Music therapy | Cam-Cancer

Music therapy

Abstract and key points

Music therapy is an established healthcare profession that uses music to address physical, emotional, cognitive and social needs. The interventions used include playing instruments, vocal and instrumental improvisation, singing, composing/song writing, music-guided imagery and music listening. Music therapy is different from music medicine, which is defined as listening to pre-recorded music, offered by medical staff. It has been suggested that music therapy can promote wellbeing, stress management, pain alleviation, emotional expression, memory enhancement, improved communication and physical rehabilitation.

Evidence from eight systematic reviews published since 2016 and eight subsequent randomized controlled trials (RCTs) suggests that music therapy may be a helpful supportive care intervention among various cancer populations.

Results from the most recent and rigorous systematic reviews suggests that:

  • Pain: Music therapy and music listening appear to have moderate to large effects in people with cancer compared to standard care, including during active cancer treatment (chemotherapy, radiation therapy, catheter placement), although not during surgery.
  • Chemotherapy-induced nausea and vomiting: Evidence for effects of music therapy is limited and contradictory.
  • Other physiological outcomes: music interventions may have small effects on blood pressure, heart rate and respiratory rate.
  • Anxiety and depression: Music therapy and music medicine both have a moderate to large effect on anxiety and a moderate effect on depression compared to usual care, including during active cancer treatment, although not during surgery. 
  • Mood: Music intervention during active cancer treatment may improve mood.
  • Fatigue: Music intervention has a small to moderate effect but not during active cancer treatment.
  • Quality of life: Music therapy has small but significant effects compared to usual care, but not music medicine.

There is considerable variation between trials with regards to type of music intervention and dosage used and it is therefore not possible to generalise the result.

No safety issues are on record although caution is advised in some patients

Document history

Fully updated and revised by Ava Lorenc in June 2020.
Fully updated and revised by Joke Bradt in May 2017.
Fully updated and revised by Helen Cooke in December 2014. 
Summary first published in January 2013, authored by Helen Cooke.

Citation

Ava Lorenc, Joke Bradt, CAM-Cancer Consortium. Music therapy [online document], http://cam-cancer.org/en/music-therapy 2020

What is it?

Description and definition

Music therapy is an established healthcare profession that uses music to address physical, emotional, cognitive and social needs (AMTA 2020; Richardson 2008). Music therapy is delivered by a trained music therapist and is characterized by the presence of a therapeutic relationship and the use of music interventions specifically tailored towards the client’s needs (Bradt 2016; Gold 2011). This is differentiated from music medicine, which has been defined as listening to pre-recorded music offered by a healthcare professional (Bradt 2016; Gold 2011; Yinger 2014). Without the presence of a therapist and a therapeutic relationship, music listening in itself is not music therapy (Gold 2011). It should be noted, however, that there is a lack of consistency in the use of this terminology in the trials reviewed for this summary.  The term “music interventions” is used to encompass both music therapy and music medicine.

Music therapists use a variety of music interventions including playing instruments, singing, instrumental and vocal improvisations, song writing, composing, music-guided imagery and listening to live, improvised or recorded music (Richardson 2008; Bradt 2016). Music therapy sessions are designed according to the needs of the individual or group and involve a systematic process which includes assessment, treatment and evaluation.  Music therapy in cancer can include replaying music from the patient’s life, exploring ‘new’ music, music relaxation and music-based gift or legacy creation (O'Callaghan and Magill 2016).

In the music medicine trials included in this summary, the pre-recorded music was often selected by the healthcare professionals. However, it has been recommended that patients be encouraged to select their own preferred music (Bradt 2016).

Background and prevalence

The use of music to improve health dates back to ancient times (Richardson 2008). Although music therapy is a relatively young health profession, it is well established in both academic and clinical contexts. The first official training program started in Austria in 1959, the UK in 1968 and Norway in 1978. Music therapists often function as a member of an interdisciplinary team in clinical settings but also offer services through private practice. There are many training programs around the world that offer music therapy training at the undergraduate, graduate and doctoral level (WFMT 2020).

The exact prevalence of the use of music therapy for people with cancer is unknown. It is thought that music therapy is a desired service for cancer patients during hospitalisation (Y-Ching 2017).

Application and dosage

In cancer care, music therapy is often offered as individual sessions with the patient and may include family members.  Music therapy is also offered in group sessions to facilitate social support among patients. In the trials included in this summary, the dosage and frequency greatly varied. The number of sessions ranged from 1 to 52 (e.g. multiple music listening sessions per day for length of hospital stay). Most sessions lasted 30 to 45 minutes. At this time, the relationship between the frequency and duration of treatment and treatment effect remains unclear.

Recipients of music therapy do not need any prior musical knowledge or experience. 

Alleged indications

In cancer care, music medicine is generally used for symptom management (Bradt 2016). It has been suggested that music therapy in cancer care can promote wellbeing, stress management, pain alleviation, emotional expression, improved communication, spiritual and emotional support, physical well-being, offer distraction during procedures, improve coping skills and a sense of control (O'Callaghan and Magill 2016; Richardson 2008; Bradt 2016). In addition to symptom management, music therapists utilize various individualized interventions with cancer patients and their families to address prevailing biopsychosocial and spiritual needs (Magill 2009; McClean 2011).

Research suggests that music therapy interventions may be more effective than music medicine interventions with medical populations for a wide variety of outcomes. It has been suggested that the difference might relate to how music therapists individualise their intervention to meet patients’ specific needs (Bradt 2016).

Mechanism of action

Possible mechanisms of actions are framed within a biopsychosocial perspective. Listening to music may reduce anxiety through suppressive action on the sympathetic nervous system, leading to decreased adrenergic activity (Gillen 2008; Nilsson 2009; Nakayama 2009), with greater effects on patients with higher sympathetic tone activity (Chen 2020). There is some very preliminary evidence that music can induce changes in gene expression in gastric cancer cells (Ramirez-Rivera 2019). In addition, research indicates that music offers an escape from stress and worries related to the cancer diagnosis, treatment, and prognosis (Bradt 2015; O'Callaghan and Magill 2016). Music also activates the rewards and motivation circuitry in the brain resulting in the release of dopamine which regulates perception of pleasure and mood (Salimpoor 2011). Music making provides opportunities for emotional expressivity which has consistently been linked to mood enhancement (Livesey 2012; Zakowski 2001). Music experiences offer opportunities to explore and process emotions in a creative process unique from other therapeutic disciplines and facilitate meaning making through music-evoked reflections. Importantly, music provides patients with an aesthetic experience that can offer comfort and peace during times of distress (Bradt 2015).

Legal issues and cost

The World Federation of Music Therapy acts as the international umbrella organization for the profession of music therapy (WFMT 2020). In the US, the Certification Board for Music Therapists grants music therapists a national board certification after successfully passing a board certification exam (AMTA 2020). Music therapists are required to recertify every 5 years. Professional music therapy courses are at postgraduate level in the UK and most of Europe. ‘Music Therapist’ is a protected title in the UK and all practicing therapists must be registered with the Health and Care Professions Council (EMTC 2020). All professionally trained music therapists commit themselves to an ethical code as a quality criteria.

Costs vary depending on the context in which the therapy is given. Some health institutions do not charge for music therapy group sessions.

Does it work?

Supportive care

Eight systematic reviews (six thereof with meta-analysis, including one Cochrane review) and eight additional randomised controlled trials (RCTs) evaluated the effects of music interventions on psychological and physical outcomes. Ten other studies were identified but not included in the data below: four studies on diagnostic procedures and two pilot studies. One systematic review by Gramaglia et al (2019) was also excluded; the authors included all study designs (not just RCTs), only searched 2 databases, did not evaluate risk of bias and did not perform a meta-analysis, so their review is of very limited use. 

The systematic reviews are described in table 1 and the RCTs in table 2. It should be noted that there is considerable variation in the manner in which the music interventions were conducted including the duration and number of sessions. Some of the interventions which were classified as music therapy simply involved participants listening to pre-recorded music without any additional therapeutic process or involvement of a music therapist.  

The results of these systematic reviews and RCTs suggest that:

  • Pain: Music therapy and music listening appear to have moderate to large effects in people with cancer compared to standard care, including during active cancer treatment (chemotherapy, radiation therapy, catheter placement), although not during surgery.
  • Chemotherapy-induced nausea and vomiting: Evidence for effects of music therapy is limited and contradictory.
  • Physiological outcomes: music interventions may have small effects on blood pressure, heart rate and respiratory rate.
  • Anxiety and depression: Music therapy and music medicine both have a moderate to large effect on anxiety and a moderate effect on depression compared to usual care, including during active cancer treatment, although not during surgery. 
  • Mood: Music intervention during active cancer treatment may improve mood.
  • Fatigue: Music intervention has a small to moderate effect but not during active cancer treatment.
  • Quality of life: Music therapy has small but significant effects compared to usual care, but not music medicine.

Description of studies

A major issue with music intervention trials is that, in most cases, participants cannot be blinded to the intervention.  This introduces a potential for biased reporting of treatment benefits by the study participants.  Many studies also had small sample sizes. As a result, the evidence of these trials is typically assessed as ‘low’ and the results need to be interpreted with caution.

Pain

Four SRs evaluated pain. A 2020 review and meta-analysis of the effects of music therapy on quality of life, anxiety, depression and pain of people with cancer, including studies in English or Chinese, found 19 RCTs (total n=1548), 9 from China (Li 2020). This review only included studies with a usual care control group. Yangoz and Ozer (2019) examined the effects of music intervention on cancer-related pain, including 6 RCTs (total n=593), all of which used passive instrumental music listening. Although they searched many databases, they failed to access full text of 6 studies, and studies had small sample sizes. Bro et al (2017) examined the effects of music intervention (music therapy or music medicine) during active cancer treatment (chemotherapy, surgery, radiotherapy or other procedures/hospitalisation), including 25 RCTs (20 for meta-analysis; total n=1565)- 17 used recorded music, 8 live music, 15 passive and 10 active participation, 20 patient-selected music and 23 individualised to the patient. They identified that the most effective mode of music intervention was passive listening to self‐selected, recorded music in a single session design, although this was also the most studied format. This review was well conducted but, again, found low study quality, high heterogeneity, and small sample sizes. A 2016 Cochrane review examined the effects of music therapy or music medicine interventions on psychological and physical outcomes in patients with cancer and included 23 music therapy and 29 music medicine trials (total n=3731) (Bradt 2016). It also compared the effects of music therapy versus music medicine interventions. 

There was evidence of moderate to large effects on pain compared to standard care for music therapy (standardized mean difference, SMD =-0.73 (Li 2020)) and music interventions (SMD = - 0.91 (Bradt 2016)). Yangoz and Ozer (2019) also found a moderate effect on cancer‐related pain of passive music listening (p = 0.001) although studies had high heterogeneity. There was no difference based on duration or frequency of intervention (Yangoz 2019). Bro et al (2017) found significant effects of music intervention for pain during active cancer treatment (SMD −0.88), although an earlier, good quality RCT (not included in Bro 2017) found no effect of music listening (researcher chosen) on pain for skin cancer patients during cutaneous surgery compared to guided imagery or standard care (Alam 2016).

Chemotherapy-induced nausea and vomiting

Kiernan et al (2017) conducted a systematic review (no meta-analysis) of music therapy for chemotherapy-induced nausea and vomiting (mostly acute), including all study types. They found 10 studies, most of which were not RCTs. The review is of limited use due to study heterogeneity and poor study quality. They found that only 2 of the 5 studies evaluating the effect of music therapy alone found significant effects (Kiernan 2017), and another SR found no significant effects of music intervention for nausea during active cancer treatment (Bro 2017). A subsequent large, good quality RCT of 474 cancer patients compared mindfulness, listening to music and standard care during chemotherapy and at home (Hunter 2020). They found significantly reduced anticipatory nausea (although only at the midpoint of chemotherapy) for music listening compared to standard care, effects similar to nurse-administered mindfulness relaxation, but no difference in vomiting.

Other physiological outcomes

The 2016 Cochrane review and another SR (Wang 2018) examined other physiological effects of music intervention in cancer. Wang et al (2018) examined the effect of music intervention (mostly receptive music listening on headphones, with music chosen by researcher and patient) for physical and mental status of patients with breast cancer compared to usual care, including 30 RCTs (total n=2559), 24 of which were Chinese.  They found substantial heterogeneity and were unable to assess publication bias. Both SRs found that music interventions may have a small effect on systolic blood pressure (MD= −7.63 mmHg (Bradt 2016); SMD –0.63 (breast cancer; Wang 2018)), diastolic blood pressure (MD= −4.94mmHg (Bradt 2016); SMD =–0.64 (breast cancer; Wang 2018)),  and heart rate (MD= mmHg (Bradt 2016); SMD =–0.454 (breast cancer; Wang 2018)), and one found effects on respiratory rate (MD=−1.83 (Bradt 2016).

Mental health

SRs suggest music therapy and interventions significantly reduce anxiety compared to usual care for cancer patients (SMD = -1.51(Li 2020)); SMD = - 0.71 (Bradt 2016); MD=-7.40 for self-rated and MD-12.40 for state anxiety (breast cancer; Wang 2018)), including music therapy during cancer treatment (SMD −0·80 (Bro 2017)). The 2016 Cochrane review found no difference between music therapy or music medicine for anxiety (Bradt 2016). The effect of music therapy on anxiety during chemotherapy is confirmed by two RCTs not included in the SRs, although this may apply to live music only (Bro 2019; Chirico 2019). Bro et al (2019) examined the effect of patient-preferred live-music or pre-recorded music during chemotherapy for 143 adult lymphoma patients. Although the sample size was powered and well randomised, floor and ceiling effects may have been present. Chirico et al (2019) compared virtual reality and pre-recorded music listening during chemotherapy for 94 breast cancer patients. However, this study was low quality due to unclear group allocation and non-concurrent controls. Further trials found significant reductions in anxiety for recorded music listening during other treatments: radiation therapy (p<0.001) and catheter placement (p<0.001) compared to standard care. Karadag et al (2019) studied 60 early stage breast cancer patients undergoing radiation therapy but did not appear to use random group allocation, and Mou et al (2020) studied 304 lung cancer patients undergoing catheter insertion. There is evidence that music therapy during surgery does not affect anxiety. One RCT (n=151) found no effect of music listening on anxiety during surgery compared to guided imagery or standard care (Alam 2016); another RCT found no effects of music therapy during blood and marrow transplantation compared to art making or standard care, although this study is underpowered (n=39), randomisation is unclear and it is not clear whether the intervention was definitely given during transplant or not. (Mische 2017).

Music therapy and interventions appear to significantly reduce depression compared to usual care (SMD =-1.12 (Li 2020); SMD = - 0.40 (Bradt 2016); MD=-7.39 (breast cancer; Wang 2018)). An SR found no effect on depression during cancer treatment (Bro 2017), and although a subsequent RCT found a significant reduction in depression during radiation therapy for recorded music listening, compared to standard care, the study quality is poor as group allocation was not random (Karadag 2019). The 2016 Cochrane review found no difference between music therapy or music medicine for depression (Bradt 2016). Another RCT found reduced depression (and improved self-esteem) for 60 paediatric brain tumour survivors after 12 months of learning to play an instrument compared to attention placebo, although the study was underpowered (Cheung 2019).

Bro et al (2017) found a significant effect of music intervention on mood during active cancer treatment (SMD=-0.55), and an RCT found music listening during chemotherapy improved mood, although it was low quality (Chirico 2019). Another review and meta-analysis from 2020 examined the effects of music therapist interventions on psychosocial outcomes from 30 studies, 21 of which were meta-analysed (Kohler 2020). They only searched 3 databases and did not report participant numbers. Kohler (2020) found small but significant effects of music therapy (from a therapist) on physical symptom distress (p = 0.017) but Bro et al (2017) found no significant effects for distress (or spirit) during cancer treatment.

Fatigue

The 2016 Cochrane review found a small to moderate effect of music therapy/music medicine on fatigue (SMD = - 0.38; Bradt 2016).  Bro et al (2017) found no significant effects of music intervention for fatigue during active cancer treatment.

Quality of life/wellbeing

Three reviews found evidence for small/moderate but significant effects of music therapy on quality of life compared to usual care (SMD=0.54 (Li et al 2020); p=0.023 (Kohler 2020), although subgroup analysis suggests this may be only for interventions of between 1 and 2 months. The 2016 Cochrane review results suggest that music therapy, but not music medicine interventions, had a moderate effect on quality of life (SMD = 0.42) (Bradt 2016).  However, Bro et al (2017) found no significant effects of music intervention for quality of life during active cancer treatment.  An RCT found improved quality of life for paediatric brain tumour survivors after 12 months of learning to play an instrument (although it was underpowered) (Cheung 2019). Kohler (2020) found small but significant effects of music therapy (from a therapist) on psychological wellbeing (p<0.001). Moderator analyses identified that studies with a single session of music therapy and the use of receptive techniques to produce larger effects regarding psychological well-being.

Anti-tumour treatment

No evidence identified.

Prevention

No evidence identified.

Is it safe?

Adverse events

No adverse events are on record (Ernst 2006). In six studies of music listening for cancer-related pain, Yangoz and Ozer (2019) found no adverse effects. Kiernan et al (2018) suggest practitioners ensure patient’s music listening does not exceed the recommended daily dose for noise.

Contraindications

No contraindications are on record (Ernst 2006), although O'Callaghan and Magill (2016) advise that as music therapy provokes emotions, music therapy may not be indicated for acutely distressed and/or emotionally fragile patients, particularly in patients with serious and life-threatening cancers. Music may be inappropriate during times of crisis or acute emotional/painful episodes, due to sensory overload (O'Callaghan and Magill 2016), and there may be specific limitations and difficulties in palliative care, including reminding patients of their altered state, and physical exhaustion (Pommeret 2019).

Interactions

No interactions are on record (Ernst 2006).

Warnings

It is important to consider the potential negative impact of the use of headphones during procedures because of hampered communication between the patient and medical personnel. This may increase anxiety in patients (Bradt 2016).

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