Return List
Contact Author
Open URL TESEO

Author´s name

Grau Sánchez, Jennifer

Thesis title in Spanish

MUSIC-SUPPORTED THERAPY IN THE REHABILITATION OF MOTOR DEFICITS AFTER STROKE

Thesis title in English

TERAPIA CON APOYO MUSICAL EN LA REHABILITACIÓN DE LOS DÉFICITS MOTORES TRAS UN ICTUS

University

Universitat de Barcelona

Year of defence

2019

Keywords

rehabilitación médica, neurología, neurociencias, and psicología clínica

Summary in Spanish

Los déficits motores de la extremidad superior están presentes en la mayoría de los pacientes con ictus, lo que tiene un impacto significativo en su autonomía y calidad de vida. La recuperación de los déficits motores después de un accidente cerebrovascular se basa principalmente en la rehabilitación, que es un proceso centrado en el paciente destinado a mejorar y mantener el funcionamiento del individuo mediante intervenciones terapéuticas para promover el aprendizaje adaptativo. Es importante destacar que la recuperación dependerá de la extraordinaria capacidad del sistema nervioso para adaptarse a las lesiones y de la capacidad de las intervenciones terapéuticas para inducir la reorganización cerebral. Existen varias técnicas para tratar la hemiparesia de la extremidad superior después de un accidente cerebrovascular y, recientemente, las intervenciones basadas en música han surgido como una herramienta prometedora ya que pueden incorporar muchos principios de la rehabilitación motora del accidente cerebrovascular. Entre ellos, la terapia asistida por música se ha desarrollado para mejorar la función motora de la extremidad superior parética en pacientes con accidente cerebrovascular tocando instrumentos musicales. Estudios anteriores han demostrado que la terapia con música puede mejorar la funcionalidad de la extremidad superior parética, promover cambios neuroplásticos funcionales y mejorar el estado de ánimo y la calidad de vida de pacientes con accidente cerebrovascular subagudo y crónico. A pesar de estos hallazgos prometedores, la terapia con música no se ha contrastado adecuadamente con la terapia convencional y, aún así, se desconocen varios aspectos de su eficacia. El objetivo principal de esta tesis fue estudiar la eficacia de la Musicoterapia como intervención terapéutica en la rehabilitación de la función motora de las extremidades superiores tras un ictus. Esta tesis se compone de cuatro estudios que hicieron uso de diferentes diseños de investigación y mediciones a nivel neuronal, funciones corporales, actividad y participación para abordar aspectos específicos que contribuyen a la efectividad de la Musicoterapia. En el Estudio 1, probamos la eficacia de la terapia con música en el tratamiento de la hemiparesia de la extremidad superior, induciendo cambios neuroplásticos en la corteza sensoriomotora y mejorando la calidad de vida en pacientes con accidente cerebrovascular subagudo. Utilizamos un diseño experimental intervencionista en el que un grupo de pacientes con accidente cerebrovascular subagudo recibieron un programa de cuatro semanas de terapia con música además del programa de rehabilitación estándar. Los pacientes fueron evaluados antes y después del tratamiento en una evaluación que comprendió pruebas motoras clínicas estandarizadas, una evaluación de la excitabilidad de la corteza sensoriomotora con estimulación magnética transcraneal y un cuestionario de calidad de vida. Además del grupo de pacientes, un grupo sano de controles emparejados se sometió a la misma evaluación. Los resultados de este estudio revelaron que los pacientes con accidente cerebrovascular subagudo mejoraron su función motora después de la terapia y que esta mejora estuvo acompañada de cambios en la excitabilidad de la corteza sensoriomotora y la reorganización del mapa motor cortical. Además, los pacientes informaron tener una mejor calidad de vida después del tratamiento. El objetivo del Estudio 2 fue probar la eficacia de agregar la terapia con música a un programa de rehabilitación estándar para pacientes con accidente cerebrovascular subagudo. Se llevó a cabo un ensayo controlado aleatorio en el que los pacientes fueron asignados aleatoriamente a un grupo de terapia con música o a un grupo de terapia convencional además del programa de rehabilitación estándar. Antes y después de cuatro semanas de tratamiento, se evaluaron las funciones motoras y cognitivas, el estado de ánimo y la calidad de vida de los pacientes. Se realizó una evaluación de seguimiento a los tres meses para probar la retención de las ganancias motoras. Ambos grupos mejoraron significativamente su función motora y no se encontraron diferencias entre los grupos, lo que indica que la terapia con música como tratamiento complementario no fue superior a las terapias convencionales para la recuperación motora. La única diferencia entre grupos se observó en el dominio del lenguaje para la calidad de vida. Un análisis más detallado reveló que los pacientes tratados con terapia apoyada por música mejoraron su tasa de aprendizaje verbal, informaron menos fatiga y emociones negativas y experimentaron una mejor calidad de vida después del tratamiento. Es importante destacar que la motivación intrínseca del paciente para participar en actividades musicales se asoció con una mejor mejora motora en el grupo de Terapia con apoyo musical. En el Estudio 3, se evaluó una submuestra del Estudio 2 con un protocolo de Imágenes por Resonancia Magnética estructural y funcional antes y después de la intervención. Este estudio tuvo como objetivo caracterizar las lesiones y el daño a la sustancia blanca de los pacientes, probar la relación entre la integridad del tracto corticoespinal y la recuperación motora y explorar los mecanismos de plasticidad cerebral inducidos por la terapia musical en pacientes con accidente cerebrovascular subagudo en comparación con la terapia convencional. Los pacientes de ambos grupos de entrenamiento presentaron lesiones principalmente a nivel subcortical, y no se encontraron diferencias en el daño de la sustancia blanca entre grupos. No encontramos ninguna asociación entre la proporción de desconexión del tracto corticoespinal y la mejora motora.

Summary in English

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. Importantly, recovery will depend on the extraordinary ability of the nervous system to adapt to injury and the capacity of therapeutic interventions to induce brain reorganisation. There are several techniques to treat the hemiparesis of the upper extremity after stroke, and recently, music-based interventions have emerged as a promising tool since they can incorporate many principles of stroke motor rehabilitation. Among them, 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 improve 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 to address specific aspects that contribute to the effectiveness of Music-supported Therapy. 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. We used an interventional experimental design where a group of subacute stroke patients received a four-week program of Music-supported Therapy in addition to the standard rehabilitation program. 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 addition to the patients¿ group, a healthy group of matched controls underwent the same evaluation. The results of this study revealed that subacute stroke patients improved their motor function after the therapy and that this improvement was accompanied by changes in the excitability of the sensorimotor cortex and cortical motor map reorganisation. Furthermore, patients reported having a better quality of life after the treatment. The aim of Study 2 was to test the effectiveness of adding Music-supported Therapy to a standard rehabilitation program for subacute stroke patients. A randomised controlled trial was conducted in which patients 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. Both groups significantly improved their motor function, and no differences between groups were found, indicating that Music-supported Therapy as an add-on treatment was not superior to conventional therapies for motor recovery. The only difference between groups was observed in the language domain for the quality of life. Further analysis revealed that patients treated with Music-supported Therapy improved their rate of verbal learning, reported less fatigue and negative emotions and experienced a better quality of life after the treatment. Importantly, the patient¿s intrinsic motivation to engage in musical activities was associated with better motor improvement in the Music-supported Therapy group. 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 in subacute stroke patients compared to conventional therapy. Patients in both groups of training presented lesions mainly at the subcortical level, and no differences were found in white matter damage between groups. We did not find any association between the proportion of disconnection of the corticospinal tract and motor improvement. The results of the functional imaging part of the study revealed that patients in the Music-supported Therapy group showed greater activations of the middle and superior temporal gyri and insula in the affected hemisphere during a motor task after the training. In Study 4, we conducted a single-case design 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. A reversal design (ABAB) was implemented in a chronic stroke patient where no treatment was provided in the A periods, and a four-week program of Music-supported Therapy was applied in the B periods. Each period was comprised of four weeks, and an extensive evaluation of the motor function using clinical motor tests and three-dimensional (3D) movement analysis was performed weekly. During the Music-supported Therapy periods, a keyboard task was recorded daily to study the patient¿s musical task performance. A follow-up evaluation was performed three months after the second Music-supported Therapy period. Improvements were observed during the first sessions in the keyboard task, but functional motor gains were noticeable only at the end of the first treatment and during the second treatment period. These improvements were maintained in the follow-up evaluation. This study evidenced that gradual and continuous motor improvements are possible with the repeated application of Music-supported Therapy. Fast-acquisition in specific motor abilities was observed at the beginning of the Music-supported Therapy sessions, but generalisation of these improvements to other motor tasks took place at the end of the training or when another treatment period was provided. Taken together, 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 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.


Return List
Contact Author
Open URL TESEO

Author´s name

Grau Sánchez, Jennifer

Thesis title in Spanish

MUSIC-SUPPORTED THERAPY IN THE REHABILITATION OF MOTOR DEFICITS AFTER STROKE

Thesis title in English

TERAPIA CON APOYO MUSICAL EN LA REHABILITACIÓN DE LOS DÉFICITS MOTORES TRAS UN ICTUS

University

Universitat de Barcelona

Year of defence

2019

Keywords

rehabilitación médica, neurología, neurociencias, and psicología clínica

Summary in Spanish

Los déficits motores de la extremidad superior están presentes en la mayoría de los pacientes con ictus, lo que tiene un impacto significativo en su autonomía y calidad de vida. La recuperación de los déficits motores después de un accidente cerebrovascular se basa principalmente en la rehabilitación, que es un proceso centrado en el paciente destinado a mejorar y mantener el funcionamiento del individuo mediante intervenciones terapéuticas para promover el aprendizaje adaptativo. Es importante destacar que la recuperación dependerá de la extraordinaria capacidad del sistema nervioso para adaptarse a las lesiones y de la capacidad de las intervenciones terapéuticas para inducir la reorganización cerebral. Existen varias técnicas para tratar la hemiparesia de la extremidad superior después de un accidente cerebrovascular y, recientemente, las intervenciones basadas en música han surgido como una herramienta prometedora ya que pueden incorporar muchos principios de la rehabilitación motora del accidente cerebrovascular. Entre ellos, la terapia asistida por música se ha desarrollado para mejorar la función motora de la extremidad superior parética en pacientes con accidente cerebrovascular tocando instrumentos musicales. Estudios anteriores han demostrado que la terapia con música puede mejorar la funcionalidad de la extremidad superior parética, promover cambios neuroplásticos funcionales y mejorar el estado de ánimo y la calidad de vida de pacientes con accidente cerebrovascular subagudo y crónico. A pesar de estos hallazgos prometedores, la terapia con música no se ha contrastado adecuadamente con la terapia convencional y, aún así, se desconocen varios aspectos de su eficacia. El objetivo principal de esta tesis fue estudiar la eficacia de la Musicoterapia como intervención terapéutica en la rehabilitación de la función motora de las extremidades superiores tras un ictus. Esta tesis se compone de cuatro estudios que hicieron uso de diferentes diseños de investigación y mediciones a nivel neuronal, funciones corporales, actividad y participación para abordar aspectos específicos que contribuyen a la efectividad de la Musicoterapia. En el Estudio 1, probamos la eficacia de la terapia con música en el tratamiento de la hemiparesia de la extremidad superior, induciendo cambios neuroplásticos en la corteza sensoriomotora y mejorando la calidad de vida en pacientes con accidente cerebrovascular subagudo. Utilizamos un diseño experimental intervencionista en el que un grupo de pacientes con accidente cerebrovascular subagudo recibieron un programa de cuatro semanas de terapia con música además del programa de rehabilitación estándar. Los pacientes fueron evaluados antes y después del tratamiento en una evaluación que comprendió pruebas motoras clínicas estandarizadas, una evaluación de la excitabilidad de la corteza sensoriomotora con estimulación magnética transcraneal y un cuestionario de calidad de vida. Además del grupo de pacientes, un grupo sano de controles emparejados se sometió a la misma evaluación. Los resultados de este estudio revelaron que los pacientes con accidente cerebrovascular subagudo mejoraron su función motora después de la terapia y que esta mejora estuvo acompañada de cambios en la excitabilidad de la corteza sensoriomotora y la reorganización del mapa motor cortical. Además, los pacientes informaron tener una mejor calidad de vida después del tratamiento. El objetivo del Estudio 2 fue probar la eficacia de agregar la terapia con música a un programa de rehabilitación estándar para pacientes con accidente cerebrovascular subagudo. Se llevó a cabo un ensayo controlado aleatorio en el que los pacientes fueron asignados aleatoriamente a un grupo de terapia con música o a un grupo de terapia convencional además del programa de rehabilitación estándar. Antes y después de cuatro semanas de tratamiento, se evaluaron las funciones motoras y cognitivas, el estado de ánimo y la calidad de vida de los pacientes. Se realizó una evaluación de seguimiento a los tres meses para probar la retención de las ganancias motoras. Ambos grupos mejoraron significativamente su función motora y no se encontraron diferencias entre los grupos, lo que indica que la terapia con música como tratamiento complementario no fue superior a las terapias convencionales para la recuperación motora. La única diferencia entre grupos se observó en el dominio del lenguaje para la calidad de vida. Un análisis más detallado reveló que los pacientes tratados con terapia apoyada por música mejoraron su tasa de aprendizaje verbal, informaron menos fatiga y emociones negativas y experimentaron una mejor calidad de vida después del tratamiento. Es importante destacar que la motivación intrínseca del paciente para participar en actividades musicales se asoció con una mejor mejora motora en el grupo de Terapia con apoyo musical. En el Estudio 3, se evaluó una submuestra del Estudio 2 con un protocolo de Imágenes por Resonancia Magnética estructural y funcional antes y después de la intervención. Este estudio tuvo como objetivo caracterizar las lesiones y el daño a la sustancia blanca de los pacientes, probar la relación entre la integridad del tracto corticoespinal y la recuperación motora y explorar los mecanismos de plasticidad cerebral inducidos por la terapia musical en pacientes con accidente cerebrovascular subagudo en comparación con la terapia convencional. Los pacientes de ambos grupos de entrenamiento presentaron lesiones principalmente a nivel subcortical, y no se encontraron diferencias en el daño de la sustancia blanca entre grupos. No encontramos ninguna asociación entre la proporción de desconexión del tracto corticoespinal y la mejora motora.

Summary in English

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. Importantly, recovery will depend on the extraordinary ability of the nervous system to adapt to injury and the capacity of therapeutic interventions to induce brain reorganisation. There are several techniques to treat the hemiparesis of the upper extremity after stroke, and recently, music-based interventions have emerged as a promising tool since they can incorporate many principles of stroke motor rehabilitation. Among them, 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 improve 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 to address specific aspects that contribute to the effectiveness of Music-supported Therapy. 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. We used an interventional experimental design where a group of subacute stroke patients received a four-week program of Music-supported Therapy in addition to the standard rehabilitation program. 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 addition to the patients¿ group, a healthy group of matched controls underwent the same evaluation. The results of this study revealed that subacute stroke patients improved their motor function after the therapy and that this improvement was accompanied by changes in the excitability of the sensorimotor cortex and cortical motor map reorganisation. Furthermore, patients reported having a better quality of life after the treatment. The aim of Study 2 was to test the effectiveness of adding Music-supported Therapy to a standard rehabilitation program for subacute stroke patients. A randomised controlled trial was conducted in which patients 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. Both groups significantly improved their motor function, and no differences between groups were found, indicating that Music-supported Therapy as an add-on treatment was not superior to conventional therapies for motor recovery. The only difference between groups was observed in the language domain for the quality of life. Further analysis revealed that patients treated with Music-supported Therapy improved their rate of verbal learning, reported less fatigue and negative emotions and experienced a better quality of life after the treatment. Importantly, the patient¿s intrinsic motivation to engage in musical activities was associated with better motor improvement in the Music-supported Therapy group. 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 in subacute stroke patients compared to conventional therapy. Patients in both groups of training presented lesions mainly at the subcortical level, and no differences were found in white matter damage between groups. We did not find any association between the proportion of disconnection of the corticospinal tract and motor improvement. The results of the functional imaging part of the study revealed that patients in the Music-supported Therapy group showed greater activations of the middle and superior temporal gyri and insula in the affected hemisphere during a motor task after the training. In Study 4, we conducted a single-case design 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. A reversal design (ABAB) was implemented in a chronic stroke patient where no treatment was provided in the A periods, and a four-week program of Music-supported Therapy was applied in the B periods. Each period was comprised of four weeks, and an extensive evaluation of the motor function using clinical motor tests and three-dimensional (3D) movement analysis was performed weekly. During the Music-supported Therapy periods, a keyboard task was recorded daily to study the patient¿s musical task performance. A follow-up evaluation was performed three months after the second Music-supported Therapy period. Improvements were observed during the first sessions in the keyboard task, but functional motor gains were noticeable only at the end of the first treatment and during the second treatment period. These improvements were maintained in the follow-up evaluation. This study evidenced that gradual and continuous motor improvements are possible with the repeated application of Music-supported Therapy. Fast-acquisition in specific motor abilities was observed at the beginning of the Music-supported Therapy sessions, but generalisation of these improvements to other motor tasks took place at the end of the training or when another treatment period was provided. Taken together, 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 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.

MUSIC-SUPPORTED THERAPY IN THE REHABILITATION OF MOTOR DEFICITS AFTER STROKE


Return List
Contact Author
Open URL TESEO

Author´s name

Grau Sánchez, Jennifer

Thesis title in Spanish

MUSIC-SUPPORTED THERAPY IN THE REHABILITATION OF MOTOR DEFICITS AFTER STROKE

Thesis title in English

TERAPIA CON APOYO MUSICAL EN LA REHABILITACIÓN DE LOS DÉFICITS MOTORES TRAS UN ICTUS

University

Universitat de Barcelona

Year of defence

2019

Keywords

rehabilitación médica, neurología, neurociencias, and psicología clínica

Summary in Spanish

Los déficits motores de la extremidad superior están presentes en la mayoría de los pacientes con ictus, lo que tiene un impacto significativo en su autonomía y calidad de vida. La recuperación de los déficits motores después de un accidente cerebrovascular se basa principalmente en la rehabilitación, que es un proceso centrado en el paciente destinado a mejorar y mantener el funcionamiento del individuo mediante intervenciones terapéuticas para promover el aprendizaje adaptativo. Es importante destacar que la recuperación dependerá de la extraordinaria capacidad del sistema nervioso para adaptarse a las lesiones y de la capacidad de las intervenciones terapéuticas para inducir la reorganización cerebral. Existen varias técnicas para tratar la hemiparesia de la extremidad superior después de un accidente cerebrovascular y, recientemente, las intervenciones basadas en música han surgido como una herramienta prometedora ya que pueden incorporar muchos principios de la rehabilitación motora del accidente cerebrovascular. Entre ellos, la terapia asistida por música se ha desarrollado para mejorar la función motora de la extremidad superior parética en pacientes con accidente cerebrovascular tocando instrumentos musicales. Estudios anteriores han demostrado que la terapia con música puede mejorar la funcionalidad de la extremidad superior parética, promover cambios neuroplásticos funcionales y mejorar el estado de ánimo y la calidad de vida de pacientes con accidente cerebrovascular subagudo y crónico. A pesar de estos hallazgos prometedores, la terapia con música no se ha contrastado adecuadamente con la terapia convencional y, aún así, se desconocen varios aspectos de su eficacia. El objetivo principal de esta tesis fue estudiar la eficacia de la Musicoterapia como intervención terapéutica en la rehabilitación de la función motora de las extremidades superiores tras un ictus. Esta tesis se compone de cuatro estudios que hicieron uso de diferentes diseños de investigación y mediciones a nivel neuronal, funciones corporales, actividad y participación para abordar aspectos específicos que contribuyen a la efectividad de la Musicoterapia. En el Estudio 1, probamos la eficacia de la terapia con música en el tratamiento de la hemiparesia de la extremidad superior, induciendo cambios neuroplásticos en la corteza sensoriomotora y mejorando la calidad de vida en pacientes con accidente cerebrovascular subagudo. Utilizamos un diseño experimental intervencionista en el que un grupo de pacientes con accidente cerebrovascular subagudo recibieron un programa de cuatro semanas de terapia con música además del programa de rehabilitación estándar. Los pacientes fueron evaluados antes y después del tratamiento en una evaluación que comprendió pruebas motoras clínicas estandarizadas, una evaluación de la excitabilidad de la corteza sensoriomotora con estimulación magnética transcraneal y un cuestionario de calidad de vida. Además del grupo de pacientes, un grupo sano de controles emparejados se sometió a la misma evaluación. Los resultados de este estudio revelaron que los pacientes con accidente cerebrovascular subagudo mejoraron su función motora después de la terapia y que esta mejora estuvo acompañada de cambios en la excitabilidad de la corteza sensoriomotora y la reorganización del mapa motor cortical. Además, los pacientes informaron tener una mejor calidad de vida después del tratamiento. El objetivo del Estudio 2 fue probar la eficacia de agregar la terapia con música a un programa de rehabilitación estándar para pacientes con accidente cerebrovascular subagudo. Se llevó a cabo un ensayo controlado aleatorio en el que los pacientes fueron asignados aleatoriamente a un grupo de terapia con música o a un grupo de terapia convencional además del programa de rehabilitación estándar. Antes y después de cuatro semanas de tratamiento, se evaluaron las funciones motoras y cognitivas, el estado de ánimo y la calidad de vida de los pacientes. Se realizó una evaluación de seguimiento a los tres meses para probar la retención de las ganancias motoras. Ambos grupos mejoraron significativamente su función motora y no se encontraron diferencias entre los grupos, lo que indica que la terapia con música como tratamiento complementario no fue superior a las terapias convencionales para la recuperación motora. La única diferencia entre grupos se observó en el dominio del lenguaje para la calidad de vida. Un análisis más detallado reveló que los pacientes tratados con terapia apoyada por música mejoraron su tasa de aprendizaje verbal, informaron menos fatiga y emociones negativas y experimentaron una mejor calidad de vida después del tratamiento. Es importante destacar que la motivación intrínseca del paciente para participar en actividades musicales se asoció con una mejor mejora motora en el grupo de Terapia con apoyo musical. En el Estudio 3, se evaluó una submuestra del Estudio 2 con un protocolo de Imágenes por Resonancia Magnética estructural y funcional antes y después de la intervención. Este estudio tuvo como objetivo caracterizar las lesiones y el daño a la sustancia blanca de los pacientes, probar la relación entre la integridad del tracto corticoespinal y la recuperación motora y explorar los mecanismos de plasticidad cerebral inducidos por la terapia musical en pacientes con accidente cerebrovascular subagudo en comparación con la terapia convencional. Los pacientes de ambos grupos de entrenamiento presentaron lesiones principalmente a nivel subcortical, y no se encontraron diferencias en el daño de la sustancia blanca entre grupos. No encontramos ninguna asociación entre la proporción de desconexión del tracto corticoespinal y la mejora motora.

Summary in English

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. Importantly, recovery will depend on the extraordinary ability of the nervous system to adapt to injury and the capacity of therapeutic interventions to induce brain reorganisation. There are several techniques to treat the hemiparesis of the upper extremity after stroke, and recently, music-based interventions have emerged as a promising tool since they can incorporate many principles of stroke motor rehabilitation. Among them, 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 improve 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 to address specific aspects that contribute to the effectiveness of Music-supported Therapy. 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. We used an interventional experimental design where a group of subacute stroke patients received a four-week program of Music-supported Therapy in addition to the standard rehabilitation program. 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 addition to the patients¿ group, a healthy group of matched controls underwent the same evaluation. The results of this study revealed that subacute stroke patients improved their motor function after the therapy and that this improvement was accompanied by changes in the excitability of the sensorimotor cortex and cortical motor map reorganisation. Furthermore, patients reported having a better quality of life after the treatment. The aim of Study 2 was to test the effectiveness of adding Music-supported Therapy to a standard rehabilitation program for subacute stroke patients. A randomised controlled trial was conducted in which patients 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. Both groups significantly improved their motor function, and no differences between groups were found, indicating that Music-supported Therapy as an add-on treatment was not superior to conventional therapies for motor recovery. The only difference between groups was observed in the language domain for the quality of life. Further analysis revealed that patients treated with Music-supported Therapy improved their rate of verbal learning, reported less fatigue and negative emotions and experienced a better quality of life after the treatment. Importantly, the patient¿s intrinsic motivation to engage in musical activities was associated with better motor improvement in the Music-supported Therapy group. 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 in subacute stroke patients compared to conventional therapy. Patients in both groups of training presented lesions mainly at the subcortical level, and no differences were found in white matter damage between groups. We did not find any association between the proportion of disconnection of the corticospinal tract and motor improvement. The results of the functional imaging part of the study revealed that patients in the Music-supported Therapy group showed greater activations of the middle and superior temporal gyri and insula in the affected hemisphere during a motor task after the training. In Study 4, we conducted a single-case design 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. A reversal design (ABAB) was implemented in a chronic stroke patient where no treatment was provided in the A periods, and a four-week program of Music-supported Therapy was applied in the B periods. Each period was comprised of four weeks, and an extensive evaluation of the motor function using clinical motor tests and three-dimensional (3D) movement analysis was performed weekly. During the Music-supported Therapy periods, a keyboard task was recorded daily to study the patient¿s musical task performance. A follow-up evaluation was performed three months after the second Music-supported Therapy period. Improvements were observed during the first sessions in the keyboard task, but functional motor gains were noticeable only at the end of the first treatment and during the second treatment period. These improvements were maintained in the follow-up evaluation. This study evidenced that gradual and continuous motor improvements are possible with the repeated application of Music-supported Therapy. Fast-acquisition in specific motor abilities was observed at the beginning of the Music-supported Therapy sessions, but generalisation of these improvements to other motor tasks took place at the end of the training or when another treatment period was provided. Taken together, 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 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.