Abstract
As global population aging accelerates, preventing and treating cognitive impairment has become a major public health priority. Music therapy is a safe, well-tolerated non-pharmacological intervention with substantial potential to improve cognitive function. This review synthesizes the neurologic music therapy (NMT) framework, encompassing techniques targeting attention, memory, and executive function, delivered through both active and receptive approaches. Clinical investigations indicate that music therapy may improve cognition and neuropsychiatric symptoms in Alzheimer’s disease (AD), vascular cognitive impairment (VCI), Parkinson’s disease–related cognitive impairment, mild cognitive impairment (MCI), and traumatic brain injury (TBI); however, effects appear to vary by intervention duration and disease stage. This narrative review aims to provide a theoretical foundation and practical guidance for the non-pharmacological intervention of cognitive impairment by collating evidence on the neuroplasticity theoretical foundations, technical systems, and clinical applications of music therapy.
1 Introduction
Cognitive impairment refers to acquired deficits in cognitive domains such as memory, executive function, and language, and encompasses a continuum ranging from MCI to dementia (; ). Globally, approximately 15% of older adults have MCI (). In China, the prevalence is 15.5% among individuals aged 60 and above, affecting an estimated 38.77 million people (). More concerningly, 10–15% of individuals with MCI progress to dementia each year, a rate substantially higher than the 1–2% observed in the general population (). Although drugs such as cholinesterase inhibitors are widely used to treat AD, their efficacy is limited, they are associated with significant adverse effects, and they provide little improvement in neuropsychiatric symptoms (). Therefore, NMT, a non-pharmacological intervention that has garnered considerable attention because it induces neuroplastic changes and provides multimodal stimulation (), has been increasingly applied in the rehabilitation of cognitive, sensory, and motor dysfunctions arising from neurological disorders (; ). This narrative review evaluates how music-based interventions may enhance the frontoparietal executive control network via rhythmic entrainment and facilitate autobiographical memory retrieval by engaging the hippocampal–amygdala circuit through emotion–memory coupling, thereby modulating attention, memory, and executive-function domains to improve cognition in individuals with specific neurological disorders.
2 The neuroplasticity theoretical basis of music therapy
2.1 Multilayered mechanisms of music-induced neural plasticity
Music-induced neural plasticity refers to the adaptive remodeling of brain structure and function driven by musical activities through multisensory stimulation (). exposed juvenile mice to music with different tones and found that musical stimulation upregulated the expression of brain-derived neurotrophic factor (BDNF) and its receptor, tropomyosin receptor kinase B (TrkB), thereby activating downstream signaling pathways, including phospholipase Cγ1 (PLCγ1)–protein kinase C (PKC), phosphatidylinositol 3-kinase (PI3K)–protein kinase B (AKT), and mitogen-activated protein kinase (MAPK)–extracellular signal-regulated kinase (ERK), and promoting dendritic spine formation and synaptic protein expression in the hippocampus and prefrontal cortex. Clinical studies in patients with AD have reported that music-based interventions can improve cognitive function. These improvements may be associated with the molecular mechanisms described above. However, direct causal evidence from clinical trials is currently lacking (). further confirmed in a mouse model of depression induced by chronic unpredictable mild stress that music intervention enhances hippocampal neurogenesis and structural plasticity by increasing the number of DCX-positive newborn neurons in the dentate gyrus. At the brain network level, hypothesized based on a narrative review that music training enhances the anterior cingulate cortex-pre-supplementary motor area (ACC-pre-SMA) node within the salience network (SN). This enhancement strengthens its driving effect on the frontoparietal control network (FPCN), thereby improving executive control efficiency. However, the model currently lacks direct experimental evidence from animal studies, clinical trials, or neuroimaging.
2.2 Neural networks for music processing and resonance mechanisms
Music therapy induces functional coupling across multiple brain regions through neural resonance mechanisms. By immediately modulating emotion and motor control, this process further drives structural and functional reorganization of brain networks, thereby improving cognitive function. Its mechanistic framework constructed based on the evidence in this manuscript is illustrated in Figure 1. Music-induced emotional processing relies on the functional coupling of various brain areas. The auditory cortex and premotor cortex are involved in cross-vocal-timbre emotion categorization (), whereas the motor and somatosensory cortices are involved in rhythmic synchronization and sensorimotor coupling (; ). Limbic structures, such as the amygdala and hippocampus, are dedicated to processing specific emotions (). The neural resonance mechanism is a key target of music therapy techniques such as rhythmic auditory stimulation (RAS), in which neural activity is selectively enhanced when external rhythms align with the brain’s endogenous oscillatory frequencies (e.g., alpha and theta waves) (). demonstrated that RAS, acting as an exogenous pacemaker, can modulate pathological beta oscillations via neural entrainment, thereby enhancing motor cortex modulation and frontoparietal cross-frequency coupling, which in turn improves motor control. Wu et al. (2022) demonstrated through clinical imaging experiments that RAS can also activate the cerebello-thalamo-cortical pathway to establish compensatory mechanisms, thereby compensating for functional brain damage in individuals with cognitive impairments. Long-term neural resonance can reshape brain network structure and function. Structural connectivity, which is based on white matter integrity, serves as the material basis for functional connectivity. In older adults, white matter fiber disruption and volume reduction lead to weakened functional connectivity (; ). Specifically, reduced within-network connectivity accompanied by enhanced between-network connectivity, decreased connectivity among task-related brain regions, and a diminished negative correlation between the task-positive network and the DMN collectively contribute to cognitive decline (Xia et al., 2022). , using diffusion tensor imaging, found that lifelong musicians exhibit a positive correlation between age and white matter integrity in the bilateral superior longitudinal fasciculus and uncinate fasciculus, whereas non-musicians show the typical negative correlation. However, the small sample size and cross-sectional design of this study limit causal inference; thus, the findings only suggest that lifelong musical training may alter the trajectory of age-related white-matter degeneration and confer cognitive reserve. reported that functional connectivity is contingent on dynamic coupling formed by neural oscillations. demonstrated that music therapy can promote functional recovery and emotional regulation by enhancing neural plasticity.
FIGURE 1
3 The neurologic music therapy system and mechanisms of action
3.1 Classification of techniques based on cognitive domains
Within the NMT framework, interventions can be classified by cognitive domains and modes of engagement into two types: standardized intervention protocols and descriptive classification Music Attention Control Training (MACT), Associative Mood and Memory Training (AMMT), and Musical Executive Function Training (MEFT), all classified by cognitive domain, originate from the standardized registered protocols (marked with ®) presented in the Handbook of Neurologic Music Therapy (, , ). These protocols possess well-defined technical specifications and scopes of application By contrast, Active Music Intervention (AMI) and Receptive Music Intervention (RMI), based on a descriptive categorization of engagement modes, correspond to interventions involving performance and singing, and to listening-based interventions, respectively, and exhibit high internal operational heterogeneity. RAS is also one of the standard techniques defined in the handbook and frequently appears as a core module of AMI (). The following provides a point-by-point introduction and explanation.
3.1.1 Music Attention control training
MACT is a core intervention technique in NMT that specifically targets cognitive dysfunction. By designing structured musical tasks, this technique systematically uses musical elements—such as rhythm, melody, and harmony—to target and train subcomponents of attention, including focused, selective, sustained, and alternating attention (). Its theoretical foundation is the three-network model of attention proposed by Posner and colleagues, comprising the alerting network (arousal and maintenance of a vigilant state), the orienting network (information filtering and orienting), and the executive control network (conflict monitoring and cognitive control) (). Based on this neurotheoretical framework, the clinical efficacy of MACT has been supported by evidence-based studies across diverse clinical populations, including individuals with acquired brain injury (; ), schizophrenia (), and neurodevelopmental disorders in children and adolescents, such as attention-deficit/hyperactivity disorder () and autism spectrum disorder (). The neurobiological mechanisms of this training method operate at multiple levels (see Table 1), mainly including the following:
TABLE 1
| Target brain regions | Neural mechanisms | Attentional function | References |
|---|---|---|---|
| Prefrontal-parietal network | Neural oscillatory entrainment. | Prioritizes task-relevant information and suppresses distractors, thereby enhancing selective attention. | (; ) |
| Brainstem, ascending reticular activating system | Brainstem auditory reflex pathways. | Rapidly activates alerting networks, facilitating rapid mobilization and optimal allocation of attentional resources. | () |
| Parietal cortex, anterior cingulate cortex, and basal ganglia network | Functional synergy across multiple regions and network integration. | Synergistically enhances executive control and attentional regulation. | () |
Neural mechanisms of MACT.
3.1.2 Associative mood and memory training
AMMT is a specialized intervention technique within NMT designed to address impairments in memory function. This technique is based on neural coupling between emotion and memory. It involves the careful selection and presentation of personally familiar music that elicits strong emotional responses, thereby facilitating autobiographical memory retrieval (). Autobiographical memory, which integrates episodic and semantic memory systems, plays a crucial role in maintaining an individual’s self-identity (; ). AMMT is primarily applicable to patients with neurodegenerative memory disorders, such as AD and VD, as well as to individuals experiencing memory deficits following brain injury or stroke (). A detailed description of its multilevel neural mechanisms is provided in Table 2.
TABLE 2
| Target brain regions | Neural mechanisms | Memory function | References |
|---|---|---|---|
| Limbic system (amygdalo-hippocampal circuit) | Uses music-induced emotion as a “retrieval key” to engage emotion-memory coupling circuits. | Enhances the efficiency of autobiographical memory retrieval. | (; ) |
| Music processing–related brain regions (caudal anterior cingulate cortex, ventral supplementary motor area) | Leverages relatively preserved musical nodes in pathological states as bridges to engage associated memory networks. | Promotes the mobilization of holistic episodic memory. | (; ) |
| Neural network connectivity (frontotemporal lobes, cortico-cerebellar connections) | Repetitive training induces bidirectional plasticity: it may optimize network efficiency by reducing redundant connections at the MCI stage and may elicit compensatory mechanisms by enhancing functional connectivity at the AD stage. | Dynamic adaptation mechanisms of “streamlining” and “enhancement” support memory. | (; ) |
Neural mechanisms of AMMT.
3.1.3 Musical executive function training
MEFT systematically enhances executive functions through active music-creation activities (). Executive functions encompass three core components—working memory, cognitive flexibility, and inhibitory control—as well as higher-order functions such as planning, decision-making, and problem-solving (; ). MEFT is applicable to patients with neurological disorders (e.g., brain injury, attention-deficit/hyperactivity disorder, and PD) and patients with neuropsychiatric disorders (e.g., depression and schizophrenia), as well as healthy older adults, individuals with MCI, and healthy individuals seeking functional optimization (). The neural mechanisms underlying MEFT are detailed in Table 3.
TABLE 3
| Target brain regions | Neural mechanisms | Executive function | References |
|---|---|---|---|
| Dorsolateral prefrontal cortex | Generates and maintains internal representations and sustained neuronal firing. | Working memory | () |
| Lateral prefrontal cortex | Anteriorly, the ventral pathway couples with the temporal lobe; posteriorly, the dorsal pathway interacts with the parieto-motor cortex network. | Musical structure planning; motor planning and hierarchical action control, from abstract structural rules to specific motor execution. | () |
| Anterior cingulate cortex | Continuously monitors conflicts arising during music creation and communicates them to the prefrontal cortex. | Cognitive control | (; ) |
| Basal Ganglia | The striatal direct pathway (D1-MSNs) disinhibits target actions, whereas the indirect pathway (D2-MSNs) increases inhibition of competing actions. | Action selection | () |
| Facilitates the shift from discrete notes to fluid phrases, enabling a shift from static planning to dynamic sequencing. | Sequence learning | () |
Neural mechanisms of MEFT.
3.2 Classification of intervention models based on participation format
3.2.1 Active music intervention
AMI integrates auditory feedback, motor planning, and attentional control through activities such as instrument playing, singing, and rhythmic training, thereby promoting multisensory synergistic processing (; ; ). The underlying neural mechanisms involve precise coordination between auditory and motor systems. reported that instrumental performance and singing activate a broad network of brain regions, including the primary auditory cortex, posterior superior temporal gyrus, intraparietal sulcus, supramarginal gyrus, dorsal premotor cortex, and primary motor cortex. Furthermore, reported that auditory–motor sequence learning is synchronized with beta oscillations (13–30 Hz) in the cingulate gyrus and cerebellum, thereby mediating temporal coupling between sensory and motor processes.
RAS, a core technique within AMI (), leverages neural entrainment between regular beats and the brain’s intrinsic oscillations to improve temporal processing and motor-cognitive functions (; ). Building on the Auditory Predictive Motor Simulation hypothesis, proposed that beat perception modulates neural oscillations and recruits motor-planning regions for predictive simulation, and that RAS reinforces this process through active synchronization. reported that RAS can improve gait parameters in patients with PD. Additionally, reported that RAS may promote post-stroke motor rehabilitation and cognitive recovery in MCI.
3.2.2 Receptive music intervention
RMI, which involves listening to self-selected music to facilitate emotional expression, offers unique advantages in ameliorating psychological symptoms such as anxiety and depression (). Its effects are mediated by activation of the reward system, involving regions such as the striatum, dopaminergic midbrain nuclei, amygdala, insula, prefrontal cortex, and orbitofrontal cortex (Zatorre, 2015). Using positron emission tomography, demonstrated that music-evoked emotional peaks are accompanied by dopamine release in the striatum. The caudate nucleus and the nucleus accumbens are activated during the anticipatory phase and peak experience, respectively, reflecting the temporal dynamics of this process.
Furthermore, music listening can modulate neuroendocrine function via the autonomic nervous system and the hypothalamic–pituitary–adrenal axis, thereby mitigating stress responses (; ). reported that listening to relaxing music enhances parasympathetic activity, increases the high-frequency component of heart rate variability, and reduces heart rate and respiratory rate. Zhang et al. (2020) demonstrated that therapist-selected music—characterized by a broader audio frequency range, a more structured musical form, and greater cultural appropriateness—more effectively activates the autonomic nervous system in patients with disorders of consciousness than patient-preferred music. This superiority is particularly evident in indices of sympathetic activation, overall ANS activity, and thermoregulatory stability. Fast-tempo music lowers cortisol levels, whereas slow-tempo music increases oxytocin levels and promotes physiological relaxation (), thereby reducing subjective anxiety and inducing positive emotions ().
4 Music therapy based on the theory of neuroplasticity in improving cognitive impairment
The intervention protocols of the NMT technical system, such as MACT, AMMT, MEFT, and RAS, although targeting distinct cognitive domains including attention, memory, and executive functions, all have therapeutic pathways that rely on neural processing mediated via the auditory pathway. AMMT leverages melodic and harmonic structures to induce activation of the emotional memory circuit and enhance functional connectivity within the hippocampal-amygdala complex (; ). RAS, through neural entrainment mechanisms, achieves the phase-locking of exogenous rhythms with endogenous θ/α oscillations, thereby driving the prefrontal-parietal executive control network (; ). This section organizes the clinical application evidence of neuro-music therapy in patients with cognitive impairment such as AD, VCI, and PD.
4.1 Alzheimer’s disease
Alzheimer’s disease (AD) is a neurodegenerative disorder characterized by progressive cognitive decline () and behavioral and psychological symptoms of dementia (BPSD) (). Music therapy, as a non-pharmacological intervention, has shown efficacy in improving cognitive function and BPSD in patients with AD (; ; Zhou et al., 2025). Table 4 summarizes progress in the specific applications of music therapy. Notably, in individuals with mild AD, improvements following music interventions are primarily observed in global cognition and memory, whereas in those with moderate-to-severe AD, benefits are mainly reflected in BPSD. Whether the differential therapeutic effects that emerge with disease progression are attributable to changes in neuroplasticity targets, or, in moderate-to-severe stages, to the limited sensitivity of cognitive assessment tools and the practical difficulties in implementing active-participation paradigms, warrants further verification.
TABLE 4
| Disease | Intervention description | Intervention duration | Clinical assessment measures | Efficacy | Mechanism of action | References | |||
|---|---|---|---|---|---|---|---|---|---|
| AD | Mild | Listening to emotionally evocative music | 5 weeks | Baseline MMSE (mean) | 14.6 | Cognitive function | Improved autobiographical memory retrieval. | Induces emotional states and enhances attention and arousal. | () |
| Listening to classical music (Mozart, Pachelbel) | 6 months | 17.7 ± 5.98 | Significantly improved abstraction (p = 0.024). | Activates prefrontal and temporal cortical circuits to enhance neuroplasticity. | () | ||||
| Mild to moderate | AMI: welcome songs, body movement; RMI: listening to songs. | 6 weeks | 15.02 ± 5.40 | Significantly Improved memory (p = 0.000, η2 = 0.69), orientatio (p = 0.000, η2 = 0.76), and language abilities (p = 0.047, η2 = 0.27). | Enhances cognitive efficiency via emotion-memory pathways, promoting brain network reorganization and right-hemisphere language compensation. | () | |||
| AMI: singing, rhythmic exercises, dancing; RMI: seated listening to personalized music | 3 months | AMI group: 17.79 ± 3.90; RMI group: 18.28 ± 6.14 | AMI significantly improved MMSE scores (p < 0.001, η2 = 0.62). | Activates multi-brain-region networks, promotes neuroplasticity, and enhances memory and executive functions. | () | ||||
| Mild | Listening to classical music (Mozart, Pachelbel) | 6 months | Baseline NPI (mean) | 7.4 ± 13.17 | BPSD | There was no significant improvement in BPSD (p = 0.431), but MT group showed numerically less deterioration. | Modulates limbic system and parasympathetic activity, stabilizes emotional states, and alleviates behavioral and psychological symptoms. | () | |
| Mild to moderate | AMI: welcome songs, body movement; RMI: listening to songs | 6 months | 17.71 ± 11.59 | Alleviated BPSD, including anxiety (p = 0.002, η2 = 0.53), delusions (p = 0.015, η2 = 0.37), hallucinations (p = 0.026,η2 = 0.33), agitation (p = 0.010, η2 = 0.41), and irritability (p = 0.025, η2 = 0.33). | Reduces physiological stress responses, evokes positive emotions, and promotes social interaction. | () | |||
| AMI: singing, rhythmic exercises, dancing; RMI: seated listening to personalized music | 3 months | AMI group: 20.92 ± 9.20; RMI group: 18.38 ± 7.48 | AMI significantly reduced NPI scores (η2 = 0.61, p < 0.001). | Regulates the stress system and emotional responses and improves behavioral symptoms. | () | ||||
| Group music intervention, percussion instrument playing | 12 weeks | / | Anxiety improved significantly (P < 0.001), whereas depressive symptoms showed no significant improvement (P = 0.214). | Evokes emotional memories, enhances interpersonal interaction, and increases alertness through instrumental touch. | () | ||||
| Moderate to severe | Group music therapy combined with AMI and RMI | 6 weeks | Baseline BEHAVE-AD (mean) | 5.5 | The treatment group showed significant improvement in activity disorders (p = 0.02) and a significant reduction in aggressive and anxious symptoms (p < 0.01). | Alleviates behavioral and psychological symptoms triggered by factors such as difficulties in environmental recognition. | () | ||
| Severe | AMI: listening to personalized music; RMI: clapping, singing, dancing | 10 weeks | Paranoia/delusions: 2.1–2.2; Movement disorders: 2.3–3.0 | In alleviating BPSD (e.g., emotional distress, anxiety, paranoia, and behavioral disturbances), AMI shows superior efficacy to RMI. | Enhances parasympathetic activity and evokes positive emotions. | () | |||
| Mild, moderate, severe | AMI: singing RMI: listening to music | 3 months | Baseline MMSE (mean) | 13.45 ± 3.66 | Cognitive function | Significantly improved immediate recall, delayed recall, and verbal fluency in mild AD (p < 0.05), with no significant effect in moderate-to-severe AD. | Activates retained cortical and subcortical brain regions. | () | |
| Baseline NPI (mean) | 26.18 ± 13.25 | BPSD | Significant improvement in BPSD for severe AD and in caregiver burden for moderate-to-severe AD, with no significant effect in mild AD. | Engages brain regions regulating emotion and behavior, together with the positive social and emotional experiences inherent in singing. | |||||
Advances in the application of music therapy in improving cognitive impairment in AD patients.
MMSE: Mini-Mental State Examination (); NPI: Neuropsychiatric Inventory (); BEHAVE-AD: Behavioral Pathology in Alzheimer’s Disease Rating Scale ().
4.2 Vascular cognitive impairment
Vascular cognitive impairment (VCI), attributable to cerebrovascular disease, encompasses a continuum ranging from mild cognitive impairment to dementia (). Approximately 70% of patients with stroke exhibit cognitive impairment (). Music therapy has been associated with improvements in cognitive function in VCI, potentially by activating cognitive networks, modulating the dopaminergic system, and promoting neural plasticity (). Table 5 summarizes the efficacy of music therapy in VCI and the putative underlying mechanisms. A randomized controlled trial demonstrated that, after an acute unilateral stroke, early listening to singing was superior to instrumental music and audiobooks in improving cognitive and language functions. The instrumental music group induced right-hemisphere neuroplasticity in the aphasia subgroup, yet no corresponding cognitive benefits were observed, suggesting that the causal relationship between neural remodeling and functional recovery still needs to be explored ().
TABLE 5
| Disease | Intervention description | Intervention duration | Efficacy | Mechanism of action | References |
|---|---|---|---|---|---|
| Acute unilateral middle cerebral artery (MCA) stroke | Listening to self-selected music (predominantly popular music, with some jazz, folk, or classical) or audiobooks | 6 months | Facilitated cognitive recovery (e.g., verbal memory and concentration) and helped prevent negative emotions (e.g., depression and confusion). | Activated bilateral temporal, frontal, and parietal cognitive networks and modulated dopaminergic emotion-related systems, potentially supporting neural remodeling. | () |
| Voxel based morphometry (VBM) showed increased gray volume in the superior frontal gyrus, subgenual anterior cingulate cortex, and ventral striatum. | () | ||||
| Ischemic stroke | Personalized music listening | 3 months | Significantly improved MoCA scores (p = 0.027, mean difference = 3.21 points), particularly in the domains of delayed recall and orientation. | Activated broad cognitive brain regions, including the cerebellum, sensory cortex, and DMN; Evoked autobiographical memories via preferred music, involving the posteromedial cortex and posterior cingulate gyrus. | () |
| Chronic ischemic stroke | VRRS attention cognitive training combined with EMS | 8 weeks | Significantly improved MoCA scores (p = 0.004, r = 0.64), intrinsic motivation, (p < 0.001, r = 0.84), depression (p < 0.001, r = 0.83), and anxiety (p = 0.003, r = 0.66). | Stabilized arousal levels and enhanced task focus; modulated limbic-prefrontal pathways; reduced heart rate and promoted autonomic balance. | () |
| Acute unilateral stroke | Listening to self-selected vocal music, instrumental music, or audiobooks | 2 months | Enhanced verbal memory (p = 0.002, η2 = 0.172) and language recovery, particularly in patients with aphasia (p < 0.001, η2 = 0.588); vocal music showed the greatest therapeutic effect. | Increased left temporal gray matter volume and DMN functional connectivity. | () |
Advances in the application of music therapy in improving cognitive impairment in VCI patients.
MoCA, Montreal Cognitive Assessment (); VRRS, Virtual Reality Rehabilitation System; EMS, Emotional Music Stimulation.
4.3 Parkinson’s disease cognitive impairment (PD-MCI)
Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by tremor and bradykinesia; most patients also present with cognitive deficits (; ). Gait disturbances often coexist with cognitive decline, and freezing of gait is significantly associated with poorer global cognition, executive function, attention, working memory, and visuospatial ability (). Executive dysfunction is an independent risk factor for falls (). NMT has demonstrated dual benefits for gait and cognition in patients with PD (), with specific applications detailed in Table 6. In a preliminary randomized controlled trial (n = 12) involving patients with Parkinson’s disease, examined the effects of dual-task–based rhythmic-cueing drum playing. The intervention was associated with a large effect size on the Stroop Color–Word Test (d = 1.04). Accordingly, the authors suggested that bimanual drum playing may improve inhibitory control in this population. However, the between-group interaction did not reach statistical significance (p = 0.100); therefore, this conclusion requires validation in studies with larger sample sizes.
TABLE 6
| Disease | Intervention description | Intervention duration | Efficacy | Mechanism of action | References | |
|---|---|---|---|---|---|---|
| Interactive RAS and fixed RAS | Rhythmic Speech and Language Therapy (rSLT) and Rhythmic Balance and Movement Training (rBMT) | 4 weeks | Cognitive function | rSLT improved working memory (p < 0.01, Cohen’s d = 0.94) and word retrieval (p < 0.01, Cohen’s d = 1.04). rBMT showed no significant cognitive gains but slowed cognitive decline. | Rhythm, as a salient stimulus, broadly activates brain networks (auditory, motor, memory [hippocampus], emotional [limbic], and language systems), thereby enhancing therapeutic engagement. | () |
| AMI: high-intensity group piano training | 10 days | Significantly improved cognitive control, as evidenced by reduced Stroop task error rates (p = 0.03, r = 0.34) and increased musical self-efficacy (p = 0.001, r = 0.48). | Activated striato-thalamo-cortical networks, thereby bolstering fine motor skills and executive planning. | () | ||
| AMI: music production, singing, and dancing | 24 weeks | Executive function and memory improved in the short term, but the effects dissipated after the intervention ended. | Stimulated and trained core executive functions, including attention, cognitive flexibility, processing speed, and working memory. | () | ||
| Dual-task-based drumming performance with rhythmic cueing (DPRC) | 12 weeks | The large effect (Cohen’s d = 1.04) for inhibitory control was non-significant (p = 0.100). | Rhythmic cues enhanced auditory–motor interactions, thereby reducing dual-task interference. | () | ||
| An autonomous closed-loop RAS automatically adjusted music tempo based on real-time gait parameters. | 6 weeks | Significantly enhance walking intensity (p = 0.001, Cohen’s d = 1.2), increase daily step count (p = 0.003, Cohen’s d = 1.08), and reduce gait variability (p = 0.029, Cohen’s d = 0.79). | Auditory–motor network synchronization bypassed dysfunctional basal ganglia circuits, thereby improving motor rhythmicity and stability. | () | ||
| Interactive RAS and fixed RAS | 6 months | Restored healthy 1/f fractal scaling, thereby enhancing gait and perceptual stability. | Stabilized the internal rhythm-generation system via mutual entrainment, thereby restoring basal ganglia function. | () | ||
| BeatWalk is a smartphone application that synchronizes music tempo with step frequency in real time and progressively increases tempo to 10% above the user’s spontaneous cadence. | 4 weeks | Significantly improved cadence, velocity, distance (p ≤ 0.01), and stride length (p = 0.04) on the 6-min walk test. | Used interactive beat-based entrainment to induce spontaneous synchronization, thereby mitigating dual-task interference and enhancing gait motivation and rhythmicity. | () | ||
Advances in the application of music therapy in improving cognitive impairment in PD-MCI patients.
4.4 Mild cognitive impairment
Mild cognitive impairment (MCI) lies between normal aging and dementia and is characterized by persistent memory decline that does not substantially affect activities of daily living; it also carries a risk of progression to dementia (). Music therapy has shown considerable potential to ameliorate overall cognitive functioning in individuals with MCI (). Specific applications are detailed in Table 7. In MCI, normal and damaged brain tissue coexist; however, no existing study has clarified whether the cognitive improvement derived from music interventions originates from compensatory recruitment of normal brain areas or from repair of damaged regions. Future studies require imaging markers to dissociate and observe the responses of the two tissue types.
TABLE 7
| Disease | Intervention description | Intervention duration | Efficacy | Mechanism of action | References |
|---|---|---|---|---|---|
| MCI | Multitask movement–music therapy | 12 weeks | Significantly improved executive function, particularly motor programming (p = 0.021, r = 0.414) and overall frontal lobe cognitive performance (p < 0.05). | Activated the prefrontal cortex, increasing cerebral blood flow and functional connectivity. | () |
| Music-and-movement intervention: rhythmic activities, music listening and song recognition, instrumental performance, and singing | 12 weeks | Significant improvements in global cognition, attention, immediate and delayed memory, and executive function (P ≤ 0.007). | Activated the prefrontal cortex, increased cerebral blood flow, and promoted the formation of new neural networks. | () | |
| RMI: listening to personalized music, group discussions, and progressive muscle relaxation training | 8 weeks | Significantly improved the total MoCA score (P < 0.001, mean difference = 2.63, 95% CI: 2.09–3.17), with a medium effect size (Cohen’s d = 0.40). | Promoted psychophysiological relaxation through rhythmic and soothing properties, stimulated autobiographical memories, and may have improved neural function by upregulating BDNF levels. | (Xue et al., 2023) |
Advances in the application of music therapy in improving cognitive impairment in MCI patients.
4.5 Traumatic brain injury
Traumatic brain injury (TBI), resulting from external mechanical forces, frequently leads to cognitive impairment, with executive dysfunction being particularly prominent (; ). Music therapy has demonstrated positive effects in ameliorating executive function in patients with TBI (; ). Table 8 details the therapeutic efficacy and the putative underlying mechanisms through which music therapy improves executive function after TBI. Preclinical evidence supports these clinical observations. In a rat model of TBI induced by controlled cortical impact (CCI), daily exposure to Baroque classical music for 1 month significantly improved spatial learning and memory (p = 0.0007). This effect was associated with upregulation of hippocampal brain-derived neurotrophic factor, modulation of neuroinflammatory responses, and a reduction in cortical lesion volume (). Interestingly, after receiving music therapy, TBI patients showed decreased connectivity between the DMN and the sensorimotor network, and the magnitude of this decrease was associated with improvements in executive function (). In populations with mild cognitive impairment and dementia, the meta-analysis by hypothesized that cognitive benefits might be associated with enhanced interactions between the DMN and the task-positive network. These opposing modulation directions suggest that the effect of music therapy on the DMN may be regulated by baseline network states.
TABLE 8
| Disease | Intervention description | Intervention duration | Efficacy | Mechanism of action | References |
|---|---|---|---|---|---|
| TBI (mild) | NMT: a structured and standardized piano training curriculum | 8 weeks | Significant improvement in cognitive function (p < 0.001); enhancement of subjective wellbeing and social behavior. | Enhanced functional connectivity within OFC networks (e.g., left anterior and posterior OFC, right OFC, etc.) was observed; repetitive practice strengthened synaptic connections; Goal attainment and perceived mastery increased dopamine release. | (; ) |
| TBI (Moderate to severe) | NMT: rhythmic training, structured cognitive–motor training, and assisted music performance | 3 months | Executive function improved significantly, as indicated by increased FAB scores (p = 0.021, r = 0.46). | Promoted white-matter structural remodeling, reflected by increased quantitative anisotropy in key regions (e.g., the right dorsal pathway, corpus callosum, thalamic radiation, and corticostriatal tract). | () |
| Executive function (p = 0.045, η2 = 0.093) and task-switching ability (p = 0.032, η2 = 0.112) improved significantly; only executive function was maintained at follow-up (p = 0.003, η2 = 0.328). | Promoted plasticity in prefrontal gray-matter structure, evidenced by increased gray-matter volume in the right inferior frontal gyrus. | () | |||
| Improved general executive function (p = 0.003, r = -0.559) and self-monitoring (p = 0.013, r = 0.485), as assessed by neuropsychological tests. | Enhanced resting-state network connectivity (FPN–DAN, FPN–SM, DAN–VIS), while reducing within-FPN hyperconnectivity and DMN-SM hyperconnectivity to optimize network efficiency. | () |
Advances in the application of music therapy in improving cognitive impairment in TBI patients.
FAB, Frontal Assessment Battery (); OFC, Orbitofrontal Cortex; FPN, Frontoparietal Network; DAN, Dorsal Attention Network; SM, Sensorimotor Metwork; VIS, Visual Network.
5 Summary and outlook
Grounded in neuroplasticity theory, this article systematically reviews the mechanisms of action, technical frameworks, and clinical evidence supporting music therapy in the rehabilitation of cognitive impairment. Research indicates that music therapy may improve both cognitive function and neuropsychiatric symptoms across a range of cognitive disorders—including AD, VCI, PD-MCI, MCI, and TBI—via multilevel mechanisms, such as upregulating BDNF, promoting hippocampal neurogenesis, and optimizing brain-network connectivity. However, clinical efficacy varies by disease stage. Music therapy appears to yield the greatest cognitive improvements in patients with MCI and early-stage AD. By contrast, in moderate to severe AD, the primary clinical role of music therapy shifts toward alleviating neuropsychiatric symptoms, underscoring the importance of early intervention. Additionally, AMI and RMI appear to exert distinct therapeutic effects. AMI emphasizes cognitive–motor training and improvements in executive function, which may be related to multisensory integration induced by active participation. RMI primarily targets emotional and stress-related responses, potentially via activation of reward circuitry and modulation of the autonomic nervous system. However, direct evidence supporting synergistic effects of combining these two modalities remains lacking.
The field continues to face substantial challenges: (1) An explanatory gap persists at the mechanistic level: evidence for alterations in molecular pathways is derived largely from animal studies, whereas evidence for brain-network plasticity is based primarily on neuroimaging; however, validated causal chains linking these levels of evidence remain lacking, making it difficult to directly attribute clinical efficacy to specific neuroplastic changes. (2) Influence of Multicultural and Musical Backgrounds: Music therapy is inherently highly individualized, and its efficacy is strongly shaped by patients’ musical backgrounds and emotional associations. However, the cited clinical studies largely involve Chinese populations and healthcare settings and typically use standardized intervention protocols to evaluate average treatment effects at the group level. Consequently, these positive findings are difficult to translate into replicable intervention guidelines. (3) Outcome Measurement Heterogeneity: The included studies used different assessment instruments, including the MMSE, MoCA, NPI, FAB, and BEHAVE-AD. Because these instruments differ in measurement properties and in sensitivity across disease stages, this heterogeneity in outcomes reduced the comparability of findings across studies and posed a substantial barrier to systematic cross-study integration. (4) Intervention models remain relatively homogeneous at the clinical-translation stage: strategies are typically implemented as fixed protocols and lack dynamic adjustment mechanisms informed by real-time patient feedback.
Future research should focus on revealing the synergistic integration pathways among multilevel mechanisms in music interventions, namely BDNF pathway activation, optimization of the salience and control networks, and preservation of white matter integrity, in order to elucidate the potential mechanisms through which these processes drive cognitive plasticity. Furthermore, incorporating real-time monitoring and feedback mechanisms into clinical trials, together with establishing a tiered, phased, and adaptive intervention framework, may render music therapy a “quantifiable science”. Meanwhile, by preserving its unique role as a carrier of human emotion, it is expected to be truly integrated into a precision rehabilitation system for cognitive disorders.
Statements
Author contributions
Z-TZ: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. J-XT: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. S-RW: Conceptualization, Writing – original draft, Writing – review & editing. L-ZL: Methodology, Writing – original draft. Z-YX: Conceptualization, Writing – review & editing. J-MW: Methodology, Writing – review & editing. JW: Funding acquisition, Writing – original draft.
Funding
The author(s) declared that financial support was received for this work and/or its publication. This research received grants from the Scientific Research Project 21YBQ057 of the Hunan Academy of Social Sciences, from the Scientific Research Project 2023XK0218 of the Hunan Disabled Persons’ Federation, and from the Scientific Research Project S202510541064 of the Department of Education of Hunan Province.
Acknowledgments
Figures were created with BioRender.com. We thank BioRender for allowing us to create the figures presented in this paper.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Summary
Keywords
clinical evidence, cognitive impairment, neural resonance mechanism, neurologic music therapy, neuroplasticity
Citation
Zeng Z-T, Tang J-X, Wang S-R, Lei L-Z, Xing Z-Y, Wang J-M and Wu J (2026) Mechanisms of action and advances in application of music therapy in improving cognitive impairment based on the theory of neuroplasticity. Front. Neurosci. 20:1828930. doi: 10.3389/fnins.2026.1828930
Received
12 March 2026
Revised
03 May 2026
Accepted
07 May 2026
Published
28 May 2026
Volume
20 - 2026
Edited by
Alice Mado Proverbio, University of Milano-Bicocca, Italy
Reviewed by
Tommaso Liuzzi, Bambino Gesù Children’s Hospital (IRCCS), Italy
Sarah Thompson, University of Colorado Cancer Center, United States
Updates
Copyright
© 2026 Zeng, Tang, Wang, Lei, Xing, Wang and Wu.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Jing Wu, jwu.music@hnucm.edu.cn
† These authors have contributed equally to this work and share first authorship
Disclaimer
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