Enriched Music-supported Therapy and motivational factors in chronic stroke rehabilitation
Abstract
More than half of stroke survivors in the chronic phase still experience upper-limb motor deficits that limit their daily activities and community participation. This ongoing disability can significantly impact their sense of autonomy, social interaction, occupational identity, and overall quality of life. Despite the rising prevalence of stroke, access to rehabilitation in the chronic phase remains limited, representing a major unmet need in this population. Developing accessible, community-based interventions is thus crucial to maintaining or improving the physical and mental health of chronic stroke survivors while alleviating the burden on healthcare systems.
Music-supported Therapy (MST) is a widely studied intervention for treating post-stroke hemiparesis through standardized instrumental training, adhering to rehabilitation principles such as mass repetition and gradual increase of difficulty. In addition, the program benefits from the audio-motor coupling activation and motivational effects provided by music. MST has consistently been shown to improve upper-limb motor functions, neuroplasticity, emotional well-being, and quality of life in subacute and chronic stroke patients. However, it did not demonstrate superior effectiveness compared to conventional physical therapy in enhancing motor function. To increase the accessibility and effectiveness of chronic stroke rehabilitation, we designed an enriched version of MST (eMST) by integrating socio-motivational and learning components proven to enhance the reacquisition of motor skills. This redesigned program was adapted for home use, incorporating both self-training and group music therapy sessions to foster autonomy and socialization, crucial factors in rehabilitation. We also increased training intensity and introduced new percussion instruments, upper-limb movements, and rhythmic patterns to further enhance motor recovery. To facilitate the intervention, we developed a tablet-based app with gamification strategies that provides instructions for conducting the home-based self-training eMST sessions.
This doctoral thesis aimed to evaluate the effectiveness of eMST in chronic stroke rehabilitation and explore the presence of anhedonia, a condition characterized by diminished sensitivity to everyday pleasures that may hinder engagement in rehabilitation. The thesis comprises four studies with different research designs to address these goals. In Study 1, we refined the MST app based on the feedback from chronic stroke patients, who confirmed the usability of the latest version of the app. After 30 hours of home-based training over 10 weeks, participants demonstrated clinically relevant upper-limb improvements, increased velocity in piano performance, high adherence, and no safety concerns, confirming the feasibility of the home-based eMST. In Study 2, we developed a clinical trial protocol to compare the effectiveness of eMST to a conventional home-based rehabilitation program for chronic stroke survivors. We designed a pragmatic parallel-group randomized controlled trial to assess the benefits of eMST when implemented as planned as well as accounting for patients who dropped out to evaluate its effectiveness under real-world conditions. The primary outcome was upper-limb functionality, and secondary outcomes included other motor and cognitive functions, emotional well-being, QoL, self-regulation, and self-efficacy. Both interventions were designed to provide 40 hours of training over 10 weeks, with the eMST intervention comprising 30 hours of self-training sessions and 10 hours of group sessions. Evaluation points were established before and after the intervention, and at three-month follow-up to assess lasting effects. In Study 3, we tested the effectiveness of eMST in chronic stroke rehabilitation compared to a home-based conventional program. For the first time, we demonstrated that eMST outperformed conventional rehabilitation in both motor and emotional outcomes. The eMST group showed greater improvements in upper-limb motor impairment after the intervention, which were maintained after three months, as well as in upper-limb functionality and motor performance during daily tasks at follow-up. These gains were observed regardless of clinical, demographic, or personal factors. Notably, motor improvements occurred in both participants who completed the interventions as planned and those who dropped out, indicating real-world benefits. The lack of association between participants’ level of musical hedonia and their motor improvements in the music intervention suggests that other factors, such as social interaction or gamification strategies, may have a greater impact on motor recovery. The eMST intervention also led to reduced anger and apathy, increased positive emotions, and enhanced community participation. Furthermore, participants found the sessions more fun and enjoyable compared to the control intervention. In Study 4, we measured the presence of anhedonia in subacute and chronic stroke survivors, and we found significantly higher levels compared to healthy controls. This difference remained even after accounting for the influence of other related negative emotions, indicating a distinct role for anhedonia after stroke. The prevalence of anhedonia was 20%, regardless of stroke etiology, lesion location, affected hemisphere, or time since the stroke, suggesting a potential effect of post-stroke low-grade chronic inflammation that disrupts the mesolimbic pathway. Furthermore, anhedonia was associated with older age, anger, and fatigue in chronic stroke survivors, highlighting its emotional impact in this phase of the disease.
In conclusion, eMST is a more effective and engaging alternative to conventional rehabilitation, improving motor function, emotional well-being, and quality of life in chronic stroke survivors. Given the high prevalence of anhedonia, which can reduce motivation for rehabilitation, the development of accessible, cost-effective, and community-based programs like eMST are essential to support long-term physical and mental health of stroke survivors while reducing the burden on healthcare systems.