Heliyon 10 (2024) e35564

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Heliyon
journal homepage: www.cell.com/heliyon

Review article

Therapeutic use of music in neurological disorders: A concise

narrative review
Medha Ramaswamy a , Johann Laji Philip a , Vijayan Priya a , Snigdha Priyadarshini a ,
Meenakshi Ramasamy a , G.C. Jeevitha b , Darin Mansor Mathkor c ,
Shafiul Haque c, d, e , Fatemeh Dabaghzadeh f , Pratik Bhattacharya g, ** ,
Faraz Ahmad a, *
a
Department of Biotechnology, School of Bio Sciences and Technology (SBST), Vellore Institute of Technology, Vellore, 632014, India
b
Department of Biosciences, School of Bio Sciences and Technology (SBST), Vellore Institute of Technology, Vellore, 632014, India
c
Research and Scientific Studies Unit, College of Nursing and Allied Health Sciences, Jazan University, Jazan, 45142, Saudi Arabia
d
Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Beirut, 1102 2801, Lebanon
e
Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
f
Department of Clinical Pharmacy, Faculty of Pharmacy, Kerman University of Medical Sciences, Kerman, Iran
g
School of Architecture, Vellore Institute of Technology, Vellore, 632014, India

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Music elicits multifactorial benefits in emotional, social, cognitive, and academic
Schizophrenia aspects of human life. Music is clinically proven to reduce stress and anxiety, and improve mood
ADHD and self-expression, particularly after traumatic events. Studies have also demonstrated that
Parkinson’s disease
music promotes parasympathetic autonomic systems, suppresses hyperactivation of stress re­
Dementia
sponses, and boosts immune functions. However, its ability to promote brain plasticity and sig­
Cognition
Circadian rhythm nalling are only beginning to be realized. Moreover, its employment as a therapy for the
treatment of specific aspects of other neurological disorders, including neurodevelopmental and
neurodegenerative conditions and their comorbidities, is fast becoming an interesting field of
research.
Objective: The aim of this review is to summarize some of the recent studies focused on evaluating
the applications of music therapy. For this purpose, we have focused on disorders encompassing
both temporal extremities of brain developmental stages, from developmental conditions of
autism and attention deficit hyperactivity disorder (ADHD), to ageing-related pathologies of
Parkinson’s disease and dementias.
Results: The findings of the reviewed studies indicate potent utilities of music-based interventions
in beneficially affecting multiple spheres of brain functions, such as sensorimotor, auditory,
communication/language, psychological/emotional, behavioural, sleep and memory and cogni­
tive attributes of patients diagnosed with diverse neuropathologies. Nevertheless, lack of

* Corresponding author. Department of Biotechnology, School of Bio Sciences and Technology (SBST), Vellore Institute of Technology, Vellore,
632014, India.
** Corresponding author. School of Architecture, Vellore Institute of Technology, Vellore, 632014, India.
E-mail addresses: [email protected] (M. Ramaswamy), [email protected] (J.L. Philip), [email protected] (V. Priya),
[email protected] (S. Priyadarshini), [email protected] (M. Ramasamy), [email protected] (G.C. Jeevitha), darin.mathkor@
gmail.com (D.M. Mathkor), [email protected] (S. Haque), [email protected] (F. Dabaghzadeh), [email protected]
(P. Bhattacharya), [email protected] (F. Ahmad).

https://doi.org/10.1016/j.heliyon.2024.e35564
Received 7 May 2024; Received in revised form 26 July 2024; Accepted 31 July 2024
Available online 8 August 2024
2405-8440/© 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
M. Ramaswamy et al. Heliyon 10 (2024) e35564

standardized protocols for music provision as well as absence of information regarding key as­
pects, such as cultural and musical orientations of subjects and therapists’/caregivers’ attitudes,
have hindered the complete realization of music’s therapeutic potential for neurological condi­
tions. Further, while some studies have undertaken assessments of core neurophysiological
mechanisms underlying music therapy, this information is largely lacking for most clinical
studies.

Table 1
Music-based interventions in different nuerological disorders and their pathophysiological effects.
INTERVENTION NEUROLOGICAL DISORDER/ OBSERVED EFFECT REFERENCE
ASSESSMENT GROUP

Rhythmical “functionally-oriented music therapy” Traumatic brain injury Improvements in executive functions and increases [75]
and “music-supported training”, including in the grey matter volumes of the right inferior
assisted music playing using instruments such frontal gyri, improvements in specific cognitive
as drums and piano processes and fine motor skills, beneficial
neuroplasticity changes in the recovering brain of
TBI patients
Long-term vocal musical expression (voice- and Right handed vocalists and pianists Strengthening of white matter networks related to [8]
piano-based) emotional regulation, voice control, sensory
perception and language
Rhythmic auditory stimulation (RAS) Traumatic brain injury Enhanced performance in Functional Gait [16]
Assessment (FGA), indicating beneficial alterations
in the spatio-temporal aspects of gait and reduced
risk of falls
Listening to different kinds of music (classical, Parkinson’s disease Genre-specific effects of music on spatio-temporal [18]
pop, rock, and heavy metal genres) via parameters of gait and trunk kinematics (e.g., music
wireless headphone belonging to classical genre diminished walking
speed and trunk tilting, while rock and heavy metal
enhanced pelvic movement)
Group instrumental music therapy Dementia-related cognitive Enhancement of social and behavioral attributes, [27]
impairment such as peer and staff interaction, communication
of emotions, daily-life activities, motivation, etc.
Musical tracks in English (rock, metal, electronic Psychological stress and anxiety English music tracks likely have comparatively [36]
and rap) and Urdu (patriotic, melodious, more effectiveness in decreasing stress level, and
qawali and ghazal) females show enhanced sensitivity of music to
reduce stress
Child-centric musical intervention involving Children (6–12 years) with autism Significant positive impacts on functional audition- [37]
instruments, songs and rhythmic cues spectrum disorder related brain connectivity, as well as parent-
reported social communication
Calm music (with and without lyrics), and Attention-deficit hyperactivity Improvements in attentive (reading, [41]
rhythmic music with lyrics disorder comprehension) abilities in ADHD, but not in
typically-developed pre-adolescents
Mozart’s piano sonata, K.488 and D major (12 h/ Sprague-Dawley rat pups exposed to Reversal of social and psychological dysfunction [46]
per day from post natal day 21–76) maternal separation-induced early induced by early life stress, resulting in significant
life psychological stress enhancements of social interactions, and reductions
in anxiety- and depression-like behavior, in
addition to enhanced mature dendritic spine
numbers in hippocampal CA1 neurons
Mozart’s piano sonata, K.488 at 65–75 dB (8 p. Juvenile Sprague-Dawley rats tested Attenuation of anxiety-like behavior, facilitation of [47]
m.–10 p.m./day for 3 weeks) for anxiety-like behavior post music fear extinction, and enhancement of BDNF levels
ecposure
Classical Indian music (stable/no variations, and Undergraduate medical students “Varying music” specifically decreased anxiety [48]
with incremental variations in tempo and scores, and stimulated switching of heightened to
octave) reduced mind wandering states
Mozart’s sonata K. 448 via a stereo system Schizophrenia Increased functional connectivity between [57]
pallidum and ventral hippocampus, and the
striatum-default mode network circuitry, reduction
in the negative schizophrenic symptoms
Emotional instrumental musical (sad/happy) Adults with autism spectrum Increased neural activity in dorsolateral prefrontal [70]
stimuli (excerpts of 12 s durations) disorder brain regions in response to happy vs. sad music in
ASD subjects, possibly indicating enhanced
cognitive processing and physiological arousal
Receptive (listening) and active music, 50 min Children and adolescents with Increased levels of serotonin, reduced levels of [72]
sessions, twice a week, for 3 months (a total of attention-deficit hyperactivity cortisol, in addition to improved psychological
24 sessions) disorder attributes of depression (as assessed by Children’s
Depression Inventory; CDI) and stress (as assessed
by Daily Hassles Questionnaire; DHQ)
Group music therapy sessions (50 min, twice Children (6–9 years) with autism Enhanced social skills (assessed by Social [76]
weekly, for 5 weeks) spectrum disorder Responsiveness Scale; SRS), improved joint
attention and eye gaze towards peers and other
people

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Conclusion: While this is not an exhaustive review of literature, we do hope that it serves as a
platform to promote future research for establishing music therapy as a relevant neurotherapeutic
strategy.

1. Introduction

In recent years, with the prevalence of detrimental life style changes and increased life expectancies, coupled with enhancements in
medical technologies, incidences of some of the most prevalent neurological conditions have been coming to forefront. These include
dysfunctions during the entire developmental spectrum, from neurodevelopmental pathologies, such as schizophrenia, autism and
attention deficit hyperactivity disorder (ADHD), to age-induced neuronal deficits encompassing Parkinson’s disease, dementia and
neuropsychological dysfunctions. Multiple research groups and organizations have directed their efforts in diagnosis and therapy of
these disorders. Music therapy has emerged as an interestingly non-pharmacological lifestyle intervention with potential multimodal
benefits for these neuropathologies (Table 1). The primary aim of this review is to critically analyse the relevances of music therapy in
the treatment of these specific disorders and their comorbidities, citing suitable examples from recently conducted research studies.
We first begin our discussion with the influences of music as a therapeutic intervention in stimulating brain plasticity and signalling.
Next we attempt to clarify the beneficial roles of music therapy in traumatic brain injuries (TBI). Lastly, we assess the abilities of music
therapy in providing specific, but multimodal enhancement of brain functions in neurodevelopmental and ageing-related pathologies
in a disease/condition specific manner.
According to the American Music Therapy Association (AMTA), music therapy is a validated health-related discipline that utilizes
music as an ameliorative regimen for addressing cognitive, social and psychological requirements. It involves employment of music for
the achievement of personalized goals, including attenuation of stress-, anxiety- and depression-like behaviours, and upliftment of

Fig. 1. Clement’s model of responses to musical stimuli. Clement’s model is depicted as a four step scheme, arranged in decreasing levels of
complexity. The first level is learned cognitive response and primal and isomorphic learned responses. The second level is circuit based approach.
The third and fourth levels comprise of mechanisms at sensory, and cellular and genetic levels, respectively.

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mood and self-expression. Indeed, the scope of music therapy is very wide, encompassing cognitive, academic, psychological, social
and communicative qualities of human life [1]. Additionally, music serves as a simple distraction from distressing events, such as
medical procedures. Moreover, music as a non-pharmacological agent has a long history of being used as a coping mechanism for
distress and aiding in the healing process after exposure to painful and/or traumatic events [2].
Music therapy is a multidisciplinary field and requires trained therapists for administering it. Although the positive psychological
effects of music therapy are well-founded, the precise underlying mechanisms remain largely obscure. In this regard, studies on rodents
indicate that specific musical stimuli lead to a shift toward stimulated parasympathetic autonomic activity, diminished endocrine
stress responses, and enhancement of immune functions [3]. A quadripartite model of responses to musical stimuli has been proposed
by Bernatzky et al., during their exploration of music therapy as pain mitigating strategy [4]. As depicted in Fig. 1, level 1a involves
triggering poignant emotions linked to specific memories, prompting event-associated actions. Level 1b deals with primordial re­
sponses to music, rooted in early heart rhythms and associated emotions. Cognitive activation of neural circuits is dealt under level 2,
while level 3 and 4 delves into stimulation of neural coherence and cellular and genetic aspects, respectively.
The study received an exemption from an Institutional Review Board/Ethics committee since no primary data were generated, and
it did not involve human participants.

2. Music and brain plasticity

Brain plasticity, also known as neuroplasticity, is the ability of neurons and other cells of the nervous system to alter its morpho-
functional characteristics in response to internal and/or external stimuli. Likewise, synaptic plasticity pertains to the capacity of the
nervous system to modify synapses, the major pathways of interneuronal communication. Synaptic plasticity plays crucial roles in
determining almost all aspects of higher-order brain functions, including learning and memory, execution and planning, and social and
emotional behaviours.
The relationship between music and brain plasticity has been extensively studied due to the multidimensional aspects of visual,
motor, and auditory cues. Favourable changes in the physiology of neurotransmitters (e.g., serotonin, dopamine, oxytocin, glutamate,

Fig. 2. Summarization of the brain region-specific effects of exposure to music. The diagram depicts region-specificity of therapeutic aspects of
music as an animation of the human brain. The different parts of cortices contribute to therapeutic effects at different levels; viz. Somatosensory,
visual, auditory, motor and mood. Hippocampus is involved in memory-related aspects, while cerebellum contributes to motor responses. Nucleus
accumbens and amygdala participate in emotional and behavioural aspects of music therapy.

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etc.) involved in social and emotional aspects of behaviour, and cognitive functions of attention, imagination and creativity can be
induced as a response to sensory perception of music [5]. Music also influences brain plasticity at multiple brain region levels (Fig. 2),
stimulating the neuronal connections between the association cortices, and aiding in the cognitive processes of multisensory
perception and responses against them [6]. Such music therapy-associated brain plasticity is also observed in volume increases in the
grey matter of multiple sub-regions of cerebral cortices of clinical cases of traumatic brain injury (TBI, section 3) upon exposure to
music-based therapeutic interventions, which have been proposed to be responsible for the significant improvements in the executive,
attention, and imaginative aspects of cognition in these subjects [7]. Lastly, white matter neuroplasticity has been proposed as another
substrate of music-based interventions. Such plastic changes in critical brain regions such as amygdala and motor cortices, may un­
derlie music’s beneficial effects on sensory processing and feedback, communication and emotional health in an experience-dependent
manner [8]. Refinement of white matter neuroplasticity in right dorsal, corpus callosum, thalamic and corticostriatal pathways may
underlie music’s beneficial effects on executive functions in TBI subjects [9].
Music perception is associated with numerous beneficial effects on sensorimotor, cognitive and emotional processing. Individuals
may associate “good” music with “musical chills”, which are characterized by stimulation of the responses of the autonomic nervous
system, often associated with enhanced heart rate, and decreased temperature and blood volume pulse [10]. Such musical chills are
associated with dopaminergic reward response regions of the hypothalamus and amygdala, activation of which signifies intense
emotions and pleasure [11]. Some of the molecular and cellular players implicated in music therapy’s positive impacts on brain
plasticity are outlined in Fig. 3. Additionally, readers are directed to a recent review by Chatterjee and colleagues [12], which
comprehensively details the multimodal effects of music interventions on brain plasticity and rewiring with regards to diverse
neuronal systems, including memory and cognition, emotional, behavioural and reward pathways, and sensorimotor, auditory, and
language networks.

3. Traumatic brain injury (TBI)

TBI occurs when there is damage to the brain due to a sudden, mechanical assault. Pathophysiology of TBI is characterized by
primary and secondary phases of vascular, axonal and neuronal degeneration, and may be associated with adverse effects on the
individual’s physical, mental, emotional, and cognitive health. As one of the more recent therapies for TBI, music has shown to have
promising effects. Music therapy in TBI is linked to evocation of brain activity and reformation and/or restoration of damaged resting
state networks [13]. Cognitive attributes, such as executive functions of TBI subjects have also been elicited to be significantly
improved via music-based interventions. In particular, rhythmic music is associated with increase in neuroplasticity and grey matter
volumes [13]. Beneficial effects of neuronal plasticity mechanisms have been proposed as pathways for music therapy-based stimu­
lation of sensorimotor, emotional and cognitive functioning of TBI subjects [14]. Particularly, deficits in attention and memory do­
mains of cognition have been reported to be robustly attenuated by neurologic music therapy regimens [15]. Music therapy has also

Fig. 3. Proposed neurobiological mechanisms underlying music therapy. The figure shows a flowchart of mechanisms underlying neurotherapeutic
aspects of music. Limbic system and prefrontal cortices relay the information to sub-regions of basal ganglia, nucleus accumbens, hippocampus,
hypothalamus and VTA. This information is converted to molecular responses in form of enhanced dopamine and oxytocin signalling, resulted in
stimulation of neurotrophic factors (BNDF and NGF), which finally cause enhancement in neuronal connections and their strengths.

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been linked to significant improvements in motor deficits following TBIs and spinal cord injuries (SCIs). Thompson and co-workers
reported that rhythmic music-induced improvements in multiple spatio-temporal attributes of gait, including speed, symmetry and
cadence [16]. A systematic analysis of primary research indicated that music-based interventions had positive impacts on gait and gait
speed in clinical subjects of CNS injuries [17]. While rhythmic music may be associated with increased activation and stimulation of
auditory-motor networks, more studies are warrantied to reaffirm these aspects of music therapy.

4. Ageing-related neuropathologies: Parkinson’s disease and dementia

Parkinson’s disease is a degenerative condition characterized by progressive loss of dopaminergic neurons in the motor-associated
brain regions, culminating into severe movement dysfunctions, particularly those related to repetitive automatic muscle functions
[18]. Musical stimuli have been proposed as therapeutic interventions in alleviating Parkinson’s disease-associated symptoms of motor
imbalance, discoordination, rigidity, and slowness [19]. Indeed, a recent systematic review of literature affirmed the effectiveness of
music therapy in inducing improvements of motor functions, cognition, communication, mental health status and spatio-temporal
reasoning in clinical subjects diagnosed with Parkinson’s disease [20].
With regard to motor functions, singing has been observed to stimulate gait and overall motor performance in both Parkinson’s
disease cases and aged adults [20]. However, it should be noted that rhythmic music, in complementation with dancing, is heavily
dependent on the severity of the disease and individual differences [21]. Interestingly, Boni and Cattaneo have reported that exposure
to music-based therapeutic regimen developed by Helvetic Music Institute in Parkinson’s disease and dementia patients resulted in
significant improvements in fine and gross motor skills, emotional and memory and cognitive attributes, as well as enhanced quality of
life [22]. Communication deficits are another key aspect of Parkinson’s disease. In this regard, intervention-based music has beneficial
effects on speech-related neural networks and pathways. Indeed, ‘ParkinSong’ as a musical intervention has been elicited to improve
speech and communication in human subjects with Parkinson’s disease [23]. Interestingly, group singing and writing sessions for PD
subjects and their spouses has been proposed to as a tremendous strategy for emotional upliftment and stimulation of couple re­
lationships [24]. Along similar lines, Hayes et al. [25] integrated music therapy sessions based upon melodic intonation therapy,
rhythmic auditory stimulation, singing and vocal exercises, and song writing, etc. In treatment regimens for aged subjects suffering
from stroke, Parkinson’s disease, or dementia. Their findings indicated that music therapy resulted in significant improvements in
motor functions of the patients, in addition to beneficial effects on speech and communication [25]. Mood and emotional upliftment
and improvement of mental health variables are other key attribute of music therapy in Parkinson’s disease [20]. Lastly, in addition to
the direct impacts on motor and communicative skills, music therapy has been evidenced to serve as a cognition- and
memory-enhancing strategy for Parkinson’s disease subjects [26]. In conclusion, music, in combination with dance therapy appears to
be a robust non-pharmacological intervention for alleviating multiple dysfunctions associated with Parkinson’s disease patients,
helping them regain joy from functional activity, improve body and soul integrity, and restore positive self-acceptance and autonomy.
Dementias represent progressive decline in a plethora of cognitive abilities including memory, planning, executive, and social
skills. In addition to amnesia, demented individuals often elicit symptoms of confusion, mood swings, difficulties in communication,
changes in personality, and hampered daily activities. Several factors have been linked to the development and progression of de­
mentias in humans. Considering the varied pathological mechanisms, dementias can be categorized into multiple types. Some of the
most prevalent dementia types include Alzheimer’s disease, vascular dementia, Lewy body dementia and fronto-temporal dementia. In
the absence of effective disease preventive regimens, symptomatic treatments often involve lifestyle changes, in combination with
other forms of therapies, such as music-based interventions.
Indeed, music-based therapy is one of the lifestyle interventions which has been found to be particularly effective in improving
patient outcomes of dementia subjects [27]. A study conducted by Moreno-Morales and co-workers confirmed music therapy’s positive
impacts on cognitive status, expressive states, and self-awareness, with consequential enhancement of quality of life in dementia
subjects. Activation of brain areas associated with cognition, in addition to circuitry for perceiving sounds, rhythms, lyrics, and
patterns were observed in these subjects [28]. Mood enhancement and attenuation of behavioural problems have also been reported to
be significant facets of music therapy in dementia subjects [29]. Consequently, music has been associated with significant improve­
ments of life quality in dementia clinical cases [30]. Further, verbal communication in demented subjects may also be beneficially
affected by listening and producing music [31]. Here, it should be noted that while improvements in behavioural and emotional health
has been observed in several studies, beneficial effects of music therapy on cognitive attributes of dementia subject is contested [32].
Conversely, other studies have reported significant successes of music-based interventions in retarding cognitive decline in dementia
subjects [33]. Various factors may be responsible for such discrepancies, as discussed in section 8.

5. Neurodevelopmental conditions: autism spectrum disorders (ASD) and attention deficit hyperactivity disorder (ADHD)

ASD is a common neurodevelopmental condition that primarily affects children under the age of six, leading to difficulties in social
communication and behavioural dysfunctions. ASD involves altered intrinsic brain connectivity, particularly in the fronto-temporal
and cortico-subcortical regions linked to social and verbal communication skills. The positive effects of music therapy in autistic
subjects have been known for a while now [34]. Children with ASD have shown enhanced pitch perception, indicating brain plasticity
and reorganization influenced by genetic factors. Listening to music is regarded as a rewarding activity for individuals with ASD,
activating the dopaminergic response system and contributing to emotional regulation and mood [35].
Exposure to the appropriate pitch, tone and tempo of music enhances melodic memory and brain processing in children, while
engaging in music activities stimulates multiple brain regions associated with memory, emotion, pleasure, and auditory processing

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[36]. Music therapy’s effectiveness in autism subjects stems from top-down reward-based cortical modulation related to learning
non-musical behaviours like social interaction, as well as bottom-up sensorimotor integration through sound and auditory-motor
processing to enhance social communication skills [37]. Neuroimaging studies indicate the potential for brain plasticity and posi­
tive impacts on communication skills in autistic subjects. By harnessing the therapeutic power of music, individuals with ASD can
experience improved social interactions, attention, and sensory processing, promoting their overall well-being and development.
On-going research in this area continues to enrich our understanding of music-based interventions for individuals with autism.
Interestingly, research on brain regions involved in speech and music development has shown that the arcuate fascicles, crucial for
these processes, appear thicker on the right hemisphere than the left in children with autism. The right hemisphere is primarily
responsible for interpreting musical sounds, while the left hemisphere is associated with speech. This finding offers a potential
explanation for how music increases engagement among children with autism [38].
According to the diagnostic statistical manual of mental disorders (DSM), attention deficit hyperactivity disorder (ADHD) is a
neurodevelopmental disorder commonly seen in children and adolescents, characterized by hyperactivity, hyperactivity, and an
inability to focus [39]. ADHD is widely prevalent, and may elicit more frequently in male subjects. Thus, Venkata et al. found ADHD
prevalence to be 11.33 % in an Indian community-based sample, with significantly more prevalence in males [40]. Stimulant med­
ications are considered a primary treatment for ADHD, and their effectiveness in reducing the risk of retention among adolescents may
be enhanced when combined with behavioural interventions, [41]. The relationship between music and ADHD brain is probably
explained by the load theory of selective attention. According to this theory, focusing on a task involves balancing two cognitive
mechanisms; early-selection, a deliberate choice of a target stimulus with a specific goal, and late-selection, involuntary attention
drawn to a dominant stimulus. Cumulatively, music-based interventions result in appreciable benefits effects on self-regulation of
ADHD subjects [42].

6. Mental health and mood disorders

It has been known since a long time that different types of music can activate differential emotional patterns in “normal” subjects
with uncompromised mental health statuses [43]. With regards to clinical cases of mental health issues, music has been elicited to
beneficially affect human behaviour and has consequently been examined for therapeutic applications against mental health condi­
tions such as depression, stress and anxiety [44]. Meta-analyses of primary research has indicated the beneficial effects of music-based
interventions, particularly in complementation of regularly practised clinical therapies, in alleviation of depression- and anxiety-like
behaviour in human subjects of all ages [45]. The probable mechanisms underlying these effects seem to be modulation of the activities
of brain regions associated with stress responses, as well as neoplastic changes in striatal regions, prefrontal cortex, amygdala, hip­
pocampus and hypothalamus. Evidences from rodent models of early life stress concur with the hypothesis that music induces positive
neuronal alterations, particularly with regards to hippocampal plasticity, for its effects of mitigation of behavioural and cognitive
deficits [46]. Two of the most important substrates of music therapy in altering neuronal plasticity and alleviating mood disorders are
dopaminergic signalling and brain-derived neurotrophic factor (BDNF). Indeed, music exposure is associated with anxiolytic conse­
quences and fear abolishment via stimulation of BDNF signalling in anterior cingulate cortex [47]. Interestingly, Indian classical music
has also been evidenced to reduce psychological stress and promote mindfulness and mitigate sleep problems, as reported by Sharma
et al., who used EEG imaging in their studies on medical students [48]. Dingle and co-workers have summarized the various forms of
music for their beneficial effects on emotions, arousal, social interactions, relaxation and cognition [49].
Considered by some as a neurodevelopmental disorder, schizophrenia is basically a behavioural disorder with varied aetiologies.
Schizophrenia is characterized by disordered thoughts, feelings, and perceptions, and can present with acute symptoms like auditory
or visual hallucinations, as well as chronic symptoms, including social withdrawal and memory issues. This condition may have
significant detrimental effects on behavioural functions, such as creativity and ability to form relationships. Music therapy is widely
regarded as a beneficial approach for managing various schizophrenia-related symptoms [50]. Indeed, recent evidences suggest music
therapy as a very prominent component of multifactorial combinatorial therapeutic strategies against schizophrenia [51]. Such
music-based interventions have been proposed to address motivational, emotional and social aspects of schizophrenics in a long-term
manner. On the contrary, other studies indicate that positive impact of music therapeutic regimens may be reversible, and discon­
tinuation may result in re-emergence and deterioration of the behavioural symptoms [52]. Moreover, duration and frequency of
music-based therapeutic episodes heavily drive their effectiveness [53].
In addition to improvements of emotional and mental health statuses of clinical subjects of schizophrenia, music therapy has been
found to significantly elevate their quality of life and social functioning [54]. Supplementing music-based interventions with regularly
used clinical interventions has been shown to attenuate negative social and behavioural symptoms, allowing schizophrenic subjects to
appreciably improve their interpersonal skills [55]. A recent meta-analysis revealed that music therapy has tremendous positive effects
with regards to mitigation of social interaction deficits, anxiety-like behaviour, auditory hallucinations, and speech patterns [56].
These results are supported by magnetic resonance imaging data which indicate increased static functional connectivity between the
limbic regions of the brain in schizophrenia patients [57,58]. Further research is however needed to gain a deeper understanding and
their implications for music therapy in schizophrenia treatment. In particular, comprehensive long-term measurement of music
therapy’s effects must be studied in order to address all ambiguities.

7. Circadian rhythm disruptions

Circadian rhythm disruptions and sleep impairments are bi-directionally related to multiple molecular and cellular aspects of brain

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functional deficits in cognition, emotion, and behaviour [59,60]. An important aspect of music therapy interventions for chronic
disorders, including neurological conditions, lies in its ability to beneficially affect circadian rhythm and sleep-wake cycle [61]. This is
supported by a recent animal study which used zebrafish as a model system to assess the therapeutic effects of long-term music therapy
on circadian disruption-induced cognitive and psychological impairments [62].
As reviewed recently by Sharma et al. [63], music is increasingly being recognized as an effective means of non-pharmacological
intervention to ameliorate circadian disruptions, and thereby act as a neuroprotective measure targeting brain structural plasticity and
other pathogenic mechanisms related to neurodegenerative states. Interestingly, the applications of music therapy for treatment of
neurodegenerative disorders can be optimized by clock timing. This is in concurrence with a trial conducted by Theorell and
co-workers [64], who illustrated that home-based music therapeutic intervention in dementia patients and their care-givers signifi­
cantly reduced their salivary cortisol levels [64]. Further, slow “sedative” music has been noted to have beneficial effects on attributes
of perceived sleep quality, duration, and latency in aged human subjects with circadian dysfunctions [65]. In concurrence, a
meta-analytical study has revealed music as one of significantly effective interventional regimen for attenuating sleep dysfunctions (as
assessed by the Pittsburgh Sleep Quality Index; PSQI) in both healthy subjects and those with varied medical conditions [66]. Further,
music provision, in addition to other chronotherapeutic strategies, has been proposed as a means to rescue dysfunctional sleep-wake
characteristics in critically ill patients suffering from delirium [67]. Lastly, in an interesting study, Ceccato and Roveran [68] proposed
that group-based music therapy before evening meals may reduce pre-meal anxiety in anorexia nervosa patients, indicating its possible
utility in attenuation of circadian disruptions.

8. Future prospects

Music therapy has been a profoundly sought after intervention for neurological disorders. Through the development of synchro­
nous rhythm, motor imitation, and joint attention, music therapy is thought to support preverbal communication [69]. In patients of
schizophrenia, non-verbal social communication that can be introduced by the use of music therapy can be particularly useful [54]. In
the case of ASD, patients showed intact emotion recognition from music, as expressed in their behavioral ratings, and in typical brain
processing of emotional music, with activation of limbic and paralimbic areas, including reward regions [70]. Patients with dementia
can remember music despite having significant memory impairments, and music can help people retain episodic memories, even if the
music is unrelated to the events being remembered. Additionally, music has been employed therapeutically to encourage social
bonding in these patients [71]. Improvements in frontal lobe functions (cognitive flexibility, processing speed, attention, and working
memory) is a relevant outcome of music-based intervention for enhancement of attention and executive functions [20]. Further,
studies in ADHD patients have revealed significant decreases in cortisol levels, indicating lowered depression and stress levels. This
was seen to occur in tandem with the responses from other neurophysiological factors like blood pressure, heart rate and hormones
[72]. Importantly, no specific adverse effects were observed in any of the studies, and almost all patients tolerated music therapy well.
In spite of potential multimodal therapeutic aspects against different neurological disorders, there is insufficient evidence for the
exact nature of music-based therapy [73]. Many studies on music therapy employed small sample sizes, which may limit the gener­
alizability of the findings. Another drawback could be the lack of control groups which makes it difficult to establish a cause-and-effect
relationship between therapy and the observed outcomes. Further, heterogeneity of the study populations is one of the top reasons for
the diverse outcomes in all interventional studies. All patients with the disorders have varying degrees of impairment and symptoms.
Hence, interventions may vary widely, depending on the patient’s needs, the therapist’s training, and the context in which the therapy
is being delivered. Further, heterogeneity at the genetic level, coupled with low samples sizes, may lead to erroneous conclusions (e.g.,
whether experience-dependent or not) regarding the neuroplasticity-related effects induced by music exposure. Along similar lines,
gender-based differences in the outcomes of music therapy for neurological conditions need to be addressed in detail. Likewise, not
many studies have comprehensively analysed the impact of music on the young nervous system [74].
Other significant limitations of studies which have focussed on music therapy for neurological disorders include absence of
standardized interventional protocols, disregard for cultural perspectives, and inadequacies in addressing the influences from con­
founders such as general environmental conditions in the hospitals/care centres, background noise, patient noise sensitivity, thera­
pists’ attitudes, etc. Further, a thorough comparison between the effects of auditory (listening), vocal (singing), motor (listening/
singing coupled with dancing) and sensorimotor (instrument playing) attributes of music intervention, as well as their complemen­
tation actions, need to be assessed in a disease- and patient-specific manner. Likewise, studies should also seek to understand how
patients’ cultural and musical orientations shape the treatment processes. By identifying these cultural specificity issues, one could
learn how to individualize the provision of music therapy in terms of patients’ cultural backgrounds and life experiences. Other key
aspects of music therapy for neurological disorders which have not been optimally evaluated in a majority of studies are the underlying
mechanisms and the longevity of the beneficial effects (particularly in acute clinical settings). Core neurophysiological mechanism
behind the therapy and effect of music should be explored in as much as detail for a better understanding of the pathways involved;
although this may be challenging under clinical and pre-clinical settings. Lastly, in order to better understand the effectiveness of the
treatment course of music therapeutic regimens, future trials need to investigate their complementation with other approaches,
including pharmacological and behavioural ones. Interaction of music and other therapies may have added effects on neuroplasticity
enhancement and functional abilities of patients.

9. Conclusions

In conclusion, music application in neurological disorders is increasingly being regarded as a promising and diverse field for

8
M. Ramaswamy et al. Heliyon 10 (2024) e35564

therapeutic approaches. This form of therapy has been found to be effective in varied conditions, including those affecting the
developing brain such as autism and ADHD, as well as ageing-related impairments such as Parkinson’s disease and dementia.
Consequently, music’s impact on influencing neuroplasticity in multiple brain regions/systems, developing and optimizing the mental,
emotional, behavioural, sleep and cognitive functions, as well as increasing quality of life reveals its opportunity to be harnessed as a
potent non-invasive and non-pharmacological treatment alternative. Nonetheless, further high-quality studies are required because
the body of research on music therapy is presently insufficient. Refinement of music applying methods and better understanding of the
underlying mechanisms and pathways should be the goals for future research. In this regard, we hope that the present review forms a
suitable research platform outlining the pertinence of music interventions, and the need forsynchronizing and extending the exper­
imentation on a larger scale in order to gain adequate understanding of its therapeutic potential for neurological disorders.

Ethical approval and informed consent statements

Not applicable, as no primary data were generated.

Data availability statement

The authors report there are no competing interests to declare.

Funding

Deputyship for Research & Innovation, Ministry of Education, Saudi Arabia - Project Number: ISP23-101.

CRediT authorship contribution statement

Medha Ramaswamy: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Resources,
Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Johann Laji Philip: Writing – review & editing,
Writing – original draft, Visualization, Validation, Software, Resources, Methodology, Investigation, Formal analysis, Data curation,
Conceptualization. Vijayan Priya: Writing – review & editing, Visualization, Validation, Methodology, Investigation, Formal analysis,
Data curation. Snigdha Priyadarshini: Writing – review & editing, Writing – original draft, Visualization, Validation, Software,
Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Meenakshi Ramasamy: Writing – review
& editing, Writing – original draft, Visualization, Validation, Software, Resources, Methodology, Investigation, Formal analysis, Data
curation, Conceptualization. G.C. Jeevitha: Writing – review & editing, Visualization, Validation, Methodology, Investigation, Formal
analysis, Conceptualization. Darin Mansor Mathkor: Writing – review & editing, Visualization, Validation, Methodology, Investi­
gation, Formal analysis, Conceptualization. Shafiul Haque: Writing – review & editing, Writing – original draft, Visualization,
Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal
analysis, Data curation, Conceptualization. Fatemeh Dabaghzadeh: Writing – review & editing, Visualization, Validation, Method­
ology, Investigation, Formal analysis, Conceptualization. Pratik Bhattacharya: Writing – review & editing, Writing – original draft,
Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Formal analysis, Data
curation, Conceptualization. Faraz Ahmad: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervi­
sion, Software, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to
influence the work reported in this paper.

Acknowledgments

The authors extend their appreciation to the Deputyship for Research & Innovation, Ministry of Education in Saudi Arabia for
funding this research work through the Project Number ISP23-101.

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