An improvisation-based approach to instrumental music training for cochlear implant users (GAME), specifically designed to facillitate audiomotor learning

Background
Research into the effects that playing a music instrument might have on aural
perception has revealed enhanced hearing capacities in musicians, not only in
the musical domain (Fujioka, Trainor et al. 2004, Lee, Skoe et al. 2009), but
also in other domains like speech perception (Kraus and Chandrasekaran 2010).
Next to that, musicians have a greater ability to identify degraded music than
non-musicians (Fuller, Galvin et al. 2014). This shows a general beneficial
effect from conventional music training on sound perception skills. Such
studies have been conducted typically on individuals who learned to play an
instrument using sheet music, they have learned to reproduce music, not to
improvise it. Furthermore, they have learned to reproduce music they
*see* (notes), a practice which has been termed *score-dependence* (Harris, van
Kranenburg et al. 2016). Basically there are two different kind of trainings,
one is based on score-dependence and the second one on improvisation.

It has been shown that auditory training with CI users is effective. For
example a study done by Lo, McMahon et al. (2015) with melodic contour
training, showed an effect on speech perception. A small effect has been shown
of both training methods in CI users on consonant identification and prosody
identification but no effect on sentences in babble. Fuller, Galvin III et al.
(2018) have showed a small cross-domain transfer on emotion identification with
music training.

In this study however, we will make use of another approach for music training,
namely improvisation. Research into the effects that improvisation and playing
*by ear* has a greater effect on the auditory cortex (Woody 2010, Vuust,
Brattico et al. 2012, Bianco, Novembre et al. 2018). Activation of the auditory
cortex while listening to both familiar and unfamiliar music is significantly
larger in improvising musicians than in score-dependent musicians (Harris and
de Jong 2015). The existence of a dedicated dorsal pathway (Milner 2006),
facilitating sensorimotor integration, implies that larger activation of the
auditory cortex in improvising musicians might be due to top-down effects of
enhanced audiomotor integration on conscious aural perception. While these
benefits might derive from any type of music training, the observed difference
between score-dependent and improvising musicians suggests that the type of
training might be critical.

In this study, we will investigate whether GAME musical training can provide
additional benefits to CI users. The project is designed to provide scientific
evidence for a music training program that will be aimed at to also be fun and
engaging for the end user, as the pilot results indicated. If this aim is
achieved, the ultimate long-term goal is to systematically create a musical
training program for CI users, designed to improve auditory perception, improve
working memory, and/or quality of life (QoL). Any benefit that can be provided
to current and future CI users will lead to an improvement in overall
satisfaction and happiness of this patient population..

The design will be a randomized controlled trial in three groups. The target
CI-user group will receive GAME music training. Second group will receive a
non-musical training (typing course). The third group, our control group, will
get no training. The training effects in each group will be explored by
comparing results over the duration of the study, and the potential benefits
from music training will be explored by comparing results between groups. These
evaluations will be for auditory perception, cognitive functioning, and will
also include self-reported/questionnaires of other domains, such as QoL, social
integration, mood. Overall feasibility will be analysed for applicability.
For the GAME music training, we will recruit certified piano teachers who are
motivated to teach playing the piano to CI users. The places of residence of CI
users will in many cases be distant from Groningen, and the recruitment of
piano teachers will be from around the country based on where the participants
live. The number of teachers recruited will be based on such factors, but for
practical purposes, we will aim to recruit piano teachers located near the
centers with the largest number of MED-EL CI recipients. The instructors will
be trained to use the GAME method, and coached for the duration of the
intervention. Individual tutors will document their teaching and the progress
of their pupils.
The CI users will be recruited from MED-EL CI users within Netherlands. Once
they meet the inclusion criteria, they will be randomly assigned to one of the
three training groups. To prevent any potential biases or priming, we will be
careful with wording in advertisements. In each group, we will start with half
of the participants first, and after a checkpoint after 2 months, refine the
procedure if necessary, and continue with the other half of the participants.

The GAME music training group will receive a 45 min. piano lesson once a week
for six months. In addition, these participants will be expected to practice
playing the piano several times during the week. When participants do not have
a piano themselves, they will either arrange a practice situation, for example
at the local music school or at the house of someone they know, or rent a
piano. If none of those options works out, we will facilitate the acquisition
or loan of an instrument. This will be discussed and determined during
enrollment. There will be two other training groups. Group 2 will be provided
with a training intervention that is motivating and rewarding, involves some
motor activity, in a manner similar to keyboard use, but will have no musical
aspect. The comparison of benefits from GAME music training group to this group
will show what benefits come specifically from involving music in training.
Group 3 will receive no active training, but will receive training from
repeated tests with feedback provided. Comparison of the GAME music training or
non-music training groups to this group will show what benefits come from
active training with instructions vs. passive repeated testing only, i.e.,
procedural learning.
To address ethical concerns about the non-musical training groups not
benefiting from music training due to random assignments, the participants in
both these groups will also be given the option for music training upon
completion of the study, which will however be of shorter duration than the
study training (2 months vs 6 months). This option will be provided only at the
end of the study to prevent any form of priming or bias over the results during
the study.

Testing will take place four times in the course of the study (see Figure 1).
We have recently developed a test battery, PICKA (Perception of Indexical Cues
in Kids and Adults) , that combines tests from similar studies from our lab
(e.g., (Fuller, Galvin et al. 2014, Ba*kent and Gaudrain 2016). These tests
include speech perception, vocal emotion identification, voice perception
(F0/VTL/gender). We also have tests for melody contour identification and can
implement simple tests of cognitive functioning/working memory. We will keep
testing sessions under 3 hours, with occasional breaks as necessary.
Additionally, questionnaires will be used to assess subjective benefits.
Participants living nearby will come to UMCG, where testing will take place in
an anechoic room or soundproof booth at the Department of Otorhinolaryngology.
When participants live too far from the hospital, we will visit them with a
portable test system (laptop and a portable speaker), either testing them at
home or at a location in their neighborhood where we are able to find a room
that is as silent as possible, a quiet office for example.

GAME therapy.

In the experiment there are no known risks or benefits associated in the
participation. In total the tests will lasts two to three hours. After every
test the participant will get a break for about 15 min or longer if necessary.