Virtual music therapy during the COVID-19 pandemic: an updated scoping review.

Introduction

Virtual music therapy (VMT) is an innovative approach to service delivery that utilizes telehealth , which the Center for Connected Health Policy defines as a tool or a method for improving health care delivery through telecommunication technology. 1 In VMT, music therapists communicate with their clients remotely, either through videoconferencing or phone calls. The terminology surrounding online delivery varies, and several terms other than virtual therapy are commonly used. Table 1 outlines the definitions applied in this paper to clarify how each term is understood.

VMT emerged with the onset of the COVID-19 pandemic, offering an alternative and innovative approach to music therapy that overcame the temporary barriers posed by restrictions on physical contact. Before the COVID-19 pandemic, only limited evidence on the topic existed, as music therapists generally did not consider telehealth to be a viable option for their practice. 2 - 4 However, the persistent limitations on face-to-face contact and the threat of job loss led to increased use of VMT. Based on data from a survey conducted in the United States at the onset of the pandemic, more than half of music therapy respondents (approximately 54.4%) began providing their services remotely, either from home or their institutions. 5 Still, only a few studies had been published on this topic even a year after the onset of the COVID-19 pandemic. 6 Therefore, various national and international music therapy organizations sought to provide guidance on how to work in a virtual environment, address issues with sound synchronization, improve the challenging quality of musical sounds, and prevent potential harms associated with VMT.

In contrast to the situation at the beginning of the pandemic in 2019, the end of the pandemic was marked by a considerable increase in published evidence on the topic. Reviewing this evidence was a necessary step to better understand the potential facilitators and challenges that VMT may pose for different groups of clients as well as for music therapy practitioners. Moreover, some emerging concerns related to the future development of VMT also arose. At the end of the pandemic, the role of VMT in future practice was unclear, as most music therapists had returned to face-to-face sessions, and the value of the experience gained during the COVID-19 pandemic could be easily questioned. However, some literature on the topic reported that VMT may be useful in some clinical situations and/or for some clients. The use of VMT increased the availability of music therapy services, particularly for individuals who may not have easy access to music therapy services in their area. 12 Given the variety of study designs, client populations, aims, and novelty of the phenomenon, a scoping review was considered the most appropriate method to systematically map the evidence and clarify key concepts in the field. 13

The current level of conceptualization in this field does not fully meet the needs of music therapy practitioners or music therapy students. However, due to the notable developments in the area of VMT over the past 3 years, it was useful to update the scoping review published in 2021. The aim of this updated scoping review was to explore how music therapists have used VMT across different client groups during the COVID-19 pandemic. Although this is an update to the previously published scoping review, there are some differences compared to the original study. 6 While the previous scoping review primarily focused on the immediate reactions of music therapists to COVID-19, this update investigates the accumulated experiences related to VMT over a longer period, during which practitioners started to develop more complex solutions for coping with pandemic restrictions. Therefore, the aim was not only to better understand how music therapists adapted their practice to overcome challenges and barriers, but also to identify the types of equipment and technology used as an immediate response to the pandemic.

During this time, more complex information representing this field and its overall adaptation over the years became available. This enabled us to explore the types of research that have been conducted in the area, identify suitable candidates for VMT, examine specific approaches to VMT, and summarize the overall experiences of music therapists during the transition and their early experiences in their new practice setting. A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted on March 17, 2022, and no other published or in-progress scoping or systematic reviews on the topic were identified.

Review questions

How did music therapists (population) use VMT (concept) across different client groups during the COVID-19 pandemic (context)?

Specifically, we were interested in the following subquestions:

What methods and techniques are therapists using for VMT?

What have been therapists’ experiences in delivering therapy in a virtual setting?

What groups of clients do music therapists have experience with in this context?

What equipment, platforms, tools, or instruments do therapists use or need?

What facilitators and challenges do music therapists experience in VMT?

Eligibility criteria

Population

This review considered studies in which music therapists practiced VMT in any capacity. The term music therapist was defined very broadly for the purposes of this review. We included all professionals providing music therapy and even considered related health care professionals who use music for therapeutic purposes, such as music medicine and other music-based interventions. 14 Studies that used vibrations or sound without musical components, such as vibration therapy, sound therapy, and tuning fork therapy, were excluded. 15

Concept

This review included studies on remote or contactless music therapy, including online or virtual forms of therapy and teletherapy, that describe the experiences, methods, and techniques used in therapy; the types of clients in therapy; and the necessary equipment and information related to the review question and objectives. Additionally, studies that reported a combination of VMT with contact-based forms of therapy were eligible. In these cases, only data pertaining to the virtual form of the intervention were extracted, ensuring that the focus remained on remote, online, or virtual delivery.

Context

This review considered studies in the context of the COVID-19 pandemic, a situation characterized by prolonged or recurrent lockdowns and the need to transition therapeutic services to a contactless format. The pandemic period was defined by the World Health Organization as spanning March 2020 to May 2023. 16 , 17 However, studies published after the end of the pandemic but addressing this period were also included. The context includes all individuals receiving music therapy, including patients, clients, and participants, regardless of their age, diagnosis, or setting. This review does not focus on music therapy methods or services that were contactless before the pandemic; it also does not include experiences with in-person therapy that utilized protective equipment against COVID-19 infection.

Types of sources

This scoping review considered quantitative, qualitative, and mixed methods studies for inclusion. Evidence synthesis in the form of evidence implementation reports were also included. While scoping reviews, systematic reviews, and literature reviews were not included, all relevant primary sources were screened and considered. The review considered papers from peer-reviewed journals and books, as well as sources from gray literature, such as diploma theses, dissertations, and posters. Studies were included if they provided information relevant to the objectives of the review. Publications that did not offer extractable or scientifically grounded data or did not provide information pertinent to the review aims, such as newspaper articles, editorials, letters to the editor, essays, and bachelor’s theses, were excluded. All relevant sources identified in the search were carefully evaluated and considered in accordance with the predefined eligibility criteria.

Methods

This is an update of the scoping review published in 2021. The protocol is registered in OSF ( https://osf.io/tnw3c/ ). 6 All authors of the original review are members of the new review team or have agreed to the update. This scoping review was conducted in accordance with the JBI methodology for scoping reviews and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). 13 , 18 , 19 Its methods were based on those of the original review, 6 with the following changes made in the context of the post-pandemic situation:

Title: The new title does not include the term adaptation , as used in the original review. Due to the broader time span of the included studies, we understood the process of adaptation in this review as a long-term adjustment rather than acute reaction to the pandemic situation, as described in the previous review. 6

Eligibility criteria for the population: The criterion that only music therapists who had previously worked in-person with their clients before the pandemic would be included was removed. We did not identify any articles in which music therapists explicitly reported having experience with VMT prior to the COVID-19 pandemic. Consequently, this criterion, originally intended to capture prior adaptation experience, proved less applicable in the context of the current review.

Type of sources: Due to the large number of included records, we did not include newspaper articles or analyze the guidance from professional organizations, as was done in the previous review.

Review questions: The review question no longer contains the word adapt . Instead, we used the word use to better capture the broader scope of VMT practice. This shift allows us to examine how VMT is implemented, experienced, and sustained in practice more generally. In addition, we have specified the key goals of our review and translated them into a series of sub questions. This structured approach enhances clarity, and supports a more focused data collection and analysis process.

We unified the terminology throughout the article by referring to virtual music therapy . For example, in the review question, the original phrase, the remote, contactless modalities of music therapy, was replaced with virtual music therapy .

The term software is used in one of the sub questions in the protocol; however, in the manuscript, we refer to the same concept as platform in order to better reflect the broader range of digital environments and tools used in VMT practice, including not only software applications but also web-based systems and integrated service platforms.

The term benefits is used in one of the subquestions in the protocol; however, because benefits is a potentially misleading term in the context of a scoping review, it was replaced with the term facilitators .

Search strategy

A 3-step search strategy was used to locate both published and unpublished studies and was developed based on the preliminary search in MEDLINE. The search strategy aligned with the research questions stated in the protocol. No essential deviations from the protocol were made, other than what has already been discussed. The search strategy, including all identified keywords and index terms, was adapted for each included information source. The full search strategy for each information source is provided in Appendix I .

Studies published from October 25, 2020 (upper date of the search from the original scoping review), until December 31, 2024, were included in the review. The databases in which the search was conducted included Scopus, Web of Science Core Collection, CINAHL Plus with Full Text, Ovid MEDLINE(R), ProQuest Central, PubMed, and PsycINFO with PsycARTICLES. This was complemented by a thorough manual search of reference lists and relevant journals published between 2020 and 2024, including Approaches: An Interdisciplinary Journal of Music Therapy, Arts in Psychotherapy, Australian Journal of Music Therapy, Canadian Music Therapy Journal, Journal of Music Therapy, La Revue Française de Musicothérapie, Music Therapy Perspectives, Nordic Journal of Music Therapy, The New Zealand Journal of Music Therapy, and Voices . The search for unpublished studies and gray literature included Google Scholar.

Study selection

Following the search, all identified records were collated and uploaded into Rayyan (Rayyan Systems Inc. Cambridge, MA, USA) where duplicates were removed. Before commencing the main screening, a pilot test of a random sample of 50 records was undertaken to ensure consistency between the reviewers (MB and BH). The results were compared, and any differences in interpretation were discussed to refine and clarify the criteria. Once satisfactory agreement was reached, the reviewers proceeded with the main screening process. Titles and abstracts were screened by 2 reviewers (MB and BH) independently to assess their compliance with the eligibility criteria. If the decision of the 2 reviewers was unclear, a third reviewer (JK) provided a final decision. Potentially relevant papers were retrieved in full, and their citation details were imported into Rayyan. 20 Full-text studies that did not meet the eligibility criteria were excluded, and reasons for their exclusion are provided in Appendix II . Any disagreements that arose between the reviewers (MB and BH) were resolved through discussion or with the help of a third reviewer (JK). The results of the source selection and inclusion process are presented in a PRISMA flow diagram. 18 , 19

Data extraction

Data were extracted from the papers included in the scoping review by at least 2 reviewers (MB, BH, KU, BG) independently using a data extraction tool developed by the reviewers and adapted from the original JBI template (see Appendix III ). The data extracted included specific details about the therapists’ experiences, the approaches, methods, and techniques used in VMT, the types of clients and settings in therapy, and specifics including the necessary equipment relevant to the review question. Basic information about each study, such as author, year, title, country, and design (which was evaluated based on Grimes and Schultz’s approach 21 ), was also included in the extraction table. Any disagreements that arose between the reviewers were resolved through discussion or with the help of a fourth reviewer (JK or MK).

Data analysis and presentation

The results are presented in tabular format, accompanied by a narrative summary in alignment with the aims of the scoping review.

Results

Study inclusion

Through the database searches, a total of 536 records were identified after running the complete search strategy. Additionally, 21 records were identified through citation searching, and 14 records through manual searches in journals. After removing 313 duplicates, titles and abstracts were screened. We excluded 87 records based on their titles and abstracts, and a total of 171 records was sought for retrieval. After assessing the full texts against the eligibility criteria, 145 new records and 5 out of 10 records from the previous scoping review met the eligibility criteria (Figure 1 ). The reasons for the exclusion of each article can be found in Appendix II .

Characteristics of included studies

The extraction table with all the included studies is provided in Appendix IV . Approximately a third of the studies (n=53) was published in 2021, with fewer in 2022 (n=36) and 2023 (n=28). Most of the texts were from North America (n=63) and Europe (n=34), followed by Asia (n=19), and Oceania (n=16). Eighteen texts were produced through international cooperation (Table 2 ). Of the record, 86% were journal articles (n=128); theses, dissertations, conference papers, posters, abstracts, book chapters and registered clinical trials comprised the remaining 14% of sources.

Study designs

We created 2 main categories for classifying the studies: research papers and other texts. Grimes and Schultz’s 2002 classification for the quantitative study designs was applied to distinguish these 2 categories. 21 Research papers were those that clearly described the methodological aspects of the study, including objectives and hypotheses. Other texts did not contain methods, objectives, or hypotheses; instead, they were project descriptions, therapists’ reports from the practice, or case illustrations.

A significant portion of the studies consisted of research articles (69%) with various study designs. We identified 23 qualitative studies describing patients’/other persons’ experiences with VMT 22 - 44 and 6 qualitative studies focused on the experiences of music therapists. 45 - 50 Furthermore, 2 qualitative studies focused on music therapy students, 51 , 52 and single studies on creative arts therapists, 53 music facilitators, 54 musicians, 55 and private practice business leaders and clinical directors from music therapy businesses. 56 Several surveys were conducted targeting music therapists to capture their reflections on the transition from face-to-face therapy to VMT. 49 , 57 - 66 We identified 5 randomized controlled trials focusing on the effects of VMT on nurses, 67 children in a dyslexia telerehabilitation process, 68 and university students 69 ; we also identified studies on the efficacy of a group of interventions, including online music for health workers 70 and effects of exercise-music training on physical and cognitive performance in patients with Alzheimer’s disease. 71 Additionally, there were several quasi-experimental studies exploring the effects of VMT on various groups of individuals, with or without specific diagnoses, 72 - 86 and on health care workers/students. 87 - 90

An evidence implementation report was identified in 1 article. 91 The implementation project focused on applying best practice criteria to Czech music therapy practice during the COVID-19 pandemic. 91

The other texts (n=44) included practice reports 11 , 92 - 119 and theoretical descriptions of programs/models 120 - 124 or institutions, 125 reflections/considerations, 126 - 128 self-help resources, 129 and reports on the adaptation of music therapy education during the pandemic. 51 , 130 - 137

Review findings

We mapped and summarized the available evidence on how music therapists used their practice during the COVID-19 pandemic. The following section presents the extracted information and addresses the research question, along with the specified objectives.

Methods and techniques

When identifying music therapy methods and techniques described in a virtual context, we distinguished between active (n=18) and receptive (n=29) music therapy. Active methods involve clients actively creating music (eg, improvising, singing, composing) as a means of expression and communication, while receptive methods focus on listening to and responding to music to evoke imagery, emotions, or reflection. 15 In most cases (n=64), a combination of both active and receptive methods was described.

Furthermore, we identified a substantial number of specific music therapy methods applied in VMT. We classified these methods to count their frequency in the included studies, as shown in Figure 2 . Specific methods or techniques were not described in every paper; however, more than 1 method or technique was often described within a single paper. The category “other” includes specific music therapy techniques such as drumming, musical life-review/reminiscence, neurological music therapy techniques, pulse marking, and music-based reading exercises.

Listening was the most frequently reported method (n=54), followed by singing (n=53). Casellas 73 presented personalized relaxation techniques, including listening to 6 instrumental tracks chosen for their steady pace, predictable melodies, and soft tones. This type of music facilitated a connection with the listener’s memories and current emotions. The criteria for music selection included stable dynamics, gradual changes in volume, rhythm, timbre, and pitch as well as a preference for a slow tempo with a maximum volume of 60 dB. An example of creating music materials involves making one’s own musical instruments, 61 , 94 , 96 , 138 - 140 uploading videos, 94 , 139 and recording of sessions online, offering livestreams, 96 , 104 , 138 and creating newsletters 96 about using music for well-being, including articles written by patients who experienced music therapy during their cancer treatment journey. Bompard 72 mentions the use of musical improvisation and musical listening, which can be enhanced through personalized audio tracks and multisensory stimulation. Overall, the reviewed studies illustrate the wide variety of music therapy methods used in VMT, with listening and singing emerging as the most prominent forms of intervention.

The identified approaches used in VMT are summarized in Table 3 . In many records, the music therapy approach was not specified. Guided imagery and music (n=9) and neurological music therapy (n=5) were the most frequently referenced approaches.

Music therapists’ experiences

A significant number of studies focused on music therapists and music therapy students, exploring their experiences of adapting to the COVID-19 pandemic and their engagement with VMT. In total, over 3271 music therapists and music therapy students shared their experiences and practices through surveys and other types of studies, 5 , 45 - 51 , 57 - 66 , 91 , 118 , 122 , 130 - 134 , 138 , 147 - 150 while another study detailed the experiences of 114 musicians delivering virtual concerts to patients. 55 Additionally, 1226 creative arts therapists, 53 , 151 62 facilitators for singing, 54 , 152 20 students in an art therapy program, 135 20 music therapy business leaders, 56 13 students learning to play musical instruments, 52 and 12 counseling students reported their experiences. 137

Shifting to a virtual setting brought various experiences for music therapists. When asked to identify any alterations required in the therapeutic process due to the transition to telehealth during COVID-19, music therapists reported that changes were necessary in session format (55.00%), their role as therapists (43.33%), the types of music experiences provided (88.33%), and therapeutic goals (68.33%). 59 Adapting the content to focus more on turn-taking was necessary in the online format and encouraged participants to listen and respond to each other accordingly. 98 Interestingly, differences were observed between regions regarding the technological shift during COVID-19. Music therapists from North America (100%) reported that they had to embrace new technologies and techniques to conduct music therapy sessions, compared to 77.8% from Asia/Oceania, and only 48.1% from Europe. 58

The gratitude expressed by music therapists for the opportunity to continue earning money and providing services was mentioned in the original scoping review. 5 In studies added during an update, a notable transition was described in which therapists assumed roles similar to those of tech support specialists, 45 or their role as therapist shifted more toward that of facilitators providing continuous service. 98 Molyneux et al . 42 described surprise at how creative and powerful it was to compose a song with participants online.

Wilcox 47 emphasizes the importance of therapists being attuned to nuances in auditory cues, reflecting a heightened sensitivity to sounds, timing, and how individuals perceive what is happening in their practice. Other therapists highlighted their challenges, emphasizing the need for self-care and structured support systems, 46 , 105 , 122 including feelings of exhaustion 46 , 61 , 105 and the difficult cognitive transition from work to rest when working from home. 122 Some music therapy students also described uncertainty about their skill sets in an online environment, calling for the future implementation of methods for online work into their education. 134 Therapists also struggled with copyright and its application in the virtual space. 27 However, positive reflections were mentioned regarding the possibility of having multiple interns participate in one virtual session. 122

Client groups and setting

Based on the evidence, a wide range of client groups accessed VMT during the pandemic. In total, 14,195 health care workers received virtual music therapy interventions. 67 , 70 , 87 - 89 , 105 , 110 VMT was also delivered to 50 caregivers 34 , 75 , 125 , 153 , 154 and offered to more than 63 families, 102 , 139 including families with children and adolescents with visual impairments 143 and children with autism spectrum disorders. 32 , 125 , 140 , 155 Other recipients of VMT included mothers raising children with developmental disorders 29 ; mothers with infants under the age of 3 years 41 ; parents with their premature infants in neonatal units 94 , 95 , 100 ; and children with various health conditions, such as developmental delays (n=14), 72 dyslexia (n=30), 68 and neurodivergent children, 140 as well as children with other conditions. 24 , 25 Overall, 166 seniors and older adults received VMT interventions, 33 , 40 , 93 , 97 , 156 , 157 along with more than 10 individuals in palliative and end-of-life care. 26 , 103 , 108 , 119 Furthermore, 44 pairs of grandparents and grandchildren experienced VMT. 86 Individuals with a wide range of health conditions and medical diagnoses also received VMT (see Table 4 ). We have provided the number of patients in parentheses for case studies that mentioned specific patient counts. The category “cancer” includes both individuals undergoing cancer treatment and cancer survivors.

Engaging entire families can be effective when delivering VMT in a home setting. 139 Parents reported a high level of enjoyment and were pleasantly surprised at their child’s ability to remain focused during VMT sessions. 139 However, it is important to consider that specific clients, such as people with dementia, 126 disadvantaged/limited individuals, or children, may require assistance from caregivers or parents 26 to operate electronic devices and participate in sessions. Clements-Cortés et al . 126 recommend providing step-by-step guidance on using platforms and technology to both the client and their caregiver. VMT also proved beneficial for caregivers of persons with dementia. 75

In 52 studies, VMT was delivered to patients in their homes. In other cases, patients received VMT in retirement homes, 33 care homes, 154 children’s homes, or assisted living facilities/residential facilities. 32 , 85 , 159 McIntyre 98 notes that some music therapists who had access to their own premises continued to provide virtual services from there, ensuring a confidential environment for clients and easing the transition to VMT. Music therapists conducted individual sessions with clients or facilitated group sessions online. Patients in hospitals received VMT in wards or units, including nursing homes, neonatal units, hospices, hospitals, and infectious disease wards for COVID-19 patients, 11 , 23 , 33 , 38 , 39 , 55 , 78 , 80 , 82 , 88 , 94 - 96 , 98 , 101 , 103 , 108 , 112 , 119 , 128 , 142 , 144 , 162 , 163 , 169 similar to health care workers. 67 , 70 , 87 , 89 , 110 Other studies explored virtual learning environments for university students of music therapy. 54 , 62 , 66 , 69 , 130 , 133 - 135 , 149 , 150

Virtual music therapy sessions

In most studies, VMT was delivered in the form of synchronous video calls, with the length of virtual sessions varying from 30 minutes to 120 minutes per session. In a report by Welgel, 144 integrative medicine workshops, which included VMT, lasting 3 hours each. However, this was a specific format of a series of workshops that incorporated more than just music therapy interventions. Clement-Cortés et al . 126 recommended that the length of the playlists for home listening should be 10 to 15 minutes long. Similarly, in the study by Giordano et al ., 87 playlists for receptive music therapy ranged from 15 to 20 minutes, while patients in the sessions reported by Hernandez et al . 74 received meditation for 20 minutes.

Periods during which VMT interventions were applied ranged from 1 session to 6-month 83 programs. In the study by Fekete and Eckhardt, 145 working with the aphasia choir lasted for 7 months. Furthermore, music therapists worked virtually with their clients once, twice, 3 or even 4 times per week. Most often, music therapists chose to conduct VMT sessions once a week. 23 , 28 , 31 , 33 , 40 , 41 , 86 , 93 , 96 , 97 , 144 , 146 However, a higher frequency of intervention was observed in one study where listening to specially created music for 1 hour daily relieved anxiety and depression in medical workers in a Chinese study. 88 Ettenberger et al ., 95 in a study focusing on music therapy in the neonatal setting, states that VMT was conducted 3 times a week at this intensity, ensuring that even with limited contact between parent and child, some form of connection could be maintained.

Platforms and equipment

The use of specific virtual platforms was mentioned in 100 studies, highlighting the importance of selecting an appropriate platform for quality service delivery in a virtual setting. Zoom (n=84), Skype (n=12), Microsoft Teams (n=10), Doxy.me (n=8), FaceTime (n=8), WhatsApp (n=6), Webex (n=4), Google Meets (n=2), Pexip (n=2), WeChat (n=2) and Coviu (n=1) were reported as platforms for VMT delivery, with Zoom being the most commonly used. A word cloud (Figure 3 ) visually illustrates the frequency of the platforms referenced in the studies.

The importance of good-quality platforms was emphasized in many cases, highlighting the need for high-quality sound and video sharing to support interaction with music and online instruments, as well as the integration of other tools for therapeutic work. 11 , 24 , 25 , 46 , 68 , 92 , 107 , 126 , 138 Concerning security and privacy, it is essential to choose a password-protected link and a data-encrypted platform when sharing connection details, with the option to set limited access for clients only. 98 Maintaining confidentiality and privacy is crucial when providing VMT and, therefore, the use of headphones is encouraged, especially during VMT conducted in a home setting. Headphones also help to ensure higher sound quality and isolation from surrounding distractions. 46 Technical reliability is vital for the smooth running of virtual sessions and can be enhanced by using an ethernet cable to secure a stable and reliable internet connection, minimizing latency during interaction. 24 , 45

A comprehensive overview of platforms, applications, programs, and virtual instruments reported in all records can be found in Figure 4 . The choice of a platform was often related to the specific music therapy method or technique, as well as the nature of the music therapy session. In terms of video sharing, one of the most user-friendly platforms was YouTube. 31 , 47 , 51 , 61 , 94 , 96 , 104 , 106 , 109 , 110 , 129 , 138 , 139 , 147 , 170 Therapists can share a variety of music and videos, and clients can also upload their music-making videos under a protected link. Spotify has proven to be a popular platform for creating playlists and listening to music while providing VMT services. 31 , 45 , 61 , 75 , 96 , 107 , 138 Another application specifically designed for music therapy purposes is the Therapeutic Listening app. 50 This app allows therapists to create and share therapeutic listening programs that can be adapted to the individual needs of clients.

Creating music

Several apps are suitable for VMT when it comes to creating music. McLellan lists GarageBand as a popular music-creation app available on various devices, including smartphones, tablets, and computers. 121 This app enables therapists and clients to create their own music and experiment with different sounds and instruments, which can have therapeutic benefits and foster creativity. Other applications for music creation include Abletone, Audacity, Aumi, Beams, Drumeo, Icredibox, Thumbjam, Ultimate Guitar, and Virtual Piano, all of which offer various possibilities for music creation, musical education, and creative expression.

Virtual musical instruments

Advanced technologies, such as eye-gaze systems, are also suitable for VMT. EyeHarp is an example of technology that enables people with disabilities to play virtual musical instruments using eye movement. 121 Several portable MIDI devices, such as Artiphon Orba, Roli Blocks, and Sensel Morph, also allow therapists and clients to play virtual instruments. 121 For live streaming and hosting musical gatherings, Facebook Live was mentioned. 102 This interactive form of music therapy allows clients to engage with music and communicate with the therapist in real time.

Equipment

We have briefly mentioned equipment throughout this review, particularly the importance of headphones for privacy and better sound quality. Other technical equipment for VMT includes laptops, computers, tablets, iPads, mobile phones, 360-degree rotatable tablets, televisions, microphones, voice recorders, external microphones, internet access, an audio interface, long USB ethernet cables, USB cameras, and high-quality speakers. Additional equipment included large sheets of paper for writing song lyrics, 93 song boards, puppets, books, and flipbook schedules. 26 Music instruments for accompaniment should also be included (eg, noise makers such as egg shakers, tambourines, and bells, along with other musical instruments, including ukuleles, guitars, percussion instruments, and handpans).

Challenges of virtual music therapy

Challenges associated with the delivery of VMT were mentioned in 86 records and were categorized into several subcategories (see Figure 5 ).

Technical issues

Technical issues 57 were reported in the following areas: connectivity, 24 - 26 , 34 , 35 , 51 , 57 , 58 , 62 , 90 , 133 , 147 , 154 , 156 , 159 , 168 audio cutting in and out, 62 poor audio/sound quality, 35 , 48 , 57 , 58 , 63 , 79 , 118 , 154 delayed audio and time lag, 46 , 48 , 57 , 58 , 61 - 63 , 89 , 98 , 101 , 104 , 107 , 108 , 118 , 126 , 130 , 138 , 143 , 145 , 147 , 154 not knowing how to use apps/software, 62 the need to mute/unmute, 62 screen freezing and pixelation, 26 , 171 and reduced sound quality. 89 A number of articles reported challenges with audio synchronization in online sessions. 35 , 41 , 59 , 92 , 99 , 107 , 118 , 126 , 130 , 135 , 140 , 151 , 159 Group improvisation was limited because current technology does not allow for simultaneous playing or singing. 99 In response to this challenge, Gelfand 45 introduced referential sound-scaping, in which the client’s voice is recorded so that they can sing along with themselves. Individuals with intellectual disabilities or learning difficulties faced challenges using the technology independently. 25

Communication and presence issues

According to some authors, the lack of physical presence 57 , 58 , 140 , 145 , 168 hindered nonverbal communication, 92 , 98 leading to the inability to provide physical cues both from music therapists to patients and vice versa. 33 , 41 , 48 , 53 , 57 , 63 , 96 , 147 Sensory information that would typically be available in person was reduced, 28 , 161 making it difficult to observe patients’ breathing patterns 53 , 104 and read body language. 30 , 151 Other reported issues included the loss of shared physical space, 53 , 140 challenges with creating a separate workspace at home, 122 , 171 and a lack of personal connection between the therapist and client. 57 , 98 , 149

Online space challenges

Issues related to online space included screen fatigue, 46 , 54 , 57 , 133 difficulty maintaining focus 24 and engagement, 63 , 138 , 155 a lack of privacy, 141 and a general lack of enjoyment in talking to a computer. 145 Marié-Bailly and Varquet pointed out that videoconferencing often involves exposing our private environment, 109 which is an important part of personal intimacy. 151 Additionally, videoconferencing requires participants to feel comfortable presenting themselves on camera. 109 In some cases, participants chose to turn off their cameras, preventing the therapist from observing their behavior during the session. 74

Instrument-related challenges

Challenges related to instruments included the patient’s inability to tune their instrument or the lack of access to an instrument at home. 61 , 62 , 91 , 107 , 108 The need for physical guidance on body positioning posture and finger placement when playing musical instruments, as well as assistance with instrument setup and maintenance, were issues that could not be addressed in a virtual setting. 62

Challenges for music therapists and caregivers

Challenges were also reported by music therapists, including a lack of prior training on working in an online setting. 48 , 58 , 91 Therapists also experienced exhaustion, anxiety, and even back pain as a result of working in a virtual environment. 48 , 56 , 63 , 134 , 138 , 171 Music therapy students also reported worries about the online placement not providing them with the full range of learning opportunities. 150

Caregivers also faced significant challenges in supporting VMT clients. 49 , 57 , 126 Additionally, Sinkuniene and Zalgiryte-Skurdeniene 29 emphasized the importance of thoroughly understanding security and confidentiality in a virtual setting.

Barriers to virtual music therapy

In terms of barriers, limited data access and internet connectivity were seen as obstacles. 39 , 42 , 48 , 63 , 139 , 152 Likewise, the lack of electronic devices hindered some individuals from participating in VMT. 58 , 139 Small phone screens were found to be minimally engaging for young children. 139 VMT also presented communication barriers. 33 Music therapists faced challenges related to insufficient skills and education in information and communication technologies (ICT) usage, as well as the cost and unavailability of ICT. The need for more support and education in the use of ICT in music therapy was reported. 60 Additionally, transitioning to telehealth raised concerns about copyright laws, which may limit the presentation and use of music. 27

Facilitators of virtual music therapy

Several factors have been identified as facilitators for the successful delivery of VMT. Accessibility emerged as a key facilitator. 40 , 43 , 93 , 154 , 158 , 170 In the study by Cole et al ., 39% of respondents cited accessibility factors as an advantage enabling telehealth. 57 These included improved access for clients in remote areas, 92 the ability to attend sessions while unwell, 39 reaching clients with reduced mobility or those without access to music therapists in their region, 125 and financial accessibility. 138 , 149

The ability to continue sessions during COVID-19 was a significant facilitator for both music therapists and patients across all areas. 52 , 58 , 63 Attending music therapy sessions virtually from home offered several advantages, such as not needing to wear a mask, 140 receiving therapy in the comfort of the patient’s home, 24 reduced travel time, 41 , 63 maintaining a sense of routine/structure for the week, 23 , 41 ensuring safety during the COVID-19 pandemic, 133 and providing a way to connect with others during isolation, 157 , 159 fostering a sense of belonging, community, and social connection. 23 , 28 , 42 , 48 , 63 , 96 , 124 , 137 , 142 , 155 Additionally, more infants were able to participate at the same time, as they could participate from their rooms. 100 Music therapy programs were described as the highlight of the week for the participants in the paper by Forrest et al . 96 VMT also enabled long-distance emotional support, allowing participants to share and validate their experiences. 96 However, some aspects were seen as both challenges and facilitators. For instance, while 1 study reported difficulties in maintaining clients’ engagement, 57 , 138 another study described increased client attention due to the excitement surrounding telehealth. 49

Discussion

The current update identified 145 new records, significantly expanding the evidence from the original review, which included 10 records. Most of the evidence emerged in 2021 (n=53), with a slight decrease observed in subsequent years. The variety of text types has broadened considerably, greatly increasing the number of research papers and creating a significant difference compared to the original review. More than two-thirds of the records were classified as research papers according to our criteria. We found quantitative, qualitative, and mixed methods evidence. The designs of the quantitative research primarily consisted of surveys on music therapists’ experiences in adapting to the VMT practice, as well as quasi-experimental studies focusing on the effects of VMT on various groups. Of all the research papers, only 4.8% were randomized controlled trials 67 - 71 and only 1 protocol for a randomized controlled trial was identified. 172 Compared to the original review, we identified a greater number of qualitative papers describing clients’ experiences. However, comparison of the effectiveness of VMT and in-person therapy could be an ongoing topic for further research.

VMT gained prominence during the pandemic, marked by a notable shift in technological adoption across regions. 58 Upon examining the differences and specifics between traditional in-person music therapy practice and VMT, we identified several distinctions. Communication in an online environment diminishes important cues and information that are typically present in face-to-face settings. It also limits therapists’ ability to use certain techniques, often requiring them to learn new methods that are better suited to the online environment. 159 While viewing this transition as an opportunity for creativity and personal growth, it can also lead to stress and be time-consuming. Regarding music therapy methods, singing and listening generally proves to be more effective than playing instruments. Structured instrumental activities involving turn-taking and call-and-response patterns faced fewer challenges than improvisation. 143 Delivering VMT at home requires either providing instruments or employing techniques that do not rely on client-owned instruments. A creative solution involves assisting clients in creating their own instruments or using non-musical objects for music-making. Additionally, songwriting and music creation can be effectively facilitated using various programs, making this approach suitable for those who enjoy engaging with computers.

VMT works with various client groups, including a newly emerging group of health care workers and caregivers transitioning from caregiving roles into the client group. While this shift appears to be specific to the pandemic context, highlighting the need for their support beyond the pandemic may be an important observation. Music therapists engage virtually with individuals, groups, or families, although certain populations, such as young children and those resistant to VMT, may be less suitable for this approach. 46 Working with families involves parents in the therapeutic process, which can significantly benefit the family as a whole.

VMT has been applied to a wide range of medical populations, although some diagnoses have only appeared in studies once (eg, schizophrenia 81 ) or twice (eg, epilepsy 26 , 78 ). People with visual impairment were mentioned in only 3 studies, 109 , 143 , 153 highlighting a lack of vibroacoustic and tactile opportunities for them. This raises the question of whether people with hearing impairment, who were not mentioned in any of the studies, are suitable for VMT for similar reasons. In contrast, VMT for people with dementia or cancer appears to be promising, with a significant number of studies highlighting these groups. Additionally, the social aspect of VMT can effectively address the isolation experienced during the pandemic.

The potential of VMT as a treatment option has been highlighted in various settings, especially for individuals with reduced mobility or limited access to in-person music therapists. 125 Overall, accessibility is a significant facilitator of VMT. Many authors have described challenges and, for most of the challenges, there is at least a partial solution. There is a need for high-quality sound, confidentiality, privacy, the use of well-developed platforms, and good-quality technical equipment. The need for privacy highlights the ethical aspects as another theme within VMT, which must be taken into account. Delivering music therapy to rural and regional communities may be simplified through virtual format. 138

Both the facilitators and the barriers of VMT for future use and for the music therapy profession must be considered. In certain circumstances, such as a pandemic or in the event the therapist cannot be physically present, VMT can provide important support during the therapeutic process, ensuring continuity. However, the shift to the virtual space has had a more significant impact on music therapy practice compared to other arts therapies. 151 This may be related to the nature of music-making, which relies on the present moment and connection through sounds and vibrations. Therefore, outside of pandemic restrictions, music therapists do not perceive VMT as a replacement but rather as a complementary service to regular face-to-face music therapy. 91 At the same time, skills for adapting music therapy methods for online use and leading virtual sessions should be integrated into the education of music therapy students to prepare them for the possibility of facing pandemics or other types of restrictions in the future.

Strengths and limitations

This review provides insights into VMT practices during the COVID-19 pandemic, primarily focusing on this period and not extending its analysis to post-pandemic scenarios. The future trajectory of VMT remains uncertain, as experiences gained during lockdowns may not seamlessly translate into sustained popularity once face-to-face therapeutic options become available again. The search strategy for this review was conducted in English. As a result, relevant evidence published in other languages may have been overlooked.

Conclusions

The global music therapy community adapted to the pandemic restrictions imposed by COVID-19 through the widespread application of VMT. This comprehensive analysis reviewed a substantial body of relevant evidence (n=150), providing detailed insights into the nuances of VMT practice. The expansion of VMT brought challenges and barriers, but also opportunities to identify facilitators within this emerging mode of therapy. Music therapists reflected on changes made in session format, their role as a therapist, as well as their therapeutic goals. These insights may guide practitioners in deciding whether to incorporate virtual sessions for specific clients or situations.

Studies have shown that music therapists explored which methods and techniques were most suitable for online work, most frequently combining active and receptive methods, with singing, listening, and music-based relaxation or imagery methods being the most common. Improvisation via online platforms presented considerable challenges, particularly regarding the synchronization of sound. This highlighted the need for turn-taking.

The establishment of VMT on a global scale also brings ethical considerations and the need for modern technologies, not only for therapists but also for clients. VMT has been applied across a wide range of populations and settings, including home-based and health care environments. Moreover, music therapy students were required to adapt to online learning, which further integrated VMT into educational contexts and highlighted the need for both students and educators to adapt.

An updated review in 5 years will be essential to evaluate the ongoing development of VMT in the post-pandemic era.

Implications for research

Future research on VMT is necessary to explore its development under post-pandemic conditions and to assess the impact of VMT on the music therapy profession. Additionally, studies comparing effectiveness of VMT to face-to-face therapy, particularly focused on different music therapy approaches and methods conducted online, will be useful in evaluating the appropriateness of VMT sessions.

Acknowledgments

Librarians, Zuzana Svobodová and Hana Pechová, for conducting the database searches. Kamila Urbanová and Barbora Goffi, for their valuable assistance with data extraction.

Funding

MB and JK received funding from University Palacky Olomouc, Faculty of Education, for the project IGRACEK titled, Evidence Synthesis in Special Education and Arts Therapies, DSGC 2021-0145. JK received funding from University Palacky Olomouc, Faculty of Education for the project, Arts Therapies and Digital Platforms, IGA_PdF_2026_027. The funders did not have any input into the conduct of the review.

Author contributions

JK, MB, BH, and MK contributed to the conceptualization of the project; MB, BH, KU, BG contributed to data collection; MB, BH, and JK contributed to data analysis; MB and BH contributed to writing the original draft; JK and MK supervised the project; MB, JK, MK, and LP-L contributed to the finalization of the draft.

Search strategy

Studies ineligible following full-text review

Dantas AC, de Medeiros Araújo JN, Coutinho Borges BE, da Silva AB, da Silva Medeiros HP, et al . Spiritual care and spirituality in academic nursing training: scoping review. Avances Enferm 2023;41(2):412010av-412010av.

Reason for exclusion: Ineligible concept

Do Vale Coutinho V, de Mendonça ÉT, de Sá Diaz FBB. Experiences coping of COVID-19 in long-term institutions for the elderly. Rev Medicina 2022;56(2).

Reason for exclusion: Ineligible concept.

Evans M, Shah P, Pearson C, Bouchard D, Curry T. Providing music therapy on inpatient mental health units in Canada: reflection on practice during the COVID-19 pandemic. Can J Music Ther 2022,28(1):44-56.

Reason for exclusion: Ineligible concept.

Fuller A. “This is Australia…online music therapy…Down Under…” Telehealth approaches to music therapy within Australia during the COVID-19 pandemic. Aus J Music Ther 2021;32(1).

Reason for exclusion: Ineligible type of text: editorial.

Giordano F, Muggeo P, Rutigliano C, Barzaghi F, Battisti L, Coccia P, et al . Use of music therapy in pediatric oncology: an Italian AIEOP multicentric survey study in the era of COVID-19. Eur J Pediatr 2023,182(2):689-96.

Reason for exclusion: Ineligible concept.

Howlin C, Hansen, N. Music in times of COVID-19 [internet]. OSF; 2022. Available from: https://osf.io/preprints/psyarxiv/z94fq_v1 .

Reason for exclusion: Ineligible type of text: literature review.

Kantorová L, Kantor J, Hořejší B, Gilboa A, Svobodová Z, Lipský M, et al . Adaptation of music therapists’ practice to the outset of the COVID-19 pandemic—going virtual: a scoping review. Int J Environ Res Public Health 2021;18(10):5138.

Reason for exclusion: Ineligible type of text: scoping review. This is the previous scoping review that we have updated.

Liew Stewart A. Providing supports for ‘covid mums’ through an adapted Sing&Grow group program. Aus J Music Ther 2021;32:2.

Reason for exclusion: Ineligible concept.

Liu Z, Yang Z, Xiao C, Zhang K, Osmani M. An investigation into art therapy aided health and well-being research: a 75-year bibliometric analysis. Int J Environ Res Public Health 2021;19(1):232.

Reason for exclusion: Ineligible concept.

Luo X, Zhang Z, Shi X, He C, Wang J, Wu Q, Huang G. Arts therapies for mental disorders in COVID-19 patients: a comprehensive review. Front Public Health 2023;11:1289545.

Reason for exclusion: Ineligible concept.

MacDonald R, Burke RE, De Nora T, Donohue ML, Birrell R. Our virtual tribe: sustaining and enhancing community via online music improvisation. Front Psychol 2021;11:623640.

Reason for exclusion: Ineligible concept.

Magee WL, Meadows T. Transitioning to teletherapy during COVID-19. Nordic J Music Ther 2022;31(3):199-202.

Reason for exclusion: Ineligible type of text: editorial.

McKinlay AR, Collins L, Fancourt D, Burton A. How did female survivors of abuse use the arts to support their mental health and wellbeing during the COVID-19 pandemic? A qualitative exploration of their views. Lancet 2022;400:S63.

Reason for exclusion: Ineligible concept.

Raglio A. Therapeutic music listening as telehealth intervention. Complement Ther Clin Pract 2020;41:101245.

Reason for exclusion: Ineligible type of text: letter to editors.

Surya N, Srivastava A, Nagda T, Palande D, Someshwar H. Education, training, and practices of neurorehabilitation in India during the COVID-19 pandemic. Front Neurol 2021;12.

Reason for exclusion: Ineligible concept.

Wang CC, Lo J, Saunders R, Adama E, Bulsara C, Etherton-Beer C, et al . Light acupuncture and five-element music therapy for nurses’ mental health and well-being during and post-COVID-19: protocol for a randomised cross-over feasibility study. BMJ Open 2022;12(4):e057106.

Reason for exclusion: Ineligible concept.

Vinciguerra C, Federico A. Neurological music therapy during the COVID-19 outbreak: updates and future challenges. Neuro Sci 2022;43(6):3473-8.

Reason for exclusion: Ineligible type of text: literature review.

McCaffrey T, McFerran K, Gattino G, Sundar S. The Global Music Therapy Educators Network. Br J Music Ther 2020;34(2):80-1.

Reason for exclusion: Ineligible type of text: essay.

Kurta T. Is music therapy an essential service? A personal reflection on the significance of music therapy in health care during COVID-19. Can J Music Ther 2022;28(1):39-43.

Reason for exclusion: Ineligible type of text: essay.

Wolfe CL. Feasibility and effectiveness of group telemusic therapy with adult survivors of acquired brain injury (ABI): a retrospective pilot trial [thesis]. Temple University; 2021.

Reason for exclusion: Ineligible context. This study was conducted in pre-pandemic setting.

Kelly L, Kenny N, McGlynn C, Richardson I, Moss H. Exploring the experiences of a person with dementia and their spouse who attended a telehealth music therapy programme: two case examples from Ireland. Nordic J Music Ther 2024;33(4):281-98.

Reason for exclusion: Ineligible context. This study was conducted in post-pandemic setting.

Mercadal-Brotons M, Pulice G, Martí P, De Castro M, Vernet M. Online support program for the use of music-based resources for daily care for families living with dementia. Music Ther Perspect 2024;42(1):18-27.

Reason for exclusion: Ineligible context. This study was conducted in post-pandemic setting.

Pearson C, Sham R, Gardner S, Klapman S, Altschuler A. Perceived quality of online music therapy sessions by older adults aging at home. Can J Aging 2023;42(4):607-20.

Reason for exclusion: Ineligible context. This study is not pandemic related.

Quigley H, MacDonald R. A qualitative investigation of a virtual community music and music therapy intervention: a Scottish–American collaboration. Musicae Scientiae 2024;28(3):573-90.

Reason for exclusion: Ineligible context. This study is not pandemic related.

Shi M, Yang L, Qumu S, Lei J, Huang K, He R, et al . Efficacy and safety of a music-therapy facilitated pulmonary telerehabilitation program in COPD patients: the COPDMELODY study protocol. Front Med 2024;11:1361053.

Reason for exclusion: Ineligible context. This study is not pandemic related.

Richard Williams N, Hurt-Thaut C, Brian J, Tremblay L, Pranjić M, Teich J, et al . Improved motor skills in autistic children after three weeks of neurologic music therapy via telehealth: a pilot study. Front Psycho 2024;15:1355942.

Reason for exclusion: Ineligible context. This study was conducted in post-pandemic setting.

Studies excluded from the original scoping review

Spectrum Retirement Communities, LLC. The enclave at Round Rock Senior Living hosts a patio music party with the help of North Austin Music Therapy [internet]. PR Newswire; 2020. Available from: https://www.prnewswire.com/news-releases/the-enclave-at-round-rock-senior-living-hosts-a-patio-music-party-with-the-help-of-north-austin-music-therapy-301030105.html .

Reason for exclusion: Ineligible type of text: newspaper article.

College of Music to continue successful virtual tele-therapy services. US Fed News Service Including US State News, 25 August 2020.

Reason for exclusion: Ineligible type of text: newspaper article. The source could not be retrieved.

Little R. Music school’s virtual approach proves a hit. Aberdeen Evening Express, 4 June 2020.

Reason for exclusion: Ineligible type of text: newspaper article. The source could not be retrieved.

Berman A. Music connects us: the use of music and the role of music therapy during a pandemic crisis situation [internet]. EMTC; 2020. Available from: Emtc-eu.com.

Type of text: Flyer

Reason for exclusion: The source could not be retrieved.

North London Music Therapy. Music therapy in the time of COVID—how NLMT’s remote sessions actually work [internet]. NLMT; 2020. Available from: https://www.northlondonmusictherapy.com/post/music-therapy-in-the-time-of-covid-how-nlmt-s-remote-sessions-actually-work .

Reason for exclusion: Ineligible type of text: website article.

Data extraction instrument

Characteristics of included studies

Footnotes

MK is as associate editor of JBI Evidence Synthesis but had no input into the editorial processing of this review. The other authors declare no conflicts of interest.

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