MUSIC THERAPY IN THE COGNITIVE AND NEURAL REHABILITATION OF TRAUMATIC BRAIN INJURY

Traumatic brain injury (TBI) can have lifelong cognitive, emotional, and physical consequences. Music engages many cognitive, motor, and emotional functions making it a promising rehabilitation tool, but the effects of music in TBI are still largely unknown. The aim of this thesis was to explore the efficacy of neurological music therapy in the rehabilitation of moderate and severe TBI, particularly on executive functions (EF). The thesis includes three studies based on a cross-over randomized controlled trial (RCT), in which 40 participants with TBI (time since injury < 2 years) were randomized into two groups (AB/BA) to receive a 3-month neurological music therapy intervention either during the first (AB, n=20) or second (BA, n=20) half of a 6-month follow-up period. Neuropsychological and motor testing, questionnaires, and structural and functional magnetic resonance imaging (MRI) were performed at baseline and at the 3-month and 6-month stage. Results from Study I showed that general EF and set shifting improved more in the AB group than in the BA group over the first 3-month period, and the effect on general EF was maintained in the 6-month follow-up. Voxel-based morphometry analysis of the structural MRI data indicated that gray matter volume in the right inferior frontal gyrus increased significantly in both groups during the intervention versus control period, which also correlated with cognitive improvement in set shifting ability. Findings from Study II reporting the questionnaire data showed that the Behavioural Regulation Index of the Behaviour Rating Inventory of Executive Function (BRIEF-A) improved more in the AB than BA group from baseline to 3-month stage, and the effect was maintained in the 6-month follow-up. Finally, Study III explored functional connectivity patterns using resting-state functional MRI and revealed both changes towards increased and decreased functional connectivity within and between several networks. Importantly, behavioral improvements in EF correlated with resting-state functional connectivity changes within the frontoparietal network and between the default mode and sensorimotor networks. All in all, these results suggest that neurological music therapy enhances EF skills, including general EF, set shifting ability and behavioral self-regulation, after TBI and that these gains are linked to volumetric and functional neuroplastic changes in the brain. These novel findings give support to the use of music therapy in rehabilitation of moderate and severe TBI.Traumaattinen aivovaurio on varsin yleinen toimintakykyä alentava vamma, joka voi aiheuttaa elinikäisiä kognitiivisia, emotionaalisia ja fyysisiä oireita. Musiikki on monimuotoinen ja motivoiva toiminto, joka aktivoi useita kognitiivisia, motorisia ja emotionaalisia aivoverkostoja, mikä tekee siitä lupaavan hoitomuodon neurologisessa. Musiikin vaikuttavuutta aivovammakuntoutuksessa on kuitenkin toistaiseksi selvitetty varsin vähän. Tässä väitöskirjassa tutkitaan neurologisen musiikkiterapian vaikuttavuutta keskivaikeiden ja vaikeiden aivovammojen hoidossa ja erityisesti toiminnanohjaustaitojen kuntoutuksessa. Tähän tutkimukseen rekrytointiin 40 potilasta, joiden vammautumisesta oli kulunut alle 2 vuotta ja heidät satunnaistettiin kahteen ryhmään AB/BA. Ensimmäinen ryhmä (AB, n=20) sai neurologista musiikkiterapiaa 6 kuukauden seurantajakson alkupuoliskolla (3 kk) ja toinen ryhmä (BA, n=20) sai intervention seurantajakson jälkimmäisellä puoliskolla. Mittaukset, mukaan lukien neuropsykologiset ja motoriset testaukset, kyselylomakkeet sekä strukturaalinen ja funktionaalinen magneettikuvaus, suoritettiin alussa, 3 kuukauden ja 6 kuukauden kohdalla. Tutkimuksen I tulokset osoittavat, että yleiset toiminnanohjaustaidot (Frontal Assessment Battery -testistöllä arvioituna) sekä erityisesti kognitiivisen prosessoinnin joustavuus (Number-Letter Task -testillä testattuna) paranivat AB-ryhmässä BA-ryhmään verrattuna seurantajakson alkupuoliskolla ja positiivinen vaikutus yleisiin toiminnanohjaustaitoihin säilyi vielä 6 kuukauden seurannassa. Myös harmaan aineen volyymi oikealla alemmalla otsolohkopoimulla kasvoi merkittävästi molemmissa ryhmissä interventiojaksolla verrattuna kontrollijaksoon. Tämä harmaan aineen lisääntyminen korreloi kognitiivisen suorituksen kanssa prosessoinnin joustavuutta vaativassa tehtävässä. Tutkimuksessa II, jossa raportoidaan kyselylomakkeiden tulokset, osoitetaan että itse raportoitu käyttäytymisen säätely Behaviour Rating Inventory of Executive Function (BRIEF-A) mittarissa kohentui enemmän AB- kuin BA-ryhmässä ensimmäisen kolmen kuukauden seurannan aikana ja saavutettu taso säilyi vielä 6 kuukauden seurannassa. Tutkimuksessa III selvitettiin aivojen toiminnallisissa verkostoissa musiikkiterapian vaikutuksesta tapahtuneita muutoksia, joita mitattiin lepotilaverkostojen toiminnallisella magneettikuvauksella. Tulokset osoittavat, että useiden lepotilaverkostojen sisällä ja välillä tapahtui joko yhteyksien vahvistumista tai rauhoittumista. Muutokset toiminnanohjaustaidoissa korreloivat frontoparietaalisen verkoston sisällä sekä oletustilaverkoston ja sensorimotoristen verkkojen välillä tapahtuvien funktionaalisten muutosten kanssa. Kokonaisuudessaan nämä tulokset osoittavat, että aivovamman jälkeen musiikkiterapia kohentaa toiminnanohjaustaitoja mukaan lukien yleistä toiminnanohjausta, kognitiivisen prosessoinnin joustavuutta sekä käyttäytymisen säätelyä ja nämä muutokset ovat yhteydessä aivojen rakenteellisiin ja toiminnallisiin neuroplastisiin muutoksiin. Nämä uudet tulokset tukevat musiikkiterapian hyödyntämistä keskivaikeiden ja vaikeiden aivovammojen kuntoutuksessa

Cognitive efficacy and neural mechanisms of music-based neurological rehabilitation for traumatic brain injury

Traumatic brain injury (TBI) causes lifelong cognitive deficits, most often in executive function (EF). Both musical training and music-based rehabilitation have been shown to enhance EF and neuroplasticity. Thus far, however, there is little evidence for the potential rehabilitative effects of music for TBI. Here, we review the core findings from our recent cross-over randomized controlled trial in which a 10-week music-based neurological rehabilitation (MBNR) protocol was administered to 40 patients with moderate-to-severe TBI. Neuropsychological testing and structural/functional magnetic resonance imaging were collected at three time points (baseline, 3 months, and 6 months); one group received the MBNR between time points 1 and 2, while a second group received it between time points 2 and 3. We found that both general EF and set shifting improved after the intervention, and this effect was maintained long term. Morphometric analyses revealed therapy-induced gray matter volume changes most consistently in the right inferior frontal gyrus, changes that correlated with better outcomes in set shifting. Finally, we found changes in the between- and within-network functional connectivity of large-scale resting-state networks after MBNR, which also correlated with measures of EF. Taken together, the data provide evidence for concluding that MBNR improves EF in TBI; also, the data show that morphometric and resting-state functional connectivity are sensitive markers with which to monitor the neuroplasticity induced by the MBNR intervention.Peer reviewe

Quality of life after traumatic brain injury: Finnish experience of the QOLIBRI in residential rehabilitation

Objective: To evaluate health-related quality of life of traumatic brain injury patients who have received intensive multidisciplinary residential rehabilitation. To examine the psychometric characteristics of the Finnish Quality of Life after Brain Injury (QOLIBRI) questionnaire. Subjects: A total of 157 adults with TBI, up to 15 years post-injury, who had been treated in the K&auml;pyl&auml; Rehabilitation Centre, Helsinki, Finland. Methods: Functional status was assessed using the Extended Glasgow Outcome Scale. Emotional state was evaluated using the Hospital Anxiety and Depression Scale. Health-related quality of life was measured using a generic measure (Short Form-36) and the QOLIBRI. Results: Quality of life was related to depression, amount of help needed, anxiety, education level and age at injury. Quality of life was not associated with time since injury, but a paradoxical relationship was found with injury severity. Internal consistency (alpha = 0.79-0.95) and test-retest reliability (rtt = 0.75-0.87) of the Finnish QOLIBRI met standard psychometric criteria. Conclusion: Quality of life remained relatively stable in the long term. Milder injuries were associated with lower life satisfaction, and careful follow-up is recommended to target patients in special need. This study confirms the reliability and validity of the Finnish QOLIBRI

Neurological Music Therapy Rebuilds Structural Connectome after Traumatic Brain Injury: Secondary Analysis from a Randomized Controlled Trial

Background: Traumatic brain injury (TBI) is a common and devastating neurological condition, associated often with poor functional outcome and deficits in executive function. Due to the neuropathology of TBI, neuroimaging plays a crucial role in its assessment, and while diffusion MRI has been proposed as a sensitive biomarker, longitudinal studies evaluating treatment-related diffusion MRI changes are scarce. Recent evidence suggests that neurological music therapy can improve executive functions in patients with TBI and that these effects are underpinned by neuroplasticity changes in the brain. However, studies evaluating music therapy induced structural connectome changes in patients with TBI are lacking. Design: Single-blind crossover (AB/BA) randomized controlled trial (NCT01956136). Objective: Here, we report secondary outcomes of the trial and set out to assess the effect of neurological music therapy on structural white matter connectome changes and their association with improved execute function in patients with TBI. Methods: Using an AB/BA design, 25 patients with moderate or severe TBI were randomized to receive a 3-month neurological music therapy intervention either during the first (AB, n = 16) or second (BA, n = 9) half of a 6-month follow-up period. Neuropsychological testing and diffusion MRI scans were performed at baseline and at the 3-month and 6-month stage. Findings: Compared to the control group, the music therapy group increased quantitative anisotropy (QA) in the right dorsal pathways (arcuate fasciculus, superior longitudinal fasciculus) and in the corpus callosum and the right frontal aslant tract, thalamic radiation and corticostriatal tracts. The mean increased QA in this network of results correlated with improved executive function. Conclusions: This study shows that music therapy can induce structural white matter neuroplasticity in the post-TBI brain that underpins improved executive function

Neurological Music Therapy Rebuilds Structural Connectome after Traumatic Brain Injury: Secondary Analysis from a Randomized Controlled Trial

Background: Traumatic brain injury (TBI) is a common and devastating neurological condition, associated often with poor functional outcome and deficits in executive function. Due to the neuropathology of TBI, neuroimaging plays a crucial role in its assessment, and while diffusion MRI has been proposed as a sensitive biomarker, longitudinal studies evaluating treatment-related diffusion MRI changes are scarce. Recent evidence suggests that neurological music therapy can improve executive functions in patients with TBI and that these effects are underpinned by neuroplasticity changes in the brain. However, studies evaluating music therapy induced structural connectome changes in patients with TBI are lacking. Design: Single-blind crossover (AB/BA) randomized controlled trial (NCT01956136). Objective: Here, we report secondary outcomes of the trial and set out to assess the effect of neurological music therapy on structural white matter connectome changes and their association with improved execute function in patients with TBI. Methods: Using an AB/BA design, 25 patients with moderate or severe TBI were randomized to receive a 3-month neurological music therapy intervention either during the first (AB, n = 16) or second (BA, n = 9) half of a 6-month follow-up period. Neuropsychological testing and diffusion MRI scans were performed at baseline and at the 3-month and 6-month stage. Findings: Compared to the control group, the music therapy group increased quantitative anisotropy (QA) in the right dorsal pathways (arcuate fasciculus, superior longitudinal fasciculus) and in the corpus callosum and the right frontal aslant tract, thalamic radiation and corticostriatal tracts. The mean increased QA in this network of results correlated with improved executive function. Conclusions: This study shows that music therapy can induce structural white matter neuroplasticity in the post-TBI brain that underpins improved executive function

Efficacy of a multicomponent singing intervention on communication and psychosocial functioning in chronic aphasia: A randomized controlled crossover trial

The ability to produce words through singing can be preserved in severe aphasia, but the benefits of group-based singing rehabilitation in aphasia are largely unknown. Our aim was to determine the efficacy of a multicomponent singing intervention on communication and speech production, emotional-social functioning and caregiver well-being in aphasia. Fifty-four patients with acquired brain injury and chronic aphasia and their family caregivers (n = 43) were recruited. Using a crossover randomized controlled trial design, participants were randomized to two groups who received a 4-month singing intervention either during the first or second half of the study in addition to standard care. The intervention comprised weekly group-based training (including choir singing and group-level melodic intonation therapy) and tablet-assisted singing training at home. At baseline, 5- and 9-month stages, patients were assessed with tests and questionnaires on communication and speech production, mood, social functioning, and quality of life and family caregivers with questionnaires on caregiver burden. All participants who participated in the baseline measurement (n = 50) were included in linear mixed model analyses. Compared with standard care, the singing intervention improved everyday communication and responsive speech production from baseline to 5-month stage, and these changes were sustained also longitudinally (baseline to 9-month stage). Additionally, the intervention enhanced patients’ social participation and reduced caregiver burden. This study provides novel evidence that group-based multicomponent singing training can enhance communication and spoken language production in chronic aphasia as well as improve psychosocial wellbeing in patients and caregivers.Peer reviewe

Neuroanatomical correlates of speech and singing production in chronic post-stroke aphasia

A classical observation in neurology is that aphasic stroke patients with impairments in speech production can nonetheless sing the same utterances. This preserved ability suggests a distinctive neural architecture for singing that could contribute to speech recovery. However, to date, these structural correlates remain unknown. Here, we combined a multivariate lesion–symptom mapping and voxel-based morphometry approach to analyse the relationship between lesion patterns and grey matter volume and production rate in speech and singing tasks. Lesion patterns for spontaneous speech and cued repetition extended into frontal, temporal and parietal areas typically reported within the speech production network. Impairment in spontaneous singing was associated with damage to the left anterior–posterior superior and middle temporal gyri. Preservation of grey matter volume in the same regions where damage led to poor speech and singing production supported better performance in these tasks. When dividing the patients into fluent and dysfluent singers based on the singing performance from demographically matched controls, we found that the preservation of the left middle temporal gyrus was related to better spontaneous singing. These findings provide insights into the structural correlates of singing in chronic aphasia and may serve as biomarkers to predict treatment response in clinical trials using singing-based interventions for speech rehabilitation.Peer reviewe

Effects of neurological music therapy on behavioural and emotional recovery after traumatic brain injury : A randomized controlled cross-over trial

Traumatic brain injury (TBI) causes deficits in executive function (EF), as well as problems in behavioural and emotional self-regulation. Neurological music therapy may aid these aspects of recovery. We performed a cross-over randomized controlled trial where 40 persons with moderate-severe TBI received a 3-month neurological music therapy intervention (2 times/week, 60 min/session), either during the first (AB, n = 20) or second (BA, n = 20) half of a 6-month follow-up period. The evidence from this RCT previously demonstrated that music therapy enhanced general EF and set shifting. In the current study, outcome was assessed with self-report and caregiver-report questionnaires performed at baseline, 3-month, 6-month, and 18-month stages. The results showed that the self-reported Behavioural Regulation Index of the Behaviour Rating Inventory of Executive Function (BRIEF-A) improved more in the AB than BA group from baseline to 3-month stage and the effect was maintained in the 6-month follow-up. No changes in mood or quality of life questionnaires were observed. However, a qualitative content analysis of the feedback revealed that many participants experienced the intervention as helpful in terms of emotional well-being and activity. Our results suggest that music therapy has a positive effect on everyday behavioural regulation skills after TBI.Peer reviewe

Music therapy enhances executive functions and prefrontal structural neuroplasticity after traumatic brain injury : Evidence from a randomized controlled trial

Traumatic brain injury (TBI) causes lifelong cognitive deficits, particularly impairments of executive functioning (EF). Musical training and music-based rehabilitation have been shown to enhance cognitive functioning and neuroplasticity, but the potential rehabilitative effects of music in TBI are still largely unknown. The aim of the present crossover randomized controlled trial (RCT) was to determine the clinical efficacy of music therapy on cognitive functioning in TBI and to explore its neural basis. Using an AB/BA design, 40 patients with moderate or severe TBI were randomized to receive a 3-month neurological music therapy intervention either during the first (AB, n = 20) or second (BA, n = 20) half of a 6-month follow-up period. Neuropsychological and motor testing and magnetic resonance imaging (MRI) were performed at baseline and at the 3-month and 6-month stage. Thirty-nine subjects who participated in baseline measurement were included in an intention-to-treat analysis using multiple imputation. Results showed that general EF (as indicated by the Frontal Assessment Battery [FAB]) and set shifting improved more in the AB group than in the BA group over the first 3-month period and the effect on general EF was maintained in the 6-month follow-up. Voxel-based morphometry (VBM) analysis of the structural MRI data indicated that gray matter volume (GMV) in the right inferior frontal gyrus (IFG) increased significantly in both groups during the intervention versus control period, which also correlated with cognitive improvement in set shifting. These findings suggest that neurological music therapy enhances EF and induces fine-grained neuroanatomical changes in prefrontal areasPeer reviewe

Beneficial effects of choir singing on cognition and well-being of older adults : Evidence from a cross-sectional study

Background and objectives Choir singing has been associated with better mood and quality of life (QOL) in healthy older adults, but little is known about its potential cognitive benefits in aging. In this study, our aim was to compare the subjective (self-reported) and objective (test-based) cognitive functioning of senior choir singers and matched control subjects, coupled with assessment of mood, QOL, and social functioning. Research design and methods We performed a cross-sectional questionnaire study in 162 healthy older (age >= 60 years) adults (106 choir singers, 56 controls), including measures of cognition, mood, social engagement, QOL, and role of music in daily life. The choir singers were divided to low (1-10 years, N = 58) and high (>10 years, N = 48) activity groups based on years of choir singing experience throughout their life span. A subcohort of 74 participants (39 choir singers, 35 controls) were assessed also with a neuropsychological testing battery. Results In the neuropsychological testing, choir singers performed better than controls on the verbal flexibility domain of executive function, but not on other cognitive domains. In questionnaires, high activity choir singers showed better social integration than controls and low activity choir singers. In contrast, low activity choir singers had better general health than controls and high activity choir singers. Discussion and implications In healthy older adults, regular choir singing is associated with better verbal flexibility. Long-standing choir activity is linked to better social engagement and more recently commenced choir activity to better general health.Peer reviewe