Prognostic Factors in Vascular Motor Aphasia after Music Therapy ()
1. Introduction
Aphasia is a language disorder linked to a brain injury or dysfunction that is characterized by difficulties in language expression and/or understanding [1]. It is present in 21 to 38% of patients with cerebrovascular accident or stroke and is associated with high morbidity, mortality and cost in the short and long term [3]. Aphasia after a stroke is estimated to affect 43 to 60 people out of 100,000 in Europe and the United States [3]. In Senegal, a prevalence of 32.35% has been reported in 2008. Motor or expressive aphasias were observed in 96.4% of cases, while 3.6% of aphasias were global [4]. In a study conducted in 2012 in Congo Brazzaville, Broca’s aphasia was the most common type after stroke and had a significant impact on the patient’s quality life [5]. Aphasia-associated disability negatively impacts the socio-professional life and mental health of patients. Speech therapy has been used to treat patients with aphasia [3]. Studies show that stimulation by music increases cerebral blood flow in patients with acute ischemic stroke and thus improves post-stroke recovery [3]. Listening to music promotes neurogenesis, regeneration and repair of neurons and neural circuits by modifying the secretions of hormones that play a role in the processes of brain plasticity [6]. During a song, major increases in blood flow were observed in the primary and secondary auditory cortex, the primary motor cortex, the frontal operculum, the supplementary motor area, the insula, the posterior cerebellum and the basal ganglia.
The repetition and harmonization of the melody produced very similar activation patterns. Listening and responding, have been reported to activate the frontal operculum (Broca’s area) [7]. In addition, the brain activation networks for articulate language and music do not completely overlap. Thus, the left brain lesions at the origin of the language disorders of most cases of aphasia could partially spare the activation networks in the brain regions that are associated with music and singing. Passive listening to music effectively engages bilateral activations with an overlap of Broca’s area. Singing (without words) correlates with the activation of left hemispheric regions (cingulate gyrus) and bilateral (pars orbitalis and insula) which have a positive effect on speech production in people with aphasias [8].
Recent studies suggest that active music-based interventions such as MIT (Melodic Intonation Therapy) are effective for speech improvement and motor recovery due to an increase in the number of fibers in the arcuate bundle of the right hemisphere. It is, however, a therapy in its own right, using the rhythmic component of music in an active way, as the patient recovers speech by singing, clapping to the rhythms and repeating phrases [9].
In Senegal, the critical shortages of rehabilitation services and speech therapists result in late and/or infrequent rehabilitation sessions. Under these conditions, the use of self-administered rehabilitative methods such as music therapy could improve the functional outcome of aphasic patients.
Thus, we carried out this study, the objective of which was to determine the prognostic factors of post-stroke motor aphasia, treated with music therapy.
2. Methodology
With the aim of contributing to and improving the overall management of patients, we conducted a study with the general objective of to determine the prognostic factors of post-stroke motor aphasia, treated with music therapy. The specific objectives were to:
Describe the sociodemographic and clinical characteristics of patients with post-stroke aphasia.
Determine the outcome of aphasia after music therapy.
Identify prognostic factors for language recovery in patients receiving music therapy.
2.1. Patients et Methods
We conducted a 9-month prospective cohort study at the Neurology, and Physical Medicine and Rehabilitation departments of the Fann University Hospital Center in Dakar. Our study population consisted of patients with language disorders following a stroke, seen in the outpatient clinic and inpatient services. From this study population, we included all clinical stable patients verbal expressive language disorders of vascular origin confirmed by medical imaging, within two weeks of the stroke event. These patients constituted the intervention group (GBI). These patients were followed in neurovascular care for 3 months plus or minus 10 days, without speech rehabilitation (GNBI).
Patients with a history of persistent motor aphasia of vascular origin and those with severe cognitive impairment were excluded.
2.2. Assessment
Aphasia was assessed using the LAST score.
The Language Screening Test (LAST) is a 15-item test that screens for aphasia. The maximum score is 15, with each item scored as 1 (correct) or 0 (incorrect). The LAST has two subscores: expression and reception. The expression index measures naming, repetition, and automatic speech. The maximum score is 8 points. The receptive index measures picture recognition and verbal instructions. The maximum score is 7 points.
LAST b score
LAST-b (15) |
Expression orale (8) |
Dénomination (5) |
crayon (1) Télévision (1) Girafe (1) Couteau (1) Papillon (1) |
Répétition (2) |
Littérature (1) Les vacanciers voudraient des glaces à la fraise (1) |
Série automatique (1) |
Compter de 1 à 10 |
Compréhension orale (7) |
Désignation (4) |
Chapeau (1) Main (1) Voiture (1) Tomate (1) |
Exécution d’ordres (3) |
«Montrez le sol» (1) «Ne prenez pas la feuille mais la clef» (1) «Touchez une de vos oreilles avec un doigt, puis votre front avec deux doigts» (1) |
Aphasia was defined by a total score of less than 15.
2.3. Procedure
The first step was to recruit all patients who met the inclusion criteria and had no exclusion criteria.
After consent, all included patients (GBI) were referred to the Physical and Rehabilitation Medicine department by the end of the fourth week, where they were randomly divided into two groups, according to the language rehabilitation method used: speech therapy (GBI1), and music therapy (GBI2). The third group, with no therapeutic intervention, was made up of patients who had been undergoing neurovascular consultation for 3 months without language rehabilitation (GBI).
For music therapy, based on an interview, patients or their relatives were asked to name 3 of their favorite songs, and to provide us with a recording of each song. A first rehearsal was carried out with the patient, to identify which song was easiest to repeat. For patients who didn’t have any favorite songs, we suggested singing the national anthem or a well-known Koranic or Christian song. The music therapy session were continued at home. Patients had to repeat the chosen song once a day, three times a week for a minimum of three months. Telephone calls (twice a month) were made to monitor and reinforce the music therapy practice. Speech therapy sessions were also conducted for up to three months.
2.4. Ethical Considerations
Informed consent was obtained from all patients prior to inclusion. Data collected was anonymized to ensure patients’ confidentiality.
Data analysis
Data were collected on data sheets, entered in a Microsoft Excel spreadsheet and analyzed with SPSS 26.0. Qualitative variables were expressed as frequencies and numbers. Quantitative variables were expressed as mean with standard deviation. The chi-square test was used to compare qualitative variables. A bivariate analysis was performed to determine the different prognostic factors associated with language recovery in the music therapy group. The threshold of significance was considered to be a value of p < 0.05.
3. Results
3.1. Socio-demographic Data
A total of 55 patients were included (Figure 1).
Figure 1. Recruitment process.
The mean age of our patients was 61.2 +/− 14.5 years, with a median of 65 years, a minimum of 16 years and a maximum of 89 years. The most affected age range was 50 - 70 (56.4%). Patients over 70 accounted for 21.8%. Other age groups, 30-50 and under 30, accounted for 16.4% and 5.5% respectively. The sex ratio was 1.2 and 61.8% had never been to school.
Aphasia-related data
Aphasia etiologies were dominated by ischemic stroke (87.3%). The main types of aphasia found were Broca’s aphasia (41.8%), global aphasia (36.4%) and Pierre Marie’s major aphasia (12.7%). Conduction aphasia and transcortical aphasia were found in 3.6% each.
3.2. Evolution of Aphasia
Forty-six (46) patients were evaluated at 1 month, including 20 in music therapy, 10 in speech therapy and 16 in GNBI. Mean scores in GBI1 were 8.7 at one month, compared with 11.4 in GBI2 and 6.3 in GNBI. Eighty percent (80%) of speech therapy patients were aphasic, compared with 90% of music therapy patients and 87.2% in the non-rehabilitation group, at 1 month. At 3 months, the study population consisted of 38 patients, including 13 in music therapy, 9 in speech therapy and 16 in GNBI. Mean scores in GBI1 were 10.55 at three months, compared with 13.41 in GBI2 and 6 in GNBI. In the speech therapy group, 66.7% had aphasia, compared with 87.5% in the non-rehabilitation group and 46.2% in the music therapy group (p = 0.023) (Figure 2).
Figure 2. Distribution of the population according to the severity of aphasia.
3.3. Prognostic Factors for Aphasia at 3 Months
Based on the LAST-b score
A statistically significant improvement was obtained by speech therapy in the naming domain of the LAST-b score (p = 0.0001). Music therapy was associated with a significant improvement in naming (p = 0.001), repetition (p = 0.001) and automatic series (p = 0.014), musical environment (p = 0, 016), aphasia etiology (p = 0.006), automatic series (p = 0.009). No statistically significant difference was observed for listening comprehension (Table 1).
Table 1. Prognostic factors for aphasia under music therapy.
Music therapy (N = 15) |
LAST items |
Aphasic |
Non aphasic |
P value |
Naming |
4 (20%) |
11(55%) |
0.001 |
Repetition |
4 (26.7%) |
11(73.3%) |
0.001 |
Automatic series |
1 (6.7%) |
14 (93.3%) |
0.014 |
Oral comprehension |
1 (6.7%) |
14 (93.3%) |
0.117 |
Prognostic factors |
(n = 26) |
(%) |
P values |
Socio-demographic |
Music
environment |
7 |
41.2 |
0.016 |
Age |
12 |
21.8 |
0.237 |
Cohabitation |
12 |
21.8 |
0.8 |
Sex |
|
|
0.9 |
Feminine |
6 |
16 |
Masculin |
6 |
16.7 |
Handedness |
|
|
0.07 |
Right |
12 |
22.2 |
Left |
0 |
0 |
Hobbies |
12 |
21.8 |
0.08 |
Clinical |
Stroke type |
|
|
|
Ischemic |
12 |
25 |
0.006 |
Hemorrhagic |
0 |
0 |
|
Repetition at onset |
11 |
20.8 |
0.5 |
Naming |
10 |
20 |
0.420 |
Automatic
series |
5 |
12.5 |
0.009 |
4. Discussion
4.1. Socio-demographic Aspects
In our study population, we found a mean age of onset of aphasia of 61y (16y - 89y) +/− 14 years. Adults aged 50-60 years were the most affected, with a median age of 65 years. These results are similar to those of Sène et al. in 2008 in Senegal, who found a mean age of 58.6 years (28 years-86 years) [4]. Runarvot et al. in 2024, in Normandy, found a median age of 63 years similar to our series [10]. Our study population was dominated by men (54.5%), with a sex ratio of 1.2; Ossou-Nguiet et al. also found a male predominance.
4.2. Clinical Aspects
Broca’s aphasia accounted for 41.6% of the study population, global aphasia for 36.4%, Pierre Marie aphasia for 12.7%, transcortical motor aphasia and conduction aphasia for 3.6%, and anomia for 1.8%. These results are similar to those of Ossou-Nguiet et al., Gnonlonfoun et al., who found Broca’s aphasia to be predominant [5] [11]. Pedersen et al. found a predominance of global aphasia (32%), followed by Broca’s aphasia (12%), transcortical motor aphasia (2%), Wernicke’s aphasia (16%), conduction aphasia (5%) and anomia (25%) [12]. This difference may be explained by the small sample size of our study.
4.3. Course and Prognostic Factors in Aphasia
In our series, patients receiving music therapy had better scores than those receiving speech therapy or no rehabilitation. Indeed, Godecke et al. had found a significant improvement in patients who had received aphasia-focused daily therapy compared with patients who had received usual therapy [12]. Mattioli et al. in 2019, in Italy, found speech therapy to be effective in the early and chronic phase (> 6 months) after stroke, with greater effects observed if intensive treatment is provided [13].
These results may be explained by the reduced number of speech therapy sessions performed by patients in our series, due to the long distance between their homes and hospital. Furthermore, music therapy showed the greatest statistically significant improvement over time, suggesting a potentially greater efficacy of music therapy compared with other methods. These results are similar to those of Lim et al., who showed that music therapy improves language function in patients with subacute non-fluent aphasia [3]. Furthermore, such findings may indicate that there are other pathways involved in speech and singing, and that speech therapy and music therapy may be effective in treating aphasia by activating the brain via different pathways [3]. Our results are also similar to those of Liu et al. in 2022, who found that music therapy can improve functional communication, repetition and naming in patients with post-stroke aphasia, but does not significantly improve comprehension [14]. Belin et al. reported normal activation of language areas when patients benefited from music therapy [15]. Kil-Byung Lim et al. in 2013 found significant improvements in spontaneous speech, comprehension and naming in the subacute and chronic groups treated with music therapy. Hypotheses explaining the effectiveness of music therapy for aphasia include the fact that words can be pronounced more slowly when singing than when speaking. In addition, singing may offer more opportunities to distinguish phonemes made up of words and phrases due to syllable length. Non-fluent aphasic patients can become more fluent by slowly singing connected segments [3]. In addition, musical environment (p = 0, 016), aphasia etiology (p = 0.008) and automatic series (p = 0.009) were significantly associated with aphasia treated by music therapy at 3 months. Other prognostic factors associated with aphasia such as laterality, age, level of education, initial severity, lesion site and size were also found [7], [9], [12]. The difference in factors can be explained by the variation in the speech therapy techniques used [16].
5. Conclusions
Ultimately, we conducted a prospective cohort study, carried out from November 2023 to July 2024. The study included patients with verbal expression disorders of vascular origin, confirmed by brain imaging, who were hemodynamically stable, with no prior history of motor aphasia or cognitive disorders, and were evaluated using the LAST score. A total of 55 patients were included, with a predominance of male participants and a mean age of 61 years ± 14 years. Broca’s aphasia accounted for two-fifths of the study population.
Furthermore, the progression of aphasia revealed average scores of 8.7 in the GBI1 group at 1 month, compared to 11.4 in the GBI2 group and 6.3 in the GNBI group. After 3 months, the average scores were 10.55 in GBI1, 13.41 in GBI2, and 6 in GNBI. In the music therapy group (GBI2), there was a statistically significant improvement in the expressive aspects of language, including naming, repetition, and automatic series.
Additionally, the musical environment, the etiology of aphasia, and the automatic series were found to be significant factors associated with aphasia treatment through music therapy.
However, there are some limitations to this study:
The small sample size.
The use of the LAST score, which may not be fully applicable to the Senegalese population.
The monocentric nature of the study, which limits the generalizability of the results to other healthcare settings.
The need for future studies to focus on well-established music therapy techniques, such as Melodic Intonation Therapy.
Therefore, it would be beneficial to extend the study with a larger cohort.