Arts and Music in Healthcare:

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1 ArtsandMusic inhealthcare: Anoverviewofthemedicalliterature: RosaliaStaricoff&StephenClift July2011 1

2 CONTENTS Page Foreword Summary 1Introduction 2Method 3Findings Maternity 3.2Neonatalandintensivecare 3.3Children 3.4Cardiovascularconditions 3.5Surgeryandpainmanagement 3.6Lungdiseases 3.7Oncology 21 4Conclusions 5References 24 2

3 Forewordandacknowledgements Iamverypleasedtointroducethisreviewofthemedicalliteratureonartsandhealth publishedsince2004. TheHospitalArtsprogrammeofChelseaandWestminsterHealthCharityhelpstocreatea healingenvironmentwithinchelseaandwestminsterhospital,wherevisualandperforming artsarecombinedtohelprelieveanxietyandassistinrecovery.in1995,thehospitalwas thefirstinbritaintoprovideweeklyliveperformancesforpatients,staffandvisitors,and thefirsttocarryoutanysignificantresearchontheimpacttheartscanhaveonpatient wellbeing. ThisreviewisthesecondpieceofresearchcompletedbyRosaliaStaricoffonbehalfof ChelseaandWestminsterHealthCharity.Between1999and2002,DrStaricoffconducteda pioneeringresearchprogrammeinchelseaandwestminsterhospital,whichprovided evidencethattheintegrationofperformingandvisualartsintothehealthcareenvironment inducepsychological,physicalandbiologicaloutcomeswhichcouldhaveclinical significance.thisresearchhasprovided,andwillcontinuetoprovide,thebasisofallthe workthatthehospitalartsteamcarryout,fromthemaintenanceoftheartcollectionto theprovisionofmusic basedinteractionswithahugerangeofpatients. IwouldliketothankRosaliaStaricoffandStephenCliftfortheircommittedandthorough workinpreparingthisreview. ChristianBrodie Chairman,ChelseaandWestminsterHealthCharity 3

4 4 SUMMARY Introduction ThisreportisanupdateofthereviewofartsinhealthresearchconductedforArtsCouncil Englandwhichappearedin2004(Staricoff,2004). Method AsearchstrategytoidentifyrelevantresearchreportswasbaseduponStaricoff(2004).The vastmajorityofstudiesidentifiedwereconcernedwithmusicinterventions,andthisreview focusesonthese.thepresentreviewisnot systematic asitcoversawiderangeofhealth issues,andtimeandresourcesprecludedtheapplicationofqualityscreensanddata extraction. Findings Onehundredandthreestudieswereidentifiedwhichofferevidenceoftheeffectofmusic interventionsonpsychologicalandphysiologicaloutcomesofpatientsinahospital environment.studiesareorganisedunderthefollowingheadings: Maternity Theinterventionofmusiconprenatalcareandchildbirthhasbeenstudiedwithincreasing interestinthelastdecademainlyaddressingthestateofanxietyanddepressionofthe mothers to be.thebeneficialeffectachievedpromotesearlymother childcontactand reduceslengthofstayinhospital. Neonatalandintensivecare Thespecialcareofprematureinfantsisthesubjectofanumberofresearchstudies exploringtheinfluencethatmusic,mothersingingandlullabiescanhaveintheir development.theyhaveshownevidenceofbeneficialeffectonweightgain,oxygen saturationimprovements,feedingandcrying.theinterventionofmusicwaswellaccepted bymedicalstaffandsupportedbyapositiveattitudeoftheparents. Children Thepsychologicalandphysiologicalresponsesofchildrentoartinterventionsinhospital carehavebeenaddressedinmanystudies.researchhasshownbeneficialeffectsofmusic interventiononbehaviourandclinicaloutcomes. Cardiovascularconditions Musicinterventionscanhaveanimportantroleduringanumberofproceduresfor screeninganddiagnosis,reducingsignificantlythelevelofstressandanxiety,bloodpressure andheartrate.theuseofmusicdeliveredbyheadphonesortapeshasbeenshowntobe veryeffectiveinreducinglevelsofanxietyandstabilizingvitalsigns.

5 Surgeryandpainmanagement Musiccanhaveapositiveroleduringthepre operativestage,duringsurgeryandforpost operativerecovery.itsignificantlyreducesanxietyandstressandhelpstonormalizevital signs.ofgreatimportancearethefindingsonthesignificantreductionofanaesthetics, medicationforsedationandanalgesics.theseresultsalsoshowedthatmusicinterventions cancontributetoachievecost benefitseffects. Lungdiseases Musicandsingingplayanimportantroleinthefunctionalactivitiesoftherespiratory system,significantlybenefitingpatientswithbreathingproblems. Oncology Musicinterventionincancercarehasbeenshowntohaveaneffectofreducingthelevelsof highanxietyanddepression,anditcouldalsohelptocontrolsomeofthesideeffectsofthe treatment. 5

6 1INTRODUCTION ThisreportisanupdateofthereviewofartsinhealthresearchconductedforArtsCouncil Englandwhichappearedin2004(Staricoff,2004).ItwascommissionedbyChelseaand WestminsterHealthCharitywithtwoprincipalobjectives: a)toidentifyrelevantliteraturepublishedbetween2004and2011ontheeffectsof artsinterventionsinthecontextofhealthcare,and b)toprovideabasisforthecharitytoplanfurtherresearchtobuilduponthe researchprogrammeconductedinchelseaandwestminsterhospitalbetween (Staricoff,2003). Thefieldofartsandhealthpracticeandresearchhasexpandedconsiderablyoverthelast twentyyearsacrosstheuk.thereisalsoconsiderableinterestinthevalueoftheartsfor healthcareandhealthpromotioninternationally. Arts&Health:Aninternationaljournal forresearch,policyandpractice haspublishedaseriesofarticlesonthestateofartsand healthinengland,theus,canada,australiaandnorway/sweden.thesepapershighlight thecreativevitalityofthisfieldanddocumentawiderangeofpracticalactivities.theyalso emphasisetheneedforrobustevaluationandresearchiftheroleofartsinhealthisto continuetodevelopandbemainstreamedinthecontextofhealthservicedelivery. ThedevelopmentofMaggie scentresforcancercarehasstimulatedfurtherdebatesabout theimportanceofhospitalarchitecture,andallaspectsofinteriorspaceanddesignin promotinghealinginaholisticsense.intheircontributionsto ArchitectureofHope,Jencks andheathcote(2010)writemovinglyaboutthepersonalcircumstancesofpeoplewithlifethreateningillnesses,andthesometimesnegativeimpactsofbeingcaredforinsoulless, drearyandnoisyhospitalenvironments.theyremindusoftheneedtorememberthe patient sperspectiveinanydiscussionsofartsandhealthpracticeandtheprocessof evaluationandresearch. ChelseaandWestminsterHospitalhasbeenattheforefrontofdevelopmentsinartsand healthintheuk,andparticularlyinpioneeringanoriginalprogrammeofresearchtoassess theclinicalcontributionsofvisualandperformingartsinthecontextofon goinghealthcare withinthehospital.theresearchprovidedevidencefromsmallcontrolledstudiesinarange ofclinicalsettingsinthehospitalofpositivebenefitsonclinicalmeasuresfromvisualart beingdisplayedandmusicperformed.thefindingsattractedconsiderableattentionandare widelyquotedbypractitionersinthefieldofhospitalarts.nevertheless,thesmall scaleof thestudiesundertakenmeantthattheworkcouldnotachievetherecognitionitdeserved throughpublicationinmainstreampeer reviewedmedicaljournals,whichhaveabias towardspublicationoflarge scalerandomisedcontrolledtrialsandepidemiological research. 6

7 Theconsequencesofthislackofpeer reviewedpublicationsareclearlyrevealedbya GoogleScholarsearchbasedontheArtsCouncilEnglandreviewandtheChelseaand Westminsterresearchreport.AsofApril2011thesereportshadbeencited,respectively,in 78and16subsequentlypublishedreportsandpapers. 1 Veryfewofthesourcesidentified throughthesesearcheswerereportingfindingsfromsubsequentresearchstudiesonartsin healthcaresettings,andcertainlynonereportedresearchwhichbuiltuponandextended thenatureoftheworkundertakeninchelseaandwestminster. ArecentreportfromtheBritishMedicalAssociation(2011)onthe PsychologicalandSocial NeedsofPatients shouldalsobementioned.theaimofthereportistoidentifythekey needsofpatientsandtoexplorewaysinwhichtheycanbemetinhealthcareenvironments beyondtheprovisionofappropriateclinicalcare.theydrawuponthefindingsfrom Staricoff(2003)inthefollowingpassage: Creatingatherapeutichealthcareenvironmentextendsbeyondtheelimination ofboredom.artsandhumanitiesprogrammeshavebeenshowntohavea positiveeffectoninpatients.themeasuredimprovementsinclude: inducingpositivephysiologicalandpsychologicalchangesinclinical outcomes reducingdrugconsumption shorteninglengthofhospitalstay promotingbetterdoctor patientrelationships improvingmentalhealthcare (BMA,2011,p.9) Thereportgoesontoidentifythefollowingrangeofactivitieswhichmaycontributeto meetingpatients psychologicalandsocialneeds:recreationalactivities;humour;creative writing,storytellingandpoetry;music;visualart;dancingandsinging(bma,2011,pp.9 11). Noneoftheresearchsourcesdrawnuponpost datethestaricoffreviewforartscouncil England. Thecurrentreview ThecurrentreviewfollowedtheproceduresemployedfortheArtsCouncilEnglandreview, andsearchedforempiricalstudiesofartsinterventionsinhealthcaresettingsfrom2004 onwards.thedetailsofthemethodemployedaregiveninthefollowingsection.itwas clearfromtheresultsofthesearchesundertakenthattheverylargemajorityofstudies identifiedwereconcernedwithmusicalinterventionsinhealthcare,andveryfewstudies meetingtheinclusioncriteriawerefoundconcernedwiththeimpactofvisualartsin healthcaresettings. Thisisanareathatdeservesmoreresearch.Asurveyconductedinthewaitingroomofa follow uprenalclinic,showedthatmagazines,puzzlebooks,plasmascreensandpaintings onthewallsweregivenhigherscoresthanwindowviews,computersorpottedplants. 1 Thesefiguresunder estimatetheextenttowhichthesereportshavebeencitedasthesearchprocessrelies upontheexactformofthecitationgiven,anddoesnotincludegreyliteraturewhichisnotreflectedinexisting researchdatabases. 7

8 Patientsexpressedtheirpreferenceforlandscapes,animalsandbirds,butveryfewwished abstractpaintingsorportraits(cusack,2010).belver(2010)explorethevalueofartsin humanising theenvironmentinchildren shospitals. Colourandlightinginhospitalenvironmentsalsohaveanimpactonpatientsandstaff.A welldesignedhospitalimprovesthequalityofpatient/staff/visitorexperienceanditcould haveaninfluenceontimeofrecoveryandsenseofwellbeing(dalke,2006).arecentstudy ontheeffectsofanimprovedprimarycareenvironmentshowedthatanenhanced environmentresultedinimprovementsinpatients perceptionofpatient doctor communication,reductioninanxietyandpatientandstaffsatisfaction(rice,2008). Giventhepreponderanceofstudiesconcernedwithmusic,thecurrentreviewfocuseson musicalinterventionsinthecontextofhealthcare.theimportanceofmusicinhealth interventionsisincreasinglywidelyrecognized,andstudiesexploringtheeffectsofmusicon cardiovascularandrespiratoryfunctionsprovideevidencefortheimportanceoftypeof music,tempo,rhythm,andindeedpausesinmusic,inmedicalcare(larsen,2011;lippi, 2010). Asystematicreviewontheevidenceoftheeffectofintroducingmusicforhospitalpatients hasbeenrecentlypublished(evans,2011).thisstudyreferssolelytorecordedmusic,and excludesstudiesinvolvinglivemusic.theauthorfoundthatmusicreducesanxiety,butits useismorecontroversialinthecontextofinvasiveprocedures,andthereisaneedfor furtherresearchonthisissue. 8

9 2METHOD Thisstudyfocusesonstudiespublishedinpeer reviewedpublications,coveringrandomized andnon randomizedcontrolledtrialsandalsosystematicandnon systematicreviews.itis importanttonotethatthecurrentreviewwasundertakenrapidlytogainanoverviewof developmentssincethe2004reviewundertakenforartscouncilengland.itisnota systematicreview.suchreviewsaremorefocused,timeconsumingandexpensiveand requireateamofpeopletocarryout.noindependentqualityscreeninganddataextraction processeswerecarriedoutwithrespecttothestudiesreviewed.thiswouldbeanessential nextstepinthedevelopmentofresearchprotocolsforfurtherresearchinthehospital. Theinitialstrategyforidentifyingrelevantresearchonartsinhealthcareenvironments involvedidentifyingcitationsforstaricoff(2004)andstaricoff(2003)ingooglescholar.the advantageofstartingwithgooglescholaristhatitdrawsuponacomprehensiverangeof existingacademicbibliographicdatabases,andalsoveryrapidlyidentifiesallsourcesciting papersandreportswhichareconsideredkeypublicationsinthefieldtobereviewed.the nextstepwastofollowthesearchprocedureoriginallyadoptedfortheartscouncilreview. Thefollowingelectronicdatabasesweresearched: Medline:forpapersontheeffectsoftheartsonmedicalconditionstreatedwithinthe healthcareenvironment EMBASE:forartsandclinicaloutcomes CINAHL:forstudiesonnursingandalliednursingliterature CochraneLibrary:forreviewsonsubjectsrelevanttothisreview Thefollowinginternetsites,amongstmanyothers,wereconsulted: Anumberofsourceswereidentifiedfromhand searchingofreferencesofrelevant publications. Keywords Artsandclinicaloutcomes,musicandchildbirth,artsandpregnancy,musicandintensive careunits,musicandpainmanagement,singingandhealth,danceandhealth,creativityand health,musicandsurgery,amongstmanyothers. 9

10 Researchstudiesincluded Thecriteriafollowedinthisstudywere: Randomizedandnon randomizedcontrolledtrials Evaluationstudieswithdatacollectedbeforeandafteranarts/musicintervention Peer reviewedstudiesandreportsfromotherreputablesources Surveyandqualitativestudiesonarts/musicinterventionscarriedoutinhospitaland healthcaresettings Artsandmusicinhealthcaresettingsandartsandmusictherapyinterventions StudiespublishedinEnglishfrom2004onwards Inaddition,systematicandnon systematicreviewsofexistingliteratureonartsandhealth whichcoveredartsinterventionsinhealthcaresettingsweredrawnupon. Studiesconcernedwiththeroleoftheartsinthetreatmentofmentalhealthissueswere notconsideredinthisreview. Onethousandandhundredandfiftyreferenceswereidentified,andonehundredandthree wereselectedforinclusioninthisreview. 10

11 3FINDINGS Theresearchstudiesidentifiedareorganisedaccordingtotheprincipalfocusofthe research.thefollowingheadingswerechosenasbeingmostrelevanttochelseaand WestminsterHealthCharityinconsideringprioritiesforfutureresearchinthehospital: maternity,neonatal/intensivecare,children,cardiovascularconditions,surgeryandpain management,lungdiseases,andoncology.inevitably,thereissomeoverlapintheissues addressedinthesedifferentsections.asnotedearlier,thisreviewisfocusedonmusical interventionsandprovidesanoverviewofprincipalfindingsasreportedbytheresearchers. Furthermoredetailedandcriticalreviewsofspecificbodiesofliteraturewouldbeneeded inthedevelopmentofresearchprotocols. 3.1Maternity MayaWaldmanleadsaWombSongworkshopwithpregnantwomenatChelseaandWestminsterHospital,2011. Theinfluenceofmusicinchildbirthhasbeenthesubjectofinterestfordecades,however, therearefewwelldesignedstudiesshowingthephysiologicalandpsychologicalnatureof itseffects.theuseofheadphonesprovidingpreviouslyselectedmusicbyagroupofwomen duringcaesareandeliveryshowedasignificantdecreaseinthelevelofanxiety,andahigher levelofsatisfactionregardingtheprocedureexperiencethanthecontrolgrouphavingno musicintervention(chang,2005).areviewevaluatingthebenefitsoflisteningtomusic duringcaesareansectionunderregionalanaesthesia(laopaiboon,2009)showedan improvementonpulserateandbirthsatisfaction,howeverotherparameterslike respirationratesandanxietylevelswerenotdifferentbetweenthegroupsreceivingornot preferredmusicbyearphones. Anotherstudyexploredtheuseofmusicsessionsoverthreeconsecutivedaysformothers hospitalizedattheendofahigh riskpregnancy(yang,2009)comparedtothoseinsimilar situationsbutnotexposedtomusic.theauthorsreportedasignificantdecreaseinthe levelsofanxietywhichwasreflectedinreducedheartratesandstablerespiratoryrates. 11

12 Theeffectofpatient selectedmusicwasinvestigatedonearlypostoperativepain,anxiety, bloodpressureorheartrate(ebneshahidi,2008;liu,2010)andshowedthatpainscoreand consumptionofanalgesicsweresignificantlyloweramongpatientsinthemusicgroup, whereasnodifferenceswerefoundonanxietyscores,bloodpressureorheartrate.these findingsarerelevantintermsofimprovingrecoveryandallowingearlycontactbetween motherandchildduringthetimeinhospital,butitappearsthattheeffectsbecomenonsignificantinthepost partumperiodathome(tseng,2010). 3.2Neonatal/IntensiveCare CopyrightNHSChoices,photographerVickiCouchman Therearedifferentopinionsofwhethertheperceptionandabilitytorespondtomusicis innateorlearned;studiesperformedinanumberofhealthyneonates(winkler,2009) stronglysupporttheviewthataninterestinmusicisaninnateabilityofthenewborninfant. Thisunderstandinghasmotivatedanumberofinvestigationsonthevalueofmusic stimulationforpreterminfantsintheneonatalintensivecareunitenvironment.astudyof theeffectsoflivemusic,recordedmusicornomusictherapyoverthreeconsecutivedays, withstrictcontrolofenvironmentalnoiselevel(arnon,2006),showedthatnophysiological andbehaviouralparametersweremodifiedduringthe30minutesofmusicintervention; however,measurementstakenatintervalsafterthetherapyendedshowedasignificant decreaseinheartrate,andimprovedbehaviouralscore.interestingly,thesepositiveresults wereonlyfoundaftertheinterventionoflivemusic.recordedmusicandnomusichadno significanteffectinthoseparameters(arnon,2006). Exposuretomusicoverarangeofdecibelslevels(Dureau,2005)onone day oldinfants showednosignificantdifferencesinheartrateorbehaviouralstateduringthreeloudness levels.ananalysisofclinicalrecordsafterdischargingpre terminfantsfromaunitthat providedaprogramofmulti modalstimulation,pacifier activated lullabytreatmentand parentstrainedstimulationoftheinfants,showedthatthoseinfantsincludedinthe programgainedmoreweight/dayandweredischargedearlierthanthosenotincludedinit (Standley,2010).Theeffectofmusicingrowingpre terminfantsshowedimprovedweight gain.apotentialmechanismcouldbeanincreasedmetabolicefficiencywhichtheauthors relatedmainlytotheexposureofmusicbymozart(lubetzky,2010). 12

13 Anotheraspecttoconsideristhemanagementofpaininneonatology.Non pharmacological methodsareincreasinglydiscussedwithregardtopainpreventionandreliefeitheraloneor incombinationwithpharmacologicaltreatment.areviewwascarriedoutstudying13 randomisedcontrolledstudiesandtwometa analyses(cignacco,2007).amongdifferent typesofnon pharmacologicalinterventions,thestudyexaminedtheeffectsofdifferent formsofmusic,suchasmusicwithintrauterinesounds,instrumentalmusicoracapella singing.thesetwolastinterventionswereeffectiveonlyinpreterminfantsolderthan31 weeks,andtheauthorsrecommendedthatmusicshouldnotbeprovidedformorethan15 minutesduetotheriskofsensoryoverload.amorerecentreview(hartling,2009)of randomisedcontrolledtrialsontheeffectsofmusicformedicalproceduresinneonates showedpreliminaryevidenceofsometherapeuticbenefitofmusicinterventionforspecific medicalindications.thosetrialsmeasuredpainscores,physiologicalandbehavioural parametersfollowingtheuseofclassicalmusic,lullabies,intra uterinemusic,andcompared theresultswithsimilargroupsnotreceivingthistypeofintervention. Apilotstudydesignedtounderstandwhethermusicenhancesweightgaininpremature infantsonfixedfeedingregimensassessedthelevelsofsalivarycortisolandheart variability,ingroupsexposedornottoliveharpmusic(kemper,hamilton,2008).the authorsreportedpreliminaryencouragingresultswhichdeservealargerstudy. Ithasbeenfoundthatneonatesrespondedtomusicwithapreferenceforlullabiesover adultsongs,andharmonicmusicoverdissonantmusic.itisalsointerestingtoexploretheir preferenceforinstrumentaland/orinstrumentalplusvocalmusic.theresponseofthe newborntomusicisevidentbychangesinheartrate,andithasdifferenteffectson neonatesofdepressedmothersversusnon depressedmothers(hernandez Reif,2006) Neonatesofdepressedmothersshowedslowerprocessinganddelayedattentioncompared toneonatesofnon depressedmothers. Thepsychotherapeuticinfluenceofinfant directedsingingbyparentspromotesandsupport demonstrationsofempathyfacilitatingdevelopmentandbondingintheparent infant relationship(o Gorman,2006;Neal,2008).Theeffectofmother ssingingwasstudiedina trialusingpre recordedsingingsongsbythemothersoffull termandpreterminfants (Cevasco,2008).Althoughtheresultsdidnotreachsignificantdifference,itisinteresting thatthepreterminfantswholistenedtothecdrecordingoftheirmothers singingleft hospitalanaverageoftwodaysearlierthanthoseinthecontrolgroup. Apilotstudy(Blumenfeld,2006;Austin,2010)ontheeffectsofmother ssingingduring feeding,didnotfindsignificantbenefits,buttheoverallimpactofmusicinpremature neonateswasshowninreducedsymptomsofstress,fasterweightgain,andshorterstaysin theneonatalintensivecareunit.theinterventionofmusicandtheuseofpacifier activatedlullabyhasshownamaximumbenefitwhenapplied30minutesbeforefeeding(cevasco, 2005;Whipple,2008;Standley,2010)resultinginadefinitetrendofgreaterweightgain. Anotheraspectinwhichtheinterventionofmusicandmaternalvoicehasproduced significantbenefitsisoninconsolablecryingofprematurebabies(keith,2009).thisstudy showedasignificantreductioninthefrequencyanddurationofthisepisode,andalsohad 13

14 significanteffectonimprovingheartandrespiratoryrate,oxygensaturationandblood pressure. Theattitudeofmedicalandnursingstaffinaneonatalcareunittowardstheintroductionof live/recordedmusicwasveryfavourable,recordedmusicwaspreferredtolivemusicandits valuewasrecognisedregardingthereductionofstress,cryingandimprovedsleepin prematurebabies(kemper,2004).similarresultswerefoundbyotherauthors(bouhairie, 2006)whentheyinvestigatedstaffattitudesandexpectationstowardsmusicinapaediatric oncologyunitversusaneonatalintensivecareunit.theywerestronglyassociatedwithprior musicaltrainingandexperience.staffattitudesarenotbarrierstoprovidingmusictherapy inneonateintensivecareunits. 3.3Children IanandFriendspuppetshowattheChelseaandWestminsterHospitalOpenDay,2011. Artplaysaveryimportantroleincreatingahumanizedhospitalenvironment,especiallyin children shospitalswheretherelationshipbetweenartandartistswithpatients,parents, carersandmedicalstaffleadstoimprovementsinchildren smanagementandbeneficial clinicalandemotionaloutcomes(belver,2010;belver,2011).theauthorsofthesepapers emphasizedtheimportanceofpayingattentiontothediversityofcultures,parent s opinionsandpatientsandstaffparticipationinthecreativeprocesses. Musicinterventions,asalistenerorasanactivemusicmaking,havebeenthesubjectof extensivework.however,theheterogeneityofinterventions,measurementsappliedand outcomesfound,makeitdifficulttoreachdefiniteconclusions.arecentreview(naylor, 2011)ofseventeenstudiesshowedtheimpactofmusicinterventiononclinicaloutcomes suchasreductioninmigrainefrequency,motorimpulsivity,anddecreasedlevelsofsalivary cortisol.amostsignificanteffectisreportedwithrespecttocopingbehaviours,especially thoserelatedtogriefanddistress.theauthorsconcludedthatthereisanurgentneedof highqualityresearch,consensusonprioritiesandstandardizedinterventions. Practiceguidelinesformusicinterventionsinchildren shospitalshavebeenattempted before(stouffer,2007).theyrecommendedidentifyingtheintentofmusicintervention,for 14

15 example:onanalgesia,distraction,relaxationorsensorystimulation.itisalsoimportant thatrealistictherapeuticgoalsandclearoutcomesarespecified.musicselectionand methodsofdeliveryareessential,andtheresponsibilitiesofmedicalstaffinrecordingthe physiologicalandpsychologicaleffectsshouldbeoutlined. Areviewoftwentytwostudiesontheinterventionofmusicinpaediatrics(Robb,2009)has identifiedgapsinplanningandreportingandtheneedforimprovingtheevidence based practice.asystematicreviewforpainandanxietyinchildrenundergoingmedical proceduresandtheefficacyofmusictherapyfoundthatthisinterventionwaseffectiveand promising,butconcludedthatitshouldbetakenasprovisionalduetothepoorqualityof thestudiesanalysed(klassen,2008). Morerecently(Irons,2010a)exploredtheissueofresearchonsinginginterventionfor childrenandadultswithbronchiestasis.thisisacommonrespiratorydiseasewithalung functionthatmaydeclinewithtime.singingmaysupportlungfunctionandenhancequality oflife,butcontrolled randomizedstudieshavenotbeenundertakenasyetandare necessarytoestablishthevalueofthisintervention.thesamemethodologywasfollowed andsimilarconclusionsreachedfromasearchforresearchontheinfluenceofsingingon lungfunctionandqualityoflifeforchildrenandadultswithcysticfibrosis(irons,2010b). Authorsstudyingtheeffectofmusiconpain,distressandanxietyafterday surgeryfound thatchildrenexposedtosoftandrelaxingmusicdeliveredbyheadphonesconsumedfewer analgesicsthanthegroupofchildrenonsimilarcircumstancesbutwiththeirheadphones turnedoff(nilsson,s.,2009).theyalsoreportedlessdistress,buttherewerenotchanges onotheraspectsofthepost operativeprocess.arandomizedtrialstudiedtheeffectof musiconchildrenwithcancerundergoinglumbarpuncture(nguyen,2010).the measurementsincludedpainscores,heartrate,bloodpressure,respiratoryrateandoxygen saturationtakenbefore,duringandaftertheprocedure.theresultsshowedthatlistening tomusicthroughearphonesreducedpainscores,heartandrespiratoryratesandlevelsof anxietywhencomparedtothecontrolgroup.apreviousrandomizedcontrolledtrialofthe activemusicengagementonchildrenwithcancer(robb,2008)foundthatthisintervention significantlyimprovedcoping relatedbehavioursinhospitalizedchildrenreceivingcancer treatment.aninterestinginitiative(barry,2010)involvedchildrencreatingamusiccdprior totheirfirstradiationtreatmentforcancer,andthenlisteningduringtreatment.thecontrol groupreceivedstandardcare.theauthorsshowedthatthisinterventionwasengagingand appropriateandthetrendforeffectivecopingstrategyapproachedsignificantresult.the interventionofmusicwasalsoeffectiveincontrollinganxietyinmechanicallyventilated patients(han,2010)andinchildrenfollowingcardiacsurgery(hatem,2006).musictherapy wasalsobeneficialforthesedationofchildrenundergoingdifferentmedicalprocedures (Loewy,2006). 15

16 3.4Cardiovascularconditions OpusIVperformingatChelseaandWestminsterHospital,2006. Arecentstudyaddressesthesubjectoftheeffectofmusiconclinicaloutcomes(Bernardi, 2011).Theauthorsaimedtoassessthepotentialclinicalinterventionofdifferenttypesof musiconthecardiovascular,cerebrovascularandrespiratorysystems,aswellasinthe modulationofstress.theyhavefoundthatmusicproducedanincreaseinfocusedattention ofthelistener,anditwasproportionaltothespeedofthemusicandrhythm.pausesor slowerrhythmsinducedarelaxingeffect.measurementsofventilation,bloodpressureand heartrateshowedanincreasewithfastertempi,whilepausesinducedadecreaseofheart rateandbloodpressure.thechoiceoftherighttypeofmusiccouldbeusefulinthe managementofcardiovasculardiseases. Astudyfoundthegreatestbenefitonhealthwithclassicalandmeditationmusic(Trappe, 2010)whereasheavymetalortechnomusiccouldevenbedangerousleadingtostressand arrhythmias.theyidentifiedthemusicbybach,mozartandsomeitaliancomposersasthe morebeneficial.apreviousreview(bradt,2009)concludedthatlisteningtomusicmay haveabeneficialeffectonbloodpressure,heartrate,respiratoryrate,anxietyandpainin individualswithcoronaryheartdisease,butmoreresearchisneededinordertoimprove theevidence. Theuseofmusic assistedrelaxationwasshowntobeeffective(niet,2011)initscapacityof inducingandimprovingqualityofsleepinpatientswithvariousconditions.the physiologicalresponsesofpatientslisteningtomusicintheintensivecareunit(chan,2009) showedthatpreferredmusicselectedbythepatient,inducesbeneficialphysiological outcomesmostlyinfemalegroupsandthoseusingaventilator.thiseffectofmusictherapy wasinvestigatedinpalliativecare(horne Thompson,2008).Theauthorsfoundasignificant reductionofanxiety,pain,tirednessanddrowsinessmeasurements. Anumberofstudiesfocusedtheiraimsinevaluatingtheeffectsofmusiclisteningandmusic therapyasausefulinterventiontoprovidestressandpainreliefduringdifferentmedical procedures.providingpatientswithheadphonesandtheirpreferredchoiceofmusicinthe endoscopysuitehasresultedinareductionofsedationamountscomparedtocontrol groups,withresultsapproachingsignificance,anda29.7%decreaseinanalgesia requirements.theauthors(rudin,2007)alsofounda21%reductioninproceduretimefor 16

17 thosepatientsreceivingtheinterventionofmusic.twometa analysisstudiesfollowedthe lastpaper(wilson,2008;bechtold,2009).theauthorswereabletoconfirmthatlisteningto musicduringacolonoscopyprocedureiseffectiveinreducingthetimeandamountof sedation,anditsuseshouldbepromoted.theinterventionoflisteningtomusicduring colposcopyreducedsignificantlythelevelsofanxietyofwomenundergoingthisprocedure (Galaal,2009).Asaresultofareviewofrandomisedandquasirandomisedcontrolledtrials theyconcludedthattheinterventionofmusicalsoinducedasignificantreductioninpain scores(cepeda,2010). 3.5Surgeryandpainmanagement ConnaughtOperaperformingonasurgicalwardatChelseaandWestminsterHospital,2004 Theinterventionofmusicinsurgeryhasbeenaddressedbyanumberofauthorswhohave evaluatedthebenefitsduringdaysurgery,anaesthesiarequirements,pre operativeand post operativemeasurements(leardi,2007).patientsselectedmusicdeliveredthrough headphonesduringsurgeryforskincancer(perischetti,2009;shenefelt,2010)resultedina verypositiveresponseoffirsttimepatients,withincreasedwillingnessofusingmusicin repeatedsurgicalprocedures. Theimpactofmusiconanxietylevelsduringshortwaitingperiodsindaysurgery(Cooke, 2005)wasreviewed,showingcost effectivebenefitsafterimplementation,althoughmore researchisneeded. Theuseofmusicduringpaediatriclacerationrepairdidnotincreasetheproportionof parentswhowereinvolvedinthisstrategyofdistraction(sobieraj,2009). Anthertypeofsurgery,whichmainlyaffectselderlypeople,istotalkneereplacement. Thesepatientshaveaslowandpainfultimeofrecoverywhichinducesanxietyand depression.musictherapyandsinging,asanon pharmacologicalinterventionhave significantlyimprovedthepsychologicaldistressofthesepatients(giaquinto,2006; McCaffrey,2006)andinducedareductionofperceivedpain(Simcock,2008). Theuseofmusicinoperatingtheatreshastakenplacefordecades;however,the understandingofitseffectsonsedationandamountsoranaesthesiarequiredisamore recentdevelopment.astudytodeterminewhetherthedecreaseinsedativerequirements 17

18 wastheresultofmusicortheeliminationofoperatingroomnoise(ayoub,2005)concluded thatwhencontrollingforroom noise,theuseofafavouritecdbythepatientresultedin almostsignificantlylessrequirementofsedative,suchaspropofol.otherstudies(zhang, 2005;Bringman,2009)havenotonlyconfirmedtheresults,butfoundasignificant reductioninmeaninductionofsedationandamountofintraoperativepropofolduring combinedspinal epiduralanaesthesiainthegroupthatlistentomusiccomparedtocontrol. Tenjournalarticleswerereviewedregardingtheuseofmusicintheoperatingtheatre duringmonitoredanaesthesiacare(newman,2010).theconclusionsofthisreviewshowed thattheinterventionofmusicishighlybeneficial;significantlyreducingtheamountof sedationrequired,reducesrecoverytime,andpreventsinmanycasestheneedfor convertingtogeneralanaesthesia. Aprotocolforevaluatingtheuseofmusicforpre operativeanxietyidentifiesthemain pointstotakeintoconsideration,suchas:theeffectsofmusictherapyversuspatient selectedmusic;theefficacyofpatient preferredmusicversusresearcher selectedmusic, andtheoveralleffectofmusiconpre operativeanxiety(dileo,2010b;ganidagli,2005).the interventionofmusichasbeenshowntobeveryeffectiveinthepost operative managementofpain(tse,2005;good,2005;good,2010).thisstrategyinducedsignificant decreasesinpainintensityovertime;patientshadalowersystolicbloodpressureandheart rate,andneededfewerdosesofanalgesics. Arandomizedclinicaltrialwasconductedtoanalysetheeffectofmusicinstressresponse tocardiacsurgery(nilsson,2009a;hatem,2006)onthefirstpost operativedayafter cardiacsurgery.measurementsofvitalsignsandcortisollevelshaveindicatedtheclinical valueoflisteningtomusicwhilerestinginbedafteropenheart surgery.inthesametypeof patientstheintroductionofsoothingmusicincreasedoxytocin(ahormonewithanti stress effects)levels,asdemonstratedbyanotherrandomizedcontrolledtrial(nilsson,2005; Nilsson,2009b).Olderpeopleundergoingcardiovascularsurgerywholistentomusic showedlessanxietyandshortertimeofintubation(twiss,2006;chan,2006). Astudyexploringadifferenttypeofsurgerysuchassolidorgantransplant(Madson,2010) foundthatmusictherapyisavaluablepsychosocialinterventionindicatingsignificant improvementsinself reportinglevelsofanxiety,pain,andnausea.inastudyregarding post operativepainafterdifferenttypesofsurgery,theinclusionofmusicasanursing interventionshowedaloweruseofanalgesics(engwall,2009;camara,2008).the requirementofmorphineconsumptionaftersurgeryinschool agedchildren(nilsson,s., 2009)wasreducedinthemusicgroupcomparedtothecontrolgroup.However,another studydoesnotsupporttheuseofmusicduringsurgeryduetothelackofconclusiveresults (Szmuk,2008).Anexploratorystudy(Sand Jecklin,2010)hasfoundapositiveimpactoflive musiconpatientsadmittedtohospital.thetherapeuticeffectofthisinterventionshoweda reductiononthelevelofpain,anxietyscoresandmuscletensionlevels.thepost operative analysisinthequalityofindicators,suchaslengthofstayandlevelofmedicationon patientsafterbrainsurgery(walworth,2008)showedaclearimprovementafterlivemusic intervention. 18

19 Asystematicreviewontheanxietyandpain reducingeffectsofmusicinterventions (Nilsson,2008)included42randomizedcontrolledtrialsinperioperativesettings.Morethan halfofthereviewedstudiesshowedapositive,lowcostpotentialofimplementationofthis interventionaddressingpatients distress.anotherreview(cepeda,2010)ontheeffectof musiconacute,chronicorcancerpainreliefconcludedthatlisteningtomusicreducespain intensitylevelsandopioidrequirements,buttheeffectswerenotalwayssignificant,andits useinclinicalpracticeremainsunclear.theneedformoreresearchontheclinicaleffectsof musicinterventionisemphasizedinareview(bradt,2010)ofstudiesonmechanically ventilatedpatients.thefindingssuggestedthatmusiclisteningmayhaveabeneficialeffect onheartandrespiratoryratesandanxietylevels. 3.6Lungdiseases PhoeneCaveleadsaSingingforBreathingworkshopatRoyalBrompton&HarefieldNHSFoundationTrust. Non pharmacologicalinterventionsforalleviatingshortnessofbreathduetoterminal cancerorrespiratorydiseaseswerereviewed(bausewein,2010).amongothers,music inducedbreathingtrainingappeartobeeffective,butthereiscurrentlynotenoughdatato judgetheevidenceanditsbenefits.singingclassesasatherapyforchronicrespiratory disease(lord,2010)haveshowntohaveabeneficialeffectinreducinganxietyandhadno adverseconsequences.measurementsofpulmonaryfunctionandqualityoflifewere conductedafterweeklyclassesofsingingpractice(bonilha,2009).theauthorsfounda significantdifferenceonchangesofoneofthefunctionalrespiratorytests,maximal expiratorypressurescontributingtoabetterqualityoflifeandrespiratoryimprovement.a veryinterestingstudyonthemechanismsofbreathingpatternsandrespiratorymuscleused bysubjectswithspinalcordinjury(tamplin,2011)foundthattheapplicationoftherapeutic singingtrainingresultedinfunctionalimprovementsinthosepatients.theevidencebaseto supporttheinclusionofmusicandsingingintreatmentsandcareofolderpeopleis increasing(skingley,2010)butmoreresearchisneededtosupportthefindingsand elaborateastrategyforimplementation. 3.7Oncology 19

20 SunbyLucyAlgar,2003,commissionforTheMacmillanCentreatChelseaandWestminsterHospital. Aprotocolforinvestigatingtheeffectsofmusicinterventiononpsychologicaland physiologicaloutcomesonpatientswithcancer(dileo,bradt,grocke,etal.,2010)hasbeen outlined.theirobjectivesincludetheidentificationofrandomisedcontrolledtrials,the comparisonbetweenmusictherapyandstandardcareandmusictherapyversusothertypes ofmusicdelivery.areviewwillfollowtoaddresstheseobjectives.previousreviewsand studiesonthesubject(pothoulaki,2006;hanser,2006;o Callaghan,2006)concludedthat moreevidenceisneededtovalidatethebenefitsofmusicinterventionincancercare.a groupofpatientswholistenedtomusicduringbonemarrowbiopsyaspiration(shabanloei, 2010)hadloweranxietyandpainlevelsthanthosewhodidnothavemusic.Acrosssectionalsurveywascarriedoutduringtwoyearsinapaediatriconcologyclinic(Kemper, 2008)inordertounderstandparents attitudesandexpectationsaboutmusicintervention onpaediatricleukaemiapatients.theresultsshowedthatparentsandclinicianshave positiveattitudesandposednobarriersfortheuseofmusicinchildrenunits. 20

21 4CONCLUSIONS Thisreviewoftheliteratureonartsinhealthhasidentifiedonehundredandthreestudies offeringstrongevidenceoftheeffectofmusicinterventionsonpsychologicaland physiologicaloutcomesofpatientsinhealthcareenvironments.thispositivecontributionis describedforanumberofdifferentareaswithinthehealthcaresetting,butalsodiscusses studieswhichfoundcontroversialorunclearresults.thefindingsofthisreviewshowthat thecontributionofmusictohealthcareisofagreatimportanceincreatingahumanized environment,decreasinglevelsofstress,anxietyanddepression,reducingdrugs consumption,andshorteninglengthofstayinhospital. Futureresearchshouldincorporateandanalyserigorouslythecontributionofawider spectrumofartsintervention.visualart:landscapes,portraitsorabstractpaintings?a researchprojectconsideringwhichtypeofpaintings/photographsarethemostappropriate fordifferentareasofthehospitalevaluatingtheemotionalandphysiologicalresponseon patientsisimportant.therearefewstudies,howevertheconfirmationoftheircontribution toareductionondrugsconsumptionandlengthofstayinhospitalrequiresfurther research.itisacceptedthatpatientswithneurologicaldiseasesarebenefitedbythe contributionofliterature,poetryandsinging.aresearchshowingconclusiveclinical outcomesshouldprovidevaluableevidence,beyondanecdotalinformation.the contributionofcreativewriting,danceanddrama/theatreisstillwaitingtobeevaluatedin relationtothepsychologicalandphysiologicalresponsesofpatientsinahospital environment.theevaluationoftheeffectofintegratingdifferentartformsintothe healthcareculturerequiresnewandchallengingideaswhichcouldinduceunforeseen benefitsforpatientsandthenationalhealthservice. Finally,animportantaspecttobeconsideredwhenestablishingaresearchprojectina hospitalenvironmentisthestrategyforrecruitingpatientsandstaff.itisimportanttotailor theobjectivesandmeasurementstoeachparticipatingunit,consideringthediversityof genderandculturesinthedevelopmentofstrategies(chlan,2009). 21

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25 Hartling,L.,Shaik,M.S.,Tjozvold,L.,Leicht,R.,Liang,Y.,Kumar,M.(2009)Musicfor medicalindicationsintheneonatalperiod:asystematicreviewofrandomisedcontrolled trials,archiveofdiseaseinchildhood,fetalandneonataledition,94:5,f349 F354. Hatem,T.P.,Lira,P.I.C.,Mattos,S.S.(2006)Thetherapeuticeffectsofmusicinchildren followingcardiacsurgery,journalofpediatrics(rioj),82:3, Hernandez Reif,M.,Diego,M.,Field,T.,(2006)Instrumentalandvocalmusiceffectson EEGandEKGinneonatesofdepressedandnon depressedmothers,infantbehaviorand Development,29, Horne Thompson,A.,Grocke,D.(2008)Theeffectofmusictherapyonanxietyinpatients whoareterminallyill,journalofpalliativemedicine,11:4, Irons,J.Y.,Kenny,D.T.,Chang,A.B.(2010a)Singingforchildrenandadultswith bronchiectasis(review),thecochranelibrary,issue4,1 15. Irons,J.Y.,Kenny,D.T.,Chang,A.B.(2010b)Singingforchildrenandadultswithcystic fibrosis(review),thecochranelibrary,issue5,1 14. Jencks,C.,Heathcote,E.(2010)TheArchitectureofHope,London:FrancisLincolnLtd. Keith,D.,Douglas,R.,Russell,K.,Weaver,B.S.(2009)Theeffectsoflisteningon inconsolablecryinginprematureinfants,journalofmusictherapy,46:3, Kemper,K.,Hamilton,C.(2008),Liveharpmusicreducesactivityandincreasesweight gaininstableprematureinfants,journalofalternativeandcomplementarymedicine, 14:10, Kemper,K.,Martin,K.,Block,S.,Shoaf,R.,Woods,Ch.(2004)Attitudesandexpectations aboutmusictherapyforprematureinfantsamongstaffinaneonatalintensivecareunit, AlternativeTherapiesinHealthandMedicine,10:2, Kemper,K.J.,McLean,T.W.(2008)Parent sattitudesandexpectationsaboutmusic simpact onpediatriconcologypatients,journalsocietyintegrativeoncology,6:4, Klassen,J.A.,Liang,Y.,Tjosvold,L.,Klassen,T.P.,Hartling,L.(2008)Musicforpainand anxietyinchildrenundergoingmedicalprocedures:asystematicreviewofrandomized trials,ambulatorypediatrics,8:2, Laopaiboon,M.,Lumbiganon,P.,Martis,R.,Vatanasapt,P.,Somjaivong,B.(2009)Music duringcaesareansectionunderregionalanaesthesiaforimprovingmaternalandinfant outcomes(review),thecochranelibrary,issue2,1 22. Larsen,P.D.,Galletly,D.C.(2011)Thesoundofsilenceismusictotheheart,Heart,92, Leardi,S.,Pietroletti,R.,Angeloni,G.,Necozione,S.,Ranalletta,G.,DelGusto,B.(2007) Randomizedclinicaltrialexaminingtheeffectofmusictherapyinstressresponsetoday surgery,britishjournalofsurgery,94:8,

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