Music/Music Therapy

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.

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.

Patients were exposed to the same kind of music played from a music set located within the chemotherapy unit while their chemotherapies were administered. Music included pieces from the album “Love Songs” by James Galway, distributed by BMG music, 2001 of which were instrumental pieces of international classical music. Patient outcomes were evaluated before and after a baseline cycle of chemotherapy and before and after a chemotherapy cycle with the musical intervention.

• The sample was comprised of 18 patients with breast cancer receiving adriamycin-containing adjuvant chemotherapy after undergoing modified radical mastectomy (median age = 45.5 years [range 28–60]).
• The majority of patients had stage II disease (77.8%), and five patients (27.7%) had associated comorbidities (e.g., hypertension, type 2 diabetes mellitus, coronary heart disease).

Outpatient clinics

This was a pilot study.

European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)

The music intervention did not demonstrate improvement in fatigue outcomes.

• The study had a small sample size.
• The study lacked a control group.

Future studies may want to account for personal preferences of the patients for the type of music listened to during chemotherapy.

To evaluate the efficacy and feasibility of music imagery.

The intervention involved 45-minute sessions with a music therapist occurring twice weekly during a four-week hospital stay. The intervention consisted of education about how to use music imagery exercises together with the opportunity to practice music imagery techniques and experience a successful music imagery encounter. The music therapist chose music for each specific patient based on an assessment of the patient’s musical preferences, current emotional state, and energy level. After the session, the patient was provided with equipment to play CDs containing music imagery exercises, and patients were encouraged to use the CDs at least daily during their hospital stay.

• To be included in the study, patients had to 18 years or older, receiving at least three radiotherapy treatments, and able to read English.
• Patients were excluded if they had a documented psychiatric illness, cognitive impairment, or current treatment for a brain tumor or were not cognitively able to participate in the intervention or answer the self-report questionnaires. 
• Patients were admitted to the Hematology-Oncology Unit at Indiana University Hospital for the treatment of acute leukemia or high-grade non-Hodgkin lymphoma.
• Forty-nine patients were hospitalized for induction chemotherapy for acute leukemia or high-grade lymphoma (24 in standard care and 25 in standard care with music imagery).

Patients were undergoing the active treatment phase of care.

This was a randomized, controlled trial.

• Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F) scale
• Patients also were asked to record how many exercises were used between meetings with the therapist, as well as the perceived effectiveness of the music imagery exercises; however, the authors reported that no patient recorded that information.

The intervention showed no effect on fatigue.

• The study had a small sample size.
• The intervention may have been too weak, despite the high rate of music imagery intervention completion, to produce significant benefits on fatigue outcomes.
• The intervention required referral to a music therapist.

To determine the effects of music therapy on subjective sensations and physiologic parameters of heart rate variability (HRV) in treated cancer survivors.The hypothesis was that music therapy significantly affects the sensations of fatigue, comfort, and relaxation, as well as the activities of the sympathetic and parasympathetic nervous systems.

Participants were asked to sit and rest for five minutes to stabilize their heart and respiration rates when they first arrived in the group therapy room. An electrocardiogram (ECG) signal then was measured for five minutes, and fatigue, comfort, and relaxation were rated subjectively on the visual analog mood scales (VAMS) as a pretest. After participating in two hours of music therapy, the same procedure was performed again as a posttest.  

The two-hour music therapy intervention consisted of three activities. In the first activity, the program aimed at establishing a rapport between therapists and participants through singing and listening. The song for the first activity was a popular Taiwanese song called ‘‘He is Our Treasure,’’ which had pleasant moderate rhythm and tempo. The second activity was to learn how to play the recorder. This activity used simple musical instrument learning to establish the participants’ self-confidence. The third activity was to perform the main five notes of a familiar melody song, ‘‘Grandfather’s Clock,’’ following the therapist’s electric keyboard accompaniment and conduct. This activity sought to encourage the participants to express themselves through playing the recorder and to create light and joyful emotions.

• The sample was comprised of 23 women with cancer (breast [n = 19], ovary [n = 2], cervical [n = 1], and bone [n = 1]).   
• Mean age was 49.9 years (standard deviation = 9.2 years) (range 30–67).
• Participants were recruited from the Hope Society for Cancer Care in Taipei, Taiwan.

• Single site
• Outpatient
• Taiwan

• Patients were undergoing the posttreatment phase of care.
• The study has clinical applicability for late effects and survivorship.

The study used a pre-/posttest, quasiexperimental design.

• ECG monitoring    
• VAMS
• HRV monitor
• The study assessed whether participants were fatigued, comfortable, and relaxed, but no questionnaire was described.
   

Comparison of the quantitative HRV measures at pre- and posttest revealed that the high frequency (HF) power and normalized HF power were significantly higher, and the low frequency (LF)/HF ratio and normalized LF power of HRV were significantly lower at posttest than at pretest (p < 0.05). The VAMS mean value for the fatigue level was significant lower after music therapy (p < 0.05). The VAMS mean value for relaxation level was significant higher after music therapy (p < 0.05).

In a small sample size including varied cancer diagnoses with limited information about the study participants, the assessment showed changes in fatigue, relaxation, comfort, and HRV.

• The study had a very small sample, with less than 30 participants.
• The study lacked a control group.
• The study included various cancer diagnoses.
• The study used a cross-sectional design.
• Symptom instruments were not multidimensional or psychometrically tested, and no description was given for how the symptom questions were presented to the participants.   

Additional research is needed, including the use of psychometrically tested symptom instruments. Based on the descriptive findings in this very small initial study evaluating HRV, fatigue, and relaxation, it may not be appropriate to include it in PEP topic research. This study was completed by colleagues in a biomedical engineering school. Describing the process of how this was accomplished (e.g., surveys with nurses assisting) might be useful.

The music-listening intervention included preferred music and recommended relaxation techniques (e.g., progressive muscle relaxation, imagery, and positive self-talk). Sessions were guided by a music therapist on a 90-minute cassette. Frequency of listening (dose) varied, but duration was not reported.

• The sample was comprised of 63 patients with cancer at varied stages undergoing curative radiotherapy (mean age = 57.8 years).
• Of the patients, 61.9% were male and 85.7% were non-Hispanic White.
• Patients were included if they were aged 18 years or older, were receiving at least three radiotherapy treatments, and were able to read English.
• Patients were excluded if they had a documented psychiatric illness, cognitive impairment, or current treatment for a brain tumor.

The study was conducted at a comprehensive cancer center, including a Veteran's Administration facility.

Not specified

This was a randomized trial in which patients were assigned to one of the two groups:  the music therapy group (n = 35) or the control group (n = 28).

• Profile of Mood States (POMS), fatigue and vigor subscales combined
• Hospital Anxiety and Depression Scale (HADS)
• Distress Numeric rating scale
• Pain Numeric Rating Scale
• Measures were taken weekly.

Fatigue increased from baseline to the end of treatment for both groups. No significant difference in intervention effects was observed. Fatigue, depression, pain, or anxiety showed a significant relation between frequency of listening and emotional distress. Higher use of music was associated with greater reduction in treatment-related stress.

• The study had a small sample size.
• Variable listening dose and relaxation are both confounding factors with music therapy.

Referral to a music therapist is necessary for the delivery of the intervention.

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.