A Home-Based,Mobile-Health-Assisted Piano Therapy to Improve Upper-Extremity Performance in Stroke Survivors: A Pilot Study

BACKGROUND/PURPOSE: The effectiveness of active music therapy, which involves patients to play instruments actively, has been demonstrated to improve post-stroke motor performance, such as finger dexterity and grip strength. The pleasing feature of music and the immediate auditory feedback with upper extremity (UE) movements may stimulate the integration of auditory-motor coupling and lead to motor improvements following stroke. However, music therapy is exclusively provided under clinical settings in which most stroke survivors have limited access, commonly due to transportation and financial restraints.

Fortunately, with the rapidly-developed mobile health (mHealth) technology, there is a potential to implement effective music therapy at individuals’ home. The application of mHealth technology can increase individuals’ access to stroke rehabilitation services while decreasing the travel burden and cost. The purpose of this pilot study was to examine (1) the feasibility and (2) the effects of using an iPad mobile app to provide in-home piano therapy in individuals with stroke.

DESIGN: A 3-week single-subject design was conducted with two visits (pre and post) to participants’ home for outcome assessments. Community-dwelling stroke survivors were recruited if they have minimal UE motor capability (Fugl-Meyer Assessment, FM, ≥ 20) and the capacity to use the app and the piano after instructions. Participants with severe UE spasticity, depression, or neglect were excluded.

METHOD: A piano and an iPad installed with the mobile app, Yousician, were provided to the participants during the 3 weeks, in which they were encouraged to use the app to play with the piano at least 1 hour/day. Yousician is interactive software that provides exercise courses and catches the real-time music that users play to provide instant feedback on accuracy and timing. Participants can also adjust the difficulty level (e.g., speed) to challenge themselves.

The exercise time recorded in the app and an exit interview facilitated at the post-visit asking participants’ feedback were used to examine the feasibility of the training. Three motor assessments – FM, Action Research Arm Test (ARAT), and 9-hole peg test (9HPT) – were conducted during the two visits to understand participants’ progress after training.

RESULTS: Five pilot participants with no piano experience were recruited (average 56.0 years old; stroke onset 2.4 years). On average, they used the app/piano for 15.6 days out of the 3 weeks and practiced 40.0 mins/day, which was closed to our suggestion of 1 hour/day. In the interview, the feedback from participants was overall positive. Two participants mentioned that they would continue the piano training after 3 weeks if it is available. Four participants reported that they were motivated and enjoyed the rehab process through piano playing.

In addition, participants showed consistent improvements in all the assessments: FM, from 50.2 to 55.6 points, ARAT, from 52.2 to 56.0 points and 9HPT, from 69.5 to 56.7 sec. Particularly, 3 of the 5 participants improved 6-7 points in the FM, which reached the minimal clinically important difference (MCID, 6.6 points) of FM.

CONCLUSION: All the pilot participants reported positive feedback about using the mobile app to receive piano therapy and showed improvements in motor performance. The findings suggest that the mHealth-assisted piano therapy may be an effective training to assist stroke survivors to regain their motor capability, and has the potential to provide an acceptable and motivating in-home rehab training for post-stroke (impact statement). This research is currently in progress and recruiting more participants to obtain a more solid conclusion.

References

Grau-Sánchez, J., Duarte, E., Ramos-Escobar, N., Sierpowska, J., Rueda, N., Redón, S., . . . Rodríguez-Fornells, A. (2018). Music-supported therapy in the rehabilitation of subacute stroke patients: a randomized controlled trial. Annals of the New York Academy of Sciences, 1423(1), 318-328. doi:10.1111/nyas.13590

Altenmüller, E., Marco-Pallares, J., Münte, T. F., & Schneider, S. (2009). Neural reorganization underlies improvement in stroke-induced motor dysfunction by music-supported therapy. Annals of the New York Academy of Sciences, 1169(1), 395-405. doi:10.1111/j.1749-6632.2009.04580

Katahira, K., Abla, D., Masuda, S., & Okanoya, K. (2008). Feedback-based error monitoring processes during musical performance: An ERP study. Neuroscience Research, 61(1), 120-128. doi:10.1016/J.NEURES.2008.02.001

Raglio, A., Zaliani, A., Baiardi, P., Bossi, D., Sguazzin, C., Capodaglio, E., . . . Imbriani, M. (2017). Active music therapy approach for stroke patients in the post-acute rehabilitation. Neurological Sciences, 38(5), 893-897. doi:10.1007/s10072-017-2827-7