Table 2.

Intervention protocol according to session progression.

Intervention protocol 1: enhancing uprighted position
Session number 1	Warm Up
Tasks' Goals	Holding head and trunk control against gravity for longer periods Holding visual contact for longer and orientation from mid line as much as possible
Musical intervention	- Auditive and visual stimuli at different heights. Musical Instruments: Music Therapist voice, triangles, guitar, keyboards, bells and cymbals - Predictable and unpredictable emphasis while keeping a regular pulse - Random participations of the patient generally requiring holding upright while pressing on the instrument
Therapist assistance	- The trunk of the patient can be assisted from the shoulders by the Music Therapist, avoiding forward or lateral tilt. - The Music Therapist support one arm during bilateral activities, while the patient focus on the other arm - Support is reduced when the patients feel more confident during the task
Adaptations	- Instruments are presented on the midline or laterally for the patient to touch or press
Intervention protocol 2: reaching with the upper limb
Session number 2-3-4	TIMP
Tasks' Goals	Unilateral and selective orientation of the arm toward the musical instrument
Musical intervention	- Music Therapists perform melodic ascendant voices with harmonic foundations progressing up and down from 5th (guitar) to guide the movement - Emphasis and anacrusis to indicate when the movement start. Dynamic intensification of the stroke - Music Therapists play and sing at the same tempo, dynamic, texture and level of complexity develop for the patient - Develop a rhythmic and harmonic tone background - Every movement is positively feedbacked with their favorite keyboard, drum or cymbal sound.
Therapist assistance	- Rhythmic background with bongos - Activity mirroring, facial expression and prosodic expressions - Positive feedback with their favorite song after trying- effort.
Adaptations	- Instruments are presented at different locations, height - Favorite sounds and timbres
Intervention protocol 3: hitting with the upper limb
Session number 5-6-7-8	TIMP
Tasks' Goals	Unilateral and selective orientation of the arm to produce sounds with the instruments
Musical intervention	- Drums or bongo are presented at different locations to required more complex arm positioning - Drums and tambourine are played by the Music Therapists, creating rhythmic combinations and emphasis of 2-3 beats, creating asking-answer and turn taking activities - Roles exchange between patient and Music Therapists
Therapist assistance	- Rhythmic pulse - Facilitation of the role exchange - Keeping motivation level - Support the instrument location and positioning
Adaptations	- Instruments are presented at different locations and height, but also into more challenging position and easier depending on motivation and motor possibilities
Intervention protocol 4: grasping and hitting with intermediate objects with the upper limb
Session number 9-10-11-12	TIMP
Tasks' Goals	Unilateral and selective orientation of the arm to produce sounds with the instruments using and intermediate object. Playing instrument in different positions
Musical intervention	- Patient plays the drums or bongo using stick, at different locations to required more complex arm positioning - Patient lying in prone or supine while stroking, hitting and grasping or using the keyboard (Casio Tone bank-6). Taking turns or asking-answer activities. - Patient sitting and using stick to play e-Drum DD 150. - Music Therapist answer rhythmically to develop and generate the musical tasks
Therapist assistance	- Stick need to reach and hit the instruments farther and in more challenging positions of the upper limbs and graps (Drums, keaboard) - Communication feedback - Support motivation - Support to grasp the sticks accordingly
Adaptations	- Stick size-width Slope–wedge cushion to adapt lying posture. - Keyboard and drums position at different heights and distances - Keyboard sounds adapted to patient's preferences
Intervention protocol 5: description of new goals
Session number 13	Activity summary and intervention closing