Development and Interrelation of Pain, Depression, and Anxiety in Music Students: Does Successful Treatment of Pain Have an Impact on Mental Health?

OBJECTIVE: Musculoskeletal pain is a common problem among professional musicians as well as music students. Studies have emphasized the effectiveness of music-specific physiotherapy for affected musicians. This study was designed to evaluate if physiotherapy treatment of pain-affected music students had an impact on pain perception as well as psychological well-being. To explore the possible development of musculoskeletal pain, depression, and anxiety, a second sample of pain-free music students, matched for age and gender, was examined twice at identical time intervals. METHODS: A convenience sample of 31 university music students with moderate to severe musculoskeletal pain and 31 pain-free music students, matched in age and gender, were included in the study. Both groups were examined physically and completed biographical, music-related, and psychological questionnaires. Perceived pain intensity was assessed with a visual-analogue scale (VAS), and depression and anxiety symptoms were assessed with the Beck Depression Inventory II (BDI-II) and the Hospital Anxiety and Depression Scale (HAD). Music students with pain received a series of 12 sessions of musician-specific physiotherapy, while controls waited for the same amount of time for retesting. RESULTS: On the 10-cm VAS, music students with pain reported an average improvement in pain intensity from a baseline of 6.25 (SD 1.95) to 2.7 (2.03) after the intervention, while the controls (music students without pain) did not change. Furthermore, music students with pain indicated higher depression and anxiety scores as compared to the control group before and after therapy. After intervention, music students with pain with higher BDI-II scores demonstrated clinical improvement concerning depression, but no significant improvement in mental health was found in the pain group taken as a whole. CONCLUSION: Physiotherapy was effective in reducing pain symptoms in music students affected by chronic musculoskeletal pain. However, physiotherapy did not improve mental health in pain-affected music students. Additional psychotherapeutic interventions may be needed to support music students with psychological comorbidities such as depression and anxiety.

Modulation of Motor Vigor by Expectation of Reward Probability Trial-by-Trial Is Preserved in Healthy Ageing and Parkinson's Disease Patients.

Motor improvements, such as faster movement times or increased velocity, have been associated with reward magnitude in deterministic contexts. Yet whether individual inferences on reward probability influence motor vigor dynamically remains undetermined. We investigated how dynamically inferring volatile action-reward contingencies modulated motor performance trial-by-trial. We conducted three studies that coupled a reversal learning paradigm with a motor sequence task and used a validated hierarchical Bayesian model to fit trial-by-trial data. In Study 1, we tested healthy younger [HYA; 37 (24 females)] and older adults [HOA; 37 (17 females)], and medicated Parkinson's disease (PD) patients [20 (7 females)]. We showed that stronger predictions about the tendency of the action-reward contingency led to faster performance tempo, commensurate with movement time, on a trial-by-trial basis without robustly modulating reaction time (RT). Using Bayesian linear mixed models, we demonstrated a similar invigoration effect on performance tempo in HYA, HOA, and PD, despite HOA and PD being slower than HYA. In Study 2 [HYA, 39 (29 females)], we additionally showed that retrospective subjective inference about credit assignment did not contribute to differences in motor vigor effects. Last, Study 3 [HYA, 33 (27 females)] revealed that explicit beliefs about the reward tendency (confidence ratings) modulated performance tempo trial-by-trial. Our study is the first to reveal that the dynamic updating of beliefs about volatile action-reward contingencies positively biases motor performance through faster tempo. We also provide robust evidence for a preserved sensitivity of motor vigor to inferences about the action-reward mapping in aging and medicated PD.SIGNIFICANCE STATEMENT Navigating a world rich in uncertainty relies on updating beliefs about the probability that our actions lead to reward. Here, we investigated how inferring the action-reward contingencies in a volatile environment modulated motor vigor trial-by-trial in healthy younger and older adults, and in Parkinson's disease (PD) patients on medication. We found an association between trial-by-trial predictions about the tendency of the action-reward contingency and performance tempo, with stronger expectations speeding the movement. We additionally provided evidence for a similar sensitivity of performance tempo to the strength of these predictions in all groups. Thus, dynamic beliefs about the changing relationship between actions and their outcome enhanced motor vigor. This positive bias was not compromised by age or Parkinson's disease.

Improved Speech in Noise Perception in the Elderly After 6 Months of Musical Instruction.

Understanding speech in background noise poses a challenge in daily communication, which is a particular problem among the elderly. Although musical expertise has often been suggested to be a contributor to speech intelligibility, the associations are mostly correlative. In the present multisite study conducted in Germany and Switzerland, 156 healthy, normal-hearing elderly were randomly assigned to either piano playing or music listening/musical culture groups. The speech reception threshold was assessed using the International Matrix Test before and after a 6 month intervention. Bayesian multilevel modeling revealed an improvement of both groups over time under binaural conditions. Additionally, the speech reception threshold of the piano group decreased during stimuli presentation to the left ear. A right ear improvement only occurred in the German piano group. Furthermore, improvements were predominantly found in women. These findings are discussed in the light of current neuroscientific theories on hemispheric lateralization and biological sex differences. The study indicates a positive transfer from musical training to speech processing, probably supported by the enhancement of auditory processing and improvement of general cognitive functions.

Elevated Forearm Coactivation Levels and Higher Temporal Variability in String Players with Musicians' Dystonia During Demanding Playing Conditions.

AIMS: There is a lack of an objective measurement tool for evaluating the quality of bowing performance in string players. The present study aimed to assess kinematic features of bow strokes performed by violinists and violists affected by bow arm dystonia, compared to healthy controls. METHODS: Seven musicians with musician's dystonia and 20 healthy controls participated in the study. A 3D motion capture system was used to record repetitive bowing on a single string at fixed velocities. Temporal variability, an indirect indicator for motor disturbances, was computed in order to evaluate the musicians' performance during the repetitive movements. Simultaneously, muscular activity of essential flexors and extensors of the right arm was recorded using surface electromyography. Antagonistic muscular coactivation and temporal variability were analyzed in a multilevel linear model framework. RESULTS: The results revealed generally higher forearm coactivation during upstrokes as compared to downstrokes in both groups. Whereas coactivation levels of the upper arm did not significantly differ between groups, we found increased forearm coactivation in patients during the more demanding playing conditions. Increased coactivation may represent an adaptive motor control strategy that is applied in order to reduce noise entering the motor system. Furthermore, affected musicians executed bow strokes with higher temporal variability than healthy controls, especially during fast playing. CONCLUSIONS: Building on these results we introduce a novel approach using simple kinematic measures to quantifying dystonic symptoms in string players. Even though dystonia patients showed higher temporal variability and elevated forearm coactivation, both variables were not correlated. This finding is discussed with respect to the heterogeneity of musicians' dystonia and its individual-specific manifestations in dystonic symptoms.

Musical Sonification of Arm Movements in Stroke Rehabilitation Yields Limited Benefits.

Neurologic music therapy in rehabilitation of stroke patients has been shown to be a promising supplement to the often strenuous conventional rehabilitation strategies. The aim of this study was threefold: (i) replicate results from a previous study with a sample from one clinic (henceforth called Site 1; N = 12) using an already established recording system, and (ii) conceptually replicate previous findings with a less costly hand-tracking system in Site 2 (N = 30), and (iii) compare both sub-studies' outcomes to estimate the efficiency of neurologic music therapy. Stroke patients in both sites were randomly assigned to treatment or control groups and received daily training of guided sequential upper limb movements additional to their standard stroke rehabilitation protocol. Treatment groups received sonification (i.e., changes in musical pitch) of their movements when they moved their affected hand up and down to reproduce a sequence of the first six notes of a C major scale. Controls received the same movement protocol, however, without auditory feedback. Sensors at the upper arm and the forearm (Xsens) or an optic sensor device (Leapmotion) allowed to measure kinematics of movements and movement smoothness. Behavioral measures pre and post intervention included the Fugl-Meyer assessment (FMA) and the Stroke Impact Scale (SIS) and movement data. Bayesian regression did not show evidence supporting an additional effect of sonification on clinical mobility assessments. However, combined movement data from both sites showed slight improvements in movement smoothness for the treatment group, and an advantage for one of the two motion capturing systems. Exploratory analyses of EEG-EMG phase coherence during movement of the paretic arm in a subset of patients suggested increases in cortico-muscular phase coherence specifically in the ipsilesional hemisphere after sonification therapy, but not after standard rehabilitation therapy. Our findings show that musical sonification is a viable treatment supplement to current neurorehabilitation methods, with limited clinical benefits. However, given patients' enthusiasm during training and the low hardware price of one of the systems it may be considered as an add-on home-based neurorehabilitation therapy.

Pathophysiology of writer's cramp: an exploratory study on task-specificity and non-motor symptoms using an extended fine-motor testing battery.

BACKGROUND: Writer's cramp (WC) is a task-specific focal dystonia which manifests itself as abnormal postures interfering with motor performance. As the spread of motor symptoms remains controversial and non-motor symptoms are widely discussed, in this exploratory study, we explore the pathophysiology of WC, focusing on task-specificity and the psychological profiles of WC patients. METHODS: In 14 right-handed WC patients and matched controls, we assessed motor control by applying motor performance tests (Vienna Test Series), as well as using writing analysis and grip-force measurements. Moreover, detailed psychological factors were assessed. Classification trees were used to distinguish patients from controls. RESULTS: The total duration of writing and the vertical writing frequency of the pen are the most important variables to split the data set successfully into patients and controls. No other variables concerning motor performance tests, grip-force measurements or psychological factors correctly separated patients and controls. CONCLUSIONS: Only variables from the writing tasks successfully separated patients and controls, indicating a strong task-specificity of WC in our patient group. Future research should be performed with larger samples of untreated WC patients in early stages of impairment, without any secondary motor disturbances, to verify our findings.

Sonification of Arm Movements in Stroke Rehabilitation - A Novel Approach in Neurologic Music Therapy.

Gross motor impairments are common after stroke, but efficient and motivating therapies for these impairments are scarce. We present an innovative musical sonification therapy, especially designed to retrain patients' gross motor functions. Sonification should motivate patients and provide additional sensory input informing about relative limb position. Twenty-five stroke patients were included in a clinical pre-post study and took part in the sonification training. The patients' upper extremity functions, their psychological states, and their arm movement smoothness were assessed pre and post training. Patients were randomly assigned to either of two groups. Both groups received an average of 10 days (M = 9.88; SD = 2.03; 30 min/day) of musical sonification therapy [music group (MG)] or a sham sonification movement training [control group (CG)], respectively. The only difference between the two protocols was that in the CG no sound was played back during training. In the beginning, patients explored the acoustic effects of their arm movements in space. At the end of the training, the patients played simple melodies by coordinated arm movements. The 15 patients in the MG showed significantly reduced joint pain (F = 19.96, p < 0.001) in the Fugl-Meyer assessment after training. They also reported a trend to have improved hand function in the stroke impact scale as compared to the CG. Movement smoothness at day 1, day 5, and the last day of the intervention was compared in MG patients and found to be significantly better after the therapy. Taken together, musical sonification may be a promising therapy for motor impairments after stroke, but further research is required since estimated effect sizes point to moderate treatment outcomes.

Musician's dystonia is highly task specific: no strong evidence for everyday fine motor deficits in patients.

OBJECTIVES: 1) To examine the fine motor skills used everyday by patients suffering from musician's dystonia (MD) in the upper limb in order to verify whether MD is task-specific; and 2) to compare the affected and non-affected hands of MD musicians vs healthy musicians in performance of these tasks in order to clarify whether dystonic symptoms can be found in the non-affected side of MD patients. BACKGROUND: MD is typically considered to be focal and task specific, but patients often report impairment in everyday life activities. Furthermore, in the course of MD, about 15% of patients complain of dystonic symptoms in other parts of the body. METHODS: Twenty-seven musicians affected by MD and 27 healthy musicians were studied using 1) the Motor Performance Test Series, 2) a kinematic analysis of handwriting, and 3) an assessment of the grip force regulation while lifting and moving a manipulandum. RESULTS: Patients performed most fine motor tasks without any evidence of a deficit. Exclusively in the handwriting tasks (2), they exhibited fewer frequencies of the written trace and a prolonged overall writing time. CONCLUSION: MD is highly task specific and does not strongly affect other motor skills. The subtle deficits in handwriting may be explained as a consequence of a general psychological disposition rather than as compensatory mechanisms to avoid the appearance of dystonic symptoms. Furthermore, we did not find signs of multifocal motor deficits in the unaffected hands of MD patients.

Moving with music for stroke rehabilitation: a sonification feasibility study.

Gross-motor impairments are common after stroke, but efficacious and motivating therapies for these impairments are scarce. We present a novel musical sonification therapy especially designed to retrain gross-motor functions. Four stroke patients were included in a clinical pre-post feasibility study and were trained with our sonification training. Patients' upper-extremity functions and their psychological states were assessed before and after training. The four patients were subdivided into two groups, with both groups receiving 9 days of musical sonification therapy (music group, MG) or a sham sonification training (control group, CG). The only difference between these training protocols was that, in the CG, no sound was played back. During the training the patients initially explored the acoustic effects of their arm movements, and at the end of the training the patients played simple melodies by moving their arms. The two patients in the MG improved in nearly all motor function tests after the training. They also reported in the stroke impact scale, which assesses well-being, memory, thinking, and social participation, to be less impaired by the stroke. The two patients in the CG did benefit less from the movement training. Taken together, musical sonification may be a promising therapy for impairments after stroke.

Sonification as a possible stroke rehabilitation strategy.

Despite cerebral stroke being one of the main causes of acquired impairments of motor skills worldwide, well-established therapies to improve motor functions are sparse. Recently, attempts have been made to improve gross motor rehabilitation by mapping patient movements to sound, termed sonification. Sonification provides additional sensory input, supplementing impaired proprioception. However, to date no established sonification-supported rehabilitation protocol strategy exists. In order to examine and validate the effectiveness of sonification in stroke rehabilitation, we developed a computer program, termed "SonicPointer": Participants' computer mouse movements were sonified in real-time with complex tones. Tone characteristics were derived from an invisible parameter mapping, overlaid on the computer screen. The parameters were: tone pitch and tone brightness. One parameter varied along the x, the other along the y axis. The order of parameter assignment to axes was balanced in two blocks between subjects so that each participant performed under both conditions. Subjects were naive to the overlaid parameter mappings and its change between blocks. In each trial a target tone was presented and subjects were instructed to indicate its origin with respect to the overlaid parameter mappings on the screen as quickly and accurately as possible with a mouse click. Twenty-six elderly healthy participants were tested. Required time and two-dimensional accuracy were recorded. Trial duration times and learning curves were derived. We hypothesized that subjects performed in one of the two parameter-to-axis-mappings better, indicating the most natural sonification. Generally, subjects' localizing performance was better on the pitch axis as compared to the brightness axis. Furthermore, the learning curves were steepest when pitch was mapped onto the vertical and brightness onto the horizontal axis. This seems to be the optimal constellation for this two-dimensional sonification.

Sensory trick phenomenon improves motor control in pianists with dystonia: prognostic value of glove-effect.

Musician's dystonia (MD) is a task-specific movement disorder that causes loss of voluntary motor control while playing the instrument. A subgroup of patients displays the so-called sensory trick: alteration of somatosensory input, e.g., by wearing a latex glove, may result in short-term improvement of motor control. In this study, the glove-effect in pianists with MD was quantified and its potential association with MD-severity and outcome after treatment was investigated. Thirty affected pianists were included in the study. Music instrument digital interface-based scale analysis was used for assessment of fine motor control. Therapeutic options included botulinum toxin, pedagogical retraining and anticholinergic medication (trihexyphenidyl). 19% of patients showed significant improvement of fine motor control through wearing a glove. After treatment, outcome was significantly better in patients with a significant pre-treatment sensory trick. We conclude that the sensory trick may have a prognostic value for the outcome after treatment in pianists with MD.

Altered sensory feedbacks in pianist's dystonia: the altered auditory feedback paradigm and the glove effect.

BACKGROUND: This study investigates the effect of altered auditory feedback (AAF) in musician's dystonia (MD) and discusses whether AAF can be considered as a sensory trick in MD. Furthermore, the effect of AAF is compared with altered tactile feedback, which can serve as a sensory trick in several other forms of focal dystonia. METHODS: The method is based on scale analysis (Jabusch et al., 2004). Experiment 1 employs synchronization paradigm: 12 MD patients and 25 healthy pianists had to repeatedly play C-major scales in synchrony with a metronome on a MIDI-piano with three auditory feedback conditions: (1) normal feedback; (2) no feedback; (3) constant delayed feedback. Experiment 2 employs synchronization-continuation paradigm: 12 MD patients and 12 healthy pianists had to repeatedly play C-major scales in two phases: first in synchrony with a metronome, secondly continue the established tempo without the metronome. There are four experimental conditions, among them three are the same AAF as in Experiment 1 and 1 is related to altered tactile sensory input. The coefficient of variation of inter-onset intervals of the key depressions was calculated to evaluate fine motor control. RESULTS: In both experiments, the healthy controls and the patients behaved very similarly. There is no difference in the regularity of playing between the two groups under any condition, and neither did AAF nor did altered tactile feedback have a beneficial effect on patients' fine motor control. CONCLUSIONS: The results of the two experiments suggest that in the context of our experimental designs, AAF and altered tactile feedback play a minor role in motor coordination in patients with musicians' dystonia. We propose that altered auditory and tactile feedback do not serve as effective sensory tricks and may not temporarily reduce the symptoms of patients suffering from MD in this experimental context.

Defective inhibition and inter-regional phase synchronization in pianists with musician's dystonia: an EEG study.

Recent neurophysiological studies have associated focal-task specific dystonia (FTSD) with impaired inhibitory function. However, it remains unknown whether FTSD also affects the inhibition (INH) of long-term overlearned motor programs. Consequently, we investigated in a Go/NoGo paradigm the neural correlates associated with the activation (ACT) and inhibition of long-term overlearned motor memory traces in pianists with musician's dystonia (MD), a form of FTSD, during a relevant motor task under constraint timing conditions with multichannel EEG. In NoGo trials, the movement related cortical potentials showed a positive shift after the NoGo signal related to inhibition and was significantly smaller over sensorimotor areas in musicians with MD. Further, we observed an increase at 850-900 ms in the power of beta oscillations which was significantly weaker for the patient group. The role of the inter-electrode phase coupling in the sensorimotor integration of inhibitory processes turned out to be the most relevant physiological marker: the global phase synchronization during INH exhibited an increase between 230 and 330 ms and 7-8 Hz, increase which was significantly smaller for pianists with MD. This effect was due to a weaker phase synchronization between the supplementary motor cortex and left premotor and sensorimotor electrodes in patients. Thus, our findings support the hypothesis of a deficient phase coupling between the neuronal assemblies required to inhibit motor memory traces in patients with MD. EMG recorded from the right flexor pollicis longus muscle confirmed that patients with MD had a disrupted INH in NoGo trials.

Brain processing of meter and rhythm in music. Electrophysiological evidence of a common network.

To determine cortical structures involved in "global" meter and "local" rhythm processing, slow brain potentials (DC potentials) were recorded from the scalp of 18 musically trained subjects while listening to pairs of monophonic sequences with both metric structure and rhythmic variations. The second sequence could be either identical to or different from the first one. Differences were either of a metric or a rhythmic nature. The subjects' task was to judge whether the sequences were identical or not. During processing of the auditory tasks, brain activation patterns along with the subjects' performance were assessed using 32-channel DC electroencephalography. Data were statistically analyzed using MANOVA. Processing of both meter and rhythm produced sustained cortical activation over bilateral frontal and temporal brain regions. A shift towards right hemispheric activation was pronounced during presentation of the second stimulus. Processing of rhythmic differences yielded a more centroparietal activation compared to metric processing. These results do not support Lerdhal and Jackendoff's two-component model, predicting a dissociation of left hemispheric rhythm and right hemispheric meter processing. We suggest that the uniform right temporofrontal predominance reflects auditory working memory and a pattern recognition module, which participates in both rhythm and meter processing. More pronounced parietal activation during rhythm processing may be related to switching of task-solving strategies towards mental imagination of the score.