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Abstract
Objectives Frail older adults need to improve their health through exercise, and effective interventions are necessary to ensure their participation. Exercise with music has been shown to enhance adherence among older adults and improve both physical and mental health outcomes, making it a suitable intervention for frail older adults. This study evaluated the impact of exercise with music on the physical and emotional health of frail, community-dwelling older adults.
Design A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.
Data sources MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane Library, PsycINFO, Google Scholar and the Virginia Henderson International Nursing Library were last searched on 14 March 2025.
Eligibility criteria for selecting studies We included randomised controlled trials (RCTs) and non-RCTs that applied exercise with music to community-dwelling frail older adults.
Data extraction and synthesis Five independent reviewers used standardised methods to search, screen and code included studies. Study quality was assessed using the revised Cochrane Risk of Bias 2 tool and the Risk of Bias in Non-Randomized Studies of Interventions tool. A meta-analysis and narrative synthesis were conducted, and the findings were summarised using Grading of Recommendation, Assessment, Development, and Evaluation evidence profiles. Publication bias was checked, and sensitivity analyses were used to assess the robustness of the results.
Results After screening the initial 1425 studies, 17 studies (13 RCTs and 4 non-RCTs) were analysed. The overall risk of bias indicated that two had high risk and three had serious risk among the RCTs, and two had serious risk and two had moderate risk among the non-RCTs included in the meta-analysis. As for physical health outcomes, studies reported on frailty, Timed Up and Go (TUG), handgrip strength, falls, balance, gait speed, endurance and other performance. As for emotional health outcomes, studies reported on depression, social support and activities, quality of life or satisfaction and cognitive function. The pooled analysis suggested that exercise with music may have a positive effect on reducing frailty (standardised mean difference (SMD)=−0.20, 95% CI=−0.34 to −0.07, p=0.003, I2=0%; very low certainty) and decreasing depression levels (SMD=−0.40, 95% CI=−0.65 to −0.15, p=0.002, I2=0%; very low certainty) compared with control group outcomes in non-RCTs. However, there was no effect on the TUG and handgrip strength. A narrative synthesis of evidence suggested potential beneficial effects on frailty and depression.
Conclusions Exercise with music may help improve frail older adults’ physical and emotional health and potentially reduce the burden of frailty. However, further rigorous investigation is needed, as the evidence has a very low level of certainty. Additionally, results from this review should be interpreted with caution because of concerns associated with the risk of bias. Community-based health professionals should consider using music when providing exercise interventions to frail older adults, while applying tailored approaches that consider their unique needs.
PROSPERO registration number CRD42022369774.
- Aged
- Exercise
- Frailty
- Review
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. All data generated or analysed during this study are included in this published article.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
This systematic review and meta-analysis included both randomised controlled trials (RCTs) and non-RCTs to provide a comprehensive evaluation of the effects of exercise with music on frail older adults.
The Risk of Bias 2 tool and the Risk of Bias in Non-Randomized Studies of Interventions tool were used to assess the overall quality of the evidence.
We used the Grading of Recommendation, Assessment, Development, and Evaluation approach to assess the certainty of the evidence.
Many studies were excluded from the meta-analysis due to differences in outcome measures and methodologies, reducing the scope of the quantitative synthesis.
The absence of control groups performing exercises without music in all studies made it difficult to isolate the specific effects of music in the interventions.
Background
Globally, populations are ageing rapidly. The WHO predicted that between 2015 and 2050, the proportion of older adults aged 60 years and over will increase from 12% to 22%.1 The challenge of addressing frailty is emerging to prevent adverse health outcomes such as mortality, hospitalisation, institutionalisation and falls2 in a rapidly ageing society. A systematic review reported that the overall weighted prevalence of frailty among community-dwelling older adults aged 65 years and over was 10.7%; however, it ranged from 4.0% to 59.1%, depending on the frailty criteria used.3 Traditional operationalising definitions of frailty have focused on the biological basis of physical functioning, including shrinking, weakness, exhaustion, slowness and low activity.2 However, recently, frailty has been recognised as multidimensional in nature, encompassing the physical, psychological and social domains, and a comprehensive paradigm approach has been emphasised.4 Frail older adults experience declining functional abilities, social isolation and loss of autonomy, which can lead to negative emotions.5 Therefore, an integral conceptual frailty model should be considered when planning interventions for community-dwelling older adults.
Exercise is the most effective intervention to reduce frailty and delay physical function dependence6 7; it also contributes to maintaining cognition and mood in frail older adults.8 9 The WHO recommends aerobics, muscle strengthening and multicomponent physical activities to enhance functional balance and strength in older adults aged 65 years and over.10 However, difficulties in participation and adherence to exercise interventions for community-dwelling older adults remain challenging.11 12 A systematic review found that only 21% of community-dwelling older adults fully adhered to an exercise programme and that adherence differed according to programme characteristics.12 Another systematic review found that fall prevention exercise for community-dwelling older adults aged 65 years and over was effective when adherence was at least 80%.11 Therefore, novel and exciting interventions are required to ensure that older adults engage in exercise and experience its benefits.
Music is known to motivate older adults to adhere to exercise; reduce perceptions of exercise-related difficulties, monotony and discomfort; and enhance interest, participation and adherence.13 Exercise with music refers to using music during exercise with the expectation of potential benefits for physical or emotional health outcomes, such as psychological, physiological, and psychophysical responses and performance.14 Previous studies have reported interventions that combine exercise and music, such as physical activity interventions where music plays an essential role (eg, dance and rhythmic gymnastics)15 and interventions where music is additionally used in general physical activity programmes.14 16 Exercise with music promotes improvements in mobility, balance, gait,17 muscle strength18 and cognition18 19 and mitigates depressive moods.20 In particular, exercise with music such as dancing is suitable for frail older adults.21 Factors closely related to frailty, such as reduced physical activity, cognitive decline and depression, can be addressed by exercise with music.22 Additionally, compared with other interventions for emotional health, such as reducing depression or anxiety symptoms and promoting quality of life, music is more cost-effective and sufficiently reflects social aspects; therefore, its usefulness has been emphasised among older adults who have experienced loss and loneliness.23
While several studies have examined the effects of exercise with music on health in community-dwelling frail older adults, a comprehensive synthesis of these findings remains limited. Some systematic reviews have focused on the effects of music during specific exercises or for individuals with certain health conditions, such as resistance training and patients with Parkinson’s disease.24 25 In addition, the effects of exercise with music have predominantly been analysed by focusing on physical functions,18 26 and additional studies are required to comprehensively analyse its physical and emotional health effects.18 A systematic review is required to provide comprehensive evidence on the effectiveness of exercise with music and explore the potential outcomes for frail older adults. Therefore, this study aimed to (1) identify the contents and characteristics of exercise with music and (2) examine the effects of exercise with music on physical and emotional health. The findings may hold implications for the implementation of exercise interventions for frail older adults by providing evidence of physical and emotional outcomes.
Methods
Protocol and registration
The protocol for this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022369774). This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 reporting statement (online supplemental table 1).27
Supplemental material
Search strategies
A systematic search was conducted using seven electronic databases: MEDLINE through PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane Library, PsycINFO, Google Scholar and the Virginia Henderson International Nursing Library. Additionally, the reference lists of published studies and reports were manually searched. The database literature search was last conducted on 14 March 2025, with no restrictions on language or publication dates. The following Medical Subject Headings terms and synonyms were used: ‘Aged’, ‘Ageing’, ‘Frail elderly’, ‘Frailty’, ‘Dance’, ‘Dance therapy’, ‘Music’, ‘Music therapy’, ‘Exercise’, ‘Physical activity’, ‘Movement’, ‘Community living’ and ‘Community-dwelling’. Medical research librarians, who specialised in literature searches, reviewed the search strategies. The detailed search strategy is presented in online supplemental table 2.
Eligibility criteria
Studies were considered eligible and included in this systematic review if they met the following criteria. (1) Population: Studies targeting frail older adults aged 65 years and over. (2) Intervention: Exercise with music refers to the use of music during exercise with the expectation of potential benefits for physical or emotional health outcomes.14 Our study included all interventions that combine exercise and music, such as physical activity interventions where music plays an essential role and interventions where music is additionally used in general physical activity programmes. (3) Control: Studies without a control group or with a control group receiving an intervention other than exercise with music. (4) Outcome: The primary outcome of interest was physical health-related variables, and the secondary outcome of interest was emotional health-related variables. Studies reporting at least one outcome related to the physical or emotional health of older adults. (5) Timing: Studies extracted data on each outcome for the end of treatment and end of follow-up. (6) Setting: Studies conducted in the community, including homes and nursing homes. (7) Study design: Studies including RCTs and non-RCTs (a quasi-experimental study design that does not use random assignment). Because randomisation may be difficult for interventions for which study participants are likely to have strong preferences, this study sought to obtain comprehensive and diverse evidence-based results, including non-RCTs.28 29
Studies were excluded if they failed to meet the following criteria: (1) studies targeting older adults without frailty-related variables; (2) studies designed only for individuals with certain conditions, such as those with arthritis or dementia; (3) studies targeting hospitalised older adults and (4) papers that did not report the study methods, were not full text or were not published.
Study selection and data extraction
Five authors (NK, MKP, JJL, LK and SY) independently screened the retrieved titles, abstracts and full texts based on the eligibility criteria, with each study assessed by at least two authors. Disagreements regarding selection were resolved through discussion or consensus with the remaining author (GSK). The five authors (NK, MKP, JJL, LK and SY) independently extracted data from assigned studies, with each study’s data extracted by at least two authors for cross-checking. The remaining author (GSK) confirmed the data and consulted on any disagreements regarding extraction. The extracted data included study characteristics (study design, setting, participant characteristics and sample size) and intervention characteristics (contents of intervention, composition and type of exercise, period and duration of intervention, type of comparison and measurement outcome variables). Regarding the meta-analysis, the means, SDs and sample sizes were extracted from the intervention and control groups. If these values were unavailable, the corresponding authors contacted the study authors to request the missing data or unclear information. Studies were excluded from the meta-analysis if the authors could not be contacted or the data could not be obtained; however, they were considered in the qualitative synthesis. When studies provided overlapping outcome measures or multiple subgroup analyses, we prioritised the most comprehensive or primary outcome reported.
Quality assessment and certainty of the evidence
Regarding the quality assessment of the included studies, the revised Cochrane Risk of Bias 2 (RoB 2) tool for RCTs and the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool were used.30 31 The RoB 2 assesses five domains: randomisation process, derivations from intended interventions, missing outcome data, measurement of the outcome and selection of reported results. Each domain was evaluated as having a low, some concerns, or high risk of bias. The ROBINS-I assesses seven domains: confounding, selection of participants, classification of intervention, deviations from intended interventions, missing data, measurement of outcomes and selection of reported results. Each domain was evaluated as having low, moderate, serious, critical or no information regarding the risk of bias. The overall risk of bias for each study was determined based on the highest risk attributable to a single domain. Studies were independently scored by four authors (NK, MKP, JJL and LK) using Review Manager (RevMan 5.4; Cochrane, London, UK) for RCTs and Excel sheets for non-RCTs, and the remaining author (GSK) was consulted when disagreements occurred. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the level of certainty of the evidence included in the meta-analyses.32 GRADE considers study design, risk of bias, inconsistency, indirectness and imprecision. The certainty of evidence was evaluated as high, moderate, low and very low.33 Two authors (NK and MKP) independently carried out the evaluation, using the GRADEpro software and Cochrane methods.
Data analysis
Where possible, a meta-analysis was conducted using RevMan 5.4 to provide summaries of intervention effects of physical and emotional aspects for the following variables in each study: frailty, Timed Up and Go (TUG) test, handgrip strength and depression. To confirm between-study heterogeneity, we conducted analyses using the I² value. Continuous data were analysed to determine changes in the mean and SD of the outcome measurements. We completed the analysis using the random-effects model, as it is more appropriate to use random-effects estimates than fixed-effects estimates when there is heterogeneity between studies.34 Standardised mean differences (SMDs) and 95% CIs were used owing to the included studies using different instruments to assess frailty and depression.35 Regarding the effect of exercise with music on physical and emotional health, the effect size was calculated using Cohen’s criteria as follows36 37: small (≥0.2 and <0.5), moderate (≥0.5 and <0.8) and large (≥0.8). The direction of the effect size was defined according to the measurement method used for each outcome. Statistical heterogeneity between studies was assessed using the I² statistic and p value. The I² statistics were assessed for inconsistencies across studies as follows: not important (0%–40%), moderate (30%–60%), substantial (50%–90%) and considerable (75%–100%).38 A p value of <0.05 was considered statistically significant. In cases of high heterogeneity, we attempted to perform additional subgroup analyses; however, the lack of detailed data and a low number of studies did not allow for further subgroup analyses. Additionally, studies with unobtainable, missing or incomparable data were not included in the meta-analysis; however, the results were narratively synthesised and structured around the characteristics of the intervention and measurement outcome variables to reflect transparency. To determine whether publication bias might be present, we planned to construct funnel plots and Egger’s tests when a sufficient number of studies allowed a meaningful presentation. Sensitivity analysis gradually eliminated one study at a time to assess the result’s dependability.
Patient and public involvement
None.
Results
Study selection
Online supplemental figure 1 illustrates the study screening and selection process according to the PRISMA guidelines. The search strategy retrieved a total of 1425 records from seven electronic databases. In total, 246 studies were identified from the retrieved citation reviews. After removing duplicates and reviewing titles and abstracts, 337 relevant papers were identified for full-text review. In total, 17 studies were included in the final analysis.
Study characteristics
Table 1 presents the characteristics of the included studies. The selected papers were published between 1993 and 2022 and included 13 RCTs and 4 non-RCTs. The sample sizes ranged from 17 to 610, and the mean age of the participants in each study was ≥65 years. Eleven of the 17 studies enrolled adults aged ≥65 years. Four studies39–42 enrolled adults aged ≥60 years, and two studies43 44 did not report the eligible age of the participants; however, the mean age reported was >65 years. Most of the participants resided at home (n=10), in nursing homes (n=4), in residential care facilities identified as not for disease treatment (n=2) and in retirement villages (n=1). Regarding participants’ frailty characteristics, seven studies22 40 45–49 recruited older adults who met frailty criteria using frailty measurements: four studies used the Fried frailty phenotype criteria40 46–49; two studies used the Kihon checklist22 48 and one study used the 28-item frailty index of Visiting Health Management Services of the Korean Ministry of Health and Welfare.45 The remaining 10 studies did not clearly explain the criteria for measuring frailty but defined participants as frail older adults and included those with reduced physical function, limited mobility and sedentary older adults.
Characteristics of the included studies (N=17)
Intervention characteristics
Online supplemental table 3 presents the characteristics of the interventions. Seven studies included dancing for older adults,40–44 48 50 and two included walking or gait retraining practice while listening to music.47 49 The remaining eight studies22 39 45 46 51–54 included multicomponent exercise with music, including movement, relaxation, stretching, resistance, balance, and flexibility.
Regarding the composition of the exercise, most exercise with music interventions included a warm-up and/or cool-down period for relaxing and organised sequences (n=13).22 39–42 44 47 48 50–54 Seven studies42 45 46 48 51 52 54 included aerobic movement; two studies were conducted with seated participants, considering the physical condition of frail older adults46 52 and four studies used elastic bands.45 46 48 51
The intervention periods ranged from 8 weeks to 12 months and were carried out 1–3 days per week. Regarding session duration, each session ranged from 24 min to 120 min, most of which were performed in groups (n=13). Three studies43 45 53 attempted multicomponent interventions for older adults, such as nutritional management,45 53 cognitive training45 and a whole-body vibration intervention with exercises.43
Control group
The reviewed studies included control groups to evaluate the effectiveness of interventions. Control groups were categorised as either nonexercise programmes or alternative exercise programmes (online supplemental table 3). Among RCTs, most studies compared interventions to nonexercise programmes. Eight studies41 44 46 49–52 54 included participants who maintained their usual daily activities, and two studies39 53 included participants engaged in music and reminiscence activities39 and social programmes.53 Three RCTs42 43 47 used flexibility programmes, passive trampoline exercises or routine-encouraged mobility exercises to provide a placebo effect without an active component of the intervention. Among non-RCTs, four studies used nonexercise programmes where participants continued with their usual daily activities,22 40 48 and one study provided education and health management material.45 In summary, the control groups across both RCTs and non-RCTs included a variety of nonexercise programmes and another exercise programme designed to maintain usual daily activities or simulate a placebo effect.
Measurement of physical and emotional health outcomes
In all of the included studies, various measurement outcome variables concerning physical and/or emotional health were identified. The health outcomes of exercise with music were divided into physical and emotional aspects (online supplemental table 3). Included studies reported physical outcomes, including frailty,22 40 45 46 48 TUG,22 41 45–47 49 handgrip strength39 45–47 51 53 and falls.42–44 47 49 Additionally, balance, gait speed, endurance and other performance measures were used to evaluate the physical aspects. Emotional health outcomes were assessed in eight studies,22 39 43 45–47 51 52 including depression,22 39 45 52 social support and activities,45 quality of life or satisfaction39 46 51 52 and cognitive function.22 39 43 47
Quality assessment and certainty of the evidence
Regarding the assessment of bias risk, RoB2 was used for RCTs and ROBINS-I was used for non-RCTs.30 31 For the RCTs, the RoB2 tool was applied to evaluate selected outcomes (frailty, TUG, handgrip strength and depression) (online supplemental figure 2). Regarding the frailty outcome, the study by Sadjapong et al46 was noted to have some concerns associated with the risk of bias. As for the TUG analysis, two out of three studies were judged to have some concerns overall.46 49 One study41 was specifically rated as high risk due to the high bias related to missing outcome data. Regarding the handgrip strength outcome, two studies46 51 showed some concerns related to the risk of bias. For the depression outcome, the study by Witham et al52 resulted in a high overall risk of bias, primarily due to significant concerns linked to missing outcome data. Overall, the included RCTs displayed some concern and high levels of risk of bias, with the most frequent concerns arising from deviations from intended interventions, missing outcome data and bias in the selection of reported results. Regarding the overall bias risk of ROBINS-I (online supplemental table 4), two studies were at moderate risk22 40 and two were judged to be at serious risk.45 48 Because the influence of the confounding variables could not be controlled and, concerning the measurement of outcomes, outcome assessors were not blinded to the intervention status.
The overall quality of evidence for the results ranged from very low to low, as assessed by GRADE. For frailty, handgrip strength and depression, the reasons for downgrade were publication bias and imprecision. For the TUG test, the reasons for the downgrade were inconsistency, imprecision and publication bias (online supplemental table 5).
Effects of exercise with music on physical health
All of the studies described various effects on physical health such as frailty, TUG test, handgrip strength, falls, balance, gait speed, endurance and performance. For quantitative analysis, the effect sizes of frailty, the TUG test and handgrip strength were available under physical health. These results from the meta-analysis are presented in figures 1–3. We performed narrative synthesis because other studies were not suitable for meta-analysis due to heterogeneity in measurement tools and methods, and incomplete data. Five studies42–44 47 49 measured variables related to falls, and the group that exercised with music had a statistically significant lower frequency42 44 47 49 and risk of falls49 compared with the control group. However, in the study by de Bruin et al,43 fall efficacy did not show a significant difference between the exercise with music group and control groups. Most studies39 42–44 47 49 conducted various measurements to confirm physical outcomes, such as functional performance/capacity, physical fitness, strength and power. However, the study designs and measurement tools were heterogeneous, and the results and effect sizes varied across studies.
Forest plots of meta-analysis results for frailty. RCT, randomised controlled trial.
Forest plots of meta-analysis results for the TUG test. RCT, randomised controlled trial; TUG, Timed Up and Go.
Forest plots of meta-analysis results for handgrip strength. RCT, randomised controlled trial.
Frailty
Figure 1 presents a forest plot of four studies22 45 46 48 using exercise with music and examining frailty according to the study design. One study46 was an RCT, and three studies22 45 48 were non-RCTs. A single RCT suggests that exercise with music may lead to decreased frailty scores compared with the control group (MD=−1.44, 95% CI=–1.95 to –0.93, p<0.00001, low certainty). The pooled results from non-RCTs suggest that exercise with music might potentially decrease the frailty score (SMD=−0.20, 95% CI=–0.34 to –0.07, p=0.003, I2=0%, very low certainty). One study40 was not suitable for meta-analysis as the authors were unable to provide relevant data; we thus present a narrative synthesis: Meng et al40 reported that the prevalence of frailty decreased over time in the exercise with the music group compared with the control group (p=0.002).
Timed Up and Go
Figure 2 presents a forest plot of four studies41 45 46 49 employing exercise with music and the TUG test according to the study design. Three studies41 46 49 were RCTs, and one study45 was a non-RCT. The RCTs and non-RCT suggest that exercise with music showed no statistically significant decrease in the TUG test score compared with the control group (RCTs, MD=−5.01, 95% CI=−10.03 to 0.02, p=0.05, I2=91%, very low certainty; non-RCT, MD=−2.30, 95% CI=−4.88 to 0.28, p=0.08, very low certainty). One study22 was not suitable for meta-analysis as the authors were unable to provide relevant data; we thus present a narrative synthesis: Sun et al22 reported that the exercise with the music group had a significant positive effect on functional mobility assessed by the TUG test compared with the control group (p<0.001).
Handgrip strength
Figure 3 presents a forest plot of three studies45 46 51 using exercise with music and assessing handgrip strength according to the study design. Two studies46 51 were RCTs, and one study45 was a non-RCT. The RCTs and non-RCT suggest that exercise with music showed no statistically significant increase in handgrip strength compared with the control group (RCTs, MD=1.77, 95% CI=−0.19 to 3.72, p=0.08, I2=38%, low certainty; non-RCT, MD=1.25, 95% CI=0.51–3.01, p=0.16, very low certainty). Two studies39 53 were not suitable for meta-analysis as the authors were unable to provide relevant data; hence, we present a narrative synthesis: McMurdo and Rennie39 reported that the exercise with music group had a significant mean improvement in handgrip strength compared with the control group (p<0.02). Chin A Paw et al53 included handgrip strength in the seven items of physical fitness they assessed and reported that the exercise with music group improved the sum score of physical fitness compared with the control group. However, since only the results for the total sum of physical fitness were presented, the exact effect of handgrip strength could not be confirmed.53
Effects of exercise with music on emotional health
Eight studies22 39 43 45–47 51 52 described various effects of music on emotional health aspects such as depression, social support/activities, quality of life/satisfaction and cognitive function. For the quantitative analysis, the effect size of depression was available under emotional health. The meta-analysis results are presented in figure 4. We performed narrative synthesis for studies that were not suitable for meta-analysis. Song and Boo45 found statistically significant increases in social support and social activity in the group exercised with music. Four studies39 46 51 52 examined the effects of quality of life/life satisfaction using different measurement tools. Only one study51 reported the maintenance of health-related quality of life. The other three studies39 46 52 did not report any significant effects. Four studies22 39 45 52 examined the effects of cognitive function using different measurement tools. Two studies22 43 reported that the group that exercised with music had a statistically significant improvement in cognitive function. However, other studies39 47 reported no effect.
Forest plots of meta-analysis results for depression. RCT, randomised controlled trial.
Depression
Figure 4 presents a forest plot of three studies22 45 52 using exercise with music and examining depression according to the study design. One study52 was an RCT, and two studies22 45 were non-RCTs. A single RCT suggests that exercise with music showed no statistically significant decrease in depression levels compared with the control group (MD=−0.30, 95% CI=−1.68 to 1.08, p=0.67, very low certainty). The pooled results from non-RCTs suggest that exercise with music might potentially decrease depression (SMD=−0.40, 95% CI=−0.65 to −0.15, p=0.002, I2=0%, very low certainty). One study39 was not suitable for meta-analysis as the authors were unable to provide relevant data; we thus present a narrative synthesis: McMurdo and Rennie39 reported that depression significantly decreased in the exercise with music group compared with the control group (p<0.01).
Publication bias and sensitivity analysis
In this study, we planned to develop funnel plots and conduct Egger’s tests for each outcome when we identified 10 or more studies, to assess the potential influence of publication bias.55 56 We identified an insufficient number of studies to use this approach in the present version of the review. However, a visual inspection for asymmetry was performed to identify potential bias (online supplemental figure 3). The statistical test of funnel plot asymmetry showed no possibility of publication bias in fragility, and Egger’s test results showed no significant publication bias (p=0.865). However, there was publication bias in the TUG test, and the Egger’s test results showed publication bias (p<0.001). Sensitivity analyses of frailty and the TUG test indicated that the overall results were stable. However, excluding Yamada et al48 led to a slight change in effect size with a widened CI and a loss of statistical significance (p=0.11); however, heterogeneity (I² = 0%) remained unchanged, and the overall effect direction was consistent (online supplemental figure 4).
Discussion
This study investigated the effects of exercise with music on the physical and emotional health of frail older adults. Our study systematically reviewed 17 studies, encompassing various exercise interventions with music. Music has been combined with various types of exercises such as stepping or walking, dancing, stretching, resistance exercises and balance exercises. This diversity emphasises the adaptability of exercise with music to various physical activities. All studies reported physical health outcomes, including frailty, TUG, handgrip strength, falls, balance, gait speed, endurance and other performance. Eight studies reported emotional health outcomes, including depression, social support and activities, quality of life or satisfaction and cognitive function. The results of the meta-analysis suggest that exercise with music may have beneficial effects on frailty and depression among frail older adults. However, the certainty of the evidence was rated as very low according to the GRADE approach, indicating that the true effects might be substantially different from the observed results. Nonetheless, the findings contribute to our understanding of the potential benefits of exercise with music for frail older adults, particularly in improving both physical and emotional health outcomes. We focus on the meta-analysis results and discuss them as follows.
Physical health effects of exercise with music
According to the meta-analysis results, exercise with music could potentially decrease the frailty score among frail older adults; however, its impact on specific physical functions such as TUG and handgrip strength remains unclear. In this study, no significant improvements were observed in TUG test scores or handgrip strength compared with the control group, suggesting that while exercise with music may benefit overall frailty, its effects on functional performance measures are inconsistent. The small effect size on frailty observed in this study suggests that although exercise with music may have beneficial effects on frailty, the reported results vary across study design. Additionally, this variability may be attributed to the heterogeneity among the studies regarding exercise duration, frequency, type of music used and the participants’ baseline frailty levels. Notably, a previous systematic review on exercise interventions in frail older adults found that exercise can improve frailty and TUG test performance, yet reported effect sizes differed significantly across studies.57 This heterogeneity emphasises the need for standardised protocols to establish optimal strategies for frail older adults to effectively exercise with music. Future studies should explore the specific characteristics of exercise programmes, including the type of music, intensity and duration of exercise, that are most effective in increasing physical function. While exercise with music has been shown to enhance physical health,58 59 its direct impact on measures like handgrip strength remains unclear. Given that handgrip strength is a key predictor of overall muscle function, fall risk and quality of life in older adults,59 60 further research is needed to determine whether tailored exercise strategies incorporating music can more effectively improve functional strength.
Emotional health effects of exercise with music
According to the meta-analysis results, exercise with music could potentially decrease depression levels among frail older adults, indicating that exercise with music is a useful intervention for emotional health. However, this effect was primarily observed in non-RCTs, while the single RCT included in the analysis did not demonstrate a significant effect, underscoring the need for further high-quality trials. Despite these limitations, our findings are consistent with recent meta-analyses that did not restrict participant characteristics and highlighted the utility of exercise with music as an intervention that benefits both physical and emotional health.14 In this review, the results showed low heterogeneity among studies that examined the effects of exercise with music on depression, suggesting a more consistent benefit in this domain. According to Jia et al,61 the incidence of depression is 2.2 times higher in frail older adults than in non-frail older adults. Additionally, frail older adults with depression have an increased risk of hospitalisation and mortality,62 63 and studies on the psychological function of frail older adults are gradually increasing.64 65 These positive impacts on depression emphasise the potential of exercise with music to address the emotional aspects of frail older adults. Despite these promising outcomes, our review identified a lack of literature concerning the effects of exercise with music on broader emotional outcomes. Only 8 of the 17 studies included emotional domains as a result of exercise with music, despite the fact that incorporating music in exercise improves emotional health.23 According to the integral conceptual model of frailty, frailty should be understood as an integrative concept involving physical, psychological and social aspects.66 Therefore, our findings call for a more inclusive approach to measuring the impact of exercise with music on emotional health. The effects of exercise combined with music have predominantly been analysed by focusing on physical function.18 26 Therefore, exercise with music that comprehensively targets psychological and physical functions should be conducted more actively.
Need for tailored interventions for frail older adults
Despite the positive outcomes on frailty and depression, the small effect sizes and variability among the studies emphasise the complexity of designing interventions for frail older adults. Various factors affect intervention results, such as participant characteristics, exercise intensity, music tempo, music application timing and the selected music.14 Given the diverse contexts and methodologies of the included studies, it is clear that tailored interventions must also consider the cultural and environmental factors that influence the effectiveness of exercise with music. For example, the appropriateness of specific music genres or exercise types may vary significantly between different populations or settings. Therefore, to maximise benefits and adherence, exercise programmes should be tailored to individual preferences, capabilities and health conditions. To achieve this, older adults should be actively involved in the developmental stage of interventions targeting frail older adults.67 Considering the physical and emotional characteristics of older adults, selecting and applying music suitable for the intensity and purpose of exercise will be a useful strategy for continuing exercise participation and health improvement in frail older adults living in the community.
In this review, we found that most exercise with music interventions were conducted in group settings. Group-based exercise may have several advantages such as increasing exercise adherence and social interaction.68 69 However, frail older adults might face accessibility hurdles owing to their unwillingness or inability to engage in regular exercise outside of their homes.70 Additionally, frail older adults exhibit a wide range of physical function levels, necessitating personalised exercise prescriptions tailored to their individual ability.71 Therefore, further studies could examine the physical and emotional effects of exercise with music on frail older adults who exercise individually at home.
Building on the need for tailored interventions, it is important to recognise the role of music in enhancing the effectiveness of and adherence to exercise programmes for frail older adults. As highlighted in our review, music plays a multifaceted role in exercise interventions, serving not only to motivate and stimulate participants40 50 but also to increase their motivation40 41 46 50 and interest45 46 53 during physical activities. Research has also demonstrated that listening to preferred music can significantly enhance exercise performance compared with nonpreferred music, further underscoring the importance of personalisation in music selection.24 The selection of appropriate music—considering factors such as tempo, genre, and participants’ preference and physical functioning—can significantly impact the success of these interventions.72 We found that in four studies, tailored music was used based on participants’ preferences.22 43 45 50 Strategies included using familiar music22 or allowing participants to choose the music themselves.45 50 This personalised approach is especially crucial for frail older adults, who may have diverse levels of physical functioning and varying emotional responses to exercise. However, there is a lack of evidence to suggest that specific genres or tempos are more suitable for particular types of exercise or participants’ physical functioning. Future research should explore how different genres and tempos enhance exercise efficacy and develop guidelines for selecting music optimised for specific activities.
Limitations and suggestions for future research
This study on integrating music with exercise interventions for frail older adults, though extensive, faced notable constraints. Of the 17 studies reviewed, only frailty, TUG test, handgrip strength and depression were suitable for meta-analysis. Many studies were not included in the meta-analysis due to heterogeneity in study design and measurement tools, and incomplete data, thus the results of each study should be interpreted in light of these limitations. Variation in study design and outcome measures, along with the absence of a control group performing exercise without music, highlights the need for more methodological consistency and proper control groups in future research to isolate the effects of music.
This study did not restrict the eligibility criteria to a specific measurement tool for defining frailty. While this reflects the dynamic changes in the definitions and diversity of frailty assessments, inconsistencies in frailty measurements posed challenges for comparing findings. This study identified four frailty measurements; however, no frailty measures were reported in some studies. The use of diverse measurements to assess frailty has been highlighted as a flaw in previous reviews on frail older adults.67 A consensus on a standardised frailty definition is needed to improve the design of exercise interventions and the overall quality of research on frail older adults.
The review of music characteristics was limited. Each study indicated that music was played during exercise; however, the tempo, timing, preferences and cultural basis of music applied to older adults were not known in detail. While the effect of exercise with music on depression was identified, evidence of music characteristics was not provided in this study. Further characterisation studies on exercise with music are suggested to develop customised interventions for frail older adults.
This review underscores the critical need for standardisation in the measurement of both frailty and the outcomes of exercise interventions, as well as a deeper exploration into the role of music within these interventions. Addressing these gaps will not only improve the methodological rigour of future studies but also contribute to the development of more targeted, effective interventions tailored to the unique needs of frail older adults.
Despite these limitations, the study findings suggest that exercise with music could potentially serve as an effective strategy for improving both physical and emotional health in frail older adults. Given the increasing prevalence of frailty and depression in ageing populations, accessible and nonpharmacological interventions are urgently needed. Music-based exercise programmes can be integrated into community centres, senior care facilities and public health initiatives as a valuable approach to promoting active ageing and improving quality of life.
Conclusion
This systematic review aimed to assess the effectiveness of exercise with music on the physical and emotional health of frail community-dwelling older adults. The findings of the meta-analysis suggest that exercise with music may have potential effects on reducing frailty and depression; however, the interpretation of these results should be considered with caution due to the considerable heterogeneity among included studies and the very low certainty of evidence based on the GRADE assessment. The variability in study designs, intervention characteristics and outcome measures highlight the need for further well-designed research to strengthen the evidence base. Moreover, the absence of control groups performing exercises without music in all included studies makes it difficult to isolate the specific effects of music from the overall benefits of exercise. Nevertheless, exercise with music remains a promising intervention that may support both the physical and emotional health of frail older adults. Future studies should include appropriate control groups to better determine the independent contribution of exercise with music while also developing standardised protocols and tailored approaches to optimise its effectiveness in frail older adults.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. All data generated or analysed during this study are included in this published article.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Footnotes
NK and MKP contributed equally.
Contributors GSK, NK, MKP, LK and JJL contributed to the conception and design of the study. NK, MKP, LK, JJL and SY contributed to data acquisition. NK, MKP, LK and JJL contributed to the analysis and interpretation of data. NK, MKP, LK and JJL drafted the manuscript, and GSK, NK and MKP critically revised it for important intellectual content. All authors approved the final version to be published. NK and MKP are the guarantor.
Funding This study was supported by the Basic Science Research Program through the National Research Foundation (NRF) of Korea and was funded by the Ministry of Education (grant number 2020R1A6A1A03041989), and the NRF of Korea grant funded by the Korea government (MSIT) (grant number RS-2024-00353845). LK received a scholarship from Brain Korea 21 FOUR Project funded by NRF of Korea, Yonsei University College of Nursing.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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