Music-supported Therapy in the rehabilitation of motor deficits after stroke

Abstract

Motor deficits of the upper extremity are present in the majority of stroke patients, having a significant impact on their autonomy and quality of life. The recovery of motor deficits after stroke mainly relies on rehabilitation, which is a patient-centred process aimed at improving and maintaining the individual’s functioning using therapeutic interventions to promote adaptive learning. Recently, music-based interventions have emerged as a promising tool since they can incorporate many principles of stroke motor rehabilitation. Among these interventions, Music-supported Therapy has been developed to enhance the motor function of the paretic upper extremity in stroke patients by playing musical instruments. Previous studies have shown that Music-supported Therapy can improve the functionality of the paretic upper extremity, promote functional neuroplastic changes and enhance the mood and quality of life of subacute and chronic stroke patients. Despite these promising findings, Music-supported Therapy has not been appropriately contrasted with conventional therapy, and still, several aspects of its effectiveness remain unknown. The main aim of this thesis was to study the effectiveness of Music-supported Therapy as a therapeutic intervention in the rehabilitation of upper extremity motor function after stroke. This thesis is composed of four studies that made use of different research designs and measurements at the neural, body functions, activity and participation level. In Study 1, we tested the effectiveness of Music-supported Therapy in treating the hemiparesis of the upper extremity, inducing neuroplastic changes in the sensorimotor cortex and enhancing the quality of life in subacute stroke patients. By using an interventional experimental design, patients were assessed before and after the treatment in an evaluation that comprised standardised clinical motor tests, an assessment of the excitability of the sensorimotor cortex with Transcranial Magnetic Stimulation and a quality of life questionnaire. In Study 2, a randomised controlled trial was conducted to test the effectiveness of adding Music-supported Therapy to a standard rehabilitation program for subacute stroke patients. Participants were randomised into a Music-supported Therapy group or a conventional therapy group in addition to the standard rehabilitation program. Before and after four weeks of treatment, motor and cognitive functions, mood, and quality of life of patients were evaluated. A follow-up evaluation was performed at three months to test the retention of motor gains. In Study 3, a subsample of Study 2 was evaluated with a structural and functional Magnetic Resonance Imaging protocol before and after the intervention. This study aimed to characterise the lesions and white matter damage of patients, test the relationship between corticospinal tract integrity and motor recovery and explore the mechanisms of brain plasticity induced by Music-supported Therapy compared to conventional therapy. In Study 4, a single-case study was conducted to explore the progression of motor improvements throughout the Music-supported Therapy sessions, examine the effects of a second period of training, study the retention of motor gains over time and investigate the generalisation of motor improvements to activities of daily living. An extensive evaluation of the motor function using clinical motor tests and three-dimensional (3D) movement analysis was performed weekly and in a follow-up evaluation. The results of this thesis show that Music-supported Therapy is an effective intervention in the rehabilitation of upper extremity function after stroke. Music-supported Therapy reduces the motor deficits and improves the functionality of the upper extremity of stroke patients in the same manner as conventional therapy, with gains that are generalised to activities of daily living and maintained over time. Moreover, patients treated with Music-supported Therapy have better language abilities, less fatigue and negative emotions, and greater quality of life than those patients treated only with conventional therapy. The pleasure experienced in musical activities is correlated with motor gains in patients treated with Music-supported Therapy, pointing out the importance of motivation in motor skill learning and stroke rehabilitation. Moreover, Music-supported Therapy promotes similar plastic changes than conventional therapy, inducing cortical motor map reorganisation and excitability changes in the sensorimotor cortex in stroke patients although further research is needed to pinpoint the neural plastic changes promoted by the therapy.

Los déficits motores de la extremidad superior están presentes en la mayoría de las personas que han sufrido un ictus, e impactan de manera significativa en su autonomía y calidad de vida. La Terapia con soporte Musical ha sido desarrollada para mejorar la función motora de la extremidad superior parética en el ictus mediante el entrenamiento con instrumentos musicales. Sin embargo, esta intervención no ha sido contrastada adecuadamente con la terapia convencional y todavía se desconocen algunos de los aspectos relacionados con su efectividad. El objetivo principal de la presente tesis doctoral fue estudiar la efectividad de la Terapia con soporte Musical como intervención terapéutica en la rehabilitación de la función motora de la extremidad superior después del ictus. Esta tesis está compuesta por cuatro estudios que utilizaron diferentes diseños y evaluaciones a nivel neuronal, de las funciones del cuerpo, y de la actividad y participación de la persona. A través de diseños experimentales, un ensayo controlado aleatorizado y un caso único se evaluaron los efectos de la Terapia con soporte Musical en mejorar la función motora y calidad de vida de las personas que han sufrido un ictus, así como se estudiaron los mecanismos de plasticidad cerebral inducidos por esta intervención. Considerando los resultados en su conjunto, la Terapia con soporte Musical es una intervención efectiva en la rehabilitación de la función de la extremidad superior después del ictus. La Terapia con soporte Musical reduce los déficits motores y mejora la funcionalidad de la extremidad superior en las personas que han sufrido un ictus de la misma manera que la terapia convencional, con mejoras que se generalizan a las actividades de la vida diaria y se mantienen a lo largo del tiempo. Además, los pacientes tratados con Terapia con soporte Musical tienen mejores habilidades lingüísticas, menos fatiga y emociones negativas, y una mayor calidad de vida que los pacientes tratados solo con terapia convencional. El placer experimentado en las actividades musicales se correlaciona con las mejoras motoras en pacientes tratados con Terapia con soporte Musical, señalando la importancia de la motivación en el aprendizaje motor y en la rehabilitación del ictus. Además, la Terapia con soporte Musical promueve cambios plásticos similares a la terapia convencional, induciendo reorganización del mapa motor cortical y cambios en la excitabilidad de la corteza sensorimotora en personas que han sufrido un ictus.