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The value of music therapy in patient care
PERIOP BRIEFING
SECOND FEATURE
The value of music therapy in patient care Kelly Putnam, Managing Editor
M
usic can be incorporated into an array of patient therapies, ranging from the passive listening of recorded music through headphones to the active use of instruments and live music to improve motor skills or cognitive abilities impaired by specific diseases or conditions. The American Music Therapy Association defines music therapy as “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.”1 Professional music therapists have demonstrated guitar, piano, drum, and vocal proficiency. Music therapy requires a referral from a physician, but nurses can play an integral role in identifying patients who may benefit from this therapy and coordinating care among the perioperative team, music therapists, patients, and family members. Various patient populations can benefit from some form of music therapy as part of an interdisciplinary approach to patient care. Multiple comprehensive reviews and meta-analyses have confirmed the effectiveness of music therapy to reduce the surgical patient’s anxiety and pain across the perioperative continuum of care.2-4 Periop Briefing spoke with Kathleen Humphries, MA, MT-BC, NICU-MT, a practicing music therapist in Long Beach, Calif., about the broad practice of music therapy and its specific benefits for surgical patients.
Engaging patients emotionally and physically Humphries advocates playing live, patientpreferred music and encouraging active participation from patients while taking into account their comfort level and demeanor. Humphries has at her disposal a cart full of drums, shakers, maracas, ukuleles, guitars, and keyboards that she can bring to each patient’s room. “With children we’ll do a lot of just improvisation on the instruments,” said Humphries. “For those who are less outgoing or more quiet and just want to play how they feel, we’ll just do that and I’ll validate and support them http://dx.doi.org/10.1016/S0001-2092(15)00712-7
P10 | Periop Briefing
musically.” For adult patients, Humphries will often begin by asking what type of music they like and playing a requested song in a style tailored to their liking. Some patients participate in songwriting or singing sessions. “Music is perfect for expressing oneself when words don’t suffice; that’s what’s great about music therapy,” said Humphries. The instruments can also provide a conduit for improving motor skills, and can even become part of physical therapy. “One example is using TIMP [therapeutic instrument music playing], where you use the placement of instruments to kind of encourage and motivate the patient to reach and do their stretches,” said Humphries. “It’s an enjoyable experience and they don’t realize they’re actually doing their physical therapy exercises.” The administration of long-term music therapy aims to improve socialization, mental health, communication, cognitive and sensory integration, and motor skills, based on the patients’ needs.
Improving patients’ perioperative experiences According to the AORN “Guideline for complementary care interventions,” music therapy can be implemented as an effective measure to reduce perioperative pain and anxiety.5 The guideline recommends that the perioperative team first assess patients’ willingness and obtain consent before incorporating music into their care. In addition, patients should be able to choose their own music and use personal listening devices to limit noise and distraction in the perioperative setting. Important factors to consider include the feasibility and cost of this type of care.6 Music therapy is only reimbursed in some states, but other sources of funding can include grants or philanthropic gifts from special foundations. According to a recent meta-analysis published in the Lancet examining the use of music across the perioperative continuum of care for more than 6,900 patients, music significantly reduced postoperative pain, anxiety, and analgesia use.2
The greatest reductions in pain and anxiety were observed when music was delivered preoperatively rather than intraoperatively or postoperatively and when general anesthetic was not required for the procedure.2 Music therapy in adult and pediatric surgical patients can reduce physiological markers of stress, such as blood pressure and glycemia.7,8
help patients with Parkinson’s disease control their gait. “They end up actually synchronizing to the appropriate walking speed of what we want them to be at with the music,” said Humphries. “The therapist is able to manipulate the music to meet the patient’s needs and change it to be where we want them to be.”
Music therapy can also improve patients’ perception of their hospital stay.2,9 Humphries suggests that by improving the patient experience in the hospital and in the OR, music therapy can help set the stage for positive experiences in the future for patients who require repeat procedures. Of the 72 randomized controlled trials analyzed in the recent meta-analysis in the Lancet, 16 of these measured the effect of music on the patients’ satisfaction with their care and collectively showed that music increased patient satisfaction.2 A study of 27 patients undergoing brain surgery measured several quality of life indicators, including perception of hospital stay, and found significant improvements among patients who received preoperative and postoperative live music therapy sessions compared to those who received no music intervention.9 Although music therapy was an effective way to improve quality of life indicators and reduce the need for analgesics and sedatives, it did not reduce the duration of hospitalization in either of these studies.2,9 More research is needed to investigate the effect of music on wound healing rates, costs of care, infections, and serious adverse events.2
For premature babies, music therapy in the form of live sounds and parent-preferred lullabies can improve vital signs and feeding behavior.13 The music not only masks the unpleasant sounds associated with the NICU, such as the beeps and alarms from necessary medical equipment, but it can also be matched to the baby’s heart rate, respiratory rate, or suck/swallow cadence to help regulate and improve these rhythms. “We can slowly, gradually actually change those rhythms; if the heart rate is too fast, we can actually decrease it by matching the music to their rate and slowly slowing it down,” said Humphries. In a study of 272 premature babies with respiratory distress syndrome, clinical sepsis, or small size for gestational age, music interventions significantly lowered heart rate and improved sucking behavior, caloric intake, and sleep patterns.13
Emerging evidence-based music therapies Two major specialties that have emerged within the field of music therapy are neurologic music therapy and neonatal intensive care unit (NICU) music therapy. Neurologic music therapy can be used to improve cognition and neurologic development in patients with developmental disabilities,10 neurologic diseases,11 or traumatic brain injury.12 Neurologic music therapy targets rehabilitating sensorimotor functioning (e.g., mobility, cadence, fine motor movements), speech and language functioning (e.g., vocal control, speech production), and cognitive functioning (e.g., attention, memory, psychosocial skills).12 For instance, focusing on rhythm and tempo can
© AORN, Inc, 2015
Benefits for family members Music therapy can be mutually beneficial for patients and their family members. “Music therapy can bring the family in and gives them a role in their loved one’s healing journey and make them feel like they’re a part of it,” said Humphries. For instance, for premature infants in the NICU, the music therapist can help the mother sing to her baby, giving her an additional role in the baby’s care. Even when family members do not participate musically, music therapy can facilitate invaluable communication among patients and their families. Examples from Humphries’s experiences include using music to help orient patients with Alzheimer’s disease to place and time so they can carry on conversations with loved ones and employing life-review memorial songwriting to give terminal cancer patients an additional way to share their final sentiments. Music therapy can be extended as an anxiolytic to patients’ family members, especially those who
September 2015 Vol 102 No 3 • Periop Briefing | P11
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MUSIC THERAPY
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spend long periods of time in a waiting room.9,13,14 A study published in the Annals of Surgery of 346 relatives and friends of patients cared for in the emergency department demonstrated that friends and family experienced less anxiety when classical music was played in the waiting room than when it was not.14 When working with surgical patients and their families, Humphries includes the family in the patient’s preoperative therapy and continues to offer musical relaxation techniques to the family while the patient undergoes the procedure to alleviate their anxiety through that process as well.
Conclusion Music therapy is an evidence-based treatment option that provides numerous physiological and emotional benefits to patients and their families. Perioperative nurses work with a wide range of patient populations who may require surgery for a variety of reasons; for some patients, music therapy may already be part of their care. In the perioperative setting, nurses have the opportunity to introduce, continue, or expand music therapy for surgical patients to reduce anxiety and pain and improve patient experience.
A patient session.
8.
9.
References 1. What is music therapy? The American Music Therapy Association. http://www.musictherapy.org/ about/musictherapy/. Accessed August 20, 2015. 2. Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. Lancet. August 2015. http://www.thelancet.com/journals/lancet/ article/PIIS0140-6736(15)60169-6/abstract. Accessed August 14, 2015. 3. Bradt J, Dileo C, Shim M. Music interventions for preoperative anxiety. Cochrane Database Syst Rev. 2013; 6:CD006908. 4. Nilsson U. The anxiety- and pain-reducing effects of music interventions: a systematic review. AORN J. 2008;87(4):780-807. 5. Guideline for complementary care interventions. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:455-467. 6. Ogg MJ. Clinical Issues—August 2015. AORN J. 2015;102(2):200-208. 7. Merakou K, Varouxi G, Barbouni A, et al. Blood pressure and heart rate alterations through music
P12 | Periop Briefing
actively participates in a music therapy
10.
11.
12.
13.
14.
in patients undergoing cataract surgery in Greece. Ophthalmol Eye Dis. 2015;7:7-12. Calcaterra V, Ostuni S, Bonomelli I, et al. Music benefits on postoperative distress and pain in pediatric day care surgery. Pediatr Rep. 2014;6(3):5534. Walworth D, Rumana CS, Nguyen J, Jarred J. Effects of live music therapy sessions on quality of life indicators, medications administered and hospital length of stay for patients undergoing elective surgical procedures for brain. J Music Ther. 2008;45(3):349-359. Dunning BA, Martens MA, Jungers MK. Music lessons are associated with increased verbal memory in individuals with Williams syndrome. Res Dev Disabil. 2014;36C:565-578. François C, Grau-Sánchez J, Duarte E, RodriguezFornells A. Musical training as an alternative and effective method for neuro-education and neurorehabilitation. Front Psychol. 2015;6(475):1-15. Hedge S. Music-based cognitive remediation therapy for patients with traumatic brain injury. Front Neurol. 2014;5(34):1-7. Loewy J, Stewart K, Dassler AM, Telsey A, Homel P. The effects of music therapy on vital signs, feeding, and sleep in premature infants. Pediatrics. 2013;131(5):902-918. Tilt AC, Werner PD, Brown DF, et al. Low degree of formal education and musical experience predict degree of music-induced stress reduction in relatives and friends of patients. Ann Surg. 2013;257(5):834838.
SECOND FEATURE
The value of music therapy in patient care Kelly Putnam, Managing Editor
M
usic can be incorporated into an array of patient therapies, ranging from the passive listening of recorded music through headphones to the active use of instruments and live music to improve motor skills or cognitive abilities impaired by specific diseases or conditions. The American Music Therapy Association defines music therapy as “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.”1 Professional music therapists have demonstrated guitar, piano, drum, and vocal proficiency. Music therapy requires a referral from a physician, but nurses can play an integral role in identifying patients who may benefit from this therapy and coordinating care among the perioperative team, music therapists, patients, and family members. Various patient populations can benefit from some form of music therapy as part of an interdisciplinary approach to patient care. Multiple comprehensive reviews and meta-analyses have confirmed the effectiveness of music therapy to reduce the surgical patient’s anxiety and pain across the perioperative continuum of care.2-4 Periop Briefing spoke with Kathleen Humphries, MA, MT-BC, NICU-MT, a practicing music therapist in Long Beach, Calif., about the broad practice of music therapy and its specific benefits for surgical patients.
Engaging patients emotionally and physically Humphries advocates playing live, patientpreferred music and encouraging active participation from patients while taking into account their comfort level and demeanor. Humphries has at her disposal a cart full of drums, shakers, maracas, ukuleles, guitars, and keyboards that she can bring to each patient’s room. “With children we’ll do a lot of just improvisation on the instruments,” said Humphries. “For those who are less outgoing or more quiet and just want to play how they feel, we’ll just do that and I’ll validate and support them http://dx.doi.org/10.1016/S0001-2092(15)00712-7
P10 | Periop Briefing
musically.” For adult patients, Humphries will often begin by asking what type of music they like and playing a requested song in a style tailored to their liking. Some patients participate in songwriting or singing sessions. “Music is perfect for expressing oneself when words don’t suffice; that’s what’s great about music therapy,” said Humphries. The instruments can also provide a conduit for improving motor skills, and can even become part of physical therapy. “One example is using TIMP [therapeutic instrument music playing], where you use the placement of instruments to kind of encourage and motivate the patient to reach and do their stretches,” said Humphries. “It’s an enjoyable experience and they don’t realize they’re actually doing their physical therapy exercises.” The administration of long-term music therapy aims to improve socialization, mental health, communication, cognitive and sensory integration, and motor skills, based on the patients’ needs.
Improving patients’ perioperative experiences According to the AORN “Guideline for complementary care interventions,” music therapy can be implemented as an effective measure to reduce perioperative pain and anxiety.5 The guideline recommends that the perioperative team first assess patients’ willingness and obtain consent before incorporating music into their care. In addition, patients should be able to choose their own music and use personal listening devices to limit noise and distraction in the perioperative setting. Important factors to consider include the feasibility and cost of this type of care.6 Music therapy is only reimbursed in some states, but other sources of funding can include grants or philanthropic gifts from special foundations. According to a recent meta-analysis published in the Lancet examining the use of music across the perioperative continuum of care for more than 6,900 patients, music significantly reduced postoperative pain, anxiety, and analgesia use.2
The greatest reductions in pain and anxiety were observed when music was delivered preoperatively rather than intraoperatively or postoperatively and when general anesthetic was not required for the procedure.2 Music therapy in adult and pediatric surgical patients can reduce physiological markers of stress, such as blood pressure and glycemia.7,8
help patients with Parkinson’s disease control their gait. “They end up actually synchronizing to the appropriate walking speed of what we want them to be at with the music,” said Humphries. “The therapist is able to manipulate the music to meet the patient’s needs and change it to be where we want them to be.”
Music therapy can also improve patients’ perception of their hospital stay.2,9 Humphries suggests that by improving the patient experience in the hospital and in the OR, music therapy can help set the stage for positive experiences in the future for patients who require repeat procedures. Of the 72 randomized controlled trials analyzed in the recent meta-analysis in the Lancet, 16 of these measured the effect of music on the patients’ satisfaction with their care and collectively showed that music increased patient satisfaction.2 A study of 27 patients undergoing brain surgery measured several quality of life indicators, including perception of hospital stay, and found significant improvements among patients who received preoperative and postoperative live music therapy sessions compared to those who received no music intervention.9 Although music therapy was an effective way to improve quality of life indicators and reduce the need for analgesics and sedatives, it did not reduce the duration of hospitalization in either of these studies.2,9 More research is needed to investigate the effect of music on wound healing rates, costs of care, infections, and serious adverse events.2
For premature babies, music therapy in the form of live sounds and parent-preferred lullabies can improve vital signs and feeding behavior.13 The music not only masks the unpleasant sounds associated with the NICU, such as the beeps and alarms from necessary medical equipment, but it can also be matched to the baby’s heart rate, respiratory rate, or suck/swallow cadence to help regulate and improve these rhythms. “We can slowly, gradually actually change those rhythms; if the heart rate is too fast, we can actually decrease it by matching the music to their rate and slowly slowing it down,” said Humphries. In a study of 272 premature babies with respiratory distress syndrome, clinical sepsis, or small size for gestational age, music interventions significantly lowered heart rate and improved sucking behavior, caloric intake, and sleep patterns.13
Emerging evidence-based music therapies Two major specialties that have emerged within the field of music therapy are neurologic music therapy and neonatal intensive care unit (NICU) music therapy. Neurologic music therapy can be used to improve cognition and neurologic development in patients with developmental disabilities,10 neurologic diseases,11 or traumatic brain injury.12 Neurologic music therapy targets rehabilitating sensorimotor functioning (e.g., mobility, cadence, fine motor movements), speech and language functioning (e.g., vocal control, speech production), and cognitive functioning (e.g., attention, memory, psychosocial skills).12 For instance, focusing on rhythm and tempo can
© AORN, Inc, 2015
Benefits for family members Music therapy can be mutually beneficial for patients and their family members. “Music therapy can bring the family in and gives them a role in their loved one’s healing journey and make them feel like they’re a part of it,” said Humphries. For instance, for premature infants in the NICU, the music therapist can help the mother sing to her baby, giving her an additional role in the baby’s care. Even when family members do not participate musically, music therapy can facilitate invaluable communication among patients and their families. Examples from Humphries’s experiences include using music to help orient patients with Alzheimer’s disease to place and time so they can carry on conversations with loved ones and employing life-review memorial songwriting to give terminal cancer patients an additional way to share their final sentiments. Music therapy can be extended as an anxiolytic to patients’ family members, especially those who
September 2015 Vol 102 No 3 • Periop Briefing | P11
PERIOP BRIEFING
MUSIC THERAPY
PERIOP BRIEFING
MUSIC THERAPY
spend long periods of time in a waiting room.9,13,14 A study published in the Annals of Surgery of 346 relatives and friends of patients cared for in the emergency department demonstrated that friends and family experienced less anxiety when classical music was played in the waiting room than when it was not.14 When working with surgical patients and their families, Humphries includes the family in the patient’s preoperative therapy and continues to offer musical relaxation techniques to the family while the patient undergoes the procedure to alleviate their anxiety through that process as well.
Conclusion Music therapy is an evidence-based treatment option that provides numerous physiological and emotional benefits to patients and their families. Perioperative nurses work with a wide range of patient populations who may require surgery for a variety of reasons; for some patients, music therapy may already be part of their care. In the perioperative setting, nurses have the opportunity to introduce, continue, or expand music therapy for surgical patients to reduce anxiety and pain and improve patient experience.
A patient session.
8.
9.
References 1. What is music therapy? The American Music Therapy Association. http://www.musictherapy.org/ about/musictherapy/. Accessed August 20, 2015. 2. Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. Lancet. August 2015. http://www.thelancet.com/journals/lancet/ article/PIIS0140-6736(15)60169-6/abstract. Accessed August 14, 2015. 3. Bradt J, Dileo C, Shim M. Music interventions for preoperative anxiety. Cochrane Database Syst Rev. 2013; 6:CD006908. 4. Nilsson U. The anxiety- and pain-reducing effects of music interventions: a systematic review. AORN J. 2008;87(4):780-807. 5. Guideline for complementary care interventions. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:455-467. 6. Ogg MJ. Clinical Issues—August 2015. AORN J. 2015;102(2):200-208. 7. Merakou K, Varouxi G, Barbouni A, et al. Blood pressure and heart rate alterations through music
P12 | Periop Briefing
actively participates in a music therapy
10.
11.
12.
13.
14.
in patients undergoing cataract surgery in Greece. Ophthalmol Eye Dis. 2015;7:7-12. Calcaterra V, Ostuni S, Bonomelli I, et al. Music benefits on postoperative distress and pain in pediatric day care surgery. Pediatr Rep. 2014;6(3):5534. Walworth D, Rumana CS, Nguyen J, Jarred J. Effects of live music therapy sessions on quality of life indicators, medications administered and hospital length of stay for patients undergoing elective surgical procedures for brain. J Music Ther. 2008;45(3):349-359. Dunning BA, Martens MA, Jungers MK. Music lessons are associated with increased verbal memory in individuals with Williams syndrome. Res Dev Disabil. 2014;36C:565-578. François C, Grau-Sánchez J, Duarte E, RodriguezFornells A. Musical training as an alternative and effective method for neuro-education and neurorehabilitation. Front Psychol. 2015;6(475):1-15. Hedge S. Music-based cognitive remediation therapy for patients with traumatic brain injury. Front Neurol. 2014;5(34):1-7. Loewy J, Stewart K, Dassler AM, Telsey A, Homel P. The effects of music therapy on vital signs, feeding, and sleep in premature infants. Pediatrics. 2013;131(5):902-918. Tilt AC, Werner PD, Brown DF, et al. Low degree of formal education and musical experience predict degree of music-induced stress reduction in relatives and friends of patients. Ann Surg. 2013;257(5):834838.