综述：治疗性器乐演奏对脑瘫儿童上肢运动功能影响的系统评价

《Brain and Cognition》：Effects of therapeutic instrumental music performance on upper limb motor function of children with cerebral palsy: A systematic review

本综述系统评价了治疗性器乐演奏（TIMP）对脑瘫儿童（CwCP）上肢运动功能的疗效。通过对8项研究（共105名CwCP）的分析表明，TIMP能有效改善患儿的手部精细运动与上肢粗大运动功能，其机制可能与促进神经可塑性有关，为临床康复提供了循证依据。

　　

Abstract

Therapeutic instrumental music performance (TIMP) can be used to improve limb motor function in children with cerebral palsy (CwCP). The purpose of this systematic review is to further analyze the potential therapeutic effects of TIMP on upper limb motor function in CwCP. We used the terms "music," "therapeutic instrumental music performance," "musical instruments," "cerebral palsy," "children," "upper limb," and "upper extremity" as our search keywords, and conducted a search of articles published in English and Chinese databases: PubMed, Cochrane, Web of Science, Wiley Online Library, CINAHL, and CNKI, Wanfang Data as of March 2025. Initially, 409 articles were retrieved. After screening titles and abstracts and assessing eligibility, eight studies were included in this review. All studies assessed hand fine motor function, and five also evaluated upper limb gross motor function. Three studies used only keyboard instruments, two exclusively percussion instruments, and three combined keyboard, percussion, and plucked instruments. The results demonstrated that TIMP effectively improves upper limb motor function in CwCP.

Introduction

Cerebral palsy (CP) is a static neurological disorder commonly observed in children, with a prevalence of approximately 0.2–0.3% [1,2]. Children constitute 74% of the total affected population [2]. CP comprises three types: spastic, dyskinetic, and ataxic, each with heterogeneous clinical symptoms [3]. Among them, spastic CP is the most common form, with a prevalence of up to 80%. It is characterized by upper motor neuron involvement, resulting in involuntary muscle spasms, morphological changes, postural abnormalities on the affected side, and impairments in proprioceptive and motor functions. Due to damage in the motor cortex and corticospinal tracts, children exhibit motor dysfunction and limb motor incoordination, either unilaterally or bilaterally [4]. Dyskinetic CP is the second most common type, with an incidence of about 15%. The involvement of the basal ganglia results in slow, writhing, involuntary movements of the proximal limbs and torso (bradykinesia), or sudden, rapid, large movements (choreoathetosis type) [4]. The rarest type of CP is ataxic CP, with a prevalence of only about 5%, this type primarily results from cerebellar involvement or its pathway involvement. Affected children suffer from poor gait due to weakness, poor coordination, and intentional tremor, making it difficult to perform movements quickly or precisely [4]. CP is not attributable to a single etiology but rather represents a heterogeneous clinical syndrome arising from immature brain tissue or white matter damage [1]. The pathogenesis involves multifactorial causes, including hypoxia, hemorrhagic/ischemic stroke, infections, trauma, cerebral malformations, hypotension, non-progressive genetic disorders, often accompanied by an inflammatory cascade triggered by the initial injury [5,6]. This damage occurs before the completion of brain development, with a prevalence of up to 80% in prenatal fetuses and 10% in postnatal infants [7].

Therapeutic instrumental music performance (TIMP) is a neurologic music therapy technique wherein patients actively play musical instruments to restore functional movement patterns in impaired limbs [8]. Since children with cerebral palsy (CwCP) typically exhibits severe upper limb motor deficits that cause difficulties in daily activities, such as grasping, which seriously affect their quality of life, TIMP is commonly used to rehabilitate upper limb movement in CwCP. The training approach focuses on improving range of motion, functional movement, and coordination of the affected limb by having CwCP play accessible percussion, plucked, and keyboard instruments [9]. The ability of this approach to enhance neuroplasticity — through continuous bidirectional information transfer between sensory and motor brain areas, combined with auditory and visual feedback — may underlie the mechanism by which TIMP improves upper limb dysfunction in CwCP [9]. The use of TIMP for upper limb motor deficits in CwCP modulates motor output from the cortical areas controlling upper limb function, inducing both structural and functional neuroplastic changes within the central nervous system to improve fine and gross motor performance [10].

Previous studies have extensively investigated the therapeutic effects of TIMP on upper limb motor function in CwCP. The majority of these studies demonstrated significant improvements in upper limb function following TIMP interventions when compared to both pretreatment baselines and control groups. Nevertheless, a comprehensive systematic review evaluating the efficacy of TIMP for upper limb rehabilitation in CwCP remains lacking. Given that upper limb motor dysfunction in CwCP substantially compromises activities of daily living for affected children and their families, there exists a pressing need for evidence-based therapeutic interventions. This systematic review therefore employed a rigorous methodology to objectively assess TIMP's effects on upper limb motor function in CwCP, with the dual objectives of evaluating its therapeutic validity and establishing an evidence base for clinical implementation.

Search strategy

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was performed in English databases (PubMed, Cochrane, Web of Science, Wiley Online Library, CINAHL) and Chinese databases (CNKI, Wanfang Data) for articles published up to March 2025. The search strategy incorporated the following key terms: “music,” “therapeutic instrumental music performance,” “musical instruments,” “cerebral palsy,” “children,” “upper limb,” and “upper extremity.”

Studies selection

A total of 409 studies were retrieved. 104 duplicates were deleted, leaving a total of 305 studies for which titles and abstracts were read. During the initial screening, titles and abstracts were reviewed, resulting in the exclusion of 261 studies that did not meet the requirements and articles that were not available in full. A total of 44 studies were read and reviewed in full. Here, we sifted through the studies that met the requirements and included eight studies with a total of 105 CwCP.

Discussion

In recent years, an increasing number of studies have explored the therapeutic effects of TIMP on upper limb motor function in CwCP, and this systematic review seeks to scrutinize all research on the effectiveness of TIMP on motor abilities in CwCP by evaluating the studies incorporated. Based on the analysis of included studies, we found that these studies reflected the therapeutic effect of TIMP on upper limb motor function in CwCP by assessing hand fine motor and upper limb gross motor, and the results were positive. The included studies utilized a variety of instruments, including keyboard, percussion, and plucked instruments, either alone or in combination. This diversity in intervention suggests the adaptability of TIMP. The underlying mechanism for improvement is believed to be linked to the enhancement of neuroplasticity through multisensory integration (auditory, visual) and continuous sensorimotor feedback during instrument playing.

Strengths and limitations

While various past studies have investigated the impact of TIMP on CwCP, the majority have focused solely on lower limb motor functions in CwCP. Moreover some studies have combined assessments of both upper and lower limbs without further refining the research, leaving the unclear impact of TIMP on the upper limb motor function in CwCP, which is the focus of our study. This systematic review evaluates all experimental studies of TIMP for upper limb motor function, and all indices were extracted from the included studies, which is a strength. A limitation of this review is the relatively small number of included studies and the heterogeneity in intervention protocols and outcome measures, which precluded a meta-analysis. Future studies with larger sample sizes and standardized protocols are needed.

Conclusion

This systematic review included eight studies, all of which provided preliminary evidence for the efficacy of TIMP in improving upper limb motor function in CwCP. Collectively, these results not only establish a solid theoretical foundation for using TIMP to treat upper limb dysfunction in CwCP but also offer clear clinical guidance for clinicians. However, it remains unclear which TIMP treatment modality is most effective for specific CwCP subtypes. Future studies could therefore start from this point to further refine intervention strategies for personalized rehabilitation.

Author's contribution

Z. L. conceptualized the entire manuscript, Z. L. and M. J. jointly searched databases for screening studies and assessed them for risk of bias, M. J. created tables and figures, Z. L. wrote the manuscript, and M. J. and Z. L. jointly reviewed the manuscript and Z. L. completed the final revisions.

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.