Choir Singing in Aphasia Rehabilitation

Efficacy of Choir Singing on Verbal, Cognitive, Emotional, and Neural Recovery From Aphasia

This study evaluates the verbal, cognitive, emotional, and neural efficacy of a choir singing intervention in chronic aphasic patients and their caregivers. Using a cross-over RCT design, half of the participants receive a 4-month singing intervention during the first half of the study and half of the participants during the second half of the study.

Study Overview

• Status: Completed
• Conditions: Stroke; Aphasia
• Intervention / Treatment: Behavioral: Singing-based rehabilitation; Other: Standard care

Detailed Description

BACKGROUND: Singing is a highly stimulating and versatile activity for the brain, combining vocal-motor, auditory, linguistic, cognitive, emotional, and social brain processes, both in the left and right hemisphere. The capacity to sing is often preserved in aphasia after stroke, and singing-based methods, such as Melodic Intonation Therapy (MIT), can be effective in rehabilitating speech production in aphasics. Also emotionally and socially, singing could provide a powerful alternative channel for aphasic patients to express their emotions and interact with others, but the communal or group-level use of singing in aphasia rehabilitation has not been systematically studied.

AIMS: The purpose of the study is to determine the clinical and neural efficacy of a novel choir singing intervention in subacute/chronic aphasia. Specifically, the targeted outcomes are (i) verbal and vocal-motor skills, (ii) cognitive skills, (iii) emotional functioning and quality of life, (iv) caregiver psychological well-being, and (v) structural and functional neuroplasticity. In addition, the capacity of singing and music learning in aphasia is explored.

METHODS: Subjects are 60 stroke patients with at least minor aphasia (≥ 6 months post-stroke) and their family members (FMs, N = 60) from Helsinki area recruited to a cross-over RCT study. Participants are randomized to two groups [N = 60 in both (30 patients, 30 FMs)], which receive a 16-week choir intervention either during the first (AB group) or second (BA group) half of the follow-up. The intervention is a combination of group training, which utilizes a novel combination of traditional senior choir singing and MIT-like speech training protocols, and home training in which the choir material is trained with a tablet computer. All patients are evaluated at baseline, 5-month, and 9-month stages with language, cognitive, and auditory-music tests and questionnaires. Half of the patients (N = 30) also undergo electroencephalography (EEG) and structural and functional magnetic resonance imaging (s/fMRI). FMs are evaluated with questionnaires.

• Study Type: Interventional
• Enrollment (Actual): 100
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Finland
  • Helsinki, Finland
    • Helsinki University Central Hospital, Department of Neurology, Rehabilitation Unit
  • Helsinki, Finland
    • Helsinki-Uusimaa Aphasia and Stroke Association

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

The following inclusion criteria are used in patient recruiment:

1. age over 18
2. Finnish-speaking
3. time since stroke > 6 months
4. at least minor non-fluent aphasia due to stroke (BDAE Aphasia Severity Rating scale score ≤ 4)
5. no hearing deficit
6. no severe cognitive impairment affecting comprehension (the patient is able to understand the purpose of the study and give an informed consent)
7. no neurological / psychiatric co-morbidity or substance abuse
8. ability to produce vocal sound (through singing or humming).

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: CROSSOVER
• Masking: SINGLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Early singing intervention (AB); Participants receive a 16 weeks of singing-based rehabilitation and standard care (SC) followed by 16 weeks of SC only.	Behavioral: Singing-based rehabilitation; The singing-based rehabilitation is a combination of group-training (16 weeks, 1 x week, 90 min), which utilizes a novel combination of traditional senior choir singing and singing-based speech training protocols, and home training (16 weeks, ≥ 3 x week, ≥ 30 min) in which the choir material is trained with a tablet computer.; Other: Standard care; Standard care comprises all rehabilitation and care services (e.g. speech therapy, physical and occupational therapy, neuropsychological rehabilitation) received by the patients in the Finnish health care system
EXPERIMENTAL: Late singing intervention (BA); Participants receive a 16 weeks of SC only followed by 16 weeks of singing intervention and SC.	Behavioral: Singing-based rehabilitation; The singing-based rehabilitation is a combination of group-training (16 weeks, 1 x week, 90 min), which utilizes a novel combination of traditional senior choir singing and singing-based speech training protocols, and home training (16 weeks, ≥ 3 x week, ≥ 30 min) in which the choir material is trained with a tablet computer.; Other: Standard care; Standard care comprises all rehabilitation and care services (e.g. speech therapy, physical and occupational therapy, neuropsychological rehabilitation) received by the patients in the Finnish health care system

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Communication ability	Total score of the Communication Action Log (CAL) questionnaire (range 0-180, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Spontaneous speech production	Spontaneous Speech subscale score of the Western Aphasia Battery (WAB) (range 0-20, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Connected speech informativeness	Percentage of correct information units (CIUs) produced in a picture description task	Change from baseline at 5 months and 9 months
Repetition of words and sentences	Repetition subscale score of the Western Aphasia Battery (WAB) (range 0-100, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Verbal agility	Verbal Agility subtest score of the Boston Diagnostic Aphasia Examinaton (BDAE) (range 0-14, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Naming and word finding	Naming and Word Finding subscale score of the Western Aphasia Battery (WAB) (range 0-100, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Verbal comprehension	Sequential Commands subtest score of the Western Aphasia Battery (WAB) (range 0-80, higher score indicates better outcome)	Change from baseline at 5 months and 9 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Executive function (correct responses)	Simon Task: score (range 0-100, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Executive function (reaction times)	Simon Task: reaction time mean (ms)	Change from baseline at 5 months and 9 months
Attention (correct responses)	Flexible Attention Test (FAT): score (range 0-48, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Attention (reaction times)	Flexible Attention Test (FAT): reaction time mean (ms)	Change from baseline at 5 months and 9 months
Working memory	Word Span subtest score of the Kielelliset Arviointitehtävät (KAT) (range 0-30, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Verbal memory	Logical Memory subtest score of the Wechsler Memory Scale III (WMS-III) (range 0-80, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Verbal learning	Word Lists subtest score of the Wechsler Memory Scale III (WMS-III) (range 0-84, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Singing ability	Acoustic features (e.g., pitch, rhythm, intensity) analyzed from recorded production of familiar and novel songs using acoustic analysis software	Change from baseline at 5 months and 9 months
Music perception	Montreal Battery of Evaluation of Amusia (MBEA) score (range 0-30, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Functional stroke recovery	Total score of the Stroke Impact Scale (SIS) questionnaire (range 0-900, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Depression	Total score of the Center for Epidemiological Studies Depression Scale (CES-D) questionnaire (range 0-60, lower score indicates better outcome)	Change from baseline at 5 months and 9 months
Mood	Total score of the Visual Analog Mood Scales (VAMS) questionnaire (range 0-800, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Social interaction	Total score of the Social Provision Scale (SPS) questionnaire (range 24-96, higher score indicates better outcome)	Change from baseline at 5 months and 9 months
Caregiver burden	Total score of the Zarit Burden Interview (ZBI-22) questionnaire (range 0-88, lower score indicates better outcome)	Change from baseline at 5 months and 9 months
Psychological stress of the caregiver	Total score of the General Health Questionnaire (GHQ-12) (range 0-36, lower score indicates better outcome)	Change from baseline at 5 months and 9 months
Electroencephalography (EEG)	Amplitude and latency of event-related potentials (ERPs) associated with learning and memory in two auditory tasks	Change from baseline at 5 months and 9 months
Structural magnetic resonance imaging (sMRI): MPRAGE sequence	Grey matter volume in frontotemporal, frontoparietal, and limbic brain regions	Change from baseline at 5 months and 9 months
Structural magnetic resonance imaging (sMRI): DTI sequence	Structural connectivity of intra- and interhemispheric white matter tracts	Change from baseline at 5 months and 9 months
Functional magnetic resonance imaging (fMRI): resting-state	resting-state fMRI sequence: functional connectivity of frontotemporal, frontoparietal, and limbic brain networks	Change from baseline at 5 months and 9 months
Functional magnetic resonance imaging (fMRI): singing-related activity	task-based fMRI sequence: frontotemporal, frontoparietal, and limbic activation patterns associated with the perception, vocal repetition, and recall of novel songs	Change from baseline at 5 months and 9 months

Collaborators and Investigators

• Sponsor: University of Helsinki
• Collaborators: Harvard Medical School (HMS and HSDM); Helsinki University Central Hospital; University of Melbourne; University of Barcelona; Hospital District of Helsinki and Uusimaa; Helsinki-Uusimaa Aphasia and Stroke Association; Finnish Brain Association; Outloud Ltd

Study record dates

Study Major Dates

• Study Start (ACTUAL): January 1, 2018
• Primary Completion (ACTUAL): January 31, 2020
• Study Completion (ACTUAL): March 15, 2020

Study Registration Dates

• First Submitted: February 16, 2018
• First Submitted That Met QC Criteria: April 10, 2018
• First Posted (ACTUAL): April 18, 2018

Study Record Updates

• Last Update Posted (ACTUAL): August 18, 2022
• Last Update Submitted That Met QC Criteria: August 17, 2022
• Last Verified: August 1, 2022

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Nervous System Diseases; Neurologic Manifestations; Neurobehavioral Manifestations; Language Disorders; Communication Disorders; Speech Disorders; Aphasia
• Other Study ID Numbers: 306625

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No