American Psychological Association 5th Edition



Music Therapy for Stroke RehabilitationSAMPLE PAPERFinal PICOT paperAbstractIn the United States, one in three adults have cardiovascular disease, and stroke is the third leading cause of death. Prompt and adequate therapies are necessary to reduce the extent of long-term disability in stroke survivors. Music therapy, including listening to music, making music, and rhythmic auditory stimulation, is a newer concept, and it is uncertain whether it is effective for stroke rehabilitation. The purpose of this paper is to describe the evidence on the effectiveness of music therapy at reducing recovery time and improving cognitive and motor function in acute stroke. The following PICO question was used to search four databases: Do hospitalized acute stroke patients who are over 65 years of age (P), treated with music therapy (I), compared to similar patients with no music therapy (C), have a shorter recovery time and better cognitive and motor function improvement (O)? A critical appraisal of one systematic review, three randomized controlled trials, and one quasi-experimental study yielded strong evidence in support of music therapy. Results included significant improvements in gait parameters, ROM, and motor function with music therapy in stroke patients. There was also evidence for improvements in verbal memory, focused attention, mood, speech, and neural reorganization. It is recommended from this evidence that music therapy be incorporated into clinical practice for stroke rehabilitation. Keywords: stroke, music therapy, acoustic stimulation, auditory stimulation, recovery time, length of stay, cognition, mobility, recovery of function, functional status, psychomotor performanceBackgroundIn the United States, approximately every 40 seconds someone has a stroke, and about every four minutes, someone dies as a result of a stroke (Go et al., 2013). In 2009, in the United States, the indirect and direct costs of cardiovascular disease and stroke were over $300 billion, which was 37% higher than cancer, and the highest of any diagnostic group (Go et al., 2013). Healthy People 2020 goals include 24 initiatives related to heart disease and stroke (U.S., 2014). A cerebrovascular accident or stroke is caused by the disruption of blood flow to the brain, and can lead to the loss of neurological functioning such as cognitive and motor abilities. In the United States, one in three adults have some type of cardiovascular disease, and stroke is the third leading cause of death. Music therapy for stroke is a new concept, and includes listening to music, making music, and rhythmic auditory stimulation (RAS). Support exists for the effectiveness of RAS improving gait parameters in Parkinson’s, but it is unclear whether music therapy is effective for stroke rehabilitation (Chouhan & Kumar, 2012). The purpose of this paper is to describe the evidence on the effectiveness of music therapy in stroke rehabilitation. Search MethodsKeywords from the following PICOT question were used to search four literature databases: Do hospitalized acute stroke patients who are over 65 years of age (P), treated with music therapy (I), compared to similar patients with no music therapy (C), have a shorter recovery time and better cognitive and motor function improvement (O)? The element of time was not included for the current clinical question. The databases searched were PubMed- Clinical Queries, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Dynamed and the Cochrane Library. The initial search terms were the following: stroke, music therapy, recovery time, length of stay, cognition, mobility, and motor function. To identify alternate and acceptable terms within the databases, medical subject headings (MeSH) were investigated within PubMed. The search term, stroke was entered as a MeSH and 28 additional synonyms were provided such as cerebrovascular accident, CVA, acute stroke, as well as the plural form of each of these terms. The MeSH music therapy was located in three different categories and the alternate search terms of acoustic stimulation and auditory stimulation were identified. The terms recovery time, cognitive improvement, and motor function were not acceptable MeSHs; however, recovery of function was an acceptable MeSH. Length of stay was considered an appropriate substitute for recovery time. Beginning with PubMed Clinical Queries, searches included combinations of the following terms: stroke, music therapy, acoustic stimulation, auditory stimulation, recovery time, length of stay, cognition, mobility, motor, and recovery of function. By using Boolean operators, similar terms were grouped together. For example, the initial search, displayed in the first column of Table 1, stroke and (music therapy or acoustic stimulation or auditory stimulation), returned 127 results in PubMed Clinical Queries. CINAHL was searched using the same terms as PubMed, and as each term was entered, the suggested medical headings were reviewed. Auditory stimulation, recovery time, mobility, motor, and recovery of function were not medical headings within the CINAHL database. The terms psychomotor performance, recovery, and functional status were suggested medical headings in CINAHL, and the PubMed search was modified to reflect these new terms. CINAHL produced 102 results for stroke and (music therapy or acoustic stimulation or auditory stimulation), compared to the 127 results from PubMed. The complete search included a total of 13 different terms, and was as follows: stroke and (music therapy or acoustic stimulation or auditory stimulation) and (recovery time or recovery or length of stay) and cognition and (mobility or motor or recovery of function or functional status or psychomotor performance). The variations of this search can be viewed in Table 1, and the last column provides the complete search of all 13 terms. Dynamed yielded three results for stroke and music therapy, which included the alternate search term of auditory stimulation. The results emphasized the impact of music therapy on improvements in gait parameters, memory, attention, flexibility, range of motion, and mood. Dynamed results were interpreted to match the search terms in use. For example, gait parameters, flexibility, and range of motion are all related to mobility, and those items were accounted for in the results that included mobility. With only three results for the terms stroke and music therapy, the maximum number of results for any of the Dynamed searches was three.The Cochrane Library search yielded one systematic review by Bradt, Magee, Dileo, Wheeler, & McGilloway (2010), which was also present in the PubMed results. Cochrane and CINAHL returned 26 results for the keywords: stroke and (music therapy or acoustic stimulation or auditory stimulation) and (mobility or motor or recovery of function or functional status or psychomotor performance); and when recovery time search terms were added, Cochrane yielded 15 results and CINAHL produced five results (Table 1). The search of National Guideline Clearinghouse (NGC) database had the most results of any of the databases when 13 search terms were entered. There were six results for NGC, compared to two for PubMed, one for Cochrane, and zero for both Dynamed and CINAHL. In addition, NGC began with 19 results for the initial search, stroke and (music therapy or acoustic stimulation or auditory stimulation) (Table 1). Limits such as date of publication and population parameters were not set on any of the searches because the quantity of results was already fairly small and manageable in most cases. Most of the articles are recent and published within the past five to ten years. With the limited amount of data on the subject, and the higher prevalence of stroke among the older adult population, including only those articles of people over 65 years of age was unnecessary. The search results listed in Table 1 were narrowed down to 26 references. Through the use of rapid critical appraisal, these results were evaluated, and the five best references for answering the PICO question were chosen (Table 2). EvidenceIn a systematic review of music therapy for brain injury in adults seven randomized controlled trials (RCTs) were chosen that evaluated gait, mood, behavior, pain, and activities of daily living (ADLs) (Bradt et al., 2010). The team began with 3,855 citations, which was initially narrowed down to 94 references, and six of the seven final selections focused on stroke patients. Two of the studies on stroke patients, which were the only two with low risk of bias, RAS provided statistically significant improvements in gait velocity, cadence, stride length, and symmetry. Three of the other RCTs provided statistical significance for increased elbow extension angle and improved speech parameters for stroke patients participating in music therapy, such as rhythmic melodic voice training, RAS, and music improvisation sessions. The last study of music therapy and stroke evaluated pain, but the results were insignificant.In a RCT in Germany, 62 patients were pseudo-randomly assigned to a music group (MG) or a control group (CG) to determine effects of music therapy on neural reorganization and motor improvement (Altenmüller, Marco‐Pallares, Münte, & Schneider, 2009). For 30 minutes, five times a week, for three weeks, patients in the MG played the MIDI-piano or electronic drum set. Both the MG and the CG received the same amount of therapy time. Motor functions were measured with valid and reliable tools including the Action Research Arm Test (ARAT), Arm Paresis Score, and the Nine Hole Peg-board Test (9HBT) (Altenmüller et al., 2009). The effect size (ES) was moderate, and improvements were noted for the MG in fine and gross motor function, specifically speed, precision, and smoothness. Neural reorganization, defined as event-related desynchronization (ERD) and measured through EEG, was hypothesized and actualized with moderate ES for the MG, with the strongest ERD on the affected limb.During a RCT in India, 45 acute stroke patients were randomly assigned, via sealed envelopes, to three groups to compare the effectiveness of RAS, visual cueing (VC), and conventional therapy, with regards to gait parameters, motor function, and mobility. Sessions were three times a week, for three weeks, and two hours per session. RAS was by metronome, and measurements used included the Dynamic Gait Index and the Fugl-Meyer assessment for mobility, both with high reliability. Data analysis included SPSS 10, ANOVA, and Bonferroni for multiple group comparison. Results were statistically significant and indicated greater improvements in both mobility measurements for the RAS and VC groups (Chouhan & Kumar, 2012). In Finland, a single-blind, three-armed RCT evaluated recovery of cognition and mood improvements for stroke patients through music therapy. Random assignment was completed using a random number generator, and a researcher not involved with enrollment. Of the initial 60 enrolled, 55 completed up to the three-month follow up, and 54 completed the entire study including the six-month follow up. Every day, for one hour, over two months, group A listened to music and group B listened to books, both of their choosing on portable devices. Group C, the control group, received only conventional therapy. A battery of tests included the Wechsler Memory Scale and the Stroke and Aphasia Quality Of Life-39. Results showed significant improvements in verbal memory and focused attention for group A, the music group, in comparison to groups B and C (S?rk?m? et al., 2008).In a Korean hospital, 30 stroke patients were randomly assigned and completed an eight-week, quasi-experimental study investigating the impact of music therapy on ROM, muscle strength, ADLs, and mood (Jun, Roh, & Kim, 2013). During the music-movement therapy, which took place for one hour, three times per week, patients listened to music selected by the researchers while doing stretching exercises. Patients then participated in singing, playing instruments, and discussion sessions for patients to express feelings. Measurements used yielded acceptable reliability coefficients, all greater than 0.87. Chi-square and Fisher’s exact test showed no statistical differences between groups at baseline. Results of the study found a statistically significantly increase in shoulder and elbow joint flexion, as well as better mood in the experimental group compared to the control group (Table 2).Synthesis of the EvidenceThe results of these studies of one SR, three RCTs and one quasi-experimental study consistently found that music therapy improved at least one outcome in each study. Bradt et al. (2010) and Chouhan and Kumar (2012) used RAS; Altenmüller et al. (2009) used a MIDI-piano and drum set; and S?rk?m? et al. (2008) and Jun, Roh, and Kim (2013) used listening and making music. The number of therapy sessions ranged from nine to 84, and length of individual sessions ranged from 30 minutes to two hours. Altenmüller et al. (2009) made a point to calculate units of therapy each group received, 29.2 for the MG and 28.3 for the CG. However, the control group in S?rk?m? et al. (2008) did not receive the same amount of time and attention. Only the MG and LG were instructed to listen independently daily, which negatively impacts the appropriateness of the control group. The measurement tools varied and none of the studies addressed all of the outcomes. Only S?rk?m? et al. (2008) measured cognition but Altenmüller et al. (2009) investigated neural reorganization and both had improvement. The other four studies focused on mobility showing improvements in gait parameters, and ROM and motor function. Implementation of Change in Clinical Practice Based on these findings, it is recommended that music therapy be used for stroke rehabilitation. The therapies used would be appropriate, and considering the benefits of music therapy in several countries, and various study designs, the findings can be generalized. The addition of music therapy to stroke rehabilitation is feasible because it is a cost effective approach that produces positive results. Implementing change will begin with disseminating the findings and providing a plan of action for the proposed policy change. Building excitement and engaging staff is crucial to facilitate change. Barriers to change include perceptions of key stakeholders, financial risks, and gaining internal review board (IRB) approval. Educational sessions will begin with a presentation of the evidence on the effectiveness of this intervention. How the change will take place and why the change is necessary to improve outcomes will then be discussed. Key stakeholders include patients, families, therapy staff, nurses, the chief executive officer, chief nursing officer, and physicians. Estimates of cost savings associated with improved recovery times will help demonstrate benefit. Necessary resources include tangible items such as RAS supplies, possibly the MIDI piano and electric drum set, salary for a certified music therapist, any additional pay for staff training, and intangible items such as time. Therapy personnel will need time for staff training and program implementation. Physicians and nurses will participate in educational sessions regarding the new therapy in which a poster presentation will outline the change and supporting evidence. Information will be collected on patient outcomes and therapy costs. The facility currently collects data on cognition and mobility, which is known as the functional independence measurement (FIM), and these data will facilitate evaluating the effectiveness of the EBP change. FIM scores will improve as ROM improves because patients will be more independent with ADLs such as dressing and undressing. Additional outcome data for ROM, gait parameters, and cognition may be collected. Networking within the facility, choosing an EBP mentor, and obtaining data analyses sources already in use will facilitate the process.There are several methods for evaluating presence and effectiveness of change. Ongoing evaluation of the number of patients eligible for music therapy compared to the number of patients prescribed music therapy will provide insight to provider adaptation to change. Staff attendance in the education and training phase will be evaluated. Music therapy participants and staff will take surveys to evaluate pre and post perceptions, as well as amount of time scheduled compared to time spent participating in music therapy. Baseline and discharge FIM scores will be analyzed for stroke patients with and without music therapy. Every three months, outcome data will be presented at meetings, and posted on bulletin boards, and sent out in dashboard emails. Positive results in outcomes measured will foster positive staff attitudes concerning music therapy and promote continuing provider adaptation to change. The meetings will also provide staff an opportunity to discuss successes, concerns, and general feedback related to the addition of music therapy. Recommendations for continuing the practice of music therapy will be determined based on the outcome data.ReferencesAltenmüller, E., Marco‐Pallares, J., Münte, T. F., & Schneider, S. (2009). Neural reorganization underlies improvement in stroke-induced motor dysfunction by music-supported therapy. Annals of the New York Academy of Sciences, 1169, 395-405.Bradt, J., Magee, W., Dileo, C., Wheeler, B., & McGilloway, E. (2010). Music therapy for acquired brain injury. Cochrane Database of Systematic Reviews, 7. doi: 10.1002/14651858.CD006787.pub2. Chouhan, S., & Kumar, S. (2012). Comparing the effects of rhythmic auditory cueing and visual cueing in acute hemiparetic stroke. International Journal of Therapy & Rehabilitation, 19, 344-351. Go, A., Mozaffarian, D., Roger, V., Benjamin, E., Berry, J., Borden, W., & ... Turner, M. (2013). Heart disease and stroke statistics- 2013 update: A report from the American Heart Association. Circulation, 127(1), e6-e245. doi:10.1161/CIR.0b013e31828124adJun, E. M., Roh, Y. H., & Kim, M. J. (2013). The effect of music-movement therapy on physical and psychological states of stroke patients. Journal of Clinical Nursing, 22(1/2), 22-31. doi: 10.1111/j.1365-2702.2012.04243.xMelnyk, B.M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Wolters-Kluwer.S?rk?m?, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila, S., Mikkonen, M., ... & Hietanen, M. (2008). Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain, 131, 866-876.U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). 2020 Topics and objectives: Heart disease and stroke. Washington, DC. Retrieved from 1Database Search Results: Music Therapy for Stroke, Recovery Time, Cognition, and MobilityStroke & (music therapy or acoustic stimulation or auditory stimulation) DatabaseStroke & (music therapy or acoustic stimulation or auditory stimulation) & (recovery time or recovery or length of stay)& (recovery time or recovery or length of stay)& cognition& cognition& cognition& (mobility or motor or recovery of function or functional status or psychomotor performance)& (mobility or motor or recovery of function or functional status or psychomotor performance)& (mobility or motor or recovery of function or functional status or psychomotor performance)& (recovery time or recovery or length of stay)& (recovery time or recovery or length of stay)& cognition& (mobility or motor or recovery of function or functional status or psychomotor performance)PubMed12735413664302CINAHL10290402650Dynamed31110310Cochrane592024226151Table 2Evidence from the Literature: Five Best Available Articles on Music Therapy for Stroke, Recovery Time, Cognition, and MobilityFirst Author, YearSampling/SettingResearch DesignData AnalysisFindingsLevel of EvidenceCommentsBradt, 2010 184 participants, acquired brain injury, 54% male, mean age 59.4 yrs. Countries: USA, Germany, Australia, South KoreaSystematic Review. 7 RCTs chosen out of 94 references, 3,855 citations. 6 of the studies were with stroke patients. 95% CI. Standard mean differences for post-test scores. Review Manger 5. I2 for heterogeneity.RAS: 95% CI, P < 0.00001, I2 = 0%, n = 98- Gait velocity (CI 10.98 to 17.67); Stride length (MD = 0.23 meters, CI 0.14 to 0.32); & Symmetry (MD = 0.12 meters, CI 0.09 to 0.15) Level IEvaluated gait, ROM, behavior, mood, pain. Quality of reporting was poor in 5 studies; only 2 had a low risk of bias, which were the RAS on gait studies. Outcomes studied varied and data could not be pooled. Altenmüller, 200962 patients, acute stroke, 65% male, mean age 54 yrs. 3 weeks, 15 sessions, ? hour each. Germany, Rehab HospitalRCT, pseudo random assignment, MG vs. CG. MIDI-piano, electronic drum set. 95% CI. CMS, ARAT, Arm Paresis, BBT, 9HPT. ANOVA, Cohen’s d. ES moderate, Motor function- Cohen’s d ranged 0.4 to 0.6. ERD was significant for MG but not CG.Level IIEvaluated neural reorganization & motor. Control Group- 6f/24m; Music Group- 16f/16m. Follow up study to Schneider et al., 2007.Chouhan, 201245 participants, acute stroke, 80% male, mean age 57 yrs. 4 weeks, 9 sessions, 2hrs each. IndiaRCT, stratified random assignment, sealed envelope, 3 groups- A) RAS, B) VC, C) Control. RAS via metronome.95% CI. DGI (0.96 reliability). Fugl-Meyer (0.96). SPSS 10, ANOVA, Bonferroni. Fugl-Meyer: A & B better than C (P < 0.001). Between A & B (P = 0.066). DGI: A & B better than C (P < 0.001). Between A & B (P = 0.255).Level IIEvaluated gait & motor. Acute stroke < 3 mos. since hospitalization. Evaluated day 1, 7, 14, 21, 28. Therapy was 3 weeks. Group A and B both did better than C. No statistical difference between Group A and B.S?rk?m?, 200854 patients, acute stroke, 53% male, mean age 59 yrs. 2 months, 1 hour daily. FinlandRCT, single blind, random assignment, three groups- MG, LG, & CG. Portable CD or cassette players. 95% CI. RMBT, WMS-R, FAB, CERAD, POMS, Balloons test, CogniSpeed software, SAQOL-39. SPSS 14.0, ANOVA, Kruskal-Wallis, chi-square, t-tests, Tukey’s.Verbal memory- MG vs. CG (P = 0.049 at 3 mos.) MG vs. LG (P = 0.006 at 3 & 6 mos.). Focused attention- MG vs. CG (P = 0.006 at 3 mos., 0.008 at 6 mos.), MG vs. LG (P = 0.058 at 3 mos., 0.016 at 6 mos.)Level IIEvaluated cognition & mood. Mood improvements were insignificant (P = 0.378 to 0.859). Participants chose music, independent setting. Jun, 201330 patients, acute stroke, 50% male, mean age 58 yrs. 8 weeks, 24 sessions, 1 hour each. KoreaQuasi-exp., random assignment, pre and post-tests. MG vs. CG. Listened, made music, and discussed in a group setting.95% CI. KMBI for ADLs & ROM (reliability of 0.87); POMS (0.94); CESD (0.90). SPSS 17.0, chi-square, Fisher’s exact test, independent t-test, Mann-Whitney U test.Shoulder flexion (t = 1.905, p = 0.030). Elbow joint flexion (t = 1.819, p = 0.040). Mood (t= 1.818, p = 0.040) Muscle strength, ADL, depression scores- not significant.Level IIIEvaluated ROM, muscle strength, ADLs, & mood. Allocation concealment concerns. 42 needed for group power 0.8, alpha 0.05 and ES 0.8, but only 30 completed. 15f/15m. Researchers chose music, group setting.9HBT- Nine Hole Peg-board Test, ARAT- Action Research Arm Test, BBT- Box and Block Test, CESD- Center for Epidemiological Studies Depression Scale, CG- Control Group, CMS- Computerized Movement Analysis System, DGI- Dynamic Gait Index, FAB- Frontal Assessment Battery, KMBI- Korean-modified Barthel index, LG- Language Group, MG- Music Group, POMS- Profile of Mood States, RBMT- Rivermead Behavioral Memory Test, RCT- Randomized Control Trial, SAQOL-39- Stroke and Aphasia Quality of Life Scale 39, TMS- Transcranial Magnetic Stimulation, VC- Visual Cues, WMS-R- Wechsler Memory Scale-RevisedBradt, J., Magee, W., Dileo, C., Wheeler, B., & McGilloway, E. (2010). Music therapy for acquired brain injury. Cochrane Database of Systematic Reviews, 7. doi: 10.1002/14651858.CD006787.pub2. Rapid Critical Appraisal of Systematic Reviews of Clinical Interventions/TreatmentsAre the results of the review valid? YESAre the studies contained in the review randomized controlled trials? Yes, two of them are pseudo- RCTs- 2-arm parallel group design. There are five regular RCTs- two of these are 2-arm parallel group designs and the other three are cross over trials Does the review include a detailed description of the search strategy to find all relevant studies? Yes, includes appendices for databases identifying search clearlyDoes the review describe how validity of the individual studies was assessed (e.g., methodological quality, including the use of random assignment to study groups and complete follow-up of the subjects)? Yes, utilized 4 criteria of quality - 1) randomization, 2) allocation concealment, 3) blinding, 4) incomplete data addressedWere the results consistent across studies? Yes & No due to variability in outcomesGait- 2 studies, results were consistent for three of four gait variables. Stride length, cadence, velocity, stride symmetry. Cadence results were inconsistentUpper extremity function- elbow extension- 2 studies, not evaluated for consistency due to heterogeneity. Statistical significance in one of the two. Communication- only one study evaluated this, significant improvementBehavior- only one study evaluated this, positive resultsPain- only one study, no statistical significanceWere individual patient data or aggregate date used in the analysis? Both depending on homogeneity of studiesWhat were the results? Mostly PositiveHow large is the intervention treatment effect (OR, RR, effect size, level of significance)? 95% CI for effect size used, significant for gait improvement, upper extremity function, some significance for communication, and behaviorHow precise is the intervention or treatment (CI)? High- 95% CIWill the results assist me in caring for my patients? YesAre my patients similar to the ones included in the review? Yes, acute stroke adultsIs it feasible to implement the findings in my practice setting? Yes, inpatient rehabWere all clinically important outcomes considered, including risks and benefits of the treatment? Yes, no risks to music therapy discussedWhat is my clinical assessment of the patient and are there any contraindications or circumstances that would inhibit me from implementing the treatment? Cognitive function may be too low, some studies participants refused, agitation may be factorWhat are my patient’s and his or her family’s preferences and values about the treatment that is under consideration? Music preference should be considered, other than that appears culturally respectful and applicable to all patients Altenmüller, E., Marco‐Pallares, J., Münte, T. F., & Schneider, S. (2009). Neural reorganization underlies improvement in stroke-induced motor dysfunction by music-supported therapy. Annals of the New York Academy of Sciences, 1169, 395-405.Critical Appraisal Randomized Clinical Trials (RCTs)Are the results of the study valid?Were the subjects randomly assigned to the experimental and control groups? PseudoWas random assignment concealed from the individuals who were first enrolling subjects into the study? Yes, completed by OTs not involved in the studyWere the subjects and providers blind to the study group? Not discussed, possiblyWere reasons given to explain why subjects did not complete the study? Yes- All 62 enrolled completed the entire study except for 8 who missed the computerized movement analysis during post treatment assessment (1MG; 7CG)Were the follow-up assessments conducted long enough to fully study the effects of the intervention? No long-term follow up, otherwise similar to other studies in lengthWere the subjects analyzed in the group to which they were randomly assigned? YesWas the control group appropriate? Yes, received similar amount of time, attentionWere the instruments used to measure the outcomes valid and reliable? Possibly, battery of tests- CMS, ARAT, Arm Paresis Score, BBT, 9HPT- no discuss for valid/reliabWere the subjects in each of the groups similar on demographic and baseline clinical variables? Only dissimilar in gender, equal distribution of right vs left strokeWhat are the results?How large is the intervention or treatment effect (NNT, NNH, effect size, level of significance)? Music supported therapy provided significant improvements in fine and gross motor function with regard to speed, precision, and smoothness. Cohen’s d used to determine size of treatment effect. Moderate effect for almost all variables.How precise is the intervention or treatment (CI)? Varies: P < 0.05 or P<0.001 (Table 4)Will the results help me in caring for my patients?Were all clinically important outcomes measured? Did not measure cognitionWhat are the risks and benefits of the treatment? No risks defined, none apparentIs the treatment feasible in my clinical setting? Yes, large rehab facilityWhat are my patients/family’s values and expectations for the outcome that is trying to be prevented and the treatment itself? Improved motor function, no risksChouhan, S., & Kumar, S. (2012). Comparing the effects of rhythmic auditory cueing and visual cueing in acute hemiparetic stroke. International Journal of Therapy & Rehabilitation, 19, 344-351. Critical Appraisal Randomized Clinical Trials (RCTs)Are the results of the study valid?Were the subjects randomly assigned to the experimental and control groups? Yes, sealed envelopes, stratified- equal number men and women in each groupWas random assignment concealed from the individuals who were first enrolling subjects into the study? YesWere the subjects and providers blind to the study group? Not discussedWere reasons given to explain why subjects did not complete the study? No drop outs, 87 screened, 24 ineligible, 10 declined, 8 lived in other cities (n = 45)Were the follow-up assessments conducted long enough to fully study the effects of the intervention? This trial lasted 4 weeks, limited because no long-term follow up.Were the subjects analyzed in the group to which they were randomly assigned? YesWas the control group appropriate? Yes, CG received conventional therapiesWere the instruments used to measure the outcomes valid and reliable? Yes, 2 reliability scores of 0.96. Dynamic Gait Index measures 8 facets of Gait. Fugl Meyer has 5 components for synergy, reflexes, wrist stability, grasping ability, and coordination.Were the subjects in each of the groups similar on demographic and baseline clinical variables? Demographics considered were age and gender- no statistical difference between groupsWhat are the results? How large is the intervention or treatment effect (NNT, NNH, effect size, level of significance)? Improved gross motor, fine motor and gait imbalance significantly compared to control group. Both RAS and VC were effective, no statistical difference between group A and B; only between group A to C and group B to CHow precise is the intervention or treatment (CI)? 95% CI, preciseWill the results help me in caring for my patients?Were all clinically important outcomes measured? Measured motor function and gait, no cognition- article eludes to effectiveness of recovery time with motor improvementWhat are the risks and benefits of the treatment? No risks definedIs the treatment feasible in my clinical setting? Yes, inpatient acute rehabWhat are my patients/family’s values and expectations for the outcome that is trying to be prevented and the treatment itself? Same music instrument all four weeks, created redundancy for patients, reduced arousal for patients. S?rk?m?, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila, S., Mikkonen, M., ... & Hietanen, M. (2008). Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain, 131, 866-876.Critical Appraisal Randomized Clinical Trials (RCTs)Are the results of the study valid?Were the subjects randomly assigned to the experimental and control groups? Yes, by random number generator completed by researcher not involved in enrollment.Was random assignment concealed from the individuals who were first enrolling subjects into the study? Yes, completed by researcher not participating in enrollment.Were the subjects and providers blind to the study group? Single-blind, providers. As good as it gets for this type of trial; can’t blind participants to music or no music. Were reasons given to explain why subjects did not complete the study? Yes- 5 drop outs- 1 misdiagnosed (TIA), 1 new stroke, 1 dementia, 2 refusals; then later 1 died MI.Were the follow-up assessments conducted long enough to fully study the effects of the intervention? Yes, 55 completed up to 3-month f/u; 54 completed 6-month f/u.Were the subjects analyzed in the group to which they were randomly assigned? YesWas the control group appropriate? Maybe not, 1) music n=19 , 2) audiobooks n=19, 3) control n=17; concern for control group though with time and attentionWere the instruments used to measure the outcomes valid and reliable? Stroke and Aphasia QOL Scale (SAQOL-39), Profile of Mood States, battery of cognitive tests: FAB, MBEA, RBMT, RT, CERAD, Wechsler Memory Scale, BVRT, clock test, and moreWere the subjects in each of the groups similar on demographic and baseline clinical variables? Yes- baseline characteristics had no statistical difference btwn groups: demographics, clinical aspects, leisure prior to stroke, cognitive performance, moodWhat are the results?How large is the intervention or treatment effect (NNT, NNH, effect size, level of significance)? (P= 0.006 to 0.058) for verbal memory and focused attention, significant at 3 months and 6 months post-test, MG did better than other 2 groupsHow precise is the intervention or treatment (CI)? 95% CI- preciseWill the results help me in caring for my patients?Were all clinically important outcomes measured? This study evaluated cognition and mood; there was no evaluation of motor function. It included QOL however. What are the risks and benefits of the treatment? No identifiable risks. Is the treatment feasible in my clinical setting? Absolutely, very inexpensive.What are my patients/family’s values and expectations for the outcome that is trying to be prevented and the treatment itself? Choosing music that patient enjoys will help patient stick with the treatment. Requires commitment to 1 hour per day.Jun, E.-M., Roh, Y. H., & Kim, M. J. (2013). The effect of music-movement therapy on physical and psychological states of stroke patients. Journal of Clinical Nursing, 22(1/2), 22-31. doi: 10.1111/j.1365-2702.2012.04243.xCritical Appraisal Randomized Clinical Trials (RCTs) Are the results of the study valid?Were the subjects randomly assigned to the experimental and control groups? Yes- 45 eligible from the neuro unit, 40 agreed to participate; 20 in each group; total 30 completedWas random assignment concealed from the individuals who were first enrolling subjects into the study? Not specified, possiblyWere the subjects and providers blind to the study group? Does not appear so; study aims, plans, benefits were explained to people who met criteria; implies this was before study. Also data collection was by the researcher and research assistants. (Double blind is difficult in music therapy studies but there are single blind studies available.)Were reasons given to explain why subjects did not complete the study? Yes, 8 discharged, 2 withdrew.Were the follow-up assessments conducted long enough to fully study the effects of the intervention? Yes, post-tests were at 8 weeks; could have done 6-month follow/up.Were the subjects analyzed in the group to which they were randomly assigned? YesWas the control group appropriate? Unclear, concern for time/attention- CG received only routine treatmentWere the instruments used to measure the outcomes valid and reliable? Yes, reliability coefficients of 0.90-0.93; measurements used were culturally appropriateWere the subjects in each of the groups similar on demographic and baseline clinical variables? Yes, similar patients, same unit, diagnosis, DEM- chi square Fisher exact test showed no statistical difference between groups Table 1What are the results?How large is the intervention or treatment effect (NNT, NNH, effect size, level of significance)? Shoulder flexion and elbow joint flexion improved significantly for experimental group and decreased or stayed the same for control group. Muscle strength and ADL scores were not statistically different between groups.How precise is the intervention or treatment (CI)? It is precise, CI 95%Will the results help me in caring for my patients?Were all clinically important outcomes measured? Rom, strength, ADLs, moodWhat are the risks and benefits of the treatment? No risks identifiedIs the treatment feasible in my clinical setting? YesWhat are my patients/family’s values and expectations for the outcome that is trying to be prevented and the treatment itself? Improved mood, better functioning; choice of music is important for this method ................
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