Evidence reviews for the clinical and cost-effectiveness of music therapy for adults after a stroke

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Evidence reviews for the clinical and cost-effectiveness of music therapy for adults after a stroke

Stroke rehabilitation in adults (update)

Evidence review N

NICE Guideline, No. 236

London: National Institute for Health and Care Excellence (NICE); 2023 Oct.

ISBN-13: 978-1-4731-5463-6

1. Music therapy

1.1. Review question

In people after stroke, what is the clinical and cost effectiveness of music therapy to improve mood and activities of daily living?

1.1.1. Introduction

Music activates a wide range of regions within the brain including networks involved in speech, motor function and cognition. Music therapy aims to facilitate recovery mechanisms in the brain to enhance rehabilitation and overall improvements.

Usually trained music therapists deliver it with an individual or in a group. Music is used in a number of different ways; for example listening to music, actively participating in music or writing and composing music.

1.1.2. Summary of the protocol

Table 1

PICO characteristics of review question.

For full details see the review protocol in Appendix A.

1.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in Appendix A and the methods document.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

Twenty one randomised controlled trials (twenty three papers) were included in the review;^{2–7, 9–12, 15–27} these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3).

The studies included the following comparisons:

Neurologic music therapy delivered by trained music therapists compared to no treatment ^{17, 26}
Music therapy delivered by trained music therapists compared to no treatment^{3, 4, 9, 10, 15, 16, 19}
Music intervention delivered by healthcare professionals compared to passive music listening²
Music intervention delivered by healthcare professionals compared to placebo music therapy²
Music intervention delivered by healthcare professionals compared to no treatment^{5–7, 11, 12, 18, 22–25, 27}
Music intervention delivered by non-healthcare professionals compared to no treatment^{20, 21}

While comparisons were available for each intervention category compared to no treatment, there was limited or no evidence comparing therapies to:

Each other
Passive music listening
Placebo music therapy

See also the study selection flow chart in Appendix C, study evidence tables in Appendix D, forest plots in Appendix E and GRADE tables in Appendix F.

1.1.4.1.1. Types of intervention

The types of interventions delivered in the studies varied. They included:

Rhythmic auditory cueing^{3, 6, 7, 12, 22, 23, 25}
Interventions where musical instruments are played (including clinical improvisation)^{4, 5, 10, 16, 19}
Receptive interventions in which participants listen to music^{2, 11, 17, 27}
Singing a music-based voice interventions^{20, 26}
Sonofication¹⁸
Combinations of the above^{9, 15}

Where heterogeneity was present there was an insufficient number of studies in each group representing different types of intervention, and so the heterogeneity was not resolved by subgroup analysis by these groups.

1.1.4.2. Excluded studies

One Cochrane review was identified that included relevant information for this review, Magee 2017¹³. This review was excluded as it included people with conditions other than stroke (including any acquired brain injury). While the review was excluded, the references were checked for studies relevant for this review.

A significant number of studies were excluded as they did not report outcomes relevant to the protocol, the majority of these reporting outcomes relevant to individual impairments (for example: motor function, communication). These outcomes were considered of a lower priority than functional outcomes (for example: activities of daily living) and were considered through other outcomes (for example: health-related quality of life).

See the excluded studies list in Appendix J.

1.1.5. Summary of studies included in the effectiveness evidence

1.1.5.1. Neurologic music therapy delivered by trained music therapists

Table 2

Summary of studies included in the evidence review.

1.1.5.2. Music therapy delivered by trained music therapists

Table 3

Summary of studies included in the evidence review.

1.1.5.3. Music interventions delivered by healthcare professionals

Table 4

Summary of studies included in the evidence review.

1.1.5.4. Music interventions delivered by non-healthcare professionals

Table 5

Summary of studies included in the evidence review.

1.1.5.5. Summary matrix

Table 6

Summary matrix of the protocol interventions compared to no treatment.

See Appendix D for full evidence tables.

1.1.6. Summary of the effectiveness evidence

1.1.6.1. Neurologic music therapy delivered by trained music therapists compared to no treatment

Table 7

Clinical evidence summary: neurologic music therapy delivered by trained music therapists compared to no treatment.

1.1.6.2. Music therapy delivered by trained music therapists compared to no treatment

Table 8

Clinical evidence summary: music therapy delivered by trained music therapists compared to no treatment.

1.1.6.3. Music interventions delivered by healthcare professionals compared to passive music listening

Table 9

Clinical evidence summary: music intervention delivered by healthcare professionals compared to passive music listening.

1.1.6.4. Music interventions delivered by healthcare professionals compared to placebo music therapy

Table 10

Clinical evidence summary: music intervention delivered by healthcare professionals compared to placebo music therapy.

1.1.6.5. Music interventions delivered by healthcare professionals compared to no treatment

Table 11

Clinical evidence summary: music intervention delivered by healthcare professionals compared to no treatment.

1.1.6.6. Music interventions delivered by non-healthcare professionals compared to no treatment

Table 12

Clinical evidence summary: music interventions delivered by non-healthcare professionals compared to no treatment.

See Appendix F for full GRADE tables.

1.1.7. Economic evidence

1.1.7.1. Included studies

One health economic study was included in this review.²⁰ This related to a music intervention delivered by non-healthcare professionals. This is summarised in the health economic evidence profile below (Table 13) and the health economic evidence table in Appendix H.

No health economic studies were included that related to neurologic music therapy delivered by trained music therapists, music therapy delivered by trained music therapists or music interventions delivered by healthcare professionals.

1.1.7.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G.

1.1.8. Summary of included economic evidence

Table 13

Health economic evidence profile: music interventions delivered by non-healthcare professionals compared to no treatment.

1.1.9. Economic model

This area was not prioritised for new cost-effectiveness analysis.

1.1.10. Unit costs

Music therapy and music interventions require additional resource use compared to not providing such interventions related to staff time and equipment. Studies included in the clinical review reported varied resource use (see Table 1 for details) due to:

Variation in the delivery of therapy sessions: studies based on music therapists delivering therapy reported both individual and group-based sessions, while all but one of the studies⁷ that delivered therapy using health care professionals (HCPs) reported sessions on an individual basis. Group therapy will be lower cost per person.
Significant variation in the frequency and duration of music therapy delivered, with sessions ranging from 20–90 minutes for 1–5 days per week. In the included clinical studies music therapy was generally delivered for between 5 and 10 weeks.
Additional equipment required as part of the intervention, such as instruments (particularly keyboards, percussion/melodic instruments), metronomes, digital audio interface programs, iPod Nanos, music tapes and mindfulness audio materials.
Clinical setting, as most studies were conducted in either an inpatient setting or as part of outpatient follow-up rehabilitation care in hospital. Jeong 2007⁷ and Tarrant (2018,²¹ 2021²⁰) were the only two studies that were conducted in a community setting. Baylan 2020¹ provided materials for participants to carry out sessions in their own time.
Music interventions delivered by non-healthcare professionals may be funded by the NHS.

Relevant unit costs are provided below to aid consideration of cost effectiveness.

Table 14

Unit costs of health care professionals who may be involved in delivering music therapy interventions.

Music therapists can complete additional specialist training to become ‘neurologically trained’ and thus provide neurologic music therapy (NMT). The committee advised that this training typically consists of a short course and people would typically still be employed at band 6 or 7. Health care professionals that delivered music interventions in the included clinical studies were either a physiotherapist or an occupational therapist. One study¹⁰ also provided counselling by a licensed psychotherapist for both trial arms, while another had therapy materials delivered by an assistant psychologist¹ however, such staff types were not mentioned in any of the other studies.

1.1.11. Evidence statements

Effectiveness/Qualitative

Economic

One cost-utility analysis found that a singing group intervention for people with aphasia was cost-effective compared to usual care (£7,980 per QALY gained). This study was assessed as partially applicable with potentially serious limitations.

1.1.12. The committee’s discussion and interpretation of the evidence

1.1.12.1. The outcomes that matter most

The committee included the following outcomes: person/participant and carer generic health-related quality of life, activities of daily living, psychological distress, stroke-specific Patient-Reported Outcome Measures, wellbeing scores, participation in leisure activities/social group scores and withdrawal due to adverse events. All outcomes were considered equally important for decision making and therefore have all been rated as critical. The committee noted that music therapy may have benefits in other outcomes, such as physical function, communication and cognition. The committee considered that the outcomes included (namely health-related quality of life, activities of daily living and stroke-specific Patient-Reported Outcome Measures) would also encompass any such benefits. The committee considered wellbeing scores and participation in leisure activities/social groups score as important to capture the holistic benefits that could be experienced by people participating in music interventions. The committee chose to investigate these outcomes at less than 6 months and more than and equal to 6 months, as they considered that there could be a difference in the short-term and long-term effects of the intervention.

All outcomes were reported in at least 1 study but were not given in others. The limited evidence produced an element of uncertainty, and the committee agreed that there was insufficient evidence to make a recommendation.

1.1.12.2. The quality of the evidence

Twenty one randomised controlled trials were included in the review. Evidence was available for the following comparisons:

Neurologic music therapy delivered by trained music therapists compared to no treatment (2 studies)
Music therapy delivered by trained music therapists compared to no treatment (7 studies)
Music intervention delivered by healthcare professionals compared to passive music listening (1 study)
Music intervention delivered by healthcare professionals compared to placebo music therapy (1 study)
Music intervention delivered by healthcare professionals compared to no treatment (11 studies)
Music intervention delivered by non-healthcare professionals compared to no treatment (1 study)

There was limited evidence comparing any intervention to comparators other than no treatment (including comparisons to other music interventions, passive music listening and placebo music therapy).

The evidence varied from moderate to very low quality, with the majority being of very low quality. Outcomes were commonly downgraded for risk of bias and imprecision. Risk of bias was commonly due to selection, performance, attrition and measurement bias. A significant number of studies had different baseline values for outcomes between the intervention and comparator study groups. The majority of studies had very small sample sizes, which contributed to the imprecision in the outcomes. In most cases, it was not possible to conduct a meta-analysis on outcomes as there was limited outcome data reported by the studies that was comparable enough to be meta-analysed. Where meta-analysis was possible, outcomes often had heterogenous results within studies where there was an insufficient number of studies to form valid subgroups. In these cases, outcomes were downgraded for inconsistency. Indirect evidence was uncommon, although 1 study reported a population that may have included people who did not have a stroke and so was downgraded for population indirectness.

The type of music therapy or music intervention varied between studies. This included rhythmic auditory cueing; interventions where music instruments are played (including clinical improvisation); receptive interventions in which participants listen to music; singing and music-based voice interventions; sonofication; and combinations of these interventions. the above. For the most part, these interventions were offered as a part of music therapy or as music interventions delivered by non-music therapists. However, the majority of studies reporting rhythmic auditory cueing were delivered by physiotherapists or occupational therapists rather than music therapists.

The no-treatment comparison varied. This included scenarios where no additional therapy was offered to participants who did not receive music interventions, but also included studies where usual care was offered to both study arms (which could include physiotherapy, occupational therapy, speech therapy and psychological support) and therefore the only difference in care was the music intervention.

The committee concluded that the evidence was of low quality. They acknowledged the effects that the heterogenous baseline values and small sample sizes had on the quality rating and took this into consideration while interpreting the evidence. They noted the potential bias introduced by the baseline values between intervention and control arms made it difficult to interpret the evidence. Consequentially, they found it difficult to interpret the effectiveness of music therapy and music interventions based on the evidence currently available.

1.1.12.3. Benefits and harms

1.1.12.3.1. Neurologic music therapy delivered by trained music therapists

The results showed that, when compared to no treatment, there were clinically important benefits in some subscales for person/participant generic health-related quality of life (namely SF-36 vitality and mental health) and psychological distress – depression at less than 6 months, but otherwise no clinically important difference in other subscales for health-related quality of life, psychological distress - anxiety and in stroke-specific Patient-Reported Outcome Measures at less than 6 months.

These outcomes were reported in 2 small studies with the outcomes being of low to very low quality. With this, the committee acknowledged that the evidence in this area was limited and insufficient to make a recommendation for neurologic music therapy. However, they noted the possible benefits in the intervention and made a research recommendation with the aim to gain more high-quality evidence. This should involve a large number of participants and where there were comparisons to active interventions that provide an equal intensity of therapy to those received from a music intervention, and placebo music therapy.

1.1.12.3.2. Music therapy delivered by trained music therapists

The results showed that, when compared to no treatment, there was a clinically important benefit in participation in leisure activities/social groups (based on 1 very small study with 18 participants). There were inconsistent effects seen in activities of daily living and stroke-specific Patient-Reported Outcome Measures with some outcomes showing clinically important benefits, others showing no clinically important difference and others showing clinically important harms. No clinically important difference was seen in person/participant generic health-related quality of life, psychological distress and withdrawal due to adverse events. No outcomes were reported at more than and equal to 6 months.

The evidence came from several small studies (the largest number of participants included in an outcome was 84) with the majority being of very low quality. With this, the committee acknowledged that the evidence in this area was limited. While there were more studies reporting music therapy than neurologic music therapy, the studies reported a range of different outcome measures in small trials that were probably not powered to show reliable changes in outcomes. Studies included intervention and control arms where the baseline values of outcomes were different at the start of the trial, making interpretation difficult. These trials were conducted comparing music therapy to no treatment (or usual care provided in both study arms), with no trials comparing music therapy to an intervention with equal contact with a professional to help show whether it is the music intervention that provides benefit or the interaction with the healthcare professional. These trials were less than 6 months duration with no long-term evidence being available. Based on this, the committee decided that the evidence was insufficient to make a recommendation for music therapy. However, they noted the possible benefits in the intervention and made a research recommendation with the aim to gain more high-quality research. This should involve a large number of participants and include comparisons to active interventions that provide an equal intensity of therapy to those received from a music intervention, or to placebo music therapy.

1.1.12.3.3. Music interventions delivered by healthcare professionals

Evidence was available comparing music interventions delivered by healthcare professionals to passive music listening, placebo music therapy and no treatment. All the outcomes comparing to passive music listening and placebo music therapy were reported in 1 study. When compared to passive music listening, there was a clinically important increase in withdrawal due to adverse events in those receiving a music intervention delivered by healthcare professionals at less than and more than and equal to 6 months (observed in one small study). This was also seen when compared to placebo music therapy. Otherwise, no clinically important difference was seen between music interventions delivered by healthcare professionals and placebo music therapy in psychological distress at less than and more than and equal to 6 months and participation in leisure activities/social group scores at less than 6 months only.

When compared to no treatment, clinically important benefits were seen in some subscales of person/participant health-related quality of life (namely SF-36 physical function, bodily pain, vitality, general health, role emotional, mental health and social function) while other measures showed no clinically important difference (McGill Quality of life) and other subscales showed clinically important harms (SF-36 role physical). Otherwise clinically important benefits were seen in activities of daily living and psychological distress (depression scores). No clinically important difference was seen in psychological distress (positive affect score), stroke-specific Patient-Reported Outcome Measures and withdrawal due to adverse events. Outcomes were only reported at less than 6 months for this comparison. The outcomes were reported in a range of different studies, with some outcomes including a larger number of participants while others had a very small number. However, the majority of evidence was of very low quality.

With this taken into account, committee acknowledged that the evidence in this area was limited. While there were more studies reporting music interventions delivered by healthcare professionals than other interventions, the studies reported a range of different outcome measures in small trials that were likely not sufficiently powered to show reliable changes in outcomes. Studies included intervention and control arms where the baseline values of outcomes were different at the start of the trial, making interpretation difficult. While there was 1 trial comparing music interventions to placebo music therapy and music listening, this was limited evidence and most comparisons studied the effect compared to no treatment (or usual care provided to both study arms). These trials were mostly performed at less than 6 months with limited long-term evidence being available. The committee noted that clinically important harms were seen in some outcomes (in particular, withdrawal due to adverse events). However, they acknowledged that due to the small sample sizes the effect on dichotomous outcomes may be overemphasised and that trials with a larger number of participants were critical for understanding this further. Based on this, the committee decided that the evidence was insufficient to make a recommendation for music interventions delivered by healthcare professionals. However, they noted the possible benefits in the intervention and made a research recommendation with the aim to gain more high-quality research. This should involve a large number of participants and include comparisons to active interventions that provide an equal intensity of therapy to those received from a music intervention, or to placebo music therapy.

1.1.12.3.4. Music interventions delivered by non-healthcare professionals

The results showed that, when compared to no treatment, there are clinically important benefits in person/participant generic health-related quality of life at more than and equal to 6 months. There were no clinically important differences in stroke-specific Patient-Reported Outcome Measures, wellbeing scores and participation in leisure activities/social group scores at less than and more than and equal to 6 months, and carer generic health-related quality of life at more than and equal to 6 months only. There were clinically important harms in person/participant health-related quality of life at less than 6 months and withdrawal due to adverse events at less than 6 months. These outcomes were reported in 1 small study (with ≤41 participants) with the majority of outcomes being very low quality. Taking this into account, the committee agreed that the evidence was limited.

On examining the effect on person/participant generic health-related quality of life, the committee thought that the small study size considered that it could be possible that people with stroke may feel apprehensive at the start of the trial and may not engage more with the singing group until later on, which may have an effect on their initial quality of life results. However, the committee acknowledged the wide confidence intervals showing very serious imprecision in the outcomes, which affected their confidence in the results. Due to the limitations in the evidence, the committee decided not to recommend music interventions delivered by non-healthcare professionals. However, they noted the possible benefits in the intervention and made a research recommendation with the aim to gain more high-quality research. This should involve a large number of participants and include comparisons to active interventions that provide an equal intensity of therapy to those received from a music intervention, or to placebo music therapy.

1.1.12.4. Cost effectiveness and resource use

No health economic studies were included that related to either music therapy (including neurologic music therapy) delivered by trained music therapists or music interventions delivered by healthcare professionals.

The review identified one health economic analysis that compared a music intervention (singing for people with aphasia (SPA)) delivered by non-healthcare professionals to no treatment. This was a within-trial cost-utility analysis of a pilot feasibility RCT which was included in the clinical review. The intervention lasted 10 weeks and involved 1.5-hour group sessions once a week which were led by a music facilitator and assisted by an individual with post-stroke aphasia. The trial was designed to assess feasibility of a trial to assess effectiveness and cost effectiveness and so had a small sample size (n=41) and was not powered to test the effectiveness of the SPA intervention.

Only intervention costs were considered. It was not stated that an NHS and PSS perspective was taken, however, the costs included are all considered relevant if the intervention is funded by the NHS. A micro-costing approach was adopted to estimate the intervention costs associated with SPA, taken from trial notes on staffing, purchases of equipment and venue costs charged by the sites. The authors then costed the staff at equivalent grades to the NHS PSSRU to show the costs that would be borne to the NHS if it were to provide these. The results found that the average cost of the intervention per participant was £399 including training costs, based on 2019-unit costs. Data on other healthcare resource use was collected but not included in cost calculations; other healthcare resource used was numerically higher with the intervention although the authors note the study was not powered to detect differences (as 1 of the objectives of the pilot study was to assess feasibility of collection).

A negative effect (-0.04) on quality of life (EQ-5D-5L) was found for participants at 3 months compared to the control group, and an improvement was found (0.10) at 6 months. Treatment effects beyond 6 months were not assessed. No change in carer quality of life (CarerQoL 7-D) was reported. Cost per QALY not reported but was estimated for this review to be £7,980 per QALY gained using 6-month EQ-5D-5L scores collected within the study and assuming no difference in mortality. This suggests that the intervention was cost-effective, however, there is uncertainty around these results as the confidence intervals for the quality-of-life follow-up estimates span across positive and negative values. As such, the committee were cautious in interpreting the results.

The study was assessed as partially applicable as mean EQ-5D-5L scores (UK tariff) at 6-months were used to calculate the cost per QALY gained for this review when the NICE reference case currently prefers EQ-5D-3L. Potentially serious limitations were noted for this study due to the small sample size and the fact that it was not powered to test the effectiveness of the music intervention or confirm differences in healthcare resource use between the groups, uncertainty around whether all relevant costs have been included, and uncertainty about long term treatment effects. Sensitivity analyses were also not performed. The committee felt that the study population (adults with post-stroke aphasia) was too specific to reflect the entire stroke population. Previous committee discussions noted that music therapy could potentially be useful to a broad range of people post-stroke but acknowledged that in practice it may be people with a higher level of disability it is used for.

In addition to this study, relevant unit costs were presented to the committee to aid consideration of cost effectiveness of neurologic or standard music therapy delivered by trained music therapists and music interventions delivered by healthcare professionals. Music therapy and interventions require additional resource use related to staff time and equipment. Studies included in the clinical review reported varied resource use, owing to a few factors such as the delivery of therapy sessions (either individual and group-based); the frequency and duration of music therapy delivered (with sessions ranging from 20 to 90 minutes for 1 to 5 days per week for between 5 and 10 weeks); additional equipment (for example, instruments) required as part of the intervention; clinical setting (most reported an inpatient setting or hospital-based outpatient follow-up) and interventions delivered by non-healthcare professionals. The heterogeneity of the interventions reported in the clinical evidence made it challenging for the committee to confidently assess the resource impact of providing these interventions nationwide. Staff costs, however, were found to be similar for healthcare professionals who may be involved in delivering music therapy or interventions. Although neurologic music therapists complete additional specialist training to become ‘neurologically trained’, the committee advised that this training typically consists of a short course and people would typically still be employed at band 6 or 7. Healthcare professionals who delivered music interventions in the included clinical studies were either a physiotherapist or an occupational therapist also be employed at band 6 or 7. One study (Kim, 2011) also provided counselling by a licensed psychotherapist for both trial arms, while another had therapy materials delivered by an assistant psychologist (Baylan, 2020), however, such staff roles were not mentioned in any other studies. The committee noted that music interventions delivered by the rehabilitation team and non-music therapists are used in current practice, but that music therapy delivered by music therapists and neurologic music therapy are not widely available in the NHS.

The committee discussed the clinical and economic evidence and, based on the limitations described in the clinical evidence section and the uncertainty in the economic evidence, were not able to make recommendations about which music interventions may be appropriate for people following a stroke. A research recommendation has been made.

1.1.12.5. Other factors the committee took into account

The committee acknowledged that benefits may be seen in outcomes specific to impairments that were not included in the protocol (for example: physical function, communication, cognition). A Cochrane review¹³ investigating music therapy for people with acquired brain injury had identified additional evidence showing benefit for these outcomes. When designing the protocol, the committee prioritised functional outcomes over impairment-based outcomes which meant that those were not identified. The committee considered that there could be additional benefits during their deliberation.

The committee highlighted that additional therapies may be present that incorporate sound and could therefore be beneficial for people after stroke (for example: sound therapy). While this was not investigated during this guideline update, this was highlighted as a potential area that could be beneficial for people to consider.

Members of the committee also spoke about their own personal experiences of music therapy, stating it significantly improved both their quality of life and that of their family members. They highlighted this as an important area that required consideration in the future. The committee believe that future studies which are larger and more rigorous than those currently available, should be conducted in this area so that a complete understanding of the intervention can be obtained.

It was noted that music therapy interventions may be delivered outside of NHS services by third sector organisations, such as charities (either as outsourcing of services by the NHS or outside of formal care). The involvement of third sector organisations was emphasised by the committee as important for the delivery of interventions in this area.

1.1.13. Recommendations supported by this evidence review

This evidence review supports the research recommendation on music therapy in Appendix K. No recommendations were made for this review.

1.1.14. References

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25.: Whitall J, Waller SM, Sorkin JD, Forrester LW, Macko RF, Hanley DF et al Bilateral and unilateral arm training improve motor function through differing neuroplastic mechanisms: a single-blinded randomized controlled trial. Neurorehabilitation and Neural Repair. 2011; 25(2):118–129 [PMC free article: PMC3548606] [PubMed: 20930212]
26.: Zhang X, Li J, Du Y. Melodic Intonation Therapy on Non-fluent Aphasia After Stroke: A Systematic Review and Analysis on Clinical Trials. Frontiers in Neuroscience. 2021; 15:753356 [PMC free article: PMC8829877] [PubMed: 35153655]
27.: Zhao L, Lyu X, Jiang H, Gao X. Musicokinetic and exercise therapies decrease the depression level of elderly patients undergoing post-stroke rehabilitation: The moderating effect of health regulatory focus. Frontiers in Psychology. 2022; 13:889510 [PMC free article: PMC9421369] [PubMed: 36046420]

Appendices

Appendix A. Review protocols

Review protocol for the clinical and cost-effectiveness of music therapy after a stroke (PDF, 299K)

Appendix B. Literature search strategies

B.1. Clinical search literature search strategy

Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies as these concepts may not be indexed or described in the title or abstract and are therefore difficult to retrieve. Search filters were applied to the search where appropriate.

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B.2. Health Economics literature search strategy

Health economic evidence was identified by conducting searches using terms for a broad Stroke Rehabilitation population. The following databases were searched: NHS Economic Evaluation Database (NHS EED - this ceased to be updated after 31^st March 2015), Health Technology Assessment database (HTA - this ceased to be updated from 31^st March 2018) and The International Network of Agencies for Health Technology Assessment (INAHTA). Searches for recent evidence were run on Medline and Embase from 2014 onwards for health economics, and all years for quality-of-life studies. Additional searches were run in CINAHL and PsycInfo looking for health economic evidence.

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Appendix C. Effectiveness evidence study selection

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Appendix D. Effectiveness evidence

Baylan, 2020 (PDF, 285K)

Cha, 2014 (PDF, 246K)

Fujioka, 2018 (PDF, 256K)

Grau-Sanchez, 2018 (PDF, 322K)

Hill, 2011 (PDF, 231K)

Jeong, 2007 (PDF, 234K)

Jun, 2013 (PDF, 241K)

Kim, 2011 (PDF, 241K)

Lin, 2017 (PDF, 230K)

Luft, 2004 (PDF, 231K)

Nayak, 2000 (PDF, 272K)

Palumbo, 2022 (PDF, 313K)

Pocwierz-Marciniak, 2017 (PDF, 293K)

Raglio, 2021 (PDF, 237K)

Raglio, 2017 (PDF, 249K)

Tarrant, 2018 (PDF, 196K)

Tarrant, 2021 (PDF, 325K)

Tian, 2020 (PDF, 293K)

van Delden, 2009 (PDF, 203K)

van Delden, 2013 (PDF, 263K)

Whitall, 2011 (PDF, 244K)

Zhang, 2021 (PDF, 282K)

Zhao, 2022 (PDF, 267K)

Appendix E. Forest plots

E.1. Neurologic music therapy delivered by trained music therapists compared to no treatment

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E.2. Music therapy delivered by trained music therapists compared to no treatment

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E.3. Music intervention delivered by healthcare professionals compared to passive music listening

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E.4. Music intervention delivered by healthcare professionals compared to placebo music therapy

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E.5. Music intervention delivered by healthcare professionals compared to no treatment

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E.6. Music intervention delivered by non-healthcare professionals compared to no treatment

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Appendix F. GRADE tables

F.1. Neurologic music therapy delivered by trained music therapists compared to no treatment

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F.2. Music therapy delivered by trained music therapists compared to no treatment

Download PDF (255K)

F.3. Music interventions delivered by healthcare professionals compared to passive music

Download PDF (180K)

F.4. Music interventions delivered by healthcare professionals compared to placebo music therapy

Download PDF (207K)

F.5. Music interventions delivered by healthcare professionals compared to no treatment

Download PDF (270K)

F.6. Music interventions delivered by non-healthcare professionals compared to no treatment

Download PDF (216K)

Appendix G. Economic evidence study selection

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Appendix H. Economic evidence tables

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Appendix I. Health economic model

New cost-effectiveness analysis was not conducted in this area.

Appendix J. Excluded studies

Clinical studies

Table 24Studies excluded from the clinical review

Study	Code [Reason]
Acalha T., Mg, Suzuki S. O. et al (2010) Effects of the task oriented and auditory cues for chronic stroke patients. Revista terapia manual 8(39): 441–447	- Full text paper not available
Ala-Ruona E. (2009) Active music therapy for post-stroke recovery.	- Full text paper not available
Altenmuller E., Marco-Pallares J., Munte T. F. et al (2009) Neural reorganization underlies improvement in stroke-induced motor dysfunction by music-supported therapy. Annals of the New York Academy of Sciences 1169: 395–405 [PubMed: 19673814]	- Study reported outcomes that were not included in the protocol
Anonymous (2008) Music in stroke rehabilitation. Lancet 371(9614): 698 [PubMed: 18313483]	- Commentary only
Aravantinou-Fatorou K. and Fotakopoulos G. (2021) Efficacy of exercise rehabilitation program accompanied by experiential music for recovery of aphasia in single cerebrovascular accidents: a randomized controlled trial. Irish Journal of Medical Science 190(2): 771–778 [PubMed: 32740716]	- Data not reported in an extractable format or a format that can be analysed
Aravantinou-Fatorou K. and Fotakopoulos G. (2021) Efficacy of exercise rehabilitation program accompanied by experiential music for recovery of aphasia in single cerebrovascular accidents: a randomized controlled trial. Irish Journal of Medical Science 190(2): 771–778 [PubMed: 32740716]	- Study not reported in English
Bamiou D. E. (2016) Auditory rehabilitation in stroke patients with auditory processing disorders. [PubMed: 27008578]	- Full text paper not available
Barnes C. L., Smith M. B., Harriet E. et al (2006) A pilot study of bilateral arm training with repetitive auditory cueing in subjects with low functioning upper limb hemiparesis as a result of chronic stroke. Journal of neurologic physical therapy 4: 221	- Conference abstract
Baylan S., Quinn T., Cullen B. et al (2016) The effects of music listening on mood and cognition post-stroke. International journal of stroke 11(suppl4): 29	- Study not reported in English
Baylan S., Swann-Price R., Peryer G. et al (2016) The effects of music listening interventions on cognition and mood poststroke: a systematic review. Expert Review of Neurotherapeutics 16(11): 1241–1249 [PubMed: 27548875]	- Systematic review used as source of primary studies
Bittman B., Poornima I., Smith M. A. et al (2020) Gospel Music: A Catalyst for Retention, Engagement, and Positive Health Outcomes for African Americans in a Cardiovascular Prevention and Treatment Program. Advances in Mind-Body Medicine 34(1): 8–16 [PubMed: 32277749]	- Population not relevant to this review protocol
Blythe LaGasse A. and Knight A. (2011) Rhythm and music in rehabilitation: A critical review of current research. Critical Reviews in Physical and Rehabilitation Medicine 23(14): 49–67	- Review article but not a systematic review
Breitenfeld T., Jergovi K., Vargek Solter V. et al (2005) Music therapy in aphatic stroke patients - a pilot study. European journal of neurology 12(suppl2): 55p1060 [PubMed: 15613148]	- Conference abstract
Breitenfeld T., Vargek Solter V., Breitenfeld D. et al (2005) Is there a benefit for aphasic stroke patients treated with music therapy? preliminary results. Cerebrovascular diseases (basel, switzerland) 19 (Suppl 2): 92–93	- Full text paper not available
Bunketorp Kall L., Lundgren-Nilsson A., Blomstrand C. et al (2012) The effects of a rhythm and music-based therapy program and therapeutic riding in late recovery phase following stroke: a study protocol for a three-armed randomized controlled trial. BMC Neurology 12: 141 [PMC free article: PMC3554429] [PubMed: 23171380]	- Study reported outcomes that were not included in the protocol
Bunketorp-Kall L., Lundgren-Nilsson A., Nilsson M. et al (2018) Multimodal rehabilitation in the late phase after stroke enhances the life situation of informal caregivers. Topics in Stroke Rehabilitation 25(3): 161–167 [PubMed: 29237339]	- Study reported outcomes that were not included in the protocol
Bunketorp-Kall L., Lundgren-Nilsson A., Samuelsson H. et al (2017) Long-Term Improvements After Multimodal Rehabilitation in Late Phase After Stroke: A Randomized Controlled Trial. Stroke 48(7): 1916–1924 [PubMed: 28619985]	- Study reported outcomes that were not included in the protocol
Bunketorp-Kall L., Pekna M., Pekny M. et al (2019) Effects of horse-riding therapy and rhythm and music-based therapy on functional mobility in late phase after stroke. Neurorehabilitation 45(4): 483–492 [PMC free article: PMC7029334] [PubMed: 31868694]	- Study reported outcomes that were not included in the protocol
Cha Y. J., Kim J. D., Choi Y. R. et al (2018) Effects of gait training with auditory feedback on walking and balancing ability in adults after hemiplegic stroke: a preliminary, randomized, controlled study. International Journal of Rehabilitation Research 41(3): 239–243 [PubMed: 29782407]	- Study reported outcomes that were not included in the protocol
Cha Y.; Kim Y.; Chung Y. (2014) Immediate effects of rhythmic auditory stimulation with tempo changes on gait in stroke patients. Journal of physical therapy science 26: 479–482 [PMC free article: PMC3996403] [PubMed: 24764615]	- Study reported outcomes that were not included in the protocol
Chen F. J., Li L., Sun J. L. et al (2015) The research into the functions of TCM five elements music therapy on anxious with anxiety due to stroke. Henan traditional chinese medicine [he nan zhong yi] 35(6): 1279–1280	- Study not reported in English
Choi W.; Lee G.; Lee S. (2015) Effect of the cognitive-motor dual-task using auditory cue on balance of surviviors with chronic stroke: a pilot study. Clinical Rehabilitation 29(8): 763–70 [PubMed: 25394396]	- Study reported outcomes that were not included in the protocol
Chouhan S. and Kumar S. (2012) Comparing the effects of rhythmic auditory cueing and visual cueing in acute hemiparetic stroke. International journal of therapy and rehabilitation 19(6): 344–351	- Study reported outcomes that were not included in the protocol
Chouhan S., Kumar S., Walker S. et al (2012) Comparative study of the effects of rhythmic auditory cueing and visual cueing in acute hemiparetic stroke. International journal of therapy & rehabilitation 19(5): 1–8	- Duplicate reference
Cofrancesco E. M. (1985) The effect of music therapy on hand grasp strength and functional task performance in stroke patients. Journal of music therapy 22(3): 129–145	- Study design not relevant to this review protocol
Conklyn D., Novak E., Boissy A. et al (2012) The effects of modified melodic intonation therapy on nonfluent aphasia: a pilot study. Journal of Speech Language & Hearing Research 55(5): 1463–71 [PubMed: 22411278]	- Study reported outcomes that were not included in the protocol
Copland D. and Roxbury T. (2019) To examine whether daily music listening in addition to usual care will result in superior aphasia recovery compared to usual care only, as measured by standard clinical language and communication assessments at 2–4 weeks, 3 months and 6 months post stroke-onset.	- Study not reported in English
Crosby LD, Wong JS, Chen JL et al (2020) An Initial Investigation of the Responsiveness of Temporal Gait Asymmetry to Rhythmic Auditory Stimulation and the Relationship to Rhythm Ability Following Stroke. Frontiers in neurology 11 [PMC free article: PMC7573161] [PubMed: 33123067]	- Study design not relevant to this review protocol Single arm trial
Dispa D.; Lejeune T.; Thonnard J. L. (2013) The effect of repetitive rhythmic precision grip task-oriented rehabilitation in chronic stroke patients: a pilot study. International Journal of Rehabilitation Research 36(1): 81–7 [PubMed: 23377231]	- Comparator in study does not match that specified in this review protocol
Do A. (2016) To determine the therapeutic effect of the music glove and conventional hand exercises to subacute stroke patients.	- Full text paper not available
Douglass-Kirk Pedro, Grierson Mick, Ward Nick S et al (2022) Real-time auditory feedback may reduce abnormal movements in patients with chronic stroke. Disability and rehabilitation: 1–7 [PubMed: 35238694]	- Study reported outcomes that were not included in the protocol - Study does not contain an intervention relevant to this review protocol Intervention lasted for 1 session only
Elsner B. (2018) Auditory stimulation for improving mobility after stroke.	- Full text paper not available
Elsner B., Scholer A., Kon T. et al (2020) Walking with rhythmic auditory stimulation in chronic patients after stroke: A pilot randomized controlled trial. Physiotherapy Research International 25(1): e1800 [PubMed: 31237045]	- Study reported outcomes that were not included in the protocol
Fachner J. C. (2014) Music Therapy for The Rehabilitation of Upper Limb With Stroke Patients (TIMPStro).	- Full text paper not available
Ford M.; Wagenaar R.; Newell K. (2007) The effects of auditory rhythms and instruction on walking patterns in individuals post stroke. Gait & posture 26: 150–155 [PubMed: 16996270]	- Study design not relevant to this review protocol
Fotakopoulos G. and Kotlia P. (2018) The Value of Exercise Rehabilitation Program Accompanied by Experiential Music for Recovery of Cognitive and Motor Skills in Stroke Patients. Journal of Stroke & Cerebrovascular Diseases 27(11): 2932–2939 [PubMed: 30072173]	- Data not reported in an extractable format or a format that can be analysed Reports outcomes for all groups combined
Fouad M. A. (2016) Effect of rhythmic auditory stimulation on gait in patients with stroke. International journal of medical and health sciences 3(6)	- Conference abstract
Friedman N., Chan V., Reinkensmeyer A. N. et al (2014) Retraining and assessing hand movement after stroke using the MusicGlove: comparison with conventional hand therapy and isometric grip training. Journal of Neuroengineering & Rehabilitation 11: 76 [PMC free article: PMC4022276] [PubMed: 24885076]	- Study reported outcomes that were not included in the protocol
Garcia-Casares Natalia; Barros-Cano Amanda; Garcia-Arnes Juan A (2022) Melodic Intonation Therapy in Post-Stroke Non-Fluent Aphasia and Its Effects on Brain Plasticity. Journal of clinical medicine 11(12) [PMC free article: PMC9225206] [PubMed: 35743571]	- Systematic review used as source of primary studies
Ghai S. (2018) Effects of Real-Time (Sonification) and Rhythmic Auditory Stimuli on Recovering Arm Function Post Stroke: A Systematic Review and Meta-Analysis. Frontiers in neurology [electronic resource]. 9: 488 [PMC free article: PMC6053522] [PubMed: 30057563]	- Systematic review used as source of primary studies
Ghai S. and Ghai I. (2019) Effects of (music-based) rhythmic auditory cueing training on gait and posture post-stroke: A systematic review & dose-response meta-analysis. Scientific Reports 9(1): 2183 [PMC free article: PMC6379377] [PubMed: 30778101]	- Systematic review used as source of primary studies
Goh M. (2001) The role of music therapy in the rehabilitation of people who have had strokes, specifically focusing on depression. National research register. Issue 1	- Full text paper not available
Grau-Sanchez J., Segura E., Sanchez-Pinsach D. et al (2021) Enriched Music-supported Therapy for chronic stroke patients: a study protocol of a randomised controlled trial. BMC Neurology 21(1): 19 [PMC free article: PMC7801568] [PubMed: 33435919]	- Protocol only
Haire C. (2017) Therapeutic instrumental music performance with sensory-enhanced motor imagery in chronic post-stroke rehabilitation.	- Comparator in study does not match that specified in this review protocol
Haire Catherine M, Tremblay Luc, Vuong Veronica et al (2021) Therapeutic Instrumental Music Training and Motor Imagery in Post-Stroke Upper-Extremity Rehabilitation: A Randomized-Controlled Pilot Study. Archives of rehabilitation research and clinical translation 3(4): 100162 [PMC free article: PMC8683865] [PubMed: 34977544]	- Comparator in study does not match that specified in this review protocol Compares therapeutic instrumental music training with the same intervention with motor imagery in addition (with and without metronome cueing) therefore comparing different types of music therapy, which is not a comparison listed in the protocol.
Hankinson Katherine, Shaykevich Alex, Vallence Ann-Maree et al (2022) A Tailored Music-Motor Therapy and Real-Time Biofeedback Mobile Phone App ('GotRhythm') to Promote Rehabilitation Following Stroke: A Pilot Study. Neuroscience insights 17: 26331055221100587 [PMC free article: PMC9125048] [PubMed: 35615116]	- Data not reported in an extractable format or a format that can be analysed Outcomes reported as median and interquartile range values
Haro-Martinez A. M., Lubrini G., Madero-Jarabo R. et al (2019) Melodic intonation therapy in post-stroke nonfluent aphasia: a randomized pilot trial. Clinical Rehabilitation 33(1): 44–53 [PubMed: 30056747]	- Study reported outcomes that were not included in the protocol
Haro-Martinez Ana, Perez-Araujo Carmen M, Sanchez-Caro Juan M et al (2021) Melodic Intonation Therapy for Post-stroke Non-fluent Aphasia: Systematic Review and Meta-Analysis. Frontiers in neurology 12: 700115 [PMC free article: PMC8371046] [PubMed: 34421802]	- Systematic review used as source of primary studies
Hewitt L. and Sanctuary C. (2015) Stroke sounds: music listening in stroke rehabilitation. International journal of stroke 10(suppl3): 64	- Conference abstract
Huang Wen-Hao, Dou Zu-Lin, Jin Hui-Min et al (2021) The Effectiveness of Music Therapy on Hand Function in Patients With Stroke: A Systematic Review of Randomized Controlled Trials. Frontiers in neurology 12: 641023 [PMC free article: PMC8185294] [PubMed: 34113305]	- Systematic review used as source of primary studies
Jarvinen-Lepisto P.; Burger B.; Ala-Ruona E. (2014) Motor performance in post-stroke recovery using active music therapy. 13th international conference for music perception and cognition / 5th conference of asia-pacific society	- Crossover trial (unit of randomisation = participant)
Jia C., Zhang H., Ni G. et al (2017) Spasmodic hemiplegia after stroke treated with scalp acupuncture, music therapy and rehabilitation: a randomized controlled trial. Zhongguo zhen jiu [Chinese acupuncture & moxibustion] 37(12): 1271–1275 [PubMed: 29354990]	- Study not reported in English
Jiang Y., Yang Y., Xiang R. et al (2015) Clinical study of post-stroke speech apraxia treated with scalp electric acupuncture under anatomic orientation and rehabilitation training. Zhongguo zhen jiu [Chinese acupuncture & moxibustion] 35(7): 661–664 [PubMed: 26521575]	- Study not reported in English
John S.; Khanna G. L.; Kotwal P. (2010) Effect of music therapy and meditation along with conventional physiotherapy management in sub-acute stroke patients. British journal of sports medicine 44(suppl1): i14	- Conference abstract
Kang T. W. (2015) Robot-assisted walking training for patients with subacute stroke: randomized controlled pilot trial of rhythmic arm swing versus arm fixation during training. [PubMed: 29140826]	- Full text paper not available
Kang T. W., Oh D. W., Lee J. H. et al (2018) Effects of integrating rhythmic arm swing into robot-assisted walking in patients with subacute stroke: a randomized controlled pilot study. International Journal of Rehabilitation Research 41(1): 57–62 [PubMed: 29140826]	- Study does not contain an intervention relevant to this review protocol Rhythmic arm swing without a music component built into the intervention
Keller I. and Lefin-Rank G. (2010) Improvement of visual search after audiovisual exploration training in hemianopic patients. Neurorehabilitation and Neural Repair 24(7): 666–673 [PubMed: 20810740]	- Study does not contain an intervention relevant to this review protocol
Kim J. H., Park S. G., Lim H. J. et al (2012) Effects of the combination of rhythmic auditory stimulation and task-oriented training on functional recovery of subacute stroke patients. Journal of physical therapy science 24(12): 1307–1313	- Study reported outcomes that were not included in the protocol
Kim J. S. and Oh D. W. (2012) Home-based auditory stimulation training for gait rehabilitation of chronic stroke patients. Journal of physical therapy science 24: 775–777	- Study reported outcomes that were not included in the protocol
Kiper P. (2017) Proprioceptive Stimulation With Manual Bilateral Rhythmic Exercise in Poststroke Patients (BAT).	- Full text paper not available
Klinke M. E., Hafsteinsdottir T. B., Hjaltason H. et al (2015) Ward-based interventions for patients with hemispatial neglect in stroke rehabilitation: a systematic literature review. International Journal of Nursing Studies 52(8): 1375–403 [PubMed: 25920700]	- Study does not contain an intervention relevant to this review protocol
Kumari N. (2017) Effects of rhythmic auditory cueing along with task oriented activities on upper limb functions in stroke patients.	- Full text paper not available
Le Danseur M., Crow A. D., Stutzman S. E. et al (2019) Music as a Therapy to Alleviate Anxiety During Inpatient Rehabilitation for Stroke. Rehabilitation Nursing Journal 44(1): 29–34 [PubMed: 30601431]	- Comparator in study does not match that specified in this review protocol
Lee S. H.; Lee K. J.; Song C. H. (2012) Effects of rhythmic auditory stimulation (RAS) on gait ability and symmetry after stroke. Journal of physical therapy science 24(4): 311–314	- Study design not relevant to this review protocol
Lee S.; Lee K.; Song C. (2018) Gait Training with Bilateral Rhythmic Auditory Stimulation in Stroke Patients: A Randomized Controlled Trial. Brain Sciences 8(9): 31 [PMC free article: PMC6162464] [PubMed: 30200282]	- Study reported outcomes that were not included in the protocol
Lin S. I. (2007) Effect of rhythmic auditory cues on gait of stroke patients. Cerebrovascular diseases (basel, switzerland) 23(suppl2): 128	- Full text paper not available
Magee Wl, Clark I, Tamplin J et al (2017) Music interventions for acquired brain injury. Cochrane Database of Systematic Reviews [PMC free article: PMC6464962] [PubMed: 28103638]	- Population not relevant to this review protocol
Mainka S., Wissel J., Voller H. et al (2018) The Use of Rhythmic Auditory Stimulation to Optimize Treadmill Training for Stroke Patients: A Randomized Controlled Trial. Frontiers in neurology [electronic resource]. 9: 755 [PMC free article: PMC6149244] [PubMed: 30271375]	- Study reported outcomes that were not included in the protocol
McCombe Waller S.; Liu W.; Whitall J. (2008) Temporal and spatial control following bilateral versus unilateral training. Human Movement Science 27(5): 749–58 [PubMed: 18639360]	- Study reported outcomes that were not included in the protocol
McCue P., Del Din S., Hunter H. et al (2020) Auditory rhythmical cueing to improve gait and physical activity in community-dwelling stroke survivors (ACTIVATE): study protocol for a pilot randomised controlled trial. Pilot & Feasibility Studies 6: 68 [PMC free article: PMC7236874] [PubMed: 32467770]	- Protocol only
McIntosh G. C., Rice R. R., Prassas S. G. et al (1993) Rhythmic auditory-motor entrainment as gait rehabilitation technique with stroke patients. International congress on stroke rehabilitation: 43	- Duplicate reference
McIntosh G. C., Thaut M. H., Rice R. R. et al (1993) Auditory rhythmic cuing in gait rehabilitation with stroke patients. Canadian journal of neurological sciences 20(suppl4): 168	- Full text paper not available
Moon S. Y. (2008) The effects of piano-playing music therapy on motor coordination of stroke patients using midi-based computer analysis. Neurorehabilitation and neural repair 22(5): 593	- Full text paper not available
Moumdjian L., Sarkamo T., Leone C. et al (2017) Effectiveness of music-based interventions on motricity or cognitive functioning in neurological populations: a systematic review. European journal of physical & rehabilitation medicine. 53(3): 466–482 [PubMed: 27879960]	- Population not relevant to this review protocol
Nikmaram N., Scholz D. S., Grosbach M. et al (2019) Musical Sonification of Arm Movements in Stroke Rehabilitation Yields Limited Benefits. Frontiers in Neuroscience 13: 1378 [PMC free article: PMC6933006] [PubMed: 31920526]	- Data not reported in an extractable format or a format that can be analysed
Oiga L. (2014) The effect of music and rhythmic auditory stimulation on upper motor strength rehabilitation of hemiparetic stroke patients in a tertiary hospital: a randomized controlled study. International journal of stroke 9suppl3: 237	- Conference abstract
Olson D. M., Perera A., Atem F. et al (2019) Music in mechanically ventilated stroke patients. British journal of neuroscience nursing 15: 8	- Comparator in study does not match that specified in this review protocol
Park I. M., Oh D. W., Kim S. Y. et al (2010) Clinical feasibility of integrating fast-tempo auditory stimulation with self-adopted walking training for improving walking function in poststroke patients: a randomized, controlled pilot trial. Journal of physical therapy science 22: 295–300	- Study reported outcomes that were not included in the protocol
Park M. O. and Lee S. H. (2018) Effects of cognitive-motor dual-task training combined with auditory motor synchronization training on cognitive functioning in individuals with chronic stroke: A pilot randomized controlled trial. Medicine 97(22): e10910 [PMC free article: PMC6392809] [PubMed: 29851819]	- Study reported outcomes that were not included in the protocol
Prassas S. G., Thaut M. H., McIntosh G. C. et al (1997) Effect of auditory rhythmic cuing on gait kinematic parameters in hemiparetic stroke patients. Gait & posture 6: 218–223	- Study design not relevant to this review protocol
Purdie H.; Hamilton S.; Baldwin S. (1997) Music therapy: facilitating behavioural and psychological change in people with stroke--a pilot study. International Journal of Rehabilitation Research 20(3): 325–7 [PubMed: 9331582]	- Data not reported in an extractable format or a format that can be analysed Does not report the number of participants in each study arm and so unable to interpret results
Raglio A. (2017) Music therapy for rehabilitation in stroke patients (SONICHAND).	- Full text paper not available
Raglio A., Attardo L., Gontero G. et al (2015) Effects of music and music therapy on mood in neurological patients. World Journal of Psychiatry 5(1): 68–78 [PMC free article: PMC4369551] [PubMed: 25815256]	- Population not relevant to this review protocol
Raglio A., Oasi O., Gianotti M. et al (2016) Improvement of spontaneous language in stroke patients with chronic aphasia treated with music therapy: a randomized controlled trial. International Journal of Neuroscience 126(3): 235–42 [PubMed: 26000622]	- Data not reported in an extractable format or a format that can be analysed Reports median and interquartile range values for outcomes only
Reagon C., Gale N., Enright S. et al (2016) A mixed-method systematic review to investigate the effect of group singing on health related quality of life. Complementary Therapies in Medicine 27: 1–11 [PubMed: 27515869]	- Population not relevant to this review protocol
Renna L., Frkovic N., Spear M. et al (2012) Stroke sounds: music listening in stroke rehabilitation. International journal of stroke 7(suppl1): 58	- Conference abstract
Richards L. G., Senesac C. R., Davis S. B. et al (2008) Bilateral arm training with rhythmic auditory cueing in chronic stroke: not always efficacious. Neurorehabilitation and neural repair 22: 180–184 [PubMed: 17660456]	- Study design not relevant to this review protocol
Rodriguez-Fornells A. (2014) Music Therapy to Restore Motor Deficits After Stroke (NEUROMUSIC).	- Full text paper not available
Rosenberg K. (2017) Multimodal Interventions Improve Stroke Recovery. American Journal of Nursing 117(10): 61 [PubMed: 28957932]	- Commentary only
Sarkamo T. Leo T. Sihvonen A. Ripolles P. Rodrı and guez-Fornells A. Tervaniemi M. (2016) Cognitive, emotional and neural benefits of music on stroke recovery. European stroke journal 1(suppl1): 730–731	- Conference abstract
Sarkamo T., Pihko E., Laitinen S. et al (2010) Music and speech listening enhance the recovery of early sensory processing after stroke. Journal of Cognitive Neuroscience 22(12): 2716–27 [PubMed: 19925203]	- Data not reported in an extractable format or a format that can be analysed
Sarkamo T., Ripolles P., Vepsalainen H. et al (2014) Structural changes induced by daily music listening in the recovering brain after middle cerebral artery stroke: a voxel-based morphometry study. Frontiers in Human Neuroscience 8: 245 [PMC free article: PMC4029020] [PubMed: 24860466]	- Study reported outcomes that were not included in the protocol
Sarkamo T., Tervaniemi M., Laitinen S. et al (2008) Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain 131(pt3): 866–76 [PubMed: 18287122]	- Data not reported in an extractable format or a format that can be analysed Reports as graph data only
Schauer M. and Mauritz K. H. (2003) Musical motor feedback (MMF) in walking hemiparetic stroke patients: randomized trials of gait improvement. Clinical Rehabilitation 17(7): 713–22 [PubMed: 14606736]	- Study reported outcomes that were not included in the protocol
Schneider S., Schonle P. W., Altenmuller E. et al (2007) Using musical instruments to improve motor skill recovery following a stroke. Journal of Neurology 254(10): 1339–46 [PubMed: 17260171]	- Study reported outcomes that were not included in the protocol
Scholz D. S., Rohde S., Nikmaram N. et al (2016) Sonification of Arm Movements in Stroke Rehabilitation - A Novel Approach in Neurologic Music Therapy. Frontiers in neurology [electronic resource]. 7: 106 [PMC free article: PMC4928599] [PubMed: 27445970]	- Data not reported in an extractable format or a format that can be analysed
Shaw Lisa, McCue Patricia, Brown Philip et al (2022) Auditory rhythmical cueing to improve gait in community-dwelling stroke survivors (ACTIVATE): a pilot randomised controlled trial. Pilot and feasibility studies 8(1): 239 [PMC free article: PMC9652598] [PubMed: 36371213]	- Study reported outcomes that were not included in the protocol
Shen J., Shen X., Chang G. F. et al (1994) Effect of music electrotherapy on cerebral infarction. Chinese journal of physical therapy 17(3): 162–164	- Full text paper not available
Shen J., Shen X., Chang G. et al (1994) Effect of music electrotherapy treatment on cerebral infarction. Chinese journal of physical therapy 17(3): 162–164	- Full text paper not available
Shin J. and Chung Y. (2017) Influence of visual feedback and rhythmic auditory cue on walking of chronic stroke patient induced by treadmill walking in real-time basis. Neurorehabilitation 41(2): 445–452 [PubMed: 28946580]	- Study reported outcomes that were not included in the protocol
Shin Jin and Chung Yijung (2022) The effects of treadmill training with visual feedback and rhythmic auditory cue on gait and balance in chronic stroke patients: A randomized controlled trial. NeuroRehabilitation [PubMed: 35964207]	- Study reported outcomes that were not included in the protocol
Sihvonen A. J., Leo V., Ripolles P. et al (2020) Vocal music enhances memory and language recovery after stroke: pooled results from two RCTs. Annals of Clinical & Translational Neurology 7(11): 2272–2287 [PMC free article: PMC7664275] [PubMed: 33022148]	- Pooled analysis of a published and an unpublished trial with inappropriate methodoloay for this review
Silveira T. M. (2018) Examining the effect of FES+iPad-based music therapy on upper limb function and wellbeing outcomes for stroke survivors.	- Full text paper not available
Soinila S. (2012) Music Listening and Stroke Recovery (MUKU2).	- Full text paper not available
Stewart C., Subbarayan S., Paton P. et al (2019) Non-pharmacological interventions for the improvement of post-stroke quality of life amongst older stroke survivors: a systematic review of systematic reviews (The SENATOR ONTOP series). European Geriatric Medicine 10(3): 359–386 [PubMed: 34652796]	- Study design not relevant to this review protocol
Stinear J. W. and Byblow W. D. (2004) Rhythmic bilateral movement training modulates corticomotor excitability and enhances upper limb motricity poststroke: a pilot study. Journal of clinical neurophysiology 21(2): 124–131 [PubMed: 15284604]	- Study desian not relevant to this review protocol
Street A. J., Magee W. L., Bateman A. et al (2018) Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trial. Clinical Rehabilitation 32(1): 18–28 [PMC free article: PMC5751852] [PubMed: 28643570]	- Crossover trial (unit of randomisation = participant)
Street A. J., Magee W. L., Odell-Miller H. et al (2015) Home-based neurologic music therapy for upper limb rehabilitation with stroke patients at community rehabilitation stage-a feasibility study protocol. Frontiers in Human Neuroscience 9: 480 [PMC free article: PMC4585041] [PubMed: 26441586]	- Protocol only
Studebaker S. (2007) The effect of a music therapy protocol on the attentional abilities of stroke patients. Unpublished masters thesis. University of kansas	- Full text paper not available
Suh J. H., Han S. J., Jeon S. Y. et al (2014) Effect of rhythmic auditory stimulation on gait and balance in hemiplegic stroke patients. Neurorehabilitation 34(1): 193–9 [PubMed: 24284453]	- Study reported outcomes that were not included in the protocol
Sukumaran S., Sivadasan S., Sakunthala P. T. et al (2019) Effect of combined visual-auditory-sensory stimulation in hemineglect syndrome following right hemispheric ischemic strokes: a randomized control trial.	- Thesis paper - Study reported outcomes that were not included in the protocol
Syros Apostolis; Kotlia Polikceni; Fotakopoulos George (2022) Preliminary findings from an acupuncture and experiential/traditional music therapy during the standard care of rehabilitation exercise program for recovery on post-stroke upper limb dysfunction. The International journal of neuroscience 132(11): 1110–1117 [PubMed: 34143714]	- Data not reported in an extractable format or a format that can be analysed Does not report the mean and standard deviations for the relevant outcomes instead reporting alternative analyses that are not as relevant
Thaut M. H., Hoemberg B., Hurt C. P. et al (1998) Rhythmic entrainment of paretic arm movements in stroke patients. Proceedings of the society for neuroscience 24: 1663	- Full text paper not available
Thaut M. H., Hoemberg V., Hurt C. P. et al (1998) Rhythmic entrainment of hemiparetic arm movements in stroke patients. Society for neuroscience abstracts 24: 1663	- Full text paper not available
Thaut M. H., McIntosh C. G., Rice R. et al (1993) Effect of rhythmic cuing on temporal stride parameters and EMG patterns in hemiparetic gait of stroke patients. Journal of neurological rehabilitation 7: 9–16	- Study design not relevant to this review protocol
Thaut M. H.; McIntosh G. C.; Rice R. R. (1997) Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. Journal of the Neurological Sciences 151(2): 207–12 [PubMed: 9349677]	- Study reported outcomes that were not included in the protocol
Thaut M. H., McIntosh G. C., Rice R. R. et al (1995) Rhythmic auditory motor training in gait rehabilitation of stroke patients. Journal of stroke and cerebrovascular diseases 5(2): 100	- Full text paper not available
Tinga A. M., Visser-Meily J. M., van der Smagt M. J. et al (2016) Multisensory Stimulation to Improve Low- and Higher-Level Sensory Deficits after Stroke: A Systematic Review. Neuropsychology Review 26(1): 73–91 [PMC free article: PMC4762927] [PubMed: 26490254]	- Study does not contain an intervention relevant to this review protocol
Tong Y., Forreider B., Sun X. et al (2015) Music-supported therapy (MST) in improving post-stroke patients' upper-limb motor function: a randomised controlled pilot study. Neurological Research 37(5): 434–40 [PubMed: 25916420]	- Study reported outcomes that were not included in the protocol
Van Criekinge T., D'Aout K., O'Brien J. et al (2019) The Influence of Sound-Based Interventions on Motor Behavior After Stroke: A Systematic Review. Frontiers in neurology [electronic resource]. 10: 1141 [PMC free article: PMC6838207] [PubMed: 31736857]	- Systematic review used as source of primary studies
Van Der Meulen I., Van De Sandt-Koenderman M. W., Heijenbrok M. H. et al (2016) Melodic Intonation Therapy in Chronic Aphasia: Evidence from a Pilot Randomized Controlled Trial. Frontiers in Human Neuroscience 10: 533 [PMC free article: PMC5088197] [PubMed: 27847473]	- Study reported outcomes that were not included in the protocol
van der Meulen I., van de Sandt-Koenderman W. M., Heijenbrok-Kal M. H. et al (2014) The Efficacy and Timing of Melodic Intonation Therapy in Subacute Aphasia. Neurorehabilitation & Neural Repair 28(6): 536–44 [PubMed: 24449708]	- Study reported outcomes that were not included in the protocol
van Vugt F. T., Kafczyk T., Kuhn W. et al (2016) The role of auditory feedback in music-supported stroke rehabilitation: A single-blinded randomised controlled intervention. Restorative Neurology & Neuroscience 34(2): 297–311 [PubMed: 26923616]	- Comparator in study does not match that specified in this review protocol
Volpi J. J. (2018) Stroke recovery and music or no music.	- Study not reported in English
Wang Y., Pan W. Y., Li F. et al (2021) Effect of Rhythm of Music Therapy on Gait in Patients with Stroke. Journal of Stroke and Cerebrovascular Diseases 30 (3) [PubMed: 33341022]	- Study reported outcomes that were not included in the protocol
Wheeler B. L.; Shiflett S. C.; Nayak S. (2003) Effects of number of sessions and group or individual music therapy on the mood and behavior of people who have had strokes or traumatic brain injuries. Nordic journal of music therapy 12(2): 139–151	- Population not relevant to this review protocol Less than 80% of participants had a stroke
Whitall J., McCombe Waller S., Silver K. H. et al (2000) Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke; a journal of cerebral circulation 31(10): 2390–2395 [PubMed: 11022069]	- Study design not relevant to this review protocol
Whitall J., McCombe-Waller S., Gordes K. et al (1999) Locomotor training with and without rhythmic auditory stimulation in patients with chronic stroke. Neurology report 23(5): 190	- Conference abstract
Wright R. L., Brownless S. B., Pratt D. et al (2017) Stepping to the Beat: Feasibility and Potential Efficacy of a Home-Based Auditory-Cued Step Training Program in Chronic Stroke. Frontiers in neurology [electronic resource]. 8: 412 [PMC free article: PMC5572237] [PubMed: 28878730]	- Comparator in study does not match that specified in this review protocol
Yakupov E. Z., Nalbat A. V., Semenova M. V. et al (2019) Efficacy of music therapy in the rehabilitation of stroke patients. Neuroscience and behavioral physiology 49(1): 121–128	- Study reported outcomes that were not included in the protocol
Yakupov E. Z., Nalbat A. V., Semenova M. V. et al (2017) Music therapy as an effective method of neurorehabilitation. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova 117(5): 14–21 [PubMed: 28638025]	- Study not reported in English
Yoo G. E. and Kim S. J. (2016) Rhythmic Auditory Cueing in Motor Rehabilitation for Stroke Patients: Systematic Review and Meta-Analysis. Journal of Music Therapy 53(2): 149–77 [PubMed: 27084833]	- Systematic review used as source of primary studies
Yoon S. K. and Kang S. H. (2016) Effects of inclined treadmill walking training with rhythmic auditory stimulation on balance and gait in stroke patients. Journal of Physical Therapy Science 28(12): 3367–3370 [PMC free article: PMC5276762] [PubMed: 28174453]	- Study reported outcomes that were not included in the protocol
Young Hui-Ju, Mehta Tapan, Herman Cassandra et al (2021) The Effects of a Movement-to-Music (M2M) Intervention on Physical and Psychosocial Outcomes in People Poststroke: A Randomized Controlled Trial. Archives of rehabilitation research and clinical translation 3(4): 100160 [PMC free article: PMC8683867] [PubMed: 34977542]	- Study reported outcomes that were not included in the protocol
Zhang J. and Chen C. (2016) Effect of audio training on executive dysfunction in patients with stroke. Chinese journal of cerebrovascular diseases 13(7): 356–359	- Full text paper not available
Zhang Xiaoying; Li Jianjun; Du Yi (2021) Melodic Intonation Therapy on Non-fluent Aphasia After Stroke: A Systematic Review and Analysis on Clinical Trials. Frontiers in neuroscience 15: 753356 [PMC free article: PMC8829877] [PubMed: 35153655]	- Systematic review used as source of primary studies
Zhang Y., Cai J., Zhang Y. et al (2016) Improvement in Stroke-induced Motor Dysfunction by Music-supported Therapy: A Systematic Review and Meta-analysis. Scientific Reports 6: 38521 [PMC free article: PMC5137001] [PubMed: 27917945]	- Systematic review used as source of primary studies
Zhang Y.; Yao Y.; Lu X. (2015) Therapeutic effect of music therapy and speech language therapy on post-stroke patients with non-fluent aphasia. Chinese journal of neurology 48(4): 274–278	- Study not reported in English
Zondervan D. K., Friedman N., Chang E. et al (2016) Home-based hand rehabilitation after chronic stroke: Randomized, controlled single-blind trial comparing the MusicGlove with a conventional exercise program. Journal of Rehabilitation Research & Development 53(4): 457–72 [PubMed: 27532880]	- Study reported outcomes that were not included in the protocol

Health Economic studies

Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2006 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.

Table 25Studies excluded from the health economic review

Reference	Reason for exclusion
None

Appendix K. Research recommendations – full details

K.1. Research recommendation

What is the clinical and cost-effectiveness of music therapy for people after a first stroke or recurrent strokes?

K.1.1. Why this is important

Music therapy is an evidence based clinical intervention, delivered by trained music therapists with the aim to help people achieve their therapeutic goals. It is becoming increasingly used to help people after a stroke to support people’s emotional, cognitive, physical and communication needs. This review identified studies that in general reported positive outcomes of music interventions. However, the majority of the evidence was for music interventions not delivered by trained music therapists. Furthermore, the evidence base was limited due to small sample sizes and a lack of cost effectiveness data. Therefore, it was not possible to make a recommendation for use in the NHS at this time. High quality randomised controlled trials, with a larger number of participants that include cost effectiveness data and compare music therapy with a time matched appropriate comparator are needed. Research should also include outcomes important to people who have had a stroke such as stroke-specific Patient-reported Outcome Measures and activities of daily living to fully explore the possible benefits of this therapy. The committee highlighted that additional therapies may be present that incorporate sound and could therefore be beneficial for people after stroke (for example: sound therapy). While this was not investigated during this guideline update, this was highlighted as a potential area that could benefit from further investigation.

K.1.2. Rationale for research recommendation

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K.1.3. Modified PICO table

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Final version

Evidence reviews underpinning recommendations for research in the NICE guideline

These evidence reviews were developed by NICE

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Bookshelf ID: NBK601175PMID: 38442221

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Evidence reviews for the clinical and cost-effectiveness of music therapy for adults after a stroke: Stroke rehabilitation in adults (update): Evidence review N. London: National Institute for Health and Care Excellence (NICE); 2023 Oct. (NICE Guideline, No. 236.)
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Evidence reviews for the clinical and cost-effectiveness of music therapy for adults after a stroke

1. Music therapy

1.1. Review question

1.1.1. Introduction

1.1.2. Summary of the protocol

1.1.3. Methods and process

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

1.1.4.1.1. Types of intervention

1.1.4.2. Excluded studies

1.1.5. Summary of studies included in the effectiveness evidence

1.1.5.1. Neurologic music therapy delivered by trained music therapists

1.1.5.2. Music therapy delivered by trained music therapists

1.1.5.3. Music interventions delivered by healthcare professionals

1.1.5.4. Music interventions delivered by non-healthcare professionals

1.1.5.5. Summary matrix

1.1.6. Summary of the effectiveness evidence

1.1.6.1. Neurologic music therapy delivered by trained music therapists compared to no treatment

1.1.6.2. Music therapy delivered by trained music therapists compared to no treatment

1.1.6.3. Music interventions delivered by healthcare professionals compared to passive music listening

1.1.6.4. Music interventions delivered by healthcare professionals compared to placebo music therapy

1.1.6.5. Music interventions delivered by healthcare professionals compared to no treatment

1.1.6.6. Music interventions delivered by non-healthcare professionals compared to no treatment

1.1.7. Economic evidence

1.1.7.1. Included studies

1.1.7.2. Excluded studies

1.1.8. Summary of included economic evidence

1.1.9. Economic model

1.1.10. Unit costs

1.1.11. Evidence statements

Effectiveness/Qualitative

Economic

1.1.12. The committee’s discussion and interpretation of the evidence

1.1.12.1. The outcomes that matter most

1.1.12.2. The quality of the evidence

1.1.12.3. Benefits and harms

1.1.12.3.1. Neurologic music therapy delivered by trained music therapists

1.1.12.3.2. Music therapy delivered by trained music therapists

1.1.12.3.3. Music interventions delivered by healthcare professionals

1.1.12.3.4. Music interventions delivered by non-healthcare professionals

1.1.12.4. Cost effectiveness and resource use

1.1.12.5. Other factors the committee took into account

1.1.13. Recommendations supported by this evidence review

1.1.14. References

Appendices

Appendix A. Review protocols

Appendix B. Literature search strategies

B.1. Clinical search literature search strategy

B.2. Health Economics literature search strategy

Appendix C. Effectiveness evidence study selection

Appendix D. Effectiveness evidence

Appendix E. Forest plots

E.1. Neurologic music therapy delivered by trained music therapists compared to no treatment

E.2. Music therapy delivered by trained music therapists compared to no treatment

E.3. Music intervention delivered by healthcare professionals compared to passive music listening

E.4. Music intervention delivered by healthcare professionals compared to placebo music therapy

E.5. Music intervention delivered by healthcare professionals compared to no treatment

E.6. Music intervention delivered by non-healthcare professionals compared to no treatment

Appendix F. GRADE tables

F.1. Neurologic music therapy delivered by trained music therapists compared to no treatment

F.2. Music therapy delivered by trained music therapists compared to no treatment

F.3. Music interventions delivered by healthcare professionals compared to passive music

F.4. Music interventions delivered by healthcare professionals compared to placebo music therapy

F.5. Music interventions delivered by healthcare professionals compared to no treatment

F.6. Music interventions delivered by non-healthcare professionals compared to no treatment

Appendix G. Economic evidence study selection

Appendix H. Economic evidence tables

Appendix I. Health economic model

Appendix J. Excluded studies

Clinical studies

Table 24Studies excluded from the clinical review

Health Economic studies

Table 25Studies excluded from the health economic review

Appendix K. Research recommendations – full details

K.1. Research recommendation

K.1.1. Why this is important

K.1.2. Rationale for research recommendation

K.1.3. Modified PICO table

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