THE REHABILITATIVE EFFECTS OF PIANO-PLAYING MUSIC …
Transcript of 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
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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
4.2 Percentage of agreement between the raters: parameter 2 -------------------91
4.3 Percentage of agreement between the raters: parameter 3 -------------------92
4.4 Percentage of agreement between the raters: parameter 4 -------------------93
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
4.12 Participant 6 Task 2 MIDI piano roll: pre and post-tests ------------------119
4.13 Participant 6 Task 1 and 2 5-Point scale comparison ------------------120
4.14 Participant 6 Task 3 MIDI piano roll: pre and post-tests ------------------121
4.15 Participant 6 Task 4 MIDI piano roll: pre and post-tests ------------------121
4.16 Participant 6 Task 3 and 4 5-Point scale comparison ------------------122
4.17 Participant 6 Task 5 MIDI piano roll: pre and post-tests ------------------123
4.18 Participant 6 Task 6 MIDI piano roll: pre and post-tests ------------------123
4.19 Participant 6 Task 5 and 6 5-Point scale comparison ------------------124
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4.20 Participant 6 Task 7 MIDI piano roll: pre and post-tests ------------------125
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
3.8 Outcome analysis set of hypothesis 2 ----------------------------------------72
3.9 Outcome analysis set of hypothesis 3 ----------------------------------------73
4.1 Definitions of the outcome variables ----------------------------------------75
4.2 Database for MIDI: outcome variable 1 ----------------------------------------76
4.3 Database for MIDI: outcome variable 2 ----------------------------------------78
4.4 Database for MIDI: outcome variable 3 ----------------------------------------80
4.5 Database for MIDI: outcome variable 4 ----------------------------------------82
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
4.9 Inter-rater reliability: outcome variable 2 ----------------------------------------87
4.10 Inter-rater reliability: outcome variable 3 ----------------------------------------88
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4.11 Inter-rater reliability: outcome variable 4 ----------------------------------------89
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
4.16 Hypothesis 1-1 Results of task 2 -------------------------------------------------98
4.17 Hypothesis 1-2 Results of task 1 -------------------------------------------------99
4.18 Hypothesis 1-2 Results of task 2 -------------------------------------------------99
4.19 Hypothesis 1-3 Results of task 1 -------------------------------------------------100
4.20 Hypothesis 1-3 Results of task 2 -------------------------------------------------100
4.21 Hypothesis 2-1 Results of task 3 -------------------------------------------------102
4.22 Hypothesis 2-1 Results of task 4 -------------------------------------------------102
4.23 Hypothesis 2-2 Results of task 3 -------------------------------------------------103
4.24 Hypothesis 2-2 Results of task 4 -------------------------------------------------103
4.25 Hypothesis 2-3 Results of task 3 -------------------------------------------------104
4.26 Hypothesis 2-3 Results of task 4 -------------------------------------------------105
4.27 Hypothesis 3-1 Results of task 5 -------------------------------------------------106
4.28 Hypothesis 3-1 Results of task 6 -------------------------------------------------107
4.29 Hypothesis 3-1 Results of task 7 -------------------------------------------------107
4.30 Hypothesis 3-2 Results of task 5 -------------------------------------------------107
4.31 Hypothesis 3-2 Results of task 6 -------------------------------------------------108
4.32 Hypothesis 3-2 Results of task 7 -------------------------------------------------108
4.33 Hypothesis 3-3 Results of task 5 -------------------------------------------------109
4.34 Hypothesis 3-3 Results of task 6 -------------------------------------------------109
4.35 Hypothesis 3-3 Results of task 7 -------------------------------------------------109
4.36 Hypothesis 3-4 Results of task 5 -------------------------------------------------110
4.37 Hypothesis 3-4 Results of task 6 -------------------------------------------------110
4.38 Hypothesis 3-4 Results of task 7 -------------------------------------------------110
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.
Hypothesis 2-1: Piano-playing music therapy will improve timing
consistency of finger movements in the affected hands of chronic stroke
patients.
Hypothesis 2-2: Piano-playing music therapy will improve velocity
evenness of finger movements in the affected hands of chronic stroke
patients.
Hypothesis 2-3: Piano-playing music therapy will improve accuracy of key
striking of finger movements in the non-affected hands of chronic stroke
patients.
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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.
Hypothesis 3-2: Piano-playing music therapy will improve velocity
evenness of bilateral finger movements in chronic stroke patients.
Hypothesis 3-3: Piano-playing music therapy will improve accuracy of key
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).
23
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
24
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
Nonmodifiable risk factors Modifiable 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
Nonmodifiable risk factors Modifiable risk factors
Family history
Aneurysm size
Aneurysm location
Prior history of aneurysmal
bleeding
Cigarette smoking
Hypertension
Cocaine use
Other causes: Trauma
Source: Smith & Korowhetz, 2004
25
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
5 63 F Left * 14 Right
6 83 M Left Hemorrhage 96 Right
7 81 M Right Hemorrhage 46 Right
8 66 M Right Infarct 20 Right
9 68 M Left Infarct 24 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
Stroke type Duration**
(months)
Handedness
11 78 F Right Infarct 13 Right
12 76 M Left * 124 Right
13 67 F Right Hemorrhage 31 Right
14 66 M Left Infarct 56 Right
15 69 M Left Hemorrhage 21 Right
16 58 F Left Infarct 75 Right
17 81 F Left Infarct 276 Right
18 84 F Left * 52 Right
19 65 F Right Hemorrhage 29 Right
20 80 F Right * 40 Right
Note: * Information not available in participant files
** Duration of time from stroke onset
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
TG Wilcoxon Wilcoxon
CG Wilcoxon Wilcoxon
AK BG Descriptive Mann-Whitney
TG Descriptive Wilcoxon
CG Descriptive Wilcoxon
Table 3.8 Outcome analysis set of hypothesis 2
Hypothesis Task Outcome
variable
Comparison MIDI 5-Point
H2 T3~T4 TC BG Descriptive Mann-Whitney
TG Wilcoxon Wilcoxon
CG Descriptive Wilcoxon
VE BG Descriptive Mann-Whitney
TG Wilcoxon Wilcoxon
CG Descriptive Wilcoxon
AK BG Descriptive Mann-Whitney
TG Descriptive Wilcoxon
CG Descriptive Wilcoxon
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
Table 3.9 Outcome analysis set of hypothesis 3
Hypothesis Task Outcome
variable
Comparison MIDI 5-Point
H3
T5~T7
TC BG N/A Descriptive
TG Descriptive Wilcoxon
CG N/A Descriptive
VE BG N/A Descriptive
TG Descriptive Wilcoxon
CG N/A Descriptive
AK BG N/A Descriptive
TG Descriptive Wilcoxon
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.
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.
75
Hypothesis 2-1: Piano-playing music therapy will improve timing
consistency of finger movements in the affected hands of chronic stroke
patients.
Hypothesis 2-2: Piano-playing music therapy will improve velocity
evenness of finger movements in the affected hands of chronic stroke
patients.
Hypothesis 2-3: Piano-playing music therapy will improve accuracy of key
striking of finger movements in the non-affected hands of chronic stroke
patients.
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.
Hypothesis 3-2: Piano-playing music therapy will improve velocity
evenness of bilateral finger movements in chronic stroke patients.
Hypothesis 3-3: Piano-playing music therapy will improve accuracy of key
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.
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
Task no. T1 T2 T3 T4 T5 T6 T7
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
Task no. T1 T2 T3 T4 T5 T6 T7
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 T2 Lim 3 2 2 Done
TG 1 post T2 Lim 5 4 4 Done
TG 1 pre T3 Lim 1 1 1 Not done
TG 1 post T3 Lim 5 5 5 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
TG 1 pre T6 Lim 1 1 1 1 Not done
TG 1 post T6 Lim 1 1 1 1 Not done
TG 1 pre T7 Lim 1 1 1 1 Not done
TG 1 post T7 Lim 1 1 1 1 Not done
TG 2 pre T1 Lim 4 4 5 Done
TG 2 post T1 Lim 5 5 5 Done
84
TG 2 pre T2 Lim 4 4 3 Done
TG 2 post T2 Lim 4 4 5 Done
TG 2 pre T3 Lim 4 5 5 Done
TG 2 post T3 Lim 5 5 5 Done
TG 2 pre T4 Lim 4 3 4 Done
TG 2 post T4 Lim 5 4 5 Done
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
TG 2 post T6 Lim 5 5 5 5 Done
TG 2 pre T7 Lim 1 1 1 1 Not done
TG 2 post T7 Lim 3 3 4 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 T2 Lim 3 2 3 Done
CG 11 post T2 Lim 2 3 2 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
CG 11 pre T6 Lim 1 1 1 1 Not done
CG 11 post T6 Lim 1 1 1 1 Not done
CG 11 pre T7 Lim 1 1 1 1 Not done
CG 11 post T7 Lim 1 1 1 1 Not done
CG 12 pre T1 Lim 4 3 3 Done
CG 12 post T1 Lim 4 3 4 Done
CG 12 pre T2 Lim 3 2 4 Done
CG 12 post T2 Lim 2 2 3 Done
CG 12 pre T3 Lim 4 3 4 Done
CG 12 post T3 Lim 5 3 5 Done
CG 12 pre T4 Lim 4 2 3 Done
CG 12 post T4 Lim 4 2 3 Done
CG 12 pre T5 Lim 1 1 1 1 Not done
CG 12 post T5 Lim 1 1 1 1 Not done
CG 12 pre T6 Lim 1 1 1 1 Not done
CG 12 post T6 Lim 1 1 1 1 Not done
CG 12 pre T7 Lim 1 1 1 1 Not done
CG 12 post T7 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
Table 4.9 Inter-Rater Reliability:
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
** Correlation is significant at the 0.01 level (2-tailed).
Note: 3 raters (Var1~3), N (16 subjects* 7 tasks* 2 tests=224)
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
Table 4.10 Inter-Rater Reliability:
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
** Correlation is significant at the 0.01 level (2-tailed).
Note: 3 raters (Var1~3), N (16 subjects* 7 tasks* 2 tests=224)
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
Table 4.11 Inter-Rater Reliability:
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
** Correlation is significant at the 0.01 level (2-tailed).
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
all the same two same but 1 different all different
% % agreement
Figure 4.2 Percentage of agreement between the raters on the 5-Point scale for
parameter 2, Velocity evenness
Figure 4.2 shows the results of the percentage of agreement between the raters
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
all the same two same but 1 different all different
% % agreement
Figure 4.3 Percentage of agreement between the raters on the 5-Point scale for
parameter 3, Accuracy of key striking
Figure 4.3 shows the results of the percentage of agreement between the raters
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
all the same two same but 1 different all different
% % agreement
Figure 4.4 Percentage of agreement between the raters on the 5-Point scale for
parameter 4, Stability of synchronizing 2-key striking
Figure 4.4 shows the results of the percentage of agreement between the raters
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
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
5 63 F Left * 14 Right
6 83 M Left Hemorrhage 96 Right
7 81 M Right Hemorrhage 46 Right
8 66 M Right Infarct 20 Right
9 68 M Left Infarct 24 Right
10*** * F Right * * Right
Note: * Information not available in participant files
** Duration of time from stroke onset
*** Participant withdrawn from the study
95
Table 4.13 General characteristics of the participants in the control group
Participant Age
(years)
Gender Hemiplegic
site
Stroke type Duration**
(months)
Handedness
11 78 F Right Infarct 13 Right
12 76 M Left * 124 Right
13 67 F Right Hemorrhage 31 Right
14 66 M Left Infarct 56 Right
15 69 M Left Hemorrhage 21 Right
16 58 F Left Infarct 75 Right
17 81 F Left Infarct 276 Right
18*** 84 F Left * 52 Right
19*** 65 F Right Hemorrhage 29 Right
20*** 80 F Right * 40 Right
Note: * Information not available in participant files
** Duration of time from stroke onset
*** 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
finger movements in the non-affected hands of chronic stroke patients.
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
Outcome variable 1, Timing consistency
Comparison MIDI 5-Point scale
Z score P (1-tailed)* Z score P (1-tailed)*
Between groups -2.170 .016 -2.984 .001
Treatment group: pre & post -1.955 .027 -2.556 .004
Control group: pre & post -1.859 .039 -1.841 .063
* Exact Sig. P (1-tailed)
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
movements in the non-affected hands of chronic stroke patients.
4.2.3.2 Hypothesis 1-2
Hypothesis 1-2 Piano-playing music therapy will improve velocity evenness of finger
movements in the non-affected hands of chronic stroke patients.
The following table describes the results from outcome variable 2, velocity evenness
based on MIDI and 5-Point analysis.
99
Table 4.17 Hypothesis 1-2 Results of task 1: Non-affected hand index finger tapping
Outcome variable 2, Velocity evenness
Comparison MIDI 5-Point scale
Z score P (1-tailed)* Z score P (1-tailed)*
Between groups -0.053 .500 -1.385 .089
Treatment group: pre & post -1.599 .064 -2.677 .004
Control group: pre & post -1.524 .064 -2.232 .016
* Exact Sig. P (1-tailed)
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.
Table 4.18 Hypothesis 1-2 Results of task 2: Non-affected hand 5-finger sequential
playing
Outcome variable 2, Velocity evenness
Comparison MIDI 5-Point scale
Z score P (1-tailed)* Z score P (1-tailed)*
Between groups -2.913 .001 -1.066 .153
Treatment group: pre & post -2.547 .004 -2.536 .004
Control group: pre & post -1.183 .148 -1.361 .125
* Exact Sig. P (1-tailed)
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
4.2.3.3 Hypothesis 1-3
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.
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.
Table 4.19 Hypothesis 1-3 Results of task 1: Non-affected hand index finger tapping
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
* Exact Sig. P (1-tailed)
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.
Table 4.20 Hypothesis 1-3 Results of task 2: Non-affected hand 5-finger sequential
playing
Outcome variable 3, Accuracy of key striking
Comparison 5-Point scale
Z score P (1-tailed)*
Between groups -2.968 .001
Treatment group: pre & post -2.533 .004
Control group: pre & post -0.422 .391
* Exact Sig. P (1-tailed)
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.
Hypothesis 2 Piano-playing music therapy will improve unilateral coordination of
finger movements in the affected hands of chronic stroke patients.
4.2.4.1 Hypothesis 2-1
Hypothesis 2-1 Piano-playing music therapy will improve timing consistency of finger
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
Outcome variable 1, Timing consistency
Comparison MIDI 5-Point scale
Z score P (1-tailed)* Z score P (1-tailed)*
Between groups Descriptive -2.670 .003
Treatment group: pre & post -0.944 .219 -2.668 .002
Control group: pre & post Descriptive -1.633 .125
* Exact Sig. P (1-tailed)
Table 4.22 Hypothesis 2-1 Results of task 4: Affected hand 5-finger sequential playing
Outcome variable 1, Timing consistency
Comparison MIDI 5-Point scale
Z score P (1-tailed)* Z score P (1-tailed)*
Between groups Descriptive -1.887 .029
Treatment group: pre & post -1.483 .094 -2.032 .031
Control group: pre & post Descriptive -1.000 .500
* Exact Sig. P (1-tailed)
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.
4.2.4.2 Hypothesis 2-2
Hypothesis 2-2 Piano-playing music therapy will improve velocity evenness 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.
Table 4.23 Hypothesis 2-2 Results of task 3: Affected hand index finger tapping
Outcome variable 2, Velocity evenness
Comparison MIDI 5-Point scale
Z score P (1-tailed)* Z score P (1-tailed)*
Between groups Descriptive -1.903 .030
Treatment group: pre & post -1.753 .063 -2.384 .008
Control group: pre & post Descriptive -1.633 .125
* Exact Sig. P (1-tailed)
Table 4.24 Hypothesis 2-2 Results of task 4: Affected hand 5-finger sequential playing
Outcome variable 2, Velocity evenness
Comparison MIDI 5-Point scale
Z score P (1-tailed)* Z score P (1-tailed)*
Between groups Descriptive -1.351 .110
Treatment group: pre & post -2.023 .031 -1.890 .063
Control group: pre & post Descriptive -1.000 .500
* Exact Sig. P (1-tailed)
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.
4.2.4.3 Hypothesis 2-3
Hypothesis 2-3 Piano-playing music therapy will improve accuracy of key striking 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.
Table 4.25 Hypothesis 2-3 Results of task 3: Affected hand index finger tapping
Outcome variable 3, Accuracy of key striking
Comparison 5-Point scale
Z score P (1-tailed)*
Between groups -2.314 .010
Treatment group: pre & post -2.521 .004
Control group: pre & post -1.604 .125
* Exact Sig. P (1-tailed)
105
Table 4.26 Hypothesis 2-3 Results of task 4: Affected hand 5-finger sequential playing
Outcome variable 3, Accuracy of key striking
Comparison 5-Point scale
Z score P (1-tailed)*
Between groups -1.576 .066
Treatment group: pre & post -2.032 .031
Control group: pre & post -1.342 .250
* Exact Sig. P (1-tailed)
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.
4.2.5.1 Hypothesis 3-1
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
Outcome variable 1, Timing consistency
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.023 .031
* Exact Sig. P (1-tailed)
107
Table 4.28 Hypothesis 3-1 Results of task 6: Both hands index finger tapping alternately
Outcome variable 1, Timing consistency
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.023 .031
* Exact Sig. P (1-tailed)
Table 4.29 Hypothesis 3-1 Results of task 7: Both hands 5-finger sequential playing
Outcome variable 1, Timing consistency
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.041 .031
* Exact Sig. P (1-tailed)
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.
4.2.5.2 Hypothesis 3-2
Hypothesis 3-2. Piano-playing music therapy will improve velocity evenness of
bilateral finger movements in chronic stroke patients.
The 5-Point scale measurement was used to analyze the outcome variable 2, velocity
evenness within hypothesis 3-2.
Table 4.30 Hypothesis 3-2 Results of task 5: Both hands index finger tapping
simultaneously
Outcome variable 2, Velocity evenness
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.032 .031
* Exact Sig. P (1-tailed)
108
Table 4.31 Hypothesis 3-2 Results of task 6: Both hands index finger tapping alternately
Outcome variable 2, Velocity evenness
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -1.633 .125
* Exact Sig. P (1-tailed)
Table 4.32 Hypothesis 3-2 Results of task 7: Both hands 5-finger sequential playing
Outcome variable 2, Velocity evenness
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.041 .031
* Exact Sig. P (1-tailed)
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).
4.2.5.3 Hypothesis 3-3
Hypothesis 3-3. Piano-playing music therapy will improve accuracy of key striking of
bilateral finger movements in chronic stroke patients.
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
Table 4.33 Hypothesis 3-3 Results of task 5: Both hands index finger tapping
simultaneously
Outcome variable 3, Accuracy of key striking
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.023 .031
* Exact Sig. P (1-tailed)
Table 4.34 Hypothesis 3-3 Results of task 6: Both hands index finger tapping alternately
Outcome variable 3, Accuracy of key striking
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.023 .031
* Exact Sig. P (1-tailed)
Table 4.35 Hypothesis 3-3 Results of task 7: Both hands 5-finger sequential playing
Outcome variable 3,
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.023 .031
* Exact Sig. P (1-tailed)
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
4.2.5.4 Hypothesis 3-4
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.
Table 4.36 Hypothesis 3-4 Results of task 5: Both hands index finger tapping
simultaneously
Outcome variable 4, Stability of synchronizing two-key strike
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.032 .031
* Exact Sig. P (1-tailed)
Table 4.37 Hypothesis 3-4 Results of task 6: Both hands index finger tapping alternately
Outcome variable 4, Stability of synchronizing two-key strike
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.032 .031
* Exact Sig. P (1-tailed)
Table 4.38 Hypothesis 3-4 Results of task 7: Both hands 5-finger sequential playing
Outcome variable 4, Stability of synchronizing two-key strike
Comparison 5-Point scale
Z score P (1-tailed)*
Treatment group: pre & post -2.032 .031
* Exact Sig. P (1-tailed)
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
5-Point Scale Comparison of Task Improvement on
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%
task1 task2 task3 task4 task5 task6 task7
Figure 4.8 5-Point Scale Comparisons on the Velocity Evenness
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4.2.6.5 5-Point scale analysis: Accuracy of Key-striking
5-Point Scale Comparison of Task Improvement on
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%
task1 task2 task3 task4 task5 task6 task7
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.
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4.2.6.6 5-Point scale analysis: Stability of Synchronization
5-Point Scale Comparison of Task Improvement on
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.
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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)
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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
Post-test (14-Dec-2005)
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)
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4.2.7.3 Task 3. Affected hand index finger tapping
Figure 4.14 Participant 6 Task 3 MIDI Piano roll view: Pre-test (14-Nov-2005) and
Post-test (14-Dec-2005)
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)
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Participant 6: Task 3~4
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 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
T3AK T3TC T3VE T4AK T4TC T4VE
Figure 4.16 Participant 6 Task 3 and 4 Five-Point Scale Comparison: Pre-test (14-Nov-
2005) and Post-test (14-Dec-2005)
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4.2.7.5 Task 5. Both hands index finger tapping simultaneously
Figure 4.17 Participant 6 Task 5 MIDI Piano roll view: Pre-test (14-Nov-2005) and
Post-test (14-Dec-2005)
4.2.7.6 Task 6. Both hands index finger tapping alternately
Figure 4.18 Participant 6 Task 6 MIDI Piano roll view: Pre-test (14-Nov-2005) and
Post-test (14-Dec-2005)
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Participant 6: Task 5~6
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 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
Figure 4.19 Participant 6 Task 5 and 6 Five-Point Scale Comparison: Pre-test (14-Nov-
2005) and Post-test (14-Dec-2005)
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4.2.7.7 Task 7. Both hands 5-finger sequential playing
Figure 4.20 Participant 6 Task 7 MIDI Piano roll view: Pre-test (14-Nov-2005) and
Post-test (14-Dec-2005)
126
Participant 6: Task 7
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 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)
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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.
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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:
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.
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Hypothesis 1-1 Piano-playing music therapy will improve timing consistency of finger
movements in the non-affected hands of chronic stroke patients.
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
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book and other tasks that require fine motor control of the fingers and hand.
Hypothesis 1-2 Piano-playing music therapy will improve velocity evenness of finger
movements in the non-affected hands of chronic stroke patients.
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.
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.
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
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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:
Hypothesis 2-1: Piano-playing music therapy will improve timing
consistency of finger movements in the affected hands of chronic stroke
patients.
Hypothesis 2-2: Piano-playing music therapy will improve velocity
evenness of finger movements in the affected hands of chronic stroke
patients.
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Hypothesis 2-3: Piano-playing music therapy will improve accuracy of key
striking of finger movements in the non-affected hands of chronic stroke
patients.
Hypothesis 2-1 Piano-playing music therapy will improve timing consistency of finger
movements in the affected hands of chronic stroke 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.
Hypothesis 2-2 Piano-playing music therapy will improve velocity evenness of finger
movements in the affected hands of chronic stroke patients.
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).
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 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.
134
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:
Hypothesis 3-1: Piano-playing music therapy will improve timing
consistency of bilateral finger movements in chronic stroke patients.
Hypothesis 3-2: Piano-playing music therapy will improve velocity
evenness of bilateral finger movements in chronic stroke patients.
Hypothesis 3-3: Piano-playing music therapy will improve accuracy of key
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.
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
135
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/
136
Table 5.1 PDF file exported from MIDI data of the event list:
Participant 6 Post-test (14-Dec-2005)
137
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
138
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
fingers) and bilateral finger movements
(3) Poor accuracy of key execution (both affected and non-affected hand
fingers) and bilateral finger movements
(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.
143
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
145
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
146
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.
148
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.
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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.
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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.
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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
Source: Bogousslavsky & Hommel, 1993, p. 73
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
Source: Bogousslavsky & Hommel, 1993, p. 79
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
Source: Bogousslavsky & Hommel, 1993, p. 83
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
Hypothesis 1 Piano-playing music therapy will improve unilateral coordination of
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)
Exact Sig. (1-tailed)
Point Probability
MT1TC
Not corrected for ties.a.
Grouping Variable: Groupb.
1.1.1.2
Task 1 Non-affected hand index finger tapping
Outcome variable 1 Timing consistency
Comparison 1 Between treatment and control groups
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T1TC
Not corrected for ties.a.
Grouping Variable: Groupb.
1.1.2.1
Task 1 Non-affected hand index finger tapping
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 1 MIDI
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
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TGT1TCpost- TGT1TCpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
1.1.2.2
Task 1 Non-affected hand index finger tapping
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
9b 5.00 45.00
0c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T1TCpost- TG5T1TCpre
N Mean RankSum ofRanks
TG5T1TCpost < TG5T1TCprea.
TG5T1TCpost > TG5T1TCpreb.
TG5T1TCpost = TG5T1TCprec.
Test S ta ti st icsb
-2.677a
.007
.004
.002
.002
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T1TCpost-
TG5T1TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
194
1.1.3.1
Task 1 Non-affected hand index finger tapping
Outcome variable 1 Timing consistency
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 1 MIDI
Rank s
6a 4.33 26.00
1b 2.00 2.00
0c
7
Negative Ranks
Positive Ranks
Ties
Total
CGT1TCpost -CGT1TCpre
N Mean RankSum ofRanks
CGT1TCpost < CGT1TCprea.
CGT1TCpost > CGT1TCpreb.
CGT1TCpost = CGT1TCprec.
Test S ta ti st icsb
-2.028a
.043
.047
.023
.008
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CGT1TCpost- CGT1TCpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
1.1.3.2
Task 1 Non-affected hand index finger tapping
Outcome variable 1 Timing consistency
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
195
Rank s
0a .00 .00
6b 3.50 21.00
1c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T1TCpost- CG5T1TCpre
N Mean RankSum ofRanks
CG5T1TCpost < CG5T1TCprea.
CG5T1TCpost > CG5T1TCpreb.
CG5T1TCpost = CG5T1TCprec.
Test S ta ti st icsb
-2.232a
.026
.031
.016
.016
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T1TCpost-
CG5T1TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
1.2.1.1
Task 1 Non-affected hand index finger tapping
Outcome variable 2 Velocity Evenness
Comparison 1 Between treatment and control groups
Outcome measurement 1 MIDI
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
MT1VE
Not corrected for ties.a.
Grouping Variable: Groupb.
1.2.1.2
Task 1 Non-affected hand index finger tapping
Outcome variable 2 Velocity Evenness
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T1VE
Not corrected for ties.a.
Grouping Variable: Groupb.
197
1.2.2.1
Task 1 Non-affected hand index finger tapping
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 1 MIDI
Rank s
7a 5.14 36.00
2b 4.50 9.00
0c
9
Negative Ranks
Positive Ranks
Ties
Total
TGT1VEpost- TGT1VEpre
N Mean RankSum ofRanks
TGT1VEpost < TGT1VEprea.
TGT1VEpost > TGT1VEpreb.
TGT1VEpost = TGT1VEprec.
Test S ta ti st icsb
-1.599a
.110
.129
.064
.016
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TGT1VEpost- TGT1VEpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
1.2.2.2
Task 1 Non-affected hand index finger tapping
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
198
Rank s
0a .00 .00
8b 4.50 36.00
1c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T1VEpost- TG5T1VEpre
N Mean RankSum ofRanks
TG5T1VEpost < TG5T1VEprea.
TG5T1VEpost > TG5T1VEpreb.
TG5T1VEpost = TG5T1VEprec.
Test S ta ti st icsb
-2.555a
.011
.008
.004
.004
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T1VEpost-
TG5T1VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
1.2.3.1
Task 1 Non-affected hand index finger tapping
Outcome variable 2 Velocity evenness
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 1 MIDI
Rank s
5a 4.60 23.00
2b 2.50 5.00
0c
7
Negative Ranks
Positive Ranks
Ties
Total
CGT1VEpost- CGT1VEpre
N Mean RankSum ofRanks
CGT1VEpost < CGT1VEprea.
CGT1VEpost > CGT1VEpreb.
CGT1VEpost = CGT1VEprec.
199
Test S ta ti st icsb
-1.524a
.128
.141
.070
.016
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CGT1VEpost- CGT1VEpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
1.2.3.2
Task 1 Non-affected hand index finger tapping
Outcome variable 2 Velocity evenness
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
6b 3.50 21.00
1c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T1VEpost- CG5T1VEpre
N Mean RankSum ofRanks
CG5T1VEpost < CG5T1VEprea.
CG5T1VEpost > CG5T1VEpreb.
CG5T1VEpost = CG5T1VEprec.
Test S ta ti st icsb
-2.226a
.026
.031
.016
.016
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T1VEpost-
CG5T1VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
200
1.3.1.2
Task 1 Non-affected hand index finger tapping
Outcome variable 3 Accuracy of key striking
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T1AK
Not corrected for ties.a.
Grouping Variable: Groupb.
1.3.2.2
Task 1 Non-affected hand index finger tapping
Outcome variable 3 Accuracy of key striking
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
201
Rank s
0a .00 .00
6b 3.50 21.00
3c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T1AKpost- TG5T1AKpre
N Mean RankSum ofRanks
TG5T1AKpost < TG5T1AKprea.
TG5T1AKpost > TG5T1AKpreb.
TG5T1AKpost = TG5T1AKprec.
Test S ta ti st icsb
-2.207a
.027
.031
.016
.016
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T1AKpost-
TG5T1AKpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
1.3.3.2
Task 1 Non-affected hand index finger tapping
Outcome variable 3 Accuracy of key striking
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
Rank s
4a 3.13 12.50
2b 4.25 8.50
1c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T2AKpost- CG5T2AKpre
N Mean RankSum ofRanks
CG5T2AKpost < CG5T2AKprea.
CG5T2AKpost > CG5T2AKpreb.
CG5T2AKpost = CG5T2AKprec.
202
Test S ta ti st icsb
-.422a
.673
.781
.391
.094
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T2AKpost-
CG5T2AKpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
2.1.1.1
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 1 Between treatment and control groups
Outcome measurement 1 MIDI
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
MT2TC
Not corrected for ties.a.
Grouping Variable: Groupb.
203
2.1.1.2
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T2TC
Not corrected for ties.a.
Grouping Variable: Groupb.
2.1.2.1
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 1 MIDI
204
Rank s
7a 5.57 39.00
2b 3.00 6.00
0c
9
Negative Ranks
Positive Ranks
Ties
Total
TGT2TCpost- TGT2TCpre
N Mean RankSum ofRanks
TGT2TCpost < TGT2TCprea.
TGT2TCpost > TGT2TCpreb.
TGT2TCpost = TGT2TCprec.
Test S ta ti st icsb
-1.955a
.051
.055
.027
.008
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TGT2TCpost- TGT2TCpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
2.1.2.2
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
1a 1.00 1.00
8b 5.50 44.00
0c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T2TCpost- TG5T2TCpre
N Mean RankSum ofRanks
TG5T2TCpost < TG5T2TCprea.
TG5T2TCpost > TG5T2TCpreb.
TG5T2TCpost = TG5T2TCprec.
205
Test S ta ti st icsb
-2.556a
.011
.008
.004
.002
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T2TCpost-
TG5T2TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
2.1.3.1
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 1 MIDI
Rank s
2a 1.50 3.00
5b 5.00 25.00
0c
7
Negative Ranks
Positive Ranks
Ties
Total
CGT2TCpost -CGT2TCpre
N Mean RankSum ofRanks
CGT2TCpost < CGT2TCprea.
CGT2TCpost > CGT2TCpreb.
CGT2TCpost = CGT2TCprec.
Test S ta ti st icsb
-1.859a
.063
.078
.039
.016
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CGT2TCpost- CGT2TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
206
2.1.3.2
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
Rank s
4a 2.50 10.00
0b .00 .00
3c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T2TCpost- CG5T2TCpre
N Mean RankSum ofRanks
CG5T2TCpost < CG5T2TCprea.
CG5T2TCpost > CG5T2TCpreb.
CG5T2TCpost = CG5T2TCprec.
Test S ta ti st icsb
-1.841a
.066
.125
.063
.063
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T2TCpost-
CG5T2TCpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
2.2.1.1
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 1 Between treatment and control groups
Outcome measurement 1 MIDI
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
MT2VE
Not corrected for ties.a.
Grouping Variable: Groupb.
2.2.1.2
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T2VE
Not corrected for ties.a.
Grouping Variable: Groupb.
2.2.2.1
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 1 MIDI
Rank s
8a 5.50 44.00
1b 1.00 1.00
0c
9
Negative Ranks
Positive Ranks
Ties
Total
TGT2VEpost- TGT2VEpre
N Mean RankSum ofRanks
TGT2VEpost < TGT2VEprea.
TGT2VEpost > TGT2VEpreb.
TGT2VEpost = TGT2VEprec.
Test S ta ti st icsb
-2.547a
.011
.008
.004
.002
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TGT2VEpost- TGT2VEpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
209
2.2.2.2
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
8b 4.50 36.00
1c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T2VEpost- TG5T2VEpre
N Mean RankSum ofRanks
TG5T2VEpost < TG5T2VEprea.
TG5T2VEpost > TG5T2VEpreb.
TG5T2VEpost = TG5T2VEprec.
Test S ta ti st icsb
-2.536a
.011
.008
.004
.004
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T2VEpost-
TG5T2VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
2.2.3.1
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 1 MIDI
210
Rank s
2a 3.50 7.00
5b 4.20 21.00
0c
7
Negative Ranks
Positive Ranks
Ties
Total
CGT2VEpost- CGT2VEpre
N Mean RankSum ofRanks
CGT2VEpost < CGT2VEprea.
CGT2VEpost > CGT2VEpreb.
CGT2VEpost = CGT2VEprec.
Test S ta ti st icsb
-1.183a
.237
.297
.148
.039
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CGT2VEpost- CGT2VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
2.2.3.2
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
Rank s
1a 2.50 2.50
4b 3.13 12.50
2c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T2VEpost- CG5T2VEpre
N Mean RankSum ofRanks
CG5T2VEpost < CG5T2VEprea.
CG5T2VEpost > CG5T2VEpreb.
CG5T2VEpost = CG5T2VEprec.
211
Test S ta ti st icsb
-1.361a
.174
.250
.125
.063
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T2VEpost-
CG5T2VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
2.3.1.2
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 3 Accuracy of key striking
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T2AK
Not corrected for ties.a.
Grouping Variable: groupb.
212
2.3.2.2
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 3 Accuracy of key striking
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
8b 4.50 36.00
1c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T2AKpost- TG5T2AKpre
N Mean RankSum ofRanks
TG5T2AKpost < TG5T2AKprea.
TG5T2AKpost > TG5T2AKpreb.
TG5T2AKpost = TG5T2AKprec.
Test S ta ti st icsb
-2.533a
.011
.008
.004
.004
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T2AKpost-
TG5T2AKpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
2.3.3.2
Task 2 Non-affected hand 5-finger sequential playing
Outcome variable 3 Accuracy of key striking
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
213
Rank s
0a .00 .00
3b 2.00 6.00
4c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T3AKpost- CG5T3AKpre
N Mean RankSum ofRanks
CG5T3AKpost < CG5T3AKprea.
CG5T3AKpost > CG5T3AKpreb.
CG5T3AKpost = CG5T3AKprec.
Test S ta ti st icsb
-1.604a
.109
.250
.125
.125
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T3AKpost-
CG5T3AKpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
214
Hypothesis 2 Piano-playing music therapy will improve unilateral coordination of
finger movements in the affected hands of chronic stroke patients
3.1.1.2
Task 3 Affected hand index finger tapping
Outcome variable 1 Timing consistency
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T3TC
Not corrected for ties.a.
Grouping Variable: Groupb.
3.1.2.1
Task 3 Affected hand index finger tapping
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 1 MIDI
215
Rank s
3a 3.67 11.00
2b 2.00 4.00
0c
5
Negative Ranks
Positive Ranks
Ties
Total
TGT3TCpost- TGT3TCpre
N Mean RankSum ofRanks
TGT3TCpost < TGT3TCprea.
TGT3TCpost > TGT3TCpreb.
TGT3TCpost = TGT3TCprec.
Test S ta ti st icsb
-.944a
.345
.438
.219
.063
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TGT3TCpost- TGT3TCpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
3.1.2.2
Task 3 Affected hand index finger tapping
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
9b 5.00 45.00
0c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T3TCpost- TG5T3TCpre
N Mean RankSum ofRanks
TG5T3TCpost < TG5T3TCprea.
TG5T3TCpost > TG5T3TCpreb.
TG5T3TCpost = TG5T3TCprec.
216
Test S ta ti st icsb
-2.668a
.008
.004
.002
.002
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T3TCpost-
TG5T3TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
3.1.3.2
Task 3 Affected hand index finger tapping
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
3b 2.00 6.00
4c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T3TCpost- CG5T3TCpre
N Mean RankSum ofRanks
CG5T3TCpost < CG5T3TCprea.
CG5T3TCpost > CG5T3TCpreb.
CG5T3TCpost = CG5T3TCprec.
Test S ta ti st icsb
-1.633a
.102
.250
.125
.125
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T3TCpost-
CG5T3TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
217
3.2.1.2
Task 3 Affected hand index finger tapping
Outcome variable 2 Velocity evenness
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T3VE
Not corrected for ties.a.
Grouping Variable: Groupb.
3.2.2.1
Task 3 Affected hand index finger tapping
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 1 MIDI
218
Rank s
4a 3.50 14.00
1b 1.00 1.00
0c
5
Negative Ranks
Positive Ranks
Ties
Total
TGT3VEpost- TGT3VEpre
N Mean RankSum ofRanks
TGT3VEpost < TGT3VEprea.
TGT3VEpost > TGT3VEpreb.
TGT3VEpost = TGT3VEprec.
Test S ta ti st icsb
-1.753a
.080
.125
.063
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TGT3VEpost- TGT3VEpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
3.2.2.2
Task 3 Affected hand index finger tapping
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
7b 4.00 28.00
2c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T3VEpost- TG5T3VEpre
N Mean RankSum ofRanks
TG5T3VEpost < TG5T3VEprea.
TG5T3VEpost > TG5T3VEpreb.
TG5T3VEpost = TG5T3VEprec.
219
Test S ta ti st icsb
-2.384a
.017
.016
.008
.008
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T3VEpost-
TG5T3VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
3.2.3.2
Task 3 Affected hand index finger tapping
Outcome variable 2 Velocity evenness
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
3b 2.00 6.00
4c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T3VEpost- CG5T3VEpre
N Mean RankSum ofRanks
CG5T3VEpost < CG5T3VEprea.
CG5T3VEpost > CG5T3VEpreb.
CG5T3VEpost = CG5T3VEprec.
Test S ta ti st icsb
-1.633a
.102
.250
.125
.125
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T3VEpost-
CG5T3VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
220
3.3.1.2
Task 3 Affected hand index finger tapping
Outcome variable 3 Accuracy of key striking
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T3AK
Not corrected for ties.a.
Grouping Variable: Groupb.
3.3.2.2
Task 3 Affected hand index finger tapping
Outcome variable 3 Accuracy of key striking
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
221
Rank s
0a .00 .00
8b 4.50 36.00
1c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T3AKpost- TG5T3AKpre
N Mean RankSum ofRanks
TG5T3AKpost < TG5T3AKprea.
TG5T3AKpost > TG5T3AKpreb.
TG5T3AKpost = TG5T3AKprec.
Test S ta ti st icsb
-2.521a
.012
.008
.004
.004
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T3AKpost-
TG5T3AKpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
3.3.3.2
Task 3 Affected hand index finger tapping
Outcome variable 3 Accuracy of key striking
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
3b 2.00 6.00
4c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T3AKpost- CG5T3AKpre
N Mean RankSum ofRanks
CG5T3AKpost < CG5T3AKprea.
CG5T3AKpost > CG5T3AKpreb.
CG5T3AKpost = CG5T3AKprec.
222
Test S ta ti st icsb
-1.604a
.109
.250
.125
.125
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T3AKpost-
CG5T3AKpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
4.1.1.2
Task 4 Affected hand 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T4TC
Not corrected for ties.a.
Grouping Variable: Groupb.
223
4.1.2.1
Task 4 Affected hand 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 1 MIDI
Rank s
4a 3.25 13.00
1b 2.00 2.00
0c
5
Negative Ranks
Positive Ranks
Ties
Total
TGT4TCpost- TGT4TCpre
N Mean RankSum ofRanks
TGT4TCpost < TGT4TCprea.
TGT4TCpost > TGT4TCpreb.
TGT4TCpost = TGT4TCprec.
Test S ta ti st icsb
-1.483a
.138
.188
.094
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TGT4TCpost- TGT4TCpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
4.1.2.2
Task 4 Affected hand 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
224
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T4TCpost- TG5T4TCpre
N Mean RankSum ofRanks
TG5T4TCpost < TG5T4TCprea.
TG5T4TCpost > TG5T4TCpreb.
TG5T4TCpost = TG5T4TCprec.
Test S ta ti st icsb
-2.032a
.042
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T4TCpost-
TG5T4TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
4.1.3.2
Task 4 Affected hand 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
1b 1.00 1.00
6c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T4TCpost- CG5T4TCpre
N Mean RankSum ofRanks
CG5T4TCpost < CG5T4TCprea.
CG5T4TCpost > CG5T4TCpreb.
CG5T4TCpost = CG5T4TCprec.
225
Test S ta ti st icsb
-1.000a
.317
1.000
.500
.500
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T4TCpost-
CG5T4TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
4.2.1.2
Task 4 Affected hand 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T4VE
Not corrected for ties.a.
Grouping Variable: Groupb.
226
4.2.2.1
Task 4 Affected hand 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 1 MIDI
Rank s
5a 3.00 15.00
0b .00 .00
0c
5
Negative Ranks
Positive Ranks
Ties
Total
TGT4VEpost- TGT4VEpre
N Mean RankSum ofRanks
TGT4VEpost < TGT4VEprea.
TGT4VEpost > TGT4VEpreb.
TGT4VEpost = TGT4VEprec.
Test S ta ti st icsb
-2.023a
.043
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TGT4VEpost- TGT4VEpre
Based on positive ranks.a.
Wilcoxon Signed Ranks Testb.
4.2.2.2
Task 4 Affected hand 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
227
Rank s
0a .00 .00
4b 2.50 10.00
5c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T4VEpost- TG5T4VEpre
N Mean RankSum ofRanks
TG5T4VEpost < TG5T4VEprea.
TG5T4VEpost > TG5T4VEpreb.
TG5T4VEpost = TG5T4VEprec.
Test S ta ti st icsb
-1.890a
.059
.125
.063
.063
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T4VEpost-
TG5T4VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
4.2.3.2
Task 4 Affected hand 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
1b 1.00 1.00
6c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T4VEpost- CG5T4VEpre
N Mean RankSum ofRanks
CG5T4VEpost < CG5T4VEprea.
CG5T4VEpost > CG5T4VEpreb.
CG5T4VEpost = CG5T4VEprec.
228
Test S ta ti st icsb
-1.000a
.317
1.000
.500
.500
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T4VEpost-
CG5T4VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
4.3.1.2
Task 4 Affected hand 5-finger sequential playing
Outcome variable 3 Accuracy of key striking
Comparison 1 Between treatment and control groups
Outcome measurement 2 5-Point scale
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
Asymp. Sig. (2-tailed)
Exact Sig. [2*(1-tailedSig.)]
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
T4AK
Not corrected for ties.a.
Grouping Variable: Groupb.
229
4.3.2.2
Task 4 Affected hand 5-finger sequential playing
Outcome variable 3 Accuracy of key striking
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T4AKpost- TG5T4AKpre
N Mean RankSum ofRanks
TG5T4AKpost < TG5T4AKprea.
TG5T4AKpost > TG5T4AKpreb.
TG5T4AKpost = TG5T4AKprec.
Test S ta ti st icsb
-2.032a
.042
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T4AKpost-
TG5T4AKpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
4.3.3.2
Task 4 Affected hand 5-finger sequential playing
Outcome variable 3 Accuracy of key striking
Comparison 3 Between pre- and post-tests in control group
Outcome measurement 2 5-Point scale
230
Rank s
0a .00 .00
2b 1.50 3.00
5c
7
Negative Ranks
Positive Ranks
Ties
Total
CG5T4AKpost- CG5T4AKpre
N Mean RankSum ofRanks
CG5T4AKpost < CG5T4AKprea.
CG5T4AKpost > CG5T4AKpreb.
CG5T4AKpost = CG5T4AKprec.
Test S ta ti st icsb
-1.342a
.180
.500
.250
.250
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
CG5T4AKpost-
CG5T4AKpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
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
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T5TCpost- TG5T5TCpre
N Mean RankSum ofRanks
TG5T5TCpost < TG5T5TCprea.
TG5T5TCpost > TG5T5TCpreb.
TG5T5TCpost = TG5T5TCprec.
Test S ta ti st icsb
-2.023a
.043
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T5TCpost-
TG5T5TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
5.2.2.2
Task 5 Both hands index finger tapping simultaneously
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
232
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T5VEpost- TG5T5VEpre
N Mean RankSum ofRanks
TG5T5VEpost < TG5T5VEprea.
TG5T5VEpost > TG5T5VEpreb.
TG5T5VEpost = TG5T5VEprec.
Test S ta ti st icsb
-2.032a
.042
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T5VEpost-
TG5T5VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
5.3.2.2
Task 5 Both hands index finger tapping simultaneously
Outcome variable 3 Accuracy of key striking
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T5AKpost- TG5T5AKpre
N Mean RankSum ofRanks
TG5T5AKpost < TG5T5AKprea.
TG5T5AKpost > TG5T5AKpreb.
TG5T5AKpost = TG5T5AKprec.
233
Test S ta ti st icsb
-2.023a
.043
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T5AKpost-
TG5T5AKpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
5.4.2.2
Task 5 Both hands index finger tapping simultaneously
Outcome variable 4 Stability of synchronizing 2-key strike
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T5SSpost- TG5T5SSpre
N Mean RankSum ofRanks
TG5T5SSpost < TG5T5SSprea.
TG5T5SSpost > TG5T5SSpreb.
TG5T5SSpost = TG5T5SSprec.
Test S ta ti st icsb
-2.032a
.042
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T5SSpost-
TG5T5SSpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
234
6.1.2.2
Task 6 Both hands index finger tapping alternately
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T6TCpost- TG5T6TCpre
N Mean RankSum ofRanks
TG5T6TCpost < TG5T6TCprea.
TG5T6TCpost > TG5T6TCpreb.
TG5T6TCpost = TG5T6TCprec.
Test S ta ti st icsb
-2.023a
.043
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T6TCpost-
TG5T6TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
6.2.2.2
Task 6 Both hands index finger tapping alternately
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
235
Rank s
0a .00 .00
3b 2.00 6.00
6c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T6VEpost- TG5T6VEpre
N Mean RankSum ofRanks
TG5T6VEpost < TG5T6VEprea.
TG5T6VEpost > TG5T6VEpreb.
TG5T6VEpost = TG5T6VEprec.
Test S ta ti st icsb
-1.633a
.102
.250
.125
.125
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T6VEpost-
TG5T6VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
6.3.2.2
Task 6 Both hands index finger tapping alternately
Outcome variable 3 Accuracy of key striking
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T6AKpost- TG5T6AKpre
N Mean RankSum ofRanks
TG5T6AKpost < TG5T6AKprea.
TG5T6AKpost > TG5T6AKpreb.
TG5T6AKpost = TG5T6AKprec.
236
Test S ta ti st icsb
-2.032a
.042
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T6AKpost-
TG5T6AKpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
6.4.2.2
Task 6 Both hands index finger tapping alternately
Outcome variable 4 Stability of synchronizing 2-key strike
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T6SSpost- TG5T6SSpre
N Mean RankSum ofRanks
TG5T6SSpost < TG5T6SSprea.
TG5T6SSpost > TG5T6SSpreb.
TG5T6SSpost = TG5T6SSprec.
Test S ta ti st icsb
-2.032a
.042
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T6SSpost-
TG5T6SSpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
237
7.1.2.2
Task 7 Both hands 5-finger sequential playing
Outcome variable 1 Timing consistency
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T7TCpost- TG5T7TCpre
N Mean RankSum ofRanks
TG5T7TCpost < TG5T7TCprea.
TG5T7TCpost > TG5T7TCpreb.
TG5T7TCpost = TG5T7TCprec.
Test S ta ti st icsb
-2.041a
.041
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T7TCpost-
TG5T7TCpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
7.2.2.2
Task 7 Both hands 5-finger sequential playing
Outcome variable 2 Velocity evenness
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
238
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T7VEpost- TG5T7VEpre
N Mean RankSum ofRanks
TG5T7VEpost < TG5T7VEprea.
TG5T7VEpost > TG5T7VEpreb.
TG5T7VEpost = TG5T7VEprec.
Test S ta ti st icsb
-2.041a
.041
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T7VEpost-
TG5T7VEpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
7.3.2.2
Task 7 Both hands 5-finger sequential playing
Outcome variable 3 Accuracy of key striking
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T7AKpost- TG5T7AKpre
N Mean RankSum ofRanks
TG5T7AKpost < TG5T7AKprea.
TG5T7AKpost > TG5T7AKpreb.
TG5T7AKpost = TG5T7AKprec.
239
Test S ta ti st icsb
-2.032a
.042
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T7AKpost-
TG5T7AKpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
7.4.2.2
Task 7 Both hands 5-finger sequential playing
Outcome variable 4 Stability of synchronizing 2-key strike
Comparison 2 Between pre- and post-tests in treatment group
Outcome measurement 2 5-Point scale
Rank s
0a .00 .00
5b 3.00 15.00
4c
9
Negative Ranks
Positive Ranks
Ties
Total
TG5T7SSpost- TG5T7SSpre
N Mean RankSum ofRanks
TG5T7SSpost < TG5T7SSprea.
TG5T7SSpost > TG5T7SSpreb.
TG5T7SSpost = TG5T7SSprec.
Test S ta ti st icsb
-2.032a
.042
.063
.031
.031
Z
Asymp. Sig. (2-tailed)
Exact Sig. (2-tailed)
Exact Sig. (1-tailed)
Point Probability
TG5T7SSpost-
TG5T7SSpre
Based on negative ranks.a.
Wilcoxon Signed Ranks Testb.
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)
Participant 1: 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 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
T1AK T1TC T1VE T2AK T2TC T2VE
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
Figure 4. Participant 1-Task 3, MIDI Piano roll view: Pre-test (05-Sep-2005) and Post-test (29-Sep-2005)
Participant 1: Task 3
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 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
Figure 6. Participant 2-Task 1, MIDI Piano roll view: Pre-test (05-Sep-2005) and Post-test (29-Sep-2005)
242
2. 2 Task 2. Non-affected hand 5-finger sequential playing
Figure 7. Participant 2-Task 2, MIDI Piano roll view: Pre-test (05-Sep-2005) and Post-test (29-Sep-2005)
Participant 2: 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 4.3 3.7 4.0 2.7 3.0 3.3
Post-test 5.0 5.0 4.7 4.7 4.0 3.3
T1AK T1TC T1VE T2AK T2TC T2VE
Figure 8. Participant 2-Task 1 ~ 2, Five-Point Scale Comparison: Pre-test and Post-test
2. 3 Task 3. Affected hand index finger tapping
Figure 9. Participant 2-Task 3, MIDI Piano roll view: Pre-test (05-Sep-2005) and Post-test (29-Sep-2005)
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
Participant 2: Task 3~4
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 3.7 3.7 3.0 3.0
Post-test 5.0 4.7 4.3 4.7 4.0 3.3
T3AK T3TC T3VE T4AK T4TC T4VE
Figure 11. Participant 2-Task 3 ~ 4, Five-Point Scale Comparison: Pre-test and Post-test
2. 5 Task 5. Both hands index finger tapping simultaneously
Figure 12. Participant 2-Task 5, MIDI Piano roll view: Pre-test and Post-test
244
2. 6 Task 6. Both hands index finger tapping alternately
Figure 13. Participant 2-Task 6, MIDI Piano roll view: Pre-test and Post-test
Participant 2: Task 5~6
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 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
T5AK T5TC T5VE T5SS T6AK T6TC T6VE T6SS
Figure 14. Participant 2-Task 5 ~ 6, Five-Point Scale Comparison: Pre-test and Post-test
2. 7 Task 7. Both hands 5-finger sequential playing
Figure 15. Participant 2-Task 7, MIDI Piano roll view: Pre-test and Post-test
245
Participant 2: Task 7
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 1.0 1.0 1.0 1.0
Post-test 4.0 3.0 2.3 4.0
T7AK T7TC T7VE T7SS
Figure 16. Participant 2-Task 7, Five-Point Scale Comparison: Pre-test and Post-test
3. Participant 3
3. 1 Task 1. Non-affected hand index finger tapping
Figure 17. Participant 3-Task 1, MIDI Piano roll view: Pre-test and Post-test
3. 2 Task 2. Non-affected hand 5-finger sequential playing
Figure 18. Participant 3-Task 2, MIDI Piano roll view: Pre-test and Post-test
246
Participant 3: 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 4.3 3.7 2.7 2.3 2.3
Post-test 5.0 5.0 4.3 4.7 3.7 3.0
T1AK T1TC T1VE T2AK T2TC T2VE
Figure 19. Participant 3-Task 1 ~ 2, Five-Point Scale Comparison: Pre-test and Post-test
3. 3 Task 3. Affected hand index finger tapping
Figure 20. Participant 3-Task 3, MIDI Piano roll view: Pre-test and Post-test
3. 4 Task 4. Affected hand 5-finger sequential playing
Figure 21. Participant 3-Task 4, MIDI Piano roll view: Pre-test and Post-test
247
Participant 3: Task 3~4
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 4.3 3.0 3.3 2.0 2.0 2.0
Post-test 5.0 5.0 4.0 4.3 3.7 3.0
T3AK T3TC T3VE T4AK T4TC T4VE
Figure 22. Participant 3-Task 3 ~ 4, Five-Point Scale Comparison: Pre-test and Post-test
3. 5 Task 5. Both hands index finger tapping simultaneously
Figure 23. Participant 3-Task 5, MIDI Piano roll view: Pre-test and Post-test
3. 6 Task 6. Both hands index finger tapping alternately
Figure 24. Participant 3-Task 6, MIDI Piano roll view: Pre-test and Post-test
248
Participant 3: Task 5~6
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 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
T5AK T5TC T5VE T5SS T6AK T6TC T6VE T6SS
Figure 25. Participant 3-Task 5 ~ 6, Five-Point Scale Comparison: Pre-test and Post-test
3. 7 Task 7. Both hands 5-finger sequential playing
Figure 26. Participant 3-Task 7, MIDI Piano roll view: Pre-test and Post-test
Participant 3: Task 7
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 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
4. 1 Task 1. Non-affected hand index finger tapping
Figure 28. Participant 4-Task 1, MIDI Piano roll view: Pre-test and Post-test
4. 2 Task 2. Non-affected hand 5-finger sequential playing
Figure 29. Participant 4-Task 2, MIDI Piano roll view: Pre-test and Post-test
Participant 4: 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 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
T1AK T1TC T1VE T2AK T2TC T2VE
Figure 30. Participant 4-Task 1 ~ 2, Five-Point Scale Comparison: Pre-test and Post-test
250
4. 3 Task 3. Affected hand index finger tapping
Figure 31. Participant 4-Task 3, MIDI Piano roll view: Pre-test and Post-test
4. 4 Task 4. Affected hand 5-finger sequential playing
Figure 32. Participant 4-Task 4, MIDI Piano roll view: Pre-test and Post-test
Participant 4: Task 3~4
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 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
T3AK T3TC T3VE T4AK T4TC T4VE
Figure 33. Participant 4-Task 3 ~ 4, Five-Point Scale Comparison: Pre-test and Post-test
251
4. 5 Task 5. Both hands index finger tapping simultaneously
Figure 34. Participant 4-Task 5, MIDI Piano roll view: Pre-test and Post-test
4. 6 Task 6. Both hands index finger tapping alternately
Figure 35. Participant 4-Task 6, MIDI Piano roll view: Pre-test and Post-test
Participant 4: Task 5~6
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 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
T5AK T5TC T5VE T5SS T6AK T6TC T6VE T6SS
Figure 36. Participant 4-Task 5 ~ 6, Five-Point Scale Comparison: Pre-test and Post-test
252
4. 7 Task 7. Both hands 5-finger sequential playing
Figure 37. Participant 4-Task 7, MIDI Piano roll view: Pre-test and Post-test
Participant 4: Task 7
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 1.0 1.0 1.0 1.0
Post-test 2.3 2.0 2.7 2.0
T7AK T7TC T7VE T7SS
Figure 38. Participant 4-Task 7, Five-Point Scale Comparison: Pre-test and Post-test
5. Participant 5
5. 1 Task 1. Non-affected hand index finger tapping
Figure 39. Participant 5-Task 1, MIDI Piano roll view: Pre-test and Post-test
253
5. 2 Task 2. Non-affected hand 5-finger sequential playing
Figure 40. Participant 5-Task 2, MIDI Piano roll view: Pre-test and Post-test
Participant 5: 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 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
T1AK T1TC T1VE T2AK T2TC T2VE
Figure 41. Participant 5-Task 1 ~ 2, Five-Point Scale Comparison: Pre-test and Post-test
5. 3 Task 3. Affected hand index finger tapping
Figure 42. Participant 5-Task 3, MIDI Piano roll view: Pre-test and Post-test
254
Participant 5: Task 3
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 1.0 1.0 1.0
Post-test 3.0 2.7 3.0
T3AK T3TC T3VE
Figure 43. Participant 5-Task 3, Five-Point Scale Comparison: Pre-test and Post-test
6. Participant 6
6. 1 Task 1. Non-affected hand index finger tapping
Figure 44. Participant 6-Task 1, MIDI Piano roll view: Pre-test and Post-test
6. 2 Task 2. Non-affected hand 5-finger sequential playing
Figure 45. Participant 6-Task 2, MIDI Piano roll view: Pre-test and Post-test
255
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 46. Participant 6-Task 1 ~ 2, Five-Point Scale Comparison: Pre-test and Post-test
6. 3 Task 3. Affected hand index finger tapping
Figure 47. Participant 6-Task 3, MIDI Piano roll view: Pre-test and Post-test
6. 4 Task 4. Affected hand 5-finger sequential playing
Figure 48. Participant 6-Task 4, MIDI Piano roll view: Pre-test and Post-test
256
Participant 6: Task 3~4
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 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
T3AK T3TC T3VE T4AK T4TC T4VE
Figure 49. Participant 6-Task 3 ~ 4, Five-Point Scale Comparison: Pre-test and Post-test
6. 5 Task 5. Both hands index finger tapping simultaneously
Figure 50. Participant 6-Task 5, MIDI Piano roll view: Pre-test and Post-test
6. 6 Task 6. Both hands index finger tapping alternately
Figure 51. Participant 6-Task 6, MIDI Piano roll view: Pre-test and Post-test
257
Participant 6: Task 5~6
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 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
Figure 52. Participant 6-Task 5 ~ 6, Five-Point Scale Comparison: Pre-test and Post-test
6. 7 Task 7. Both hands 5-finger sequential playing
Figure 53. Participant 6-Task 7, MIDI Piano roll view: Pre-test and Post-test
Participant 6: Task 7
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
Figure 54. Participant 6-Task 7, Five-Point Scale Comparison: Pre-test and Post-test
258
7. Participant 7
7. 1 Task 1. Non-affected hand index finger tapping
Figure 55. Participant 7-Task 1 MIDI Piano roll view: Pre-test and Post-test
7. 2 Task 2. Non-affected hand 5-finger sequential playing
Figure 56. Participant 7-Task 2 MIDI Piano roll view: Pre-test and Post-test
Participant 7: 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 4.3 3.7 4.3 3.3 3.0
Post-test 4.7 4.7 4.0 4.3 3.7 3.3
T1AK T1TC T1VE T2AK T2TC T2VE
Figure 57. Participant 7-Task 1 ~ 2, Five-Point Scale Comparison: (14-Nov-2005) and Post-test
259
7. 3 Task 3. Affected hand index finger tapping
Figure 58. Participant 7-Task 3 MIDI Piano roll view: Pre-test and Post-test
Participant 7: Task 3
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 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
8. 1 Task 1. Non-affected hand index finger tapping
Figure 60. Participant 8-Task 1, MIDI Piano roll view: Pre-test and Post-test
260
8. 2 Task 2. Non-affected hand 5-finger sequential playing
Figure 61. Participant 8-Task 2, MIDI Piano roll view: Pre-test and Post-test
Participant 8: 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 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
T1AK T1TC T1VE T2AK T2TC T2VE
Figure 62. Participant 8-Task 1 ~ 2, Five-Point Scale Comparison: Pre-test and Post-test
8. 3 Task 3. Affected hand index finger tapping
Figure 63. Participant 8-Task 3 MIDI Piano roll view: Pre-test and Post-test
261
8. 4 Task 4. Affected hand 5-finger sequential playing
Figure 64. Participant 8-Task 4 MIDI Piano roll view: Pre-test and Post-test
Participant 8: Task 3~4
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 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
T3AK T3TC T3VE T4AK T4TC T4VE
Figure 65. Participant 8-Task 3 ~ 4, Five-Point Scale Comparison: Pre-test and Post-test
8. 5 Task 5. Both hands index finger tapping simultaneously
Figure 66. Participant 8-Task 5, MIDI Piano roll view: Pre-test and Post-test
262
8. 6 Task 6. Both hands index finger tapping alternately
Figure 67. Participant 8-Task 6, MIDI Piano roll view: Pre-test and Post-test
Participant 8: Task 5~6
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 4.3 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
T5AK T5TC T5VE T5SS T6AK T6TC T6VE T6SS
Figure 68. Participant 8-Task 5 ~ 6, Five-Point Scale Comparison: Pre-test and Post-test
8. 7 Task 7. Both hands 5-finger sequential playing
Figure 69. Participant 8-Task 7, MIDI Piano roll view: Pre-test and Post-test
263
Participant 8: Task 7
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 2.3 2.3 2.0 2.3
Post-test 3.7 3.3 3.0 3.3
T7AK T7TC T7VE T7SS
Figure 70. Participant 8-Task 7, Five-Point Scale Comparison: Pre-test and Post-test
9. Participant 9
9. 1 Task 1. Non-affected hand index finger tapping
Figure 71. Participant 9-Task 1, MIDI Piano roll view: Pre-test and Post-test
9. 2 Task 2. Non-affected hand 5-finger sequential playing
Figure 72. Participant 9-Task 2, MIDI Piano roll view: Pre-test and Post-test
264
Participant 9: 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 4.3 4.0 3.3 3.0 2.3
Post-test 4.7 4.7 4.3 4.7 4.0 3.0
T1AK T1TC T1VE T2AK T2TC T2VE
Figure 73. Participant 9-Task 1 ~ 2, Five-Point Scale Comparison: Pre-test and Post-test
9. 3 Task 3. Affected hand index finger tapping
Figure 74. Participant 9-Task 3 MIDI Piano roll view: Pre-test and Post-test
Participant 9: Task 3
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 1.0 1.0 1.0
Post-test 2.0 2.3 2.0
T3AK T3TC T3VE
Figure 75. Participant 9-Task 3, Five-Point Scale Comparison: Pre-test and Post-test
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
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