Music/Music Therapy

• FINAL NUMBER STUDIES INCLUDED = 10
• TOTAL PATIENTS INCLUDED IN REVIEW = 488 (62 lost to attrition)
• KEY SAMPLE CHARACTERISTICS: The frequency of intervention and type of intervention varied (Note: 10 studies of 8 different intervention foci.): 70% of the sample studies held intervention sessions once per week for a total of three to eight weeks. Participants with terminal cancer were studies either weekly or bi-weekly until death. The dance movement study held sessions two times per week for six weeks then once weekly for six weeks. One study held a music therapy session during chemotherapy.

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care

Depression and anxiety were shown to improve in three of the studies although the interventions were different (music therapy, art therapy, and mindfulness-based art therapy). Other psychological factors also improved: lower ratings of somatic symptoms in an art therapy study and a creative arts study, and psychiatric symptom improvement. Improvements in various measures of quality of life were reported in studies of mindfulness-based art therapy, art therapy, music therapy, creative arts therapy, and dance/movement therapies. Art therapy showed improvements in coping resources and mood states. Music therapy showed improvements in stress and anger. Creative arts therapy showed improvements in specific aspects of the Profile of Mood States (POMS) that were reported: tension-anxiety, depression-dejection, anger-hostility, and confusion-bewilderment.

Evidence reviewed in this study is inconclusive regarding effectiveness of various creative interventions.

• Selected articles using creative psychological interventions did not include writing therapy or drama therapy.  
• Meta-analysis was not possible, although rationale was clearly explained by the writers.
• Only one of the 10 articles was evaluated as having high quality; the remaining were satisfactory.
• Follow-up measures were not included in several studies.
• The number of articles included in the sample was small (n = 10).
• There appear to be discrepancies in accuracy of references to specific studies in the table: example, page 4, last paragraph indicates lack of replicated findings, whereas the table indicates otherwise.
• Specified Creative Psychological Interventions delivered by a qualified therapist were shown to improve well-being on several measures. 

The therapies were implemented by qualified therapists and were varied in nature, although not exhaustive of available therapies. The value of music, art, and movement therapies are shown to effectively reduce symptoms of anxiety and depression and improve quality of life, coping, and mood. Suggestions for further research are offered.

STUDY PURPOSE: To review the evidence for efficacy of music interventions for patients with cancer receiving palliative care and review the neurobiological evidence to explain pathways by which music may have an effect

TYPE OF STUDY: Systematic review

DATABASES USED: PubMed, CINAHL, Plus, Ovid, PsycINFO, PoQuest, and the Cochrane Library

KEYWORDS:  music; music therapy; cancer; oncology; palliative care; pain; anxiety; depression; mood; quality of life; neuroscience; endogenous opioids; dopamine; GABA; 5HT; permutations

INCLUSION CRITERIA: RCT; meta-analysis or systematic review from 1970–2012

EXCLUSION CRITERIA: Not reported

TOTAL REFERENCES RETRIEVED: Not reported

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Not reported

• FINAL NUMBER STUDIES INCLUDED = six studies regarding pain, eight studies for anxiety, four studies regarding quality of life, four studies involving effect on mood, and eight studies exploring the neurobiologic evidence
• SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW = 527 in pain (range: 30–136) and 410 for anxiety (range: 20–136)
• KEY SAMPLE CHARACTERISTICS: Samples included adults and children. Most interventions were done during a diagnostic or other procedure.

• PHASE OF CARE: Multiple phases of care     
• APPLICATIONS: Palliative care

In the acute pain setting, music had a moderate analgesic effect with SMD of -.059, 95% CI -0.90, -0.27 (p = .0003). Effect for chronic pain is not known and has not been well studied. The study cites results of a Cochrane review of effects of music on anxiety (SMD -11.2, p = .0088). It is noted that effect on anxiety only has been studied in the acute, situational setting. Longer-term effects and application in palliative care are unknown. Review of neurobiologic evidence suggests that music may affect specific pathways that are implicated in the pathophysiology of pain, anxiety, and depression.

Music interventions have a moderate positive effect on procedural pain and acute, situational anxiety.

• This review does not report results of the literature search nor any quality evaluation of manuscripts retrieved. 
• For pain analysis, no description is provided of methods to calculate SMD or any findings regarding heterogeneity. 
• For anxiety, this report just repeats findings from a previous Cochrane review. 
• Although inclusion criteria stated RCT, the authors did include at least one single-group trial in the review.

Music may be helpful to reduce acute anxiety and procedure-related pain. This is a simple intervention nurses could use in a variety of settings. Longer-term effects and effects in different situations are not known.

To examine the effects of music therapy and \"medical music\" on patients with cancer.

• Databases searched were MEDLINE, EMBASE, LILACS, CINAHL, Computer-Assisted Information Retrieval Service System (CAIRSS), and Cochrane Collaboration. The investigators also evaluated for inclusion studies listed on web sites about clinical trials or on the web sites of relevant professional organizations, those cited in journals dealing with music and music therapy, and those included in the reference lists of relevant articles.
• The investigators provided an extensive list of search terms in the report.
• Studies were included if patients, of any age, had cancer and if the studies compared music interventions to standard care, alternative interventions plus standard care, or placebo. Studies were included if they were randomized, controlled trials or incorporated quasiexperimental designs.
• Studies were excluded if they involved patients who were undergoing diagnostic procedures.

• The investigators retrieved a total of 773 studies.
• The investigators evaluated the quality of the studies according to the criteria in the Cochrane Handbook for Systematic Reviews of Interventions.

• The final number of studies analyzed was 30.
• The studies analyzed included a total of 1,891 patients.
• The range of mean patients per study was 8 to 86.
• The analyzed studies comprised multiple cancer types and age groups.

• Patients were undergoing multiple phases of care.
• The study has clinical applicability for pediatrics and palliative care.

• Findings from seven trials, regarding effect on anxiety, showed positive effects for reducing anxiety (standardized mean difference [SMD] = –0.61; 95% confidence interval [CI] [–0.97, –0.26]; p = 0.0007).
• Findings from six trials, regarding effect on pain, showed positive effects on perceived pain (SMD = –0.59; 95% CI [–0.92, –0.27]; p = 0.0003).
• The investigators noted no significant effects on depression or fatigue.
• Several studies showed that music listening and music interventions affected physical findings—for example, the studies reduced pulse rate.
• Many studies had high risks of bias, and the type, duration, and timing of the interventions varied greatly.

Music interventions appear to have beneficial effects regarding pain reduction and short-term reduction of anxiety.

• The investigators found a relatively small number of studies that examined a specific symptom or outcome.
• The interventions were very different in terms of sample types, timing, and duration; therefore, synthesizing the findings was difficult. 
• Most studies had small sample sizes and high risks of bias.

Music therapy and listening to music may be helpful means of reducing anxiety and perceived pain, and these interventions can have an effect of moderate size. The effects may be relatively short-lived, and the evidence is somewhat weak in terms of study design. However, listening to music has no risks for patients, can be easy to implement, and is an intervention that patients can do themselves. Nurses can suggest that patients use this approach to help manage pain and anxiety.

STUDY PURPOSE: To assess and compare the effects of music therapy and music medicine interventions for psychological and physical outcomes in people with cancer

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 39 studies in meta-analysis, 52 studies in qualitative review
• TOTAL PATIENTS INCLUDED IN REVIEW = 3,313
• SAMPLE RANGE ACROSS STUDIES: 8–182
• KEY SAMPLE CHARACTERISTICS: Various tumor types and age groups during multiple phases of care

PHASE OF CARE: Multiple phases of care

The standard mean difference for fatigue in the music intervention group was 0.38 (7 studies, 253 participants, p = 0.03). Anxiety was reduced with music (13 studies, 1,028 patients, mean difference = –8.54, p < 0.0001). Results also showed a positive effect for depression (7 studies, 723 participants, standard mean difference = –0.4, p = 0.02).

Music interventions also had a small to moderate beneficial effect on fatigue, anxiety, and depression.

• Mostly low quality/high risk of bias studies
• High heterogeneity

Music therapy may have a small to moderate effect on fatigue, anxiety, and depression.

To clarify the effect of music interventions on anxiety for adult patients with cancer from rigorously conducted studies
 

TYPE OF STUDY: Meta-analysis and systematic review

• Databases searched were PubMed, PsycINFO, CINAHL, Web of Science, and the WorldCat dissertation database.
• Search keywords were music, music therapy, music intervention and cancer, neoplasm, and malignancy.
• Studies were included in the review if they
  • Were a randomized controlled trial
  • Tested a music intervention
  • Studied an adult population
  • Reported measurable anxiety outcomes
  • Used validated measures
  • Were accessible in full text
  • Scored at least 5 on the PEDro scale, indicating a high-quality study.
• Exclusion criteria were not specified.

• A total of 606 references were retrieved.
• The PEDro scale was used to evaluate quality, applied independently by two people.

• A final number of 13 studies were reviewed, with 4 included in meta-analysis.
• A total of 709 patients were included in the review, with a sample range across studies of 20–98.
• The sample had various tumor types. Most studies were done during active treatment. One study was done related to a bone marrow biopsy procedure.

Patients were undergoing active antitumor treatment.

Length of the intervention varied substantially from 5 minutes to 4 hours. There was high variability in the number of sessions delivered. Most studies examined a single intervention with immediate pre and post anxiety measurement. Three delivered live music, 1 involved a music therapist, and 11 involved listening to music via headphones. Meta-analysis showed no significant difference between the music intervention and controls (SMD = -0.003 (95% CI -0.51, 0.52).

Meta-analysis showed no significant effect of music interventions on anxiety in adults with cancer.

• A low number of studies were included in meta-analysis.
• There was high heterogeneity among the studies.
• There was variability in the type, duration, and timing of the music interventions used.

Results of this analysis do not support an effect of music interventions on anxiety in adults with cancer.

• FINAL NUMBER STUDIES INCLUDED =  12
• TOTAL PATIENTS INCLUDED IN REVIEW = 358
• KEY SAMPLE CHARACTERISTICS:  Mean age of 8.4 years, age ranged from 1–19 years; 55% male participants; 120 participants from Greece; 62% Caucasian; majority had hematologic cancer; many studies were conducted during painful procedures such as lumbar puncture and venipuncture.

PHASE OF CARE: Multiple phases of care

APPLICATIONS: Pediatrics

Integrative interventions may be very effective for pain and anxiety in children undergoing cancer treatment. Integrative modalities, however, warrant further study with larger sample sizes to better determine their effectiveness in this population.

• No description existed of the time window during which data were extracted.
• Various interventions were combined and analyzed as a unit.
• Only included randomized controlled trials and thus reduced literature sample size
• The sample size for each intervention was small.
• The effect of each intervention is not clear.

This study provided some evidence that complementary modalities can help children undergoing cancer treatment or painful procedures. The usefulness of a particular method should be further examined.

STUDY PURPOSE: To evaluate the effects of music on symptoms in patients with cancer

TYPE OF STUDY: Meta-analysis and systematic review

DATABASES USED: Ovid, PsycARTICLES, and PsycINFO (2002–2012)

KEYWORDS: neoplasms, cancer, and music or melody

INCLUSION CRITERIA: Used a music intervention in patients with cancer; quantitative methods; quasi-experimental or experimental design; reported statistical information to describe results; evaluated effects on anxiety, depression, pain, or fatigue

EXCLUSION CRITERIA: Qualitative design, case studies, or single-group studies

TOTAL REFERENCES RETRIEVED = 367

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Quality assessment with adapted Cochrane guidelines; the k value between reviewers was 0.9.

• FINAL NUMBER STUDIES INCLUDED =  21–17 for anxiety, 8 for depression, 6 for pain, and 5 for fatigue
• SAMPLE RANGE ACROSS STUDIES = 32–126

APPLICATIONS: Pediatrics, palliative care

For anxiety, music therapy had a moderate and significant effect with an effect size of -0.553 (Hedges; g) (95% CI -0.716, -0.398). There was significant heterogeneity in the sample. For depression, music therapy moderately and significantly reduced depression with an effect size for each study ranging from -0.151 to -0.787. Results were homogenous. Five of eight studies showed significant effects. For pain, music had an overall effect size of -0.656 (Hedges' g) (95% CI -1.016 to about -0.295), showing moderate-level effects on pain. There was significant heterogeneity among studies. For fatigue, music therapy had a small effect size of -0.422 (Hedges' g) (95% CI -0.669, -0.175). Results were homogenous. Studies were seen to be of good quality. Results of subgroup analysis suggest that music therapy is more effective in adults than children and more beneficial when the music is selected by the patient rather than the therapist.

This analysis shows that music interventions can reduce anxiety, depression, pain, and fatigue in patients with cancer with small-to-moderate effect sizes.

In several areas, there was high heterogeneity. Sample sizes, timing, and types of music interventions varied substantially, and, in most, the impact was evaluated immediately after the music intervention. Whether music has ongoing effectiveness with continued use or any lasting effect on the symptoms assessed is unclear.

Music interventions can be a good adjunctive and non-medication therapy that is of benefit in reducing anxiety, depression, pain, and fatigue in patients with cancer. The most beneficial ways and times to use music therapy are unclear. Nurses can suggest that patients use listening to music as part of self-care and can advocate for use of music as a low-risk intervention to ameliorate acute anxiety and pain symptoms.

To determine if brief guided imagery or music can reduce patient pain and anxiety during cutaneous procedures

Consecutive adults undergoing surgery for basal or squamous cell carcinoma of the face were randomized to three groups: (a) guided imagery, (b) music, or (c) control. The guided imagery patients were sent a recording of the guided imagery by mail and instructed to listen to this at least once daily starting at least four days before surgery. Those in the music group listened to music via earphones during the surgery. Patients in the other two groups also wore earphones during the surgery, but without any sound. Pain and anxiety scores were obtained before and after the procedure on the day of surgery.

• N = 155   
• MEDIAN AGE = 62.4–64.2 across study groups 
• MALES: 58%, FEMALES: 42%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: All had basal or squamous cell skin cancer and were undergoing facial surgery
• OTHER KEY SAMPLE CHARACTERISTICS: No significant differences across groups in the duration of surgery

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: Northwestern University Hospital

• PHASE OF CARE: Active antitumor treatment

• Single-blind randomized, controlled trial

• Visual analog scale (VAS) for pain
• State-Trait Anxiety Inventory (STAI) short form
• Heart rate
• Blood pressure

There were no significant differences in average change in pain or anxiety scores between groups.

The visual imagery and music interventions as used here had no apparent effect on perioperative pain or anxiety.

• Unintended interventions or applicable interventions were not described that would influence results.
• Measurement validity/reliability questionable
• The logic of expecting to see a decline in pain from pre-op to post-op is questionable.
• No patient education on the use of the visual imagery recording was given.
• Patient adherence to use of the visual imagery was not explored.

This study did not show an effect of music or visual imagery on perioperative pain or anxiety. The lack of effects may be associated with the ways in which the interventions were provided or in the study design—it would be expected that pain should increase postoperatively and anxiety would decline after the surgery was completed. In addition, analysis was done regarding pre- and post-symptom change rather than actual postoperative symptom levels.

To compare the effects of music therapy and music medicine on pain and psychological outcomes, and to explore relevant patient experiences

Patients were randomly assigned to receive either two music therapy or two music medicine interventions during a two-week timeframe. After two weeks, subjects were crossed over to the other intervention. Music therapy was provided by a certified therapist and included a brief discussion of patients' concerns followed by the provision of live music based on assessed needs. Participants were invited to play an instrument, participate in breathing exercises, and express thoughts and emotions. Music medicine involved providing music based on preferences. Patients were asked not to engage in any other activity during listening. A blinded assessor interviewed patients after each music session and after the final session. Verbatim transcripts were analyzed by two coders to identify reported benefits or harms from descriptions of the experience.

• N = 31  
• MEAN AGE = 53.8 years (range = 32–88 years)
• MALES: 22.3%, FEMALES: 67.7%
• KEY DISEASE CHARACTERISTICS: Multiple tumor types with breast being most common
• OTHER KEY SAMPLE CHARACTERISTICS: 77% had high school or less education; 74.2% African American; 71% outpatient; and 29% inpatient

• SITE: Single site  
• SETTING TYPE: Multiple settings    
• LOCATION: Philadelphia, PA

• APPLICATIONS: Palliative care 

Single-blinded, randomized crossover trial

• 100 mm Visual Analog Scale (VAS) for mood and anxiety
• 11-point Numeric Rating Scale (NRS) for pain

Anxiety was reduced by 15 points with music therapy and 12 points with music medicine (p < 0.0001). There was no difference between the two conditions. Pain was reduced by 0.9–1.1 points (p < 0.0005) with no difference between the groups. Common themes from the qualitative analysis were experiencing the music as relaxing, peaceful, and soothing, and many patients appreciated the playful nature of interactive therapy sessions.

Both music therapy and listening to preferred music were associated with reductions in pain and anxiety.

• Small sample (< 100)
• Risk of bias (sample characteristics)
• Other limitations/explanation: The sample was predominantly African American. Although findings were statistically significant, the actual change in outcomes measured was small. Whether this level of change was clinically meaningful was not clear. VAS measurement for anxiety has questionable reliability. The context in which patients were involved was not stated, so there was no way to determine whether patients were in anxiety-producing situations.

Listening to music was shown to be as effective as music therapy provided by a therapist to assist in reducing pain and anxiety. Although the degree of change shown here was small and this study had several limitations, listening to music is a low-risk and simple intervention that may be beneficial to patients. Nurses should consider employing this technique with patients in anxiety-producing situations and as part of pain management.

To evaluate the effect of musical therapy on anxiety in patients with breast cancer receiving conventional treatment

Patients were randomly assigned to the music or control group. While in the waiting room for 30 minutes prior to chemotherapy treatment, those assigned to the music group had the opportunity to choose and listen to pretaped musical themes with a Walkman and earphones for 15 minutes. Control patients received standard care. Anxiety levels were measured at baseline and after 15 minutes.

• The study reported on a sample of 60 female patients (30 in each study group).
• Mean patient age was 49.2 years +/- 6.9 in the experimental group and 52.7 years +/- 6.1 in the control group.
• All patients had stage I or II breast cancer and were receiving adjuvant chemotherapy.
• All patients had social support persons or family members present at the time of study.

• Single site
• Italy

Patients were undergoing the active treatment phase of care.

A randomized controlled trial design was used.

Speilberger State and Trait Anxiety Inventories

There were no differences between groups in pretreatment anxiety levels. Both groups demonstrated moderate pretreatment anxiety levels. Pretreatment state anxiety levels were higher than trait anxiety levels in both groups (p < 0.05). Post-test anxiety scores in the experimental group decreased by 9.9 (p < 0.001). In the control group, there was no significant change, although anxiety increased slightly after 15 minutes. There were no significant relationships between anxiety scores and demographic variables.

Listening to music may reduce anxiety related to chemotherapy administration. The levels of state anxiety compared to trait anxiety indicates that chemotherapy treatment is a stressful situation for patients.

• The study reported on a small sample, with less than 100 participants.
• The study was a single brief intervention, and it is not clear if listening to music would always have an effect of reducing anxiety before treatment.
• The study was limited to women with breast cancer and may not be readily applicable to patients with more advanced disease, those receiving treatments other than adjuvant chemotherapy, males, or those with other types of cancer.
• Other potential symptoms were not evaluated, so it is unclear how music would impact anxiety in the setting of additional patient symptoms.

Chemotherapy administration can be stressful for patients, and listening to music prior to treatment may be helpful to them. Providing the opportunity to listen to music is a simple intervention that has no inherent risks to patients and could easily be incorporated into practice in healthcare settings.

To determine the feasibility and possible benefits of a music imagery intervention for hospitalized patients with acute leukemia or high-grade non-Hodgkin lymphoma

Study patients completed baseline self-report instruments to assess affect, anxiety, and fatigue. Participants were then randomized to receive standard care or standard care plus music imagery. Standard care was hospitalization in a HEPA-filtered room with restricted visitor access and supportive medical care. A board-certified music therapist provided music imagery sessions. Sessions included relaxation and music imagery and were designed to provide participants with an opportunity to practice music imagery techniques, provide a successful music imagery experience, and answer any questions. When the initial session was complete, the therapist provided a CD with four 20-minute music imagery exercises as well as a CD player. Participants were encouraged to use the exercises at least once a day, and more frequently if they could. Participants used a journal to record how many exercises were used and their perceived effectiveness of the music therapy exercises. During therapist visits, patients could ask questions, change music imagery selections, and experience a therapist-led music imagery session. Music for the study included light classical and new age music chosen by the therapist based on assessment of the patients’ musical preferences and current emotional state and energy level. Sessions by the therapist occurred within three days of admission and twice a week during the hospital stay, up to four weeks.

• The study reported on a sample of 30 patients; 19 patients withdrew early from the study.
• Mean patient age was 52.47 years +/- 15.36 in the music imagery group and 55.53 years +/- 15.88 in the control group.
• The sample was 61% female and 39% male.
• Patients were hospitalized in a protective environment; all had either acute leukemia or non-Hodgkin lymphoma.
• Sixty-five percent of patients were married.

• Single site
• Inpatient setting
• Hematology oncology unit of Indiana University Hospital

Patients were undergoing the active treatment phase of care.

A randomized controlled trial design was used.

• Functional Assessment of Chronic Illness Therapy–Fatigue scale (FACIT-F)
• Spielberger State Anxiety Inventory (STAI-S)
• Music Imagery Journal
• Feasibility was assessed by rate of consent to participate, percent of completed music imagery sessions, and completion of measurement instruments.

Overall, 72% of therapy sessions were completed when accounting for study dropouts. No one completed the music imagery journal, due to feeling too sick or not remembering. Forty-nine percent completed an average of 60% of the measurement instruments. Analysis of mean scores over time, using repeated measures ANOVA, showed that both study groups improved in terms of greater positive affect, less negative affect, less fatigue, and less anxiety (p < 0.001). There were no differences in these results between study groups. Within those patients with low negative affect at baseline, those who received the therapy had lower anxiety at week 4 or hospital discharge than those in the control group.

Music imagery therapy is feasible in this population. Only those patients who had low initial negative affect demonstrated a potential benefit of the intervention in terms of lower anxiety at the end of the study period. Anxiety and fatigue declined over time in all patients.

• The study reported on a small sample, with less than 30 participants.
• The study design lacked an attentional control.
• The authors interpreted findings regarding apparent benefit only in those with lower initial negative affect scores to reflect an inability on the part of more negative patients to engage in the intervention. This suggests that patients who may need help for anxiety reduction the most would be those who are least able to benefit from this type of intervention.
• There was no way to evaluate actual use of therapy exercises because patients did not maintain the journals provided. This suggests that patients who are this severely ill may not be able to attend to this type of data collection.
• It cannot be determined whether patients used these exercises in between therapist-led sessions or not, and how this affected findings.
• The study had a high drop-out rate, with 10 patients (20% of the initial sample) withdrawing due to being too sick to carry out the intervention or voluntary withdrawal.

Results suggest that this type of intervention may only be of benefit in a select group of patients who are not as severely ill and do not have a high negative affect. The drop-out rate also suggests that this is a type of intervention for which participation and effect are highly dependent upon the patients’ preferences and interest in involvement. Findings suggest that once patients acclimate to the hospital environment, anxiety, fatigue, and negative affect decline, suggesting that nursing attention to helping patients with this acclimation may be most important in addressing these patient problems.

To evaluate the effect of 15 minutes of music on anxiety prior to receiving radiation therapy

Participants were randomly assigned to control or music group. Both took pretests using the State-Trait Anxiety Inventory and filled out demographic questionnaires, and vital signs were obtained. The intervention group received 15 minutes of self-selected music with similar tempo from a provided list. Patients were able to select which day they received intervention, select music that was paced at 60-80 beats/min. Postintervention data were obtained from both groups.

• N = 200  
• MEAN AGE =  55.06 (SD = 13.5); 55.66 (SD = 11.41)
• MALES: 64%; 57%, FEMALES: 36%; 43%
• KEY DISEASE CHARACTERISTICS: Head and neck, gynecologic, breast, digestive tract, lung, and prostate cancers
• OTHER KEY SAMPLE CHARACTERISTICS: Literate, all tumor stages, patients blinded to assignment

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Far Eastern Memorial Hospital, Taipei, Taiwan

• PHASE OF CARE: Active antitumor treatment

• Single blind RCT

• State-Trait Anxiety Inventory (STAI)
• Personal demographics
• Vital signs

STAI scores decreased significantly in both groups, but decreased more in intervention group and was statistically significantly lower in the intervention group (decline of 7.19 with intervention, 1.04 decline in control; p < .001). Both groups had significant decrease in heart rate and resting rate (pre- and postintervention). Music group had statistically significant difference in mean change of systolic blood pressure.

Anxiety levels and systolic blood pressure may decrease when music therapy intervention is provided before radiation therapy treatment.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Findings not generalizable
• Other limitations/explanation: Cancer types and stages were varied. Music was organized randomly without any rationale except for constant tempo, and researchers allowed participants to choose their own music. Random assignment was simple random sampling.

A choice of music therapy provided at radiation treatment centers may help to reduce anxiety that is caused by treatment and provide a way for the patient to relax at the treatment center and at home.

To determine the effect of watching a music relaxation video on pain and anxiety in women diagnosed with gynecological cancer who were undergoing intra-cavitary brachytherapy

A music relaxation video was played four times for a total of 120 minutes during the first 44 hours of brachytherapy treatment, with monitoring of pain scores, opioid consumption, and perceived anxiety scores compared to usual nursing care during the same time period.

• N = 60  
• MEAN AGE = 46 years (range = 23-70 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Gynecological cancer, cervix, uterus. 
• OTHER KEY SAMPLE CHARACTERISTICS: 51% white women, 67% married, 55% high school as the highest degree

• SITE: Single site    
• SETTING TYPE: Inpatient    
• LOCATION: Academic cancer care center in the southwestern United States

• PHASE OF CARE: Active antitumor treatment

• Randomized, controlled trial

• Pain severity was measured with a visual rating scale
• Opioid consumption was measured with a PCA pump
• Anxiety was measured using the Strat-Trait Anxiety Inventory

Women in the intervention group reported less pain. There was no difference in levels of opioid consumption between the intervention and control groups. Participants in the music viewing group indicated significantly reduced anxiety levels in analysis (p = 0.001).

Nurses and other medical personnel should consider using music relaxation videos to help reduce pain and anxiety during intracavitary brachytherapy and other procedures that may be uncomfortable.  The intervention is non-invasive, with beneficial effects.

• Small sample (less than 100 participants)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: Baseline pain was higher in the experimental group

This non-invasive intervention could be nurse-driven without a physician’s order.  Women undergoing brachytherapy must lie still in a shielded isolation room for 2-3 days with limitations on visitors, resulting in physical and psychological discomforts, including pain. This study shows that pain experiences may be lessened with music relaxation videos.

To examine the effect of music on patients undergoing HCT with the purpose of reducing social confinement in this group of patients

Patients were assigned to music and control groups by a throw of dice. Live music sessions with a therapist were done in the patient’s room twice weekly for 30 minutes each. Study assessments were done at the end of music therapy sessions.

• N = 100   
• AGE: Mean = 33.35 years
• MALES: 55%  
• FEMALES: 45%
• CURRENT TREATMENT: Combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: All were undergoing HCT; most were allogeneic

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Brazil

PHASE OF CARE: Active anti-tumor treatment

RCT

Visual analog scale (VAS) for pain and anxiety

Anxiety was lower in the music group after the first (p < 0.001) and last sessions (p = 0.002). Pain was lower after the first music session in the music group but, at study completion, there was no difference between groups in pain.

Music may help to alleviate anxiety associated with social isolation in patients undergoing HCT.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results
• Measurement validity/reliability questionable
• Other limitations/explanation: Only post-measurement of symptoms, so no data regarding if symptom levels changed with music. The duration of the study was not described, so timeframe of final measurement for both groups is unclear. VAS measurement for anxiety not validated. No way to tell if baseline anxiety was clinically relevant or not, there were no baseline measures

This study showed that music therapy may be helpful for patients undergoing HCT in terms of anxiety. This study has multiple design limitations. Music therapy is a low-risk intervention; however, it does require staff time of a music therapist. Further research regarding benefit of live music therapy versus listening to music would be helpful.

To explore effects of music and relaxation interventions on anxiety among patients with cancer and orthopedic interventions

Patients were randomly assigned to the music group, relaxation group or usual care control. Participants in the music group listened to a 20 minute CD of music composed by the hospital’s music therapist. The CD used harp and vocal music with spoken relaxation instructions. Patients in the relaxation group listened to and viewed a music video for 20 minutes that featured nature scenes and instrumental music. The control group were allowed 20 minutes of unstructured free time and were not allowed to listen to music during that time. The intervention was provided once during the first 48 hours of hospital admission. Study data were obtained immediately before and after the intervention.

• N = 112
• MEAN AGE = 60.6 years (range = 24-87 years)
• MALES: 37%, FEMALES:  63%
• KEY DISEASE CHARACTERISTICS: 49% were patients with cancer
• OTHER KEY SAMPLE CHARACTERISTICS: 59% were receiving anti-anxiety medications

• SITE: Single site  
• SETTING TYPE: Inpatient  
• LOCATION: Illinois

• PHASE OF CARE: Active antitumor treatment

• Randomized, controlled trial

• Spielberger State Trait Anxiety scale
• Blood pressure and heart rate

Although there were some differences among groups in single items on the anxiety measurement tool, there were no differences across groups for total anxiety scores. Anxiety scores declined in all on average (p < 0.001)

Results did not show effectiveness of the music and relaxation interventions used here, although anxiety did decline somewhat more in both intervention groups.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results
• Other limitations/explanation: Interventions were delivered via the hospital TV system, so could only be viewed at certain times. There is no description of the reason for hospitalization, so the degree to which some patients may have been in more anxiety-producing situations is unknown. There was no subgroup analysis to account for the potential impact of anti-anxiety drugs administered.

This study did not provide strong evidence supporting effectiveness of music and relaxation interventions for anxiety among the hospitalized patients involved. At the same time, there have been some studies showing benefits of music for various symptoms, and although not significant, this study did show greater reduction in anxiety with the intervention. This type of intervention is low risk and low cost, and may be beneficial to some patients. Here, the intervention was provided via the hospital television system, which can provide a very practical approach to delivery of the intervention.

To investigate the effects of live music on anxiety levels of patients undergoing treatment with chemotherapy

Possible participants were approached by the researcher at the beginning of a chemotherapy treatment session. Consenting patients completed questionnaires and were randomly assigned to the control group or to receive live music. The live music consisted of 20 minutes of singing with guitar accompaniment. During the intervention, patients were encouraged to sing along and to request other preferred songs. Control group patients completed questionnaires but had no other contact with the researcher. After 20 minutes, both groups completed a second questionnaire.

• The study reported on a sample of 50 patients.
• The ages and diagnoses of patients were not reported.
• Of the sample, 64% had chemotherapy six or more times previously. Only five patients were undergoing chemotherapy for the first time.

• Single site
• Outpatient setting
• Tallahassee Memorial HealthCare

Not decribed

A randomized controlled trial design was used.

• Visual analog scales (VAS): 8 centimeter VAS for six items; specific VAS items included anxiety, fear, worry, fatigue, comfort, and relaxation.
• Heart rate
• Blood pressure

Mean anxiety declined in the experimental group, and increased in the control group. These changes were significantly different between groups (p = 0.009). Responses regarding fear (p = 0.047), relaxation (p = 0.004), and fatigue (p = 0.001) also showed a similar difference. There were no significant differences in heart rate or blood pressure changes between groups. Many patients in the experimental group were involved in the music with hand clapping, etc. Patients who received the music therapy stated that it made the time pass more quickly.

Use of live music may be helpful to patients who are receiving chemotherapy to manage anxiety related to the treatment.

• The study had a small sample, with less than 100 patients.
• The study had a high risk of bias since there was no blinding of patients or the researcher who also obtained and analyzed the data.
• The report provided no analysis or findings regarding patient demographics or other characteristics that could have influenced results seen.
• The setting was not described, and it is not clear whether patients in the experimental group received the intervention in private, or if the music would have also been overheard by others in the area.
• Changes in VAS results were small, so, although some were statistically significant, clinical significance of changes was not discussed.
• Appropriate attentional control was not provided, so it cannot be determined if findings had to do with use of live music or if any type of distraction would have achieved the same results.

Findings suggest that distractions such as live music as provided here can be helpful to patients during chemotherapy. This is a low-risk intervention that might be of benefit for some patients.

To study the effect of music on anxiety and depression

Patients listened to music for at least 20 minutes daily for three consecutive days. Music was provided through headphones and consisted of light music selected by experts. Study measurements were done daily after the intervention.

• N = 60   
• AGE: Range = 18-65
• MALES: 57.2%  
• FEMALES: 42.8%
• KEY DISEASE CHARACTERISTICS: 54% had soft tissue tumors; others were bone cancer and leukemia. The majority in both groups had stage IV disease.
• OTHER KEY SAMPLE CHARACTERISTICS: 63% had less than high school education. Baseline HADS score was slightly over 14 in both groups.

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: India

Two-group, non-random, quasi-experimental

Hospital Anxiety and Depression Scale (HADS)

There was no significant change in HADS scores in the control group. HADS scores declined significantly over the three days of the music group (p < 0.001)

Listening to music was associated with short-term reduction in symptoms of anxiety and depression.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results

Listening to music is a low-risk intervention that may be of benefit in managing symptoms of anxiety and depression.

To measure the effect of a music intervention on anxiety related to bronchoscopy

Patients undergoing bronchoscopy were randomly assigned to listen to music via earbuds during the procedures or use earplugs with no sound. On admission to the hospital, patients completed a study questionnaire, and blood cortisol samples were obtained. On admission to the operating area, baseline vital signs were taken, and actigraph sensors were applied to the patients' wrists, ankles, head, and hips. After 10 minutes, study measures were obtained again. About 60 minutes after bronchoscopy, the study measures were repeated.

• N = 135   
• MEAN AGE = 63.7 years (SD = 11.6 years)
• MALES: 51.7%, FEMALES: 48.3%
• CURRENT TREATMENT: Other

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Denmark

PHASE OF CARE: Diagnostic

Single-blind, randomized, controlled trial

• State-Trait Anxiety Inventory (STAI) 
• Vital signs

Prior to bronchoscopy, the music group had lower STAI scores. After the bronchoscopy, anxiety was lower in both groups, with no difference between groups. No differences in duration of the procedure, sedatives, or amount of patient movement during the procedure were reported.

Music was not shown to reduce anxiety associated with bronchoscopy.

• Risk of bias (no blinding)
• Measurement validity/reliability questionable
• Subject withdrawals ≥ 10%

Music during bronchoscopy was not shown to affect patients' level of anxiety. Measurement of anxiety immediately prior to or during a procedure to perform this type of research is difficult and questionable.

To examine effects of music and visual imagery on anxiety and chemotherapy-induced nausea and vomiting (CINV) in patients receiving chemotherapy

Patients were assigned to the control group during their second cycle of chemotherapy and to the experimental condition during the third cycle of chemotherapy. Anxiety and CINV were measured before and after chemotherapy administration. Nature paintings were used for visual imagery, and instrumental Turkish music was selected for each image. Patients selected the image that was most appealing to them and were told to imagine being in the location of the painting. Patients were given the related music CD to listen to during chemotherapy with headphones.

• The study reported on a sample of 40 patients.
• Mean patient age was 59.65 ± 9.67 years.
• The sample was 77.5% male and 22.5% female.
• Of the sample, 80% had lung cancer, and all were receiving highly emetogenic chemotherapy.

The study was conducted at a single site, outpatient setting in Turkey.

Patients were undergoing active antitumor treatment.

A pre- and post-test repeated measures, single-group design was used.

• The Spielberger State-Trait Anxiety Inventory was used.
• Nausea was rated on a 100-mm visual analog scale (VAS).
• The Morrow Assessment of Nausea and Vomiting was used.

Anxiety declined from prechemotherapy to postchemotherapy administration in both conditions. Both pre- and postchemotherapy state anxiety levels were lower during the intervention course of treatment. CINV declined over time for both pre- and postchemotherapy administration. Both pre- and postchemotherapy CINV levels were significantly lower during the intervention condition.

This study does not provide any clear conclusions about the effects of music and visual imagery.

• The study had a small sample, with less than 100 participants.
• The study had risk of bias due to lack of a control group, blinding, random assignment, and an appropriate attentional control condition.
• The authors stated use of a 100-mm VAS but then stated that they grouped scores into 1 cm intervals. It is not clear if actual score differences were maintained, as this was not well described.
• The authors concluded that the intervention was effective based on analysis of differences before and after chemotherapy between the two study conditions; however, they did not show analysis of the change between pre- and postscores in each condition. This does not make sense as an approach to evaluate the effects.
• The study design had multiple risks of bias and threats to internal validity. Patients were assigned to the experimental condition in the third cycle—it is possible that anxiety and CINV simply declined over time, unrelated to the intervention.

Findings are inconclusive regarding the efficacy of music and visual imagery for anxiety and CINV during chemotherapy administration because of numerous study design and analysis limitations.

This intervention was music versus simple distraction and control (treatment as usual).

The study reported on a sample of 58 patients with cancer having painful, cancer-related medical procedures.

A randomized controlled trial design was used.

• Spielberger State-Trait Anxiety Inventory (STAI-S) pre- and post-procedure
• Pain intensity (0–10)
• Perceived control (single item, 0–10)

There were no significant differences in post-procedure anxiety (no p values reported), pain, or perceived control across conditions.

• The study had a small sample size.
• One-third of the sample used analgesics and anxiolytics.

To evaluate the effects of music therapy on anxiety in women undergoing breast cancer surgery

Patients admitted to the hospital for mastectomy were randomly assigned to receive either music therapy or usual care. Patients in the intervention group listened to music they selected through a headphone connected to an MP3 player during their hospital stay. Music was provided twice daily for 30 minutes per session. The total time in the hospital receiving therapy was an average of 13.6 days following radical mastectomy and 18.9 days for chemotherapy. Assessments were done at baseline on the day before surgery, the day before hospital discharge, on second hospital admission for chemotherapy, and on a third hospital admission for chemotherapy.

• The study reported on a sample of 120 female patients with breast cancer.
• Mean patient age was 45 years.
• Most patients (93%) had modified radical mastectomy, and the rest had radical mastectomy.
• Approximately 20% of patients had some college education.

• Single site
• Inpatient setting
• China

Patients were undergoing active antitumor treatment.

A randomized controlled trial design was used.

State Anxiety Inventory

Pretest results showed that patients had moderate to severe anxiety levels prior to surgery. Mean post-test anxiety scores were lower in the experimental group, on the first post-test 4.57 points, and increasing across time to 9.69 points lower at the final post-test (p < 0.0001). Mean anxiety scores declined over time in all patients.

Findings suggest that listening to music can be beneficial in reducing anxiety during treatment for breast cancer.

• The study had baseline sample/group differences of import.
• The study had risk of bias due to no blinding, no appropriate attentional control condition, and sample characteristics.
• Control patients had higher anxiety levels at baseline.
• Usual care was not described. It is not known if all patients received the same type and schedule of chemotherapy, which could have influenced results. Data reported shows that more patients in the control group did not receive as many courses of chemotherapy, so it would appear that some of these patients did not complete all follow-up self reports. Actual sample sizes contributing to the data at all time points were not reported.
• The sample consisted of lower economic group patients in China and may not be generalizable to other cultures.

Listening to music is a simple and low-cost intervention that may be helpful for some patients in reducing anxiety associated with cancer treatment.

To identify patients in high-anxiety states and to test the effects of a music intervention

Cancer and its treatment provoke a series of changes in the emotional sphere of patient anxiety. In addition, there is a subgroup of patients who are in a high-anxiety state. These patients, when identified, obtain the most benefits from music or verbal relaxation. This study consisted of 98 patients in three groups: the music therapy group, which received 60-minute, single-music sessions; the verbal relaxation group, which received 30 minutes of guided relaxation; and the control group, which received usual care. Because patients were asked to rate their anxiety preintervention, the study also was able to test the intervention's effects on those in high-anxiety states.

• N = 98
• AVERAGE AGE = 53 years
• MALES: 34%, FEMALES: 66%
• KEY DISEASE CHARACTERISTICS: Primarily patients' first chemotherapy session
• OTHER KEY SAMPLE CHARACTERISTICS: Participants who were married were more prevalent. Breast cancer was more prevalent than lung or other cancers. Cancers were in stages 2 and 3. Elementary-level education was the most prevalent educational status.  

• SITE: Single-site  
• SETTING TYPE: Outpatient  
• LOCATION: Outpatient clinic, University Medical Center, Taiwan

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Pediatrics, elder care, palliative care 

Randomized, controlled trial

• Spielberger State-Trait Anxiety Instrument (STAI)
• Emotional Visual Analog Scale (VAS)  
• Three biobehavioral indicators, skin temperature, heart rate, and consciousness level, were measured before and after chemotherapy.

All groups experienced a significant decline in anxiety. The music intervention group experienced a greater decrease in poststate anxiety (p = .005). Physiologic indicators also changed in patients with high-anxiety states in the music therapy group. This study highlighted the need to target patients in high-anxiety states and to offer additional support, relaxation, and interventions such as music therapy to this population.

Music intervention and relaxation therapy reduces chemotherapy-induced anxiety.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Selective outcomes reporting
• Key sample group differences that could influence results
• Other limitations: This study is difficult to reproduce as it requires one-on-one staff time. Relaxation and music during chemotherapy often is interrupted. Baseline anxiety was lower in the music intervention group.

This study highlighted the need to identify patients in high-anxiety states pretreatment. This population can then be offered additional interventions. Music and relaxation can reduce anxiety during chemotherapy. Most infusion centers offer personal music devices or allow patients to bring their own. Music can be offered via headphones if a patient desires. This intervention can be recommended safely.

To evaluate the effect of music in children with cancer who undergo lumbar puncture (LP)

Children were randomized to use either earphones with music (intervention group ) or earphones without music (control group) using iPods. The researcher and physician were blinded to participant group assignment. Immediately prior to the LP procedure, heart rate, blood pressure, oxygen saturation, and respiratory rate were obtained, and pain and anxiety scores were recorded. Directly after the procedure was finished, anxiety was remeasured. Self-reported pain was obtained before, during, and after LP. Physiologic parameters were recorded throughout the procedure. No local anesthetics or other analgesics were administered, which was usual care. Ten children in each group were chosen to be interviewed as well immediately after the LP procedure.

• The study reported on a sample of 40 pediatric patients.
• Patient age ranged from 7 to 12 years.
• The sample was 37.5% female and 32.5% male.
• All children had leukemia and were to have a lumbar puncture procedure.

• Single site
• Outpatient setting
• Hanoi, Vietnam

• Patients were undergoing the active treatment phase of care.
• The study has clinical applicability for pediatrics.

A double-blind, randomized controlled trial design was used.

• Pain Numeric Rating Scale (NRS): Pain intensity self-reported from 0 (no pain) to 10 (worst pain)
• Spielberger State-Trait Anxiety Inventory (STAI)–short form
• Physiologic measures of heart rate, blood pressure, etc.
• Brief semi-structured interview

Pain scores during LP were significantly lower for the music group (p < 0.001), 2.35 compared to 5.65 in controls. Pain scores after the procedure were also lower for the music group (p < 0.003). Anxiety scores after 10 minutes of music before LP were lower for children in the music group (p < 0.001). Anxiety after LP was also lower in the music group (p < 0.001) compared to controls; however, pre- and post-differences in anxiety in both intervention and control groups were minimal. Heart rate and respiratory rate were significantly different between the two groups, with lowered heart (p = 0.012) and respiratory rate (p = 0.009) during the procedure. In interviews, most of the children in the music group indicated that listening to their favorite music helped them feel calm and took their minds off the procedure.

Use of music as a distraction may be helpful to reduce pain and anxiety in children undergoing lumbar puncture.

• The study had a small sample, with less than 100 participants.
• The STAI was developed for and generally used in adults, and has not been validated in children.
• The children themselves could not be blinded to the intervention, and because the children in the control group were entered into the study with the knowledge that they might be given the intervention, but were then assigned to control, they may have felt they were missing something. This could have influenced findings.
• Potential risks with reuse of earphones for providing the music may be present.
• Post-anxiety between groups was reported, but no pre-post change in anxiety was reported. The music group also had lower anxiety at baseline, so it is not clear whether any post difference was due to the intervention.

This study does not provide convincing support for effectiveness of listening to music to reduce anxiety, but it appeared to reduce pain during the procedure. Music provision is a potentially low-risk and low-cost intervention that may be helpful to reduce pain and anxiety in children who are undergoing uncomfortable procedures. Further study of the use of music in combination with other forms of distractions and methods to combat pain are indicated. It is not clear if providing music via use of iPod and earphones is the best approach, as children in this study did indicate that the earphones were somewhat uncomfortable, and use of earphones for multiple patients could be a potential source for transmission of infection.

To determine if a decrease in the amount of anesthesia and a decrease in recovery time would occur in either of the treatment groups receiving music therapy compared to the usual care or control group.

Patients who met inclusion criteria were randomly assigned to a five-minute intervention or usual care in one of three groups: patient-selected live music (LM) with therapist-selected recorded music during the operative procedure; patient-selected recorded music (RM) preoperatively with therapist-selected recorded music during the operative procedure; or usual care (UC) preoperatively with noise-blocking earmuffs during the surgical procedure.

• N = 207 (LM = 69, RM = 70, UC = 68) 
• AGE: Range = 18-94 years
• FEMALES:  100 %
• KEY DISEASE CHARACTERISTICS: Breast cancer or suspected breast cancer biopsy, lumpectomy, and re-excision
• OTHER KEY SAMPLE CHARACTERISTICS: English-speaking women undergoing known or suspected breast cancer surgery; aged 18-years or older; ASA classification I–III; all were given fentanyl 1 mcg/kg and versed 0.02 mg/kg followed by adherence of a monitor sensor to the forehead and a propofol drip. 

• SITE: Multi-site    
• SETTING TYPE: Outpatient    
• LOCATION: University Hospitals Case Medical Center in Cleveland, OH; University Hospitals Richmond Medical Center in Richmond Heights, OH

• PHASE OF CARE: Diagnostic

• Randomized, controlled trial using three groups

• Global Anxiety-Visual Analog Scale (GA-VAS): before and after the five-minute music intervention or control condition
• Bispectral Index (BIS) monitor sensor: an intraoperative measure of sedative effects on the brain corresponding to alertness (goal of BIS 70 was target for recording amount of propofol administered)
• Recovery time: the interval between the end of surgery and the time the recovery nurse determined that d/c criteria was met
• Patient satisfaction: five-item questionnaire administered before discharge with questions based on the CAHPS Surgical Care Survey of the Consumer Assessment of Health Providers and Systems (CHAPS) program

No significant baseline differences in the three groups nor in amount of propofol used to achieve sedation level of BIS 70. Intervention groups showed significantly decreased levels of anxiety compared to control group; no significant difference in changes between the two groups were noted. Greater changes in anxiety level were seen when baseline anxiety scores were high: (i.e., the higher the pretreatment anxiety, the greater the change [reduced anxiety] in anxiety level after treatment). The amount of change (slope) in the LM group and RM groups were not different from each other, but were different from the amount of change (slope) in the control group. Recovery time, or time to discharge readiness determined by the recovery nurse, was not different for the intervention groups compared to the control group, but was shorter in the LM group compared to the RM group. Patient satisfaction scores revealed no differences among the three groups.

Noise-blocking earmuffs and music therapy were not found to reduce the amount of anesthesia required as measured by the BIS monitor. Satisfaction scores were high with and without music therapy. Music therapy was found to reduce anxiety more when initial anxiety scores were high.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: Blinding was not possible in busy preoperative or operative setting. Completing a questionnaire about anxiety may stimulate anxious thoughts. There were no attentional control as usual care in preoperative setting involves caring personnel. The BIS monitor may not provide the sensitivity for measuring changes based on music therapy in these types of patients undergoing these types of operative procedures.

Patients felt cared for and cared about with or without music therapy; anxiety levels were lowered with either type of music therapy when baseline anxiety levels scored high. Nurses may conduct anxiety screening and offer music therapy to reduce anxiety scores as part of the usual care environment.

To evaluate the effects of guided meditation and music on patients’ anxiety, pain, and fatigue during breast biopsy

Patients were randomly assigned to meditation, music, or standard care with supportive dialogue. Patients in the meditation and music groups were given headphones. During the procedure, patients in the meditation group listened to an audio recorded medication designed to help patients relax and focus on feelings of kindness and compassion. The music group listened to their choice of music. The standard care control group received supportive dialogue during the procedure. Biopsies were done with local anesthesia. Study assessments were done pre and post biopsy.

• N = 121   
• MEAN AGE = 52.96 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Patients undergoing breast biopsy. Of these, 30% had previous breast biopsy.  
• OTHER KEY SAMPLE CHARACTERISTICS: The majority were Caucasian. The average education level was 15 years.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: North Carolina

• PHASE OF CARE: Diagnostic

• Three-group, randomized, controlled trial

• State-Trait Anxiety Inventory (STAI)
• Numeric pain scale (0–10)
• Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F)
• Questionnaire on the Quality of Physician-Patient Interaction (QQPPI)
• 11-point numeric scale to assess engagement in the study interventions

Anxiety declined in all groups, while those in the meditation group (p = 0.04) and the music group (p = 0.03) had greater decline in anxiety compared to controls. Fatigue declined in all, with no significant differences between groups. Decline in pain differed among the study groups. The music group had greater increases in pain than the meditation group (p = 0.03), and pain increased in the control group. No difference in pain scores existed between the music and control groups. Overall post-procedure pain scores averaged 1.8.

The study findings suggest that a meditation intervention during biopsy may help to reduce patient anxiety and pain.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Very low pain scores suggest floor effects in measurement.
• Single point in time measurement of anxiety post-procedure—does not determine longer term effects on anxiety

This study showed that listening to a meditation intervention during breast biopsy was associated with lower anxiety postprocedure. This is a low-risk intervention that may be helpful for patients; however, whether this effect would have lasted for any length of time after the procedure is unknown.

To assess the effect of noise-canceling headphones, with or without music, on patient pain and anxiety associated with routine, office-based transrectal ultrasound-guided prostate biopsy  

Patients were randomly assigned to one of three groups: control group (no noise-canceling headphones), headphones group (patients wore noise-canceling headphones), or music group (which listened to Bach's Brandenburg Concertos through noise-canceling headphones). Patients donned headphones immediately before the procedure, after hearing a thorough description of the procedure and getting into position for the procedure.

• The study reported on a sample of 88 patients: 28 in the control group, 29 in the headphones group, and 31 in the music group.  
• Mean patient age was 62.5 years: 60 years in the control group, 68 in the headphones group, and 61.4 years in the music group.
• The sample was 100% male.
• Patients had an elevated prostate-specific antigen level or abnormal findings as revealed by a digital rectal examination.
• The sample was predominantly white.

• Site was unspecified.
• Office-type setting, although authors did not state the location of the office site or whether practitioners in more than one office participated in the study. (Authors are from the Duke University Medical Center, in Durham, N.C.)

Randomized controlled trial

• Verbal response scale (VRS), to measure pain
• Visual analog scale (VAS), to measure pain
• McGill Pain Questionnaire
• State-Trait Anxiety Inventory
• Physiologic measures: systolic blood pressure, diastolic blood pressure, differential blood pressure, heart rate, and respiratory rate

Mean VRS scores showed that pain significantly increased from baseline to postprocedure for all groups (control group, 0.79–2.49, p = 0.001; headphones group, 0.89–2.29, p = 0.009; music group, 0.52–2.13, p < 0.001). In no group did anxiety level change from baseline to postprocedure. The music group had the lowest overall mean State-Trait Anxiety score. Blood pressure levels remained fairly stable from baseline to postprocedure. The control group’s mean diastolic blood pressure increased from 82.3 to 88.4, the headphones group’s mean diastolic blood pressure increased from 79.38 to 81.9, and the music group’s mean diastolic blood pressure increased from 82.5 to 84.9. Authors reported that these changes were not statistically significant.

According to this study, music or noise-canceling headphones do not appear to relieve pain perception and anxiety during transrectal prostate biopsy; however, further research is warranted due to the small sample size.

• The study had a small sample size, with fewer than 100 patients.
• The patients and physician were not blinded.
• The volume setting (the music played at a comfortable level) and genre of music may have been a limitation; because the biopsy gun was quite loud, those in the noise-canceling headphones group could hear the biopsy gun.

Although this study did not find music or noise-canceling headphones to be effective in decreasing pain perception and anxiety, nurses may want to ask patients if they would like to listen to music in the circumstances outlined. Listening to music may be a distraction and potentially mitigate pain.

To examine effects of live music therapy on quality-of-life indicators, medications administered, and length of stay in patients undergoing brain surgery

Patients were met 30–45 minutes prior to surgery in the outpatient surgery check-in area, inpatient room, or preoperative holding area and completed baseline study measures. Patients in the experimental group received 20–30 minutes of patient-preferred live music and completed postintervention measures prior to surgery. Those in the experimental group received the music intervention each subsequent day of hospital stay, and completed both pre- and postintervention measures. Patients, family members, and visitors could participate by singing, playing rhythm instruments, or listening. Techniques included lyric analysis, songwriting, progressive muscle relaxation, and guided imagery. Control group patients also completed study measures postoperatively and daily during their hospital stay.

• The study reported on a sample of 27 patients.
• Median patient age was 48 years, with a range of 8–73 years.
• The sample was 55.6% female and 44.4% male.
• Diagnoses included aneurysm, meningioma, neuralgia, malignant neoplasm, osteoma, angioma, intracranial abscess, and metastatic cancer to the brain.
• Surgical procedures varied according to patient situation.

• Single site
• Inpatient setting
• Florida

Patients were undergoing the active treatment phase of care.

A randomized controlled trial design was used.

• Visual analog scale for mood, pain, relaxation, stress, and perception of hospitalization
• Total milligrams of vicodin and morphine
• Medications for nausea
• Hospital length of stay

There were no significant differences between groups for anxiety, mood, pain, perception of hospitalization, relaxation, or stress. There were no differences between groups for medications used. There was no significant difference between groups for length of stay.

Results do not support an effect of live music therapy on anxiety, pain, medication use, or length of hospital stay in patients undergoing brain surgery.

• The study had a small sample, with less than 30 patients.
• The study design lacked an attentional control.
• The practicality of providing such an intervention preoperatively in a check-in area or preoperative holding area is questionable, and the authors did state that many of these interventions were interrupted. Sessions during hospital stay were also interrupted for various aspects of care.
• Range of age was very broad, and no other demographic information about patients was provided.

This study does not demonstrate effectiveness of music therapy in hospitalized patients undergoing brain surgery. Practical application of this type of intervention in most acute inpatient settings and perioperative settings is questionable.

To test whether women who listened to music during screening mammography report lower levels of pain and anxiety than women who did not listen to music

On three days of the week, patients listened to music during screening mammorgraphy, and on two days of the week, music was not provided. An MP3 player was preloaded with various types of music. Patients who were part of the music group were asked to select the music of their choice. Patients rated pain and anxiety immediately after completing the mammography.

• N = 100
• MEAN AGE = 54.1 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Most were Caucasian. About 45% had had 13 or more previous mammographies.
   

• SITE: Multi-site 
• SETTING TYPE: Outpatient 
• LOCATION: United States

• PHASE OF CARE: Diagnostic

• Non-random, two-group comparison

• 10-point Likert-type scale for pain and anxiety

No significant differences in pain or anxiety were seen between groups.

This study did not show an effect of listening to music during mammography on pain or anxiety.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Measurement validity/reliability questionable
• No baseline anxiety measures—if patients were not anxious to begin with, they unlikely would have a result.

This study did not show an effect of listening to music during screening mammography, but evidence has shown effectiveness of music in reducing anxiety during invasive procedures. Listening to music during mammography is a low-cost and low-risk intervention that may be helpful to some patients. This study had multiple limitations.

To examine effects of music therapy and progressive muscle relaxation (PMR) training on depression and anxiety in Chinese patients with breast cancer 

Patients randomly were assigned to the intervention group (which received the music and PMR intervention) or a usual care group after a radical mastectomy. To avoid contamination, intervention and control patients were placed in different inpatient areas. Music therapy involved listening to music via headphones connected to an MP3 player for 30 minutes twice per day. This began within 48 hours after surgery. Patients selected their preferred music. PMR training was conducted on the second postoperative day. Training was conducted twice per day for 30 minutes until discharge. Patients were encouraged to do PMR and music listening exercises together. Patients in the control group received the usual postoperative nursing care only. Study measures were obtained the day before surgery and the day before hospital discharge. Data collectors were blinded to group assignment.

• N = 170  
• MEAN AGE = 47.01 years (SD = 9.5 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Most had modified radical mastectomy and 89% had chemotherapy immediately after surgery

• SITE: Single-site    
• SETTING TYPE: Inpatient    
• LOCATION: China

• PHASE OF CARE: Active antitumor treatment

Randomized, controlled, single-blinded trial

• Zung Self-Rating Depression Scale (SDS)
• State-Trait Anxiety Inventory (STAI)

Analysis showed that there was a significant reduction in anxiety and depression over time alone (p < .001) as well as by group (p < .001), and there was a significant interaction between group and time (p = .0009). Depression scores declined an average of 7.2 points in the intervention group and 4.6 points in the control group. Anxiety scores declined an average of 16 points in the intervention group and 11 points in the control group. Hospital stay time was significantly lower in the intervention group (p < .001). Hospital stay length was shorter in the intervention group.

The findings of this study suggest that the combination of PMR and listening to music was helpful in reducing anxiety and depression in women after mastectomies.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results
• Findings not generalizable
• Other limitations/explanation: No information was provided regarding other potential confounders such as postoperative complications, pain levels, etc. that could influence reported outcomes. Data collection was conducted via face-to-face interview, and although it was stated that data collectors were blinded, it is not clear where the data collection took place. If it took place in the hospital, data collectors could deduce group assignment because of the different locations in the hospital. This study was of Chinese women, so applicability to other groups is not known. It is not clear in the report whether all sessions of the intervention were guided by the investigators or done by the patients on their own. It is not clear how, if supervised by investigators, the patient could listen to the PMR training if they also were listening to music via headphones.

Listening to music and using progressive muscle relaxation may have a positive impact on anxiety and depression in patients postoperatively. These are low-risk, low-cost interventions that may be beneficial. The findings of this study showed that those who had the intervention also had shorter hospital stays. There is insufficient evidence to determine the real impact of this intervention on duration of hospitalization; however, these findings suggest that this area deserves further exploration.

4,900 references were identified that were published between January 1, 1990 and December 31, 2013. 203 articles were included in the final review although only 174 were referenced. Grades used and reported here were A: recommended, high certainty of benefit, B: recommended, high certainty of moderate to substantial benefit, D: recommends against use, moderate to high certainty of no net benefit, and H: recommends against use, moderate to high certainty that harms outweigh benefits.

Interventions for specific symptoms that had strong recommendations for or against use were:

• Anxiety: Music therapy during RT and chemotherapy sessions, meditation, and yoga for patients undergoing therapy (B-level recommendation)
• Depression: Mindfulness-based stress reduction for patients undergoing radiotherapy, relaxation, and yoga (level A recommendation); massage and music therapy (level B)
• Fatigue: Energy conservation (level B)
• CINV: Acupressure and electroacupuncture in addition to antiemetics (B level)
• Neuropathy: Acetyl L carnitine was not recommended because of harm (H level).
• Radiodermatitis: Aloe vera and hyaluronic acid cream were not recommended as standard therapy because of lack of effect (D level).

It appears that only specific types of interventions were included, and there are numerous types of integrative or complementary interventions that were not considered in this review. The findings considered were limited to women with breast cancer. Quality rating of evidence was not discussed individually.

These guidelines provided an evidence-based evaluation of various integrative therapies in women with breast cancer. This set of interventions is not all-inclusive; however, it does provide some guidance to clinicians and others regarding evidence strength in these areas as assessed by this specific study group.