Should music therapy be used as an adjunctive non‑pharmacologic intervention for adult ischemic or hemorrhagic stroke survivors in any recovery phase who have motor weakness, gait disturbance, speech/language deficits, or mood changes, and what are the recommended treatment parameters?

Music Therapy for Stroke Rehabilitation

Music therapy should be used as an adjunctive intervention for stroke survivors, with specific applications: rhythmic auditory cueing for gait rehabilitation, receptive music therapy for mood disorders and verbal memory improvement, and consideration for cognitive enhancement—though treatment parameters and evidence quality vary by indication. 1

Evidence-Based Applications by Deficit Type

Motor Function and Gait Disturbances

Rhythmic auditory cueing (RAC) demonstrates the strongest evidence for gait rehabilitation. 1

• Synchronizing walking to rhythmic auditory cues produces short-term improvements in gait velocity and stride length in stroke patients, though the American Heart Association rates this as Class IIb (uncertain effectiveness) with Level B evidence. 1

• The mechanism involves audio-motor coupling where overground walking is synchronized to rhythmic music, improving temporal and spatial gait measures. 1

• A 2019 systematic review found positive effects on gait parameters and balance when focusing on high-to-moderate quality evidence, though most included studies had high risk of bias. 2

• Treatment parameters: RAC should be integrated with conventional rehabilitation during walking practice sessions, with rhythm matched to target cadence. 1

Important caveat: The American Heart Association explicitly states that "further high-quality studies are needed before recommendations for clinical practice can be made" for rhythmic auditory cueing. 1 This reflects the uncertain evidence quality despite promising results.

Speech and Language Deficits

Evidence for music therapy in aphasia rehabilitation is limited and mixed. 2

• Melodic intonation therapy lacks sufficient evidence to determine effectiveness for post-stroke aphasia, according to systematic review analysis. 2

• The 2016 AHA/ASA guidelines do not provide specific recommendations for music therapy in speech rehabilitation, focusing instead on traditional speech-language pathology interventions. 1

Cognitive Impairment and Memory

Music therapy may be reasonable specifically for improving verbal memory (Class IIb recommendation, Level C evidence). 1

• This represents a narrow, conditional recommendation—music therapy is suggested only for verbal memory enhancement, not global cognitive improvement. 1

• For broader cognitive rehabilitation, the guidelines prioritize cognitive training strategies, compensatory techniques, and exercise over music therapy. 1

• Virtual reality training receives similar uncertain recommendations (Class IIb, Level C) for verbal, visual, and spatial learning. 1

Mood Disorders and Depression

Receptive music therapy (listening to music) improves mood in stroke survivors based on moderate-quality evidence. 2

• A 2019 systematic review found positive effects on mood when analyzing high-to-moderate quality studies. 2

• However, the primary AHA/ASA guidelines for post-stroke depression prioritize SSRIs as first-line pharmacotherapy and cognitive behavioral therapy as first-line psychotherapy, with no specific mention of music therapy. 3

• Music therapy should be considered adjunctive to, not replacement for, evidence-based depression treatments (SSRIs, CBT, exercise programs of ≥4 weeks duration). 3

Recommended Treatment Parameters

Intensity and Duration

The guidelines do not specify standardized music therapy dosing, but context from rehabilitation intensity recommendations suggests: 1

• Music interventions should be integrated within the recommended ≥3 hours daily of multidisciplinary therapy, ≥5 days per week. 1

• For rhythmic auditory cueing specifically, sessions should occur during scheduled gait training periods as an adjunctive technique. 1

Implementation Approach

Music therapy works best when combined with conventional rehabilitation, not as standalone treatment. 1, 2

• For gait training: Integrate rhythmic auditory cues during overground walking practice within physical therapy sessions. 1

• For mood: Use receptive music listening as a complementary intervention alongside standard depression treatment. 2

• For verbal memory: Consider music therapy as one component of a comprehensive cognitive rehabilitation program. 1

Patient Selection

Music interventions may be most appropriate for: 2

• Patients with gait impairments who can participate in walking practice (for RAC). 1
• Patients with post-stroke depression as adjunctive mood support. 2
• Patients with verbal memory deficits seeking additional cognitive strategies. 1

Critical Limitations and Pitfalls

Evidence Quality Concerns

The majority of music therapy studies have high risk of bias and methodological shortcomings. 2

• Small sample sizes, lack of blinding, and inconsistent outcome measures plague the literature. 2

• The American Heart Association consistently rates music therapy recommendations as Class IIb (uncertain benefit) or Class III (experimental). 1

What NOT to Expect

Active music therapy (playing instruments) lacks sufficient evidence to recommend for stroke rehabilitation. 2

• Unlike receptive music therapy (listening), active participation in music-making has not demonstrated clear benefits in high-quality trials. 2

Music therapy does not replace core rehabilitation interventions. 1

• Intensive, repetitive, task-specific training remains the Class I (strongly recommended) intervention for motor recovery. 1
• Cognitive rehabilitation strategies and compensatory techniques are better established for memory deficits than music therapy. 1

Comparison to Other Adjunctive Therapies

Music therapy's evidence base is weaker than several alternatives: 1

• Exercise receives stronger recommendations (Class IIb, Level C) for cognitive improvement and is established for depression. 1
• Constraint-induced movement therapy, mirror therapy, and task-specific practice have more robust evidence for motor recovery. 4
• SSRIs and cognitive behavioral therapy are first-line treatments for post-stroke depression, not music therapy. 3

Practical Clinical Algorithm

For stroke patients with gait impairment:

1. Ensure intensive task-specific gait training is the foundation (Class I recommendation). 1
2. Consider adding rhythmic auditory cueing during walking practice sessions. 1
3. Match rhythm to target cadence; monitor for improvements in velocity and stride length. 1
4. Recognize this is adjunctive with uncertain long-term benefit. 1

For stroke patients with depression:

1. Screen with validated tools (PHQ-9, Hamilton Depression Rating Scale). 3
2. Initiate SSRI/SNRI and/or cognitive behavioral therapy as first-line treatment. 3
3. Consider receptive music listening as complementary mood support. 2
4. Add structured exercise program ≥4 weeks duration. 3

For stroke patients with verbal memory deficits:

1. Implement compensatory strategy training (visual imagery, semantic organization, external aids). 1
2. Consider music therapy as one adjunctive technique for verbal memory specifically. 1
3. Prioritize errorless learning and specific memory training frameworks. 1

For stroke patients with aphasia:

1. Refer to speech-language pathology for evidence-based aphasia therapy. 1
2. Do not rely on melodic intonation therapy as primary intervention given insufficient evidence. 2