Esther Duarte

Music supported therapy promotes motor plasticity in individuals with chronic stroke.

Novel rehabilitation interventions have improved motor recovery by induction of neural plasticity in individuals with stroke. Of these, Music-supported therapy (MST) is based on music training designed to restore motor deficits. Music training requires multimodal processing, involving the integration and co-operation of visual, motor, auditory, affective and cognitive systems. The main objective of this study was to assess, in a group of 20 individuals suffering from chronic stroke, the motor, cognitive, emotional and neuroplastic effects of MST. Using functional magnetic resonance imaging (fMRI) we observed a clear restitution of both activity and connectivity among auditory-motor regions of the affected hemisphere. Importantly, no differences were observed in this functional network in a healthy control group, ruling out possible confounds such as repeated imaging testing. Moreover, this increase in activity and connectivity between auditory and motor regions was accompanied by a functional improvement of the paretic hand. The present results confirm MST as a viable intervention to improve motor function in chronic stroke individuals.

Musical training as an alternative and effective method for neuro-education and neuro-rehabilitation.

In the last decade, important advances in the field of cognitive science, psychology, and neuroscience have largely contributed to improve our knowledge on brain functioning. More recently, a line of research has been developed that aims at using musical training and practice as alternative tools for boosting specific perceptual, motor, cognitive, and emotional skills both in healthy population and in neurologic patients. These findings are of great hope for a better treatment of language-based learning disorders or motor impairment in chronic non-communicative diseases. In the first part of this review, we highlight several studies showing that learning to play a musical instrument can induce substantial neuroplastic changes in cortical and subcortical regions of motor, auditory and speech processing networks in healthy population. In a second part, we provide an overview of the evidence showing that musical training can be an alternative, low-cost and effective method for the treatment of language-based learning impaired populations. We then report results of the few studies showing that training with musical instruments can have positive effects on motor, emotional, and cognitive deficits observed in patients with non-communicable diseases such as stroke or Parkinson Disease. Despite inherent differences between musical training in educational and rehabilitation contexts, these results favor the idea that the structural, multimodal, and emotional properties of musical training can play an important role in developing new, creative and cost-effective intervention programs for education and rehabilitation in the next future.

Rehabilitation profiles of older adult stroke survivors admitted to intermediate care units: A multi-centre study

Background Stroke is a major cause of disability in older adults, but the evidence around post-acute treatment is limited and heterogeneous. We aimed to identify profiles of older adult stroke survivors admitted to intermediate care geriatric rehabilitation units. Methods We performed a cohort study, enrolling stroke survivors aged 65 years or older, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, we included age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, cognitive impairment and stroke severity in a cluster analysis. We also proposed a practical decision tree for patient’s classification in clinical practice. We analyzed differences between profiles in functional improvement (Barthel index), relative functional gain (Montebello index), length of hospital stay (LOS), rehabilitation efficiency (functional improvement by LOS), and new institutionalization using multivariable regression models (for continuous and dichotomous outcomes). Results Among 384 patients (79.1±7.9 years, 50.8% women), we identified 3 complexity profiles: a) Lower Complexity with Caregiver (LCC), b) Moderate Complexity without Caregiver (MCN), and c) Higher Complexity with Caregiver (HCC). The decision tree showed high agreement with cluster analysis (96.6%). Using either linear (continuous outcomes) or logistic regression, both LCC and MCN, compared to HCC, showed statistically significant higher chances of functional improvement (OR = 4.68, 95%CI = 2.54–8.63 and OR = 3.0, 95%CI = 1.52–5.87, respectively, for Barthel index improvement ≥20), relative functional gain (OR = 4.41, 95%CI = 1.81–10.75 and OR = 3.45, 95%CI = 1.31–9.04, respectively, for top Vs lower tertiles), and rehabilitation efficiency (OR = 7.88, 95%CI = 3.65–17.03 and OR = 3.87, 95%CI = 1.69–8.89, respectively, for top Vs lower tertiles). In relation to LOS, MCN cluster had lower chance of shorter LOS than LCC (OR = 0.41, 95%CI = 0.23–0.75) and HCC (OR = 0.37, 95%CI = 0.19–0.73), for LOS lower Vs higher tertiles. Conclusion Our data suggest that post-stroke rehabilitation profiles could be identified using routine assessment tools and showed differential recovery. If confirmed, these findings might help to develop tailored interventions to optimize recovery of older stroke patients.

La atención hospitalaria al paciente con ictus en Cataluña: resultados del «Primer Audit Clínic de l'Ictus. Catalunya, 2005/2006»

Objetivo: Analizar la calidad de la atencion hospitalaria al paciente con ictus en los hospitales publicos catalanes antes de la difusion de la Guia de Practica Clinica (GPC) del ictus, estudiando el grado de adhesion a determinadas recomendaciones de la GPC. Metodos: Mediante revision retrospectiva de historias clinicas de pacientes con ictus definidos mediante los codigos CIE-9 431, 433.x1, 434.x1, 436, e ingresados consecutivamente en 48 hospitales publicos catalanes en el primer semestre de 2005, se recogio informacion sobre distintos indicadores del proceso asistencial al ictus seleccionados segun su evidencia cientifica o su importancia clinica. Los hospitales participantes reclutaron 20, 40 o 60 casos, segun el numero de ingresos/ano. Se llevo a cabo una auditoria externa en el 9,3% de los casos reclutados en cada centro, tras seleccion aleatoria, para determinar la calidad de los datos recogidos. Los indicadores se agruparon en 6 perfiles relacionados con diferentes aspectos de la practica clinica. Resultados: Se incluyeron 1.791 casos, un 53,9% hombres, con una media (desviacion estandar) de edad de 75,6 (12,4) anos. La concordancia global entre observadores fue de 0,7. El cumplimiento de los perfiles asistenciales (porcentaje medio [intervalo de confianza del 95%]) fue: calidad de la historia clinica, 78,5% (77,5-79,4); estandares de atencion basica, 92,4% (91,5-93,2); evaluacion neurologica, 38,3% (37,3-39,3); medidas iniciales del tratamiento rehabilitador, 44,9% (43,2-46,7); prevencion y manejo de complicaciones, 68,4% (66,9-70), y medidas preventivas iniciales, 78,9% (77,3-80,4). Conclusiones: En 2005 la atencion hospitalaria al ictus era mejorable, sobre todo los aspectos relacionados con la evaluacion y el seguimiento neurologico del paciente y la rehabilitacion.

Overactivation of the supplementary motor area in chronic stroke patients

Stroke induces a loss of neural function, but it triggers a complex amount of mechanisms to compensate the associated functional impairment. The present study aims to increase our understanding of the functional reshape of the motor system observed in chronic stroke patients during the preparation and the execution of movements. A cohort of 14 chronic stroke patients with a mild-to-moderate hemiparesis and 14 matched healthy controls were included in this study. Participants were asked to perform a bimanual reaction time task synchronizing alternated responses to the presentation of a visual cue. We used Laplacian-transformed EEG activity (LT-EEG) recorded at the locations Cz and C3/C4 to study the response-locked components associated with the motor system activity during the performance of this task. Behaviorally, patients showed larger variable errors than controls in synchronizing the frequency of execution of responses to the interstimulus interval, as well as slower responses compared with controls. LT-EEG analysis showed that whereas control participants increased their supplementary motor area (SMA) activity during the preparation of all responses, patients only showed an increment of activity over this area during their first response of the sequence. More interestingly, patients showed a clear increment of the LT-EEG activity associated with SMA shortly after motor responses as compared to the control participants. Finally, patients showed a hand-dependent inhibitory activity over motor areas ipsilateral to the response hand. Overall, our findings reveal drastic differences in the temporal dynamics of the LT-EEG components associated with the activity over motor and premotor cortices in chronic stroke patients compared with matched control participants during alternated hand responses.

Time Course of Motor Gains Induced by Music-Supported Therapy After Stroke: An Exploratory Case Study.

Objective: Previous studies have shown that Music-Supported Therapy (MST) can improve the motor function and promote functional neuroplastic changes in motor areas; however, the time course of motor gains across MST sessions and treatment periods remain unknown. The aim of this study was to explore the progression of the rehabilitation of motor deficits in a chronic stroke patient for a period of 7 months. Method: A reversal design (ABAB) was implemented in a chronic stroke patient where no treatment was provided in the A periods and MST was applied in the B periods. Each period comprised of 4 weeks and an extensive evaluation of the motor function using clinical motor tests and 3D movement analysis was performed weekly. During the MST periods, a keyboard task was recorded daily. A follow-up evaluation was performed 3 months after the second MST treatment. Results: Improvements were observed during the first sessions in the keyboard task but clinical gains were noticeable only at the end of the first treatment and during the second treatment period. These gains were maintained in the follow-up evaluation. Conclusions: This is the first study examining the pattern of motor recovery progression in MST, evidencing that gradual and continuous motor improvements are possible with the repeated application of MST training. Fast-acquisition in specific motor abilities was observed at the beginning of the MST training but generalization of these improvements to other motor tasks took place at the end or when another treatment period was provided.

[In-hospital stroke care in Catalonia [Spain]. Results of the "First Clinical Audit of Stroke. Catalonia, 2005/2006"].

OBJECTIVE To determine the quality of in-hospital stroke care in public acute care hospitals in Catalonia before the implementation of a clinical practice guideline (CPG) on stroke by determining adherence to specific recommendations of the CPG. METHODS We retrospectively reviewed the case notes of consecutive patients with stroke (defined with ICD-9 codes: 431, 433.x1, 434.x1, and 436) admitted to 48 Catalan hospitals within the first half of 2005. Data were collected on indicators of the healthcare process selected on the basis of their scientific evidence and/or clinical relevance. The participating hospitals included 20, 40 or 60 stroke cases according to their annual stroke caseload. After random selection, up to 9.3% of all cases recruited at each study center were externally monitored to assess the quality of the data gathered. Indicators were grouped into six different dimensions related to distinct aspects of clinical practice. RESULTS We analyzed data from 1,791 stroke cases (53.9% men, mean age: 75.6 [12.4] years). Overall inter-observer agreement was 0.7. Compliance with the six dimensions was as follows (mean percentage [95%CI]): quality of medical records, 78.5% (77.5-79.4); initial interventions, 92.4% (91.5-93.2); neurological assessment, 38.3% (37.3-39.3); assessment of rehabilitation needs, 44.9% (43.2-46.7); prevention and management of medical complications, 68.4% (66.9-70), and initial preventive measures, 78.9% (77.3-80.4). CONCLUSIONS In the first half of 2005, in-hospital stroke care in Catalonia showed room for improvement particularly in aspects related to the neurological assessment and follow-up of patients and their rehabilitation process.

Music‐supported therapy in the rehabilitation of subacute stroke patients: a randomized controlled trial

The effect of music‐supported therapy (MST) as a tool to restore hemiparesis of the upper extremity after a stroke has not been appropriately contrasted with conventional therapy. The aim of this trial was to test the effectiveness of adding MST to a standard rehabilitation program in subacute stroke patients. A randomized controlled trial was conducted in which patients were randomized to MST or conventional therapy in addition to the rehabilitation program. The intensity and duration of the interventions were equated in both groups. Before and after 4 weeks of treatment, motor and cognitive functions, mood, and quality of life (QoL) of participants were evaluated. A follow‐up at 3 months was conducted to examine the retention of motor gains. Both groups significantly improved their motor function, and no differences between groups were found. The only difference between groups was observed in the language domain for QoL. Importantly, an association was encountered between the capacity to experience pleasure from music activities and the motor improvement in the MST group. MST as an add‐on treatment showed no superiority to conventional therapies for motor recovery. Importantly, patients intrinsic motivation to engage in musical activities was associated with better motor improvement.

The Return Home Program: integrated health and social care for post-stroke patients

Introduction : Stroke represents the third cause of morbidity and mortality in adults, the first medical determinant of disability and the second of dementia. Around 50% of stroke survivors develop mobility limitations and disability in the activities of daily living (ADL). After a stroke, treatment aims include the recovery of the maximum possible independence and the promotion of social and working reinsertion, while reducing the risk of institutionalization and mortality. Early supported discharge from acute care has demonstrated quicker return home and a higher chance of achieving independence. Efficiency of such programs is associated, among other factors, with an appropriate selection of patients and with coordination with community and social services. In Barcelona, both the healthcare and social systems provide a wide range of resources, but the two systems are not integrated. After a stroke, patients admitted to acute or intermediate care hospitals are currently discharged with a personal healthcare plan, but the activation of social resources requires further assessments by primary healthcare and municipal social services at the patient’s home; this activates a process to assign resources and to establish the economic contribution of the user. The Return Home Program (RHP) aims at facilitating home discharge and the achievement of maximum possible independence. It is directed to improve coordination in order to: - Early detect post-stroke patients admitted to acute or intermediate care hospitals and candidate to home-based social and rehabilitation interventions. - Direct activate municipal social services (including personal assistance, house cleaning, tele-care, meals-on-wheels, rehabilitation aids) through the empowerment of social workers staff of the hospitals, which traditionally could only refer the person to primary care or social services. During the first weeks after discharge, activation is independent of the economic situation of the person. - Guarantee the availability of social resources right at discharge. - Provide the most efficient rehabilitation resource. Methods : Quasi-experimental study, with pre-post intervention and comparison groups. Aims: to evaluate short and middle-term impacts of RHP on functional recovery, quality of life and return home, as well as patients’ and caregivers’ satisfaction; to evaluate cost-effectiveness of RHP, compared to usual care. Target population: stroke patients admitted to acute or intermediate care hospitals ,with >2 impaired ADL and social needs. Barcelona healthcare services are organized in 4 Integral Healthcare Areas (IHA): the intervention group includes hospitals of the Left and Seaboard IHAs (reference population= 815.285 inhabitants), whereas the control group includes hospitals of the other 2 IHAs (812.177 inhabitants). Progress report : RHP will start in January 15th 2016, and the pilot will run for 1 year. So far, we concluded: - Bibliographic review about similar interventions and outcomes - Program and study design, by 3 parallel and partially overlapping working groups: 1) “intervention working group”, including specialists in rehabilitation and geriatrics, nurses, social workers from the healthcare and social sectors, psychologists, who defined the program, target population and screening and assessment tools; 2) “evaluation working group”, which sums, to the previous profiles, experts in public health and healthcare assessment, who refined study design and methods; 3) “implementation working group”, expanded to strategic stakeholders from the participants institutions, in charge of the training and follow-up. - Institutional support and funding (gratuity of municipal social resources and study funding), by the Government of Catalonia and the Municipality of Barcelona. Discussion : This experience, in a highly fragmented environment such as the city of Barcelona, adds the value of integrating healthcare social services in the hospital and basic municipal social services in the community. Early detection of needs in the hospital is cardinal for the effectiveness of the intervention. A further innovative aspect is the gratuity for the patient, independent of the economic level. The design of the study will allow the estimation of effectiveness and cost-effectiveness of the program through the comparison between the study groups. In order to guarantee the feasibility of the study, we included in the project all the relevant stakeholders, experts professionals, who allowed taking into account the context and possible barriers, and leaders from the involved public administrations. We will present preliminary results at ICIC16. Conclusions : RHP is an innovative program which will promote integrated health and social care for a group of particularly vulnerable adults, in a high fragmented environment. Due to these elements of difficulty, in case of positive results we envision the translation of this program to other groups and contexts. After completing the design and planning phases, we will start the program shortly.