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The Benefits of Music-Movement Therapy with Post-Stroke Patients

Final Research Proposal

PES 670- Research Methods

Central Michigan University Doctoral Program in Physical Therapy

By: Sierra Moore, SPT

8/1/17
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Introduction

According to the American Stroke Association, every year approximately 795,000 people

in the United States will have a stroke1. Stroke is currently the 5th leading cause of death and the

leading cause of prolonged disability in the U.S. Every 40 seconds someone will have a stroke,

occurring more frequently with women1. Post-stroke patients should have individualized

treatment since every stroke is unique. Patient presentation following a stroke depends on the

area of the brain that was effected. However, the following are common ways that people are

affected: memory loss, hemi-paralysis, slow movements, vision problems, and/or

speech/language issues. Almost 90% of strokes are ischemic, meaning that a blood clot prevents

blood flow to the brain1. According to the American Physical Therapy Association (APTA), the

prevalence of stroke has increased around the world by 25% among adults that are 20-64 years-

old1. Following a stroke more and more patients will need to receive physical therapy. Therefore,

it is of vital importance that physical therapists determine the best form of treatment to provide

for their patients.

Physical therapists use various techniques post-stroke in order to help patients regain

their upper body strength and control, relearn how to walk, and how to perform functional

activities that they may perform on a daily basis. Unfortunately recovering from a stroke can

have a prolonged to recovery and most patients will not return to their prior level of functioning.

This may be part of the reason that patients are at risk for post-stroke depression, which affects

1/3 of patients2. Post-stroke depression has been underdiagnosed meaning that this statistic

should actually be higher2. The issue of depression among patients following a stroke may need

to be addressed by the physical therapist in terms of screening and/or providing additional

resources for the patient to receive help. Depression can have an influence on the motivation of
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the patient and will actually prolong the recovery period2. Patient motivation has an influence on

treatment time and how much a patient will benefit from therapy. It is imperative that researchers

determine the psychological affect of the patient post-stroke in terms of depression and

motivation.

Research about music-movement therapy with patients post-stroke has been very limited.

A previous study3 examined the effects of traditional therapy combined with music-movement

therapy on muscle strength, range of motion, activities of daily living, depression, and mood

states3. These patients were in a hospital setting and were still wheel-chair bound, which may be

the reason there were no significant changes found in their lower extremities post-treatment3.

However, there were significant findings for mood improvement and upper extremity range of

motion for shoulder and elbow flexion. Another study examined dance therapy with patients

diagnosed with Parkinson’s disease.4 The researchers found that there were significant

improvements in motor and executive functioning among these patients4.Even though this was

an entirely different condition, Parkinson’s Disease, both populations have cognitive and motor

dysfunctions in common. Dancing or music-movement therapy may be an unconventional yet

effective form of treatment for patients. The few studies that have been done on dancing or

music-movement therapy may indicate the need for further research in order to determine the

benefits for patients post-stroke.

The purpose of this study is to determine the effect of music-movement therapy on

healing time, motivation, and goal achievement among post-stroke patients ages 50-75 in an

outpatient neuro-rehab setting. This study will also determine whether women benefit more from

music-movement therapy in comparison to men.

Methods
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Research Design

The quasi experimental research study will take place over a period of 10 weeks in an

outpatient neuro-rehab setting. The control group will receive routine care, while the treatment

group will receive a combination of routine care and music movement therapy. There will be at

least eight patients total with four patients in each group; two females and two males in each

group. There will be three treatment sessions per week and data will be collected on the last

session of each week. In order to control for differences in physical therapist styles, each patient

will work with two different therapists. For example, patient 1 will work with physical therapist

1 for the first session. Then on the second session, patient 1 will work with physical therapist 2.

This pattern will continue throughout the study and the patient will rotate between therapists.

Patients will be randomly assigned to either the experimental group or the control group using

the fishbowl method. Patients will not be aware of their group assignment. If the experimental

group demonstrates greater benefits from the combination therapy, the control group will be able

to receive the same treatment pro-bono for four weeks following the study.

Recruitment

Patients coming into therapy will be asked at their initial evaluation if they would be

willing to participate in the study. Local M.D.s in the area will be asked to refer their patients

that fit into the required criteria. The current doctor-therapist relationships that this neuro-rehab

clinic has will be utilized, but in order to recruit more patients the researchers may need to use

various marketing techniques. The researchers may need to make phone calls to physicians,

make flyers, and send emails.

Participants
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Patients will be between the ages of 50-75 and will be at least 4-weeks post-stroke. The

following criteria must be met in order to qualify for participation in the study: 1) Patient

experienced an acute ischemic right or left temporal, frontal, parietal, or subcortical brain

regions. 2) Able and willing to participate in the study. 3) Able to do a portion of the treatment

session in weight-bearing in order to perform the exercises. 4) No hearing deficit. 5) Able to

communicate verbally. 6). And able to understand the informed consent process.

Tests & Measures

At the last session of each week, the participants will take the Patient Health

Questionnaire (PHQ-9) and will be asked to rate their level of motivation for therapy using a

Likert scale (0=not motivated to 10= extremely motivated). The physical therapist will test the

patient’s upper extremity and lower extremity AROM using a goniometer. The therapist will also

test the patient’s strength with upper extremity and lower extremity manual muscle tests. Inter-

rater error will be controlled by having the same therapist perform the tests for the same patient

each time. ANOVA will be used to determine how significant the results are between the two

groups and between the men and women in the experimental group.

Hypotheses

H0: The experimental group will show faster healing time, greater motivation, and will

achieve more goals in comparison to the control group.

Null H0: There will be no significant difference between the control group and the

experimental group in terms of healing time, motivation, and goal achievement.

Null H0: Women will benefit more from the combination of music movement therapy in

comparison to the men receiving the same therapy combination.

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Null H0: There will be no significant difference between the men and women in the

experimental group.

Treatment Procedures

The patients in the control group will receive one full hour of routine care. On the other

hand, the experimental group will receive a half hour of routine care and a half hour of music

movement therapy. Patients will be encouraged to dance and sing along to the music. The songs

will vary at each session, but will stay within the 50s and 60s eras of music. These songs will be

upbeat and are intended to influence the patient’s motivation to participate. Songs will be played

the entire course of the experimental group’s treatment session. There will be no music playing

during the control group’s treatment session.

Appendix A: Extensive Review of Literature

Introduction

After performing an extensive review of the literature, it has become even more apparent

that the need for research in music-movement therapy is needed. Most of the current research has

been done outside of the U.S. and the studies that have been performed have had beneficial

results for their patients. This review of literature will be organized in different sections and with

further subsections within them. First, the background information about stroke will be explored,

which will be subdivided into historical background, physiology, diagnosis, risk factors, and

demographic information. Subsequently, instruments and scales that may be used in this study

that have been successfully used in other studies will be explored. The final section will examine

the details of the previous research that has been done and that is similar in comparison to the

current research proposal.

Background Information
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Historical background

Stroke was first recognized 2,400 years ago by Hippocrates.5 Stroke was first referred to

as apoplexy, which in Greek means “structure struck down by violence.”1 This term was given to

the condition due to the person’s paralysis and convulsions. Hippocrates was also the first to

recognize that the person’s paralysis occurred on the opposite side of the body than the injury.6

In the mid-1600s, Jacob Webfer discovered that patients who died from stroke had bleeding in

the brain or a blockage of blood to the brain.5 Until then, there was little known about the cause

of stroke or even the anatomy or physiology of the brain. In 1928, apoplexy was divided into

terms that defined the cause of the incident.5 This led to the terms cerebral vascular accident

(CVA), stroke, and “brain attack.”

Physiology

There are three primary types of strokes; hemorrhagic, ischemic, and transient ischemic

attack (TIA). The most common is an ischemic stroke, which occurs in about 87 percent of all

cases.7 An ischemic stroke is caused by a blood clot, or blockage, that restricts blood flow to the

brain. The primary cause of these blockages is from a build-up of fatty deposits. These fatty

deposits can be divided into two types: cerebral thrombosis or cerebral embolism.7 A cerebral

thrombosis is a fatty deposit that builds up at the congested portion of the blood vessel. On the

other hand, a cerebral embolism is a blood clot that forms at another location and it breaks loose

until it reaches a clogged part of a vessel.

A hemorrhagic stroke occurs when a weakened blood vessel breaks open and bleeds into

the surrounding brain tissue. This type of stroke is less common than an ischemic stroke and

accounts for 13 percent of stroke cases.7 There are two kinds of weakened blood vessel ruptures:

an aneurysm and an arteriovenous malformation.7 An aneurysm is defined as a “ballooning” of

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the weakened portion of the vessel. The weakened portion of the vessel will continue to grow

weaker and “balloon” until it finally breaks open and pools out. Between 0.5 and 3 percent of

people will suffer from brain bleeding caused by an aneurysm.7 Aneurysms are caused by

constant blood pressure and the vessel will gradually grow thinner as they increase in size. It is

believed that people are not born with a disposition for aneurisms. The second type of weakened

vessel is an arteriovenous malformation (AVM). An AVM is a tangle of malformed blood

vessels that mixes up the blood flow of oxygenous blood and de-oxygenous blood. These

abnormal blood vessels will actually drive blood away from the brain tissues. AVMs are

extremely rare, only occurring in less than 1 percent of Americans (1 in 2,000-5,000).7 Usually

AVMs are congenital, not hereditary.

A transient ischemic attack (TIA) is a temporary blockage of blood flow to the brain.

These are also referred to as “mini strokes” in the medical field. These serve as warning signs for

a potential oncoming stroke, which is very likely. The person experiencing a TIA will have

stroke symptoms due to a clot or blockage. However, the symptoms will pass after a few minutes

as the blockage either disintegrates or dislodges. According to the American Stroke Association,

approximately 1/3 of Americans have experienced symptoms identical to symptoms of TIA.7

This form of stroke does not usually cause permanent damage to the brain.7

Diagnosis

The event of a stroke is diagnosed based on the person’s signs and symptoms and the

medical history. The typical signs and symptoms of stroke are consistent with the following:

dizziness, difficulty breathing, sudden onset of weakness, paralysis, numbness or tingling,

confusion, loss of bowel and/or bladder control, difficulty with speaking or understanding

speech, problems with vision, loss of balance or being able to walk, severe headache, and loss of
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consciousness.8 The physician will check the person’s affect and alertness along with the

person’s balance and coordination. The physician will obtain the person’s health history and will

look at factors such as smoking, heart disease, hypertension, and a previous stroke.8 These

factors increase the likelihood of experiencing a stroke. The doctor will check for indications of

atherosclerosis that may be present in the carotid arteries. The medical term atherosclerosis

refers to the hardening and narrowing of the arteries in the body from a build-up of lipids or fat

cells. This hardening and narrowing begins to prevent blood flow from passing through and is

usually the cause of stroke and heart attacks.9 The physician may order a brain computed

topography (CT scan), magnetic resonance imaging (MRI), CT arteriogram, carotid angiography,

electrocardiogram (EKG), echocardiography, and/or blood tests to diagnose a stroke.8

Risk Factors

There are many risk factors that increase the probability of having a stroke. Some of these

factors can be controlled, while unfortunately others cannot. The likelihood of having a stroke

increases with age. In fact, for every 10 years that are lived over the age of 55, will double the

probability of a stroke.10 For example, a person that is 85 years-old will have 6 times the chance

of having a stroke in comparison to a person that is 55 years-old. Approximately 65 percent of

strokes occur in those that are 65 years and older.10 Those that have a family or a personal history

of stroke are at greater risk. Strokes are more prevalent among certain populations, such as

blacks, Hispanics, and Asian-pacific islander.10 Strokes also occur more frequently in women.

However, this may be due to the fact that women usually live longer in comparison to men.

There are also certain health factors that increase the chances of stroke, which include the

following: diabetes, hypertension, high cholesterol, heart disease, and smoking, drug or alcohol

use, stress, depression, sedentary lifestyle, and obesity.10,11 There are certain medical conditions
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that may play a role in having a stroke for example, sickle cell disease, vasculitis, and bleeding

disorders.11

Demographic Information

The prevalence of stroke is very high in the U.S. killing more than 130,000 annually (1

out of 20 people).12 Approximately every 40 seconds, someone will have a stroke. On the other

hand, approximately every 4 minutes, someone will die of a stroke. Stroke is currently the fifth

leading cause of death among Americans.12 Due to the growing issue of obesity, it will not be

long until this moves closer to number one. Stroke is also the primary cause of long-term

disability in the U.S. This high prevalence of stroke is one of the many reasons why more

research must be done with stroke patients in physical therapy. It is especially important to

determine, which forms of therapy are more beneficial for patients.

Instruments

There are a few measuring instruments that may be used. The Beck Depression Inventory

(BDI) may be used in order to measure depression in stroke patients. Depression among this

population is often overlooked and the current study will measure depression throughout the

course of therapy. The BDI is widely used and has been appropriate to use among stroke

patients.13 The current study will also measure motivation using a Likert scale (0=not motivated

to 10=extremely motivated).

Many of these scales are not useful for patients with aphasia. However, the criteria for

participation in the current study is the ability to communicate verbally. The Berg Balance Scale

(BBS) may also be used in this study to measure the patient’s ability to balance.13 The BBS has

been well established for use with stroke patients and it is very sensitive to change in scores. The

BBS will demonstrate the patient’s improvements in their ability to maintain balance over the
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course of therapy. This test also only takes about 10 minutes to administer, which is a desirable.

There are other scales that have been used to measure such things as the patient’s activities of

daily living (ADLs), movement, motor function, and disability. But, these scales have been

proven to not be very effective among stroke patients and most of them been found to have low

sensitivity. Therefore, these will not be used in the current research. In order to test muscle

strength, the therapist will use standardized manual muscle testing. The therapist will also use a

goniometer to measure the patient’s range of motion (ROM). The functional short-term goals (5

weeks) and long-term (10 weeks) goals will be developed at the initial visit taken from the

patient’s subjective interview. There will be 2 short-term goals and 2 long-term goals made

concerning patient ADLs. There will be 2 short-term goals and 2 long-term goals developed for

ROM and also for strength prior to the onset of treatment.

Current Research

As mentioned previously, there is a lack of research available about music-movement

therapy with post-stroke patients. This demonstrates the urgency for studies such as this one in

order to determine the most valuable form of treatment and thus improving the patient’s quality

of care.

A study3 investigated the effects that combined music-movement therapy had on the

psychological and physical functioning of patients. However, this study took place in an acute

rehab setting in a hospital. This study took place over the course of an 8-week period. The

researchers used a quasi-experimental design that included pre-tests and post-tests. The subjects

that were in the control group received routine care, while the experimental group received

routine care combined with music-movement therapy.3 The study consisted of 30 patients that

were hospitalized within two weeks following their strokes. Out of the 30 patients there were 15
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males and 15 females that were primarily aged 40 years and older. In order to qualify for the

study, the patients were required to fit the following criteria: “(1) had an acute ischemic stroke in

the left or right temporal, frontal, parietal or subcortical brain regions, (2) had no prior

neurological or psychiatric disease, (3) had no hearing deficit, (4) were hospitalized less than

two weeks, (5) were fully conscious without L tube or T tube, (6) could communicate verbally,

(7) had a Korean Mini-Mental State Examination score >20 points and (8) were able and willing

to participate in the study.”3 The participants were randomly assigned to either the control group

or the experimental group. Before this 8- week study, the researchers executed a pilot study that

included three patients that participated in music-movement therapy three times for just one

week.3 The researchers found that the regimen was possible for these patients and that the

patients had fun participating in the sessions.3

The music-movement therapy included preparatory activities for 20 minutes, main

activities for 30 minutes, and then finishing activities for 10 minutes.3 This treatment regimen

took place three times every week over the period of eight weeks during the study. Since these

patients had one-side mobility issues, they participated while sitting in their wheel-chairs. The

preparatory activities included 22 stretching techniques for the entire body. The music during

this period was quiet meditational music that was thought to enhance joint range of motion.3 The

music was carefully chosen to match the era of music that would have been popular when the

patients were younger. The main activities began by having the patients sing and play musical

instruments with the music using their healthy side first. A total of eight songs were played and

patients used instruments such as maracas and tambourines. The treatment ended with finishing

activities in which patients were encouraged to express their emotions and talk about any

difficulties or frustrations that they had during the music-movement therapy.3

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The physical functioning of these patients was measured before the study and after the

study. The patient’s strength was measured using the Medical Research Council, which ranks

strength on a scale of 0-5.3 The patient’s shoulder, elbow, wrist, hip, and knee ROM was

measured using a goniometer. The patient’s ADLs were measured by the Korean-modified

Barthel index (K-MBI).3 This instrument particularly evaluates the patient’s mobility and ADL

functioning. The scale scores the test into three types of dependence: complete dependence (0-

20), moderate dependence (62-90), and complete independence (100).3

The psychological functioning of these patients was also measured before and after the

research study. The patient’s state of mood was measured using the Profile of Mood States Brief

Instrument that evaluates patient anxiety, anger, alertness, and depression.3 The researchers used

the Korean version of this instrument. The instrument used a 5-point Likert scale that consists of

34 items. The patient could score anywhere from 0-136; the higher the score, the negative the

patient mood state.3 In order to measure depression among the patients, the researchers used The

Center for Epidemiologic Studies Depression Scale (CES-D).3 This scale uses a 4-point Likert

scale with 20 items. Scores range from 0-60 and the higher the score means that the patient is

experiencing a greater amount of depression.3

The researchers found that ROM on the affected shoulder, elbow, and hip was increased

following music-movement therapy. In the control group, the ROM for shoulder, elbow, and hip

on the affected side either worsened or remained the same. In particular, elbow and shoulder

range of motion in the experimental group was statistically significant in comparison to the

control group.3 The upper and lower extremity muscle strength between groups was not

significantly different. The patient’s mood states in the experimental group were significantly
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higher compared to the patient’s assigned to the control group. However, the depression scores

did not demonstrate significant differences between groups.3

Another study14 used Transcranial Magnetic Stimulation (TMS) to determine the

functional changes in the sensorimotor cortex and the associated motor improvements following

music-movement therapy. In this study 20 patients that were right-hand dominant were recruited

to the experimental group. In order to fit the criteria for participation the patients had to have had

a stroke at least 6 months before enrollment and a Barthel Index over 50 with a maximum score

of 100 to determine patient ADL.14 Patients were excluded if they had a history of seizures, a

significant cognitive impairment, prior musical skills, and any major comorbidities. Out of the 20

participants in the experimental group, the majority were men (n=15) and the average age was 59

years-old. The control group consisted of 14 healthy individuals that were within the same age

range, gender, and educational level. These participants were most men (n=12) and were the

average age of 56 years-old. These patients did not have a history of stroke, neurological disease,

seizures, comorbidities, or cognitive impairments.14

Over the course of four weeks, patients in the experimental group received twenty 30-

minute treatment sessions of music-movement therapy. These patients participated in these

sessions individually unlike the previous study3 mentioned above. This study used a MIDI-piano

with the aim to improve fine motor function and an electric drum pad set to improve gross motor

function.14 For drum training, the participants sat on a chair in front of the drum pad set. Each

exercise was first played by the researcher and the participant had to repeat it on their drum pad.

For piano training, the exercise was also first demonstrated by the researcher and the participant

repeated it on their keyboard. The exercises were progressed as needed by first playing single

tones to playing a sequence of notes to playing simple children’s songs.14

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To measure upper extremity motor functions the researchers used the Action Research

Arm Test (ARAT). The subtests of this instrument assessed grasp, grip, pinch, and gross

movement. The researchers also used a computerized movement analysis system to measure the

frequency, velocity, and smoothness of the movement.14

The results found that significant upper extremity motor function improvement occurred

accompanied by plastic changes among the experimental group. The researchers also found that

there was an increase in motor cortex excitability in the affected side of the brain after training.

The researchers also found that there was an association between changes in the affected motor

cortex and improved motor functioning with the affected upper extremity. The participants in the

experimental group also demonstrated improvements in frequency, velocity, and smoothness of

movement.14

Another study15 examined the effects of using musical instruments to improve motor skill

recovery with patients following a stroke.15 The study took place at an inpatient neurological

rehabilitation hospital and included 40 patients. The patients had to fit the following criteria to

qualify for participation: “(a) patients had to have residual function of the affected extremity, i.e.,

had to be able to move the affected arm without help from the healthy side, and to move the

index finger without help from the healthy hand. Moreover, (b) an overall Barthel Index over 50

(possible score 100) [26] was demanded and (c) performance on the Nine Hole Pegboard Test

had to be slower than that of the mean minus 2 SD of a healthy control group.”15 Before being

able to participate in the study, the patients were also screened for aphasia and cognitive

impairments.15

There were 20 participants randomly assigned to the experimental group that received a

combination of music-movement therapy and conventional therapy over the course of the 3-week
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study. There were 20 participants randomly assigned to the control group that received

conventional therapy alone. The researchers used computer movement analysis to quantify the

velocity, frequency, and smoothness of the movement before the study and after the treatment.15

The patients in the control group received 27.2 units of conventional therapies, each a duration of

30 minutes over the course of the study. The patients in the experimental group received 27.4

units of conventional therapy.15 Conventional therapy included individual physical therapy and

occupational therapy. The experimental group received 15 individual treatment sessions that

were 30 minutes in duration. A MIDI-piano was used to enhance fine motor skills and an

electrical drum set was used to enhance gross motor skills.15 Treatment was individualized to the

patient and some of the patients trained exclusively on the piano or on the drums, or both. The

instructor would first play the first note, and if the patient was able to repeat the single note

successfully multiple times then the difficulty would be increased. The difficulty of the required

task was increased until the patient could play all 8 notes successfully in different sequences. The

highest level of difficulty was to play the beginning of a children’s song that included 5-8 notes

with the affected side.15

The researchers found that the patients in the experimental group had a significant

increase in their available ROM, speed of movement, and quality of movement in comparison to

the control group. The patients receiving the music-movement therapy also provided subjective

feedback to the researchers and they all found enjoyment from the sessions.15

Another study16 was similar, but instead of using instruments the study used a music

sonification system. This system required the patient to stick their arm in a box and it would then

associate the movement with a sound. The researchers wanted to pair music’s beneficial effects

on the brain’s neuroplasticity and with voluntary movements of the upper extremities. The
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researchers were also aware that repetitive movements in the rehabilitation of stroke patients was

also beneficial, therefore they made the training techniques repetitive.16 There were four patients

that participated in the study and they all had moderate impairments of upper extremity motor

function following a stroke. The criteria for participation included the following: “[the patient

must] (A) have a residual function of the affected extremity (i.e., the ability to move the affected

arm and the index finger without help from the healthy side); (B) have an overall Barthel Index

higher than 50; (C) be right handed; (D) have had a stroke that affected the left-brain

hemisphere; and (E) not have other neurological or psychiatric disorders.”16

The patients were randomly assigned to the experimental group (n=2) and the control

group (n=2). The experimental group received conventional physical therapy and 9 days of

musical sonification therapy. Both patients in the experimental group happened to have

subcortical lesions following an ischemic stroke. The control group received conventional

physical therapy and 9 days of sham sonification training. The sham sonifcation training required

the same movements, but with no association sound. Both patients in the control group happened

to have frontal lesions following a hemorrhagic stroke.16

Multiple instrument scales were used to assess upper extremity motor functioning such as

the Fugl-Meyer Assessment (FMA), the Action Research Arm test (ARAT), the Box and Block

Test (BBT), and the Nine-Hole Pegboard Test (9HPT). The Stroke Impact Scale was used to

assess the patient’s memory, thinking, social participation, and psychological well-being.16

The researchers found that those in the experimental group improved on all functional motor

tests and the psychological well-being test. This study did have some limitations due to the fact

that it was a pilot study and that the patients in each group happened to have the same type of
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brain lesion. The type of brain lesion in the experimental group may have had an impact on the

results of the study and there was the limitation of a small sample size.16

This study17 sought to determine the impact that music-supported therapy had on

improvements in neurological reorganization, thus promoting improvement in motor functioning.

There were 62 patients that were recruited form an inpatient neurological rehabilitation center.

These patients had moderate impairments in upper extremity motor functioning and had no

previous musical experience. The patients had to fit the following criteria to participate:

“(a)patients had to have a residual function of the affected extremity (i.e. the ability to move the

affected arm and index finger without help from the healthy side). Moreover, (b) an over-all

Barthel Index over 50 was required; and (c) performance on the Nine-Hole Pegboard Test had to

be slower than that of the mean minus 2 SD of a healthy control group (mean peg/s 0.68, SD

0.14).”18 The patients were randomly assigned to the experimental group (n=32) that received

conventional therapy and music-supported therapy or to the control group that received

conventional therapy only (n=30).17

The experimental group received 15 sessions over the course of the 3-week study. The

musical instruments used were a MIDI-piano and an electrical drum set. The same procedures

from a previous study16 were followed for this study as well. The results reflected a significant

improvement in motor functioning in terms of speed, precision, and smoothness of the

movement. The researchers also found that there were electrophysiological changes associated

with stronger cortical connectivity and activation of the motor cortex. Not only did they find that

this music-supported therapy could improve motor functioning in terms of gross and fine

movement, they also found that there were changes in the neuroplasticity of the brain.17
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