventricular and left thalamus H 16 6/6 0 1 28
13 57 M Left posterior limb of internal capsule I 64 6/6 0 0 30
Age (years), gender (male/female), etiology (hemorrhagic/ischemic), time since stroke (months), CMSA =Chedoke McMaster StrokeAssessment (arm/hand scores,
max =7), MAS =Modified Ashworth Scale (max=5), musical experience (years), MoCA =Montreal Cognitive AssessmentTest (max =30).
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Villeneuve et al. Piano playing after stroke
Table 3 | Changes on motor function tests post- vs. pre-intervention.
Participants BBT NHPT FTN Index FTT Jebsen Home Practice Training progression
%%%%% Time (min) # songs/level
SEVERELY AFFECTED
1 4 200 Ø Ø 5 100.0 5 100.0 Ø Ø 170 2/1
2 4 33.3 Ø Ø Ø Ø 6 100.0 60.9 12.1 180c2/1
3 7a50 Ø Ø 5 55.6 5 50.0 63.2 31.0 185c2/1
MODERATELY AFFECTED
4 3 25 Ø Ø 1 14.3 8 47.1 63.8 31.5 50 5/2
5 6a27.3 17.7 15.0 4 36.4 4 33.3 61.9 44.5 60 7/3
6 4 14.3 36.6a29.6 7 58.3 2 9.1 39.7 43.3 135 5/2
MILDLY AFFECTED
7 11a30.6 19.4 40.3 4 25.0 1 3.6 17.5b27.6 227c5/2
8 6a14.6 11.9b32.2 5 31.3 2 6.3 26.5 31.8 155 5/2
9 10a28.6 7.4 14.0 5 29.4 4 9.8 9.5b18.7 140 6/2
10 7a16.3 9.6b28.3 5 35.7 2 3.6 12.1b25.4 195c6/2
11 5a9.3 7.1b25.8 6 23.8 6 9.4 20.0b41.6 245c9/3
12 12ab 21.1 7.1b29.2 3 12.5 21 46.7 3.0b11.6 225c9/3
13 17ab 32.1 2.7ab 11.1 7 36.8 7 17.1 10.6a31.1 315c8/3
Mean (sd) 7.4a(4.1) 38.6 (49.6) 13.3 (10.2) 25.1 (9.7) 4.7 (1.6) 35.3 (25.2) 5.6 (5.1) 33.5 (34.2) 32.4 (24.0) 27.1 (12.9) 175.5 (72.1) 5.5 (2.4)
, Change between pre- and post-intervention; %, percent change between pre- and post-intervention; Ø, participant unable to perform the test;
aparticipant reached the smallest real difference (SRD) score;
bparticipant reached the norms for his/her age group;
cParticipant practiced at least 180min at home (2 min ×30 min).
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Villeneuve et al. Piano playing after stroke
FIGURE 3 | Individual performances for all participants [severely affected (gray
solid line), moderately affected (black dashed line), and mildly affected (black
solid line)] on the (A) Box and BlockTest (BBT); (B) Nine Hole PegTest (NHPT)
and; (C) Jebsen Hand FunctionTest (Jebsen) at baseline, pre-intervention,
post-intervention, and follow-up.The area between the vertical doted lines
represents the 3-week intervention period. In (C), the y-axis is discontinued
for a better overview of results. Note that four participants could not complete
the NHPT and one could not complete the Jebsen (see text for more details).
No significant relationships were observed between change
scores on the clinical measures as a result of the intervention
(absolute changes between post vs. pre-intervention on the BBT,
NHPT, FTN, FTT, and Jebsen) and variables such as age and time
since stroke (r=0.01–0.27, p0.3). Participants with larger base-
line scores on the BBT showed larger change scores on the BBT
and Jebsen (r=0.64–0.70, p<0.01), but not on other clinical tests
(NHPT, FTN, and FTT,p>0.1). Participants with higher scores on
the hand component of CMSA also showed larger change scores on
the BBT (r=0.54, p<0.05) and the Jebsen (r=0.63, p<0.01),
but no significant correlations were observed for other clinical
tests (p>0.5). Better scores on the BBT, NHPT, FTN, and FTT
at baseline were associated with longer home practice durations
(r=0.5–0.7, p>0.05).
In response to the feedback questionnaire, participants rated
their interest in the supervised training session between 8 and
10, while their interest in the musical pieces ranged between 7
and 9. Their interest in the home program received scores that
ranged between 2 and 10. Answers to the open-ended questions
revealed that five participants considered the home training to be
less interesting and not as motivating compared to the supervised
sessions due to the lack of feedback received during playing. Six
participants reported that the training was good for their mood
and motivation to engage in upper extremity exercises, and 11
participants reported that they observed a change in upper extrem-
ity function, expressed as an increased mobility of their paretic
hand, improvement in fluidity of movements as well as increased
coordination and dexterity. More concretely, three participants
mentioned that they could pick up small objects more easily and
that they dropped objects less often when using the paretic hand,
while two participants reported improvements in writing and typ-
ing skills. Three participants reported adverse or negative effects,
including shoulder stiffness (n=1), fatigue (n=1),and mild hand
numbness (n=1), which resolved either immediately or within
the hour following the session. Finally, five participants expressed
the desire to continue piano lessons after their participation in the
study; reasons mentioned included the sense of achievement and
success (n=2) and the perceived change in motor function and
desire to experience further recovery (n=3).
DISCUSSION
This study examined, for the first time, the short-term and reten-
tion effects of a 3-week piano training program that included
supervised sessions and home practice. For this purpose, we have
developed a structured program with graded levels and clear cri-
teria for progression, which is amenable to use in clinical setting
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Villeneuve et al. Piano playing after stroke
by rehabilitation therapists who do not have specialized musi-
cal training. Gains in upper extremity function were observed
in all participants, with larger improvements being observed in
those with higher levels of motor recovery at baseline. Gains were
maintained 3 weeks after the end of intervention, suggesting that
the intervention results in longer-term improvements in upper
extremity function.
Our results are consistent with previous research in acute
stroke where improvements in finger movement coordination and
manual dexterity were reported as a result of a 3-week mixed-
instrument intervention (Altenmuller et al., 2009). The fact that
fine and gross manual dexterity was improved in chronic stroke
survivors in the context of our study may be attributable to the
specificity of the piano intervention, which involved repeated prac-
tice of dissociated finger movements while promoting speed and
movement accuracy. Other contributing factors include the rapid
establishment of auditory–motor coactivation induced by musical
training (Altenmuller et al., 2009;Amengual et al., 2013;Grau-
Sanchez et al., 2013) and the melody that is a powerful source of
auditory feedback providing instantaneous knowledge of move-
ment timing and accuracy. Hence, both the temporal and spatial
features of finger movements can be trained, leading to enhanced
movement coordination.
In the present study, participants also experienced an enhance-
ment in the functional use of the paretic upper extremity as a result
of the intervention, indicating that gains were transferred to func-
tional tasks of daily living and that finger movement coordination
training could be a key component of upper extremity rehabilita-
tion. The piano intervention, which yielded a mean increase of 7.4
blocks on the BBT, may compare advantageously with other ther-
apies such as constraint-induced movement therapy where gains
of 4–4.5 blocks were reported after intensive arm restriction (3 h
to 90% of waking hours for 2–4 weeks) (Leung et al., 2009;Siebers
et al., 2010). Since the piano intervention relies on user-friendly
and commercially available equipment, it also has the potential to
be self-managed and pursued beyond the usual rehabilitation time
frame.
A large variability in terms of initial scores and change scores
on the different clinical outcomes was observed across partici-
pants. Given this variability, individual responses were examined
with regard to smallest real differences, which are available for
the BBT (+6 blocks) and the NHPT (32.8 s) (Chen et al., 2009);
eight participants exceeded the smallest real difference for the BBT
(Table 3). Although only one participant reached the smallest real
difference for the NHPT, it was observed that five participants
(mildly affected) scored within norms at post-intervention. Sim-
ilarly, six mildly affected participants attained the norms on the
Jebsen. Participants with higher scores on the CMSA and BBT
at baseline were also the ones who showed larger gains on most
outcome measures, along with longer home practice durations. It
cannot be excluded, however, that some of the clinical tests used
in this study might not be sensitive enough to detect changes in
individuals with more severe deficits in motor recovery. In fact,
the NHPT proved to be too difficult to use in four participants
who were severely or moderately affected, such that changes in
fine manual dexterity that might have occurred in these indi-
viduals could not be assessed. Changes in FTN and FFT scores,
however, reveal that these same participants improved in finger
and arm movement coordination, in many instances to an extent
that was comparable to changes observed in mildly affected partici-
pants. Taken together, these observations suggest that a significant
proportion of the participants showed a true change in manual
dexterity and upper extremity, and that the piano intervention
has the potential to allow participants with mild impairments in
motor function to improve their performance up to a level that is
within normal limits. While mildly affected participants showed
the largest improvements as a result of the intervention, results
also show that all participants were able to complete the program,
suggesting that a piano-specific intervention is feasible for chronic
stroke survivors with different levels of motor recovery, including
patients who only present some capacity for active wrist and finger
movements (CMSA score of 3) (Gowland et al., 1993).
The location (cortical vs. subcortical) and side of stroke are
often important factors to consider in assessing intervention out-
comes. Participants investigated in this study predominantly suf-
fered from subcortical stroke, with an equal distribution of left-
and right-sided lesions. It was not possible to conduct statistical
analysis on both subgroups due to the small number of partici-
pants. However, we can observe that six out of seven participants
presenting a subcortical lesion reached the smallest real difference
on the BBT, as did three out of four in the cortical subgroup. Sim-
ilarly, we can observe that five out of six participants with a left
lesion reached the smallest real difference on the BBT, as com-
pared to four out of six participants with a right lesion. Although
these observations do not suggest a clear difference between the
type and side of the lesion, further investigations are needed with
a larger sample size to validate these observations.
Information from the participant feedback questionnaire indi-
cated that participants enjoyed the training program and felt
motivated, especially during the supervised training sessions. All
participants were able to complete the 60-min sessions while keep-
ing a high level of motivation and attention for the entire practice
time. We believe that the music-like nature of the pieces was an
important factor that motivated participants to engage in training
that requires many repetitions. We also believe that the gaming”
nature of the training (with scores and levels) added a sense of
success and an awareness of improvement that made the interven-
tion gratifying. Some participants rated their satisfaction with the
home practice as lower due to the absence of feedback. However,
most met or exceeded the requested practice time. Some partici-
pants even expressed the desire to pursue the piano lessons after
the intervention. The sense of achievement and success, the per-
ception of being engaged in a socially valued leisure activity, and
the observation of improvements in upper extremity function are
factors that may encourage stroke survivors to continue piano
training on the long term, such that gains can be maintained and
possibly further improved. Although MST should involve minimal
risks or disadvantages, these had never been reported in previous
studies. In the present study, minor unwanted effects were reported
by some participants, including temporary fatigue and arm stiff-
ness/numbness. While these unwanted effects resolved within the
hour following the intervention, it may be advised to closely mon-
itor the level of exertion and other factors such as stiffness or pain
in future intervention studies.
Frontiers in Human Neuroscience www.frontiersin.org August 2014 | Volume 8 | Article 662 | 8
Villeneuve et al. Piano playing after stroke
Main limitations of this study include a small sample size and
inherent limitations of single subject designs. This work, how-
ever, was an essential step toward determining the feasibility of
the intervention in post-stroke participants having different levels
of motor recovery, before larger clinical trial can be undertaken.
Although we did not have a no-treatment or standard treatment
control group, this limitation was partially addressed with the use
of an AABA design, controlling for the passage of time and ensur-
ing that participants were stable prior to the beginning of the
intervention. However, whether the improvements are specifically
related to the musical aspect of the intervention cannot be deter-
mined. Nevertheless, this preliminary study provides evidence that
an intervention providing musical feedback that combines inten-
sive practice and high motivation can be beneficial for chronic
stroke survivors. A future larger study will also allow us to com-
pare the intervention to a standard treatment. Future directions for
research include the investigation of a larger pool of participants,
possibly with longer training duration and a longer-follow-up.
CONCLUSION
This study provides the first evidence that a piano training inter-
vention combined to home practice can lead to improvements in
manual dexterity, finger movement coordination, and functional
use of the upper extremity that persist 3 weeks after the interven-
tion. In addition to representing a socially valued and enjoyable
activity, piano training has the potential to be self-managed and
to enable people with chronic stroke to pursue upper extremity
exercises beyond the usual rehabilitation time frame.
ACKNOWLEDGMENTS
We are thankful to the participants involved in this study. This
project was supported by the Foundation of the Jewish Rehabilita-
tion Hospital. Myriam Villeneuve was the recipient of a scholarship
from the School of Physical and Occupational Therapy, McGill
University. Anouk Lamontagne holds a Junior-2 Salary Award
from FRSQ.
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Conflict of Interest Statement: The authors declare that the researchwas conducted
in the absence of any commercial or financial relationships that could be construed
as a potential conflict of interest.
Received: 17 June 2014; accepted: 08 August 2014; published online: 22 August 2014.
Citation: Villeneuve M, Penhune V and Lamontagne A (2014) A piano training pro-
gram to improve manual dexterity and upper extremity function in chronic stroke
survivors. Front. Hum. Neurosci. 8:662. doi: 10.3389/fnhum.2014.00662
This article was submitted to the journal Frontiers in Human Neuroscience.
Copyright © 2014 Villeneuve, Penhune and Lamontagne . This is an open-access article
distributed under the terms of the Creative Commons Attribution License (CC BY).
The use, distribution or reproduction in other forums is permitted, provided the original
author(s) or licensor are credited and that the original publication in this journal is cited,
in accordance with accepted academic practice. No use, distribution or reproduction is
permitted which does not comply with these terms.
Frontiers in Human Neuroscience www.frontiersin.org August 2014 | Volume 8 | Article 662 | 9
... Musicsupported Therapy (MST) is a structured training program with keyboard and electronic drum exercises aimed to enhance upper-limb motor function post-stroke [13]. This intervention has shown to improve upper-limb mobility, cognitive functions, QoL, and emotional well-being in subacute and chronic stroke participants [13][14][15][16][17][18][19][20][21]. Studies evaluating MST-induced plasticity with neuroimaging and neurophysiological techniques reported an increase in the excitability and reorganization of the lesioned sensorimotor cortex in subacute and chronic stroke survivors [16,22]. ...
... In line with previous MST trials [19][20][21], eMST improved emotional well-being and QoL [13][14][15][16][17][18][19][20][21], reducing anger and increasing self-perceived positive emotion and community participation compared to the control group. Furthermore, eMST participants reported higher enjoyment during the sessions, which might have reinforced their emotional well-being and intrinsic motivation for eMST adherence. ...
Article
Full-text available
Objective Many stroke survivors still present with upper-limb paresis six months post-stroke, impacting their autonomy and quality of life (QoL). We designed an enriched Music-supported Therapy (eMST) program to reduce disability in this population. We evaluated the eMST’s effectiveness in improving functional abilities and QoL in chronic stroke individuals compared to the conventional motor program Graded Repetitive Arm Supplementary Program (GRASP). Methods We conducted a pragmatic two-arm parallel-group randomized controlled trial with a 3-month follow-up and masked assessment. The eMST involved playing instruments during individual self-administered and group music therapy sessions. The GRASP consisted of self-administered motor exercises using daily objects. Both interventions were completed at home with telemonitoring and involved four one-hour weekly sessions for 10 weeks. The primary outcome was upper-limb motor function measured with the Action Research Arm Test. Secondary outcomes included motor impairment, daily life motor performance, cognitive functions, emotional well-being, QoL, self-regulation, and self-efficacy. Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted including participants who discontinued the intervention and those who completed it entirely, respectively. Results Fifty-eight chronic stroke patients were randomized to the eMST-group (n = 26; age: 64.2 ± 12.5; 6 [23.1%] females; 2.8 ± 2.9 years post-stroke), and the control group (n = 32; age: 62.2 ± 12; 8 [25%] females; 1.8 ± 6.2 years post-stroke). The eMST-group had more participants achieving a clinically relevant improvement in motor impairment post-intervention than the control group for the ITT (55% vs 21.6%; OR = 4.5 (95% CI 1.4–14); p = .019) and PP analyses (60% vs 20%; OR = 6 (95% CI 1.5–24.7); p = .024), sustained at follow-up. The eMST-group reported greater improvements in emotion (difference = 11.1 (95% CI 0.8–21.5; p = 0.36) and participation (difference = 10.3 (95% CI 0.6–25.9); p = 0.41) subscales of QoL, and higher enjoyment during the sessions (difference = 1 (95% CI 0.3–1.5); p = 0.12). No changes were found in other outcomes. Conclusion eMST demonstrated superiority over conventional motor rehabilitation program in enhancing upper-limb functions and QoL in chronic stroke individuals. Trial Registration ClinicalTrials.gov (ID: NCT04507542).
... Second, the unnecessary complexity of the traditional music notation systems is a barrier to fully developing the potential of music therapy in most populations. Some effective forms of active music therapy, such as playing the piano [37][38][39][40][41][42], require reading music sheets that are extremely complex for people without a musical background. ...
... Playing the piano is an effective form of active music therapy [37][38][39][40][41][42]. The piano is one of the easiest instruments to play music notes with; if we press any piano key, we will hear a clean note with perfect pitch. ...
Preprint
Full-text available
Abstract: Recent research shows that listening to music and making music can promote health-related quality of life in healthy populations and people with a variety of conditions and diseases such as stress, anxiety, depression, Alzheimer disease and cancer. In active music therapy, patients are asked to make music, e.g., by singing, playing instruments or composing songs. Unfortunately, the unnecessary complexity of traditional music notation systems and the lack of an international language to read music notes are obstacles to music learning and delivery in therapeutic and educational settings. Here I propose a simple music notation system, compatible with the traditional systems, that can be used globally to facilitate music reading and learning. This notation system, called MoSyNum (Movable Syllabic Numerical), contains several layers of complexity so that it can be useful for people with no musical background and for professional and non-professional musicians. It is based on four concepts. First, the 12 degrees of the chromatic scale are notated with 12 easy-to-sing syllables (i.e., No-Mo-Ke-Ma-Ni-Pa-Pe-Co-Lo-Sa-Na-Pi) not used in other syllabic systems such as "fixed Do" or "movable Do" solfege. This provides an international and information-rich language for reading and singing the music notes of instrumental and non-instrumental songs. Second, the 5 lines of the classical staff are reduced to 1 line; the 12 notes of the chromatic scale are identified by their corresponding syllable written below the line, and octave changes are notated by moving the rhythmic figures up or down the line using leger lines. This modification greatly simplifies the process of reading music. Third, the upper part of the MoSyNum staff provides the chord progression of the composition using a numerical and standardized chord notation system. Chord notation (e.g., 1m7M) involves several parts: a scale-degree number to identify the 12 possible root notes of the chord (i.e., 1-b2-2-b3-3-4-b5-5-b6-6-b7-7), a letter or letters to inform on the three notes that make the triad of the chord (e.g., M = major, m = minor, dim = diminished, etc.), one or several numbers with or without a letter or symbol to indicate possible notes added to the triad (e.g., 7, 7M, b9, #11, etc.), and a bass note when necessary. Bass notes of slash chords (figured bass) are easily and unequivocally notated by using the scale degree of the key; for example, if the song is in any mode of C (e.g., C Major, C Minor, C Dorian, C Phrygian, etc.), the chord G7/F is notated as 5M7/4. Fourth, since each syllable always represents the same scale degree (e.g., No = 1, Mo = b2, Ke = 2, Ma = b3, Ni = 3, etc.) and the chords are notated numerically, MoSyNum is a movable system. This means that a song notated in this system can be sung and played in any of the 12 keys without changing the names of the melody notes. The same music sheet can be used by a vocalist singing in any key, a pianist, a guitarist, a B-flat clarinetist or an E-flat saxophonist. After describing the MoSyNum language and its multiple practical applications (e.g., production of international audio music scores for teaching purposes or for visually-impaired people), this article provides useful tools, charts and guidelines to facilitate its implementation in therapeutic and educational settings. Keywords: music therapy, music intervention, international solfege, fixed Do, movable Do, chords, scales, harmonic analysis, music theory, piano, MoSyNum tools, audio music sheets, static MoSyNum.
... Therefore, a total of 59 full text articles were excluded with reasons. Of these remaining 26 studies, 17 were RCTs (Ghasemi et al., [19] , Basha [27] ; Fujioka et al., [28] ; Grau-Sánchez et al., [29] ; Street et al., [30] ; Bunketorp-Kall et al., [31] ; Jeba et al., [32] ; Van Vugt et al., [33] ; Zondervan et al, [34] ; Tong et al., [35] ; Yoon et al., [36] ; Van Vugt et al., [37] ; Friedman et al., [38] ; Monticone et al., [39] ; Thieme et al., [40] ; Fritz et al., [41] ; Liao et al., [42] ), 7 quasiexperimental studies (Yoo, [43] ; Nikmaram et al., [44] ; Raglio et al, [45] ; Raghavan et al., [46] ; Scholz et al., [47] ; Villeneuve et al., [48] ; Amengual et al., [49] ), 1 case series (Villeneuve et al., [50] ), and 1 case study (Grau-Sánchez et al., [51] ). ...
Article
Full-text available
Background: Stroke, a leading cause of disability worldwide, often leaves survivors grappling with functional impairments that significantly impact their daily lives. Enhancing the functional status of stroke survivors is not only a personal achievement but also a critical public health concern. Aim: A systematic review of literature was conducted to identify the various forms of structured exercises and music therapy used in enhancing the functional status of stroke survivors, and the various outcome measures used in measuring the functional status of the stroke survivors. Design: A systematic review. Data Extraction: The titles and abstracts of articles were screened and studies that did not meet the eligibility criteria were excluded. Full texts of eligible studies were further scrutinized. The results were interpreted and reported with respect to their level of evidence, design, sample size, duration, quality appraisal and risk of bias. Result: A total of 2,427 studies were identified through initial search of the databases. Additional 8 records were identified through other sources making it a total of 2,435 records. 2,350 duplicate studies were removed after screening. The remaining 85 full-text articles were screened for eligibility criteria and further reduced to 26. Of these 26 studies, 17 were Randomized Controlled Trials (RCTs), 7 quasi-experimental studies, 1 case series, and 1 case
... Apart from being used in research for comparison, Synthesia has also been used for other purposes. For example, supervised piano training sessions using Synthesia combined with home practice exercises without Synthesia were used to improve manual dexterity, finger movement coordination, and upper extremity function in chronic stroke survivors (Villeneuve et al. 2014). Villeneuve et al. carried out a study involving thirteen participants with chronic stroke. ...
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Full-text available
This work presents the development of a mixed reality (MR) application that uses color Passthrough for learning to play the piano. A study was carried out to compare the interpretation outcomes of the participants and their subjective experience when using the MR application developed to learn to play the piano with a system that used Synthesia (N = 33). The results show that the MR application and Synthesia were effective in learning piano. However, the students played the pieces significantly better when using the MR application. The two applications both provided a satisfying user experience. However, the subjective experience of the students was better when they used the MR application. Other conclusions derived from the study include the following: (1) The outcomes of the students and their subjective opinion about the experience when using the MR application were independent of age and gender; (2) the sense of presence offered by the MR application was high (above 6 on a scale of 1 to 7); (3) the adverse effects induced by wearing the Meta Quest Pro and using our MR application were negligible; and (4) the students showed their preference for the MR application. As a conclusion, the advantage of our MR application compared to other types of applications (e.g., non-projected piano roll notation) is that the user has a direct view of the piano and the help elements appear integrated in the user’s view. The user does not have to take their eyes off the keyboard and is focused on playing the piano.
... I was aware that home practice is essential to achieve sufficient repetition of movements to bring about neurological change and improved arm function. Evidence for the importance of dosage is supported by both music-based (Ripolles et al., 2015;Villeneuve & Penhune, 2014) and non-music-based studies, as is the need to improve ways of recording independent home practice (Turton et al., 2017). ...
Article
Full-text available
This case study describes how a music therapist (Stephen) and a music therapy intern (Sahitya) worked conjointly with a client and her granddaughter in a remote part of North India. The description provides a unique insight into conditions, culture, and lifestyle in this location, and how these two clinicians were able to merge broader arts-based and holistic approaches, on a journey towards client-centered and functional neurologic music therapy exercises to help the client regain more independence. The background to initial work undertaken by the music therapist, which lasted for one year and eleven months, is followed by a summary of five weekly conjoint sessions with the intern, including the evolution of exercises, rationale, and client responses, illustrated with embedded video excerpts. The communication, relationship, and trust-building with the client and her granddaughter, together with the intern joining the dynamic, paved the way for assimilating music therapy theoretical models that were new to them, and adapting neurologic music therapy approaches using an electronic keyboard that incorporated preferred facilitating music. This resulted in greater client engagement with higher levels of motivation and adherence and increased hand use in daily activities.
... The impact of music is well-documented in stroke rehabilitation, as it can enhance various gait parameters, including velocity, cadence, stride length, and balance [10][11][12][13][14][15], as well as upper limb movements [16][17][18][19][20][21], language [22][23][24], mood, and psychological aspects [25][26][27][28][29][30][31]. Gait rehabilitation studies for Parkinson's Disease (PD) [32][33][34][35] and multiple sclerosis [24,[36][37][38] yield comparable results. ...
Article
Full-text available
Background: Movement sonification has been recently introduced into the field of neuromotor rehabilitation alongside Neurologic Music Therapy and music-based interventions. This study introduces the use of musical auditory cues encompassing the melodic-harmonic aspect of music. Methods: Nineteen patients with Parkinson’s disease were randomly assigned to the experimental (n = 10) and control (n = 9) groups and underwent thrice-weekly sessions of the same gait training program, with or without sonification. Functional and motor parameters, as well as fatigue, quality of life, and the impact of intervention on patients’ well-being, were assessed at baseline (PRE), the end of treatment (POST), and at follow-up (FU). Between-group differences were assessed for each outcome measure using linear mixed-effects models. The outcome measure was entered as the dependent variable, group and time as fixed effects, and time by group as the interaction effect. Results: Mini BESTest and Dynamic Gait Index scores significantly improved in the experimental group (p = 0.01 and p = 0.03, respectively) from PRE to FU, demonstrating a significant impact of the sonification treatment on balance. No other significant differences were observed in the outcome measures. Conclusions: Larger sample sizes are needed to confirm the effectiveness of sonification approaches in Parkinson’s disease, as well as in other neurological disorders.
... Training of controlled index finger movements in the chronic post-stroke phase also leads to partially recovered dexterous hand use and is accompanied by reorganization of cortical sensorimotor networks [11]. Friedman et al. [12] showed enhanced recovery of dexterous hand use after MusicGlove training, and piano training may improve motor recovery of individuated finger movements [13]. However, randomized controlled trials are lacking and it remains therefore unclear whether finger-training approaches have enhanced efficacy to improve hand motor impairments and activity limitations compared to conventional therapy. ...
Article
Full-text available
Objective: To compare the efficacy of Dextrain Manipulandum™ training of dexterity components such as force control and independent finger movements, to dose-matched conventional therapy (CT) post-stroke. Methods: A prospective, single-blind, pilot randomized clinical trial was conducted. Chronic-phase post-stroke patients with mild-to-moderate dexterity impairment (Box and Block Test (BBT) > 1) received 12 sessions of Dextrain or CT. Blinded measures were obtained before and after training and at 3-months follow-up. Primary outcome was BBT-change (after-before training). Secondary outcomes included changes in motor impairments, activity limitations and dexterity components. Corticospinal excitability and short intracortical inhibition (SICI) were measured using transcranial magnetic stimulation. Results: BBT-change after training did not differ between the Dextrain (N = 21) vs CT group (N = 21) (median [IQR] = 5[2-7] vs 4[2-7], respectively; P = 0.36). Gains in BBT were maintained at the 3-month post-training follow-up, with a non-significant trend for enhanced BBT-change in the Dextrain group (median [IQR] = 3[- 1-7.0], P = 0.06). Several secondary outcomes showed significantly larger changes in the Dextrain group: finger tracking precision (mean ± SD = 0.3 ± 0.3N vs - 0.1 ± 0.33N; P < 0.0018), independent finger movements (34.7 ± 25.1 ms vs 7.7 ± 18.5 ms, P = 0.02) and maximal finger tapping speed (8.4 ± 7.1 vs 4.5 ± 4.9, P = 0.045). At follow-up, Dextrain group showed significantly greater improvement in Motor Activity Log (median/IQR = 0.7/0.2-0.8 vs 0.2/0.1-0.6, P = 0.05). Across both groups SICI increased in patients with greater BBT-change (Rho = 0.80, P = 0.006). Comparing Dextrain subgroups with maximal grip force higher/lower than median (61.2%), BBT-change was significantly larger in patients with low vs high grip force (7.5 ± 5.6 vs 2.9 ± 2.8; respectively, P = 0.015). Conclusions: Although immediate improvements in gross dexterity post-stroke did not significantly differ between Dextrain training and CT, our findings suggest that Dextrain enhances recovery of several dexterity components and reported hand-use, particularly when motor impairment is moderate (low initial grip force). Findings need to be confirmed in a larger trial. Trial registration ClinicalTrials.gov NCT03934073 (retrospectively registered).
... Finally, it should be mentioned that the ability to positively alter motor circuits could offer valuable therapeutic potential for neurological motor disorders such as Parkinson's and Huntington's disease (Devlin et al., 2019), stuttering (Alm, 2004) or stroke (Altenmüller et al., 2009;Villeneuve et al., 2014). ...
Article
Full-text available
Musical training can improve fine motor skills, cognitive abilities and induce macrostructural brain changes. However, it is not clear whether the changes in motor skills occur simultaneously with changes in cognitive and neurophysiological parameters. In this study, 156 healthy, musically naïve, and right-handed older adults were recruited and randomly assigned to a piano training or a music listening group. Before, after six and twelve months participants were scanned using MRI and assessed for fine motor skills, auditory working memory and processing speed. A Bayesian multilevel modeling approach was used to examine behavioral and neurophysiological group differences. The relationships between motor and cognitive and between motor and neurophysiological parameters were determined using latent change score models. Compared to music listening, practicing piano resulted in greater improvement in fine motor skills and probably working memory. Only in the piano group, unimanual fine motor skills and gray matter volume of the contralateral M1 changed together during the 6-12-month period. Additionally, M1 co-developed with ipsilateral putamen and thalamus. Playing piano induced more prevalent coupling between the motor and cognitive domain. However, there is little evidence that fine motor control develops concurrently with cognitive functions. Playing an instrument promotes motor, cognitive and neural development into older age. During the learning process, the consolidation of piano skills appears to take place in sensorimotor networks, enabling musicians to perform untrained motor tasks with higher acuity. Relationships between the development of motor acuity and cognition were bidirectional and can be explained by a common cause as well as by shared resources with compensatory mechanisms.
Article
Zusätzlich zur klassischen Musiktherapie konnten Behandelnde mit der musikunterstützten Therapie (MST) bei Parkinson- und Schlaganfallpatient*innen gute Erfolge erzielen. Hierbei handelt es sich um strukturiertes Trainingsprogramm mit Keyboard- und Trommelübungen zur Verbesserung der motorischen Funktionen der oberen Gliedmaßen. Randomisierte kontrollierte Studien belegen die Wirksamkeit. Musikalische ­Interventionen können die Mobilität der oberen Gliedmaßen sowohl bei subakuten als auch bei chronischen Schlaganfallpatien­t*innen verbessern. Musikbasierte Interventionen, die auf rhythmischer Stimulation beruhen, haben bei Parkinson-Patient*innen einen positiven Einfluss auf die Gehgeschwindigkeit, die Schrittlänge und die Mobilität.
Article
Purpose: To examine the feasibility of stroke survivors receiving music-based rehabilitation via a mobile app. Materials and methods: We recruited ten chronic stroke survivors who were community-dwelling with mild-moderate upper extremity (UE) paresis. Participants were encouraged to exercise their paretic UE with a commercial instrument training app, Yousician, with a piano keyboard at home for three weeks. The feasibility of the training was measured by: (a) the acceptance of using the app to receive in-home piano training (e.g., daily usage time, exit interview) and (b) the effects of the app functionality as a rehabilitation tool (e.g., participants' motor improvements after training). Results: Our small sample size of participants demonstrated general positive feedback and self-motivation (e.g., interest in extended training time) about using a mobile app to receive in-home, music-based UE training. Participants showed no trend of declined usage and practiced on average ∼33 min per day for 4-5 days per week during the 3-week participation. We also observed positive results in the Fugl-Meyer Assessment, Action Research Arm Test, and Nine Hole Peg Test after training. Conclusions: This study provided insight into the feasibility of delivering music-based interventions through mobile health (mHealth) technology for stroke populations. Although this was a small sample size, participants' positive and negative comments and feedback provided useful information for future rehab app development. We suggest four ways to further improve and design a patient-oriented app to facilitate the use of a mHealth app to deliver in-home music-based interventions for stroke survivors.
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Full-text available
Playing a musical instrument demands the engagement of different neural systems. Recent studies about the musician's brain and musical training highlight that this activity requires the close interaction between motor and somatosensory systems. Moreover, neuroplastic changes have been reported in motor-related areas after short and long-term musical training. Because of its capacity to promote neuroplastic changes, music has been used in the context of stroke neurorehabilitation. The majority of patients suffering from a stroke have motor impairments, preventing them to live independently. Thus, there is an increasing demand for effective restorative interventions for neurological deficits. Music-supported Therapy (MST) has been recently developed to restore motor deficits. We report data of a selected sample of stroke patients who have been enrolled in a MST program (1 month intense music learning). Prior to and after the therapy, patients were evaluated with different behavioral motor tests. Transcranial Magnetic Stimulation (TMS) was applied to evaluate changes in the sensorimotor representations underlying the motor gains observed. Several parameters of excitability of the motor cortex were assessed as well as the cortical somatotopic representation of a muscle in the affected hand. Our results revealed that participants obtained significant motor improvements in the paretic hand and those changes were accompanied by changes in the excitability of the motor cortex. Thus, MST leads to neuroplastic changes in the motor cortex of stroke patients which may explain its efficacy.
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Full-text available
Background Several recently developed therapies targeting motor disabilities in stroke sufferers have shown to be more effective than standard neurorehabilitation approaches. In this context, several basic studies demonstrated that music training produces rapid neuroplastic changes in motor-related brain areas. Music-supported therapy has been recently developed as a new motor rehabilitation intervention. Methods and Results In order to explore the plasticity effects of music-supported therapy, this therapeutic intervention was applied to twenty chronic stroke patients. Before and after the music-supported therapy, transcranial magnetic stimulation was applied for the assessment of excitability changes in the motor cortex and a 3D movement analyzer was used for the assessment of motor performance parameters such as velocity, acceleration and smoothness in a set of diadochokinetic movement tasks. Our results suggest that the music-supported therapy produces changes in cortical plasticity leading the improvement of the subjects' motor performance. Conclusion Our findings represent the first evidence of the neurophysiological changes induced by this therapy in chronic stroke patients, and their link with the amelioration of motor performance. Further studies are needed to confirm our observations.
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