A systematic review of music-based interventions for procedural support.

Journal of Music Therapy, 52(1), 2015, 1–77 doi:10.1093/jmt/thv004; Advance Access publication April 15, 2015 © the American Music Therapy Association 2015. All rights reserved. For permissions, please e-mail: [email protected]

A Systematic Review of Music-Based Interventions for Procedural Support Olivia Swedberg Yinger, PhD, MT-BC Lori F. Gooding, PhD, MT-BC

Background: Individuals undergoing medical procedures frequently experience pain and anxiety. Music-based interventions have the potential to help alleviate these symptoms. Objective: This review investigated the effects of music-based interventions (music therapy and music medicine) on pain and anxiety in children and adults undergoing medical procedures. Methods: This systematic review examined randomized controlled trial music intervention studies to manage patient-reported pain and/or anxiety during medical procedures. All studies were published in English and peer-reviewed journals. Quality and risk of bias were assessed using criteria from the Checklist to Evaluate a Report of a Nonpharmacological Trial (CLEAR-NPT). Results: Fifty studies met inclusion criteria, the majority of which (84%) had a high risk of bias. It was not possible to perform a meta-analysis because studies varied greatly in terms of medical procedure and intervention type. Results varied across studies, with approximately half (48%) indicating less anxiety for music intervention participants; fewer studies (36%) reported less pain for music intervention participants. Conclusions: There is a need to clearly define and differentiate between music therapy and music medicine interventions in procedural support research. Further research is necessary to determine which patients would benefit most from music interventions during medical procedures, and which interventions are most beneficial. To improve research quality and reduce risk of bias, when designing studies investigators need to carefully consider factors related to design, including randomization, treatment allocation concealment, blinding outcome assessors, and intention-to-treat analysis. In addition, more detailed intervention reporting is needed when publishing results. Keywords: music therapy; music medicine; medical procedure; pain; anxiety The authors would like to thank Mark Ingram for assistance in designing the search parameters. Address correspondence concerning this article to Olivia Swedberg Yinger, 105 Fine Arts Building, University of Kentucky, Lexington, KY 40506-0022. Phone: 859218-0997. E-mail: [email protected].

Downloaded from http://jmt.oxfordjournals.org/ at North Dakota State University on July 10, 2015

University of Kentucky

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Journal of Music Therapy

Definition of Outcome Measures For the purposes of this review, the authors used the following operational definitions for outcome measures of interest. Pain was defined as “a basic bodily sensation that is induced by a noxious stimulus, is received by naked nerve endings, is characterized by physical discomfort (as pricking, throbbing, or aching), and typically leads to evasive action” (Merriam Webster, 2014). Although some definitions of pain allude to the aspects of emotional and mental lack of well-being, in medicine, pain is often used to describe physical discomfort, whereas the term anxiety is used to describe the feelings of emotional and mental discomfort that accompany noxious physical sensations. The authors used the National Cancer Institute’s definition of anxiety: “feelings of fear, dread, and uneasiness that may occur as a reaction to stress” (National Cancer Institute, 2013). Pain and anxiety are commonly measured through selfreport, behavioral observation, or physiological measures. In addition, the amount of analgesic or anxiolytic medication used can also be a measure of perception of pain or anxiety, respectively. Definition of Music-Based Interventions In research on the use of music-based interventions in medical settings, it is important to differentiate music therapy from music medicine. The following operational definitions of music-based interventions were used within this review. Music therapy was defined as the use of music interventions by a credentialed music therapist to accomplish individualized goals within a therapeutic relationship


Medical procedures are a common source of pain and anxiety. A medical procedure can be any activity or task in which a patient takes part so that healthcare professionals can diagnose or treat an illness or disease, or help improve the patient’s health (Becker & Landau, 1986). Music has a long history of being used to help treat pain and anxiety. In their review of music as a non-pharmacological pain treatment, Bernatzky, Presch, Anderson, & Panksepp (2011) remarked that “the alleviation of pain and the reduction of anxiety which can exacerbate pain appear to be the most promising use of music therapy” (p. 1991). Absent from the literature is a comprehensive and systematic review of music interventions to manage pain and anxiety in patients during medical procedures.

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Systematic Reviews on Music-Based Interventions in Healthcare Systematic reviews on the use of music-based interventions in healthcare have focused on specific diagnoses (Bradt, Dileo, Grocke, & Magill, 2011), age groups (Evans, 2002), and outcomes (Bradt et al., 2013). In a Cochrane review of music therapy and music medicine interventions for patients with cancer, Bradt et al. (2011) found moderate beneficial effects for reduction of pain and moderate to large effects for reduction of anxiety. However, many of the 30 studies included in the review by Bradt et al. (2011) had a high risk of bias, meaning the true effect of the intervention may have been overstated or understated, and results should be interpreted with caution. Another Cochrane review examined the effects of music interventions, all of which involved listening to prerecorded music, on preoperative anxiety for surgical patients. Based on the 26 trials reviewed, the authors concluded that music listening had a moderate effect on reducing preoperative anxiety (Bradt et al., 2013); however, most studies in this review also had a high risk of bias. Evans (2002) conducted a systematic review and subsequent metaanalyses of 29 studies on interventions using recorded music for adult hospital patients (both those receiving normal hospital care and those undergoing medical procedures). A meta-analysis of six studies revealed a moderate effect of listening to music via headphones on anxiety reduction during normal hospital care. Listening to recorded music had no effect on anxiety for patients


(American Music Therapy Association, 2014). Credentialed music therapists make decisions about treatment based on knowledge about music perception, clinical applications of music, and the specific needs of the patient with whom they are working. Music therapy interventions often, but not always, involve live music implemented by the music therapist. Patients often engage in music therapy interventions in ways that extend beyond passive listening, such as singing, playing instruments, or moving to music, in order to help meet their non-musical goals. Music medicine was defined as passive listening to prerecorded music provided by medical personnel other than a music therapist (Bradt, Dileo, & Shim, 2013). In music medicine treatment, listening interventions are often administered via headphones and patients may or may not be involved in selecting the music.

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undergoing bronchoscopy or surgery with spinal anesthesia; however, this finding was based on the results of only two studies. Music listening had no effect on pain for patients receiving normal hospital care, experiencing renal lithotripsy, or undergoing chest tube removal, but these findings were based on the results of only three studies (Evans, 2002). Results from existing systematic reviews on the use of music-based interventions in healthcare reveal that music has the potential to help alleviate pain and anxiety; however, effects vary across individual studies and many studies appear to have a high risk of bias. The variability in results across studies could be due in part to the use of different types of music-based interventions with patients who have a wide range of needs. There is a need for additional research on the use of music-based interventions to address pain and anxiety within specific healthcare situations. One specific application of music to help address pain and anxiety in healthcare is the use of music as a form of procedural support, in which music is used to promote healthy coping and decrease distress in individuals undergoing medical procedures (Ghetti, 2012). To date, three published reviews on the use of music interventions as procedural support have been published (Bechtold et al., 2009; Good, 2011; Klassen, Liang, Tjosvold, Klassen, & Hartling, 2008). In a systematic review of music interventions during pediatric needle-related procedures, Good (2011) identified three randomized controlled trials and found benefits of music on pain reduction when compared to standard care or a placebo in two out of three studies (Good, 2011). Likewise, Bechtold et al. (2009) carried out a meta-analysis of eight randomized controlled trials in which adults listened to music during colonoscopies. Results revealed significant differences with music in terms of improving the patients’ overall experience, yet no significant differences were found in pain, dose of analgesic or anxiolytic medication, procedure time, or willingness to repeat the procedure in the future. In a systematic review of randomized, controlled trials involving the use of music interventions during pediatric medical procedures, Klassen et al. (2008) found a significant reduction in pain and anxiety for participants who received music interventions. The authors classified all studies that involved music interventions as music therapy, regardless of whether treatment was administered by a credentialed music therapist. They further

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classified the interventions using two subsets—active music therapy and passive music therapy. Studies were classified as active music therapy if a music therapist engaged the child in a live music interaction, whereas studies that involved listening to music without a music therapist were classified as passive music therapy. Only 5 out of the 19 studies reviewed included the use of active music therapy. Klassen et al. (2008) then conducted a meta-analysis on a subset of the trials reviewed, including two studies on active music therapy and seven studies on passive music therapy. Significant effects were found for passive but not active music therapy compared to a control condition, with further analysis revealing a therapist effect in one of the active music therapy studies. Although the systematic review by Klassen et al. focused on the use of music during medical procedures, not all included studies used music during the procedure. Three of the included studies classified as active music therapy used music in preparation for or during recovery from a procedure but not during the procedure. In the study by Bechtold et al. (2009), the terms music therapy and therapeutic uses of music appeared to be used interchangeably, and neither term was defined. As stated previously, Klassen et al. (2008) defined any use of music as music therapy, with subsets for active and passive interventions. The inconsistent use of terminology related to music interventions in systematic reviews by Bechtold et al. (2009) and Klassen et al. (2008) highlights the need to clarify definitions in future research. In the three aforementioned reviews, there were more music medicine than music therapy interventions, indicating a need for more research on the use of music therapy as procedural support, with a particular emphasis on techniques used by the music therapist. The purpose of this systematic review was to summarize the results of randomized controlled trials on music-based interventions (including music therapy and music medicine) on pain and anxiety in children and adults undergoing medical procedures, in order to provide recommendations for future research and clinical practice. More specifically, for children and adults undergoing medical procedures (participants), what are the effects of music medicine and music therapy (interventions) compared to standard care (comparison) on pain and anxiety (outcomes)?


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Methods Identification of Relevant Studies

1. Studies were primary research, published in English in peerreviewed journals published between 1975 and 2014. 2. Studies were randomized controlled trials of human participants, with no restrictions as to gender or ethnicity. 3. Participants were at least 3 years old. 4. Studies included music interventions during the procedure, although music interventions may have started prior to or continued after the procedure. 5. Music was a primary stimulus (regardless of delivery method, live or recorded). 6. Studies measured pain and/or anxiety using self-report measures. Studies were excluded if they were not primary research studies (e.g., meta-analyses, systematic reviews, or Cochrane reviews); if they were published in languages other than English; if they were not published in peer-reviewed journals; if they were not randomized controlled trials; if they did not include human participants; if they included infants or toddlers under age 3; if music was not present during a medical procedure; and if they did not measure pain or anxiety using self-report measures. Search Strategies The authors identified potential studies for analysis by searching PubMed, Cochrane, ProQuest, PsycInfo, CINAHL, ERIC, and Web of Science databases between May 30, 2014, and June 9, 2014. In


This review examined studies that used music-based interventions as procedural support. Prior to beginning the systematic review process, the authors first consulted relevant literature on systematic review protocols, including the works of Akobeng (2005), Garg, Hackman, and Tonelli (2008), and Hanson-Abromeit and Sena Moore (2014). Based on the previously stated definitions of music-based interventions and outcome measures, the authors included studies that utilized music interventions to help alleviate pain and/or anxiety during medical procedures for both children and adults. In order to be included, studies had to meet the following inclusion criteria:

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Table 1. Electronic Search Strategy for Studies on Music Interventions as Procedural Support, 1975–2014 Date

Database

May 30, 2014

PubMed

June 2, 2014

Cochrane

June 2, 2014

ProQuest

June 4, 2014

PsycInfo

June 4, 2014

CINAHL

June 9, 2014

ERIC

June 9, 2014

Web of Science

Terms

Music therapy “music therapy” Music and procedural Music AND procedural AND English “music therapy” And Procedural “music therapy” AND procedural AND English (music or music therapy) and procedural (music or music therapy) and procedural and English “music therapy” AND “procedural support” and English Music therapy Music therapy AND procedure Music AND procedure AND medical Music therapy AND procedure AND medical music therapy music therapy AND procedure music AND procedure AND medical music therapy AND procedure AND medical music therapy AND procedure AND medical music therapy AND procedure AND medical

Hits

4,048 2,671 52 49 23 22 52 30 17 7,973 305 95 55 2,441 50 13 10 23 76


addition to the database search, all issues of the following journals published between 1975 and 2014 were hand-searched between June 9 and 17, 2014: Arts in Psychotherapy, Australian Journal of Music Therapy, British Journal of Music Therapy, Canadian Journal of Music Therapy, Journal of Music Therapy, Music and Medicine, Music Therapy, Music Therapy Perspectives, New Zealand Journal of Music Therapy, and Nordic Journal of Music Therapy. These journals were selected because of their relationships with major music therapy professional organizations. Reference lists of articles were also examined to identify other potentially relevant studies. Search terms used included music, music therapy, procedural, and medical. The full electronic search strategy is included in Table 1.

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Data-Collection Process

Quality Assessment Process In addition to collecting data, studies were also assessed for quality. The authors adapted the CLEAR NPT Checklist (Boutron et al., 2005), a checklist developed to evaluate the quality of reports of RCTs assessing non-pharmacological treatments. The original checklist consisted of 10 items and 5 sub-items related to intervention standardization, care provider influence, and additional measures to minimize bias. The adapted version consisted of 8 items and 4 sub-items. The quality assessment rating guidelines used in this review are shown in Table 2. Studies were again divided evenly between the authors, and each author gave their assigned studies an initial assessment score using the quality assessment rating checklist. All studies were then reviewed by both authors to determine a final quality score. When discrepancies arose, studies were discussed until consensus was reached and a final quality score assigned. The lowest score a study could receive was 0, and the highest score a study could receive was 8. For the purpose of this review, only studies with scores of 5 or greater could be considered high-quality studies, as studies with scores lower than 5 were automatically at high risk of bias.


A table for extracting data from relevant studies was created based on the research question. Information mined and summarized for each study included (1) participant characteristics, including the age group (pediatric or adult), total number of participants, percentage of female participants, mean age of participants, and age range of participants within each group; (2) type of medical procedure; (3) publication information, including authors’ names, date of publication, and the country in which the study was conducted; (4) intervention characteristics, including the timing, selection, and delivery of the music and number of participants who underwent each type of intervention, as well as the intervention type (music medicine or music therapy); (5) outcome measures; (6) results; and (7) quality assessment and resulting risk of bias. Articles were evenly divided and independently reviewed, and each author extracted information from their assigned articles. The authors then met and discussed the information extracted from all included articles. Any discrepancies were discussed until consensus was reached.

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Table 2. Quality Assessment Rating Guidelines, Adapted from the CLEAR-NPT (Boutron et al., 2005)


1. Was the generation of allocation sequences adequate? Give 1 point only if a suitable method was used to generate the sequence of randomization (i.e., simple randomization via table of random numbers or computer-generated random numbers). 2. Was the treatment allocation concealed? Give 1 point only if participants and investigators enrolling participants could not foresee upcoming group assignments. 3. Were details of the intervention administered to each group made available? Give 1 point only if all of the following information was described in the report or made available in some type of addendum: information about who selected the music; type of music; music delivery method; intervention materials; intervention strategies; frequency of administration; duration of music during treatment; whether music was present before, during, and/or after the procedure; and general principles of individualization procedures when necessary. 4. Was care providers’ experience or skill in each arm appropriate? Give 1 point only if an individual with training in music perception and clinical applications of music (e.g., a credentialed music therapist) was involved in designing and/or implementing treatment. 5. Were participants adequately blinded? Give 1 point only if participants were unaware of their group assignment, or if blinding was not feasible due to research design. (Answer questions 5.1 and 5.2 only if no points were awarded for question 5.) 5.1. If participants were not adequately blinded, were all other treatments and additional care similar in each randomized group? Give 0.5 points only if participants in both groups received similar treatment. 5.2. If participants were not adequately blinded, were withdrawals and the number of participants lost to follow-up similar in each randomized group? Give 0.5 points only if the number and/or description of withdrawals and those lost to follow-up were similar between groups. 6. Were care providers adequately blinded? Give 1 point only if care providers were unaware of participants’ group assignment, or if blinding was not feasible due to research design. (Answer questions 6.1 and 6.2 only if no points were awarded for question 6.) 6.1. If care providers were not adequately blinded, were all other treatments and care similar in each randomized group? See guidelines for 5.1. 6.2. If care providers were not adequately blinded, were withdrawals and the number of participants lost to follow-up similar in each randomized group? See guidelines for 5.2. 7. Were outcome assessors adequately blinded to assess the primary outcomes? Give 1 point only if outcome assessors were unaware of participants’ group assignment, or if blinding was not feasible due to research design. (Answer question 7.1 only if no points were awarded for question 7.)

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Table 2. Continued

In addition to evaluating the quality of included studies, the risk of bias for each study was determined. Risk of bias was based on five of the quality assessment criteria: (1) adequate generation of allocation sequences; (2) treatment allocation concealment; (3) blinding of care providers; (4) blinding of outcome assessors; and (5) whether outcomes were analyzed according to the intentionto-treat principle. Studies that fully met all five of these criteria (and had earned 1 point each for questions 1, 2, 6, 7, and 8 on the quality assessment checklist) were considered to have a low risk of bias. Studies that fully met four of these criteria (meaning they had earned 1 point for questions 1, 2, 8, and either 6 or 7), but only partially met the fifth criteria (meaning they only earned 0.5 points for either question 6 or question 7 and therefore only earned 4.5 points total), were considered to have a moderate risk of bias. Studies that met four criteria or fewer were considered to have a high risk of bias. These criteria for determining risk of bias are similar to those used by Bradt et al. (2013). Because only these five criteria were used to determine the risk of bias, it was possible for a study to have initially received a high-quality assessment score (5 or higher) but still be at moderate or high risk of bias. Further Analysis Due to the number of studies with high risk of bias and the heterogeneity of the studies in terms of (1) outcomes measured; (2) medical procedures; (3) participant ages; and (4) uses of music, a meta-analysis was not feasible. When possible, the authors calculated Cohen’s d for primary outcomes (pain and anxiety) from studies with low or moderate risk of bias. According to Cohen’s guidelines (1988), an effect size of 0.20 is a small effect size, 0.50 is a moderate effect size,


7.1. If outcomes assessors were not adequately blinded, were specific methods used to avoid ascertainment bias (systematic differences in outcome assessment)? Give 0.5 points only if the main outcome was objective or “hard,” or if outcomes were assessed by an independent reviewer who was blinded to the purpose of the study and hypotheses. 8. Were the main outcomes analyzed according to the intention-to-treat principle? Give 1 point only if all participants who were randomly assigned to a group completed the study in the group to which they were originally assigned, or an intention-to-treat analysis was conducted.

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and greater than 0.80 is a large effect size. A series of Mann-Whitney U tests were used to compare quality assessment factors of studies by intervention type (music medicine and music therapy). Search and Inclusion Results

Figure 1. Study selection flowchart.


As illustrated in Figure 1, the search yielded a total of 191 possible studies. After screening study abstracts, only 85 articles met eligibility criteria. Each of these full text articles was read to determine eligibility for inclusion, with 50 being included in the final review.


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Results

Table 3. Summary of Participant Age Groups, Procedures, Intervention Types, and Outcome Measures Age Group

Pediatric

Adult

Total pediatric Total adult Overall total

Procedurea

Burn care Immunizations IV cannulation Lumbar puncture Venipuncture Angiogram BMA Burn care Chemotherapy Chest tube removal Colposcopy Endoscopy ESWL Labor & delivery MRI Radiation therapy Surgery

Intervention Type

Outcome Measures

MM

MT

Pain

Anxiety

0 2 2 1 1 4 2 0 0 1 1 11 2 2 0 1 14 6 38 44

1 1 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 2 4 6

1 3 2 1 1 2 2 1 0 1 0 5 2 3 0 0 9 8 25 33

1 0 0 1 0 4 2 1 1 0 1 7 1 1 1 1 11 2 31 33

Total

1 3 2 1 1 4 2 1 1 1 1 11 2 3 1 1 15 8 42 50

a BMA = Bone marrow aspiration; ESWL = Extracorporeal shock wave lithotripsy; IV = Intravenous; MRI = Magnetic resonance imaging.


Publication dates ranged from 1994 to 2013, with nine studies from the 1990s, 27 studies from 2000 to 2009, and 14 studies from 2010 to 2013. Age groups, procedures, intervention types, and outcome measures are summarized in Table 3. Forty-two studies (84%) included adult participants (age 18 or older), whereas only eight studies (16%) included pediatric participants (age 3 to 17 years). Included studies focused on the use of music interventions with 16 types of medical procedures, the most common procedures being surgery (major or minor: n = 14; 28%) and endoscopy (n = 11; 22%). Forty-four studies (88%) used music medicine as an intervention; only six studies (12%) used music therapy interventions. There were 33 studies that measured pain as an outcome measure and 33 that measured anxiety.

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Quality Assessment and Risk of Bias Generation of allocation sequences was adequate in 28 (56%) of the studies, and treatment allocation was concealed in 14 (28%) of the studies (Table 2 contains criteria for adequate allocation sequences, treatment allocation concealment, details of interventions, care provider experience, blinding, and intention-to-treat analysis). Details of the interventions were adequate in 18 (36%) of the studies, and care providers’ experience was appropriate in 10 (20%) of the studies. Blinding of participants was not feasible in any of the studies because of the nature of music interventions; however, 35 (70%) of the studies blinded care providers (i.e., interventionists) and 26 (52%) blinded outcome assessors. In 26 (52%) of the studies, the main outcomes were analyzed according to the intention-to-treat principle, either through intention-to-treat analysis, or because all participants who were randomized were included in analysis. Five studies (10%) had low risk of bias, three studies (6%) had moderate risk of bias, and 42 studies (84%) had high risk of bias. Information regarding quality assessment and risk of bias is also included in Table 4. Quality assessment scores for studies that examined music medicine interventions ranged from 1.5 to 7 (median = 4.5), whereas studies that included music therapy interventions had a narrower range of quality assessment scores, from 3.5 to 5 (median = 4.5). A similar trend was found for bias scores, with scores for music medicine studies ranging from 0.5 to 5 (median = 3.0) and scores for music therapy studies only ranging from 1.5 to 3 (median = 2.0). Results of a series of Mann-Whitney U tests comparing quality assessment scores by intervention type are shown in Table 5. Music medicine studies received significantly higher scores for use of intention-to-treat principle (p < .01), whereas music therapy studies received significantly higher scores for care provider skill


Studies were found from 17 different countries, with 21 (42%) having been conducted in the United States. After the United States, Canada was the country with the greatest number of studies, with five studies. Five of the studies that used music therapy were conducted in the United States, and one (Browning, 2001) was conducted in Canada. Data extracted from the included studies are shown in Table 4, organized first by age group and then by procedure.

Type of Medical Procedure

WhiteheadPleaux et. al (2006), U.S.

Publication Information

Tx. Live music therapy during procedure (improvisation and singing), with music selected by pt from researcher’s list, n = 8 (MT) C. Verbal support, n = 6

Intervention Characteristics (Intervention Type)

1. NSD between groups.

Results

2. Anxiety (Fear 2. Significantly more thermometer) fear pre and during in Tx group compared to C group. 3. Pain (NAPI) 3. Tx group displayed significantly more distress than C group. 4. HR, RR 4. Tx group HR decreased significantly more than C group. NSD between groups for RR.

1. Pain (FACES)

Outcome Measures


Pediatric Burn care (donor N = 14 site dressing (56% female) changes) 6–16y

Participant Characteristics

Data Extraction Table

Table 4.

QA/

3.5 High

Bias Risk

14 Journal of Music Therapy


Intervention Characteristics (Intervention Type) Outcome Measures

Results

C. Standard care, n = 49

2. HR, BP 3. Behavioral distress (OSBD)

2. NSD between groups 3. Tx group showed significantly lower distress than C group.

Kristjánsdóttir & Tx1. Recorded music via 1. Pain (VAS) 1. After controlling Kristjánsdóttir headphones during for covariates, (2011), procedure, selected by listening to music Iceland pt from researcher’s list, without headphones n = 38 (MM) was a significant Tx2. Recorded music via predictor of speakers, n = 41 (MM) perceiving less pain. C. Standard care, n = 39 Megel et al. Tx. Recorded music during 1. Pain (FACES 1. NSD between groups (1998), U.S. procedure, selected by portion of the pt from researcher’s list, Oucher) n = 50 (MM)



Pediatric Immunizations N = 99 (51% female) 3–6y M = 4.5y

Pediatric Immunizations N = 118 (47% female) 13–15y M = 14y


Table 4. Continued

3 High

7 High

Bias Risk

QA/

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IV cannulation


Noguchi (2006), Tx1. Interactive story with 1. Pain (FACES, U.S. recorded music created by pt and by the researcher during observer) procedure, delivered via headphones, n = 21 (MT) Tx2. Interactive recorded 2. Distress spoken story, delivered (OSBD) via headphones, n = 21 C. Standard care, n = 20 3. Focus of attention Arts et al. (1994), Tx1. Local anesthetic, n = 601. Pain (FACES, Australia VAT)


1.5 High

3. NSD between groups 1. Tx1 group reported significantly less pain than Tx2 and C groups. Differences greatest for 4–6y.

2. NSD between groups

4 High


QA/ Bias Risk

Results


Pediatric

Pediatric Immunizations N = 62 (41% female) 4–6y M = 4.6y


Table 4. Continued


2. Behavioral distress (OSBD-R)

3. HR


Hartling et al. (2013), Canada

Pediatric IV cannulation N = 42 (33% female)

Outcome Measures

1. Pain (FACES)


C. Placebo cream, n = 60 Tx. Recorded music during procedure, selected by researcher, n = 21 (MM)


Tx2. Recorded music 2. Behavioral before and during reaction procedure, selected by (global researcher, n = 60 (MM) assessment)


Bias Risk

7 Low

2. Tx1 group showed significantly fewer pain-related behaviors than Tx2 and C groups. Differences greatest for 4–6y. 1. Tx group showed a significantly smaller increase in pain than C group. 2. For children who showed distress, Tx group showed a significantly smaller increase in behavioral distress than C group. 3. NSD between groups

QA/ Results


N = 180 (44% female) 4–16y M = 9.7y


Table 4. Continued

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Pediatric

3–11y M = 6y

Lumbar puncture


Nguyen et al. (2010), Vietnam

Publication Information Outcome Measures

Results

4. Parent 4. NSD between groups satisfaction (LTS) and anxiety (STAI) 5. Healthcare 5. Healthcare providers provider reported that it was satisfaction significantly easier and ease of to provide care for performing Tx group, and were procedure significantly more (LTS) satisfied with the procedure for pts in Tx group than C group. Tx. Recorded music before 1. Pain (NRS) 1. Tx group reported and during procedure, significantly less selected by pt, n = 20 pain than C group (MM) during and after procedure.




Table 4. Continued QA/

6 Low

Bias Risk


N = 40 (38% female) 7–12y Tx. M = 8.8y C. M = 9.4y






Results

2. Anxiety (short 2. Tx group showed form STAI) significantly less anxiety than C group after 10 minutes of music but before the procedure, as well as after the procedure. 3. HR, RR, BP, 3. Tx group showed SpO2 significantly greater reductions in RR and HR during the procedure than C group, and in RR after the procedure. NSD between groups in BP or SpO2.


Table 4. Continued

Bias Risk

QA/

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2. Rated by parent

3. Rated by investigator

4. Rated by independent observer

2. Tx1 group parent pain ratings significantly lower than Tx2 at 1 min. 3. Tx1 group investigator pain ratings significantly lower than Tx2 at 0, 1, and 5 min. 4. Tx1 group observer pain ratings significantly lower than Tx2 at 5 min.

1. NSD between pt pain ratings.

Results


C. Placebo cream, n = 50

Pediatric Venipuncture for Balan et al. Tx1. Recorded music Pain (VAS): N = 150 blood collection (2009), India before, during, and after (41% female) procedure, selected by 5–12y researcher, n = 50 (MM) M = 8y Tx2. Local anesthetic, 1. Rated by pt n = 50



5.5 High

Bias Risk


Angiogram (coronary angiography)

Angiogram (coronary angiography)

Adult N = 238 (50% female) Tx. M = 67y C. M = 64y


Nilsson et al. (2009), Sweden

Bally et al. (2003), Canada


Results

4.5 High

4. Analgesic, 4. NSD between groups anxiolytic meds Tx. Recorded music during 1. Pain (NRS) 1. NSD between groups procedure, selected by researcher, n = 121 (MM) C. Standard care, n = 117 2. Anxiety (STAI) 2. NSD between groups 3. Anxiolytic, 3. NSD between groups analgesic meds 4. Angina (NRS) 4. NSD between groups

3. HR, BP

4.5 High

Bias Risk

QA/


Tx. Pt-selected recorded 1. Pain (VAS) 1. NSD between groups music from researcher’s list before, during, and after procedure, n = 58 (MM) C. Standard care, n = 55 2. Anxiety (STAI) 2. NSD between groups





Table 4. Continued

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Adult N = 30

Angiogram (cerebral angiography)


Schneider et al. (2001), Germany


Results

5. Experience 5. NSD between groups of the sound environment (NRS) 6. Discomfort 6. NSD between groups of lying still (NRS) Tx. Recorded music before 1. Anxiety (STAI) 1. High state anxiety and during procedure, was significantly selected by pt from correlated with low researcher’s list, cortisol levels in Tx n = 15 (MM) group but not C group. C. Standard care, n = 15 2. Stress 2. Plasma cortisol hormones increased significantly over time for C group, but remained stable for Tx group. NSD between groups for adrenaline and noradrenaline.





2.5 High

Bias Risk


Adult N = 48 (81% female) 23–78y Tx. M = 46y C. M = 52y

(53% female) 25–59y Tx. M = 42.1y C. M = 44.3y

Angiogram (cerebral angiography)


Vanderboom et al. (2012), U.S.


3. HR, BP

Outcome Measures

Results

QA/ Bias Risk

3. Tx group had significantly lower SBP than C group. NSD between groups for HR or DBP. Tx. Recorded music during 1. Anxiety (STAI) 1. C group had 5.5 procedure, selected by a significantly Moderate pt from researcher’s list, greater reduction n = 24 (MM) in anxiety than Tx group, although differences between groups in state and trait anxiety were present at baseline. C. Standard care, n = 24 2. HR, SBP 2. NSD between groups 3. Analgesic meds 3. NSD between groups




Table 4. Continued

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BMA (Bone marrow biopsy)

BMA (Bone marrow aspiration and biopsy)

Adult



Results

Tx. Recorded music before 1. Pain (VAS) 1. NSD between groups and during procedure, selected by pt from researcher’s list, n = 29 (MM) C. Standard care, n = 30 2. Anxiety (STAI) 2. NSD between groups 3. Pt satisfaction 3. NSD between (NRS) groups. 66% of Tx group answered very much when asked if they would like to listen to music during future procedures. Shabanloei et al. Tx. Recorded music during 1. Pain (VAS) 1. Tx group reported (2010), Iran procedure, selected by significantly less researcher, n = 50 (MM) pain than C group after procedure.

Danhauer et al. (2010), U.S.



Adult N = 59 (59% female) 22–78y M = 50.9y


Table 4. Continued

6 High

2 High

Bias Risk

QA/


Adult N = 29

N = 100 (55% female) 18–60y Tx. M = 32.3y C. M = 34.7y

Burn care (dressing changes)




Results

2. Anxiety (STAI) 2. Tx group reported significantly less state anxiety after procedure compared to C group. Tan et al. (2010), Tx. Live, pt-selected music 1. Pain (NRS) 1. Significantly less U.S. therapy, with music-based pain before, during, imagery before and after and after dressing procedure and music changes on Tx days alternate engagement compared to C days. (active music making) during procedure, n = 29 (MT) C. Standard care, n = 29 2. Anxiety (NRS) 2. Significantly greater decreases in anxiety on Tx days compared to C days.




Table 4. Continued

5 High

Bias Risk

QA/

Vol. 52, No. 1 25

Adult N = 50 (52% female) 21–78y M = 55y

(17% female) 8–71y M = 14.3y

Chemotherapy


Ferrer (2007), U.S.


Results

3. Muscle tension 3. Significantly greater inventory scale decreases in muscle tension on Tx days compared to C days. Tx. Listening to and 1. Anxiety (VAS) 1. Tx group had singing pt-selected live significantly lower music during procedure, anxiety than C n = 25 (MT) group. C. Standard care, n = 25 2. Fear (VAS) 2. Tx group had significantly lower fear than C group. 3. Worry (VAS) 3. NSD between groups. 4. Fatigue (VAS) 4. Tx group had significantly lower fatigue than C group. 5. Comfort (VAS) 5. NSD between groups. 6. Relaxation 6. Tx group had (VAS) significantly greater relaxation than C group.




Table 4. Continued

5 High

Bias Risk

QA/


Adult

Adult N = 156 (31% female) 42–87y M = 66.4y



7. HR, BP

Outcome Measures

7. NSD between groups for HR or SBP. Tx group had significantly lower DBP than C group. 1. NSD between groups

Colposcopy

Rickert et al. Tx. Recorded music video (1994), U.S. during procedure [Study 2 only] selected by researcher, n = 30 (MM)


2.5 High

3. Narcotic intake 3. NSD between groups 1. Anxiety (STAI) 1. NSD between groups

6 High

Bias Risk

QA/ Results

Chest tube removal Broscious (1999), Tx1. Recorded music 1. Pain (NRS) after open heart U.S. before and during surgery procedure, selected by pt from researcher’s list, n = 70 (MM) Tx2. White noise, n = 36 2. HR, DBP, SBP 2. NSD between groups




Table 4. Continued

Vol. 52, No. 1 27

Adult

N = 30 (100% female) 13–20y M = 16.5y

Endoscopy (Colonoscopy)




Results

2. Pain behaviors 2. Tx group showed (interval significantly fewer coding system) body movements associated with pain, required less physician reassurance, received fewer procedural explanations than C group. NSD between groups for other behaviors. 3. HR 3. NSD between groups 4. Pt satisfaction 4. NSD between groups Andrada et al. Tx. Recorded music before 1. Anxiety (STAI) 1. Tx group showed (2004), Spain and during procedure, significantly greater selected by researcher, decreases in anxiety n = 63 (MM) compared to C group.




Table 4. Continued

7 Low

Bias Risk

QA/


Adult N = 59 (56% female)

N = 118 (50% female) Tx. M = 46y C. M = 49y

Endoscopy (EGD and/or colonoscopy)


C. Headphones only, n = 55


Bampton & Tx. Recorded music before, Draper (1997), during, and after Australia procedure, selected by researcher, n = 28 (MM) C. Headphones only, n = 31


Results

2. Number of cardiorespiratory incidents during procedure NSD between groups. 1. NSD between groups

1. Anxiety before 2. NSD between groups procedure 2. Willingness to 3. NSD between undergo repeat groups. Significantly procedure greater proportion of pts in C group rated the procedure as at least moderately unpleasant.

VAS:

2. HR, BP, SpO2



Table 4. Continued

5 High

Bias Risk

QA/

Vol. 52, No. 1 29


Bechtold et al. (2006), U.S.


3. Procedure tolerance Tx. Recorded music before 1. Pain (VAS) and during procedure, selected by researcher, n = 85 (MM) C. Standard care, n = 81 2. Duration 3. Sedation 4. Anxiolytic, analgesic meds 5. Insertion difficulty 6. Pt experience (3 VAS)


5. NSD between groups 6. Tx group rated significantly higher than C group on 2 out of 3 experience scales, indicating better tolerance/ pleasantness but no difference in how the procedure compared to expectations

7 Low


2. NSD between groups 3. NSD between groups 4. NSD between groups

Bias Risk

QA/ Results


Adult Endoscopy N = 166 (Colonoscopy) (Tx. 51.8% female, C. 48.1% female) Tx. M = 58.5y C. M = 54.1y

Tx. M = 48y C. M = 49y


Table 4. Continued


Endoscopy (Flexible sigmoidoscopy)

Endoscopy (Flexible fiberoptic bronchoscopy)



Tx. Recorded music during procedure, selected by pt from researcher’s list, n = 30 (MM) C. Standard care, n = 34


Colt et al. (1999), Tx. Recorded music U.S. during procedure, selected by researcher, n = 30 (MM) C. Standard care, n = 30

Chlan et al. (2000), U.S.

Publication Information Results

1. Anxiety (STAI) 1. Tx group reported significantly less state anxiety than C group after the procedure. 2. Discomfort 2. Tx group reported (NRS) significantly less discomfort than C group after the procedure. 3. Pt satisfaction 3. NSD between groups (LTS) 4. Perceived 4. NSD between groups compliance with future screening (LTS) 1. Anxiety (STAI) 1. NSD between groups in state or trait anxiety after the procedure, or in difference between pre- and postprocedure anxiety ratings.

Outcome Measures


Adult N = 64 (69% female) M = 54.6y



7 Low

5.5 High

Bias Risk

Vol. 52, No. 1 31


5 High


QA/ Bias Risk

Results

2. Tx group reported significantly less discomfort than C group. 3. Sedation dose 3. Tx group used significantly less sedation than C group. 4. Duration of 4. NSD between groups procedure 5. Recovery time 6. Tx group had significantly shorter recovery time than C group. 6. Willingness to 7. NSD between groups undergo repeat procedure

Harikumar et al. Tx. Recorded music during 1. Pain (VAS) (2006), India procedure, selected by pt from researcher’s list, n = 38 (MM) C. Standard care, n = 40 2. Discomfort (VAS)


Endoscopy (Colonoscopy, polypectomy)



Adult N = 78 (% female not given) 16–60y


Table 4. Continued




C. Sedation only, n = 55

Lee et al. (2002), Tx1. Recorded music Hong Kong during procedure, selected by pt from researcher’s list, plus sedation, n = 55 (MM) Tx2. Music only, n = 55 (MM)


4.5 High


QA/ Bias Risk

Results

2. Tx1 group required significantly less propofol than C group. 3. Complications 3. NSD between groups 4. Recovery time 4. NSD between groups 5. Satisfaction 5. NSD between groups 6. Willingness to 6. Significantly more undergo repeat pts in Tx1 group procedure than in Tx2 or C groups were willing to repeat procedure.

2. Pt controlled sedation

1. Pain (VAS)

Outcome Measures


Adult Endoscopy N = 165 (Colonoscopy) (46% female) 16–75y Tx1. median = 54y Tx2. median = 51y C. median = 47y


Table 4. Continued

Vol. 52, No. 1 33

Adult

Adult N = 60 (53% female) 20–75y



Results

Bias Risk

QA/

Ovayolu et al. Tx. Recorded music before 1. Pain (VAS) 1. Tx group reported 3.5 (2006), Turkey and during procedure, significantly less High selected by researcher, pain than C group. n = 30 (MM) C. Standard care, n = 30 2. Anxiety (STAI) 2. Tx group reported significantly less anxiety than C group. 3. Anxiolytic, 3. NSD between groups analgesic meds 4. Pt satisfaction 4. Tx group reported (VAS) significantly higher satisfaction than C group. 5. Willingness to 5. Tx group was undergo repeat significantly more procedure willing than C (VAS) group to repeat procedure. Endoscopy (Flexible Palakanis et al. Tx. Recorded music before 1. Anxiety (STAI) 1. Tx group reported 5.5 sigmoidoscopy) (1994), U.S. and during procedure, significantly less Moderate selected by pt from anxiety than C researcher’s list, n = 25 group. (MM)





Table 4. Continued



N = 50 (26% female) 20–76y Tx. M = 55y C. M = 49y



Smolen et al. (2002), U.S.


2. HR, MAP

1. Anxiety (SAI)

2. HR, BP

3. Sedation

Tx. Recorded music before and during procedure, selected by pt from researcher’s list, n = 16 (MM) C. Standard care, n = 16

Outcome Measures



2. HR and BP decreased significantly for Tx group, yet remained stable in C group. 3. Tx group required significantly less physicianadministered sedation than C group.

2. Tx group had significantly lower HR and MAP than C group. 1. NSD between groups

Results



Table 4. Continued

4.5 High

Bias Risk

QA/

Vol. 52, No. 1 35


Extra-corporeal shock wave lithotripsy


Cepeda et al. (1998), Colombia

Tx. Recorded music (unclear who selected music) before, during, and after procedure, n = 97 (MM) C. Standard care, n = 96

5 High

3 High


2. Cortisol levels increased significantly less for Tx group compared to C group. 1. NSD between groups


QA/ Bias Risk

Results

2. Analgesic meds 2. NSD between groups 3. Side effects 3. NSD between groups

1. Pain (NRS)

4. Duration of procedure Uedo et al. Tx. Recorded music during 1. Pain (NRS) (2004), Japan procedure, selected by researcher, n = 15 (MM) C. Standard care, n = 14 2. Salivary cortisol




Tx. M = 58.6y C. M = 61.1y Adult N = 29 Endoscopy (38% female) (Colonoscopy) Tx. M = 54y C. M = 54y


Table 4. Continued



Tx. M = 40.7y C. M = 41y

Extra-corporeal shock wave lithotripsy



4. Analgesia quality 5. Pt satisfaction 6. Pt acceptance of procedure 1. Pain (VAS)

Outcome Measures


4 High

Bias Risk

QA/ Results

Yilmaz et al. Tx. Recorded music 1. NSD between groups (2003), Turkey delivered via headset during procedure, selected by pt from researcher’s list, without sedation, n = 48 (MM) C. Sedation; wore headset 2. Anxiety 2. NSD between groups with no music, n = 50 (OAA/S, STAI) in OAA/S, state anxiety. Tx group had significantly lower trait anxiety than C group. 3. HR, RR, MAP, 3. Tx group showed a SpO2 significant decrease in MAP. C group showed a significant decrease in SpO2.




Table 4. Continued

Vol. 52, No. 1 37

Adult

Tx. M = 40.9y C. M = 39.3y

Labor and vaginal delivery



Browning (2001), Tx. Recorded music with Canada coaching in breathing exercises and progressive muscle relaxation before (via 2–3 home visits from the music therapist) and during procedure; music selected by pt from researcher’s list and pt’s own collection of music, n = 9 (MT)

Publication Information Results

4. Analgesic meds 4. Tx group required significantly less analgesic med compared to C group. 5. Satisfaction 5. Tx group reported (VRS) significantly less distress and more comfort than C group after procedure. 1. Pain (MPQ) 1. NSD between groups

Outcome Measures




4 High

Bias Risk




Results

C. Standard care, with 2. Attitude Toward 2. NSD between coaching in breathing Childbirth groups but music exercises and progressive Scale participants showed muscle relaxation, n = 10 a significant increase in perceptions of personal control postnatal. 3. Relaxation 3. Tx group was significantly more relaxed than C group. 4.Medications 4. NSD between groups Liu et al. (2010), Tx. Recorded music before 1. Pain (VAS) Tx group had Taiwan and during procedure, significantly better selected by pt from outcomes than researcher’s list, n = 30 C group on all (MM) measures during C. Standard care, n = 30 2. Anxiety (VAS) the latent phase of 3. Nurse rating labor. NSD between of behavioral groups on any intensity outcome measures 4. Finger during the active temperature phase of labor.



Adult Labor and vaginal N = 60 delivery (100% female) 18–39y M = 27.1y

N = 19 (100% female) Ages not given


Table 4. Continued

2 High

Bias Risk

QA/

Vol. 52, No. 1 39


Adult N = 88 (65% female) 15–93y M = 62y

MRI


Results

Taghinejad et al. Tx1. Massage, n = 51 1. Pain (VAS) 1. Tx1 group reported (2010), Iran Tx2. Recorded music during significantly less procedure, selected by pain and pain less pt from researcher’s list, severe than Tx2 n = 50 (MM) group. Walworth (2010), Tx. Live music matching 1. Anxiety (VAS) 1. NSD between U.S. the tempo of the groups. MRI machine during procedure, selected by pt, delivered via headphones, n = 44 (MT) C. Recorded music 2.Perception of 2. Tx group reported selected by staff during procedure significantly procedure, delivered better perceptions via headphones, n = 44 of procedure (MM) compared to C group.



Adult Labor and vaginal N = 101 delivery (100% female) 20–30y Tx1. M = 21.3y Tx2. M = 21.5y



5 High

4 High

Bias Risk


Smith et al. (2001), U.S.



Tx. Recorded music before 1. Anxiety (STAI) and during procedure, selected by pt from researcher’s list, n = 19 (MM) C. Standard care, n = 23 Adult Surgery (Cesarean Chang & Chen Tx. Recorded music before 1. Anxiety (VAS) N = 64 section delivery) (2005), Taiwan and during procedure, (100% female) selected by pt from Tx. M = 30.3y researcher’s list, n = 32 C. M = 32.3y (MM) C. Standard care, n = 32 2. HR, RR, DBP, SBP, SpO2 3. Pt satisfaction (NRS)


3. Tx group had significantly higher satisfaction than C group.


1. Tx group had significantly less anxiety than C group

4.5 High


3.5 High

Bias Risk

QA/ Results


Adult Radiation therapy N = 42 (0% female) 39–78y Tx. M = 62.2y C. M = 63.4y


Table 4. Continued

Vol. 52, No. 1 41


Cruise et al. (1997), Canada


QA/

C. Operating room sounds, n = 30

3. Pt satisfaction (VAS)

Tx3. White noise, n = 29

2. C group showed significant decreases in SBP that were not evident in Tx groups. NSD between groups for HR, RR, or DBP. 3. Tx1 group rated satisfaction significantly higher than Tx2, Tx3, or C groups.

2. HR, RR, BP

Bias Risk

Tx2. Relaxing suggestion, n = 30

Results

1. Anxiety (STAI, 1. NSD between groups 5.5 VAS) Moderate

Outcome Measures

Tx1. Recorded music during procedure, selected by researcher, n = 32 (MM)



Adult Surgery (Cataract N = 121 surgery) (64% female) Tx1. M = 70.8y Tx2. M = 68.5y Tx3. M = 73.6y C. M = 68.3y


Table 4. Continued



Adult N = 219


Results

Tx1. Recorded music 1. Anxiety (RAA) 1. Among pt with delivered via headphones moderate or high before, during, and after anxiety, those in procedure, selected by Tx1 and Tx2 groups pt from researcher’s list, showed significantly n = 43(MM) greater decreases in anxiety compared to C group. Tx1 group had the lowest postoperative anxiety scores. Tx2. Headphones only, 2. Narcotic meds 2. NSD between groups n = 35 C. Standard care, n = 41 Surgery (Impacted Kim et al. (2011), Tx. Recorded music during 1. Pain (VAS) 1. NSD between groups mandibular third South Korea procedure, selected by molar extraction) pt from researcher’s list, n = 106 (MM) C. Standard care, n = 113 2. Anxiety 2. Tx group reported (Corah’s significantly less Dental Anxiety intraoperative Scale) anxiety than C group.



Adult Surgery Johnson et al. N = 119 (Gynecologic (2012), U.S. (100% female) same day surgery) M = 38.8y



1.5 High

2.5 High

Bias Risk

Vol. 52, No. 1 43


3. HR, RR, BP

Outcome Measures

Surgery (Gynecologic laparoscopy)

Adult

Tx1. Recorded music before 1. Pain (NRS) and during procedure, selected by pt from researcher’s list, n = 24 (MM) Tx2. Book on tape as a 2. Anxiety (STAI) distraction, n = 14 C. Standard care, n = 20 3. Perceived control over pain and anxiety (NRS) Laurion & Fetzer Tx1. Recorded music 1. Postoperative (2003), U.S. before, during, and after pain (NRS) procedure, selected by researcher, n = n.r. (MM)


Surgery (Noxious Kwekkeboom medical (2003), U.S. procedures, like tissue biopsy or vascular port placement)


3 High


1. Both Tx1 and Tx2 groups reported significantly less pain at discharge than C group. NSD in pain on arrival in the PACU or one hour after arrival.


3 High

3. HR increased significantly less in Tx group compared to C group. NSD between groups for RR and BP. 1. NSD between groups

QA/ Bias Risk

Results


Adult N = 58 (69% female) M = 53.3y

(44% female) Ages not given


Table 4. Continued



N = 84 (100% female) 20–55y M = 34.5y


Surgery (Day surgeryLeardi et al. for orthopedic (2007), Italy disease, inguinal hernia, varicose vein, or proctologic disease)

Type of Medical Procedure Outcome Measures

Tx2. Researcher selected recorded music before and during procedure, n = 20 (MM) C. Standard care, n = 20



3. HR, RR, BP



Results

2. Analgesia use

Tx2. Guided imagery 2. Postoperative audiotape, which nausea and included a musical score, vomiting n = n.r. (MM) C. Standard care, n = n.r. 3. Length of stay 4. Analgesia doses Tx1. Pt-selected recorded 1. Pain (VAS) music from researcher’s list before and during procedure, n = 20 (MM)




Table 4. Continued

6 High

Bias Risk

QA/

Vol. 52, No. 1 45

Adult

25–85y M = 65y


Surgery (NonLepage et al. oncological (2001), surgery under Canada spinal anesthesia)


Results

4. Plasma cortisol 4. Tx1 group had levels significantly lower postoperative cortisol than Tx2 group. 5. Lymphocytes 5. Tx2 group had significantly lower intra-operative natural killer lymphocyte cells than C group. NSD between groups in T, suppressor, helper, or B lymphocytes. Tx. Recorded music 1. Anxiety (STAI, 1. NSD between groups before, during, and after VAS) procedure, selected by pt from researcher’s list, n = 25 (MM)




Table 4. Continued

4 High

Bias Risk

QA/


Tx1. Recorded music during procedure, selected by researcher, n = 30 (MM)



Adult N = 90 Surgery (100% (Hysterectomy female) Tx1. under general M = 51y anesthesia)




1. Pain (VAS)

2. Pt controlled sedation

Outcome Measures

2. Sedation requirements during surgery and postoperatively were significantly less for Tx group compared to C group. 1. Tx1 group reported significantly less pain than C group on 1st day after surgery. NSD between groups in pain on day of surgery and 2nd, 3rd days after surgery.

Results


N = 50 (38% female) Tx. M = 37.8y C. M = 38.9y


Table 4. Continued

5 High

Bias Risk

QA/

Vol. 52, No. 1 47

Tx2. M = 52y C. M = 50y




Results

Tx2. Music and therapeutic 2. Analgesic meds 2. Tx2 group required suggestion, n = 31 (MM) significantly less post-procedure analgesia than C group on day of surgery. NSD between groups on 1st, 2nd, 3rd days after surgery. C. Operating room sounds, 3. Nausea, emesis, 3. NSD between groups n = 28 and bowel function 4. Fatigue 4. Tx1 and Tx2 groups were significantly less fatigued than C group at discharge. 5. Well-being 5. NSD between groups 6. Duration of 6. NSD between groups hospital stay 7. Time to sitting, 7. Tx1 group took standing, and significantly less walking after time to sit up than surgery C group. NSD between groups in time to standing or walking.




Bias Risk





Tx1. Intraoperative recorded music selected by researcher, n = 51 (MM) Tx2. Postoperative recorded music selected by researcher, n = 51 (MM) C. White noise, n = 49


1. Pain (NRS) 2. Anxiety (NRS) 3. Morphine requirement 4. Nausea 5. Fatigue 6. Pt satisfaction

Outcome Measures

1. Tx1 and Tx2 groups reported significantly less pain than C group 1 and 2 hours postop. NSD between groups at discharge or 1–2 days following surgery. 2. NSD between groups 3. Tx2 group required significantly less morphine than C group 1 hour postoperatively. NSD between groups at 2 hours postoperatively. 4. NSD between groups 5. NSD between groups6. NSD between groups

Results


Adult N = 151 Surgery (Day case (28% surgery for female) inguinal hernia 21–85y Tx1. repair or varicose M = 54y vein surgery Tx2. under general M = 53y anesthesia) C. M = 54y



6 High

Bias Risk

Vol. 52, No. 1 49

Adult N = 75 (4% female) Tx1. M = 55y Tx2. M = 56 C. M = 57y


Surgery (Open Nilsson et al. hernia repair day (2005), surgery) Sweden


Tx1. Intraoperative 1. Pain (NRS) recorded music selected 2. Anxiety by researcher, n = 25 (NRS) (MM) Tx2. Postoperative 3. Plasma recorded music selected cortisol by researcher, n = 25 4. Blood (MM) C. Standard care, glucose n = 25 5. IgA levels 6. Morphine use 7. HR, BP, SpO2

Intervention Characteristics (Intervention Type) Bias Risk

4.5 High

1. Tx2 group reported significantly less pain than C group. 2. Tx2 group reported significantly less anxiety than C group. 3. Tx2 group showed a significantly greater decrease in plasma cortisol compared to C group. 4. NSD between groups 5. NSD between groups 6. Tx2 group required significantly less morphine than C group 1 hour after surgery and significantly less total morphine. 7. NSD between groups

QA/ Results



Table 4. Continued



Twiss et al. (2006), U.S.

Surgery (Transrectal Tsivian et al. prostate biopsy) (2012), U.S.


Results

Tx1. Recorded music 1. Pain (VRS, 1. NSD between during procedure, VAS, MPQ) groups 2. NSD selected by pt from 2. Anxiety between groups researcher’s list, n = 31 (STAI) 3. HR, 3. DBP increased (MM) Tx2. Headphones RR, BP significantly for only, n = 29 C. Standard Tx2 and C groups, care, n = 28 yet did not change significantly in Tx2 group. NSD between groups for HR, RR, or SBP. Tx. Recorded music during 1. Anxiety (STAI) 1. Tx group reported and after procedure, 2. Intubation significantly lower selected by pt from time (minutes) state anxiety than C researcher’s list, n = 42 group. 2. Tx group (MM) C. Standard care, had significantly n = 44 shorter intubation time than C group.



Adult Surgery (CABG N = 60 surgery) (67% female) Tx. M = 72.6y C. M = 75.1y

Adult N = 88 (0 % female ) M = 62.5y


Table 4. Continued

4 High

3.5 High

Bias Risk

QA/

Vol. 52, No. 1 51

Surgery (Port catheter placement)



Results

Zengin et al. Tx. Recorded music before 1. Pain (VAS) 1. Tx group reported (2013), Turkey and during procedure, 2. Anxiety significant selected by researcher, (STAI) 3. Stress reductions in pain n = 50 (MM) C. Standard hormones compared to C care, n = 50 (cortisol and group. 2. Tx group ACTH) 4. HR, reported significant RR, BP reductions in anxiety compared to C group. 3. Tx group showed significant reductions in cortisol and ACTH compared to C group. 4. Tx group showed significant reductions in HR, RR, SBP, and DBP compared to C group.



QA/

4.5 High

Bias Risk

Note. ACTH = Adrenocorticotropic hormone; BP = Blood pressure; C = Control group; DBP = Diastolic blood pressure; FACES = WongBaker FACES Scale; HR = Heart rate; LTS = Likert-type scale; MAP = Mean arterial pressure; MM = Music medicine; MPQ = McGill Pain Questionnaire; NAPI = Nursing Assessment of Pain Intensity; n.r. = not reported; NRS = Numeric rating scale; NSD = No significant difference; OAA/S = Observer’s Assessment of Alertness/Sedation; OSBD = Observation Scale of Behavioral Distress; Pt = Patient; QA = Quality assessment; RAA = Rapid Assessment Anxiety; RR = Respiration rate; SAI = State anxiety inventory; SBP = Systolic blood pressure; SpO2 = Oxygen saturation; STAI = State/trait anxiety inventory; Tx = Treatment group; VAS = Visual analog scale; VAT = Visual analog toy scale; VRS = Verbal rating scale; y = years.

Adult N = 100 (44% female) 18–75y Tx. M = 49y C. M = 50.7y


Table 4. Continued


Vol. 52, No. 1

53

Table 5. Results of Mann-Whitney U Tests Comparing Quality Assessment Scores by Intervention Type N of Studies That Received a Score of 1 (%)a Quality Assessment Factors

MT (n = 6)

U

p

r

26 (59%) 14 (32%) 17 (39%) 4 (9%) 44 (100%) 29 (66%)

2 (33%) 0 (0%) 1 (17%) 6 (100%) 6 (100%) 6 (100%)

98 90 103 12 132 87

.24 .11 .30 < .01* 1.00 .10

– – – –0.73 – –

21 (48%)

5 (83%)

84

.10

–

26 (59%)

0 (0%)

54

.01*

–0.38

A score of 1 represents adequate consideration of the quality assessment factor. For factors 5, 6, and 7, studies could receive 0.5 points for partial consideration of factors related to blinding. 1 point was awarded for each of these factors if blinding was not feasible due to the study design.

a

b

(p < .01). No significant differences were found between groups for quality assessment ratings of treatment allocation, allocation concealment, intervention reporting, or blinding of participants, care providers, or outcome assessors. Intervention Reporting Intervention reporting was adequate in 18 (36%) of the reviewed studies (see Table 2 for the criteria for adequate intervention reporting, based on criteria described by Robb, Burns, & Carpenter, 2011). Studies must have reported the following in order for intervention reporting to be deemed adequate: (1) the person who selected the music; (2) the genre(s) or specific pieces of music used; (3) the music delivery method (live or recorded, headphones or speakers); (4) intervention materials; (5) intervention strategies; (6) whether music was provided before, during, and/or after the procedure; (7) the duration of the music during treatment; and (8) the total duration of the treatment. Lack of information about the duration of music and treatment was the most common reason studies were determined to have insufficient information about the intervention.


1: Treatment allocation 2: Allocation concealment 3: Intervention reporting 4: Care provider skill 5: Blinding of participantsb 6: Blinding of care providersb 7: Blinding of outcome assessorsb 8: Intention-to-treat principle

MM (n = 44)

54


Outcome Measures and Results Sixteen studies (32%) included both pain and anxiety as outcome measures, whereas 17 (34%) measured only pain and 17 (34%) measured only anxiety. Thirty-three studies (66%) used self-report measures of pain, with the most common measures being visual analog scales (VAS) and numeric rating scales (NRS). Thirty-three (66%) studies used self-report measures of anxiety. The State-Trait Anxiety Inventory (STAI) was used most frequently to measure anxiety, although a few studies used VAS and NRS. Study results were mixed. For music medicine studies that measured anxiety (n =29), 14 (48%) favored the group that received the music medicine intervention, one study (3%) favored the control group, and 14 studies (48%) found no significant difference between groups. For music therapy studies that measured anxiety (n = 4), two studies (50%) favored the experimental group, one study (25%) favored the control group, and one study (25%)


Four studies (8%) used live music, and 46 (92%) used recorded music. All 44 of the music medicine studies involved listening to recorded music; however, four of the music medicine studies incorporated additional elements within the music intervention, such as musical distraction (Kristjánsdóttir & Kristjánsdóttir, 2011), guided imagery (Laurion & Fetzer, 2003), therapeutic suggestion (Nilsson, Rawal, Uneståhl, Zetterberg, & Unosson, 2001), or the visual elements of a music video (Rickert, Kozlowski, Warren, Hendon, & Davis, 1994). Four of the music therapy studies involved the use of live music, and two involved the use of recorded music, combined with elements such as an interactive story (Noguchi, 2006) or coaching from the music therapist in relaxation strategies and breathing techniques prior to and during the procedure (Browning, 2001). The music was selected by the researcher without input from the patient in 19 studies (38%). The patient selected music from a list compiled by the researcher in 26 studies (52%), and in one study (2%), it was unclear who selected the music. Music was chosen by the patient in four studies (8%). In 22 studies (44%), music was provided during the procedure only. The music was also provided before the procedure in 17 studies (34%), after the procedure in three studies (6%), and before, during, and after the procedure in eight studies (16%).

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Table 6. Summary of Results Outcome Measure

No Significant Difference

Favored Alternate Intervention

Favored Control Group

Total

Music medicine 11 (38%) Music therapy 1 (25%) Total 12 (36%)

16 (55%) 3 (75%) 19 (58%)

2 (7%) 0 2 (6%)

0 0 0

29 4 33

Music medicine 14 (48%) Music therapy 2 (50%) Total 16 (48%)

14 (48%) 1 (25%) 15 (45%)

0 0 0

1 (3%) 1 (25%) 2 (6%)

29 4 33

Intervention Type

Favored Music Intervention

Pain

Anxiety


found no significant differences between groups. Among music medicine studies that measured pain (n = 29), 11 (38%) favored the experimental group, two studies (7%) favored a group that received an alternate intervention (local anesthesia or massage), and 16 studies (55%) showed no significant differences between groups. Among music therapy studies that measured pain (n = 4), one study (25%) favored the music therapy group and three studies (75%) found no significant differences. The results of included studies are summarized in Table 6. Table 7 contains a summary of the findings of the eight studies with low or moderate risk of bias, all of which used music medicine interventions, and the results of the Cohen’s d analysis. Five of the studies measured patient anxiety using the STAI. Two of these studies (Colt, Powers, & Shanks, 1999; Cruise, Chung, Yongendran, & Little, 1997) found no significant difference between groups in anxiety. Three of these studies found significant differences in anxiety, producing effect sizes of 0.47 (Andrada et al., 2004), 1.47 (Nguyen, Nilsson, Hellström, & Bengston, 2010), and –0.42 (Vanderboom et al., 2012). Two of the studies measured pain, one of which found no significant difference between groups (Bechtold, Perez, Puli, & Marshall, 2006) and one of which produced an effect size of 1.05 (Nguyen et al., 2010). Two of the studies with low or moderate risk of bias included pediatric patients, both of which measured pain and one of which measured anxiety. Significant effects were found for pain and anxiety in the two studies of pediatric patients, whereas only one of four studies with adults found significant

Ferrer (2007)

Browning (2001)

Women in the experimental group participated in music-assisted childbirth.

Description of Music Interventions

Strengths

Limitations

• Findings add to • Preliminary study with limited body of small sample size evidence Music selected by patient and therapist. • Describes theoretical • Lacked adequate basis for the use of allocation information music to manage pain Interventions used: • Lacked adequate information about concealing treatment allocation Recorded music listening via Walkman • Lacked adequate intervention details Music-structured progressive muscle relaxation • Main outcomes not analyzed according to the intention-to- treat principle Music-structured breathing techniques Pre-posttest Patients in the experimental group received • Provided adequate • Variation in control group 20 minutes of familiar live music during intervention number of previous design with two chemotherapy. information chemotherapy arms. treatments among participants Music selected by patient. • Lacked adequate allocation information

Pre-posttest control group design with two arms.

Design


Author

Descriptions of Interventions used in Music Therapy Studies, as Well as Strengths and Limitations

Table 7.


Noguchi (2006)

Listening to live, familiar music (guitar/ voice)

Interventions used:


Strengths

Listening to a recorded, interactive musical story via headphones

Interventions used:

Participating in singing 3 (condition) x 3 Children participated in an interactive musical • Provided adequate (time) control story during immunizations, with the music intervention group design. therapist’s prompting and encouragement. information Music selected by researcher.

Design

Limitations

• C onfounding variables may have impacted results • Lacked adequate allocation information • Lacked adequate information about concealing treatment allocation • Main outcomes not analyzed according to the intention-to- treat principle

• L acked adequate information about concealing treatment allocation • Main outcomes not analyzed according to the intention-to- treat principle


Author

Table 7. Continued

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Design


Strengths

• T ook steps to reduce bias among outcome assessors Participants naïve to study hypothesis

Limitations

acked adequate • L information about concealing treatment allocation • Main outcomes not analyzed according to the intention-to- treat principle

• M edians and interquartile ranges reported for outcomes • No M or SD reported

• W ide age range (8–71Y) with only one participant under 18


Music alternate engagement

Music-based imagery

Interventions used:

Tan et al. (2010) Two-group Patient-selected, preferred, familiar songs, live • Provided detailed crossover RCT. and recorded, CD player, voice, rhythm descriptions of instruments, music-based imagery before interventions and after burn care, and music alternate engagement (active music listening, therapeutic singing, song phrase cued response, deep breathing exercise, and therapeutic instrumental playing) during burn care. Music selected by patient. • Tested for sequence effects

Author

Table 7. Continued


Walworth (2010)


Recorded music listening via radiology audio system

Live music listening with musical selections matched in tempo to the MRI machine

Interventions used:

Pre-posttest Patients received live music therapy control group intervention during MRI scans. Standard design with two care included listening to recorded music arms. selected by radiology staff. Music selected by patient.

Design

Limitations

• P rovided adequate intervention information

• L acked adequate information about concealing treatment allocation • Main outcomes not analyzed according to the intention-to- treat principle

• L ack of equality between groups for number of previous scans • Main outcomes not analyzed according to the intention-to- treat principle MRI scans • Small effect size

• D ifferences in music choices

• Adequate sample size • V ariability in types of MRI scans

Strengths


Author

Table 7. Continued

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WhiteheadPleaux et al. (2006)

Design

Experimental randomized control


Strengths

Singing

Improvisation

Limitations

Small sample size

lear conclusions C could not be drawn from study results

onfusion about C measurement tool • Measurement tools did not capture effect of music on pain/ anxiety

Music selected by the patient, plus additional • Anecdotal information • improvised songs created by the music provides possible therapist, were sung to each child during insight for future donor site dressing change. studies Music selected by the patient from a list • Intervention theory is • compiled by the researcher. clearly described Interventions used: •


Author

Table 7. Continued


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effects for anxiety and neither of the two studies with adult patients that measured pain found significant effects. Discussion

Implications for Clinical Practice Six of the 50 reviewed studies used a music therapy intervention, and all were at high risk of bias. However, details of the interventions used may be of interest to clinicians and researchers studying music therapy as procedural support. Music therapy interventions are summarized in Table 8, along with a list of methodological strengths and limitations. It is necessary to exercise caution when inferring clinical implications from the studies included in the present review because of their heterogeneous nature, mixed results, and overall high risk of bias.


The purpose of this systematic review was to summarize research on music-based interventions for children and adults undergoing medical procedures. Most of the research in this area has focused on the use of recorded music during medical procedures for adult participants. Across all intervention studies (music therapy and music medicine), the majority were at high risk of bias and had inadequate intervention reporting. Only eight studies (all music medicine interventions) had a low or moderate risk of bias. Large effect sizes (1.05 for pain and 1.47 for anxiety) found in one of these studies suggest that passive listening to recorded music, where the music is chosen by the patient, can greatly decrease pain and anxiety for pediatric patients (Nguyen et al., 2010). Pediatric patients also reported significantly less pain when passively listening to recorded music chosen by the researcher with input from a music therapist (Hartling et al., 2013), although an effect size could not be calculated from the results of this study. The small effect size for anxiety (0.47) found in the study by Andrada et al. (2004), which included adult patients, should be interpreted carefully in light of other findings. The fact that four of the studies with low or moderate risk of bias that included adult patients found no significant differences in pain or anxiety, and one study found a small effect size for anxiety favoring the control group (–0.42), points to the need for additional research on the use of recorded music with adult patients.

Quality Score and Risk of Bias

Design: Pre-posttest ML during colonoscopy Patients selected 7: Low Risk control group decreased anxiety level music from with two arms. without other anxiolytic researcher’s list. Intervention: Music methods. Music was delivered medicine. via headphones. Selections used included “Aria de la Suite en RE,” “Jesu Joy of Man’s Desiring” (Bach), “Morning Mood” (Grieg), “Pachelbel’s Canon,” “Concerto No. 21 for Piano” (Mozart), “Flower Duet” (Delibes), “Gymnopedie” (Satie), “In Paradisum” (Fauré), and “Concert for Violin” (Mendelssohn).

Musical Selections

Andrada et al. (2004)

Summary of Findings

Design and Intervention Type


Author

Summary of Findings and Musical Selections used in Studies with Low and Moderate Risk of Bias

Table 8.

STAI: 0.47

Cohen’s d



Cohen’s d

Cruise et al. (1997)

Colt, Powers, & Shanks (1999)

Design: Posttest-only ML during colonoscopy Music selected by 7: Low Risk Pain: NSD control group did not lead to shorter researcher. Music design with two procedure times, consisted of arms. Intervention: lower sedative doses “Watermark” by Music medicine. or perceived pain. Enya. ML patients reported greater satisfaction. Design: Pre-posttest ML during flexible Music selected by 7: Low Risk STAI: NSD control group fiberoptic bronchoscopy researcher. “Relax” design with two did not decrease from Expansion arms. Intervention: procedure-related Records. Music medicine. anxiety. Design: Pre-posttest ML during cataract Music selected 5.5: Moderate Risk STAI: NSD control group surgery increased both by researcher. (outcome assessors design with patient and surgeon Musical selections not blinded but four arms: satisfaction, but no included classical specific methods music, relaxing significant differences in music paired with were used to avoid suggestions, white anxiety were found. The nature sounds ascertainment bias) noise, OR noise. authors raised concerns (bioacoustics). Intervention: Music related to volume levels, medicine. electrical equipment safety standards, and musical selection.

Musical Selections

Bechtold et al. (2006)

Summary of Findings



Author

Table 8. Continued

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Nguyen et al. (2010)

Design: Pre-posttest In children with distress, Music selected by 7: Low Risk control group ambient ML during researcher with design with two IV cannulation led to input from a arms. Intervention: significantly less distress music therapist. Music medicine. and improved pain Music consisted scores. of “The Planets” Op. 32, “Jupiter”; “Storms in Africa,” “Disco Beat,” and “Sunny Days.” ML selections were chosen by a music therapist. Design: Mixed Child-chosen ML during Music selected by 6: Low Risk methods: Prelumbar puncture led to patients. posttest control lower pain scores and Traditional group design with lower heart/ Vietnamese songs two arms, and respiratory rates. and children’s interviews with songs.ML selections openwere self-selected by ended questions. patients. Intervention: Music medicine.

Musical Selections

Hartling et al. (2013)

Summary of Findings



Author

Table 8. Continued

Pain: 1.05 STAI: 1.47

Pain: ML group reported significantly less pain; Cohen’s d could not be calculated because SD not reported.

Cohen’s d



Summary of Findings

Musical Selections


Cohen’s d


Note. BPM = beats per minute; IV = intravenous; ML = music listening; NSD = no significant difference; SD = standard deviation; STAI = State Trait Anxiety Inventory.

Design: Pre-posttest Music during flexible Music selected by 5.5: Moderate Risk STAI: Results control group sigmoidoscopy was patients from a (care providers not unclear; design with two found to be an effective list compiled by adequately blinded Cohen’s d arms. Intervention: anxiolytic adjunct. researcher. Musical but withdrawals could not be Music medicine. Eightyselections included and number lost calculated eight percent of patients classical, countryto follow up were because SD felt music was helpful in western, popular, the same in each not reported. reducing their anxiety. rhythm and blues, group) Patients were able to and gospel music. control ML volume. Vanderboom (2012) Design: Pre-posttest ML via ambient speakers Music selected by 5.5: Moderate Risk STAI: –0.42 control group during cerebral patient from a (outcome assessors design with two angiography did list compiled by not blinded but arms. Intervention: not demonstrate a researcher. Patient specific methods Music medicine. significant reduction selected genres were used to avoid in stress response, from list including ascertainment bias) anxiety, or medication. classical, jazz, new However, results may age, country, pop, have been influenced rock, folk, acoustic, by differences between and meditative the groups in the timing, trance. purpose, and length of the procedure.

Palakanis et al. (1994)

Author

Table 8. Continued

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The two music therapy studies that showed significant benefits both used interactive interventions with live music for adult patients, tailored to the patient’s needs and music preferences (Ferrer, 2007; Tan, Yowler, Super, & Fratianne, 2010). The music therapy interventions implemented in the four studies in which no significant differences were found contained some, but not all, of the elements present in the interventions used by Ferrer and Tan. Although the study by Walworth (2010) also used live music chosen by the adult participants (with music matched to the tempo of the MRI), patients were not able to actively participate in the music intervention during the procedure, due to the need for the patient to be completely still while undergoing MRI. The study conducted by Whitehead-Pleaux, Baryza, and Sheridan (2006) also used live, interactive music interventions (singing and improvisation) with pediatric patients, but participants chose music from a list compiled by the researcher, limiting their ability to select the music to some degree. Browning (2001) used recorded music, selected by the patient in consultation with the music therapist, to structure deep breathing and progressive muscle relaxation. Noguchi (2006) used recorded music, selected by the researcher, to help engage pediatric patients in an interactive story. Whereas the results of the present review do not clearly indicate that one particular element of music interventions is superior when addressing pain and anxiety, music therapists designing procedural support interventions for adult patients might consider combining the use of live, interactive, individualized music interventions using music selected by the patient. There were four music medicine studies in which elements, in addition to passive music listening, were added to the music intervention. Kristjánsdóttir and Kristjánsdóttir (2011) consulted a music therapist when designing their musical distraction intervention, in which the nurse administering the procedure explained the purpose of listening to music to adolescent participants and prompted them to concentrate on the music for several minutes before they received an immunization. Laurion and Fetzer (2003) compared guided imagery, music listening, and standard care; however, the guided imagery recording included music in the background. Nilsson et al. (2001) assigned one group to listen to recorded music only, one group to listen to recorded music with therapeutic suggestions, and a third group to listen to operating

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room sounds. Rickert et al. (1994) allowed participants to watch a music video during a colposcopy procedure. Participants who engaged in musical distraction, guided imagery with background music, or music with therapeutic suggestions reported significantly less pain (Kristjánsdóttir & Kristjánsdóttir, 2011; Laurion & Fetzer, 2003; Nilsson et al., 2001), whereas participants who watched a music video showed no significant differences in anxiety (Rickert et al., 1994). Other healthcare professionals seeking to help patients manage levels of pain and anxiety during medical procedures through the use of recorded music might wonder which music is most appropriate, who should select the music, when the music should begin, whether the patient should wear headphones, and a number of other questions related to intervention design and delivery. As the results of this review show, there are many factors involved in designing music interventions for procedural support, and the answers to the questions listed above will depend on the characteristics and needs of the patient. However, upon looking at the results of the three music medicine studies with low or moderate risk of bias (Andrada et al., 2004; Hartling et al., 2013; Nguyen et al., 2010), there are some characteristics that are worth considering when designing music listening interventions. The intervention designed by Nguyen et al. (2010) for pediatric patients undergoing lumbar puncture was the only music medicine intervention in which patients could choose the music on their own (rather than selecting songs or genres from a list compiled by the researcher), and results indicated large effects for pain (1.05) and anxiety (1.47). In the study by Hartling et al. (2013), which was also conducted with pediatric patients, the music was chosen by a music therapist on the research team (although the intervention itself consisted of passive music listening implemented by another healthcare professional, making it a music medicine intervention). Hartling et al. also reported significantly less pain for the group that listened to music. Andrada et al. (2004) used classical music chosen by the researchers, and although they did not provide a rationale for selecting this specific type of music, adults in their study who listened to music reported a small effect for anxiety (0.47). Although large effect sizes were observed in the one music medicine study in which the music was of the patients’ choosing (Nguyen

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Future Research This review included studies conducted across many different countries. Therefore, definitions of music therapy may have differed based on the location of the study. There were 14 studies that referred to the music intervention as music therapy, when the intervention was not delivered by a credentialed music therapist and would more accurately have been described as music medicine. This highlights the need for clarification in future research regarding the definition of music therapy, and a need for those reading studies on music therapy to understand that the meaning of the term music therapy may vary depending on the author’s country of origin. The level of pain and anxiety experienced before, during, and after a medical procedure depends upon a number of factors, including the patient’s previous medical experiences, trait anxiety,


et al., 2010) and the two music therapy studies that showed significant differences in pain and anxiety both used music chosen by the patient, a number of other studies in this review revealed significant decreases in pain and anxiety when the music was chosen by someone other than the patient (either the researcher chose the music or the patient chose music from a list created by the researcher). This finding highlights the fact that using patient-selected music may not always be optimal, and in some situations it could be more beneficial to use music chosen based on certain musical parameters (with which the patient may be unfamiliar). A comment from a participant in the study by Browning (in which patients worked with a music therapist to select music) illustrates this point. The participant said, “If some of the pieces I had wanted on the tapes originally had gotten on, I’m not sure it would have been relaxing” (2001, p. 78). Because of the many decisions that must be made when designing music interventions for procedural support, other healthcare professionals should consider consulting credentialed music therapists at their facility or in their community, if possible, for recommendations on how to tailor music listening interventions to best meet the needs of their patients. Music therapists, who have in-depth knowledge of music perception research and clinical applications of music, can help design music interventions that are based on the best available research, as well as the needs of the patient.

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and coping skills, as well as the nature of the procedure itself. The needs of the patients during the procedure may be different during invasive procedures compared to non-invasive procedures. Whether the procedure is diagnostic, curative, palliative, routine, preventative, or elective may also impact the psychological state of the participant. For this reason, interventions intended to make medical procedures more tolerable should be designed to meet the specific needs of the patient. Moreover, there is a need to carefully select outcome measures that will appropriately capture the nature of any changes that take place with the use of music interventions. Future studies should find ways to both carefully address, and control for, these complex issues. Many studies in the present review included behavioral and/ or physiological indicators of pain and anxiety as outcome measures. Physiological outcomes that were measured included heart rate, blood pressure, respiration rate, oxygen saturation, transcutaneous oxygen pressure, mean arterial pressure, finger temperature, and heart rhythm. Some authors inferred that changes in vital signs were indicative of pain, whereas other authors interpreted physiological changes as indicative of anxiety. Still other authors made no interpretation about the meaning of changes in physiological measures. Other studies included dosage of medication administered as an outcome measure, including analgesic medications and anxiolytic medications. Several studies measured cortisol levels, which are indicative of the degree of stress an individual is experiencing. Some studies measured outcomes that were not directly related to pain or anxiety. Other outcome measures included fatigue, nausea and vomiting, bowel function, procedure duration, recovery time, length of hospitalization, wellbeing, comfort, rating of the procedure, patient and healthcare provider satisfaction, and willingness to undergo a repeat procedure with the same treatment. Future researchers may wish to measure outcomes such as these to help better understand the effects of music-based interventions on individuals undergoing medical procedures. When incorporating physiological outcome measures, researchers should carefully consider whether these measures are stable and accurate indicators of anxiety or pain, since it is possible for music to elicit changes in vital signs without necessarily being indicative of changes in anxiety or pain (Bartlett, 1996).

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Risk of bias was high in many of the included studies. Future studies should be designed to help reduce the potential for bias. There is also a need for clearer descriptions of the intervention under investigation and better reporting (see Robb, Burns, & Carpenter, 2011). Aspects of music interventions warranting future investigation include the timing and duration of music administration, the ideal mode of delivery for recorded music (headphones or speakers), and whether patient-selected music is comparable to patient-selected music from a researcher-compiled list. The question of whether live or recorded music is more beneficial is often confused with the comparison of active versus passive music. Many studies have added music as a complement to standard care; however, future research on the use of music as an alternative to the use of sedation is warranted. Several of the reviewed studies compared aspects of music interventions by assigning participants to one of two or more treatment conditions. In a study by Kristjánsdóttir and Kristjánsdóttir (2011), one group listened to music via headphones while a second group listened to music delivered by speakers. Both groups were compared to a standard-care control group. Listening to music via speakers was the only factor predictive of decreased pain. Two studies (Nisson, Rawal, & Unosson, 2003; Nilsson, Unosson, M., & Rawal, 2005) compared music delivered intraoperatively with music delivered postoperatively. In one study (Nilsson et al., 2003), both groups reported significantly less pain compared to a standard-care control group but only the group that listened to music postoperatively required significantly less morphine. In the second study (Nilsson et al., 2005), only the group that listened to music postoperatively showed significantly greater decreases in cortisol, morphine requirement, pain, and anxiety compared to the standard-care control group. Walworth (2010) compared live, patient-selected music delivered during MRI to standard care, which consisted of recorded music selected by the staff. Although there was no significant difference between groups after a Bonferroni correction, there was a trend in decreased anxiety favoring the group that received live music therapy. All of the above studies were high in risk of bias, so results should be interpreted with caution. More research is needed to compare individual aspects of music interventions as procedural support.

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Leardi et al. (2007) allowed one group to select music from a list compiled by the researchers, while a second group listened to music selected by the researchers. Compared to a standard-care control group, participants who selected their own music showed significantly decreased cortisol, while participants who listened to researcher-selected music had significantly lowered natural killer

Summary of Recommendations for Future Research Consideration

Design

Randomization Treatment allocation concealment Intervention reporting

Blinding care providers

Blinding outcome assessors

Intention-to-treat principle

Reporting results

Recommendation for Future Research

Compare specific music therapy and music medicine interventions with alternate treatments, in addition to a standard care group. For instance, recorded music via headphones vs. speakers; music chosen by researcher vs. music chosen by patient; active vs. passive music interventions. Specify method of randomization. Blind participants and researchers to treatment allocation until after consent is given. Follow CONSORT intervention reporting guidelines (see Robb, Burns, & Carpenter, 2011). Be specific regarding the timing and duration of music. If it is not feasible to blind care providers (as in many music therapy studies), ensure that treatments (other than the independent variable) provided to both groups are equivalent and that the number lost to follow-up within each group is similar. Blind outcome assessors by having individuals other than the care providers perform outcome measurement. If it is not possible to blind outcome assessors to group assignment, use multiple outcome measures, including both objective and subjective measures. Specify whether all participants who were randomized were included in analysis. If this was not possible due to withdrawals, use an imputation or similar method to adhere to intention to treat principle. Report means and standard deviations for outcome measures, allowing for effect size calculations to be made.


Table 9.

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Limitations and Conclusion The present review is not without limitations. Although the authors made every effort to include all eligible studies, it is possible that the search terms used led to incomplete retrieval of existing research. By hand-searching music therapy journals, the authors hoped to be as inclusive as possible with regard to music therapy studies; however, because authors publish across a wide range of healthcare journals, the list of included studies may be incomplete. The exclusion of unpublished studies and studies written in other languages is another limitation; however, given the breadth of the topic, the authors felt it appropriate to include only those studies published in English. Perhaps future reviews that focus on specific areas of procedural support (for instance, music medicine interventions for adults) could be more inclusive in order to address factors such as publication bias, and would have a degree of homogeneity that would make it possible to conduct a meta-analysis. In summary, we recommend that future research on music for procedural support address (1) age-related factors; (2) differences in music therapy and music medicine interventions; (3) factors that


cells. Future research should further investigate the relative benefits of having the researcher select the music, allowing the patient to choose the music completely on their own, or some option in which both the researcher and the patient provide input, such as having the patient select music in conjunction with a music therapist or allowing the patient to choose music from a list created by the researcher. The study of music-based interventions for procedural support is multifaceted and complex in nature. In the past, music-based intervention studies have been criticized for the absence of a theoretical framework guiding the intervention content (Burns, 2012), and the need to articulate a theoretical framework in research on procedural support music therapy has been noted (Ghetti, 2012). The current investigation did not include an analysis of theoretical frameworks; however, future research may wish to include this information in order to better articulate how and why music is selected and applied, and to promote greater understanding of the mechanisms of change at work during different procedures. Future studies should carefully consider theory as part of the investigation.

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Funding The authors received no funding for this work. References (References included in the systematic review are marked with an asterisk.) Akobeng, A. K. (2005). Understanding systematic reviews and meta-analysis. Archives of Disease in Childhood, 90, 845–848. doi:10.1136/adc.2004.058230 American Music Therapy Association (2014). What is music therapy? Retrieved from http://www.musictherapy.org/about/musictherapy/ *Andrada, J. M. L. C., Vidal, A. A., Aguilar-Tablada, T. C., Reina, I. G., Silva, L., Guinaldo, A. R.,…Roldán, A. B. (2004). Anxiety during the performance of colonoscopies: Modification using music therapy. European Journal of Gastroenterology & Hepatology, 161, 1381–1386. *Arts, S. E., Abu-Saad, H. H., Champion, G. D., Crawford, M. R., Fisher, R. J., Juniper, K. H., & Ziegler, J. B. (1994). Age-related response to lidocaine-prilocaine (EMLA) emulsion and effect of music distraction on the pain of intravenous cannulation. Pediatrics, 93, 797–801. *Balan, R., Bavdekar, S. B., & Jadhav, S. (2009). Can Indian classical instrumental music reduce pain felt during venepuncture? Indian Journal of Pediatrics, 76, 469–473. *Bally, K., Campbell, D., Chesnick, K., & Tranmer, J. E. (2003). Effects of patientcontrolled music therapy during coronary angiography on procedural pain and anxiety distress syndrome. Critical Care Nurse, 23, 50--57. *Bampton, P., & Draper, B. (1997). Effect of relaxation music on patient tolerance of gastrointestinal endoscopic procedures. Journal of Clinical Gastroenterology, 25, 343–345. Bartlett, D. L. (1996). Physiological responses to music and sound stimuli. In D. A. Hodges (Ed.), Handbook of music psychology, 2nd ed. (pp. 343–385). San Antonio, TX: IMR Press. *Bechtold, M. L., Perez, R. A., Puli, S. R., & Marshall, J. B. (2006). Effect of music on patients undergoing outpatient colonoscopy. World Journal of Gastroenterology, 12, 7309–7312. Bechtold, M. L., Puli, S. R., Othman, M. O., Bartalos, C. R., Marshall, J. B., & Roy, P. K. (2009). Effect of music on patients undergoing colonoscopy:


influence pain/anxiety; (4) improved intervention reporting; (5) music compared to standard care or other treatment conditions; and (6) reduced risk of bias. Specific recommendations for designing high-quality studies on music-based interventions for procedural support are provided in Table 9. More research is needed to determine best practices for the use of music interventions to alleviate pain and anxiety during medical procedures, particularly the use of music therapy interventions as procedural support.

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A meta-analysis of randomized controlled trials. Digestive Diseases and Sciences, 54, 19–24. doi:10.1007/s10620-008-0312-0 Becker, E. L., & Landau, S. I. (1986). International dictionary of medicine and biology. Ann Arbor, MI: Wiley Medical Publishers. Bernatzky, G., Presch, M., Anderson, M., & Panksepp, J. (2011). Emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neuroscience and Biobehavioral Reviews, 35, 1989–1999. doi:10.1016/j. neubiorev.2011.06.005 Boutron, I., Moher, D., Tugwell, P., Giraudeau, B., Poiraudeau, S., Nizard, R., & Ravaud, P. (2005). A checklist to evaluate a report of a nonpharmacological trial (CLEAR NPT) was developed using consensus. Journal of Clinical Epidemiology, 58, 1233–1240. Bradt, J., Dileo, C., Grocke, D., & Magill, L. (2011). Music interventions for improving psychological and physical outcomes in cancer patients. Cochrane Database of Systematic Reviews, 2011, Issue 8. Art NO.: CD006911. doi:10/10112/14651858. CD006911.pub2 Bradt, J., Dileo, C., & Shim, M. (2013). Music interventions for preoperative anxiety. Cochrane Database of Systematic Reviews, 2013, Issue 6. Art NO.: CD006808. doi:10.1002/14651858.CD006908.pub2 *Broscious, S. K. (1999). Music: An intervention for pain during chest tube removal after open heart surgery. American Journal of Critical Care, 8, 410–415. *Browning, C. A. (2001). Music therapy in childbirth: Research in practice. Music Therapy Perspectives, 19, 74–81. Burns, D. (2012). Theoretical rationale for music selection in oncology intervention research: An integrative review. Journal of Music Therapy, 49, 7–22. *Cepeda, M. S., Diaz, J. E., Hernandez, V., Daza, E., & Carr, D. B. (1998). Music does not reduce alfentanil requirement during patient-controlled analgesia (PCA) use in extracorporeal shock wave lithotripsy for renal stones. Journal of Pain and Symptom Management, 16, 382–387. *Chang, S. C., & Chen, C. H. (2005). Effects of music therapy on women’s physiologic measures, anxiety, and satisfaction during Cesarean delivery. Research in Nursing & Health, 28, 453–461. *Chlan, L., Evans, D., Greenleaf, M., & Walker, J. (2000). Effects of a single music therapy intervention on anxiety, discomfort, satisfaction, and compliance with screening guidelines in outpatients undergoing flexible sigmoidoscopy. Gastroenterology Nursing, 23, 148–156. Cohen, J. (1988). Statistical power analysis for the behavioral sciences, 2nd ed.. Hillsdale, NJ: Lawrence Erlbaum Associates. *Colt, H. G., Powers, A., & Shanks, T. G. (1999). Effect of music on state anxiety scores in patients undergoing fiberoptic bronchoscopy. Chest, 116, 819–824. *Cruise, C. J., Chung, F., Yongendran, S., & Little, D. (1997). Music increases satisfaction in elderly outpatients undergoing cataract surgery. Canadian Journal of Anaesthesiology, 44, 43–48. *Danhauer, S. C., Vishnesky, T., Campbell, C. R., McCoy, T. P., Tooze, J. A., Kanie, K. N.,…Cruz, J. (2010). Music for patients with hematological malignancies undergoing bone marrow biopsy: A randomized controlled study of anxiety, perceived pain, and patient satisfaction. Journal of the Society for Integrative Oncology, 8, 140–147.

Vol. 52, No. 1

75


Evans, D. (2002). The effectiveness of music as an intervention for hospital patients: A systematic review. Journal of Advanced Nursing, 37, 8–18. *Ferrer, A. J. (2007). The effect of live music on decreasing anxiety in patients undergoing chemotherapy treatment. Journal of Music Therapy, 44, 242–255. Garg, A. X., Hackman, D., & Tonelli, M. (2008). Systematic review and meta-analysis: When one study is just not enough. Clinical Journal of the American Society of Nephrology, 3, 253–260. doi:10.2215/CJN.01430307 Ghetti, C. M. (2012). Music therapy as procedural support for invasive medical procedures: Toward the development of music therapy theory. Nordic Journal of Music Therapy, 21, 3–35. doi:10.1080/08098131.2011.571278 Good, H. B. (2011). Is a musical intervention effective in the reduction of needle relate procedural pain in children? PCOM Physician Assistant Studies Student Scholarship. Paper 35. Hanson-Abromeit, D., & Sena Moore, K. (2011). The systematic review as a research process in music therapy. Journal of Music Therapy, 51, 4–38. doi:10.1093/jmt/ thu002 *Harikumar, R., Raj, M., Paul, A., Harish, K., Kumar, S. K., Sandesh, K.,…Varghese, T. (2006). Listening to music decreases need for sedative medication during colonoscopy: A randomized, controlled trial. Indian Journal of Gastroenterology, 25, 3–5. *Hartling, L., Newton, A. S., Liang, Y., Jou, H., Hewson, K., Klassen, T. P., & Curtis, S. (2013). Music to reduce pain and distress in the pediatric emergency department: A randomized clinical trial. JAMA Pediatrics, 167, 826–835. doi:10.1001/ jamapediatrics.2013.200 *Johnson, B., Raymond, S., & Goss, J. (2012). Perioperative music or headsets to decrease anxiety. Journal of PeriAnesthesia Nursing, 27, 146–154. doi:10.1016/j. jopan.2012.03.001. *Kim, Y., Kim, S., & Myoung, H. (2011). Musical intervention reduces patients’ anxiety in surgical extraction of an impacted mandibular third molar. Journal of Oral and Maxillofacial Surgery, 69, 1036–1045. Klassen, J. A., Liang, Y., Tjosvold, L., Klassen, T. P., & Hartling, L. (2008). Music for pain and anxiety in children undergoing medical procedures: A systematic review of randomized controlled trials. Ambulatory Pediatrics, 8, 117–128. *Kristjánsdóttir, O., & Kristjánsdóttir, G. (2011). Randomized clinical trial of musical distraction with and without headphones for adolescents’ immunization pain. Scandinavian Journal of Caring Sciences, 25, 19–26. doi:10.1111/j.1471-6712.2010.00784.x *Kwekkeboom, K. L. (2003). Music versus distraction for procedural pain and anxiety in patients with cancer. Oncology Nursing Forum, 30, 433–440. doi:10.1188/03. ONF.433–440 *Laurion, S., & Fetzer, S. J. (2003). The effect of two nursing interventions on the postoperative outcomes of gynecologic laparoscopic patients. Journal of PeriAnesthesia Nursing, 18, 254–261. doi:10.1016/S1089-9472(03)00131-X *Leardi, S., Pietroletti, R., Angeloni, G., Necozione, S., Ranalletta, G., & Del Gusto, B. (2007). Randomized clinical trial examining the effect of music therapy in stress response to day surgery. British Journal of Surgery, 94, 943–947. doi:10.1002/bjs.5914

76



*Lee, D. W. H., Chan, K., Poon, C., Ko, C., Chan, K., Sin, K.,…Chan, A. C. W. (2002). Relaxation music decreases the dose of patient-controlled sedation during colonoscopy: A prospective randomized controlled trial. Gastrointestinal Endoscopy, 55I, 33–36. doi:10.1067/mge.2002.120387 *Lepage, C., Drolet, P., Girard, M., Grenier, Y., & DeGagné, R. (2001). Music decreases sedative requirements during spinal anesthesia. Anesthesia & Analgesia, 93, 912–916. *Liu, Y., Chang, M., & Chen, C. (2010). Effects of music therapy on labour pain and anxiety in Taiwanese first-time mothers. Journal of Clinical Nursing, 19, 1065– 1072. doi:10.1111/j.1365-2702.2009.03028.x *Megel, M. E., House, C., W., & Gleaves, L. S. (1998). Children’s responses to immunizations: Lullabies as a distraction. Issues in Comprehensive Pediatric Nursing, 21, 129–145. Merriam-Webster (2014). Pain. Retrieved from http://www.merriam-webster.com/ medical/pain National Cancer Institute (2013). Dictionary of cancer terms. Retrieved from http://www.cancer.gov/dictionary *Nguyen, T. N., Nilsson, S., Hellström, & Bengston, A. (2010). Music therapy to reduce pain and anxiety in children with cancer undergoing lumbar puncture: A randomized controlled trial. Journal of Pediatric Oncology Nursing, 27, 146–155. doi:10.1177/1043454209355983 *Nilsson, U., Lindell, L., Eriksson, A., & Kellerth, T. (2009). The effect of music intervention in relation to gender during coronary angiographic procedures: A randomized controlled trial. European Journal of Cardiovascular Nursing, 8, 200–206. doi:10.1016/j.ejcnurse.2009.01.001 *Nilsson, U., Rawal, N., Uneståhl, L. E., Zetterberg, C., & Unosson, M. (2001). Improved recovery after music and therapeutic suggestions during general anaesthesia: A double-blind randomised controlled trial. Acta Anaesthesiologica Scandinavica, 45, 812–817. *Nilsson, U., Rawal, N., & Unosson, M. (2003). A comparison of intra-operative or postoperative exposure to music: A controlled trial of the effects on postoperative pain. Anesthesia, 58, 699–703. *Nilsson, U., Unosson, M., & Rawal, N. (2005). Stress reduction and analgesia in patients exposed to calming music postoperatively: A randomized controlled trial. European Journal of Anaesthesiology, 22, 96–102. *Noguchi, L. K. (2006). The effect of music versus nonmusic on behavioral signs of distress and self-report of pain in pediatric injection patients. Journal of Music Therapy, 43, 16–38. *Ovayolu, N., Ucan, O., Pehlivan, S., Pehlivan, Y., Buyukhatipoglu, H., Savas, M. C., & Gulsen, M. T. (2006). Listening to Turkish classical music decreases patients’ anxiety, pain, dissatisfaction, and the dose of sedative and analgesic drugs during colonoscopy: A prospective randomized controlled trial. World Journal of Gastroenterology, 12, 7532–7536. *Palakanis, K. C., DeNobile, J. W., Sweeney, W. B., & Blankenship, C. L. (1994). Effect of music therapy on state anxiety in patients undergoing flexible sigmoidoscopy. Disease of the Colon & Rectum, 37, 478–481.

Vol. 52, No. 1

77


*Rickert, V. I., Kozlowski, K. J., Warren, A. M., Hendon, A., & Davis, P. (1994). Adolescents and colposcopy: The use of different procedures to reduce anxiety. American Journal of Obstetrics & Gynecology, 2, 504–508. Robb, S. L., Burns, D. S., & Carpenter, J. S. (2011). Reporting guidelines for music-based interventions. Music and Medicine, 3, 271–279. doi: 10.1177/1943862111420539 *Schneider, N., Schedlowski, M., Schürmeyer, T. H., & Becker, H. (2001). Stress reduction through music in patients undergoing cerebral angiography. Neuroradiology, 43, 472–476. *Shabanloei, R., Golchin, M., Esfahani, A., Dolatkhah, R., & Rasoulian, M. (2010). Effects of music therapy on pain and anxiety in patients undergoing bone marrow biopsy and aspiration. AORN Journal, 91, 746–751. doi:10.1016/j.aorn.2010.04.001 *Smith, M., Casey, L., Johnson, D., Gwede, C., & Riggin, O. Z. (2001). Music as a therapeutic intervention for anxiety in patients receiving radiation therapy. Oncology Nursing Forum, 28, 855–862. *Smolen, D., Topp, R., & Singer, L. (2002). The effect of self-selected music during colonoscopy on anxiety, heart rate, and blood pressure. Applied Nursing Research, 16, 126–136. doi:10.1053/apnr.2002.34140 *Taghinejad, H., Delpisheh, A., & Suhrabi, Z. (2010). Comparison between massage and music therapies to relieve the severity of labor pain. Women’s Health, 6, 377–381. doi:10.2217/WHE.10.15 *Tan, X., Yowler, C. J., Super, D. M., & Fratianne, R. B. (2010). The efficacy of music therapy protocols for decreasing pain, anxiety, and muscle tension levels during burn dressing changes: A prospective randomized crossover trial. Journal of Burn Care & Research, 31, 590–597. doi:10.1097/BCR.0b013e3181e4d71b *Tsivian, M., Qi, P., Kimura, M., Chen, V. H., Chen, S. H., Gan, T. J., & Polascik, T. J. (2012). The effect of noise-cancelling headphones or music on pain perception and anxiety in men undergoing transrectal prostate biopsy. Urology, 79, 32–36. doi:10.1016/j.urology.2011.09.037 *Twiss, E., Seaver, J., & McCaffrey, R. (2006). The effect of music listening on older adults undergoing cardiovascular surgery. Nursing in Critical Care, 11, 224–231. *Uedo, N., Ishikawa, H., Morimoto, K., Ishihara, R., Narahara, H., Akedo, I.,… Fukuda, S. (2004). Reduction in salivary cortisol level by music therapy during colonoscopic examination. Hepato-Gastroenterology, 51, 451–453. *Vanderboom, T. L., Arcari, P. M., Duffy, M. E., Somarouthu, B., Rabinov, J. D., Yoo, A. J., & Hirsch, J. A. (2012). Effects of a music intervention on patients undergoing cerebral angiography: A pilot study. Journal of NeuroInterventional Surgery, 4, 229–233. doi:10.1136/neurintsurg-2011–010052 *Walworth, D. D. (2010). Effect of live music therapy for patients undergoing magnetic resonance imaging. Journal of Music Therapy, 47, 335–350. *Whitehead-Pleaux, A. M., Baryza, M. J., & Sheridan, R. L. (2006). The effects of music therapy on pediatric patients’ pain and anxiety during donor site dressing change. Journal of Music Therapy, 43, 136–153. *Yilmaz, E., Ozcan, S., Basar, M., Basar, H., Batislam, E., & Ferhat, M. (2003). Music decreases anxiety and provides sedation in extracorporeal shock wave lithotripsy. Urology, 61, 272–286. *Zengin, S., Kabul, S., Al, B., Sarcan, E., Doǧan, M., & Yildirim, C. (2013). Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complementary Therapies in Medicine, 21, 689–696.

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Systematic review of clinical decision support interventions with potential for inpatient cost reduction.

Procedural and Physical Interventions for Vaccine Injections: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials.

Behavioral and Educational Interventions to Support Family Caregivers in End-of-Life Care: A Systematic Review.

A systematic review of telehealth tools and interventions to support family caregivers.

A systematic review of perinatal depression interventions for adolescent mothers.

Qualitative studies of psychosocial interventions for dementia: a systematic review.

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Treatment Interventions for Early Childhood Obesity: A Systematic Review.

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Online interventions for depression and anxiety - a systematic review.

Health behaviour change interventions for couples: A systematic review.

Psychosocial interventions for adults with visible differences: a systematic review.

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