An Evaluation of A Stroke Rehabilitation Study At Rotman Research Institute

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An Evaluation of A Stroke
Rehabilitation Study At Rotman
Research Institute
Joanna (Yijing) Rong
Co-op Health Studies
January 2015 – August 2015
First and Second Work Term

RONG, Joanna An Evaluation of a Stroke Rehabilitation Study at Rotman Research Institute
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TABLE OF CONTENTS
1. ABSTRACT
.......………………...….……...…….……………………….. 2
2. INTRODUCTION
...…………………………………………….………………. 2
3. OVERVIEW OF PLACEMENT
……...…………………...………......................................... 3
4. ANALYSIS
….........……..….…………………...…….…….…………... 5
5. CONCLUSIONS AND RECOMMENDATIONS
...………………...…............................................................ 6
6. APPENDIX
…………………………………………...…....……………. 8
7. BIBLIOGRAPHY
……...…...………………………......…..………………….. 9

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ABSTRACT
With an increased numbers of stroke patients in Canada in recent years, the stroke
rehabilitation research has gradually became one of the most popular research areas in
many research institutes. This report aims to provide a list of comprehensive
measurements employed in the Music-Supported Rehabilitation (MSR) study, and to
address the limitations of each measurement. In addition, this report will also look at
the gaps between stroke rehabilitation research findings and its translation into clinical
practice, as well as the possible recommended steps needed to eliminate this barrier.
INTRODUCTION
Stroke is one of the most deadly chronic diseases in developed countries such as US
and Canada. Approximately 800,000 people suffer from one or more strokes each year,
about one stroke incident every 4 second (Hachinski,V., et al, 2010). Stroke was first
recognized and described as the sudden onset of paralysis by the father of medicine,
Hippocrates, over 2,400 years ago (Walker,M.F., et al, 2013). Until recently, modern
medicine has had very little power over this disease, but the world of stroke research is
changing and new and better therapies are being developed rapidly every day.
The evidence base for stroke rehabilitation has grown exponentially in the last 20
years. In particular, the co-op research project Examination of Therapeutic Intervention
Methods on Brain Recovery After Stroke is a study that was designed to compare the
effect of two different types of rehabilitation on stroke recovery, the Music-Supported
Rehabilitation (MSR) in contrast to GRASP (Graded Repetitive Arm Supplementary
Program). The overall goal of this study is to examine the mechanisms of stroke
recovery, and to inform ageing research and rehabilitation science of new training
procedures.
GRASP is an arm and hand exercise program for stroke patients with upper extremity
impairments, and it have already been implemented in variety of clinical settings. It
was shown by many studies that patients who supplemented standard rehabilitation
care with GRASP had better arm and hand function than a control group who only had
standard rehabilitation care. Better function was demonstrated when patients were
discharged from the rehabilitation hospital and also at 5 months post-stroke (Lin, K., et
al, 2007).
On the other hand, MSR is a relatively new stroke rehabilitation program that has only
been discovered in the recent years, and yet it hasn’t been implemented in a real
clinical setting. MSR was only been introduced to stroke patients through the medium
of research, therefore, it is still relatively novel to many stroke patient and clinicians in
terms of its effectiveness of stroke rehabilitation. In some studies, however, it has been
reported that incorporating music into standard stroke rehabilitation can improve
recovery of speech and memory (Schneider, S. et al., 2007). Music therapy melodies can
boost patient’s alertness, mood and attention by stimulating the release of
neurotransmitter in certain areas of the brain responsible for feeling of pleasure and

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memory. This may have a flow over effect helping activate other area of the brain, such
as areas that are responsible for motor skills (Schneider, S. et al., 2010).
In this rehabilitation study, each participant with stroke was randomly assigned to one
of the treatment arms where they received either music-supported rehabilitation (MSR)
or GRASP. Both of the rehabilitations focus on improving patient’s arm and hand
functions. After each treatment and therapy period, participants were required to attend
the mandatory post-test assessments, which were designed to help researchers to
investigate and determine the behavioural consequences and neurophysiological
mechanisms precipitated by MSR in comparison with the control treatment (GRASP).
The main post-test assessments includes an eclectic battery of behavioural
assessments, structural MRI scans and a compilation of MEG paradigms. All three of the
assessments took place at Rotman Research Institute at Baycrest. Specifically,
participant have to come to Baycrest in separate three to four business days in order to
complete one post-test assessment. Also, participants were required to attend a follow
up testing at the end with all three identical assessments after 3 months of their
treatments.
This report is aiming to provide an overview of some of the procedural measurements
utilized and applied in this stroke rehabilitation research study as well as its underlying
purpose of administering these tests. Moreover, it will also focus on the limitations of
these measurements. Lastly, this report will discuss the challenges associated with one
of the stroke rehabilitations - MSR in terms of promoting the translation of research
evidence into practice.
OVERVIEW OF PLACEMENT
Baycrest is an internationally recognized academic health sciences centre focused on
healthy aging and exemplary care of older adults through evidence-based care and
education. The unit that my co-op placement took place was at The Rotman Research
Institute (RRI). RRI specializes in brain health research with a particular emphasis on
prevention, diagnosis and treatment of aging-related disorders. The research conducted
at Rotman focus on memory and executive (frontal lobe) functions of the brain, both in
normal ageing and in the presence of diseases and conditions which affect the brain
such as Alzheimer’s and other dementias, stroke, traumatic brain injuries (TBIs) and
focal lesions. Furthermore, the scientists function as the heart of the Rotman. In
particularly, Dr. Bernhard Ross, a senior scientist exploring the neuroplasticity
reorganization of brain physiology. Ross’s extensive research in studying brain
mechanisms suggests that through appropriate training and learning brain functions
are plastic and malleable; more importantly they posses rewiring capabilities (Ross B.
et al., 2013). Throughout the past eight months, an extensive investment of effort and
time has been committed to the Examination of Therapeutic Intervention Methods on
Brain Recovery After Stroke. This study is designed to compare the effect of two different
types of rehabilitation on stroke recovery, the Music-Supported Rehabilitation (MSR) in
contrast to Conventional Physical Therapy (CPT). The aim of this study is to understand

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the mechanisms of learning and stroke recovery, and to inform ageing research and
rehabilitation science of new training procedures.
As a research assistant for this study, the scope of duties encompasses a broad range of
responsibilities, spanning from administrative tasks to data collection and
management. My primary responsibility was data collection, which utilized various
forms of measurements including measuring brain activity via
magnetoencephalography (MEG) assessment protocols, conducting behavioral and
neuropsychological testing and MRI screening and preparation. Another important
aspect of being a research assistant was recruiting eligible participants for this study,
which requires the enlistment of only a specific subset of individuals, who suffer from a
certain type of stroke to meet explicit eligibility criteria. Furthermore, maintaining a
larger database that consists of the data collected from these tests to ensure reliable
results for publication.
ANALYSIS
ASSESSMENTS OVERVIEW & THEIR LIMITATIONS
Three different forms of measurements are employed to assess and elicit the
effectiveness of the two types of interventions in this study. The first assessment
exploited is magnetoencephalography, which is known for MEG. The study implements
three MEG protocols to monitor and track the neural networks underlying the
neurophysiological changes the participants experience before and after their
treatments with one of the rehabilitated therapy that they were randomly assigned to.
The MEG consists of many tiny coils located in a large container that fit over a person’s
head like a hair dryer. During each MEG recording, participant is required to perform
various simple tasks such as listening to tones, finger-tapping, receiving finger
stimulation with gentle air-puffs, or making decision about sounds or visual symbols.
each MEG session lasts approximately 1.5-2 hours including 30-35 minutes of
preparation. The MEG allows the researchers to measure the magnetic fields outside of
participant’s head, and it is a non-invasive and passive way to measure the magnetic
field that the brain generates naturally. This method is used in hospital and medical
centers, and it is known as a very low-risk with no known short or long term side
effects. One study propose that the brain’s ability to elicit a MMN response, particularly
to detect discriminable change in an acoustic repetitive patterns, demonstrates the
brain’s capability to automatically compare complex auditory stimuli between
consecutive sounds (Garrido M.I.et al., 2009).
The second assessment used is resonance imaging (MRI). Participants are required to
participant in the MRI scans immediately following the completion of the MEG
assessments. The MRI technique uses magnets and radio waves to construct a picture
of the brain on a computer. In conjunction of the MEG assessment, MRI scans allow the
researchers to identify exactly where the brain activities recorded by the MEG
measurement occurred as well as where the brain areas are communicating with each

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other. Similar to MEG, MRI scan is not associated with any known risks to the brain
health and there is no evidence that there will be either short-term or long-term side
effects.
Lastly, this study also employed a battery of behavioural assessments that was
designed to gauge developments of participant’s motor skills, executive cognitive
functions and quality of life. The behavioural testing consisting of a set of standardized
tests for hearing, motor skills, cognitive functions and questions about how the stroke
may have impact the participant’s day-to-day life. In particular, different behavioral
assessment is used for evaluate various aspect of stork recovery. The Grooved pegboard
test measure the fine motor movements of participants. Gross motor movement was
evaluated by using The Arm and Hand Chedoke McMaster Impairment Inventories, The
Action Research Arm Test (ARAT) and the Box and Block Test. Other assessments such
as Alpha Span and Montreal Cognitive Assessment (MOCA) tasks are used to measure
the executive functions that recruit working memory, reasoning, planning and
execution of tasks, and Trail Making tests and Reaction Time tasks varying in degree of
difficulty. Lastly, participant’s quality of post-stroke life is evaluated by employing
questionnaires such as Stroke Impact Scale and Positive and Negative Scale.
All three different forms of assessments in this study were carefully chosen to evaluate
the motor and cognitive development of participants in order to compare and contrast
the effectiveness of the GRASP therapy and MSR therapy. Each of the assessments have
their own useful set of techniques and features that help researchers to extract
accurate information, however, each assessment have its drawbacks regarding the
technique itself as well as the user experience. For example, constructed MRI data has
poor temporal sequencing precision in correlation with brain activity, even though it
has the capability to detect average brain activity with relatively high and constant
spatial resolution (Dale A.M. and Sereno M.I., 1993). As for MEG, its relative insensitivity
to deep or radial sources, rendering it unconscious and plainly blind to certain patterns
of brain activity (Dale A.M. and Sereno M.I., 1993). Although both the MEG and MRI are
noninvasive brain imaging techniques, both of the imaging techniques require
participants to remain as still as possible during the operation of the recording for a
long period of time (MEG for 2 to 3 hours, and MRI for 40 minutes). Participants,
especially those who have little to no stroke recovery with low motor function tend to
find it extremely difficult to stay still during MEG or MRI testing. Sometimes the slight
movements of participants result in low quality results such as the blurry MRI brain
imagines and MEG data with high levels of artifact. Furthermore, behavioural
assessments also subject to many limitations. This assessment encompasses and
surveys a broad rage of participants’ abilities from motor skills to gauge their quality of
life, through conditionally cost-efficient means. Despite this convenience, administering
behavioural assessments is vulnerable and subject to partiality and bias. For example,
the varied interpretation of instructions of the assessments through translation of
diverse administrator yields optimal performance levels and results, because
implementation of tests can be more accommodating and individual-specific.

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MUSIC-SUPPORT REHABILITATION OVERVIEW AND ITS TRANSLATION
Music Supported Rehabilitation (MSR) utilizes music making activities to address
physical disability sustained by patients following stroke (Rojo, N., et al., 2011). Several
studies using MSR found that musically naive sub-acute patients receiving MSR
improved motor skills better than patients receiving conventional physical therapy
(CPT) in randomized controlled studies (Villeneuve, M. et al. 2013). MSR has also been
found to improve the use of the affected upper extremity, increasing neural
reorganization in the sensorimotor cortex, improved cortical connectivity, and improved
activation of the motor cortex (Chen, J.L et al. 2008). This study, aims to examine the
neural and behavioural outcomes of MSR through the ongoing randomized control trial.
MSR in this study uses electronic drum pads and a keyboard to serve the purpose of
rhythm exercises, which is useful in terms of stimulating auditory-motor coupling. In
addition, each session focus on one new technique with an associated motor goal, and
variations in melody and rhythm are built in to enhance the training effects based on
motor learning challenges, and effective feedback as well as bimanual coordination.
The therapist guides patients through the exercises and provides adjustment and
encouragement to achieve goals.
Despite the beneficial outcomes from these studies, the effectiveness of MSR for
chronic stage patients has yet to be systematically established. In addition, MSR
incorporates gross and fine motor movements as patients play drum and keyboard
instruments. However existing guidance is limited for providing actual practice of MSR
therapy for chronic patients. Therefore, there is a need for developing MSR protocol for
clinical use in stroke rehabilitation. Furthermore, the translation of MSR into practice
remains a challenge partly because of the following reasons: instruments used in the
MSR in this study embedded high cost and it is not yet available in any clinical settings.
For example, the electronic drum pads in this study were specifically built for patient
with chronic physical disability, and it needs to be connected to the keyboard in order
to function. Due to this reason, patients are not able to practice what they learnt from
the therapy sessions unless it is take place in the experimental therapy session.
CONCLUSIONS AND RECOMMENDATIONS
Overall, this report provides an overview of some of the procedural measurements
utilized and applied in a stroke rehabilitation research study and its underlying purpose
of administering these tests. All the different forms of measures employed in this stroke
recovery study play a vital role in yielding fruitful results. The three MEG protocols is
designed to monitor and track the neural networks underlying the neurophysiological
changes the participants experience before and after their treatments. The MRI scans is
used in conjunction alongside the MEG data obtained to fully comprehend the changes
in somatosensory processing, auditory memory and auditory-motor coupling
mechanisms of the MSR patients. Lastly, behavioural assessments were used as a
measure to evaluate the progression and recovery of participants’ motor skills,
executive functions and quality of life. Despites the useful features that these

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assessments use to capture accurate data that the study needs, there are limitations
exist in terms of the technology itself and the user experience that needs to be address
for future study. This report also address the challenges associated with one of the
stroke rehabilitations - MSR in terms of promoting the translation of research evidence
into practice.
Improving participant experiences is critical to a study’s success as participants are the
primary data sources in this particular study. Most research study usually convinced
that the more data they gain, the more reliable their findings are going to be.
Therefore, an assumption is made which by lengthening their studies, they are able to
collect more data from the same numbers of participants and as a result, it would make
the study more reliable. However, researchers sometimes fail to see that human are not
robots, and do not have an unlimited attention span. As researchers, we have to
recognize that participant fatigue is one of the most challenging aspect of data
collection, and it is also an unavoidable occurrence that oppresses and hampers all
form of measures, especially with participant with chronic physical disability. There is a
need to implement a middle ground between gaining enough data to compensate the
research finding and maintaining the participants attention when it comes to time
taken to conduct a study. It is understandable that researchers may find it extremely
challenging to determine how far into a study it is which participants begin to become
disengaged with the task given to them. One tool that can be implemented is to use
pilot studies. Employing pilot study is a great way to overcome any floor and ceiling
effects in studies or in this case, to minimize participant fatigue. This could be done by
using a range of study lengths in the pilot studies to try and determine which stage in
the study it is that participant start to experience fatigue. Also, through careful
planning and organization of scheduling appointment, compensation to some degree
can be atoned for this inescapable element.

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APPENDIX
ROLE:
Research Assistant
JOB RESPONSIBILITIES:
● Laboratory routines on daily basis, which included checking function of
equipment for MEG recording, checking the MEG system by recording and
evaluating system noise, measuring and documenting Helium level and flow
rate, as well as performing data backup and organization of data storage.
● Conducted neuroimaging testing for stroke patients, including performing
complete MEG scans using auditory and somatosensory stimulation as well as
motor tasks, recording the electro-myogram from finger muscles.
● Conducted neurobehavioural testing of stroke patients, including audiometric
evaluation and administering behavioural tests.
● Screening for eligibility for MRI scans and preparing patients for the MRI scan,
informing the patients about the studies and taking informed consents.
● Administrative tasks of scheduling appointments for research participants,
organizing payments for participant compensation, organizing lab supplies,
entering test results in data bases.
● Training of new students about laboratory procedures and tests.

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BIBLIOGRAPHY
Chen, J.L. et al. (2008) Listening to musical rhythms recruits motor regions of the brain. Cerebral
Cortex, 18 (12), 2844-2854.
Dale A.M. and Sereno M.I. (1993). Improved Localization of Cortical Activity by Combining EEG
and MEG with MRI Cortical Surface Reconstruction: A Linear Approach. Journal of Cognitive
Neuroscience. 5(2): 162-176.
Garrido M.I., Kilner J.M., Stephan K.E., and Friston K.J. (2009). The mismatch negativity: a review
of underlying mechanisms. Clinical Neurophysiology. 120, pp. 453-463.
Hachinski, V., Donnan, G. A., Gorelick, P. B., Hacke, W., Cramer, S. C., Kaste, M., . . . Tuomilehto, J.
(2010). Stroke: Working toward a prioritized world agenda. Cerebrovascular Diseases, 30(2),
127-47.
Lin, K., Wu, C., Wei, T., Gung, C., Lee, C., & Liu, J. (2007). Effects of modified constraint-induced
movement therapy on reach-to-grasp movements and functional performance after chronic
stroke: A randomized controlled study. Clinical Rehabilitation, 21(12), 1075-86.
Rojo, N., et al. (2011). Music-supported therapy induces plasticity in the sensorimotor cortex in
chronic stroke: a singlecase study using multimodal imaging (fMRI-TMS). Brain Injury, 25, 787–
793
Schneider, S. et al. (2007) Using musical instruments to improve motor skill recovery following
a stroke. J Neurol, 254 (10), 1339-1346.
Schneider, S. et al. (2010) Music-supported training is more efficient than functional motor
training for recovery of fine motor skills in stroke patients. Music Perception, 27 (4), 271-280.
Villeneuve, M. et al. (2013). Playing piano can improve upper extremity function after stroke.
Stroke Res & Treat, ID 159015, 1-5.
Walker, M. F., Fisher, R. J., Korner Bitensky, N., McCluskey, A., & Carey, L. M. (2013). From what
we know to what we do: Translating stroke rehabilitation research into practice. International
Journal of Stroke, 8(1), 11-17.

An Evaluation of A Stroke Rehabilitation Study At Rotman Research Institute

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