Music/Music Therapy

Music/Music Therapy

PEP Topic 
Acute Pain
Description 

Music therapy involves using music to influence physiologic, psychological, and emotional functioning. Music therapy is often used with other behavioral techniques, such as relaxation. Music interventions vary and range from simply listening to recorded music or live music to formal therapy sessions provided by music therapists. Professional music therapy involves individualization of the intervention; may include the patient in music making; and incorporates a systematic therapeutic process of assessment, treatment, and evaluation. Music and music therapy have been evaluated for effects on anxiety, chemotherapy-induced nausea and vomiting, depression, dyspnea, pain, fatigue, and caregiver strain and burden.

Likely to Be Effective

Systematic Review/Meta-Analysis

Archie, P., Bruera, E., & Cohen, L. (2013). Music-based interventions in palliative cancer care: A review of quantitative studies and neurobiological literature. Supportive Care in Cancer, 21, 2609–2624.

doi: 10.1007/s00520-013-1841-4
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Purpose:

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

Search Strategy:

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

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: Not reported

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Not reported

Sample Characteristics:

  • 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 and Clinical Applications:

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

Results:

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.

Conclusions:

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

Limitations:

  • 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.

Nursing Implications:

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.

Bradt, J., Dileo, C., Grocke, D., & Magill, L. (2011). Music interventions for improving psychological and physical outcomes in cancer patients. Cochrane Database of Systematic Reviews, 8, CD006911.

doi: 10.1002/14651858.CD006911.pub2
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Purpose:

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

Search Strategy:

  • 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.

Literature Evaluated:

  • 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.

Sample Characteristics:

  • 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.

Phase of Care and Clinical Applications:

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

Results:

  • 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.

Conclusions:

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

Limitations:

  • 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.

Nursing Implications:

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.

Cepeda, M.S., Carr, D.B., Lau, J., & Alvarez, H. (2010). Music for pain relief. Cochrane Database of Systematic Reviews 2010(8).

doi: 10.1002/14651858.CD004843.pub2
Print

Purpose:

To evaluate the effect of listening to music on acute or chronic cancer pain; to relate the effect of listening to music on analgesic requirements

Search Strategy:

  • Databases searched were the Cochrane Pain, Palliative & Supportive Care Group Trials Register and the Cochrane Central Register of Controlled Trials (Sept. 14, 2004); MEDLINE (1966–Oct. 4, 2004); EMBASE (1980–Sept. 15, 2004); PsycINFO (1985–Sept. 24, 2004); and LILACS (1982–Sept. 8, 2004).
  • Search keywords included free text, MeSH, and Emtree terms: music, music therapy, analges*, and pain. The report provides an extensive list of search terms.
  • Studies were included if they
    • Were randomized controlled trials.
    • Evaluated the effect of music on acute, chronic neuropathic cancer pain or experimental pain in children or adults.
    • Involved evaluation of pain intensity, pain relief, global improvement, or opioid requirement.
  • Studies were excluded if a music intervention was combined with any nonpharmaceutical approach to pain.

Literature Evaluated:

  • Investigators retrieved 113 studies, 62 of which the investigators excluded.
  • Authors assessed study quality by scoring subject assignment, study blinding, dropout rate, and intention-to-treat analysis.

Sample Characteristics:

  • The final sample included 51 studies.
  • The 51 studies comprised 1,867 patients who received a music intervention and 1,796 control patients, who did not.
  • Eight studies evaluated the use of music to treat the pain of children and neonates.
  • The range of patients in a sample was 11–233. Median sample size was 53.
  • Samples included patients with chronic pain, acute pain, postoperative pain, and labor pain.

Results:

  • Pain intensity: Meta-analysis involved 30 studies that used the same scale of pain intensity. The pooled estimate of effect was a 0.46 reduction on a 0–10 point scale (95% CI = –0.75 through –0.17, not significant). The studies comprised significant heterogeneity, and authors' analysis showed that one study had a major influence on overall effect size. When this study was removed, the effect of music was deleterious, being associated with a pain increase of 0.3.
  • Studies of children: In the eight studies of children, four studies did not provide quantitative data. Overall, no effect on pain proved significant, though some positive results were reported.
  • Pain relief: Four studies showed that 70% of those who used music had a greater probability of at least a 50% reduction in pain, relative risk (RR) – 1.70 (95% CI 1.21–2.37, p = 0.002).
  • Opioid requirement: Thirteen studies evaluated differences in opioid requirements. These studies were of patients who had procedural or postoperative pain. The mean difference (MD) supported use of the music intervention: –1.29, (95% CI –2.22 through –0.37, p = 0.006)
  • Authors judged that half the analyzed studies were of low quality. Authors noted a high level of heterogeneity in most subgroup analyses.

Conclusions:

Music has limited utility in clinical practice for pain reduction: A music intervention was associated with minimal reduction in pain intensity. A music intervention was associated with a small reduction in opioid use for the treatment of acute pain. The reduction was smaller than that associated with the use of an NSAID or paracetamol.

Nursing Implications:

The analysis provided little support for the effectiveness of music in the reduction of pain: The size of effects is small, and their clinical relevance is unclear. On the other hand, the analysis revealed no negative effects from the music intervention. Clinicians should be aware of the limited utility of music for pain management. Most of the studies in the analysis did not include patients with cancer; however, the highest effect sizes were in the setting of chronic pain, so a music intervention may be relevant to patients with cancer. Use of music along with other nonpharmaceutical and maximal pharmaceutical pain management may be helpful for some patients. Further research in this area would be useful.

Rheingans, J.I. (2007). A systematic review of nonpharmacologic adjunctive therapies for symptom management in children with cancer. Journal of Pediatric Oncology Nursing: Official Journal of the Association of Pediatric Oncology Nurses, 24(2), 81–94.

doi: 10.1177/1043454206298837
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Purpose:

To assist the health care practitioner by summarizing research studies that have examined the use of nonpharmacologic adjunctive therapies (NATs) for symptom management in pediatric oncology patients

Search Strategy:

  • Databases searched were Cochrane Library, PubMed, CINAHL, and PsycINFO.
  • Authors included an extensive list of search keywords. Of particular relevance to the pediatric oncology setting were pain, cancer, oncology, self-care, nausea, vomiting, fatigue, and coping.
  • Studies were included if they dealt with nonpharmacologic therapies to help alleviate symptoms associated with cancer treatment in children.

Literature Evaluated:

Investigators retrieved and reviewed 41 studies. Their review related to symptoms studied, modalities used, study design, sample size, and study results. The analysis included all 41 studies. The studies pertained to multiple modalities, including hypnosis, imagery, breathing, distraction, relaxation, cognitive behavioral therapy, art therapy, and music therapy.

Sample Characteristics:

  • Sample sizes ranged from N – 1 to 122 patients.
  • Across studies, participants included in the samples were pediatric patients receiving chemotherapy, needlesticks, radiation, lumbar punctures, bone marrow aspiration, IV insertion, MRI, or port placement for the treatment of unspecified disease.

Results:

Over all the studies, the results are mixed in regard to the effect of NATs on procedural pain. Some studies indicated that hypnosis produced promising results in reducing procedural pain. Cognitive behavioral therapy and distraction showed both an effect and no effect on pain. One study (based on observation and self-reporting) indicated that NATs had no effect on procedural pain. In a few studies, hypnosis (along with distraction and relaxation and cognitive behavioral therapy) produced significant pain reduction. Studies found that music therapy had little to no effect on the pain of bone marrow aspiration.

Conclusions:

This review of NATs produced mixed results.

Limitations:

  • The samples studied were inconsistent in regard to modality.
  • Some terms (e.g., anxiety and distress) were found to be interchangeable; on the other hand, hypnosis encompassed several definitions.
  • The sample size of some of the studies was small.
  • In the pediatric populations studied, the intervention provider (patient, professional, or parent) was unclear.

Nursing Implications:

More research needs to be done in this area. Health care practitioners, patients, and families need education about NATs and their application to pediatric oncology.

Tsai, H.F., Chen, Y.R., Chung, M.H., Liao, Y.M., Chi, M.J., Chang, C.C., & Chou, K.R. (2014). Effectiveness of music intervention in ameliorating cancer patients' anxiety, depression, pain, and fatigue: A meta-analysis. Cancer Nursing, 37, E35–E50.

doi: 10.1097/NCC.0000000000000116
Print

Purpose:

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

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy:

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

Literature Evaluated:

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.

Sample Characteristics:

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

Phase of Care and Clinical Applications:

  • APPLICATIONS: Pediatrics, palliative care

Results:

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.

Conclusions:

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

Limitations:

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.

Nursing Implications:

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.

Research Evidence Summaries

Li, X.M., Yan, H., Zhou, K.N., Dang, S.N., Wang, D.L., & Zhang, Y.P. (2011). Effects of music therapy on pain among female breast cancer patients after radical mastectomy: Results from a randomized controlled trial. Breast Cancer Research and Treatment, 128(2), 411–419.

doi: 10.1007/s10549-011-1533-z
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Study Purpose:

To explore the effects of music on pain, in patients with breast cancer, after radical mastectomy  

Intervention Characteristics/Basic Study Process:

The intervention group consisted of 60 patients who received MP3 players with headphones. The players were loaded with 202 selections of music; the music was of four types. Patients were instructed to listen to music, during the postoperative period and two chemotherapy periods (18.9 days, SD = 7.1 days), for 30 minutes twice a day, between 6 and 8 a.m. and between 9 and 11 p.m. While patients were in the hospital, a researcher encouraged adherence to the schedule. After the patients were discharged, a researcher used the telephone to encourage adherence. The control group consisted of 60 patients who were not blinded regarding the music intervention. All patients took four tests (one at baseline and three postrandomization). Pain levels were assessed before the surgery, on the first preoperative day; on the day before disharge; and upon admission for the first and second chemotherapy sessions. Cycle lengths for chemotherapy were 14, 21, or 28 days. The assesment one day prior to discharge was known as the first post-test. The assesments before the chemotherapy sessions were known as the second and third post-tests, respectively.

 

Sample Characteristics:

  • The sample was composed of 120 breast cancer patients.
  • The age range of patients was 25–65 years.
  • All patients were female.
  • All patients had breast cancer and underwent radical, modified radical, or extensive radical mastectomy. All patients received patient-controlled analgesia following surgery.

Setting:

  • Single site
  • Inpatient
  • Surgical department of oncology center, First Affiliated Hospital of Xi’an, Jiaotong University, Shanghai
     

Phase of Care and Clinical Applications:

Clinical applications: late effects and survivorship

Study Design:

Randomized controlled trial

Measurement Instruments/Methods:

  • General questionnaire    
  • Chinese version of Short-Form McGill Pain Questionnaire (which included a visual analog scale, VAS, and a measure of present pain intensity, PPI)
  • Pain Rating Index

Results:

Both groups reported improvement in all areas of assessment from baseline through the third post-test. At the first post-test (day prior to discharge), the difference between the two groups was –2.38% in favor of music (p < 0.05). By the third post-test, the differences had decreased to –1.87 (p < 0.05).

Conclusions:

Findings show that listening to music was associated with reduction in pain severity.

Limitations:

  • The report provided no information regarding the use or nonuse of any form of analgesia in the postoperative period and during chemotherapy. 
  • Limitations outlined by the authors include an assessment procedure that depended on self-reporting, which is affected by many factors; the use of quantitative research only; the lack of biomarkers or physiological measurements; the fact that the assessor was not blinded to patient assignment to intervention or control group; and risk of bias due to no attentional control condition.

Nursing Implications:

This study should be refined to determine and differentiate types and quality of pain and to consider the fact that pain typically decreases during the postoperative period. The differences noted between groups may indicate that music could play a role in reducing the pain that patients experience in the period immediately following surgery.

Tsivian, M., Qi, P., Kimura, M., Chen, V.H., Chen, S.H., Gan, T.J., & Polascik, T.J. (2012). The effect of noise-cancelling headphones or music on pain perception and anxiety in men undergoing transrectal prostate biopsy. Urology, 79, 32–36.

doi: 10.1016/j.urology.2011.09.037
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Study Purpose:

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  

Intervention Characteristics/Basic Study Process:

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.

Sample Characteristics:

  • 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.

Setting:

  • 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.)

Study Design:

Randomized controlled trial

Measurement Instruments/Methods:

  • 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

Results:

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.

Conclusions:

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.

Limitations:

  • 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.

Nursing Implications:

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.

Zavotsky, K.E., Banavage, A., James, P., Easter, K., Pontieri-Lewis, V., & Lutwin, L. (2014). The effects of music on pain and anxiety during screening mammography. Clinical Journal of Oncology Nursing, 18, E45–E49.

doi: 10.1188/14.CJON.E45-E49
Print

Study Purpose:

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

Intervention Characteristics/Basic Study Process:

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.

Sample Characteristics:

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

Setting:

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

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Diagnostic

Study Design:

  • Non-random, two-group comparison

Measurement Instruments/Methods:

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

Results:

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

Conclusions:

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

Limitations:

  • 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.

Nursing Implications:

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.


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