THE REHABILITATIVE EFFECTS OF PIANO-PLAYING MUSIC …

THE REHABILITATIVE EFFECTS OF PIANO-PLAYING MUSIC THERAPY ON

UNILATERAL AND BILATERAL MOTOR COORDINATION OF

CHRONIC STROKE PATIENTS: A MIDI ANALYSIS

So-Young Moon

B.Mus, Grad.Dip.Mus.Th., M.Mus

Thesis submitted in total fulfilment of the requirements

of the degree of Doctor of Philosophy

December, 2007

Faculty of Music

The University of Melbourne

2

ABSTRACT

This study examined the effects of piano-playing music therapy on the motor

coordination of stroke patients using MIDI-based analysis to measure finger

coordination. Within a modified controlled trial, twenty participants were assigned to

either a music therapy treatment group or a control group. Half-hour individual music

therapy sessions comprising various piano-playing techniques were conducted three

days per week for four weeks, consisting of 12 sessions in total. Using the MIDI

analysis, the participants‟ finger movements were measured before and immediately

after the interventions. A five-point scale assessment was also undertaken as a

secondary outcome measurement. The results of performance comparison between the

groups in pre and post-tests showed statistically significant improvements in timing

consistency, velocity evenness, accuracy of key striking, and stability of synchronizing

two-key striking. This indicates that piano-playing music therapy could be a viable

intervention in rehabilitating motor coordination of chronic stroke patients.

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DECLARATION

THE UNIVERSITY OF MELBOURNE

Faculty of Music

TO WHOM IT MAY CONCERN

This is to certify that the thesis presented by me for the degree of Doctor of Philosophy

comprises only my original work except where due acknowledgment is made in the

text to all other material used.

Signature:

Name in Full: So-Young Moon

Date: December, 2007

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ACKNOWLEDGEMENTS

I would like to thank the patients for their willingness to participate in the study and

warm feedback throughout the sessions.

I would like to especially thank Associate Professor Dr. Denise Grocke for her

supervision. I am always thankful for her support and encouragement. Without her, it

would not have been possible to complete this study.

I am also ever grateful for my parents, Sun-Soon Won and Chang-Woo Moon whose

unfailing love and prayers enabled me to carry out this research.

“Trust in the LORD with all your heart

And lean not on your own understanding;

In all your ways acknowledge Him,

And He will make your paths straight.”

(Proverb 3: 5~6)

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TABLE OF CONTENTS

Abstract ------------------------------------------------------------------------------2

Declaration ------------------------------------------------------------------------------3

Acknowledgement --------------------------------------------------------------------4

Table of contents --------------------------------------------------------------------5

List of figures ------------------------------------------------------------------------------8

List of tables ------------------------------------------------------------------------------10

CHAPTER 1 INTRODUCTION

1.1 Background to the study ----------------------------------------------------------12

1.1.1 Trends related to the study and arising issues ----------------------------12

1.1.2 Importance of the study ------------------------------------------------13

1.2 Purposes ------------------------------------------------------------------------------13

1.3 Question and hypotheses ----------------------------------------------------------14

1.4 Definitions of terms ----------------------------------------------------------15

1.5 Outline of the remainder of the thesis --------------------------------------16

CHAPTER 2 REVIEW OF LITERATURE

2.1 Stroke ------------------------------------------------------------------------------17

2.1.1 Definitions and sub-classifications --------------------------------------17

2.1.2 Epidemiology ----------------------------------------------------------18

2.1.3 Aetiology and diagnosis ------------------------------------------------20

2.1.4 Risk factors --------------------------------------------------------------------22

2.2 Consequences of stroke ----------------------------------------------------------26

2.2.1 Mortality --------------------------------------------------------------------26

2.2.2 Neurological outcomes ------------------------------------------------26

2.2.3 Functional outcomes related to motor skill ----------------------------30

2.3 Stroke rehabilitation ----------------------------------------------------------34

2.3.1 Theoretical frameworks ------------------------------------------------34

2.3.2 Clinical interventions ------------------------------------------------38

2.3.3 Rehabilitation strategies ------------------------------------------------40

2.4 Music therapy in neurological rehabilitation ----------------------------41

2.4.1 Theoretical background and clinical studies ----------------------------41

2.5 Rehabilitative effects of piano-playing music therapy ------------------45

2.5.1 General aspects of piano playing --------------------------------------45

2.5.2 Rehabilitative effects of piano-playing music therapy ------------------45

2.6 Summary of literature review -----------------------------------------------46

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CHAPTER 3 METHOD

3.1 Research design -------------------------------------------------------------------47

3.1.1 Rationale for research design -----------------------------------------------47

3.1.2 Context for the study ---------------------------------------------------------47

3.1.3 Process of randomization -----------------------------------------------48

3.1.4 Obtaining consent for participation -------------------------------------48

3.1.5 Criteria for participant selection -------------------------------------49

3.2 Participants -------------------------------------------------------------------51

3.2.1 Description of group formation and characteristics of participants -------51

3.3 Clinical setting -------------------------------------------------------------------53

3.4 Apparatus -----------------------------------------------------------------------------54

3.4.1 MIDI keyboard and computer -----------------------------------------------54

3.4.2 MIDI analysis: Home Studio 2004 program ---------------------------55

3.5 Music therapy intervention ---------------------------------------------------------57

3.5.1 Criteria of piano-playing intervention -------------------------------------57

3.5.2 Piano-playing music therapy protocol -------------------------------------58

3.5.3 The therapeutic relationship -----------------------------------------------62

3.6 Outcome measurements ---------------------------------------------------------64

3.6.1 Primary outcome measurement: MIDI analysis ---------------------------64

3.6.2 Secondary outcome measurement: 5-Point scale ---------------------------64

3.7 Outcome variables -------------------------------------------------------------------66

3.7.1 Four outcome variables ---------------------------------------------------------66

3.8 Statistical methods -------------------------------------------------------------------71

3.8.1 Analysis of comparison between the treatment and control groups -------71

3.8.2 Analysis of comparison between the pre- and post-tests in the groups 71

3.8.3 Summary of outcome analysis set -------------------------------------71

CHAPTER 4 RESULTS

4.1 Analyzing the data -------------------------------------------------------------------74

4.1.1 Database design for primary outcome analysis -----------------76

4.1.2 Database design for secondary outcome analysis ---------------------------83

4.2 Report of the results ---------------------------------------------------------86

4.2.1 Inter-rater reliability ---------------------------------------------------------86

4.2.2 Participants -------------------------------------------------------------------94

4.2.3 Hypothesis 1 -------------------------------------------------------------------97

4.2.4 Hypothesis 2 -------------------------------------------------------------------102

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4.2.5 Hypothesis 3 ----------------------------------------------------------------------106

4.2.6 Results of group comparisons --------------------------------------------------112

4.2.7 Results of individual comparisons ----------------------------------------118

4.3 Summary of results ----------------------------------------------------------------------127

CHAPTER 5 DISCUSSIONS AND CONCLUSIONS

5.1 Hypotheses ----------------------------------------------------------------------128

5.1.1 Hypothesis 1 ----------------------------------------------------------------------128

5.1.2 Hypothesis 2 ----------------------------------------------------------------------131

5.1.3 Hypothesis 3 ----------------------------------------------------------------------134

5.1.4 Discussion for MIDI software --------------------------------------------------135

5.1.5 Main findings related to the literature ----------------------------------------138

5.2 Contribution to current music therapy literature ------------------------------141

5.2.1 The music therapist-researcher‟s intervention ------------------------------141

5.2.2 The effect of elements of music on motor coordination and rehabilitation 143

5.2.3 The role of feedback provided by MIDI ----------------------------------------144

5.2.4 Rehabilitation strategies for piano-playing music therapy ----------145

5.3 Methodological issues ------------------------------------------------------------147

5.3.1 Research design ------------------------------------------------------------147

5.3.2 Outcome measurements ------------------------------------------------------------147

5.4 Study limitations and recommendations for future study ----------149

5.4.1 Research design ------------------------------------------------------------149

5.4.2 Outcome analysis ------------------------------------------------------------150

5.5 Conclusions ----------------------------------------------------------------------151

REFERENCES ----------------------------------------------------------------------152

APPENDIX

6.1 Anatomy of the Brain ------------------------------------------------------------163

6.2 Glossary --------------------------------------------------------------------------------173

6.3 Review of a Low-risk Project involving humans ------------------------------177

6.4 Consent Form ----------------------------------------------------------------------186

6.5 Plain Language Statement ------------------------------------------------------------188

6.6 Results of group comparisons --------------------------------------------------191

6.7 Results of individual comparisons --------------------------------------------------240

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LIST OF FIGURES

3.1 Music therapy setting -----------------------------------------------------------53

3.2 MIDI keyboard: SL-760 -----------------------------------------------------------54

3.3 Computer: Trigem Dreambook Lite -------------------------------------------------54

3.4 Home Studio 2004 Program -----------------------------------------------------------55

3.5 Thumb-Index finger simple passage -------------------------------------------------58

3.6 Thumb-Index-Middle finger simple passage (a) -----------------------------59

3.7 Thumb-Index-Middle finger simple passage (b) -----------------------------59

3.8 Five-finger simple passage -----------------------------------------------------------60

3.9 Arirang: melody exercise -----------------------------------------------------------61

3.10 Arirang: original version -----------------------------------------------------------61

3.11 Interpretation of data analysis for timing consistency -----------------------------67

3.12 Interpretation of data analysis for velocity evenness -----------------------------68

3.13 Interpretation of data analysis for accuracy of key striking -------------------69

3.14 Interpretation of data analysis for stability of two-key striking ---------70

4.1 Percentage of agreement between the raters: parameter 1 -------------------90




4.5 MIDI comparisons on the timing consistency ----------------------------112

4.6 MIDI comparisons on the velocity evenness ----------------------------113

4.7 5-Point scale comparison on the timing consistency ----------------------------114

4.8 5-Point scale comparison on the velocity evenness ----------------------------115

4.9 5-Point scale comparison on the accuracy of key-striking ------------------116

4.10 5-Point scale comparison on the stability of synchronization ------------------117

4.11 Participant 6 Task 1 MIDI piano roll: pre and post-tests ------------------118


4.13 Participant 6 Task 1 and 2 5-Point scale comparison ------------------120







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4.21 Participant 6 Task 7 5-Point scale comparison ----------------------------126

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LIST OF TABLES

2.1 Clinical features of ischemic stroke subcategories by classification ----------- 21

2.2 Ischemic stroke risk factors -------------------------------------------------23

2.3 Intracerebral hemorrhage risk factors --------------------------------------------------24

2.4 Subarachnoid hemorrhage risk factors ----------------------------------------24

2.5 Clinical features in internal carotid artery disease ------------------------------27

2.6 Clinical features in anterior cerebral artery disease ------------------------------28

2.7 Clinical features in middle cerebral artery disease ------------------------------28

2.8 Clinical features in posterior cerebral artery disease ------------------------------29

2.9 Cortical involvement: location and motor impairments --------------------31

2.10 Noncortical involvement: location and motor impairments --------------------32

2.11 Studies on the rehabilitation of hand and finger function: exercise therapy 37

2.12 Studies on the rehabilitation of hand and finger function: CIM therapy 39

2.13 Rehabilitation of physical function: clinical outcome studies ------------------- 44

3.1 Characteristics of the inclusion criteria ----------------------------------------50

3.2 Characteristics of the exclusion criteria ----------------------------------------50

3.3 Description of the participants in the treatment group ------------------------------51

3.4 Description of the participants in the control group ------------------------------52

3.5 Example of MIDI event list data -------------------------------------------------56

3.6 Piano-playing exercise criteria -------------------------------------------------57

3.7 Outcome analysis set of hypothesis 1 ----------------------------------------72



4.1 Definitions of the outcome variables ----------------------------------------75

4.2 Database for MIDI: outcome variable 1 ----------------------------------------76




4.6 Database for 5-Point scale: treatment group ----------------------------------------83

4.7 Database for 5-Point scale: control group ----------------------------------------85

4.8 Inter-rater reliability: outcome variable 1 ----------------------------------------86



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4.12 General characteristics of the participants in the treatment group ----------94

4.13 General characteristics of the participants in the control group ----------95

4.14 Comparison of the general characteristics of the groups -------------------96

4.15 Hypothesis 1-1 Results of task 1 -------------------------------------------------97
























5.1 PDF file exported from MIDI data of the event list -----------------------------------136

5.2 Excel database transferred from PDF file -----------------------------------------------137

5.3 Comparison between the primary and secondary outcome measurements ---------148

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CHAPTER 1

INTRODUCTION

This chapter provides a background to the study and trends found in the literature that

are related to the study, including unsolved issues. Following this, the importance and

purpose of the study are described, and the research question comprising three

hypotheses are presented. Corresponding to the research hypotheses, major terms are

defined for the purpose of this study.

1.1 Background to the study

Stroke has been ranked as the most common disease among all the neurological

disorders of adult life. The Australian National Heart Foundation study indicates that

stroke is the second most common cause of death and the largest single cause of adult

disability of all neurological disorders (Australian Institute of Health and Welfare, 2004).

In Korea, stroke has been ranked as the most prevalent cause of death in those

individuals who are over 50 years old (Korean Stroke Society, 2003). The neurological

outcomes following stroke have shown variable clinical features in the areas of

cognitive, communication, physical, and socio-emotional deficits. The range of

rehabilitation services described in this study is limited to physical rehabilitation

programs and the specific role of music therapy within the clinical setting for stroke

patients.

1.1.1 Trends related to the study and arising issues

Rehabilitation of chronic stroke patients often emphasizes the physical rehabilitation of

walking, speech, and activities of daily living. Music therapy is often used to

complement physical rehabilitation but little attention has been given in recent years to

the use of playing musical instruments in developing muscle coordination and strength

in the hands and fingers.

While some early music therapy literature advocated piano playing in

rehabilitation (Cofrancesco, 1985; Erdonmez, 1991; Joshepa, 1964; Kozak; 1968; Thaut,

1992), there have been few studies done on the use of playing the piano in the

rehabilitation of hand and finger movements (Cofrancesco, 1985; Erdonmez, 1991). The

few studies that have been conducted are not recent and their emphases are on hand

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grasp and hand strength, with little attention to independent finger agility, speed, and

coordination.

1.1.2 Importance of the study

Considering the high incidence of stroke and its devastating consequences, it is

inevitable to develop rehabilitation techniques for stroke patients focusing on upper

extremity motor coordination. Rehabilitation of stroke patients with upper extremity

hemiparesis often focuses on the gross motor functional training and less emphasis on

fine motor coordination and control.

Furthermore, the rehabilitation of bilateral fine motor coordination has not yet

been addressed although many daily tasks involve bimanual dexterity. Music therapy is

used to complement upper extremity rehabilitation but little attention has been given in

contemporary research to the use of playing musical instruments in developing

unilateral and bilateral motor coordination in the hands and fingers. This study aims to

add to the literature and to investigate appropriate techniques for practicing music

therapists to assist those who have physical disorders affecting the hand.

The experience of witnessing stroke patients‟ recovery of function and the

observation of their joy regaining quality of life is very rewarding. This is just as strong

a motivating factor in pursuing this type of clinical research as is the academic

satisfaction which also follows. This study is designed to evaluate whether a piano-

playing regimen is an effective music therapy intervention in the rehabilitation of

unilateral and bilateral finger coordination with stroke patients. One of the factors in

choosing piano exercises is the researcher‟s background and qualification in piano

performance.

1.2 Purposes

The purpose of this study is to develop a piano-playing music therapy intervention

protocol for rehabilitating motor coordination of chronic stroke patients. Secondly, the

study investigates the effects of piano-playing music therapy interventions in

rehabilitating unilateral and bilateral motor coordination of chronic stroke patients.

Thirdly, this study developed a MIDI-based music therapy assessment tool to measure

finger coordination, and the use of MIDI is evaluated in this study.

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1.3 Question and Hypotheses

The over-arching research question of the study is can piano-playing music therapy

improve unilateral and bilateral motor coordination in chronic stroke patients? Based

on the question, three major hypotheses are stated with their sub-hypotheses referring to

the outcome variables.

Hypothesis 1: Piano-playing music therapy will improve unilateral coordination of

finger movements in the non-affected hands of chronic stroke patients.

Hypothesis 1-1: Piano-playing music therapy will improve timing

consistency of finger movements in the non-affected hands of chronic

stroke patients.

Hypothesis 1-2: Piano-playing music therapy will improve velocity

evenness of finger movements in the non-affected hands of chronic stroke

patients.

Hypothesis 1-3: Piano-playing music therapy will improve accuracy of key

striking of finger movements in the non-affected hands of chronic stroke

patients.

Hypothesis 2: Piano-playing music therapy will improve unilateral coordination of

finger movements in the affected hands of chronic stroke patients.


consistency of finger movements in the affected hands of chronic stroke

patients.


evenness of finger movements in the affected hands of chronic stroke

patients.



patients.

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Hypothesis 3: Piano-playing music therapy will improve bilateral coordination of

finger movements in chronic stroke patients.


consistency of bilateral finger movements in chronic stroke patients.


evenness of bilateral finger movements in chronic stroke patients.


striking of bilateral finger movements in chronic stroke patients.

Hypothesis 3-4: Piano-playing music therapy will improve stability of

synchronizing two-key strike in bilateral finger movements in chronic stroke

patients.

1.4 Definitions of terms

For the purpose of this study, chronic stroke patients are referred to those individuals

who have been diagnosed with stroke, with more than six-months duration from the

onset of stroke, as confirmed by a MRI or CT scan.

Referring to the outcome variables, timing consistency, for the purpose of this

study, refers to the condition of keeping a steady pace for key striking. Velocity evenness,

for the purpose of this study, refers to the condition of keeping a steady dynamic rate for

key striking. Accuracy of key striking, for the purpose of this study, refers to the degree

of accuracy, based on correct finger positioning. Stability of synchronizing two-key

strike, for the purpose of this study, refers to the degree of duration evenness and

velocity evenness between the two keys.

The term, coordination is defined as “the harmonious working together,

especially of several muscles or muscle groups in the execution of complicated

movements” (Stedman‟s Medical Dictionary, 2000, p.190).

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1.5 Outline of the remainder of the thesis

The remainder of the thesis is organized into four major chapters. Chapter 2 provides an

overview of stroke and its consequences, followed by a review of research literature

related to stroke rehabilitation and a review of the use of music therapy in neurological

rehabilitation. Chapter 3 describes the method of the study, including the research

design and music therapy intervention, with information about participants, clinical

setting and apparatus. This chapter also includes explanations of outcome measurements

and variables. Chapter 4 presents the results of the study by addressing each of the

hypotheses. Finally, Chapter 5 discusses the major findings referring to the hypotheses,

methodological issues, and contribution to current music therapy literature. Following

this, recommendations for future studies and conclusions are described.

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CHAPTER 2

REVIEW OF LITERATURE

This chapter is comprised of five major sections: (1) definitions and classification of

different types of stroke, (2) the consequences of stroke, (3) stroke rehabilitation, (4)

music therapy in neurological rehabilitation, and (5) rehabilitative effects of piano-

playing music therapy. The first two sections introduce the reader to a thorough

description of stroke and its consequences. A basic knowledge of brain structures and

functions by the reader is assumed, however, a brief review of the anatomy of the brain

is illustrated in Appendix 6.1a ~ 6.1d, including diagrams of brain structure and

functions. Words in bold are defined in the glossary (See Appendix 6.2 Glossary).

2.1 Stroke

2.1.1 Definitions and Sub-classifications

Stroke is a broad term commonly used as an alternative to Cerebrovascular Accident

(CVA). The World Health Organization (WHO) defines a stroke as “rapidly developing

clinical signs of focal (or global) disturbance of cerebral function lasting more than 24

hours (unless interrupted by surgery or death) with no apparent cause other than a

vascular origin” (Tunstall-Pedoe, 2003, p. 54).

This generic term is further explained as any acute clinical event that is related

to impairment of cerebral circulation (Stedman's Medical Dictionary, 2000). Depending

on the location and extent of the damage to brain tissue known as an infarction, a stroke

involves irreversible changes to brain cells (Adams, Victor, & Ropper, 1997).

From a pathological perspective, a stroke is referred to as a sudden,

nonconvulsive loss of neurologic function due to an ischemic or hemorrhagic

intracranial vascular event referred to as (1) ischemic stroke, or (2) hemorrhagic stroke

(Adams et al., 1997).

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These two types of stroke are generally classified by the nature of the

disturbance resulting from circulatory impairment. An ischemic stroke is caused by

atherothrombosis or embolism of a major cerebral artery, whereas a hemorrhagic

stroke is associated with a ruptured saccular aneurysm, vascular malformation and

bleeding disorders (Adams et al., 1997; Alexander, 1997; Stedman's Medical Dictionary,

2000). According to a report of the Australian Institute of Health and Welfare (AIHW),

the incidence rate of ischemic stroke is about five times higher than strokes of the

hemorrhagic type but the fatality rate of hemorrhagic stroke is much higher than

ischemic stroke (AIHW, 2004). Both ischemic stroke and hemorrhagic stroke may be

further subcategorised.

One of the widely accepted classifications, investigated by Adams and his

colleagues (1993), provides

five subtypes of ischemic stroke: (1) large-artery

atherosclerosis, (2) cardioembolism, (3) small-vessel occlusion (lacunar), (4) stroke of

other determined aetiology, and (5) stroke of undetermined aetiology (Adams, Bendixen,

Kappelle, Biller, Love, & Gordon, 1993).

Hemorrhagic stroke may be also subdivided into two main categories based on

the primary location of bleeding: (1) intracerebral hemorrhage (ICH) occurs as a result

of bleeding from an arterial source directly into the substance of brain, and (2)

subarachnoid hemorrhage where rupture of abnormal blood vessels is associated with

the subarachnoid space (SAH) (D'Esposito, 1997; Sims & Korowhetz, 2004). More

specific characteristics of individual subtype stroke are presented in this chapter in

section 2.1.3 under aetiology and diagnosis according to pathophysiological mechanism.

2.1.2 Epidemiology

2.1.2.1 Incidence

Stroke has been ranked throughout the world as the most common disease among all the

neurological disorders of adult life. Along with heart disease and cancer, a stroke is the

leading cause of death and disability, although the incidence of stroke has gradually

decreased (Tunstall-Pedoe, 2003). The WHO study provides the largest international

data on the incidence of stroke. This project reported stroke data from 15 international

populations, standardized for the 35-64 age group, for the period from 1982 to 1995.

The average annual incidence rate varied among populations, from about 120 to 450 in

men and from approximately 60 to 390 in women per 100,000 of the population

(Tunstall-Pedoe, 2003).

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In Korea, stroke has been ranked as the most prevalent cause of death in those

individuals who are over 50 years old (KSS, 2003). The Australian National Heart

Foundation study indicates that stroke is the second most common cause of death and

the largest single cause of adult disability of all the neurological disorders (AIHW,

2004). Epidemiological data indicate that the incidence of stroke is approximately

40,000-48,000 cases per year in Australia and it is equivalent to a figure of stroke

occurring every 11-13 minutes (Wolf, 2004).

2.1.2.2 Prevalence

The 2001 National Health Survey reported that 217,500 Australians, or 1.2% of those

who participated in that survey, had a stroke at some time in their lives (AIHW, 2004).

Based on this data, the prevalence of stroke in men was 32.2% higher than for women.

A comparison in age was also noticeable, in that of the total number of Australians with

stroke, 60.0% were aged 65 years and over, while 18.8% were under the age of 55.

2.1.2.3 Recurrence

Different studies have cited variable recurrence rates for stroke. Of the total reported

strokes, recurrent strokes accounted for 18-22% (Thorvaldsen, Asplund, Kuulasmaa,

Rajakangas, & Schroll, 1995). Each year in Australia, about 12,000 people who have

previously had a stroke suffer another stroke (AIHW, 2004).

The recurrence of stroke varies according to the subtypes of stroke. From an

early investigation, Sacco, Foulkes, Mohr, Wolf, Hier, and Price (1989) found that

patients with stroke resulting from large artery atherosclerosis had the highest

recurrence rate (8-18%). Patients diagnosed with cardioembolic stroke and cryptogenic

stroke had intermediate rates (3-5%) and the lowest recurrence rate was found for

lacunar stroke (Sacco et al., 1989). Compared to the incidence of first-ever strokes,

recurrent strokes have a higher rate of mortality and disability (Smith & Korowhetz,

2004).

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2.1.3 Aetiology and diagnosis

With technological advances in brain mapping analysis, the aetiology and diagnosis of

stroke have been identified according to subtypes. Three types of stroke are described in

the following section: (1) ischemic stroke, (2) intracerebral hemorrhagic stroke, and (3)

subarachnoid hemorrhagic stroke.

2.1.3.1 Ischemic stroke

Based on the Classification of Acute Stroke Subtypes, the clinical features of the

ischemic stroke subcategory are presented in Table 2.1.

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Table 2.1 Clinical features of ischemic stroke subcategories by classification

Subcategories Aetiology Size of lesion

1. Large-artery

atherosclerosis

(embolus /

thrombosis)

Cortical, subcortical, brain

stem, or cerebellar dysfunction

More than 50% lesion

Occlusion in vessel in an

infarct

Larger than 1.5 cm

2. Cardioembolism Cortical, subcortical, brain

stem, or cerebellar dysfunction

Larger than 1.5 cm and

presence of high-risk or

medium-risk cardiac

pathology

3. Small-vessel

occlusion (lacunar)

Lacunar syndrome (pure

motor, sensorimotor, pure

sensory, ataxia hemiparesis,

dysarthria-clumsy hand)

Lesion smaller than 1.5 cm

4. Stroke of other

determined aetiology

Nonatherosclerotic

vasculopathies,

hypercoaguable states,

hematologic disorders

5. Stroke of

undetermined

aetiology

(cryptogenic)

Two or more aetiologies of

stroke, no possible source

Source: Adams et al., 1993; Sims & Korowhetz, 2004

Although the causes of infarction, which lead to an ischemic stroke, may be

complicated and varied, the three dominant clinical features identified in Table 2.1 are:

(1) large-artery atherosclerosis, (2) cardioembolism, and (3) small vessel occlusion

(lacunar) (Adams et al., 1993; Alexander, 1997).

A large-artery atherosclerosis is a blockage that prevents sufficient blood flow

through an artery and thus causes an infarction. The blockage is either complete (the

blood vessel is occluded), or incomplete (the artery is stenosed). The most commonly

involved artery is the internal carotid artery.

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The second cause of infarction as listed in Table 2.1 is a cardioembolus. The

term embolus is defined as a plug, composed of a detached blood clot that blocks one of

the blood vessels, e.g. an artery (Stedman's Medical Dictionary, 2000). The main site of

an embolic stroke is the heart, and these are called cardiogenic emboli.

The lacunar type of stroke is the third cause of infarction. The term lacune

refers to a small, deep infarction causing primary arterial disease (Marti-Vilalta, Arboix,

& Mohr, 2004). Initially small vessels are involved, however lacune may progress to

involve other arteries (Alexander, 1997).

2.1.3.2 Hemorrhagic stroke

From pathologic studies, Kase, Mohr, and Caplan (2004) found that spontaneous

Intracerebral Hemorrhage (ICH) occurs predominantly in the deep portions of the

cerebral hemispheres, most commonly in the putamen, and is commonly caused by

hypertension. On the other hand, there are a number of cases in which ICH occurs with

nonhypertensive causes, such as: (1) small vascular malformations, (2)

sympathomimetic drugs, (3) intracranial tumours, (4) anticoagulants, and (5) cerebral

vasculitis.

Another type of hemorrhagic stroke, subarachnoid hemorrhage (SAH) is caused

by the rupture of cerebral saccular aneurysms as a result of congenital weakening of the

artery walls. Unlike other types of stroke, SAH may be easily diagnosed with an MRI or

CT scan (Adams & Davis, 2004; D'Esposito, 1997).

2.1.4 Risk factors

While providing an overview of stroke, it is also important to draw attention to the

underlying risk factors, as knowledge of their interactions may prevent or decrease the

consequences of stroke. Based on the data from an Australian survey (AIHW, 2004), the

death rate from stroke has rapidly declined by about 68% since the 1960s, and the report

indicates that it has been attributable to the improvements of some risk factors.

Due to the heterogeneous nature of stroke, various risk factors have been

associated with different types of stroke (Batchelor & Cudkowicz, 1999; Smith &

Korowhetz, 2004).

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The risk factors are presented separately for the following sub-classifications of

stroke: (1) Ischemic stroke, (2) Intracerebral hemorrhage (ICH), and (3) Subarachnoid

hemorrhage (SAH). The risk factors for each subtype of stroke are either nonmodifiable,

or modifiable.

2.1.4.1 Risk factors by stroke subtypes

2.1.4.1.1 Ischemic stroke

Table 2.2 lists the known modifiable and nonmodifiable risk factors for ischemic stroke

based on observational and intervention studies (Goldstein, Adams, Becker, Furberg,

Gorelick, & Hademenos, 2001; Smith & Korowhetz, 2004). Among the risk factors,

hypertension is the highest, especially in younger patients, whereas the second leading

factor, atrial fibrillation is more prevalent in those individuals who are 80 or more

years old. Other risk factors (including diabetes, hyperlipidemia resulting from rising

levels of total serum cholesterol, smoking, and obesity) are frequently documented as

common risk factors because of their high prevalence.

Table 2.2 Ischemic stroke risk factors

Nonmodifiable risk factors Modifiable risk factors

Age

Gender

Race

Family history

Hypertension

Atrial fibrillation

Smoking

Diabetes

High cholesterol levels

Myocardial infarction

Obesity

Physical inactivity

Source: Goldstein, Adams, Becker, Furberg, Gorelick, & Hademenos, 2001; Smith &

Korowhetz, 2004

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2.1.4.1.2 Intracerebral hemorrhage

Table 2.3 presents the causative risk factors for ICH, with hypertension again leading

the list (Smith & Korowhetz, 2004).

Table 2.3 Intracerebral hemorrhage risk factors


Age

Race

Apolipoprotein E ε2 or ε4 allele

Cerebral amyloid angiopathy

Hypertension

Alcohol use

Ischemic stroke

Coagulopathy

Cigarette smoking

Vascular malformation

Intracerebral tumors

Source: Smith & Korowhetz, 2004

2.1.4.1.3 Subarachnoid hemorrhage

A summary of risk factors of subarachnoid hemorrhage is presented in Table 2.4.

Occurrences of head trauma and rupture of a saccular aneurysm are most commonly

associated with potential risk of SAH (Smith & Korowhetz, 2004).

Table 2.4 Subarachnoid hemorrhage risk factors

Saccular aneurysms


Family history

Aneurysm size

Aneurysm location

Prior history of aneurysmal

bleeding

Cigarette smoking

Hypertension

Cocaine use

Other causes: Trauma

Source: Smith & Korowhetz, 2004

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2.1.4.2 Risk factor management

Through reviewing risk factors for each stroke subtype, several common major factors

are evident including: (1) hypertension, (2) diabetes, (3) blood lipids, (4)

anticoagulation in atrial fibrillation, (5) cigarette smoking and alcohol consumption,

and (6) obesity and physical inactivity. Wolf (2004) suggests that these risk factors may

be prevented through management and educating people at risk. Included among the

possible risk factor interventions are:

(1) Lifestyle modification and adjunctive therapy for reduction of elevated blood

pressure (Lloyd-Jones & O'Donnell, 2004)

(2) Evaluation of hyperlipidemia and lipid-lowering therapy (Topcuoglu,

Buonanno, & Kelly, 2004)

(3) Use of Warfarin anticoagulation medication (Wolf, 2004)

(4) Cessation of cigarette smoking and reduction of alcohol consumption

(Topcuoglu & Furie, 2004)

(5) Increase in physical activity and promotion of weight reduction (Furie, 2004)

26

2.2 Consequences of stroke

2.2.1 Mortality

Stroke mortality has been on the decline due to improvement in preventive interventions

(AIHW, 2004; Smith & Korowhetz, 2004; Wolf, 2002). Despite this trend, the

epidemiological data of stroke-related diseases indicate that stroke remains the second

most common cause of death in Australia. The 2001 National Health Survey reported

that about 40,000-48,000 Australians had strokes each year and only 28,000 of those

survived (AIHW, 2004).

Several studies have determined the fatality rates of stroke based on the specific

stroke subtypes. Of the total number of strokes, hemorrhagic stroke accounts for 20%

and ischemic stroke for 80%. However hemorrhagic stroke carries greater mortality than

ischemic stroke, with fatality rates of 40-50% (Smith & Korowhetz, 2004). Potential

risk factors leading to mortality include level of hemorrhage volume, low score on the

Glasgow Coma Scale score, and the presence of intraventricular hemorrhage (Wolf,

2002).

In ischemic stroke, mortality from cardioembolic causes is ranked highest,

whereas mortality by lacunar stroke is the lowest risk of death, with an acute mortality

rate of 1% (Smith & Korowhetz, 2004). The risk factors associated with mortality are

large hemispheric infarction and major basilar territory infarction (Wolf, 2002).

2.2.2 Neurological outcomes

The neurological outcomes following stroke have shown variable clinical features

depending on the specific types of stroke. Potential reasons for this may be attributable

to the severity of the brain damage and where in the brain the stroke occurred (Adams,

Victor, & Ropper, 1997; Wolf, 2002). Thus, the major clinical features after stroke are

separately described in this section according to the location of infarctions and stroke

types.

27

Based on the anatomic distribution of blood vessels, ischemic infarcts are

reviewed in six subtypes: (1) internal carotid artery disease, (2) anterior cerebral artery

disease, (3) middle cerebral artery disease, (4) posterior cerebral artery disease, (5)

vertebrobasilar disease, and (6) lacune. (See Appendix 6.1 for a diagram of arteries of

the brain). Two subtypes of hemorrhagic strokes are then described referred as (1)

intracerebral hemorrhage and (2) subarachnoid hemorrhage.

2.2.2.1 Internal carotid artery disease

The internal carotid artery is the most common site of a large-artery atherosclerosis

(Bogousslavsky & Hommel, 1993; Ghika, Bogousslavsky, & Regli, 1989; Mohr &

Gautier, 2004). In a study of 100 patients, Bogousslavsky and Hommel described the

features of an infarct associated with internal carotid circulation and these are listed in

Table 2.5. The major clinical features of the lesions are also presented based on the size

of the infarct as measured on a CT scan.

Table 2.5 Clinical features in internal carotid artery disease

Clinical features Small infarcts

(% < 15 mm)

(n = 42)

Large infarcts

(% > 15 mm)

(n = 58)

Pure motor hemiparesis 42 16

Motor hemiparesis and neuropsychological

dysfunction

5 30

Sensorimotor stroke 21 18

Sensorimotor stroke and neuropsychological

dysfunction

9 18

Ataxic hemiparesis 12 11

Hypesthetic ataxic hemiparesis 2 3

Pure sensory stroke 2 1

Other 7 3

Source: Bogousslavsky & Hommel, 1993, p. 66

28

The consequences of cerebral artery disease differ according to the site of the

artery itself, which may in the anterior, middle or posterior areas of the brain. In the next

section, common signs and symptoms for these specific areas are presented.

2.2.2.2 Anterior cerebral artery disease

Clinical features of lesions of the anterior cerebral artery are itemized in Table 2.6. (See

Appendix 6.1e). Major symptoms and signs associated with this disease, and relevant to

this study, include (1) weakness and sensory loss in the contralateral limbs

(hemiparesis), (2) akinetic mutism, (3) language disturbance, (4)cognitive impairment,

(5) mood disturbance, and (6) incontinence and other autonomic changes

(Bogousslavsky & Hommel, 1993; Brust & Chamorro, 2004).

2.2.2.3 Middle cerebral artery disease

Mohr and colleagues (2004) have classified the neurological outcomes following

middle cerebral artery disease in three subcategories: (1) infarction of either hemisphere,

(2) left hemispheric infarction, and (3) right hemispheric infarction.

Clinical syndromes resulting from infarction of either hemisphere affect a

number of functional abilities, including: (1) loss of consciousness, (2) hemiplegia and

hemiparesis, (3) dizziness and vertigo, (4) sensory disturbances, (5) visual field

disturbances, (6) various types of neglect, (7) movement disorders, and (8) autonomic

disturbances (Mohr et al., 2004).

Neurological outcomes referable to left hemispheric infarction are associated

with various types of aphasia and apraxia due to its prime role in language function and

skilled movement activity (Bogousslavsky & Hommel, 1993; Mohr et al., 2004). More

detailed descriptions are listed in Table 2.7. (See Apendix 6.1f).

If the infarction is limited to the right hemisphere of middle cerebral artery

territory, various clinical features are evident, including cognitive deficits, such as visual

and spatial neglect, confusion, and delirium (Mesulam, 2000). Several spatial operative

functions governed by the right hemisphere are also affected including disorders of

spatial localization, disorientation of place, loss of topographic memory, dressing

apraxia, and constructional apraxia (Mohr et al., 2004). Other syndromes referable to

right hemisphere stroke may include amusia, aprosody, and affective agnosia (Brust,

1980; Mohr et al., 2004).

29

2.2.2.4 Posterior cerebral artery disease

The clinical features of posterior cerebral artery disease include cognitive and

behavioral deficits, syndromes such as amnestic aphasia, transcortical sensory aphasia,

memory disorder, color dysnomia, reading disorder, topographical disorientation,

prosopagnosia, and visual agnosia (Binder & Mohr, 2004; Bogousslavsky & Hommel,

1993). Motor syndromes of posterior cerebral artery disease include hemiparesis,

hemiplegia, hyperkinetic and dystonic syndromes and hemichorea-hemiballism

(Binder & Mohr, 2004; Bogousslavsky & Hommel, 1993). (See Table 2.8, in Appendix

6.1g, for further details of posterior cerebral artery disease).

2.2.2.5 Lacunes

Lacune refers to a small, deep infarct attributable to the degeneration of small vessel

due to an occlusion (Alexander, 1997; Marti-Vilalta, Arboix, & Mohr, 2004). Clinical

syndromes associated with lacunar state include hemiparesis, dysarthria, imbalance,

incontinence, pseudobulbar signs, and a short-step gait (Marti-Vilalta et al., 2004).

Other features such as pure motor stroke, pure sensory stroke, sensorimotor stroke,

ataxic hemiparesis, and dysarthria-clumsy hand syndrome may be followed after lacuna

stroke (Marti-Vilalta et al., 2004). Of importance to this present study is that the

syndromes that usually lead to dysfunctions of forearm, hand, and fingers, may be

involved with lacunar infarcts (Kim, Kim, & Cha, 1999; Marti-Vilalta et al., 2004).

2.2.2.6 Intracerebral hemorrhage

The neurological outcomes of intracerebral hemorrhagic stroke may vary, depending on

the sites of hypertensive bleeding (D'Esposito, 1997). When the hemorrhage has

occurred in the putamen, syndromes such as pure motor stroke, pure sensory stroke,

and hemichorea-hemiballism are evident (Kase, Mohr, & Caplan, 2004). If the

hemorrhagic bleed is in the thalamus, it causes a number of functional deficits including

impairments of consciousness, hemiplegia-hemiparesis, hemisensory deficit,

hemianopia, aphasia, mutism, anosognosia, upward gaze palsy, horizontal ocular

deviation, and pupillary abnormalities (Kase et al., 2004).

2.2.2.7 Subarachnoid hemorrhage

The clinical features following subarachniod hemorrhage may involve severe and

persistent neurological damages (Alexander, 1997) due to recurrent hemorrhage and

extensive bleeding. These factors may cause cranial nerve palsies, paralysis, aphasia,

and psychiatric disturbances. Cognitive and behavioral disorders include impairment of

30

executive function impairment, memory impairment (including amnesia), confabulation,

and apathy (Adams & Davis, 2004; Alexander, 1997).

2.2.3 Functional outcomes related to motor skill

Due to the loss of neurological functions after the onset of stroke, significant deficits in

the movement-related functions are prevalent among the majority of stroke patients. In

this section the functional outcomes on the scope of motor areas are reviewed. Firstly,

the functional areas of the brain involving motor skills are described and the specific

characteristics of motor dysfunctions follow. See Appendix 6.1a ~ 6.1d, for a diagram of

the brain and effects of stroke.

2.2.3.1 Functional areas of the brain involving motor skills

The functional areas of the brain responsible for motor control vary in complexity.

According to the functions of the cerebral cortex studied by Arnadottir (2004), the

frontal lobe is the primary motor area, particularly the precentral gyrus which governs

the execution of movement. A secondary area of the frontal lobe is the premotor cortex

which serves planning, programming, sequencing, timing, and organization of

movement (Arnadottir, 2004).

Based on an analysis of motor involvement in the location of the brain,

Arnadottir further determined motor dysfunctions in cortical areas and noncortical areas.

Table 2.9 lists specific motor involvements in cortical areas and its possible motor

impairments after stroke.

31

Table 2.9 Cortical involvement: location and motor impairments

Artery Location Motor impairments

Middle cerebral

artery: upper trunk

Lateral aspect of frontal

and parietal lobe

Dysfunction of either hemisphere:

contralateral hemiplegia

(especially of the upper extremity),

ideational apraxia

Right hemisphere dysfunction:

left unilateral motor apraxia,

left unilateral body neglect

Left hemisphere dysfunction:

bilateral motor apraxia

Anterior cerebral

artery

Medial and superior

aspects of frontal and

parietal lobes

Contralateral hemiparesis

Left unilateral apraxia

Anterior choroidal

artery, a branch of

the internal carotid

artery

Globus pallidus

Lateral geniculate body

Posterior limb of the

internal capsule

Medial temporal lobe

Hemiparesis of limbs

Basilar artery

proximal

Pons Quadriparesis

Bilateral asymmetric weakness

Vertebral artery Lateral medulla and

cerebellum

Clumsiness of ipsilateral limbs

Hypotonia of ipsilateral limbs

Gait ataxia

Source: Arnadottir, 2004

32

The various motor impairments in noncortical areas are presented according to

the anatomical location of the brain in Table 2.10 (Arnadottir, 2004).

Table 2.10 Noncortical involvement: location and motor impairments

Location Motor impairments

Anterolateral thalamus: either side Minor contralateral motor abnormalities

Lateral thalamus Contralateral limb ataxia

Internal capsule or basis pontis Pure motor stroke

Putamen Contralateral hemiparesis

Motor impersistence

Pons Quadriplegia

Cerebellum Ipsilateral limb ataxia

Gait ataxia

Source: Arnadottir, 2004

2.2.3.2 Motor dysfunction

After a stroke, several aspects of motor dysfunctions are evident in the upper and lower

extremities that severely limit functional movement control. Hemiparesis with uniform

weakness of each limb is the most frequent motor deficit profile, constituting at least

two thirds of all stroke-related impairments (Mohr, Foulkes, & Polis, 1993).

The inability to execute purposeful movements may be associated with not only

hemiparesis but also other neurobehavioral sequelae related to the stroke. Patients with

motor neglect show a lack of initiation moving their limbs even in the presence of

preserved strength, and patients with motor impersistence are unable to maintain

voluntary action (Kane & Buckley, 2004).

Apraxia is referred to as a disorder of skilled, purposeful movement in the

absence of impaired motor function and comprehension (Alexander, 1997). Apraxic

abnormalities are associated with left hemisphere damage, in particular injuries

involving the left frontal and inferior parietal lobes (Arnadottir, 2004).

Patients after a stroke typically experience changes in muscle tone, contralateral

weakness, and poor endurance (Kane & Buckley, 2004). Motor weakness is seen in

approximately in 80-90% of all stroke patients (Bogousslavsky, Van Melle, & Regli,

33

1988). Both flaccidity and spasticity may develop in the acute phase (Mohr et al., 1993).

Left unattended over time, muscle stiffness and learned nonuse are likely to occur (Taub,

1980).

34

2.3 Stroke rehabilitation

An overview of studies related to the rehabilitation of stroke patients is presented in this

section. Of particular importance are the studies related to motor rehabilitation,

specially those related to hand and finger exercises, as this is the area most relevant to

the present study.

2.3.1 Theoretical frameworks

2.3.1.1 Compensation through biomedical mechanisms

Several studies have clinically demonstrated that brain damage may destroy some

neurons outright while causing other neurons to be only temporarily impaired

(Goldstein and Ruthven, 1980; Plotnik and Mollenauer, 1978). It has been suggested

that the function of the neuron can therefore be compensated for by other biomedical

mechanisms.

Goldstein and Ruthven (1980) indicated that by studying damaged functional

brain systems, rehabilitation efforts can focus on restoring behaviours by “1) getting

another part of the brain to take over mediation of impaired behaviour; 2) substituting a

simple set of operations for a more complex skill; 3) substituting a complex skill for a

basic skill; or 4) finding a new way to perform affected tasks that does not depend on

the damaged area of the brain”(pp. 40-41).

Based on animal studies, Plotnik and Mollenhauer (1978) report that

undamaged neurons send out new extensions to compensate for loss. This increase in

neural connections, or sprouting, may be one way the brain compensates for damage

and loss of function.

In addition, a study by Erdonmez (1991) of a patient with a left cerebral

vascular accident indicated that new motor skills could be acquired through

involvement of new pathways and strategies where the brain compensated for impaired

areas.

A clinical study by Gerloff, Corwell, Chen, Hallett, and Cohen (1997)

suggested that there appears to be an extraordinary restorative potential of the brain to

compensate for supplementary motor area lesions. High-frequency repetitive

transcranial magnetic stimulation (rTMS) was used to study the role of the mesial

frontocentral cortex in the organisation of sequential finger movements of different

complexities involving piano-playing. In 15 subjects, rTMS was randomly applied to

the scalp overlying the region of the supplementary motor area and over other positions

35

during the performance of finger sequences on an electronic piano. The findings showed

that the number of errors induced by rTMS over the supplementary motor area

decreased when rTMS training was administered repeatedly. It was found that even after

large corticectomies, patients could recover substantially or completely from early

postoperative motor deficits within less than one month after the operation (Zentner,

Hufnagel, Pechstein, Wolf, and Schramm, 1996).

Similarly, a study of Pascual-Leone, Dang, Cohen, Brasil-Neto, Cammarota,

and Hallett (1995) examined the role of changes of the human motor system in the

acquisition of new fine motor skills. The subjects were required to practice one-handed,

five-finger exercise in daily 2-hour manual practice sessions. Over a course of 5 days,

the cortical motor areas targeting the long finger flexor and extensor muscles enlarged,

and their activity threshold decreased. They concluded that acquisition of the new fine

motor skills was associated with modulation of the cortical motor output to the muscles

involved in the task. Additionally, this rapid modulation may occur through an increase

of synaptic efficacy in existing neural circuits or unmasking of existing connections due

to disinhibition.

2.3.1.2 Brain reorganization and functional recovery

With technological advances in brain mapping analysis, it has been shown that damaged

functional brain systems may be reorganized by certain types of process (Baker & Roth,

2004; Carr & Shepherd, 2003; Johansson, 2000). Carr and Shepherd (2003) indicated

the types of functional recovery process from stroke: (1) reorganization of affected

motor lesions, and (2) changes in the unaffected hemisphere.

Also, Johansson (2000) advocated the potential of functional recovery

suggesting, “it is not only the number of neurons left, but how they function and what

connections they can make that will decide functional outcome” (cited in Carr &

Shepherd, 2003, p.8). These connections are thought to be a response to stimuli such as

exercise and training functional tasks. Rehabilitation using music therapy intervention

relies on this adaptive plasticity for reorganization of neural connections within

surviving brain tissues (Baker & Roth, 2004).

36

2.3.1.3 Skill acquisition

In the process of rehabilitation, skills may need to be re-learned, as if for the first time.

A brief review of theories of skill acquisition is relevant to the current study. Fitts

(1964) proposed a three-stage model of skill acquisition. First, there is a cognitive stage,

during which basic procedures are learned and their execution is highly demanding.

Then there is an associative stage, during which one tries out different task components

and associates them with resulting success or failure. Through this associative process,

task components that contribute to success are retained, whereas failed task components

are discarded. Feedback on performance is especially important during this phase

(Johnson, 1984). In the third stage, the automatic stage, behaviors can be performed

quickly and consistently with less deliberate attention. Performance at this stage is

possible even when the learner engages in other tasks simultaneously.

Mental practice has been shown to aid learning of motor tasks, though not as

much as physical practice. Mackay (1981) examined the value of mental practice in his

speeded-reaction task. The findings suggest that mental practice can aid learning

through the strengthening of high-level memory units.

2.3.2 Clinical interventions

2.3.2.1 Exercise-related interventions: exercise therapy

Table 2.11 summarizes studies of the rehabilitation of hand and finger functions using

exercise therapy. The information is helpful because it shows the research design and

the duration of the intervention, and these factors influenced decisions made in this

current study. Several acronyms are used in this table: (1) S refers to subject, (2) EG

refers to experimental group, (3) CG refers to control group, (4) G1 refers to group 1,

(5) G2 refers to group 2, and (6) SD refers to stimulation duration.

37

Table 2.11 Studies on the rehabilitation of hand and finger function: exercise therapy

Reference Subjects Methods Duration

1 Carey

1990

16 Ss

Spastic hemiparetic

stroke

Randomized controlled

design

Manual stretch

2 Duncan et al.

1998

20 Ss

1-3 months post-

stroke

Randomized controlled

design

EG: Home-based exercise

CG: usual care

8 weeks

3 days/

week

24 sessions

3 Johansen-

Berg et al.

2002

7 Ss Home-based therapy

(restraint of unaffected

limb)

fMRI analysis

2 weeks

4 Cauraugh

et al.

2003a

20 Ss

Chronic CVA with

partial paralysis

Randomized

2 groups design

G1: unilateral movement+

stimulation

G2: bilateral movement+

stimulation

2 weeks

2 days/

week

(1.5h/day)

4 sessions

5 Cauraugh

et al.

2003b

26 Ss

Chronic stroke

Randomized

3 groups design

G1: 5s stimulation

duration (SD)

G2: 10s SD

CG: No SD

2 weeks

2 days/

week

(1.5h/day)

4 sessions

6 Cauraugh

et al.

2003c

34 Ss post-stroke

mean time 3.2 years

Randomized

3 groups design

G1: blocked practice +

stimulation

G2: random practice + S

CG: no stimulation

2 weeks

2 days/

week

(1.5h/day)

4 sessions

7 Chiang et al.

2004

6 Ss

post-stroke

E1: EEG +

visual

feedback on

E2: EEG +

additional

visual

4 weeks

3 days/

week

38

force output feedback 12 sessions

8 Jang et al.

2003

4 Ss

chronic hemiparetic

stroke

Task-oriented training

fMRI analysis

4 weeks

4 days/

week

40 min/day

16 sessions

9 Trombly et al.

1986

20 Ss

post-stroke

G1: resisted grasp exercise

G2: resisted extension

G3: ballistic extension

CG: no treatment

10 Pohl et al.

1999

10 Ss

unilateral stroke

10 Ss

Non-disabled

controls

Matched sample of right-

handed adults

Aiming task with practice

11 Rothgangel

et al. 2004

Subjects with

Chronic hemiparetic

stroke

Single blind randomized

clinical trials

EG: exercise therapy with

mirror therapy

CG: exercise therapy

5 weeks

12 Smania et al.

2003

4 Ss

pure sensory stroke

Multiple baseline, pre-

post, follow-up trials with

single cases

Behavioral training

30 sessions

50 min/

session

13

Woldag et al.

2003

21 Ss

stroke with middle

cerebral artery

territory

Longitudinal multiple

baseline design with single

cases

39

2.3.2.2 Exercise-related interventions: constraint-induced movement therapy

Table 2.12 summarizes studies of the rehabilitation of hand and finger functions

applying constraint-induced movement therapy (CIMT). Constraint-induced movement

is referred to as immobilization of the damaged part of the limb (Stedman‟s Medical

Dictionary, 2000). The information is also useful because it demonstrates the research

design and the duration and the frequency of the intervention. The current study has

been formulated based on these factors.

Table 2.12 Studies on the rehabilitation of hand and finger function: constraint-induced

therapy

Reference Subjects Methods Duration

1 Blanton

et al.

1999

1 Subject

4 months

post-stroke

Single case design

CIMT + task practice

14 days

5 days/week

6 hrs/day

2 Levy

et al.

2001

2 Ss

post-stroke

Baseline, pre, post-test

CIMT + training

fMRI analysis

2 weeks

5 days/week

6 hrs/day

3 Page et al.

2002

1 S

5 months

sub-acute

stroke

Multiple baseline, pre, post-

test

Modified CIMT + physical +

occupational therapy

10 weeks

3 days/week

1 hr/day (therapy)

5 hrs/day

(MCIMT)

4 Sterr et al.

2002

15 Ss

(13 stroke,

2 TBI)

2 groups randomized design

Baseline, pre, post, follow-up

test

G1: 6 hrs/day

G2: 3 hrs/day

14 days

6 hrs vs. 3 hrs/day

5 Tremblay

et al.

2001

2 Ss

8-12 weeks

sub-acute

stroke

CIMT + training

Home based exercise

14 days

40

2.3.3 Rehabilitation strategies

A study by Wade, Langton-Hewer, Skilbeck, and David (1985) proposed several ways

in which physical therapy can help in rehabilitating brain injured patients:

(1) Prevention of complications, such as illness, muscle weakness, or

contractures as the natural recovery process is hampered by such symptoms.

(2) Where the patient is no longer able to use a certain body part, the use of an

alternative body part can be developed to adapt to the disability.

(3) The exercise techniques are targeted at retraining the nervous system that

has been affected by the accident.

(4) The appropriate tools and aids, essential for the patient‟s daily activities are

used as much as possible.

An observation that has also been subject of a study by Taub (1980) is that

“some long-term disabilities…are not due to the original loss, but rather to learned non

use (p.230).” Taub advocates that the affected limb is exercised, even if movement is

severely restricted (cited in Thaut, 1999).

In developing rehabilitation strategies, Carr and Shepherd (2003) suggest

further considerations in order to optimize motor skills of stroke patients. Training

techniques should highlight each exercise to bring it to the patient‟s attention,

reinforcing maintenance of the rehabilitative goals. Carr and Shepherd also advocate

that feedback is an essential aspect of rehabilitation strategies, providing knowledge of

the results of the action and performance itself. When appropriate feedback is available

to the patients, optimal learning is produced in physical rehabilitation process (Carr &

Shepherd, 2003).

From this overview of studies using exercise as a rehabilitative intervention, it

follows that music-related exercises, specially piano-playing exercises may be effective

in the rehabilitation of hand and finger movement in stroke patients. In the next section,

music therapy studies are reviewed.

41

2.4 Music therapy in neurological rehabilitation

2.4.1 Theoretical background and Clinical studies

Music therapy techniques have been advocated in research and clinical settings that

focus on the rehabilitation need of the brain injury patients in the areas of cognitive,

communication, physical, and socio-emotional deficits. The range of rehabilitation

services described in this literature review is limited to physical rehabilitation programs

and the specific role of music therapy within the clinical setting for brain damaged

patients. The following research demonstrates that music therapy can be a unique

intervention in physical rehabilitation programs.

In a pioneering study, Fields (1954) reported that music was used to promote

muscular activity and coordination in the treatment of brain injured patients. The music

therapy sessions involved instrumental playing to increase flexion-extension and

rotation patterns of shoulder, wrist, and finger joints. Rhythmic control gained through

instrument playing was carried over into daily activities of walking and other tasks.

Based on her work with 28 patients over a 3 year time period, Fields offered insights

into the selection of music with respect to the developmental patterns of neurological

and gross motor growth showing that where a reflex action in muscle activity is blocked

(is inactive), carefully selected music may overcome the inactivity and evoke action.

In a related study, Cross, McLellan, Vomberg, Monga, and Monga (1984)

described a group “movement-to-music” therapy program for 24 stroke patients.

Subjects included both right and left hemiplegic patients who had experienced a stroke

within 1 to 9 months prior to the onset of the program. The following list of

observations was demonstrated via an analysis of videotapes of the music therapy

sessions:

(1) The patients exhibited more activity in various directions when music was

provided, than without music.

(2) The tunes that were familiar to the patients triggered the best responses from the

patients.

(3) The music needed to be simple and have a clear and distinctive beat and

rhythmic pattern.

(4) The movement and music needed to be appropriately matched for speed, pattern,

and phrase.

(5) Changes in tempi could be made when playing the music live.

42

(6) The therapists needed to provide various prompts through verbal and visual

signals throughout the sessions.

(7) Movement was rehearsed prior to performance to the music (p.199).

Music is incorporated into movement exercises to provide motivation, purpose,

and structure to the therapeutic exercises of the patient (Thaut, 1988; Thaut, 1999;

Thaut; 2005). Music-based physical rehabilitation programs can facilitate the retraining

of movement coordination by using music as a timing cue in physical exercise (Thaut,

1999). Thaut suggests that rhythmic accents can be predictable timing cues, therefore

learning to follow rhythm helps the patient organize movement in time. Additionally,

Thaut states some therapeutic benefits in using musical instruments:

(1) The use of musical instruments provides instant feedback for the patient that is

rewarding to the patient, and therefore encourages the proper movement

performance.

(2) Playing a musical instrument provides an important motivation factor.

(3) When patients play musical instruments the muscles are activated in

synchronicity with the rhythm. This process helps develop a smooth flow,

essential to proper coordination (p. 230).

In clinical practice, music therapists base their treatment techniques and

activities on the above-mentioned theories and rationales. The following research shows

how these principles have been utilized in the rehabilitation setting especially focusing

on the treatment and functioning of paralyzed upper extremities.

Kozak (1968) used music therapy with a patient with poliomyelitis. Treatment

involved keyboard instruction to promote finger strength and to keep finger joints

partially flexed in a normal playing position. The results showed improved functioning

of the patient‟s right hand while using the keyboard.

Similarly, Cofrancesco (1985) examined the effect of music instrument playing

on the improvement of hand grasp strength and functional tasks with stroke patients in

rehabilitation settings. During treatment sessions, exercises were devised to increase

hand grasp and extension and to enhance function via the playing of musical instrument.

The results indicated improved hand grasp strength in all subjects.

The aforementioned music therapy studies suggest the utility of this approach.

According to Josepha (1964), “Instrumental performance is of value as a type of

physical therapy in that it provides its own work incentive. The musical results, meager

as they may be, serve as an immediate reward and tend to stimulate further and

43

continued effort” (p. 74).

In the area of gait rehabilitation, music therapy has provided an effective and

enjoyable technique during a prolonged rehabilitation process. Staum (1983)

investigated the application of rhythmic auditory stimuli in facilitating proprioceptive

control of rhythmic gait. Twenty-five subjects who had gait disorders listened to

individually selected music and rhythmic percussive sounds and attempted to match

their footsteps to the stimuli. Analysis of walking indicated that 10 subjects (45%)

achieved a normal rhythmic evenness, with an additional nine subjects (41%)

approaching differences of only 2-3 seconds. Consistency in speed improved for 68% of

the subjects. Based on the results, Staum concludes that superimposed music and

auditory stimuli could provide substantive modification that may result in an

individual‟s enhanced appearance, increased stability, and independent mobility.

More recently, rhythmic auditory stimulation (RAS) was studied as a

therapeutic stimulus to facilitate gait patterns of eight patients with traumatic brain

injury (Hurt, Rice, McIntosh, & Thaut, 1998). After five weeks of daily rhythmic

auditory training, the patients‟ mean velocity increased significantly by 51%(p< .05),

and cadence and stride length also showed statistically significant improvement from

pre-test to post-test (F=5.63; p < .035).

While there is considerable research into music therapy techniques in the

rehabilitation of gait disorders, there has been little research into music therapy

techniques for hand and finger rehabilitation. The few studies that have been conducted

are not recent and their emphases are on hand grasp and hand strength, with little

attention to independent finger strength, agility and speed. This study aims to add to the

literature and to investigate appropriate techniques for practicing music therapists to

assist those who have physical disorders affecting the hand.

Table 2.13 includes information about the therapeutic use of music instruments

in rehabilitation of brain damage patients. The summary informs the study design of the

present investigation.

44

Table 2.13 Rehabilitation of physical function (upper limb): clinical outcome studies

Reference Subjects Methods Duration Results

Josepha

1964

1Subject

Congenitally

missing left

hand

Piano playing Significant

improvement on upper

extremity

Kozak

1968

1S

Adult male

poliomyelitis

Keyboard

playing: finger

strength, distal

finger joints

flexibility

Improved function on

right hand

Cofrancesco

1985

3S

>5 weeks

post-stroke

Age ranges

50-75 yrs

A: percussion

instrument

playing

B: piano-playing

C: autoharp

playing

3 weeks

30-35

minutes,

5days/week,

15-20

sessions

Multiple baseline

design,

Between pre & post-

test,

Improved hand grasp

strength

Erdonmez

1991

1S

Left CVA

Piano

performance

3 years

Weekly

session

Improvement in

rhythmic short-term

memory,

keyboard dexterity,

complex performance

ability

Moon

2000

1S

19 months

post-TBI

Piano exercises 6 weeks

30 minute

5 days/week

30 sessions

Between pre & post

assessments,

significant

improvement in

velocity evenness

(p<0.01~0.00002) and

duration evenness

(p<0.1~0.006)

45

2.5 Rehabilitative effects of piano-playing music therapy

2.5.1 General aspects of piano playing

Playing the piano demands orderly, sequential control of individual finger movements in

accordance with a high degree of bimanual coordination (Moon, 2000). There are four

aspects of piano playing that a pianist must consider: (1) hand position, (2) finger

motion, (3) the sequence of keys to press, and (4) the duration and velocity of each key

press. The piano player must understand the demand of the task, develop a cognitive

representation of it, and initiate eye-hand coordination. At first, the player‟s hands will

move slowly with fluctuating accuracy and speed, and success will require visual,

proprioceptive and auditory feedback. With practice, the player can refine each single

movement, link the different movements with a desired timing, and attain stability and

fluency in the ordered sequence (Pascual-Leone et al. 1995).

Piano playing has rhythmic and expressive elements that are not found in any

other bimanual movements. Furthermore, piano exercise can convey different metrical

organization of the notes by varying the time and force of the key striking (Rosenbaum,

1991).

2.5.2 Rehabilitative effects of piano-playing music therapy

Piano playing has been advocated as a therapeutic use of music (Cofrancesco, 1985;

Erdonmez, 1991; Kozak, 1968; Lundin, 1967; Thaut, 1992; Velasquez, 1991). Musical

exercises played on the piano benefit flexion of wrists, fingers, and exercise the muscles

of arms, shoulders, neck and back. A proper therapy plan for piano playing could

include staccato movements, arpeggios, wrist flexion, and an emphasis on specific

fingers that need exercise (Lundin, 1967).

In a clinical setting, Cofrancesco (1985) used individual finger movements on

the piano comprising chordal positioning and repetitious patterns. The treatment aimed

at assisting the patients in rehabilitating muscular strength, joint motion, and finger

dexterity. Results indicated improved hand grasp and strength in all subjects as well as

progress in coordination and functional skills.

Erdonmez (1991) studied the rehabilitation of piano performance skills with a

patient following a left cerebral vascular accident. Weekly music therapy sessions were

carried out over a 3-year period. Results of the study demonstrated improvement in

rhythmic short-term memory, keyboard dexterity, and the performing ability of

46

increased complexity in key and rhythm. It also indicated that new motor skills could be

acquired through involvement of new pathways and strategies where the impaired area

was compensated for by another area of the brain.

More recently, Moon (2000) determined the effect of piano exercises on

rehabilitation of right hand finger coordination for a 25 years old woman with traumatic

brain injury. The medical report indicated she sustained a severe closed head injury and

right-sided hemiparesis. The initial music therapy assessment revealed several

dysfunctions of finger coordination associated with piano playing skills of the right

hand. Half-hour daily music therapy sessions comprising intensive piano practice and

duet performance were conducted for 3 weeks. Following a week of music therapy

withdrawal, a further 3 weeks of therapy sessions were conducted. Assessments were

made before the start of music therapy sessions, at the end of the 3rd

week, at the end of

the 4th week, and at the end of the 7

th week. Using the MIDI data analysis, key velocity

and key duration were measured. The results of performance comparison showed a

statistically significant improvement in velocity and duration evenness between the

baseline and the final assessments. This indicated piano playing is recommended as a

viable music therapy tool in rehabilitation of finger coordination.

2.6 Summary of literature review

In summary, this chapter presented a comprehensive overview of stroke, followed by a

description of stroke consequences. The basic concepts of stroke rehabilitation were

presented, including both theoretical frameworks and clinical interventions. Through

exercises and training functional tasks, rehabilitation using music therapy interventions

has been shown to effectively assist adaptive plasticity for reorganization of neural

connections within surviving brain tissues. Following this, the use of music therapy

interventions in neurological rehabilitation and the therapeutic effects of piano-playing

were described.

47

CHAPTER 3

METHOD

This chapter explains the music therapy research design, its rationale and process of

research conduct. Following this, a description of participants, clinical settings and

apparatus is provided. The next section describes the music therapy intervention,

including the music therapy protocol that comprised five steps. In order to evaluate the

results, outcome measurements and outcome variables are explained with relevant

figures. Lastly, information regarding the statistical methods used in the analysis of data

of the study is provided.

3.1 Research design

3.1.1 Rationale for research design

The purpose of this study was to investigate the rehabilitative effects of a piano-playing

music therapy intervention on motor coordination of chronic stroke patients. Within a

modified controlled trial with pre-test and immediate post-test, twenty participants were

assigned to either a music therapy treatment group or a control group. The study is an

experimental clinical trial. The unique advantage of using an experimental research

design is to investigate the cause and effect of the specific treatment techniques.

Controlled experiments also allow a systematic observation of the changes that occur

during the intervention so that data interpretation might be more reliable (Hanser and

Wheeler, 2005).

This study is classified as quantitative research, where the anticipated form of

data was numeric and the data were analyzed by statistical methods. The statistical

analysis was conducted using the Statistical Package for Social Science (SPSS) version

12.0, including data entry and data management.

3.1.2 Context for the study

This study was carried out at three elderly day-care centers owned by the Seoul City

Council, Korea-south. The facilities provide a service that is respectful of physical,

emotional, psychological, social, spiritual, and rehabilitative needs of the elderly clients.

48

Center 1 caters for 21 clients, center 2, 16 clients, and center 3, 20 clients. Each

day-care center offers nursing care, physiotherapy, occupational therapy, counseling,

family support, and medical care, etc. At the time of conducting this study, music

therapy had been provided at center #1, but not at centers, #2 or #3.

The clients who attended these centers, have experienced stroke, heart disease,

Parkinson‟s disease, frailty due to old age, and dementia.

The three centers are located in close proximity, in the metropolitan area of

Seoul.

3.1.3 Process of group allocation

The research design was a randomized controlled trial with equal numbers in an

intervention group and a control group. The randomization was conducted by the

Statistical Consulting Centre at the University of Melbourne using a system of

sequentially-numbered, opaque envelopes. At the preparatory phase of the research

design, group assignment for a each participant was planned to be conducted by a

coordinator at the clinical facilities, separately from the music therapist-researcher

involved in administering the interventions.

Initially it was planned that patients in the day-care center would be randomly

assigned to either the music therapy group or the control group. However, the Director

of the facility #1 argued that for clinical reasons all patients in the center should receive

a music therapy program. In order to create a control condition, two other day-care

centers for stroke patients were approached and they agreed to participate as the control.

These patients did not receive music therapy intervention but standard care was

provided. This study is therefore a modified controlled trial.

Twenty participants met the inclusion criteria for this study and consented to

take part in the study. A written protocol for dealing with the practical aspects of group

allocation was provided to the coordinator of the facility.

3.1.4 Obtaining consent for participation

3.1.4.1 Research ethics

This study was approved by the Human Research Ethics Committee at the University of

Melbourne (No.050502). See Appendix 6.3 for a copy of the form for review of a low-

risk project involving humans.

49

3.1.4.2 Informed consent

The informed consent of participants was made prior to conducting the research project.

The draft was in English and translated into Korean. See Appendix 6.4 for a copy of the

consent form. This document included the following information:

(1) The right of participants to refuse to participate and to withdraw from the

research at any time without being penalized

(2) The degree of anonymity and confidentiality which was afforded to the

participants

(3) Issues relating to data collecting, data storage and security

The plain language statement was attached to the consent form. See Appendix 6.5

for the plain language statement. The detailed information sheet provided such as:

(1) The aims and purpose of the study

(2) The anticipated outcomes of the research

(3) Details of what the participant will be required to do

(4) Possible benefits and risks to the participant

(5) The anticipated use of the data

3.1.4.3 Obtaining consent

A voluntary participation process after receiving detailed information about the

purposes of the study and the risks involved was carried out. Prior to obtaining consent,

a proper length of time for raising questions and discussion about the clinical trial was

provided to the participants. If the participants volunteered to join the project by signing

the consent form, they were admitted to the project.

3.1.5 Criteria for participant selection

3.1.5.1 Inclusion criteria

The description of participant characteristics that determine inclusion in this study is

presented in Table 3.1. This explanation also includes specific functional levels required

for the enrollment of the study.

50

Table 3.1 Characteristics of the inclusion criteria

Characteristics for inclusion

1 At least 6-month from onset of stroke with unilateral cerebral lesions

confirmed by MRI or CT scan

2 Mini-Mental State Examination-Korea score of at least 24

3 Ability to follow simple instructions

4 Modified Barthel Index score of at least “moderate help required”

5 At least minimal antigravity movement in the shoulder of the paretic arm

6 Ability to extend wrist at least 20 degrees and fingers at least 10 degrees

3.1.5.2 Exclusion criteria

Table 3.2 describes participant characteristics that determine exclusion from being

enrolled in this study with the relevant rationales and clinical conditions.

Table 3.2 Characteristics of the exclusion criteria

Characteristics for exclusion

1 Previous history of stroke and cardiac disease that limits function by unstable

angina

2 Significant orthopedic or chronic pain conditions that interfere with arm and

hand movement

3 Previous history of brain injury

4 Dementia

5 Severe visual and auditory impairments

6

7

8

9

10

11

Global aphasia

Major post-stroke depression that could limit participation

Severe elbow or finger contractures that would preclude passive range of

motion and positioning of the arm and hand

Use of medications for functional movements

Enrollment in another motor recovery rehabilitation protocol

Previous extensive piano training or typing that might influence finger

performance on the keyboard

51

3.2 Participants

Twenty people from the community with chronic stroke participated in this study. The

demographic information and type of stroke are listed in the following section.

3.2.1 Description of group formation and characteristics of participants

3.2.1.1 Treatment group

Ten participants were assigned to the treatment group receiving the music therapy

intervention (Center #1). The general characteristics of the participants in the treatment

group are described in Table 3.3.

Table 3.3 Description of the participants in the treatment group

Participant Age

(years)

Gender Hemiplegic

site

Stroke type Duration**

(months)

Handed-

ness

1 77 F Left * 62 Right

2 68 M Left Infarct 13 Right

3 77 M Left Infarct * Right

4 77 F Right Infarct * Right


6 83 M Left Hemorrhage 96 Right

7 81 M Right Hemorrhage 46 Right

8 66 M Right Infarct 20 Right


10 * F Right * * Right

Note: * Information not available in participant files

** Duration of time from stroke onset

52

3.2.1.2 Control group

Ten participants from Center #2 and #3 formed the control group, against which the

effect of the music therapy intervention was compared. General standard care was given

to the participants in the control group. Table 3.4 describes the general characteristics of

the participants who were assigned to the control group.

Table 3.4 Description of the participants in the control group

Participant Age

(years)

Gender Hemiplegic

site


(months)

Handedness

11 78 F Right Infarct 13 Right

12 76 M Left * 124 Right

13 67 F Right Hemorrhage 31 Right



16 58 F Left Infarct 75 Right




20 80 F Right * 40 Right



3.2.1.3 Response rate and compliance

Twenty participants were eligible according to the criteria for inclusion in the research

project. The regularity with which participants adhered to the research protocol was

managed. During the intervention periods, four out of twenty participants were

withdrawn from the study due to the following factors: misdiagnosis, transferring to

another facility, incidence of death, or complaint due to headache.

53

3.3 Clinical setting

3.3.1 Music therapy setting

The individual music therapy sessions were carried out in a therapy room at center #1.

Figure 3.1 shows the clinical setting. The room was equipped with an electronic

keyboard and this was connected to a laptop computer through a MIDI interface box

made to fit the software program „Home Studio 2004‟.

Figure 3.1 Music therapy setting

54

3.4 Apparatus

3.4.1 The Musical Instrument Digital Interface (MIDI) keyboard and computer

Studiologic SL-760, an electronic keyboard, has 76 keys with a range of six octaves

from EE to g4 (See Fig. 3.2). The keys have a relatively stiff touch compared to a piano

keyboard. The keys are also touch sensitive, i.e., the dynamic level (or tone intensity)

corresponds with the speed of key descent. The size and depth of the keys (3/8 of an

inch deep) are the same as those found on the standard acoustic piano.

Figure 3.2 MIDI keyboard: SL-760

The electronic system was equipped with the MIDI in-though-out connecter jacks,

through which the musical information was received and transmitted to the computer

(See Fig. 3.3).

Figure 3.3 Computer: Trigem Dreambook Lite

55

3.4.2 MIDI analysis: Home Studio 2004 program

Figure 3.4 Home Studio 2004 program

The Musical Instrument Digital Interface (MIDI) provides three key elements:

(1) A reading on the pitch by number and name

(2) A reading on temporal key events by its own clock time

(3) A reading on velocity of key descent by defined units ranging from 1 to 127

56

Table 3.5 Example of a MIDI event list data

Track HMSF MBT Ch Kind Data Velocity Duration

2 00:02:28:24 62:04:936 3 Note E flat 6 109 574

Table 3.5 displays an example of the MIDI event list data. Each line of the event list

view shows a single event with all of its parameters. The terms and their corresponding

abbreviations and definitions are listed below:

Track (Trk), refers to MIDI‟s representation of one or more lines of music with

shared properties.

Hours:Minutes:Seconds:Frames (HMSF), is the time format used for Home

Studio 2004 software. It is a complete music production package for personal

computer users. The software program records live instruments and edits MIDI

with studio-quality audio effects. In HMSF, Frame rate, the smallest unit for

time synchronization, indicates the number of frames per second.

Measure:Beat:Tick (MBT), is another set of timing representation. “Tick” refers

to a thousandth-part of a quarter note. For example, 62:04:936 indicates the

936th

tick of the fourth beat of the 62nd

measure.

Channel (Ch), refers to the path through which MIDI transmits information.

Data indicates the pitch by the octave number and the name of the key, with

flats and sharps to display notations.

Velocity, in the Home Studio 2004 software program, refers to how fast or how

hard a key is struck when a track is recorded. The range of velocity

encompasses 1 to 127.

Duration, in the Home Studio‟s Step Record dialog box, refers to the actual

length of time that a note sounded. This amount is shown in beats and ticks.

57

3.5 Music therapy intervention

3.5.1 Criteria of piano-playing intervention

In order to design a rehabilitation-oriented program, the music therapist-researcher

utilized a piano-playing intervention based on several exercise criteria. Table 3.6

presents a description of piano-playing exercise criteria including relevant perspectives

and its corresponding outcomes.

Table 3.6 Piano-playing exercise criteria

Perspective Exercise criteria Outcome

Accessibility Exercises are designed to be

as accessible (or easy) as

possible.

Patients can actively execute them by

themselves, (giving them a feeling of

controlling their movements.

Informed

feedback

Exercises have to be recorded

as accurately as possible.

Patients can be motivated by their

objective progress feedback.

Credibility Exercises have to be measured

as accurately as possible.

Performance can be analyzed

statistically.

Sequence Exercises are graded in

progression.

Patients can undertake their exercises

at a step-by step pace.

Relevancy Exercises have to be as

relevant as possible to

activities of daily living (e.g.

using eating implements,

turning the pages of a book).

Performance improvements can meet

the patients‟ pragmatic needs.

Musicality Exercises have to be as

musical as possible using

musical elements.

Patients can integrate their exercises

in a creative musical way receiving

auditory feedback.

Prevention Exercises have to be within a

range of patients‟ endurance.

Fatigue and pain can be prevented.

58

3.5.2 Piano-playing music therapy protocol

The individual music therapy sessions were carried out for half an hour, three days per

week for four weeks. The music therapist-researcher conducted each music therapy

session. The procedure of piano-playing music therapy protocol comprised five steps.

Each step is described in the following sections with relevant figures. Time proportion

for each step was evenly distributed, approximately 5 minutes for each exercise.

3.5.2.1 Dialogue and warm-up

Each session began with a conversation between the patient and the music therapist-

researcher. In this dialogue, the patient expressed his or her concerns and the therapist

observed his/her felt needs and the level of physical condition. Based on the observation,

the therapist decided on the intensity of each exercise for the patient, and explained a

specific aim for the therapy session. Following this, a warm-up exercise was introduced,

which included hand and finger relaxation and stretch.

3.5.2.2 Thumb-Index finger exercises

(1) The patient put his non-affected index finger on the D# key (next to the

middle C#), then pressed all the black keys in both ascending and descending

directions.

(2) The patient then put his non-affected thumb on the C# key (next to the

middle C) and practiced thumb tapping in both ascending and descending

directions.

(3) A combination of thumb and index finger playing of a simple passage was

then required of the patient. (See Figure 3.5) The exercise was practiced as

evenly as possible in the patient‟s comfortable speed. If the patient was able to

execute the finger movement of the affected hand, the procedure was repeated

in the same manner using his affected hand fingers.

Figure 3.5 Thumb-Index finger simple passage ⓒ So-Young Moon, 2007

59

3.5.2.3 Thumb-Index-Middle finger exercises

(1) In this exercise, the patient put his non-affected thumb, index, and middle

fingers on three of the black keys (F#, G#, and A#), then pressed each key in a

consecutive manner in both ascending and descending directions. (See Figure

3.6)

(2) The patient then moved his hand posture to play the black keys C#, D#, and

F#, and pressed each key in a consecutive manner in both ascending and

descending directions. (See Figure 3.7)

(3) If the patient was able to execute finger movement in his affected hand, the

procedure was repeated in the same manner using the affected hand fingers.

Each exercise was practiced as relaxed and even as possible at the patient‟s

preferred or maximum tempo. Based on the level of the patient‟s capability, the

exercises were directed in both unilateral and bilateral movements.

Figure 3.6 Thumb-Index-Middle finger simple passage (a) ⓒ So-Young Moon, 2007

Figure 3.7 Thumb-Index-Middle finger simple passage (b) ⓒ So-Young Moon, 2007

60

3.5.2.4 Five-finger exercises

(1) In this exercise, the patient put his non-affected five fingers on five black

keys C#, D#, F#, G#, and A#, then pressed each key in a consecutive

manner in both ascending and descending directions. (See Figure 3.8)

(2) If the patient was able to execute finger movement in his affected hand, the

procedure was repeated in the same manner using the affected hand fingers.

Each exercise was practiced as relaxed and even as possible at the patient‟s

preferred or maximum tempo. Based on the level of the patient‟s capability,

the exercises were directed in both unilateral and bilateral movements.

Figure 3.8 Five-finger simple passage ⓒ So-Young Moon, 2007

3.5.2.5 Creative piano-playing exercises

(1) In the final step of a series of exercises, the therapist introduced some

Korean traditional piano pieces. An example of the music score is illustrated in

Figure 3.9 and 3.10. Each piece of music was rearranged into an easier version

at the level the patient could practice with minimal difficulty. See Figure 3.9 for

a simplified version of Arirang.

(2) The patient then learnt how to play the modified melodic line with his non-

affected hand according to the finger numbers in a consecutive pattern.

(3) The therapist then provided chordal accompaniment on the lower register of

the keyboard. In this duet performance, the therapist utilized some

improvisation techniques, such as matching, accompanying, and grounding to

facilitate the patient‟s playing more creatively and spontaneously.

61

Figure 3.9 Arirang: melody exercise ⓒ So-Young Moon, 2007

Figure 3.10 Arirang: original version ⓒ So-Young Moon, 2007

62

3.5.3 The therapeutic relationship

Piano-playing music therapy differs from piano lessons (provided by a piano teacher),

due to the therapeutic relationship that is developed between the patients and the

therapist. The roles of the therapist based on the therapeutic relationship are described

as:

(1) Building rapport and maintaining a therapeutic presence

(2) Understanding the patient‟s clinical needs

(3) Assessing the patient‟s abilities

(4) Assessing the patient‟s challenges and potentials (Grocke & Wigram, 2007;

Hanser, 1999)

(1) Building rapport and maintaining a therapeutic presence

It was achieved by listening attentively to the patient (particularly if he or she

had speech problems resulting from the stroke), being comfortable in silences, and

rewarding effort rather than working toward a perfect performance (Grocke & Wigram,

2007).

In rehabilitation program settings, if a therapist maintains an attitude of

„empathetic understanding‟ and „affirmative respect‟ for a patient‟s situation, then the

patient tends to display active participation in rehabilitation training. This postulate is

based on human beings‟ inter-personal tendencies. An empathetic understanding is when

the therapist tries to put herself in the patient‟s shoes to see things from his perspective

in order to better understand the patient (Rogers, 1959). Through empathetic

understanding, the music therapist may also be able to analyze what the patient

expresses. To show an affirmative respect to the patient means always maintaining a

sense of unconditional acceptance and an uncritical attitude. In the application of

patient-centered therapy in a rehabilitation setting, the therapist‟s own evaluation and

purpose is less of an influence on the direction of the therapy than what the patient

wants to do. As the patient searches his own problem and discovers how to solve the

problem, the therapist exists as only an assistant to help it (Moon, 2000).

(2) Understanding the patient‟s clinical needs

The music therapy piano-playing protocol differs from piano teaching in that

the music therapist understands the patient‟s needs. In this study the music therapist-

researcher had studied the types of stroke and the outcomes (see literature review for the

overview of different types of stroke), and she had studied music therapy approaches in

63

working with stroke, as discussed the literature but also from her clinical experience of

working with people who have stroke and ABI (Moon, 2000).

(3) Assessing the patient‟s abilities

The music therapist-researcher assessed each patient‟s level of skill at the start of

each session, drawing on experience in observing aspects such as degree of tiredness,

whether speech production was intelligible or not, and the general energy level of the

patient. Based on this assessment, the research then introduced the exercises in a

manner that best enabled the patient to participate, for example allowing time for the

person to respond according to their level of physical energy.

(4) Assessing the patient‟s challenges and potentials

The assessment of challenges and potentials is different from 3) above, in that

the therapist must make an experienced assessment of how much the patient can

progress in the session, and at what pace the patient might progress. If the music

therapist-researcher expected too much, the patient may become discouraged. If the

music therapist-researcher did not expect enough, then the patient may not be motivated

enough to complete the exercises.

In these four aspects the music therapy piano-playing protocol differs from

piano lessons given by a piano teacher.

64

3.6 Outcome measurements

In order to collect comprehensive data, multiple measurements were made across a

broad range of clinical outcomes. These included specification of the primary and

secondary outcome variables. “In practice, a single outcome measurement will rarely be

adequate to assess the risks, costs and diverse benefits that may arise from the use of a

new intervention (Peat, 2001, p. 86)”.

For the purpose of this study, two different types of data analysis were

completed on the outcome measurements: (1) Primary outcome measurement: MIDI

analysis, and (2) Secondary outcome measurement: 5-Point scale analysis.

3.6.1 Primary outcome measurement: MIDI analysis

The primary outcome analysis was conducted using the electronic system, Musical

Instrument Digital Interface (MIDI). The raw MIDI data provided three key elements:

(1) A reading on the pitch by number and name

(2) A reading on temporal key events by its own clock time

(3) A reading on velocity of key descent by defined units ranging from 1 to 127

The three major sets of raw data were exported from the MIDI event list, then

transferred to a PDF file format. In order to conduct the statistical analysis, the raw data

were then exported from PDF to MS Excel files.

3.6.2 Secondary outcome measurement: 5-Point Scale measurement

Based on the raw MIDI data representation, the secondary outcome analysis was carried

out using 5-point scale measurement by a panel of three raters. The raw 5-point scale

data provided a rating of five units ranging from 1 (none, 0% of performance) to 5

(good, more than 75% of performance). This scale was developed by the researcher for

this study purpose. The measurement is an English translation of the scale which was

originally in Korean for the clinical study. The 5-point scale is shown on the following

page.

65

FIVE-POINT SCALE

Rater Name ______________ Date ______________

Participant Code __________ Task No. ___________

Instruction: Please place a mark on the column below to rate the level of performance

that you have observed.

Parameter 1 Timing consistency in unilateral finger movements

1 2 3 4 5

None

(0%)

Poor

(<25%)

Sub-average

(<50%)

Fair

(50~75%)

Good

(75%>)

Parameter 2 Velocity evenness in unilateral finger movements

1 2 3 4 5

None

(0%)

Poor

(<25%)

Sub-average

(<50%)

Fair

(50~75%)

Good

(75%>)

Parameter 3 Accuracy of key striking in unilateral finger movements

1 2 3 4 5

None

(0%)

Poor

(<25%)

Sub-average

(<50%)

Fair

(50~75%)

Good

(75%>)

Parameter 4 Stability of two-key striking in bilateral finger movements

1 2 3 4 5

None

(0%)

Poor

(<25%)

Sub-average

(<50%)

Fair

(50~75%)

Good

(75%>)

66

3.7 Outcome variables

3.7.1 Four outcome variables

Corresponding to the two types of outcome measurements, four outcome variables were

made for the purpose of the study:

(1) Timing consistency

(2) Velocity evenness

(3) Accuracy of key striking

(4) Stability of synchronizing 2-key striking

A definition of each outcome variable and its rationale for data analysis are

explained in the following sections with relevant figures.

67

3.7.1.1 Timing Consistency (TC)

Consistency of timing, for the purpose of this study, refers to the condition of keeping a

steady pace for key striking. This is measured by calculating the standard deviation of

each key length (duration).

Midi Data Rater’s 5-scale evaluation

Standard Deviation of each key striking

Duration of 1 key

Score of parameter 1. Timing consistency

(TC)

Figure 3.11 Interpretation of data analysis for timing consistency

68

3.7.1.2 Velocity Evenness (VE)

Evenness of velocity, for the purpose of this study, refers to the condition of keeping a

steady dynamic rate for key striking. This is measured by calculating the standard

deviation of each key velocity.

Figure 3.12 Interpretation of data analysis for velocity evenness

69

3.7.1.3 Accuracy of Key Striking (AK)

Accuracy of key striking, for the purpose of this study, refers to the degree of accuracy,

based on correct finger positioning. This indicates how accurately the patients executed

their finger movements in the required tasks.

Midi Data Rater’s 5-scale evaluation

Total

Nos.of key

strokes

1

2 Nos. of mistakes

Score of parameter 3. Accuracy of key

striking (AK)

Figure 3.13 Interpretation of data analysis for accuracy of key striking

70

3.7.1.4 Stability of Two-Key Striking in a Synchronized Pattern (SS)

Stability of synchronizing two-key striking, for the purpose of this study, refers to the

degree of duration evenness and velocity evenness between the two keys. It is measured

by calculating the standard deviation of each key time length (duration) and velocity.

Figure 3.14 Interpretation of data analysis for stability of two-key striking

71

3.8 Statistical methods

3.8.1 Analysis of comparison between the treatment and control groups

The Wilcoxon signed-rank test (also called 2-sample related Wilcox test) was used to

analyze differences between the treatment group and the control group in the study. This

is a non-parametric alternative to the paired two-sample t-test. It is used in those

situations in which the data are paired and the differences are mutually independent.

However, it does not require assumptions about the form of a normal distribution

(Siegel, 1956).

3.8.2 Analysis of comparison between the pre- and post-tests in the groups

The 2-independent Mann-Whitney test was adopted to analyze differences between the

pre-tests and the post-tests in each group of the study. This is a non-parametric analog

for assessing whether two samples of data come from the same distribution. It is used

primarily when the data have not met the assumption of normality given small sample

sizes. It requires the two samples to be independent and the situations to be repeated

measurements. Generally, this test is appropriate in analyzing differences in medians

with equal variances (Conover, 1998).

3.8.3 Summary of outcome analysis set

The outcome analysis set for hypothesis 1 is summarized in Table 3.7. This set includes

relevant task numbers and outcome variables and the type of comparisons, for example

(1) between treatment group and control group (BG), (2) between pre- and post-tests in

treatment group (TG), and (3) between pre- and post-tests in control group (CG). For

the comparison between treatment and control groups, the Wilcoxon signed-rank test

was used in both the MIDI and the 5-point scale analysis. The 2-independent Mann-

Whitney test was adopted to analyze differences between the pre-tests and the post-tests

in each group of the study. It should be noted that the outcome variable of accuracy of

key striking for the MIDI data was analyzed using descriptive statistical methods. This

was due to the fact that the data could not be transformed from MIDI to Excel format

for analysis.

72

Table 3.7 Outcome analysis set of hypothesis 1

Hypothesis Task Outcome

variable

Comparison MIDI 5-Point

H1 T1~T2 TC BG Mann-Whitney Mann-Whitney

TG Wilcoxon Wilcoxon

CG Wilcoxon Wilcoxon

VE BG Mann-Whitney Mann-Whitney


CG Wilcoxon Wilcoxon

AK BG Descriptive Mann-Whitney

TG Descriptive Wilcoxon

CG Descriptive Wilcoxon



variable


H2 T3~T4 TC BG Descriptive Mann-Whitney



VE BG Descriptive Mann-Whitney



AK BG Descriptive Mann-Whitney



Table 3.8 shows the summary of outcome analysis set for hypothesis 2. The same

statistical methods were adopted for analyzing data from the 5-point scale results,

whereas only the Wilcoxon signed-rank test was available for MIDI results comparing

the differences between the pre-tests and the post-tests in the treatment group, due to the

mechanical limitation of data exporting and transforming process as explained at Table

3.7.

73



variable


H3

T5~T7

TC BG N/A Descriptive


CG N/A Descriptive

VE BG N/A Descriptive


CG N/A Descriptive

AK BG N/A Descriptive


SS

CG

BG

TG

CG

N/A

N/A

Descriptive

N/A

Descriptive

Descriptive

Wilcoxon

Descriptive

Table 3.9 presents the summary of the outcome analysis set for hypothesis 3. It should

be noted that only the Wilcoxon signed-rank test was adopted for analyzing data from

the 5-point scale results comparing the differences between the pre-tests and the post-

tests in the treatment group, due to the inconsistencies of level of task completion in the

control group. Within the mechanical limitation of the data exporting and transforming

process, descriptive statistics were used to analyze the comparison between the pre-tests

and the post-tests in the treatment group immediately after the music therapy

interventions.

3.9 Summary of Method

In summary, this chapter explained the method of the study, including the music therapy

research design, its underlying rationale and the process of research conduct. Following

this, a description of participants and clinical settings including MIDI apparatus were

presented. The music therapy intervention, comprising five steps of the therapy protocol

was described with relevant figures and scores. For the purpose of research analysis,

outcome measurements and outcome variables were explained, including statistical

analysis methods. In the next chapter, the results of the study will be presented.

74

CHAPTER 4

RESULTS

This chapter presents the results of the data regarding the effects of the piano-playing

music therapy intervention for the treatment group compared with the control group.

First, the hypotheses are re-stated with the definition of the outcome variables. Next, a

description of the database design is presented with an explanation of how the MIDI

results are shown in the Tables. Following this, the results of inter-rater reliability are

provided, and the characteristic of the participants outlined. The results, corresponding

to the proposed research hypotheses, are then reported under the following

categorization: (1) comparison of the outcome variables between the treatment and

control groups, (2) comparison of the outcome variables between pre- and post-tests in

treatment group and control group, and (3) comparison of the effects of music therapy

intervention in one individual case to demonstrate how the MIDI data was illustrated

graphically.

4.1 Analyzing the data

The three major hypotheses and definitions of outcome variables are briefly restated

here as the database design refers to them.

Hypothesis 1: Piano-playing music therapy will improve unilateral coordination

of finger movements in the non-affected hands of chronic stroke patients.



stroke patients.



patients.



patients.

Hypothesis 2: Piano-playing music therapy will improve unilateral coordination

of finger movements in the affected hands of chronic stroke patients.

75



patients.



patients.



patients.

Hypothesis 3: Piano-playing music therapy will improve bilateral coordination

of finger movements in chronic stroke patients.









patients.

Definitions of the outcome variables are presented in Table 4.1.

Table 4.1 Definitions of the outcome variables

Outcome variables Operative definitions

Timing consistency Condition of keeping a steady pace for key striking

Velocity evenness Condition of keeping a steady dynamic rate for key

striking

Accuracy of key striking Degree of accuracy in key striking

Stability of synchronizing

2-key strike

Degree of duration evenness and velocity evenness

between two keys played in succession

76

4.1.1 Database design for primary outcome analysis: A MIDI-based analysis

For the primary outcome analysis, a database was designed to include data type and

coding to identify sub-categories of the outcome variables. The data type and data

coding method were pre-determined prior to data entry. In Table 4.2, the first column

indicates either treatment group (TG) or control group (CG). The second column

represents consenting patients, coded numerically. Column three shows the type of test

is defined as either pre-test (Pre) or post-test (Post). Columns 4~11, present data from

each outcome variable, categorized under the sub-division of task type, ranging from 1

to 7 (T1-T7). Tasks 5~7 include additional columns with data from left hand (LH) and

right hand (RH), where the tasks involve bilateral finger movements. A statistical

consultant conducted the data entry procedure, and then it was double-checked by the

researcher to identify any missing information and inconsistencies in data entry.

Table 4.2 Database for MIDI: Outcome variable 1, Timing consistency

Group Patient Test 1.TC

Contents Stdevs of time length of each stroke

Task no. T1 T2 T3 T4 T5 T6 T7

Hand LH RH LH RH LH RH

TG 1 Pre 410.2 13328.7

TG 1 Post 76.0 131.3

TG 2 Pre 141.6 1654.8 911.0 2741.7 2686.9 479.4 2795.9 1693.3

TG 2 Post 76.2 463.3 51.0 587.9 77.0 93.6 79.5 421.6 2121.4 555.6

TG 3 Pre 36.5 220.6 86.6 395.0 52.8 36.0 85.2 51.4

TG 3 Post 30.3 471.2 64.7 1086.7 65.7 23.4 101.2 97.0 653.9 1320.9

TG 4 Pre 40.7 191.1 48.5 2632.5 39.3 57.7 93.5 101.1

TG 4 Post 118.4 918.9 52.4 397.4 57.2 175.3 70.8 208.7

TG 5 Pre 5694.7 1618.4

TG 5 Post 104.9 173.1

TG 6 Pre 130.4 527.0 355.3 855.1 285.3 435.0 347.9 336.1 913.1 1161.4

TG 6 Post 53.5 179.3 78.8 155.2 112.2 65.3 117.4 109.6 224.7 374.0

TG 7 Pre 89.8 325.0

TG 7 Post 83.9 252.3

TG 8 Pre 68.2 2179.3 49.2 592.3 327.4 53.0 3846.9 188.2 3729.4 1728.4

TG 8 Post 69.9 355.1 135.8 173.1 55.3 50.5 119.4 93.8 1131.7 599.8

TG 9 Pre 38.1 1735.4

77

TG 9 Post 89.6 420.7

CG 11 Pre 452.9 2051.1

CG 11 Post 443.2 2642.7

CG 12 Pre 292.4 672.1 97.5 469.3

CG 12 Post 169.5 1682.7 61.7 462.5

CG 13 Pre 208.4 181.2 702.7

CG 13 Post 35.7 158.1 188.9

CG 14 Pre 30.5 353.7

CG 14 Post 10.3 340.1

CG 15 Pre 44.2 233.9

CG 15 Post 23.6 612.5

CG 16 Pre 270.6 215.0

CG 16 Post 143.0 530.5

CG 17 Pre 40.9 323.8 44.4 106.9

CG 17 Post 51.1 544.7 61.3 130.1

Table 4.2 describes the MIDI database analysis of outcome variable 1, Timing

consistency. The numeric data for timing consistency was measured by calculating the

standard deviation of time length for each key striking. It should be noted that the

vacant columns indicate those participants who were unable to attempt the task due to

their functional limitations. Where the incomplete data affected the outcome analysis,

descriptive analysis was used to compare the groups and participants (See Chapter 3,

Table 3.7~3.9), using the 5-Point scale. Raters gave a score, „1‟ to refer to the task „not

done‟ (See Table 4.6).

78

Table 4.3 Database for MIDI: Outcome variable 2, Velocity Evenness

Group Patient Test 2.VE

Contents Stdevs of velocity of each stroke


Hand LH RH LH RH LH RH

TG 1 Pre 30 34

TG 1 Post 9.8 24

TG 2 Pre 5.6 28 16 29 19 10 39 19

TG 2 Post 7.8 19 5.2 11 9.8 7.3 4 7.7 28 21

TG 3 Pre 6.4 38 14 35 12 5.3 10 2.6

TG 3 Post 1.7 22 9 19 14 2.1 14 4 30 37

TG 4 Pre 11 26 15 36 10 21 10 17

TG 4 Post 7 29 7.1 21 13 18 6.5 17

TG 5 Pre 24 44

TG 5 Post 1.9 3.2

TG 6 Pre 7.2 27 22 30 17 17 20 13 34 32

TG 6 Post 10 11 6 19 17 12 15 5.8 21 19

TG 7 Pre 10 22

TG 7 Post 10 13

TG 8 Pre 4.5 8.5 8.5 5.4 13 13 20 15 12 11

TG 8 Post 4.1 5 8.7 4.9 5.6 7.2 11 10 4.7 4.2

TG 9 Pre 5.4 13

TG 9 Post 4.3 5.2

CG 11 Pre 22 25

CG 11 Post 26 34

CG 12 Pre 22 29 19 20

CG 12 Post 24 26 7.9 25

CG 13 Pre 21 20 32

CG 13 Post 6.6 17 21

CG 14 Pre 13 31

CG 14 Post 7.2 34

CG 15 Pre 9.5 16

CG 15 Post 5.4 24

CG 16 Pre 11 19

CG 16 Post 10 26

CG 17 Pre 11 26 22 21

79

CG 17 Post 5.5 27 10 27

Table 4.3 describes the MIDI database analysis of outcome variable 2, Velocity

evenness. The numeric data for velocity evenness was measured by calculating the

standard deviation of velocity of each key striking.

80

Table 4.4 Database for MIDI: Outcome variable 3, Accuracy of Key striking

Group Patient Contents 3.AK


Total no. of

Key strokes 30 25 30 25 60 60 50

No. of wrong-key strokes

TG 1 Pre 3 2

TG 1 Post 0 0

TG 2 Pre 0 2 1 1 3 9

TG 2 Post 0 0 0 0 0 0 1

TG 3 Pre 0 1 0 0 0 0

TG 3 Post 0 0 0 0 0 0 0

TG 4 Pre 0 0 0 0 0 0

TG 4 Post 0 0 0 0 0 1

TG 5 Pre 4 16

TG 5 Post 0 0

TG 6 Pre 0 1 4 6 4 8 10

TG 6 Post 0 0 0 0 0 2 0

TG 7 Pre 0 0

TG 7 Post 0 0

TG 8 Pre 0 1 0 0 2 9 12

TG 8 Post 0 0 0 0 0 1 0

TG 9 Pre 0 5

TG 9 Post 0 0

CG 11 Pre 0 0

CG 11 Post 2 11

CG 12 Pre 15 6 2 3

CG 12 Post 2 1 0 0

CG 13 Pre 0 0 14

CG 13 Post 0 1 5

CG 14 Pre 0 0

CG 14 Post 0 0

CG 15 Pre 0 0

CG 15 Post 0 0

CG 16 Pre 0 0

CG 16 Post 0 0

81

CG 17 Pre 0 4 1 1

CG 17 Post 0 2 0 0

Table 4.4 describes the MIDI database analysis of outcome variable 3, Accuracy of key

striking. The numeric data for accuracy of key striking was measured by calculating the

number of mistakes on each required key striking.

82

Table 4.5 Database for MIDI: Outcome variable 4, Stability of Synchronizing two-keys

Group Patient Test 4.SS

Contents Dura E. Velo E DE VE DE VE

Task no. T5 T6 T7

Hand

TG 1 Pre

TG 1 Post

TG 2 Pre 25.2 13.7 1070.2 9.2

TG 2 Post 60.1 9.5 1088.5 6.9 31.4 25.0

TG 3 Pre 134.7 31.5 837.3 16.6

TG 3 Post 204.9 35.3 657.1 21.8 617.4 26.7

TG 4 Pre 79.4 31.9 603.1 34.3

TG 4 Post 109.8 48.0 1026.1 18.5

TG 5 Pre

TG 5 Post

TG 6 Pre 115.6 31.3 1185.1 32.3 333.0 30.9

TG 6 Post 29.5 25.3 703.4 18.8 146.3 23.3

TG 7 Pre

TG 7 Post

TG 8 Pre 87.2 16.8 990.3 23.2 275.1 12.7

TG 8 Post 88.2 12.6 775.1 21.5 222.1 4.3

TG 9 Pre

TG 9 Post

Table 4.5 describes the MIDI database analysis of outcome variable 4, Stability of two-

key striking in a synchronizing pattern. The numeric data for stability of two-key

striking was measured by calculating the standard deviation of time length of each key

striking and the standard deviation of velocity of each key striking. The outcome

variable of stability of two-key striking corresponds with bilateral tasks (from task 5 to

7) and the fourth column of the database includes data from duration evenness (DE) and

velocity evenness (VE). The data was only obtained from the treatment group as the

control group participants did not complete this task.

83

4.1.2 Database design for secondary outcome analysis: 5-Point scale assessment

For the secondary outcome analysis, a database was designed to include data type,

participant coding and the three independent assessors‟ evaluation of the sub-categories

of the independent variables. The data type and data coding method were pre-

determined prior to data entry. In Table 4.6 and 4.7, the first column identifies either

treatment group (TG) or control group (CG). The second column represents consenting

patients coded numerically. Next, the type of test is defined as either pre-test (Pre) or

post-test (Post). Following this, data from each outcome variable is categorized under

sub-division of task type ranging from 1 to 7. In the fifth column, the members of the

panel of three raters are indicated using their family names. Then, the four outcome

variables are shown in the order of timing consistency (TC), velocity evenness (VE),

accuracy of key striking (AK), and stability of synchronizing two-keys (SS). Each

variable is numerically rated in a range of 1 to 5. Lastly, the level of task completion is

depicted either „done‟ or „not done‟ in the database design. The following Table 4.6

shows an excerpt of a 5-Point Scale database for analysis of treatment group.

Table 4.6 Database for 5-Point scale:

Treatment group (excerpts)

Group Patient Test Task_No Rater TC VC AK SS Completion

TG 1 pre T1 Lim 2 2 2 Done

TG 1 post T1 Lim 5 5 5 Done



TG 1 pre T3 Lim 1 1 1 Not done


TG 1 pre T4 Lim 1 1 1 Not done

TG 1 post T4 Lim 1 1 1 Not done

TG 1 pre T5 Lim 1 1 1 1 Not done

TG 1 post T5 Lim 1 1 1 1 Not done







84







TG 2 pre T5 Lim 5 3 3 3 Done

TG 2 post T5 Lim 5 4 4 4 Done

TG 2 pre T6 Lim 4 5 5 4 Done




The following Table 4.7 shows an excerpt of a 5-Point Scale database analysis

of the control group. A statistical consultant conducted the data entry procedure, and

then it was double-checked by the researcher to identify any contaminated data, missing

information and inconsistencies in data entry.

85

Table 4.7 Database for 5-Point scale: Control group (excerpts)

Group Patient Test Task_No Rater TC VC AK SS Completion

CG 11 pre T1 Lim 4 3 5 Done

CG 11 post T1 Lim 5 4 5 Done



CG 11 pre T3 Lim 1 1 1 Not done

CG 11 post T3 Lim 1 1 1 Not done

CG 11 pre T4 Lim 1 1 1 Not done

CG 11 post T4 Lim 1 1 1 Not done

CG 11 pre T5 Lim 1 1 1 1 Not done

CG 11 post T5 Lim 1 1 1 1 Not done



















86

4.2 Report of the results

4.2.1 Inter-rater reliability

Inter-rater reliability was calculated for the 5-Point scale analysis. A panel of three

clinicians executed the 5-Point scale assessments across the tests with 16 participants.

VAR00001 to VAR00003 refers to the three raters. The following Table 4.8 shows the

results of Pearson‟s correlation between the three raters on the scores of timing

consistency. Table 4.8 shows that a statistically significant inter-rater reliability was

achieved between all raters, with correlation levels of .000 for all cases.

Table 4.8 Inter-Rater Reliability:

5-Point Scale for the outcome variable 1, Timing Consistency

Correlations

VAR0000

1

VAR0000

2

VAR0000

3

VAR00001 Pearson

Correlation 1 .956(**) .926(**)

Sig. (2-tailed) . .000 .000

N 223 222 223

VAR00002 Pearson

Correlation .956(**) 1 .947(**)

Sig. (2-tailed) .000 . .000

N 222 222 222

VAR00003 Pearson

Correlation .926(**) .947(**) 1

Sig. (2-tailed) .000 .000 .

N 223 222 223

** Correlation is significant at the 0.01 level (2-tailed).

Note: 3 raters (Var1~3), N (16 subjects* 7 tasks* 2 tests=224)

87


5-Point Scale for the outcome variable 2, Velocity Evenness

Correlations

VAR0000

1

VAR0000

2

VAR0000

3

VAR00001 Pearson

Correlation 1 .929(**) .921(**)

Sig. (2-tailed) . .000 .000

N 223 223 223

VAR00002 Pearson

Correlation .929(**) 1 .937(**)

Sig. (2-tailed) .000 . .000

N 223 223 223

VAR00003 Pearson

Correlation .921(**) .937(**) 1

Sig. (2-tailed) .000 .000 .

N 223 223 223



Table 4.9 indicates the results of Pearson‟s correlation between the three raters

on the scores of velocity evenness. As observed in Table 4.8, there is a similar

correlation tendency, and statistically significant inter-rater reliability was achieved

between all raters, with correlation levels of .000 for all cases.

88


5-Point Scale for the outcome variable 3, Accuracy of Key striking

Correlations

VAR0000

1

VAR0000

2

VAR0000

3

VAR00001 Pearson

Correlation 1 .964(**) .948(**)

Sig. (2-tailed) . .000 .000

N 223 223 223

VAR00002 Pearson

Correlation .964(**) 1 .944(**)

Sig. (2-tailed) .000 . .000

N 223 223 223

VAR00003 Pearson

Correlation .948(**) .944(**) 1

Sig. (2-tailed) .000 .000 .

N 223 223 223



Table 4.10 indicates the results of Pearson‟s correlation between the three raters

on the scores of parameter 3, accuracy of key striking. As observed in Table 4.9, there is

a similar correlation tendency and a statistically significant inter-rater reliability was

achieved between all raters, with correlation levels of .000 for all cases. The scores of

Pearson‟s correlation between the raters were even higher than the previous results on

Table 4.8 and 4.9.

89


5-Point Scale for the outcome variable 4, Stability of Synchronizing Two-key striking

Correlations

VAR0000

1

VAR0000

2

VAR0000

3

VAR00001 Pearson

Correlation 1 .968(**) .942(**)

Sig. (2-tailed) . .000 .000

N 95 95 95

VAR00002 Pearson

Correlation .968(**) 1 .966(**)

Sig. (2-tailed) .000 . .000

N 95 95 95

VAR00003 Pearson

Correlation .942(**) .966(**) 1

Sig. (2-tailed) .000 .000 .

N 95 95 95


3 raters (Var1~3), N (16 subjects* 3 tasks* 2 tests=96)

Table 4.11 presents the results of Pearson‟s correlation between the three raters

on the scores of parameter 4, stability of synchronizing 2-key striking. Again, there is a

similar correlation tendency and a statistically significant inter-rater reliability was

achieved between all raters, with correlation levels of .000 for all cases.

In the following section, the results of the percentage agreements between the

raters on the 5-Point scale are presented. Each figure corresponds to the individual

parameters.

90

% Agreement between Raters on the 5-Point scale TC parameter

60

35

5

0

10

20

30

40

50

60

70

all the same two same but 1 different all different

% % agreement

Figure 4.1 Percentage of agreement between the raters on the 5-Point scale for

parameter 1, Timing consistency

Figure 4.1 shows the results of the percentage of agreement between the raters

on timing consistency (outcome variable 1). Out of the total number of 223 test cases,

all raters gave the same scores in 134 cases (60% all the same). For 78 cases, two raters

agreed on the same scores but one rater gave a different score (35% two the same, but

one different). All raters marked different scores in only 11 cases (indicating 5% all

different).

91

% Agreement between Raters on the 5-Point scale VE parameter

59

35

6

0

10

20

30

40

50

60

70


% % agreement


parameter 2, Velocity evenness


on velocity evenness (outcome variable 2). A very similar trend was observed between

Figure 4.1 and 4.2. Out of the total number of 223 test cases, all raters gave the same

scores in 132 cases (59% all the same). For 78 cases, two raters gave the same scores

but one rater gave a different score (35% two the same, but one different). All raters

marked different scores in only 13 cases (indicating 6% all different).

92

% Agreement between Raters on the 5-Point scale AK parameter

63

31

6

0

10

20

30

40

50

60

70


% % agreement


parameter 3, Accuracy of key striking


on accuracy of key striking (outcome variable 3). Out of the total number of 223 test

cases, all raters gave the same scores in 141 cases (60% all the same). Compared to

timing consistency (outcome variable 1) and velocity evenness (outcome variable 2), the

100% agreement between the raters was slightly higher in accuracy of key striking. For

69 cases, two raters gave the same scores but one rater gave a different score (31% two

same but one different). All raters marked different scores in only 13 cases (indicating

6% all different).

93

% Agreement between Raters on the 5-Point scale SS parameter

81

14

5

0

10

20

30

40

50

60

70

80

90


% % agreement


parameter 4, Stability of synchronizing 2-key striking


on stability of synchronizing 2-key striking (outcome variable 4). Out of the total

number of 95 test cases, all raters gave the same scores in 77 cases (81% all the same).

For 13 cases, two raters gave the same scores but one rater gave a different score (14%

two the same, but one different). All raters marked different scores in only 5 cases (5%

all different).

In summary, a very high inter-rater reliability was achieved between all raters

on all four parameters.

94

4.2.2 Participants

Twenty participants met the criteria for inclusion in this research and consented to take

part in the study. Table 4.12 reproduces the general characteristics of the participants

who were allocated to the treatment group.

Table 4.12 General characteristics of the participants in the treatment group

Participant Age

(years)

Gender Hemiplegic

site


(months)

Handed-

ness



3 77 M Left Infarct * Right

4 77 F Right Infarct * Right



7 81 M Right Hemorrhage 46 Right

8 66 M Right Infarct 20 Right


10*** * F Right * * Right



*** Participant withdrawn from the study

95

Table 4.13 General characteristics of the participants in the control group

Participant Age

(years)

Gender Hemiplegic

site


(months)

Handedness

11 78 F Right Infarct 13 Right

12 76 M Left * 124 Right






18*** 84 F Left * 52 Right

19*** 65 F Right Hemorrhage 29 Right

20*** 80 F Right * 40 Right



*** Participant withdrawn from the study

Table 4.13 shows the general characteristics of the participants in the control

group. Four participants (one for treatment group, three for control group) were

withdrawn from the study with the following reasons: misdiagnosis, transferring to

another facility, incidence of death, or complaint due to headache.

96

Table 4.14 Comparison of the general characteristics in the treatment and control groups

Characteristics Treatment group Control group

Participant N=10 N=10

Age (year) Mean=73.33 Mean=72.4

Gender F=4, M=6 F=7, M=3

Withdrawal N=1 N=3

Hemiplegic site Left=6, Right=4 Left=6, Right=4

Stroke type* H=2, I=5, NC=3 H=3, I=4, NC=3

Duration (month)

Handedness

Mean=39.29

Left=0, Right=10

Mean=39.62**

Left=0, Right=10

Note: * Stroke type: H=Hemorrhage, I=Infarct, NC=Not Classified

** Outliers removed

Table 4.14 indicates the comparison of the general characteristics between the

treatment group and control group. From the demographic information, the number of

the participants was evenly divided. However, gender distribution was not evenly

matched between the groups. The means of age and duration from the stroke onset and

the type of stroke were well matched between the groups when the outliers were

removed. The hemiplegic site and handedness were exactly matched between the groups.

The incidence of withdrawal was slightly higher in the control group. Overall, the two

groups were fairly matched in demographic information.

97

4.2.3 Hypothesis 1

With reference to the research hypotheses, a large proportion of the results are reported

in the following section. Each hypothesis has sub-hypotheses referring to the outcome

variables. The four major hypotheses and their sub-hypotheses are briefly restated with

the results of primary and secondary outcome analysis.

In order to present the results in an efficient manner, the MIDI analysis and the

5-Point scale analysis will be described together for each hypothesis and sub-hypothesis.

Hypothesis 1 Piano-playing music therapy will improve unilateral coordination of


4.2.3.1 Hypothesis 1-1

Hypothesis 1-1 Piano-playing music therapy will improve timing consistency of finger

movements in the non-affected hands of chronic stroke patients.

The outcome variable 1, timing consistency was measured by the two different types of

data analysis: (1) MIDI as a primary outcome measurement and (2) the 5-point scale as

a secondary outcome measurement. Table 4.15 provides the results of the data analysis

under the following comparisons: (1) comparison between the treatment group and the

control group, (2) comparison between pre-test and post-test in the treatment group, and

(3) comparison between pre-test and post-test in the control group. See Appendix 6.6 for

the raw data of group comparisons.

Table 4.15 Hypothesis 1-1 Results of task 1: Non-affected hand index finger tapping

Outcome variable 1, Timing consistency

Comparison MIDI 5-Point scale

Z score P (1-tailed)* Z score P (1-tailed)*

Between groups -0.582 .303 -0.806 .225

Treatment group: pre & post -1.244 .125 -2.677 .003

Control group: pre & post -2.028 .0215 -2.232 .016

* Exact Sig. P (1-tailed)

Based on Table 4.15, there is not enough evidence to reject the hypothesis 1-1

due to the inconsistent ranges of p-values in each comparison. However, the comparison

between pre-test and post-test in the treatment group by 5-point scale shows statistically

significant improvements (Exact Sig. P= .003).

98

Table 4.16 Hypothesis 1-1 Results of task 2: Non-affected hand 5-finger sequential

playing




Between groups -2.170 .016 -2.984 .001




In Table 4.16, statistically significant outcomes were obtained on the

comparison between the groups (P= .016 in MIDI and P= .001 in 5-point scale) and on

the comparison between the tests in the treatment group (P= .027 in MIDI and P= .004

in 5-point scale). This suggests that the hypothesis 1-1 within task 2 of non-affected

hand 5-finger sequential playing is accepted.

Overall, the results from the group comparisons of task 1 and 2 support

hypothesis 1-1: piano-playing music therapy will improve timing consistency of finger



Hypothesis 1-2 Piano-playing music therapy will improve velocity evenness of finger


The following table describes the results from outcome variable 2, velocity evenness

based on MIDI and 5-Point analysis.

99


Outcome variable 2, Velocity evenness



Between groups -0.053 .500 -1.385 .089




In the above Table 4.17, the calculated p-values from the MIDI analysis exceed

0.05. On the contrary, the p-value from 5-Point scale in the comparison between pre-test

and post-test in the treatment group (P= .004) is less than the significance level of 0.05

indicating significant differences after the music therapy interventions. It should be

noted that there are conflicting p-values between the two different types of data analysis.

The reason why this occurs is further described in Chapter 5, Discussion.


playing




Between groups -2.913 .001 -1.066 .153




Table 4.18 shows statistically significant differences in the comparison between

the groups (P= .001 in MIDI) and the comparison between the tests in the treatment

group (P= .004 in MIDI and 5-point scale), and thus the hypothesis 1-2: piano-playing

music therapy will improve velocity evenness of finger movement in the non-affected

hand of chronic stroke patients is accepted.

100


Hypothesis 1-3 Piano-playing music therapy will improve accuracy of key striking of


Referring to the outcome variable 3, accuracy of key striking, a statistical hypothesis

testing was carried out using secondary outcome analysis based on the 5-Point scale

data.


Outcome variable 3, Accuracy of key striking

Comparison 5-Point scale

Z score P (1-tailed)*

Between groups -0.219 .426

Treatment group: pre & post -2.207 .016

Control group: pre & post -2.264 .016


Table 4.19 presents the p-values of task 1 on outcome variable 3, indicating

statistical significance in the comparison of pre-test and post-test in the treatment group

(P= .016). It is interesting to note that the control group also shows statistical

differences between the tests. This outcome may be attributed to a task repetition factor.


playing








101

In Table 4.20, it is very obvious that the comparison between the groups shows

statistically significant differences (P= .001). Similar statistical significance was also

obtained in the comparison of pre-test and post-test in the treatment group (P= .004)

whereas there was no statistical significance in the control group (P= .391). Overall, the

results from the group comparisons of task 1 and 2 support hypothesis 1-3: piano-

playing music therapy will improve accuracy of key-striking of finger movements in the

non-affected hands of chronic stroke patients.

In summary, statistical significance was achieved in the data to support the sub-

hypotheses, and thus the proposed hypothesis 1: piano-playing music therapy will

improve unilateral coordination of finger movement in the non-affected hands of

chronic stroke patients is accepted.

102

4.2.4 Hypothesis 2

Hypothesis 2 has three sub-hypotheses referring to the outcome variables. These are

briefly restated here with the results of primary and secondary outcome analysis.





movements in the affected hands of chronic stroke patients.

The outcome variable 1, timing consistency was measured by MIDI and 5-Point scale

analysis. From Table 4.21 to Table 4.24, it should be noted that the MIDI data from

between groups and control group comparison were analyzed using descriptive

statistical methods. See the following section of 4.2.6 Results of group comparison:

descriptive analysis.

Table 4.21 Hypothesis 2-1 Results of task 3: Affected hand index finger tapping




Between groups Descriptive -2.670 .003


Control group: pre & post Descriptive -1.633 .125


Table 4.22 Hypothesis 2-1 Results of task 4: Affected hand 5-finger sequential playing








103

A similar trend was observed in Table 4.21 and 4.22. In the comparisons of

treatment group and control group, statistically significant results were obtained from

the 5-Point scale (P= .003, P= .029). The p-values of comparisons between pre- and

post-tests in the treatment group were also statistically significant (P= .002, P= .031)

whereas there was no statistical differences in the control group. Overall, the results

from Table 4.21 and 4.22 support the hypothesis 2-1: piano playing music therapy will

improve timing consistency of finger movements in the affected hands of chronic stroke

patients.




The following Table 4.23 and 4.24 present the results from outcome variable 2, velocity

evenness based on MIDI and the 5-Point analysis.

















104

As depicted in Table 4.23 and 4.24, the results of comparison between the

treatment and control group present statistical significance providing p-value of .030 in

the 5-Point scale analysis. It should be noted that there are slight inconsistent ranges of

p-values in the comparison of pre- and post-tests in the treatment group. The most

significant p-value was observed in task 3 based on 5-Point scale analysis (P= .008)

whereas p-value of .063 was calculated in task 4 approaching the significant level of

0.05.

Overall, the results from above Tables support hypothesis 2-2: piano playing

music therapy will improve velocity evenness of finger movements in the affected

hands of chronic stroke patients.




Referring to the outcome variable 3, accuracy of key striking, statistical hypothesis

testing was carried out using secondary outcome analysis based on the 5-Point scale

data. The following Table 4.25 and 4.26 describe the results from outcome variable 3,

based on task 3 and 4.









105









Based on Tables 4.25 and 4.26, statistically significant outcomes were observed

in the comparison of pre-test and post-test in the treatment group (P= .004, P= .031)

whereas there was no statistical significance in the control group (P= .125, P= .250).

This evidence supports the hypothesis 2-3: piano-playing music therapy will improve

accuracy of key-striking of finger movements in the affected hands of chronic stroke

patients.

In summary, statistically significant results were achieved among the sub-

hypotheses, and thus hypothesis 2: piano-playing music therapy will improve unilateral

coordination of finger movement in the affected hands of chronic stroke patients is

accepted.

106

4.2.5 Hypothesis 3

With the reference to hypothesis 3, results are reported under the four sub-hypotheses

corresponding to the outcome variables. Due to the inconsistencies of level of task

completion in the control group only, the results of treatment group are presented in the

following section.

Hypothesis 3. Piano-playing music therapy will improve bilateral coordination of

finger movements in chronic stroke patients.


Hypothesis 3-1. Piano-playing music therapy will improve timing consistency of

bilateral finger movements in chronic stroke patients.

The outcome variable 1, timing consistency was measured by the secondary outcome

measurement, 5-Point scale analysis. The following description of the results of

treatment group presents outcomes in the comparison between the pre-tests and the

post-tests immediately after the music therapy interventions. These are described under

the three different types of bilateral tasks: (1) task 5 both hands index finger tapping

simultaneously, (2) task 6 both hands index finger tapping alternately, and (3) task 7

both hands 5-finger sequential playing.

Table 4.27 Hypothesis 3-1 Results of task 5: Both hands index finger tapping

simultaneously






107

Table 4.28 Hypothesis 3-1 Results of task 6: Both hands index finger tapping alternately






Table 4.29 Hypothesis 3-1 Results of task 7: Both hands 5-finger sequential playing






Based on Tables 4.27, 4.28 and 4.29, statistically significant results were

observed from comparison of the treatment group (P= .031) suggesting hypothesis 3-1:

piano-playing music therapy will improve timing consistency of bilateral finger

movements in the chronic stroke patients is accepted.


Hypothesis 3-2. Piano-playing music therapy will improve velocity evenness of


The 5-Point scale measurement was used to analyze the outcome variable 2, velocity

evenness within hypothesis 3-2.


simultaneously






108













It should be noted that there was a single exception in Table 4.31 (P= .125)

indicating non-significant differences between pre-test and post-test in the treatment

group comparison whereas significant statistical outcomes were observed in Tables 4.30

and 4.32 (P= .031).


Hypothesis 3-3. Piano-playing music therapy will improve accuracy of key striking of


The outcome variable 3, accuracy of key striking was measured by the 5-Point scale

analysis. Tables 4.33, 4.34 and 4.35 provide the results of treatment group comparison

referring to the three different tasks.

109


simultaneously













Outcome variable 3,





The consistent p-values of .031 were obtained on all tasks in Tables 4.33, 4.34

and 4.35. This statistically significant results supports hypothesis 3-3: piano-playing

music therapy will improve accuracy of key striking of bilateral finger movements in

chronic stroke patients.

110


Hypothesis 3-4. Piano-playing music therapy will improve stability of synchronizing

two-key strike of bilateral finger movements in chronic stroke patients.

Referring to the outcome variable 4, stability of synchronizing two-key strike, the

description of results based on the 5-Point scale analysis is presented in the following

Tables under the three tasks.


simultaneously

Outcome variable 4, Stability of synchronizing two-key strike

















111

Similar to the results of hypothesis 3-2, consistent statistical significances were

obtained on all tasks in Table 4.33, 4.34 and 35 (P = .031). The results support

hypothesis 3-4: piano-playing music therapy will improve stability of synchronizing

two-key strike of bilateral finger movements in chronic stroke patients.

In summary, statistically significant results were achieved among the sub-

hypotheses, and thus the proposed hypothesis 3: piano-playing music therapy will

improve bilateral coordination of finger movements in chronic stroke patients is

accepted.

112

4.2.6 Results of group comparisons: Descriptive analysis

The results of group comparisons between pre-tests and post-tests were analyzed

comparing percentage changes of task improvements based on MIDI and 5-Point scale

analysis. The following figures describe the task improvements referring to the outcome

variables.

4.2.6.1 MIDI analysis: Timing Consistency

MIDI Comparison on the Timing Consistency:

% change of standard deviation of time length of each key between pre & post-tests

-100.0%

-90.0%

-80.0%

-70.0%

-60.0%

-50.0%

-40.0%

-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Treatment Group -21.3% -49.3% -47.3% -79.0% -34.2% -51.3% -53.1% 0.5% -72.5% -66.5%

Control Group -37.5% 77.1% -23.9% 10.1%

T1 T2 T3 T4 T5LH T5RH T6LH T6RH T7LH T7RH

Figure 4.5 MIDI Comparisons on the Timing Consistency

113

4.2.6.2 MIDI analysis: Velocity Evenness

MIDI Comparison on the Velocity Evenness:

% change of standard deviation of velocity of each key between pre & post-tests

-100.0%

-90.0%

-80.0%

-70.0%

-60.0%

-50.0%

-40.0%

-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Treatment Group -22.9% -49.3% -43.2% -38.4% -23.8% -41.5% -31.6% -22.8% -49.5% -51.2%

Control Group -27.6% 15.2% -48.4% 25.5%

T1 T2 T3 T4 T5LH T5RH T6LH T6RH T7LH T7RH

Figure 4.6 MIDI Comparisons on the Velocity Evenness

Two lines represented in Figure 4.5 and 4.6 show the percentage changes of standard

deviation referring to timing consistency and velocity evenness. In MIDI analysis, it

should be noted that only unilateral tasks (task 1~4) were obtained from control group

due to the inconsistencies of level of task completion. The changes of task performance

between the tests in the treatment group demonstrate a remarkable significance in

executing all tasks. Although the value of percentage change was represented in

negative values, this indicates positive change.

114

4.2.6.3 5-Point scale analysis: Timing Consistency

Using the 5-Point scale analysis, the results of group comparisons between pre-tests and

post-tests were analyzed comparing percentage changes of task improvements. The

following figures depict the task improvements referring to the four outcome variables:

(1) timing consistency, (2) velocity evenness, (3) accuracy of key striking, and (4)

stability of synchronization.

5-Point Scale Comparison of Task Improvement on

Timing Consistency

-50.0%

-40.0%

-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

110.0%

120.0%

130.0%

140.0%

150.0%

Treatment Group 38.9% 35.2% 122.2% 31.3% 54.3% 18.1% 65.9%

Control Group 14.0% -9.4% 9.7% 1.6% 0.0% 0.0% 0.0%

task1 task2 task3 task4 task5 task6 task7

Figure 4.7 5-Point Scale Comparisons on the Timing Consistency

115

4.2.6.4 5-Point scale analysis: Velocity Evenness


Velocity Evenness

-50.0%

-40.0%

-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

110.0%

120.0%

130.0%

140.0%

150.0%

Treatment Group 24.5% 24.8% 89.1% 15.7% 50.9% 4.2% 58.5%

Control Group 20.0% 14.3% 8.6% 2.4% 0.0% 0.0% 0.0%


Figure 4.8 5-Point Scale Comparisons on the Velocity Evenness

116

4.2.6.5 5-Point scale analysis: Accuracy of Key-striking


Accuracy of Key-striking

-50.0%

-40.0%

-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

110.0%

120.0%

130.0%

140.0%

150.0%

Treatment Group 31.4% 48.8% 126.9% 37.1% 60.9% 20.0% 85.4%

Control Group 11.2% -4.0% 10.5% 4.8% 0.0% 0.0% 0.0%


Figure 4.9 5-Point Scale Comparisons on the Accuracy of Key-striking

Based on Figures 4.7, 4.8 and 4.9, a remarkable task improvement was observed in all

tasks between the pre-test and post-test in the treatment group whereas there was no

significant difference in the control group. Also, it should be noted that the degree of

improvement varies among the tasks. The contributing factors related to this result are

further stated in Chapter 5, Discussion.

117

4.2.6.6 5-Point scale analysis: Stability of Synchronization


Stability of Synchronization

-50.0%

-40.0%

-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

110.0%

120.0%

130.0%

140.0%

150.0%

Treatment Group 58.4% 44.2% 77.0%

Control Group 0.0% 0.0% 0.0%

task5 task6 task7

Figure 4.10 5-Point Scale Comparisons on the Stability of Synchronization

It should be noted that Figure 4.10 presents bilateral tasks only (task 5, 6, and 7)

referring to the outcome variable 4, which involves bimanual tasks. Similar to the

results of previous figures, consistent task improvements were obtained on all tasks in

Figure 4.10.

In summary, significant task improvements were achieved among outcome

variables based on both MIDI and 5-Point analysis, supporting the research hypotheses.

118

4.2.7 Results of individual comparisons: Descriptive analysis of participant 6

The results of individual comparisons between the tests were analyzed using primary

and secondary outcome analysis. Referring to this, two types of figures are presented in

the following section: (1) individual piano roll view by MIDI analysis and (2) individual

bar-graph comparisons by 5-Point scale analysis. The case of participant 6 was selected

from the treatment group and the graphical representations of his results are described

below in accordance with each task. The purpose of presenting this case result is to

demonstrate how the MIDI data is illustrated graphically. See Appendix 6.7 for all the

participants‟ descriptive analysis.

4.2.7.1 Task 1. Non-affected hand index finger tapping

Figure 4.11 Participant 6 Task 1 MIDI Piano roll view: Pre-test (14-Nov-2005) and

Post-test (14-Dec-2005)

119

4.2.7.2 Task 2. Non-affected hand 5-finger sequential playing

Figure 4.12 Participant 6-Task 2 MIDI Piano roll view: Pre-test (14-Nov-2005) and


120

Participant 6: Task 1~2

5-Point Scale Comparison between Pre-test and Post-test

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 4.7 4.0 4.0 4.0 3.0 3.0

Post-test 5.0 5.0 4.3 4.7 4.0 3.7

T1AK T1TC T1VE T2AK T2TC T2VE

Figure 4.13 Participant 6 Task 1 and 2 Five-Point Scale Comparison: Pre-test (14-Nov-

2005) and Post-test (14-Dec-2005)

121

4.2.7.3 Task 3. Affected hand index finger tapping



4.2.7.4 Task 4. Affected hand 5-finger sequential playing

Figure 4.15 Participant 6Task 4 MIDI Piano roll view: Pre-test (14-Nov-2005) and Post-

test (14-Dec-2005)

122



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.3 3.3 3.3 2.3 2.3 2.3

Post-test 5.0 5.0 4.3 4.7 3.7 3.3




123

4.2.7.5 Task 5. Both hands index finger tapping simultaneously



4.2.7.6 Task 6. Both hands index finger tapping alternately



124



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.0 2.7 3.3 3.0 3.0 3.0 3.3 3.0

Post-test 4.7 4.3 4.3 4.7 4.7 4.3 4.0 4.0

T5AK T5TC T5VE T5SS T6AK T6TC T6VE T6SS



125

4.2.7.7 Task 7. Both hands 5-finger sequential playing



126

Participant 6: Task 7


0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.0 2.7 2.3 2.7

Post-test 4.3 4.0 3.3 4.0

T7AK T7TC T7VE T7SS

Figure 4.21 Participant 6 Task 7 Five-Point Scale Comparison: Pre-test (14-Nov-2005)

and Post-test (14-Dec-2005)

127

4.3 Summary of Results

In summary, this chapter presented the results of the study, regarding the effects of the

piano-playing music therapy intervention for the treatment group compared with the

control group. The description of the database design was shown, with an explanation of

how the MIDI data and the 5-Point scale generated results for the research hypotheses.

The results of inter-rater reliability were also provided. The results were then reported

under each hypothesis, comparing (1) outcome variables between the treatment and

control group, and (2) outcome variables between pre- and post-tests in treatment group

and control group. In the next chapter these results will be discussed in detail.

128

CHAPTER 5

DISCUSSIONS AND CONCLUSIONS

This chapter provides a discussion about the results of the study. First, the hypotheses

are discussed, and the findings related back to the literature. Next, the methodological

issues are discussed, in particular the initial problems in transferring data from MIDI for

analysis, and the need for the 5 point scale as a form of statistical and descriptive

statistics. Following this there is a discussion of the therapeutic issues in doing this

study, identifying specific approaches that were used for the stroke patients. Finally the

discussion highlights the contribution of this study to clinical practice in music therapy,

and makes recommendations for future studies.

5.1 Hypotheses1

5.1.1 Hypothesis 1

The first hypothesis of the study was that piano-playing music therapy will improve

unilateral coordination of finger movements in the non-affected hands of chronic stroke

patients. There were three sub-hypotheses, namely:



stroke patients.



patients.



patients.

129



The results for hypothesis 1.1 indicated that there was no statistical difference

between the groups on finger tapping of the non-affected hand (task 1), and there were

mixed scores between the MIDI analysis and the 5-point scale on the pre- and post

treatment group results. The reason for there being no statistical difference between the

groups may be attributed to the characteristics of task 1, which was index finger tapping

of the non-affected hand. This was a very simple task, and perhaps lacked interest so

that motivation to do the task was low. When the task was more complicated e.g.,

involving coordination (such as task 2, five-finger sequential playing of non-affected

hand), the statistical significance was evident (P= .016). Therefore it may be argued that

piano-playing exercise may be less beneficial when it involves a simple task such as

finger tapping, however, statistically significant differences were achieved in

complicated tasks involving five-finger sequential playing. This outcome was also

consistent with the MIDI analysis on percentage change on timing consistency (See

Figure 4.5). Therefore there may be a possible correlation between the degree of task

complexity and task improvement following a piano-playing exercise.

Second, there was a wide difference between the MIDI p-value (.125) and the

5-point scale p-value (.003). The reason for this difference may be due to the

heterogeneous nature of the two measurements. The most different characteristic was

found in the data format and data process. The MIDI data was retrieved from a

computerized event list in the form of numeric data, whereas the 5-point scale analysis

was processed by a panel of raters with a value judgment, using five categories as a

format of ordinal data. Therefore gaps occurred between the two measurements;

especially there were less significant results in the MIDI analysis.

Third, the results for hypothesis 1.1, task 2 showed a significant difference

between groups on both MIDI and the 5-point scale, as well as between the pre and post

tests of the treatment group. The second task for hypothesis 1.1 was sequential playing

of the non-affected hand, and this finding supports other literature (Cofrancesco, 1985;

Erdonmez, 1991; Moon, 2000) indicating that sequential finger coordination is

improved by piano-playing. This is an important finding because developing sequential

coordination between the fingers is difficult to achieve through other types of therapy,

such as physical therapy that often focuses on gait re-training. Piano playing however

develops coordination of each finger movement, so that the patient is better able to

manage tasks of daily living, such as using eating implements, turning the pages of a

130

book and other tasks that require fine motor control of the fingers and hand.



The findings of hypothesis 1.2 indicate mixed results for velocity evenness on

finger tapping of the non-affected hand. This trend is similar to the findings of

hypothesis 1.1 on task 1, index finger tapping of the non-affected hand. As

aforementioned in hypothesis 1.1, these conflicting outcomes may be attributed to two

different types of data analysis and the simplicity of the task.

Second, the MIDI results from task 2 showed significant difference between

groups (P= .001), as well as between the pre- and post tests of the treatment group

(P= .004). As observed in the results of task 2, timing consistency (hypothesis 1.1),

velocity evenness was also significantly improved in the five-finger sequential playing

of the non-affected hand. The rehabilitative effects of piano-playing exercise were

addressed in other studies (Cofrancesco, 1985; Erdonmez, 1991; Moon 2000) and the

results of the hypothesis 1.2 support this literature.

Third, a possible correlation between the degree of improvement and the

complexity of tasks is also depicted in hypothesis 1-2. As seen in Figure 4.6 (MIDI

comparison on velocity evenness), the percentage change of standard deviation of

velocity evenness between pre- and post-tests, were –22. 9% (task 1, index finger

tapping) and –49. 3% (task 2, five-finger sequential playing) in the treatment group. It

should be noted that the value of percentage change was represented in negative values,

but this indicates positive change toward improvement. The trend of a much higher

percentage change in task 2 of performance comparison shows that the more

complicated the task, the more significant improvement is achieved after the piano-

playing intervention.



The results of hypothesis 1.3 were analyzed only by the secondary outcome

measurement based on the 5-point scale data. The reason for not being able to adapt the

raw MIDI data for statistical analysis, is depicted in Table 4.4. In the table, the number

of mistakes on required key striking was recorded. However, when the comparison of

pre- and post-tests was recorded in a manner, such as 3 to 0, or 2 to 0, this type of data

131

coding was problematic for the purpose of statistical analysis, although, it is possible to

say that the accuracy of key striking was improved when the number of mistakes was

decreased. Therefore a statistical hypothesis testing was conducted using the 5-point

scale analysis.

Second, the results for hypothesis 1.3 indicated a statistically significant

difference between the pre- and post tests in both treatment group and control group on

index finger tapping of the non-affected hand (task 1). It is noticeable that the control

group also showed task improvements after the period of non-intervention. However,

when the performance on task 2, five-finger sequential playing, was compared between

the tests in the control group, there was no statistical significance (P= .391), whereas

there was a consistent statistical significance on both task 1 and 2 in the comparison of

the tests in the treatment group (P= .016, P= .004).

In summary, the results from each sub-hypothesis demonstrated that piano-

playing music therapy improved unilateral coordination of finger movements in the

non-affected hands of chronic stroke patients. This finding supports other literature

(Baker & Roth, 2004; Carr & Shepherd, 2003; Johansson, 2000), indicating that

exercise involving the non-affected motor lesion as well as affected motor lesion has a

rehabilitative effect, as the process of functional recovery occurs in both affected and

unaffected hemispheres of the brain.

Also, coordination of finger movements of the non-affected hand was improved

by piano-playing music therapy and noticeably, there was a correlation between the

degree of task improvement and the complexity of task.

5.1.2 Hypothesis 2

The second hypothesis of the study was that piano-playing music therapy will improve

unilateral coordination of finger movements in the affected hands of chronic stroke

patients. Three sub-hypotheses are restated in the following section:



patients.



patients.

132



patients.



The MIDI results for hypothesis 2.1 indicated no statistical difference between

pre- and post-tests in the treatment group, whereas the 5-point scale results showed a

statistically significant difference between groups and between tests in the treatment

group. This conflicting statistical outcome was observed in hypothesis 1 and as

previously stated, it was attributed to the different characteristics between the MIDI

analysis and the 5-point scale analysis.

Second, based on the 5-point scale, the results for hypothesis 2.1, task 3

(affected hand index finger tapping) showed a significant difference between groups, as

well as between the pre- and post-tests of the treatment group. A similar statistical

significance was also obtained on task 4 (affected hand five-finger sequential playing).

This finding supports the hypothesis that timing consistency of finger movements of the

affected hand is improved by piano-playing exercises.

As aforementioned in the literature, upper extremity dysfunctions and limited

functional hand and finger control are evident following stroke (Alexander, 1997; Kane

& Buckley, 2004; Mohr et al., 1993). However, Taub (1980) pointed out that some

chronic disability is caused by learned non-use. Also, Johansson (2000) addressed the

need for exercise and training, indicating changes in the affected motor lesion through

functional connections facilitated by exercise rehabilitation. Therefore the results for

hypothesis 2.1 are supported by the notion that motor re-learning in the coordination of

the affected hand and fingers is possible when a piano-playing intervention is given to

patients with chronic stroke.



The results for hypothesis 2.2 indicate slightly higher statistical difference in

the MIDI analysis, compared to the results from hypothesis 2.1 with outcome variable 1,

timing consistency. The most significant result was achieved in task 4 of the affected

hand 5-finger sequential playing (P= .031) based on the MIDI analysis. It should be

133

noted that a similar outcome was found on the result of hypothesis 1-2 (non-affected

hand 5-finger sequential playing on outcome variable 2, velocity evenness) indicating a

statistical difference (P= .004) in the MIDI analysis. It may be possible to say that

piano-playing music therapy contributed to rehabilitative effects on velocity evenness

(outcome variable 2) for stroke patients in both their affected and non-affected hand

fingers.

Second, the overall results from the 5-point scale analysis show statistical

differences in both task 3 and 4, supporting hypothesis 2.2: piano-playing music therapy

will improve velocity evenness of finger movements in the affected hands of chronic

stroke patients. As previously mentioned in the literature, piano-playing music therapy

may be a viable intervention, developing motor coordination related to velocity

evenness in the affected hands and fingers of chronic stroke patients (Cofrancesco,

1985; Erdonmez, 1991; Moon, 2000).



In order to answer hypothesis 2.3 referring to outcome variable 3, accuracy of

key striking, statistical testing was carried out using the secondary outcome

measurement, the 5-point scale analysis. The results for hypothesis 2.3 indicated a

statistical difference between the groups (P= .010) on index finger tapping of the

affected hand (task 3), as well as between the pre- and post tests of the treatment group

(P= .004). Also, task 4 of five-finger sequential playing showed significant difference in

the comparison of pre- and post tests in the treatment group (P= .031).

The results of hypothesis 2.3 were consistent between task 3 and task 4.

Furthermore, there was consistent statistical difference on the results of hypothesis 1.3

with task 1 and task 2. Therefore it is possible to say that piano-playing music therapy

improves accuracy of key striking of finger movements in chronic stroke patients. From

the previous literature review, Moon (2000) assessed the effect of piano exercises on the

rehabilitation of finger coordination. In the study, she used two major outcome

variables: velocity evenness (outcome variable 2, velocity evenness in the current study)

and duration evenness (outcome variable 1, timing consistency in the current study).

Measurement of accuracy of key striking was not attempted in Moon‟s (2000) study, nor

in other literature in relation to piano exercises and finger rehabilitation. Therefore this

finding may add new knowledge to the music therapy rehabilitation literature,

expanding the range of possible outcome measurements in finger coordination.

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5.1.3 Hypothesis 3

The third hypothesis was that piano-playing music therapy will improve bilateral

coordination of finger movements in chronic stroke patients. There were four sub-

hypotheses, namely:









patients.

Prior to discussing the results of hypothesis 3, it should be noted that there were

some methodological issues and limitations in assessing bilateral coordination of finger

movements. Referring to hypothesis 3, the music therapist-researcher devised three

bimanual tasks: (1) both hands index finger tapping simultaneously (task 5), (2) both

hands index finger tapping alternately (task 6), and (3) both hands 5-finger sequential

playing (task 7). When the pre-test assessment took place in the treatment group, there

were only five participants (out of ten) who were able to carry out task 5 and task 6 and

only 2 participants completed task 7 (See table 4.6 in the Results chapter). In the control

group, none were able to complete any of three bimanual tasks. Therefore it should be

noted that the characteristics of the bimanual tasks were not well matched to the chronic

stroke patients‟ residual functions (the degree of task complexity was too difficult for

them). Also, the level of task completion was not evenly matched between the groups.

Having this issue, statistical hypothesis testing was made using the secondary outcome

analysis with limited data from the treatment group.

From the 5-point scale analysis, the results for hypothesis 3 showed statistically

significant differences among all sub-hypotheses in comparison to pre- and post tests of

the treatment group, except for a score of p-value for hypothesis 3.2 in task 6. The most

significant results were found in participant 2 and participant 3. In the pre-test, they

were not able to attempt task 7 of both hands 5-finger sequential playing, however after

6-weeks of the music therapy intervention, they completed the task in the post-test. As

suggested by other studies (Carr & Shepherd, 2003; Johansson, 2000), this finding may

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support the notion that functional recovery involves bilateral rehabilitation as well as

unilateral rehabilitation as the process of brain reorganization occurs in both affected

and unaffected hemispheres of the brain.

As aforementioned in the introduction chapter, the scope of previous studies

was limited to emphasizing unilateral hand and finger rehabilitation (Cofrancesco,

1985; Erdonmez, 1991; Kozak, 1968; Moon, 2000). Therefore this current finding may

serve as a preliminary finding in drawing attention to the rehabilitation effects of

bilateral coordination in the hands and fingers.

5.1.4 Discussion for MIDI software

There was mixed achievement in using the MIDI analysis as a primary outcome

measurement to assess bimanual finger coordination. Initially there were problems

transporting the MIDI raw data of an event list (See Table 3.5, for an example of the

MIDI event list data) to any form of word-type document files. However the initial

problems were overcome and the data could be transported using the following steps.

The researcher:

(1) Transported the MIDI data of the event list to a PDF file (See Table 5.1)

(2) Manually correct any contaminated, or missing data in PDF

(3) Transported the PDF file to an Excel document (See Table 5.2)

(4) Manually correct any contaminated, or missing data in Excel

(5) Conducted database design, data coding, and data entry in Excel, and

(6) Carried out statistical analysis from the Excel files.

Software program, „MIDI toolbox‟ is now available to export MIDI data for

statistical analysis, and in future studies these toolboxes would allow for easier

exportation of data. The website for the MIDI toolbox is followed:

http://www.jyu.fi/hum/laitokset/musiikki/en/research/coe/materials/miditoolbox/

http://www.jyu.fi/hum/laitokset/musiikki/en/research/coe/materials/miditoolbox/

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Table 5.1 PDF file exported from MIDI data of the event list:

Participant 6 Post-test (14-Dec-2005)

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Table 5.2 Excel database transferred from PDF file:

Participant 6 Post-test (14-Dec-2005)

ID Trk HMSF Ch Kind Data Velocity MBT_Length

TG P6 2 00:00:03:27 3 Note Db6 114 510

TG P6 2 00:00:04:22 3 Note Eb6 114 529

TG P6 2 00:00:05:14 3 Note F#6 109 439

TG P6 2 00:00:06:06 3 Note G#6 114 484

TG P6 2 00:00:07:00 3 Note Bb6 109 912

TG P6 2 00:00:08:22 3 Note Db6 109 498

TG P6 2 00:00:09:13 3 Note Eb6 104 369

TG P6 2 00:00:10:04 3 Note F#6 104 368

TG P6 2 00:00:10:25 3 Note G#6 74 467

TG P6 2 00:00:11:17 3 Note Bb6 98 651

TG P6 2 00:00:13:06 3 Note Db6 95 328

TG P6 2 00:00:13:24 3 Note Eb6 109 333

TG P6 2 00:00:14:13 3 Note F#6 98 320

TG P6 2 00:00:15:03 3 Note G#6 109 350

TG P6 2 00:00:15:21 3 Note Bb6 95 887

TG P6 2 00:00:16:24 3 Note Db6 98 309

TG P6 2 00:00:17:12 3 Note Eb6 114 275

TG P6 2 00:00:17:29 3 Note F#6 104 279

TG P6 2 00:00:18:17 3 Note G#6 109 316

TG P6 2 00:00:19:07 3 Note Bb6 74 486

TG P6 2 00:00:20:12 3 Note Db6 95 317

TG P6 2 00:00:20:29 3 Note Eb6 109 259

TG P6 2 00:00:21:15 3 Note F#6 109 285

TG P6 2 00:00:22:02 3 Note G#6 114 299

TG P6 2 00:00:22:19 3 Note Bb6 91 663

TG P6 2 00:00:31:28 3 Note Eb5 76 462

TG P6 2 00:00:33:02 3 Note Db5 70 523

TG P6 2 00:00:33:29 3 Note Bb4 54 410

TG P6 2 00:00:34:20 3 Note G#4 67 509

TG P6 2 00:00:35:15 3 Note F#4 58 654

TG P6 2 00:00:36:18 3 Note Eb5 59 534

TG P6 2 00:00:37:17 3 Note Db5 66 528

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Compared to the previous study by Moon (2000), this current study

encompassed larger aspects of piano playing in assessing coordination of finger

movements. There were two elements of MIDI analysis which were determined by

Moon: (1) the velocity units (performance variable 1) for dynamic measurement, and

(2) the duration units (performance variable 2) for temporal measurement.

Based on this analysis, the researcher set four outcome variables for the current

study: (1) timing consistency (by capturing each key duration), (2) velocity evenness

(by capturing each key velocity), (3) Accuracy of key striking (by capturing key notes),

and (4) stability of synchronizing 2-key striking (by capturing duration evenness and

velocity evenness between the two keys). These outcome variables were then compared

between the groups and between the pre- and post tests, examining the effects of piano-

playing in unilateral and bilateral finger coordination. Although there were limitations

in capturing the data for bilateral tasks due to the degree of task complexity, statistical

hypothesis testing was carried out using the secondary outcome measurement, based on

graphical representation data retrieved from MIDI.

In addition, MIDI analysis provided an effective visual assessment tool in

assessing progress of finger performance of the patients (See Figure 4.11~ 4.20 of piano

roll view). This graphical representation showed how MIDI allows descriptive analysis

of the performance of a patient‟s finger functions. Therefore, MIDI was found to be a

valid and reliable means of capturing the research data.

5.1.5 Main findings related to the literature

5.1.5.1 Compensation through therapeutic exercise

The aim of this study was to investigate whether piano-playing music therapy was

effective in the motor coordination of chronic stroke patients. The pre-tests indicated

that the patients had difficulties in playing basic piano exercises due to hemiparesis and

physical deficits. Problems in piano-playing skills in both hands were as follows:

(1) Poor timing consistency in unilateral (both affected and non-affected hand

fingers) and bilateral finger movements

(2) Poor dynamic evenness in unilateral (both affected and non-affected hand


(3) Poor accuracy of key execution (both affected and non-affected hand


(4) Poor stability of synchronization in bilateral finger movements

(5) Poor balance in the affected hand and finger posture

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(6) Rigidity in the affected hand fingers

(7) Over-extendedness in the affected hand fingers

(8) Lack of strength in the affected hand fingers

At the end of four weeks of music therapy treatment comprising intensive piano-

playing exercises, patients‟ piano-playing had improved significantly alleviating many

of the above-mentioned problems. The fact that the patients improved on both unilateral

and bilateral hand finger coordination in playing the piano suggests that the damaged

function of the brain may be compensated for by certain therapeutic exercises and

strategies that develop other areas of the brain. As suggested by Erdonmez (1991) in a

study of rehabilitation of piano performance skills in a man following a left CVA,

“the brain effectively compensated for areas of damage, enabling the patient to learn

new material accurately” (p.568).

Other studies also suggest that there seems to be a restorative potential of the

brain to compensate for the damages to the brain motor system (Baker & Roth, 2004;

Carr & Shepherd, 2003; Gerloss et al., 1995; Johansson, 2000; Pascual-Leone et al.,

1997). Johansson (2000) stated the potential of functional recovery, emphasizing

functional connections within surviving brain tissues, made through exercise and

training. The rehabilitative effects of piano-playing music therapy in the current study

rely on this adaptive plasticity for reorganization of neural connections in the brain.

In this study no analysis was undertaken according to the site of the stroke and

the degree of rehabilitation effects. Therefore it is recommended to investigate any

correlation between subtypes of stroke and differences of rehabilitation progress in a

future study, using statistical analysis such as regression models.

5.1.5.2 Skill acquisition on hand and finger coordination

The results of patients‟ performance showed that the effect of piano-playing music

therapy contributed to the acquisition of new fine motor skills. As suggested by Fitts

(1964), patients‟ process of skill acquisition on the unilateral and bilateral hand finger

coordination involved a model of three stages: 1) cognitive stage, 2) associative stage,

and 3) automatic stage.

During the first cognitive stage, patients learned the basic procedures of piano-

playing skills with the non-affected hand. The required tasks involved the affected

hands. While the tasks were considerably demanding for the participants, the researcher

provided a demonstration of playing the exercises several times to enable the

participants to model from the therapists, and to enhance their cognitive level. Several

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types of cues (e.g., visual/aural cue, tactile cue, and sung cue) were also given to the

patients to facilitate their level of cognition while performing the exercises.

In the second stage of association, the patients tried to associate the different

task elements required for a desired performance with resulting success or failure. In

this stage, feedback on the performance was essential (Carr & Shepherd, 2003; Johnson,

1984; Thaut, 1999). Most significantly the immediate musical feedback on their

performance provided instant reward and therefore encouraged the proper movement

performance. This essential feedback is also a feature of Thaut‟s (1999) Neurologic

Music Therapy. He includes feedback as an important aspect of rehabilitation where it

be gait retraining or other rehabilitation technique (Thaut, 1999).

Also, the music therapist-researcher‟s verbal feedback played an important

factor in reinforcing the patients‟ performances. When the therapist observed any

smallest improvement on their piano-playing, she immediately addressed their changes

and acknowledged their efforts and patience toward achievements, using positive words.

In the final automatic stage, the patients were able to perform the piano

exercises, showing consistency in piano playing performance, maintaining dynamic and

temporal evenness. As aforementioned under the section of hypotheses discussion,

several fine motor skills of the patients were acquired through the music therapy

interventions. The tasks that the patients showed significant improvements on as

evidenced in both MIDI and 5-point analysis were: 1) timing consistency in the non-

affected hand 5-finger sequential playing and 2) velocity evenness in the non-affected

hand 5-finger sequential playing. Noticeably, there was no significant difference in

timing consistency and velocity evenness in the non-affected hand index finger tapping

of the patients. In terms of accuracy of key-striking in a non-affected hand, there were

significant improvements in both index finger tapping and 5-finger sequential playing,

based on 5-point analysis.

In the results of the affected hand finger skill acquisition, significant difference

was achieved in velocity evenness of 5-finger sequential playing in the patients,

whereas there was no significant difference in timing consistency of both simple and

complex tasks, based on MIDI analysis. However, from the 5-point analysis based on

the value judgment of a panel of raters, there were improvements in timing consistency,

velocity evenness, and accuracy of key-striking in both simple and complex tasks of the

patients‟ performance. This finding supported the notion that the rehabilitative effect of

piano-playing music therapy contributed to the acquisition of new fine motor skills in

the affected hand and fingers of stroke patients.

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5.2 Contribution to current music therapy literature:

major factors in the rehabilitation process

In this section four major contributions of this study to clinical practice of music

therapy are outlined. These include 1) the role of the therapist-researchers interventions,

2) the effect of the music elements on the success of rehabilitation, 3) the role of the

MIDI and 4) the strategies used in the rehabilitation process.

5.2.1 The music therapist-researcher’s intervention

Two aspects of the music therapist-researcher‟s intervention are related to the theoretical

underpinnings of the approach, namely that a humanistic approach was incorporated and

secondly that the intervention itself was a creative and process-oriented approach.

5.2.1.1 The Humanistic approach: a patient-centered therapy

Self-actualization is one of the ultimate needs of a human being (Rogers, 1959). Patients

with chronic stroke have immense obstacles to over come in managing their

environment and their activities of daily living. Simple tasks such as eating, dressing,

toileting, and bathing pose significant challenges. Beyond these activities of daily living

a person need for leisure and quality of life are also severely affected by a stroke. The

patients in this study however, demonstrated a basic desire to feel the sense of their own

worth and where possible overcome the difficulties confronting them. From a

humanistic perspective, it was fundamental for the music therapist-researcher to be a

guide to lead the patient to find his own worth and identity and therefore lead him to

achieve his self-actualization.

Case vignette: Lee

Lee was a 77 year old female participant who had suffered a stroke for 62

months prior to the start of the program. Her type of stroke was not identified according

to the intake report. As a result of the stroke, she sustained left-sided hemiparesis which

restricted her gross motor skill.

She considered the affected side of her body to be „a dead body‟. The staff of

the resident unit described her as unmotivated – she was not able to face a new day,

having given up hope of things ever changing for her. Lee often asked the question

“What is the point of doing things, such as piano-playing with a dead body?” indicating

that she lacked a sense of purpose and poor self-esteem.

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The music therapist-researcher, in order to raise self-awareness and self-respect

in Lee, prepared her slowly to be comfortable with herself by 1) pacing the exercises

gradually so that Lee could accomplish them with success, 2) providing verbal

encouragement to her when she was attempting to use her non-affected hand, and 3)

arranging a duet piano performance, utilizing some improvisation techniques. This

approach enabled Lee to become more aware and be pleased with her own musical

accomplishment on the keyboard with her non-affected hand. Lee also developed trust

in the music therapist-researcher, so she was more willing to try the exercises.

Lee was then slowly encouraged to initiate exercising her affected hand on the

keyboard. This was very difficult for her, as she was confronted with the “deadness” of

the hand. In order to exercise the affected hand she had to accept and visually watch the

fingers as they attempted the exercises. Gradually, she allowed and accepted her „dead

hand‟ being included in the exercises of bilateral tasks with the researcher‟s support.

One of the outcomes of the therapy sessions was that although she had very little self-

esteem before the therapy started, after the session she had built a sense of personal

reality and sense of self-esteem.

5.2.1.2 A creative, process-oriented approach

The music therapy intervention used in this study incorporated a balance of structured

exercises, and more creative tasks such as playing duets with the music therapist-

researcher, and singing a familiar Korean folk song. The use of a creative approach

enhanced enjoyment for the participants and enabled them to concentrate for longer

periods of time. The music therapist was both researcher and therapist to the patients,

and as such was involved in:

(1) Designing the music therapy protocol

(2) Writing the simple, graded exercises, being aware of the limitations that

stroke causes to patients

(3) Expanding the simple exercises to make creative, musical piano-playing

exercises

(4) Directing duet performance using improvisation techniques, such as

matching the patient‟s rhythm, dynamics, and tempo, grounding the patient‟s

efforts by playing octave or tonal chords, and accompanying the patient so

that the patient was supported.

(5) Providing cues (verbal cues including counting, tactile cues, sung cues

including singing and humming, and visual cues including pointing) for

facilitating the patients‟ musical responses.

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In relation to expanding the simple tasks to musical piano pieces, the music

therapist introduced a Korean traditional song, Arirang. The main reason for using this

Korean traditional song was that its musical construction is based on the penta-tonic

scale. When the patients were involved in exercising 5-finger sequential playing on the

five black keys (C#, D#, F#, G#, and A#), the F# major scale was generated and then it

was well matched to the penta-tonic melody of Arirang in F# major. The patients could

practice the melody with minimal difficulties when appropriate finger numberings were

provided. The use of a familiar melody in piano-playing and its benefits have been

addressed in the literature (Cross et al., 1984; Moon, 2000).

Case Vignette: Kim

Kim was a 66 year old man who had suffered an ischemic type of stroke for 20

months prior to the start of the study. The medical report indicated that he sustained

right-sided hemiparesis, due to an infarction in the left hemisphere. Motor weakness,

motor neglect, and poor endurance were also presented following a stroke, as

aforementioned in the literature under the section of motor dysfunction.

He was quite doubtful about the usefulness of the piano-playing program at the

initial sessions. He thought that piano-playing would not strengthen his hands and

commented that he didn‟t know how to play the piano and therefore did not understand

how it would be helpful. His attitude and interest were then slowly changed as he began

to learn the simplified melodic version of the song. During the session, he exclaimed, “I

am not exercising the fingers, I am playing „Arirang‟”! Playing a musical tune gave him

opportunities for not only alleviating the monotony of repetitive tasks but also a sense

of engaging in a meaningful activity and enjoyment of its aesthetic quality throughout

the sessions. As suggested by Carr and Shepherd (2003), active participation was

important for motor skill learning and it was enhanced by utilizing a familiar song

melody in piano-playing exercises.

5.2.2 The effect of elements of music on motor coordination and rehabilitation

The effect of specific music elements in rehabilitating hand and finger coordination was

noticeable throughout the sessions, particularly the importance of rhythm, and familiar,

predictable melodies.

The use of rhythm in music as a rhythmic auditory stimulation exerts a

powerful influence on the rehabilitation process for brain injured patients (Hurt et al.,

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1998; Staum, 1983). Thaut (1999) has developed a specific technique called Rhythmic

Auditory Stimulation that he uses in gait re-training. Also, rhythmic elements in playing

the piano can be adopted for a therapeutic purpose in rehabilitating finger movements

(Cofrancesco, 1985; Erdonmez, 1991; Kozak, 1968; Lundin, 1967; Moon, 2000; Thaut,

1999; Velasquez, 1991).

During the piano-playing music therapy sessions, several techniques utilizing

rhythmic elements contributed to the success of the music therapy treatment. For

example, in Thumb-Index finger exercise (see page 58) the application of dotted

rhythmic patterns strengthened the patient’s finger attack. In Thumb-Index-Middle

finger exercise (see pager 59) the staccato movements developed the patients’ finger

independence and strength. Initially the rhythms of the exercises were not very exact,

but the patients became more skilled the rhythmicity of the exercises improved.

Similarly, the staccato action initially was not very precise, but after several sessions

the patients were able to make the staccato attack very effectively.

The use of a familiar and preferred melody enhances the optimal response from

patients (Cross et al., 1984; Moon 2000). Apart from the technical exercises in rhythmic

pattern, a simplified version of the Korean traditional song was utilized to reduce the

monotony of repetitive tasks therefore enhancing some level of enjoyment to the

practice. The song was well-known, and therefore the patients were motivated to play it

correctly and spontaneously and to sing along as they played. A series of simple piano

exercises was devised by the music therapist-researcher with consideration for the

patients‟ limitation with the affected hand and fingers. In was important to order the

fingering on the exercises, carefully writing which finger should press each note. The

orderings changed for each person depending on the level of their disability and the

hemiplegic site.

5.2.3 The role of feedback provided by MIDI

Giving feedback to patients on their exercising is an essential aspect of stroke

rehabilitation (Carr & Shepherd, 2003; Johnson, 1984; Thaut, 1999), and as mention

above in discussion of , the MIDI was found to be a valid and reliable tool for

measuring finger strength and velocity in this study, The MIDI software was also

important in providing different types of sensory feedback. There were two principal

forms of feedback: 1) auditory feedback, and 2) visual feedback.

First, auditory feedback naturally occurred as the patients executed their finger

exercises on the MIDI keyboard. The immediate auditory feedback served as a means of

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providing information about success or failure of the patients‟ finger exercises. When

the auditory feedback was generated from the MIDI output function, the patients‟

attention was directed to controlling the execution of tasks and then it led them to

correct any mistakes. If the task was successful, it provided instant reward reinforcing

proper movements.

Second, visual feedback was available from the piano roll view of the MIDI

program (See Figures 4.11 ~ 4.20 of descriptive analysis on MIDI piano roll view). This

exact feature on piano performance was important in providing conviction that the

patients were gradually progressing. During the sessions, it was observed that some

patients were conservative in acknowledging their progress, but then the therapist

showed them the MIDI piano roll view from the pre-tests. The graphical representation

of performance comparison was transparent and the patients gained positive insights

into their improvements thus engaging them to active participation in the piano-playing

intervention. In addition, the quantified, computerized feedback was accumulated, and

the documentation of the MIDI event list and piano roll view served as a consistent

reminder for the patients reinforcing their efforts to the practice. Providing motivation

for stroke patients in rehabilitation is acknowledged as one of the most important

features of an effective intervention (Baker & Roth, 2004; Carr & Shepherd, 2003;

Thaut, 1999).

5.2.4 Rehabilitation strategies for piano-playing music therapy

There were several strategies and guidelines to maximize the rehabilitative effects of

piano-playing exercises focusing on hand and finger coordination, as follows.

(1) The aim of the study and the specific goal for each session were clearly

explained to the patients at the beginning of the session. In reminding them of the aims,

the participants were able to focus on the therapeutic purpose of each exercise and

enabled them to be aware of whether the finger movement was purposeful, based on the

aims.

(2) During duet performance, the song materials were selected based on the

patients‟ requests and their music preference. Also, patients‟ achievement and

improvement were given positive feedback even if the achievements were simple and

small. These two factors contributed to the enhancement of the patients‟ motivation and

self-esteem.

(3) Appropriate physical support, such as holding the patient‟s affected elbow

and wrist underneath was provided when the patients had difficulties in balancing hand

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and finger posture and relaxing the stiffness and over-extendedness of the finger

muscles.

(4) A systematic therapeutic-teaching method was applied to learn a new task.

For example, the music therapist-researcher first demonstrated how to play a new

melody at a slow tempo. Following the patient‟s initial warm-up on the piano, several

cues (visual, aural, tactile, and sung cue) were provided to enhance the learning process

more effectively. Then, partial practice was given to a complicated phrase needing

repetitive practice and specific attention. Finally, chordal accompaniment was provided

by the music therapist-researcher while the patient played the melody.

(5) Each session was either audio-taped or video-taped for the purpose of the

study and evaluation. The session recording afforded the music therapist-researcher

opportunities to identify her blind spots that can sometimes be missed or misperceived

during the session. During the context of the recording, finger movements which

indicated improved physical coordination in the patient‟s performance were recorded in

the descriptive notes that were analyzed and used for the next session plan.

(6) A patient-centered therapy approach was fundamental in this study of stroke

rehabilitation. The music therapist was aware of the patients‟ vulnerability, caused by

the stroke, and by the rehabilitation environment and their needs for regaining self-

esteem and motivation. The therapy setting was an individual format and the music

therapist was able to provide personalized nurturing attention. Throughout the sessions,

the therapist incorporated active listening skills and positive verbal reward, prompting

and maintaining the patients‟ motivation in the rehabilitation process. Also, a systematic

music therapy protocol was applied at a pace that was most comfortable to the patients,

thus showing sensitivity to his or her level of tolerance of discomfort and personal

progression.

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5.3 Methodological issues

In this section several methodological issues will be raised and discussed, including

issues with the research design and the outcome measures.

5.3.1 Research design

A modified controlled trial with equal numbers in an intervention and control group was

used in the study. The initial research design, however, was a randomized controlled

trial. In the preparatory stage of conducting the clinical work, a random allocation was

planned for the stroke patients‟ day-care center. However, there were difficulties in

randomly assigning patients to either the music therapy group or the control group. The

issue was an ethical one; the Director of the facility argued that all patients in his centre

should have the benefit of music therapy, and he was not willing to allow any of the

patients in his centre to be denied music therapy in order to form a control condition.

Therefore the participants for the control group were recruited from two other day-care

centers and they consented to take part in the study as the control groups. In this respect,

a process of homogeneity of sample was not estimated and there was an uneven

distribution in gender, and the degree of task completion between the participants of two

groups.

Second, within a modified controlled trial with pre-test and immediate post-test,

there was a music therapy intervention in the treatment group, but no intervention was

given in the control group. The comparison of a single intervention may generate a bias

regarding benefits of some form of intervention in the treatment group, compared with

no-intervention in the control group. Future studies could control for this issue by

insuring that the control condition included some form of individual attention by a

therapist or researcher, such as reading from a newspaper, or discussing current events,

or playing games.

5.3.2 Outcome measurements

The purpose of this study was to investigate the rehabilitative effects of a piano-playing

music therapy intervention on the motor coordination of hands and fingers of chronic

stroke patients. In order to answer the research hypotheses, two different types of

outcome measurements were adopted: 1) the MIDI analysis as a primary outcome

measurement, and 2) the 5-point scale analysis as a secondary outcome measurement.

Table 5.1 describes the comparison of general characteristics between the measurements.

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Table 5.1 Comparison between the primary and secondary outcome measurements

The MIDI-based analysis The 5-Point scale assessment

Primary outcome measurement Secondary outcome measurement

Four outcome variables

Event list format

Four outcome variables/ parameters

Five-category format

Numeric data Ordinal data

Mechanical process

Computerized assessment

Less significant statistical outcomes

Value judgment

Evaluated by a panel of raters

More significant statistical outcomes

In obtaining statistical outcomes, there were wide differences between the

MIDI analysis and the 5-point scale analysis due to the heterogeneous nature of the

measurements. Therefore interpretation of the results under each hypothesis was made

separately. The issues in transporting the MIDI raw data for statistical analysis were

discussed in the previous section, referring to MIDI software.

The methodological issues related to the 5-point scale measurement were raised

by the panel of raters. When they were asked to rate the degree of performance of each

participant under each parameter, they found the five categorization of „none, poor, sub-

average, fair, or good‟ was not responsive for measuring subtle changes in the level of

performance between pre- and post-tests. To increase the responsiveness of this type of

scale, the range may need to be lengthened by adding subcategories between the main

scores, such as average, and excellent. These additions would then expand the scale to a

7-point scale.

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5.4 Study limitations and recommendations for future study

5.4.1 Research design

In this study, a modified controlled trial was implemented due to the Director‟s

instruction that he would not allow his patients to be denied music therapy. In future

studies it would be important to have this clarified prior to randomization. Although the

study was granted ethical approval as a randomized controlled trial, and the Director

had agreed to the study, it was not until the study actually commenced that he realized

half the patients would miss out on music therapy services, and that was when he stated

all patients would receive music therapy. While this is evidence of recognition of how

important music therapy is, it was problematic for running a well-controlled study.

Second, an experimental design with a single intervention may cause an

external invalidity in regard to interaction of testing and comparison of a single

intervention with no intervention in the control group. Therefore it is desirable to

arrange a possible modification of the intervention for the control group, or at least

matching the individual attention given to the treatment group by the music therapist.

Third, recruiting of participants was limited within a timeframe of the research

project. Therefore greater number of participants is recommended in a future study. Also,

in the current study, it was underestimated how to increase statistical power if the

number of participants available is limited. In a future study, a proper consideration

should be given to the issues of statistical power and estimating an effect size.

Fourth, the clinical population of the study was chronic stroke patients.

Although it was evident that the functional areas of the affected and non-affected

hemisphere of the brain responsible for motor recovery varied in complexity (Arnadottir,

2004), this study was limited to providing any correlation between types of stroke and

progress of rehabilitation. Therefore it is recommended to stratify the data by type of

stroke, investigating any possible factors between subtypes of stroke and differences of

rehabilitation process in a future study.

150

5.4.2 Outcome analysis

A MIDI based analysis was used as a primary outcome measurement in the study. The

patients‟ performance on the electronic keyboard was then assessed using the MIDI data

analysis. Based on the analysis, the raw MIDI data provided two numerical

measurements:

(1) The key velocity (speed of key descent) in units of comparable precision

(2) The key duration (length of the time each key is held depressed) in precise

timing units.

Although the MIDI data analysis could quantify the degree of improvement in

finger touch control on the keyboard, there were other aspects of finger movements

which were not measured by the MIDI system such as the:

(1) Balance in the bilateral hand and finger posture

(2) Rigidity in the affected hand fingers

(3) Over-extendedness in the affected hand fingers.

Therefore it is recommended that in order to identify any non-responsive

aspects in a primary outcome measurement, adding an audio-visual recording analysis

in a future study would provide a valuable means of gathering back-up data.

In addition, in the current study, an investigation of the transference effects to

the activities of daily living of chronic stroke patients was not implemented. Therefore

in a future study a base-line measure on a related task – e.g. hand grasp strength would

be an important addition, with a follow-up test, to see if advances in the music therapy

intervention carried over to other tasks. Various hand and finger tests such as the Jebson

Hand Function Test (Jebson, Taylor, Trieschmann, Trotter, & Howard, 1969), the

Rosenbusch Test of Finger Dexterity (Stein and Yerxa, 1990), and the Box and Block

test (Mathiowetz, Volland, Kashman, & Weber, 1985) are recommended in conjunction

with a multiple outcome analysis.

Lastly, it is recommended to implement recent brain mapping technologies in

future studies. For example, functional MRI may offer an objective analysis for

identifying changes in brain activity potentially acquired by a piano-playing music

therapy intervention.

151

5.5 Conclusions

This study investigated whether a music therapy piano-playing intervention is valuable

in the rehabilitation of unilateral and bilateral coordination for patients with chronic

stroke patients. The therapeutic potential of a piano-playing intervention had been

under-represented in the music therapy literature as a viable therapeutic method and this

study set out to assess whether it was a viable therapeutic intervention. Based on the

results of the study, a music therapy piano-playing intervention was found to be

effective, and therefore adds important evidence in support of greater attention being

given to it. Furthermore, the scope of previous studies was limited to emphasizing

unilateral hand and finger rehabilitation and this study showed a preliminary finding in

drawing attention to the rehabilitative effects of bilateral coordination in the hands and

fingers of patients affected by stroke.

A systematic piano-playing music therapy protocol and strategies were

explained in this study in order to optimize motor coordination skills of stroke patients.

The protocol and strategies make a seminal contribution to our understanding of music

therapy techniques for those who have suffered a stroke. A humanistic approach in

relation to a patient-centered therapy and process-oriented approach were suggested as

important factors in the rehabilitation process, enhancing the stroke patients‟ motivation

and active participation. It was also recommended that these strategies and guidelines be

adopted and that further research is warranted to see if these strategies work with other

patients, and those with related physical problems.

Additionally, a MIDI-based analysis was shown to be a viable music therapy

assessment tool to measure unilateral and bilateral finger coordination. Furthermore,

practicing music therapists could develop their own progressive musical exercises in

conjunction with the physical areas requiring of motor coordination in hand and finger

rehabilitation.

This study therefore contributes to the sparse literature on music therapy and

hand/finger rehabilitation. It is hope that further research will expand this neglected area

of rehabilitation so that patients will benefit from it to a greater extent.

152

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163

APPENDIX 6.1a Anatomy of the Brain

Source: http://www.flickr.com/photos/cobalt/157247236/in/photostream/

164

APPENDIX 6.1b Arteries of the Brain

Source : http://psyweb.com/Brain/Bimages/braina0.gif

165

APPENDIX 6.1c Effects of Stroke

Region of the

Cerebrum Damaged

by Stroke

Signs and Symptoms

Wernicke's area (central

language area)

Difficulty speaking understandably and

comprehending speech; confusion between left

and right; difficulty reading, writing, naming

objects, and calculating

Broca's area (speech) Difficulty speaking and, sometimes, writing

Parietal lobe on the left

side of the brain

Loss of coordination of the right arm and leg

Facial and limb areas of

the motor cortex on the

left side of the brain

Paralysis of the right arm and leg and the right

side of the face

Facial and arm areas of

the sensory cortex

Absence of sensation in the right arm and the

right side of the face Optic radiation Loss of the

right half of the visual field of both eyes

Source: http://www.medem.com/MedLB/article_detaillb.cfm

166

APPENDIX 6.1d Structure and function of the Brain

Brain Structure Function

Cerebral Cortex

Ventral View (From bottom)

The outermost layer of the cerebral

hemisphere which is composed of gray

matter. Cortices are asymmetrical. Both

hemispheres are able to analyse sensory

data, perform memory functions, learn

new information, form thoughts and make

decisions.

Left Hemisphere Sequential Analysis: systematic, logical

interpretation of information.

Interpretation and production of symbolic

information: language, mathematics,

abstraction and reasoning. Memory stored

in a language format.

Right Hemisphere Holistic Functioning: processing multi-

sensory input simultaneously to provide

"holistic" picture of one's environment.

Visual spatial skills. Holistic functions

such as dancing and gymnastics are

coordinated by the right hemisphere.

Memory is stored in auditory, visual and

spatial modalities.

Corpus Callosum

Connects right and left hemisphere to

allow for communication between the

hemispheres. Forms roof of the lateral and

third ventricles.

167

Frontal Lobe

Ventral View (From Bottom)

Side View

Cognition and memory.

Prefrontal area: The ability to concentrate

and attend, elaboration of thought. The

"Gatekeeper"; (judgment, inhibition).

Personality and emotional traits.

Movement:

Motor Cortex (Brodman's): voluntary

motor activity.

Premotor Cortex: storage of motor

patterns and voluntary activities.

Language: motor speech

Parietal Lobe

Processing of sensory input, sensory

discrimination.

Body orientation.

Primary/ secondary somatic area.

Occipital Lobe

Primary visual reception area.

Primary visual association area: Allows

for visual interpretation.

168

Temporal Lobe

Auditory receptive area and association

areas.

Expressed behaviour.

Language: Receptive speech.

Memory: Information retrieval.

Limbic System

Olfactory pathways:

Amygdala and their different pathways.

Hippocampi and their different pathways.

Limbic lobes: Sex, rage, fear; emotions.

Integration of recent memory, biological

rhythms.

Hypothalamus.

Basal Ganglia

Subcortical gray matter nuclei. Processing

link between thalamus and motor cortex.

Initiation and direction of voluntary

movement. Balance (inhibitory), Postural

reflexes.

Part of extrapyramidal system: regulation

of automatic movement.

Source: http://www.waiting.com/brainfunction.html

169

APPENDIX 6.1e Clinical features in anterior cerebral artery disease

Table 2.6 Clinical features in anterior cerebral artery disease

Hemiparesis Predominance

Brachiofacial

Hemihypesthesia Same distribution as hemiparesis

Contralateral grasp reflex

Urinary incontinence

Left infarct (Initial mutism) Transcortical motor aphasia or minor variants

(Right motor neglect)

Unilateral left apraxia

Abulia, apathy

Frontal syndrome

Right infarct (Initial mutism) Left motor/spatial neglect

Apathy

Acute confusional state

Frontal syndrome

Ipsilateral grasp reaction

Bilateral infarct Bilateral hemiparesis including

pseudoparaplegia

Akinetic mutism, severe mood disturbances

Long-lasting incontinence


170

APPENDIX 6.1f Clinical features in middle cerebral artery disease

Table 2.7 Clinical features in middle cerebral artery disease

Areas Features Left Right Bilateral

Prefrontal

artery

“Frontal”

syndrome

Transcortical motor

aphasia

Motor

hemineglect

Precentral

artery

Hemiparesis

with proximal

predominance

Premotor syn-

drome of Luria

Minor variant of

Broca’s aphasia

Agraphia

Central

sulcus

artery

Faciobrachial

hemiparesis,

Distal mono-

paresis of

upper limb

Cortical

dysarthria

Anterior

parietal

artery

Pseudothalamic

hemisensory

loss

Conduction

aphasia, Ideo-

motor apraxia,

Phonological

agraphia/alexia

Postrolandic

motor

hemineglect

Upper

posterior

parietal/

angular

gyrus cut

Lateral hemi-/

lower-quadrant

anopia

Wernicke‟s aphasia

variants, Lexical

alexia with

agraphia,

Aparaxia

Gertsmann’s

syndrome

Autotopo-agnosia

Hemineglect &

other visuo-spatial

disturbances,

Asomatognosia,

Constructive

apraxia, Optic

ataxia, Bilateral

eye tracking

impairment

Balint’s

syndrome

Altitudinal

neglect

Lower

posterior

parietal/

temporal

arteries

Lateral hemi-/

upper-

quadrant

anopia

Wernicke’s

aphasia asymbolia

for pain

Acute confusional

state, Spatial

hemineglect,

Spatial delirium

Pure word

/Cortical

deafness

Rejection

behavior

Source: Bogousslavsky & Hommel, 1993, p. 55-56

171

APPENDIX 6.1g Clinical features in posterior cerebral artery disease

Table 2.8-a Clinical features in posterior cerebral artery disease (a)

Structure involved Neurological dysfunction

Midbrain Hemiplegia

Thalamus:

paramedian,

inferolateral,

posterior choroidal

See table 2.8-b

Medial temporal

lobe

Memory disturbances

Occipital lobe Lateral hemianopia

Visual hallucinations, metamorphopsias, monocular diplopia

Impairment of movement perception, astereopsis left tactile-

visual anomia/left-hand diagnostic apraxia

Left Dysmnesia

Pure alexia, optic aphasia

Transcortical sensory aphasia

Hemiachromatopsia, color anomia

Visual hemineglect

Acute hemineglect, acute delirium

Right Dysmnesia, transient global amnesia

Visual hemineglect

Palinopia

Impaired mental imagery

Bilateral Bilateral hemianopia

Cortical blindness, Anton‟s syndrome

Altitudinal hemianopia

Prosopagnosia, visual object agnosia

Amnesia


172

Table 2.8-b Clinical features in posterior cerebral artery disease (b)

Areas Features

Inferolateral territory

infarcts

Hemihypesthesia and partial variants, pain

Mild hemiparesis or ataxia

No neuropsychological disturbances

Tuberothalamic

territory infarcts

Left Dysphasia

Right Hemineglect

Mild hemiparesis or hemihypesthesia

Paramedian territory

infarcts

Decreased consciousness, hallucinosis

Moderate hemiparesis, asterixis, ataxia, astasia, action-

induced dystonia

Upgaze limitation, vertical one-and-a-half syndrome

Left Dysphasia, dysmnesia, hemineglect

Right Hemineglect, dysmnesia, confusional state

Bilateral Mitral coma, severe amnesia, confusional

state, dysphasia, neglect, loss of self-psychic

activation, ataxia, gaze palsy

Posterior choroidal

territory infarcts

Visual filed

cut

Horizontal homonymous sector-anopia,

Quadrant-anopia

Mild hemiparesis/ hemihypesthesia /speech disturbances


173

APPENDIX 6.2 Glossary

174

175

176

177

APPENDIX 6.3 Review of a Low-risk Project Involving Humans

178

179

180

181

182

183

184

185

186

APPENDIX 6.4a Consent Form (English)

THE UNIVERSITY OF MELBOURNE

FACULTY OF MUSIC

Consent form for persons participating in research projects

PROJECT TITLE: The Rehabilitative Effects of Piano Playing Exercises on

Bilateral Fine Motor Coordination: A MIDI Analysis with Chronic Stroke Patients

Name of participant:

Name of investigators: A/Prof Dr Denise Grocke, Faculty of Music, University of Melbourne

Ms So-Young Moon, Doctorate student, Faculty of Music, University of Melbourne

1. I consent to participate in the project named above, the particulars of which -

including details of the procedures, tests, and interviews - have been explained

to me. A written copy of the information has been given to me to keep.

2. I authorise the researcher or her assistant to use with me the procedures, tests,

and interviews, referred to under (1) above.

3. I acknowledge that:

(a) The possible effects of the procedures, tests, and interviews have been

explained to me to my satisfaction

(b) I am free to withdraw from the project at any time without explanation or

prejudice and to withdraw any unprocessed data previously supplied

(c) The project is for the purpose of research

(d) The confidentiality of the information I provide will be safeguarded subject to

any legal requirements

(e) I understand the procedures, tests, and interviews are recorded and my

identity will be kept confidential and all written articles or conference

presentations will maintain that confidentiality

Signature Date

(Participant)

187

APPENDIX 6.4b Consent Form (Korean)

188

APPENDIX 6.5a Plain Language Statement (English)

Plain Language Statement

(This draft is in English and to be translated into Korean language)

Re: A study of rehabilitative effects of piano playing exercises on bilateral fine

motor coordination: a MIDI analysis with chronic stroke patients

Investigators: A/Prof Dr Denise Grocke, Faculty of Music, University of Melbourne

Ms So-Young Moon, Doctorate student, Faculty of Music, University of Melbourne

We are interested in the rehabilitative effects of piano playing exercises on bilateral fine

motor coordination, and the development of a MIDI based music therapy assessment

tool in measuring finger dexterity. We wish to carry out a research project on this topic,

which is part of So-Young Moon‟s studies towards a Ph D degree at this University.

This project has been approved by the Human Research Ethics Committee at the

University.

We would like to invite you to participate in our research project. Your name and

contact details have been drawn from a database of the hospital with the permission of

the Rehabilitation Medicine Department. Should you agree to be involved, you would

be assigned to either the intervention or the control group. If you are placed into the

intervention group, the music therapy sessions will be held for half an hour, 3 days per

week for 4 weeks. The sessions will be conducted by the investigator, So-Young Moon,

and will consist of therapeutic piano playing exercises. Standard care will be given to

the participants of the control group.

In order to assess bimanual coordination you will be required to do some simple finger

tests at three times: before, after the interventions, and 1 month follow-up. You will be

asked to play the index finger tapping and the 5-finger exercises in unimanual and

bimanual movements. With your permission, each finger movement will be recorded on

the computer. Additionally, two hand function tests will be conducted and a short

interview will be given at the end of the project. The interviews will be recorded and

transcribed by the investigator. We estimate that the total time commitment for

assessment procedures would not exceed 30 minutes.

189

At all times your identity will be kept confidential. A pseudonym will be used in any

reports of this study, and any identifying information will be disguised. Your data will

be kept in a separate, password-protected computer file and stored securely for five

years from the date of publication, before being destroyed.

Your participation in this project is completely voluntary. If you would like to

participate, please indicate that you have read and understood this information by

signing the accompanying consent form. Should you agree to involve in the study, you

will be free to withdraw at any time. If you wish to withdraw this will not influence

your continuing music therapy sessions adversely.

Once this research has been completed, a brief summary of the findings will be

available to you. The results of this study may be helpful to other people who have

sustained stroke, and also to music therapists who work with people who have had

physical disorder affecting the hand. It is possible that the outcomes of the study will be

published in journal articles and books, and presented at academic conferences.

If you would like to ask any further information, please contact either of the

investigators on the numbers as follows; A/Prof Dr Denise Grocke: Fax +61-3-8344

5346, Ms So-Young Moon: +82-2-300 1452. If you have any concerns about the

conduct of the project, please do not hesitate to contact the Executive Officer, Human

Research Ethics, The University of Melbourne, on phone: +61-3-8344 2073, or fax:

9347 6739.

190

APPENDIX 6.5b Plain Language Statement (Korean)

191

APPENDIX 6.6 Results of Group Comparisons: Raw Data


finger movements in the non-affected hands of chronic stroke patients

1.1.1.1

Task 1 Non-affected hand index finger tapping

Outcome variable 1 Timing consistency

Comparison 1 Between treatment and control groups

Outcome measurement 1 MIDI

Rank s

9 9.11 82.00

7 7.71 54.00

16

Group1.00

2.00

Total

MT1TCN Mean Rank

Sum ofRanks

Test S tati st icsb

26.000

54.000

-.582

.560

.606a

.606

.303

.035

Mann-Whitney U

Wilcoxon W

Z

Asymp. Sig. (2-tailed)

Exact Sig. [2*(1-tailedSig.)]

Exact Sig. (2-tailed)


Point Probability

MT1TC

Not corrected for ties.a.

Grouping Variable: Groupb.

1.1.1.2




Outcome measurement 2 5-Point scale

192

Rank s

9 9.33 84.00

7 7.43 52.00

16

Group1.00

2.00

Total

T1TCN Mean Rank

Sum ofRanks

Test S tati st icsb

24.000

52.000

-.806

.420

.470a

.449

.225

.017

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T1TC



1.1.2.1



Comparison 2 Between pre- and post-tests in treatment group


Rank s

6a 5.50 33.00

3b 4.00 12.00

0c

9

Negative Ranks

Positive Ranks

Ties

Total

TGT1TCpost- TGT1TCpre

N Mean RankSum ofRanks

TGT1TCpost < TGT1TCprea.

TGT1TCpost > TGT1TCpreb.

TGT1TCpost = TGT1TCprec.

193

Test S ta ti st icsb

-1.244a

.214

.250

.125

.023

Z




Point Probability


Based on positive ranks.a.

Wilcoxon Signed Ranks Testb.

1.1.2.2





Rank s

0a .00 .00

9b 5.00 45.00

0c

9

Negative Ranks

Positive Ranks

Ties

Total

TG5T1TCpost- TG5T1TCpre


TG5T1TCpost < TG5T1TCprea.

TG5T1TCpost > TG5T1TCpreb.

TG5T1TCpost = TG5T1TCprec.


-2.677a

.007

.004

.002

.002

Z




Point Probability

TG5T1TCpost-

TG5T1TCpre

Based on negative ranks.a.


194

1.1.3.1



Comparison 3 Between pre- and post-tests in control group


Rank s

6a 4.33 26.00

1b 2.00 2.00

0c

7

Negative Ranks

Positive Ranks

Ties

Total

CGT1TCpost -CGT1TCpre


CGT1TCpost < CGT1TCprea.

CGT1TCpost > CGT1TCpreb.

CGT1TCpost = CGT1TCprec.


-2.028a

.043

.047

.023

.008

Z




Point Probability

CGT1TCpost- CGT1TCpre



1.1.3.2





195

Rank s

0a .00 .00

6b 3.50 21.00

1c

7

Negative Ranks

Positive Ranks

Ties

Total

CG5T1TCpost- CG5T1TCpre


CG5T1TCpost < CG5T1TCprea.

CG5T1TCpost > CG5T1TCpreb.

CG5T1TCpost = CG5T1TCprec.


-2.232a

.026

.031

.016

.016

Z




Point Probability

CG5T1TCpost-

CG5T1TCpre



1.2.1.1


Outcome variable 2 Velocity Evenness



Rank s

9 8.56 77.00

7 8.43 59.00

16

Group1.00

2.00

Total

MT1VEN Mean Rank

Sum ofRanks

196

Test S tati st icsb

31.000

59.000

-.053

.958

1.000a

1.000

.500

.041

Mann-Whitney U

Wilcoxon W

Z





Point Probability

MT1VE



1.2.1.2


Outcome variable 2 Velocity Evenness



Rank s

9 7.06 63.50

7 10.36 72.50

16

Group1.00

2.00

Total

T1VEN Mean Rank

Sum ofRanks

Test S tati st icsb

18.500

63.500

-1.385

.166

.174a

.179

.089

.006

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T1VE



197

1.2.2.1


Outcome variable 2 Velocity evenness



Rank s

7a 5.14 36.00

2b 4.50 9.00

0c

9

Negative Ranks

Positive Ranks

Ties

Total

TGT1VEpost- TGT1VEpre


TGT1VEpost < TGT1VEprea.

TGT1VEpost > TGT1VEpreb.

TGT1VEpost = TGT1VEprec.


-1.599a

.110

.129

.064

.016

Z




Point Probability




1.2.2.2





198

Rank s

0a .00 .00

8b 4.50 36.00

1c

9

Negative Ranks

Positive Ranks

Ties

Total

TG5T1VEpost- TG5T1VEpre


TG5T1VEpost < TG5T1VEprea.

TG5T1VEpost > TG5T1VEpreb.

TG5T1VEpost = TG5T1VEprec.


-2.555a

.011

.008

.004

.004

Z




Point Probability

TG5T1VEpost-

TG5T1VEpre



1.2.3.1





Rank s

5a 4.60 23.00

2b 2.50 5.00

0c

7

Negative Ranks

Positive Ranks

Ties

Total

CGT1VEpost- CGT1VEpre


CGT1VEpost < CGT1VEprea.

CGT1VEpost > CGT1VEpreb.

CGT1VEpost = CGT1VEprec.

199


-1.524a

.128

.141

.070

.016

Z




Point Probability




1.2.3.2





Rank s

0a .00 .00

6b 3.50 21.00

1c

7

Negative Ranks

Positive Ranks

Ties

Total

CG5T1VEpost- CG5T1VEpre


CG5T1VEpost < CG5T1VEprea.

CG5T1VEpost > CG5T1VEpreb.

CG5T1VEpost = CG5T1VEprec.


-2.226a

.026

.031

.016

.016

Z




Point Probability

CG5T1VEpost-

CG5T1VEpre



200

1.3.1.2


Outcome variable 3 Accuracy of key striking



Rank s

9 8.72 78.50

7 8.21 57.50

16

Group1.00

2.00

Total

T1AKN Mean Rank

Sum ofRanks

Test S tati st icsb

29.500

57.500

-.219

.827

.837a

.848

.426

.021

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T1AK



1.3.2.2





201

Rank s

0a .00 .00

6b 3.50 21.00

3c

9

Negative Ranks

Positive Ranks

Ties

Total

TG5T1AKpost- TG5T1AKpre


TG5T1AKpost < TG5T1AKprea.

TG5T1AKpost > TG5T1AKpreb.

TG5T1AKpost = TG5T1AKprec.


-2.207a

.027

.031

.016

.016

Z




Point Probability

TG5T1AKpost-

TG5T1AKpre



1.3.3.2





Rank s

4a 3.13 12.50

2b 4.25 8.50

1c

7

Negative Ranks

Positive Ranks

Ties

Total

CG5T2AKpost- CG5T2AKpre


CG5T2AKpost < CG5T2AKprea.

CG5T2AKpost > CG5T2AKpreb.

CG5T2AKpost = CG5T2AKprec.

202


-.422a

.673

.781

.391

.094

Z




Point Probability

CG5T2AKpost-

CG5T2AKpre



2.1.1.1

Task 2 Non-affected hand 5-finger sequential playing




Rank s

9 6.22 56.00

7 11.43 80.00

16

Group1.00

2.00

Total

MT2TCN Mean Rank

Sum ofRanks

Test S tati st icsb

11.000

56.000

-2.170

.030

.031a

.031

.016

.004

Mann-Whitney U

Wilcoxon W

Z





Point Probability

MT2TC



203

2.1.1.2





Rank s

9 11.61 104.50

7 4.50 31.50

16

Group1.00

2.00

Total

T2TCN Mean Rank

Sum ofRanks

Test S tati st icsb

3.500

31.500

-2.984

.003

.001a

.001

.001

.000

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T2TC



2.1.2.1





204

Rank s

7a 5.57 39.00

2b 3.00 6.00

0c

9

Negative Ranks

Positive Ranks

Ties

Total







-1.955a

.051

.055

.027

.008

Z




Point Probability




2.1.2.2





Rank s

1a 1.00 1.00

8b 5.50 44.00

0c

9

Negative Ranks

Positive Ranks

Ties

Total






205


-2.556a

.011

.008

.004

.002

Z




Point Probability

TG5T2TCpost-

TG5T2TCpre



2.1.3.1





Rank s

2a 1.50 3.00

5b 5.00 25.00

0c

7

Negative Ranks

Positive Ranks

Ties

Total

CGT2TCpost -CGT2TCpre


CGT2TCpost < CGT2TCprea.

CGT2TCpost > CGT2TCpreb.

CGT2TCpost = CGT2TCprec.


-1.859a

.063

.078

.039

.016

Z




Point Probability

CGT2TCpost- CGT2TCpre



206

2.1.3.2





Rank s

4a 2.50 10.00

0b .00 .00

3c

7

Negative Ranks

Positive Ranks

Ties

Total







-1.841a

.066

.125

.063

.063

Z




Point Probability

CG5T2TCpost-

CG5T2TCpre



2.2.1.1





207

Rank s

9 5.44 49.00

7 12.43 87.00

16

Group1.00

2.00

Total

MT2VEN Mean Rank

Sum ofRanks

Test S tati st icsb

4.000

49.000

-2.913

.004

.002a

.002

.001

.000

Mann-Whitney U

Wilcoxon W

Z





Point Probability

MT2VE



2.2.1.2





Rank s

9 9.61 86.50

7 7.07 49.50

16

Group1.00

2.00

Total

T2VEN Mean Rank

Sum ofRanks

208

Test S tati st icsb

21.500

49.500

-1.066

.286

.299a

.306

.153

.012

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T2VE



2.2.2.1





Rank s

8a 5.50 44.00

1b 1.00 1.00

0c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.547a

.011

.008

.004

.002

Z




Point Probability




209

2.2.2.2





Rank s

0a .00 .00

8b 4.50 36.00

1c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.536a

.011

.008

.004

.004

Z




Point Probability

TG5T2VEpost-

TG5T2VEpre



2.2.3.1





210

Rank s

2a 3.50 7.00

5b 4.20 21.00

0c

7

Negative Ranks

Positive Ranks

Ties

Total



CGT2VEpost < CGT2VEprea.

CGT2VEpost > CGT2VEpreb.

CGT2VEpost = CGT2VEprec.


-1.183a

.237

.297

.148

.039

Z




Point Probability




2.2.3.2





Rank s

1a 2.50 2.50

4b 3.13 12.50

2c

7

Negative Ranks

Positive Ranks

Ties

Total






211


-1.361a

.174

.250

.125

.063

Z




Point Probability

CG5T2VEpost-

CG5T2VEpre



2.3.1.2





Rank s

9 11.61 104.50

7 4.50 31.50

16

group1.00

2.00

Total

T2AKN Mean Rank

Sum ofRanks

Test S tati st icsb

3.500

31.500

-2.968

.003

.001a

.001

.001

.000

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T2AK


Grouping Variable: groupb.

212

2.3.2.2





Rank s

0a .00 .00

8b 4.50 36.00

1c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.533a

.011

.008

.004

.004

Z




Point Probability

TG5T2AKpost-

TG5T2AKpre



2.3.3.2





213

Rank s

0a .00 .00

3b 2.00 6.00

4c

7

Negative Ranks

Positive Ranks

Ties

Total







-1.604a

.109

.250

.125

.125

Z




Point Probability

CG5T3AKpost-

CG5T3AKpre



214


finger movements in the affected hands of chronic stroke patients

3.1.1.2

Task 3 Affected hand index finger tapping




Rank s

9 11.28 101.50

7 4.93 34.50

16

Group1.00

2.00

Total

T3TCN Mean Rank

Sum ofRanks

Test S tati st icsb

6.500

34.500

-2.670

.008

.005a

.005

.003

.001

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T3TC



3.1.2.1





215

Rank s

3a 3.67 11.00

2b 2.00 4.00

0c

5

Negative Ranks

Positive Ranks

Ties

Total







-.944a

.345

.438

.219

.063

Z




Point Probability




3.1.2.2





Rank s

0a .00 .00

9b 5.00 45.00

0c

9

Negative Ranks

Positive Ranks

Ties

Total






216


-2.668a

.008

.004

.002

.002

Z




Point Probability

TG5T3TCpost-

TG5T3TCpre



3.1.3.2





Rank s

0a .00 .00

3b 2.00 6.00

4c

7

Negative Ranks

Positive Ranks

Ties

Total







-1.633a

.102

.250

.125

.125

Z




Point Probability

CG5T3TCpost-

CG5T3TCpre



217

3.2.1.2





Rank s

9 10.44 94.00

7 6.00 42.00

16

Group1.00

2.00

Total

T3VEN Mean Rank

Sum ofRanks

Test S tati st icsb

14.000

42.000

-1.903

.057

.071a

.060

.030

.005

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T3VE



3.2.2.1





218

Rank s

4a 3.50 14.00

1b 1.00 1.00

0c

5

Negative Ranks

Positive Ranks

Ties

Total







-1.753a

.080

.125

.063

.031

Z




Point Probability




3.2.2.2





Rank s

0a .00 .00

7b 4.00 28.00

2c

9

Negative Ranks

Positive Ranks

Ties

Total






219


-2.384a

.017

.016

.008

.008

Z




Point Probability

TG5T3VEpost-

TG5T3VEpre



3.2.3.2





Rank s

0a .00 .00

3b 2.00 6.00

4c

7

Negative Ranks

Positive Ranks

Ties

Total







-1.633a

.102

.250

.125

.125

Z




Point Probability

CG5T3VEpost-

CG5T3VEpre



220

3.3.1.2





Rank s

9 10.89 98.00

7 5.43 38.00

16

Group1.00

2.00

Total

T3AKN Mean Rank

Sum ofRanks

Test S tati st icsb

10.000

38.000

-2.314

.021

.023a

.020

.010

.002

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T3AK



3.3.2.2





221

Rank s

0a .00 .00

8b 4.50 36.00

1c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.521a

.012

.008

.004

.004

Z




Point Probability

TG5T3AKpost-

TG5T3AKpre



3.3.3.2





Rank s

0a .00 .00

3b 2.00 6.00

4c

7

Negative Ranks

Positive Ranks

Ties

Total






222


-1.604a

.109

.250

.125

.125

Z




Point Probability

CG5T3AKpost-

CG5T3AKpre



4.1.1.2

Task 4 Affected hand 5-finger sequential playing




Rank s

9 10.22 92.00

7 6.29 44.00

16

Group1.00

2.00

Total

T4TCN Mean Rank

Sum ofRanks

Test S tati st icsb

16.000

44.000

-1.887

.059

.114a

.053

.029

.018

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T4TC



223

4.1.2.1





Rank s

4a 3.25 13.00

1b 2.00 2.00

0c

5

Negative Ranks

Positive Ranks

Ties

Total







-1.483a

.138

.188

.094

.031

Z




Point Probability




4.1.2.2





224

Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.032a

.042

.063

.031

.031

Z




Point Probability

TG5T4TCpost-

TG5T4TCpre



4.1.3.2





Rank s

0a .00 .00

1b 1.00 1.00

6c

7

Negative Ranks

Positive Ranks

Ties

Total






225


-1.000a

.317

1.000

.500

.500

Z




Point Probability

CG5T4TCpost-

CG5T4TCpre



4.2.1.2





Rank s

9 9.67 87.00

7 7.00 49.00

16

Group1.00

2.00

Total

T4VEN Mean Rank

Sum ofRanks

Test S tati st icsb

21.000

49.000

-1.351

.177

.299a

.187

.110

.040

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T4VE



226

4.2.2.1





Rank s

5a 3.00 15.00

0b .00 .00

0c

5

Negative Ranks

Positive Ranks

Ties

Total







-2.023a

.043

.063

.031

.031

Z




Point Probability




4.2.2.2





227

Rank s

0a .00 .00

4b 2.50 10.00

5c

9

Negative Ranks

Positive Ranks

Ties

Total







-1.890a

.059

.125

.063

.063

Z




Point Probability

TG5T4VEpost-

TG5T4VEpre



4.2.3.2





Rank s

0a .00 .00

1b 1.00 1.00

6c

7

Negative Ranks

Positive Ranks

Ties

Total






228


-1.000a

.317

1.000

.500

.500

Z




Point Probability

CG5T4VEpost-

CG5T4VEpre



4.3.1.2





Rank s

9 10.00 90.00

7 6.57 46.00

16

Group1.00

2.00

Total

T4AKN Mean Rank

Sum ofRanks

Test S tati st icsb

18.000

46.000

-1.576

.115

.174a

.122

.066

.018

Mann-Whitney U

Wilcoxon W

Z





Point Probability

T4AK



229

4.3.2.2





Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.032a

.042

.063

.031

.031

Z




Point Probability

TG5T4AKpost-

TG5T4AKpre



4.3.3.2





230

Rank s

0a .00 .00

2b 1.50 3.00

5c

7

Negative Ranks

Positive Ranks

Ties

Total







-1.342a

.180

.500

.250

.250

Z




Point Probability

CG5T4AKpost-

CG5T4AKpre



231

Hypothesis 3 Piano-playing music therapy will improve bilateral coordination of finger

movements in chronic stroke patients

5.1.2.2

Task 5 Both hands index finger tapping simultaneously




Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.023a

.043

.063

.031

.031

Z




Point Probability

TG5T5TCpost-

TG5T5TCpre



5.2.2.2





232

Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.032a

.042

.063

.031

.031

Z




Point Probability

TG5T5VEpost-

TG5T5VEpre



5.3.2.2





Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total






233


-2.023a

.043

.063

.031

.031

Z




Point Probability

TG5T5AKpost-

TG5T5AKpre



5.4.2.2


Outcome variable 4 Stability of synchronizing 2-key strike



Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total

TG5T5SSpost- TG5T5SSpre


TG5T5SSpost < TG5T5SSprea.

TG5T5SSpost > TG5T5SSpreb.

TG5T5SSpost = TG5T5SSprec.


-2.032a

.042

.063

.031

.031

Z




Point Probability

TG5T5SSpost-

TG5T5SSpre



234

6.1.2.2

Task 6 Both hands index finger tapping alternately




Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.023a

.043

.063

.031

.031

Z




Point Probability

TG5T6TCpost-

TG5T6TCpre



6.2.2.2





235

Rank s

0a .00 .00

3b 2.00 6.00

6c

9

Negative Ranks

Positive Ranks

Ties

Total







-1.633a

.102

.250

.125

.125

Z




Point Probability

TG5T6VEpost-

TG5T6VEpre



6.3.2.2





Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total






236


-2.032a

.042

.063

.031

.031

Z




Point Probability

TG5T6AKpost-

TG5T6AKpre



6.4.2.2





Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.032a

.042

.063

.031

.031

Z




Point Probability

TG5T6SSpost-

TG5T6SSpre



237

7.1.2.2

Task 7 Both hands 5-finger sequential playing




Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.041a

.041

.063

.031

.031

Z




Point Probability

TG5T7TCpost-

TG5T7TCpre



7.2.2.2





238

Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.041a

.041

.063

.031

.031

Z




Point Probability

TG5T7VEpost-

TG5T7VEpre



7.3.2.2





Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total






239


-2.032a

.042

.063

.031

.031

Z




Point Probability

TG5T7AKpost-

TG5T7AKpre



7.4.2.2





Rank s

0a .00 .00

5b 3.00 15.00

4c

9

Negative Ranks

Positive Ranks

Ties

Total







-2.032a

.042

.063

.031

.031

Z




Point Probability

TG5T7SSpost-

TG5T7SSpre



240

APPENDIX 6.7 Results of Individual Comparisons: Descriptive Analysis

1. Participant 1 1. 1 Task 1. Non-affected hand index finger tapping

Figure 1 Participant 1-Task 1, MIDI Piano roll view: Pre-test (05-Sep-2005) and Post-test (29-Sep-2005,)

1. 2 Task 2. Non-affected hand 5-finger sequential playing

Figure 2. Participant 1-Task 2, MIDI Piano roll view: Pre-test (05-Sep-2005) and Post-test (29-Sep-2005)



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 2.0 2.0 2.0 2.0 2.3 2.7

Post-test 5.0 4.7 4.7 4.0 4.5 3.7


Figure 3. Participant 1-Task 1 ~ 2, Five-Point Scale Comparison: Pre-test and Post-test

241

1. 3 Task 3. Affected hand index finger tapping




0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 1.0 1.0 1.0

Post-test 5.0 4.7 4.3

T3AK T3TC T3VE

Figure 5. Participant 1-Task 3, Five-Point Scale Comparison: Pre-test and Post-test

2. Participant 2

2. 1 Task 1. Non-affected hand index finger tapping


242





0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 4.3 3.7 4.0 2.7 3.0 3.3

Post-test 5.0 5.0 4.7 4.7 4.0 3.3





243

2. 4 Task 4. Affected hand 5-finger sequential playing

Figure 10. Participant 2-Task 4, MIDI Piano roll view: Pre-test and Post-test



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 4.7 4.0 3.7 3.7 3.0 3.0

Post-test 5.0 4.7 4.3 4.7 4.0 3.3



2. 5 Task 5. Both hands index finger tapping simultaneously


244

2. 6 Task 6. Both hands index finger tapping alternately




0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.7 3.7 3.0 3.3 4.0 3.3 4.0 3.3

Post-test 4.3 4.3 3.3 4.0 4.7 4.3 4.3 3.7



2. 7 Task 7. Both hands 5-finger sequential playing


245



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 1.0 1.0 1.0 1.0

Post-test 4.0 3.0 2.3 4.0

T7AK T7TC T7VE T7SS


3. Participant 3





246



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 4.7 4.3 3.7 2.7 2.3 2.3

Post-test 5.0 5.0 4.3 4.7 3.7 3.0







247



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 4.3 3.0 3.3 2.0 2.0 2.0

Post-test 5.0 5.0 4.0 4.3 3.7 3.0







248



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.0 3.0 3.3 3.0 3.0 3.7 3.7 3.3

Post-test 5.0 5.0 4.0 5.0 4.7 4.0 4.0 4.3







0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 1.0 1.0 1.0 1.0

Post-test 3.3 3.0 2.3 3.0

T7AK T7TC T7VE T7SS

249

4. Participant 4







0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.7 4.0 4.0 2.7 3.3 3.0

Post-test 5.0 4.7 4.3 4.0 3.0 4.3



250







0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.7 4.0 4.3 2.7 2.7 2.7

Post-test 5.0 5.0 4.3 4.3 4.7 3.7



251







0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 1.0 1.0 1.0 1.0 4.3 4.3 3.3 4.3

Post-test 5.0 4.3 4.7 4.7 4.7 4.7 3.3 4.7



252





0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 1.0 1.0 1.0 1.0

Post-test 2.3 2.0 2.7 2.0

T7AK T7TC T7VE T7SS


5. Participant 5



253





0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.0 2.3 3.7 3.0 3.0 3.3

Post-test 5.0 4.7 4.3 4.7 4.3 4.7





254



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 1.0 1.0 1.0

Post-test 3.0 2.7 3.0

T3AK T3TC T3VE


6. Participant 6





255



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 4.7 4.0 4.0 4.0 3.0 3.0

Post-test 5.0 5.0 4.3 4.7 4.0 3.7







256



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.3 3.3 3.3 2.3 2.3 2.3

Post-test 5.0 5.0 4.3 4.7 3.7 3.3







257



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.0 2.7 3.3 3.0 3.0 3.0 3.3 3.0

Post-test 4.7 4.3 4.3 4.7 4.7 4.3 4.0 4.0






5-Point Scale Comparison betw een Pre-test and Post-test

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 3.0 2.7 2.3 2.7

Post-test 4.3 4.0 3.3 4.0

T7AK T7TC T7VE T7SS


258

7. Participant 7


Figure 55. Participant 7-Task 1 MIDI Piano roll view: Pre-test and Post-test





0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 4.7 4.3 3.7 4.3 3.3 3.0

Post-test 4.7 4.7 4.0 4.3 3.7 3.3


Figure 57. Participant 7-Task 1 ~ 2, Five-Point Scale Comparison: (14-Nov-2005) and Post-test

259





0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 1.0 1.0 1.0

Post-test 4.3 3.7 2.0

T3AK T3TC T3VE

Figure 59. Participant 7-Task 3, Five-Point Scale Comparison: (14-Nov-2005) and Post-test

8. Participant 8



260





0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 5.0 4.3 4.3 3.7 3.0 3.0

Post-test 5.0 4.7 4.3 4.7 3.7 3.3





261





0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 5.0 4.3 4.3 3.7 3.0 3.3

Post-test 5.0 4.7 4.3 4.7 4.0 3.3





262





0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 4.3 4.3 3.3 4.0 3.0 2.3 3.3 2.7

Post-test 4.7 4.7 4.3 4.7 4.3 4.0 3.3 4.0





263



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 2.3 2.3 2.0 2.3

Post-test 3.7 3.3 3.0 3.3

T7AK T7TC T7VE T7SS


9. Participant 9





264



0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 4.7 4.3 4.0 3.3 3.0 2.3

Post-test 4.7 4.7 4.3 4.7 4.0 3.0







0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

4.4

4.6

4.8

5.0

5.2

Pre-test 1.0 1.0 1.0

Post-test 2.0 2.3 2.0

T3AK T3TC T3VE


Minerva Access is the Institutional Repository of The University of Melbourne

Author/s:Moon, So-Young

Title:The rehabilitative effects of piano-playing music therapy on unilateral and bilateral motorcoordination of chronic stroke patients: a MIDI analysis

Date:2007

Citation:Moon, S. (2007). The rehabilitative effects of piano-playing music therapy on unilateral andbilateral motor coordination of chronic stroke patients: a MIDI analysis. PhD thesis, Facultyof Music, The University of Melbourne.

Publication Status:Unpublished

Persistent Link:http://hdl.handle.net/11343/37500

Terms and Conditions:Terms and Conditions: Copyright in works deposited in Minerva Access is retained by thecopyright owner. The work may not be altered without permission from the copyright owner.Readers may only download, print and save electronic copies of whole works for their ownpersonal non-commercial use. Any use that exceeds these limits requires permission fromthe copyright owner. Attribution is essential when quoting or paraphrasing from these works.

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THE REHABILITATIVE EFFECTS OF PIANO-PLAYING MUSIC …