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The Sound of Therapy

Nurses have played key roles in fostering music as therapy for anxiety in patients with cancer and other serious illnesses.

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Each year the number of people diagnosed with cancer continues to increase and remains one of the top causes of death. Along with the physical manifestations of this disease, anxiety remains a prevalent symptom among this population.1

 A cancer diagnosis and the journey that follows can be a confusing and anxious experience for many patients. Even if there is no history or predisposition to anxiety, the patient may still be at risk.

According to the American Society of Clinical Oncology, up to 30% of people with cancer experience significant anxiety.2 

Beyond the fear experienced following initial diagnosis, the stress of undergoing conventional cancer treatment, and the worry associated with reoccurrence many cancer patients are faced with the additional demands of making decisions about alternative therapies.3

Some patients have difficulty expressing emotions relating to their pain and anxiety, and if left untreated can turn into a debilitating depression. This depression can impede the healing process and lead to increased medical costs.2

Studies summarized in this article have reported the benefits of patients engaging in alternative or complementary therapies, such as music therapy. These therapies are geared toward decreasing anxiety levels that are more productive or conducive to the patient and their healing process.

A multitude of alternative therapies have evolved over time and been utilized by patients to help with their illness, while much money and time have been spent to evaluate the effectiveness, safety and cost effectiveness.2 

Research has exposed the increasing popularity of alternative therapies in the past 15 years, but the problem is many patients are unaware of these therapies since information is not readily available to them or provided information by their physicians, not to mention the out-of-pocket expenses.

The majority of these patients are seeking to improve health, decrease anxiety, increase quality of life, and a supplement to treatment.

For these individuals, music can serve as an outlet in which these emotions can be expressed.


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Origins of Music Therapy

Music therapy was utilized as a therapeutic tool in the healthcare setting after World War II. Musicians from the community would visit veterans while hospitalized to help ease their physical and emotional suffering.

Today, music therapy is utilized in a variety of healthcare settings, such as inpatient, outpatient, and hospice settings as part of a complementary medical program.4  The American Music Therapy Association defines music therapy as an intervention that can promote wellness and manage stress in a healthy way.5 A music therapist must undergo extensive classroom and clinical training.

Music therapy is increasingly recognized as a therapeutic intervention in cancer care by helping deal with emotions, such as withdrawal, anger, fear and anxiety.6 This type of therapy is based on a well-established set of scientific medical interventions, but treatment plans are customized to assess the patient's needs, interests and other treatment barriers before beginning music therapy.5

Music therapy can be categorized as active and passive. Playing music and singing is considered active whereas listening to live or pre-recorded music is passive.4 While active music therapy includes not only listening or playing music, but also writing lyrics or even discussing how the lyrics or songs have an emotional impact on their state of well-being.

Music & the Oncology Patient   

A discussion of music therapy and the responses from oncology patients necessitates an analysis of literature. This discussion based on nursing research will examine the role of music therapy with oncology patients in a variety of settings such as, outpatient clinics, radiation therapy, hospices and palliative care settings.

In an attempt to understand the concept of how music therapy aids in reducing anxiety levels, Kenyon (2008), Burns et al., (2008) and Ferrer (2008) conducted studies2,4,6 among women undergoing their first chemotherapy treatment for breast cancer and gynecological cancer. These studies utilized a control and experimental group to assess the effectiveness of music during treatment.

Kenyon (2008) selected 40 participants in which 31 of the participants listened to pre-recorded tapes via headset; while the remaining 19 did not receive music intervention during treatment in an outpatient cancer center.

Kenyon randomly selected patients with the help of a nurse to distribute questionnaires to all of the participants. Once the questionnaires were completed and collected, the experimental group was given headsets while the control group began chemotherapy treatment.

Both groups remained in one room during the therapy and completed a post-test either after the music therapy or the chemotherapy. The experimental group's answers to the pre-test and post-test revealed lower anxiety in relation to the control group.

A similar study, conducted over a two-week period by Burns et al. (2008), with the help of a research nurse who selected patients that would be receiving treatment for two weeks, included 29 outpatient cancer patients. The experimental group listened to pre-recorded classical music while the control group received their standard chemotherapy.

The two groups were separated from one another for this study. After the two-week sessions, the participants were interviewed about their feelings on music therapy being incorporated into their treatment. Comments made by the study participants included, "I felt more whole", "The power of the music uplifted my spirits" and "I felt calm and happy."6.

Finally, Ferrer (2008) conducted a randomized study of oncology patients who were undergoing outpatient chemotherapy. The purpose of his study was to investigate if there was a difference in anxiety levels among cancer patients who received music therapy during treatment. Ferrer's sample size was 50 in which he divided the sample equally and separated into two rooms. The experimental group participated in music therapy by either listening to live music or played an instrument along with the therapist. 

At the conclusion of treatment the patients needed to answer the following questions asked by the research nurse that included: (a) did you enjoy listening to music while receiving chemo therapy (b) do you think the music helped reduce your anxiety, and (c) would you like to receive this service again? The results were 100% yes, with comments such as "Music was soothing and took my mind off of everything. The songs played brought me happy memories. It was relaxing and I enjoyed singing along" and "I would recommend this activity for patients."2 

The empirical results recorded from these studies support the thought that if cancer patients receive music therapy, then they will exhibit lower levels of anxiety.

Breast Cancer & Music Therapy

Breast cancer has been reported to be the second most commonly diagnosed cancer, and the most prevalent cancer in the world.7 

Breast cancer patients receiving chemotherapy experience psychological distress about the fear of side effects and reoccurrence. It has been reported that the prevalence of depression with breast cancer patients varies from 8% to 36% depending on the extent of disease and any underlying depression and anxiety symptoms prior to diagnosis.7

There are few studies focusing on breast cancer patients utilizing music therapy. To examine the anxiety levels breast cancer may potentially inflict, So et al., (2009) and Bulfone et al.8, (2009) distributed a survey to patients who were receiving chemotherapy in an outpatient cancer center and utilized the Hospital Anxiety and Depression Scale for content validity. The results showed anxiety was present and had a detrimental effect on quality of life. 

The Hospital Anxiety and Depression Scale designed by Zigmond and Snaith9 was developed in 1983. It is a 14-item questionnaire that generates ordinal data to detect any anxiety and or depression a person maybe experiencing .

Bulfone et al., (2009) intended to evaluate the effects of music therapy on the anxiety of breast cancer patients receiving conventional medical treatment.The control group received their standard therapy, while the experimental group listened to pre-taped music for 15 minutes. Both groups were given a questionnaire scored on a scale from one to four using the Spielberg State Trait Anxiety Inventory (STAI) for content validity after treatment and therapy.

Results revealed a decline in anxiety in the experimental group. In both of these studies, based on the results of both studies, the researchers support the theory that quality of life is affected by the anxiety imposed by breast cancer treatment, and that the role of music alleviates the affliction these patients endure.

The significance of this research is displayed by the scores of the post-tests the experimental groups completed. 

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Bone Marrow Transplant & Music Therapy

Little research exists on music intervention on anxiety in bone marrow transplant patients. Most bone marrow patients experience anxiety due to the unknown side effects they may experience with treatment.These patients receive intensive chemotherapy and experience distress related to both the cancer diagnosis and isolation they endure due to side effects of the intensive and vigorous doses of chemotherapy.

The isolation bone marrow transplant patients are placed in over a period of time is the reason music therapy was tested in this treatment group.

To examine anxiety in relation to music therapy a study conducted by Burns et al., (2008) consisted of a randomized study incorporating music therapy three days after the patient's admission and continuing twice weekly for four weeks with each session lasting 20 minutes. A subset of individuals did experience a positive intervention effects. These patients reported feeling of lower distress and anxiety with comments such as, "I focused on the music rather than what side effect will I experience today. It took my mind off my disease for a few minutes".6  

A study conducted by Shabanloei, et al (2010) wanted to quantify and evaluate the effectiveness of music therapy on patients' undergoing bone marrow biopsy and aspirations. One hundred participants with ages ranging from 18 to 60 undergoing a biopsy or aspiration were chosen by use of a random number table.10  This questionnaire, completed five minutes before the therapy began, consisted of 40 questions divided into 20 questions each asking how patients felt "right now" and the remaining twenty on how they were "feeling generally". During the study, three songs were played, and then after one minute another questionnaire was completed. After the procedure, participants in the experimental group reported significant lower anxiety.

 The results of this study support the theory of music's ability to decrease anxiety on patients undergoing biopsy and aspiration. This therapy is inexpensive and non - invasive way to reduce anxiety for this type of procedure.

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Radiation Therapy & Music Therapy

Radiation therapy is a common form of treatment for oncology patients. Although there is a large body of literature on the use of music as a therapeutic intervention, there are a few studies that have examined the role of music with oncology patients' receiving radiation therapy.

In Smith, et al (2009), the purpose of the study was to assess if music decreases any anxiety that a radiation therapy patient may experience. Participants included patients who were to receive at least five weeks of radiation treatments.

This randomized study consisted of an experimental and control group who listened to pre-recorded music of their choice. Both groups completed a questionnaire for pre and post radiation treatment. The experimental groups made comments such as, "I was completely relaxed" or "I wasn't as nervous since I knew the music would help me relax during my treatment."11

Hospice & Music Therapy

Music is a powerful tool that can evoke emotions and enhance communication.

Often palliative and hospice patients have difficulty expressing emotion relating to their chronic pain and anxiety. These patients have endured intensive chemotherapy and its side effects, and when treatment becomes ineffective these patients turn to palliative care and hospice for improved quality of life and comfort.

At this point, anxiety can be extremely debilitating and continually increases as patients become more aware of their impending death. For these individuals, music is an appropriate choice that can serve as an outlet in which emotions can be expressed.  It can address spiritual and emotional needs of the patient, and is crucial in end of life care.12

As with palliative care patients, hospice patient's needs and emotions must be addressed in their end-of -life care. Anxiety and depression have been found to be the most frequent psychological problems hospice care patients encounter.12

The ultimate goal for hospice patients is comfort and relaxation during their final days considering their terminal illness paired with an underlying anxiety disorder, may cause fear about losing control and exacerbate the fear of dying.1 

Although research literature from the 1990s and early 2000s varied in focus and design, all reviewed support the premise that music therapy reduces levels of anxiety among hospice patients.

In the Thompson and Grocke (2008) study, participants were in patients receiving palliative care services. The experimental group received live music for four weeks with the results supporting the use of music therapy. Participants commented, "Music therapy helped me relax", and "The music let my mind focus on how helpful this medicine is to help me with my pain".1

In the area of comfort, Hanser (2008) reported that after a single music therapy session, with 80 hospice patients expressed an increased level of physical comfort and relaxation. These studies have been beneficial in demonstrating that music therapy significantly reduces anxiety for terminally ill patients.13

Evidence-Based Therapy

 A diagnosis of cancer brings unpredictability to patients' lives. While undergoing treatment patients may experience a series of side effects that can cause emotional upsets and tremendous feelings of anxiety (Olofsson & Fossum, 2009).3

Music therapy is an evidence-based alternative therapy enhances quality of life by decreasing anxiety by addressing the patients' physical, emotion and spiritual needs. It can provide a mean of transcending to moments and places of peace and beauty.

With the multidisciplinary team members participating in complementary therapies paired with modern medicine we will facilitate quality of life by decreasing anxiety among this population (Bardia, Barton, Prokop, Bauer & Moynihan, 2009).14

References for this article can be accessed here.

Felice Kloss-Hefferan has been as staff nurse for 15 years. Her career experience began working with oncology patients for 10 years, in which complementary therapies were implemented. Currently, she works as a cardiac nurse at Main Line Health.

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Sound therapy is definitely a science which has evolved since thousands of years. And listening to the healing sounds can definitely help a person overcome his illnesses which is specifically designed for that ailment and the troubled frequencies of the sick organ.

mark robinson,  analyst,  noneApril 16, 2014
florida, FL

I have been using Rhythmic Medicine's MUSICAL ACCUPUNCTURE for years for helping people to relax. One person awaiting a lung transplant said that she received more relief from the music than the meds ordered. Janalea Hoffman does an excellent job of writing music that entrains one to slow down and relax.

doris houghtaling,  RN FCNSeptember 26, 2013
sugar grove, IL

This is a well written article that provides great research and information about Music Therapy. As a Board Certified Music Therapist, I appreciate the information being shared with other professionals. Music Therapy is much more than just listening to music. It is a relationship between the music, the patient, and the Music Therapist, not all music is going to be relaxing and anxiety reducing for every individual. A Board Certified Music Therapist needs to provide an assessment to each individual. Other professionals also need to recognize the difference between Music Therapists and Music Practitioners, Music Practioners provide music at bedside but is not the same thing as Music Therapy.

Bessie Barth,  MT-BC, NMT,  Music To Grow OnSeptember 26, 2013
Sacramento, CA

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