Music therapy for end-of-life care, J Bradt, C Dileo

Tags: Cochrane Collaboration, end-of-life care, John Wiley & Sons, Music therapy, review, Hilliard, palliative care, studies, Florida State University, hospice patients, social support, The Cochrane Collaboration, Cochrane Library, psychological outcomes, Florida, included studies, Cochrane review, conference information, music therapists, music therapist, massage therapy, Creative Arts Therapies, Cochrane Pain, relevant studies, respiratory rate, Cochrane Central Register of Controlled Trials, pediatric patients, Journal of Music Therapy, inclusion criteria, Supportive Care, outcome measures, future studies, Cochrane Cancer Network
Content: Music therapy for end-of-life care (Review) Bradt J, Dileo C This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2010, Issue 11 http://www.thecochranelibrary.com Music therapy for end-of-life care (Review) Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
AUTHORS' CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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WHAT'S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
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INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22
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[Intervention Review] Music therapy for end-of-life care Joke Bradt1, Cheryl Dileo2 1Creative Arts Therapies, Drexel University, Philadelphia, PA, USA. 2Department of Music Therapy and The Arts and Quality of Life Research Center, Boyer College of Music and Dance, Temple University, Philadelphia, USA Contact address: Joke Bradt, Creative Arts Therapies, Drexel University, 1505 Race Street, rm 1041, Philadelphia, PA, 19102, USA. [email protected] Editorial group: Cochrane Pain, Palliative and Supportive Care Group. Publication status and date: Edited (no change to conclusions), published in Issue 11, 2010. Review content assessed as up-to-date: 1 October 2009. Citation: Bradt J, Dileo C. Music therapy for end-of-life care. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007169. DOI: 10.1002/14651858.CD007169.pub2. Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
Music therapy in end-of-life care aims to improve a person's quality of life by helping relieve symptoms, addressing psychological needs, offering support, facilitating communication, and meeting spiritual needs. In addition, music therapists assist family and caregivers with coping, communication, and grief/bereavement.
Objectives
To examine effects of music therapy with standard care versus standard care alone or standard care combined with other therapies on psychological, physiological, and social responses in end-of-life care.
Search strategy
We searched CENTRAL, MEDLINE, CINAHL, EMBASE, PSYCINFO, LILACS, CancerLit, Science Citation Index, www.musictherapyworld.de, CAIRSS for Music, Proquest Digital Dissertations, ClinicalTrials.gov, Current Controlled Trials, and the National Research Register to September 2009. We handsearched music therapy journals and reference lists, and contacted experts to identify unpublished manuscripts. There was no language restriction.
Selection criteria
We included all randomized and quasi-randomized controlled trials that compared music interventions and standard care with standard care alone or combined with other therapies in any care setting with a diagnosis of advanced life-limiting illness being treated with palliative intent and with a life expectancy of less than two years.
data collection and analysis
Data were extracted, and methodological quality was assessed, independently by review authors. Additional information was sought from study authors when necessary. Results are presented using weighted mean differences for outcomes measured by the same scale and standardized mean differences for outcomes measured by different scales. Posttest scores were used. In cases of statistically significant baseline difference, we used change scores.
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Main results Five studies (175 participants) were included. There is insufficient evidence of high quality to support the effect of music therapy on quality of life of people in end-of-life care. Given the limited number of studies and small sample sizes, more research is needed. No strong evidence was found for the effect of music therapy on pain or anxiety.These results were based on two small studies. There were insufficient data to examine the effect of music therapy on other physical, psychological, or social outcomes. Authors' conclusions A limited number of studies suggest there may be a benefit of music therapy on the quality of life of people in end-of-life care. However, the results stem from studies with a high risk of bias. More research is needed. PLAIN LANGUAGE SUMMARY Music therapy for end-of-life care Music therapy is increasingly used in end-of-life care, with a growing number of music therapists being employed in hospices and hospital-based palliative care programs each year. Music therapy in end-of-life care aims to improve a person's quality of life by helping relieve symptoms, addressing psychological needs, offering support and comfort, facilitating communication, and meeting spiritual needs. In addition, music therapists assist family and caregivers with coping, communication, and grief/bereavement. Music therapy requires the implementation of a music intervention by a trained music therapist, the presence of a therapeutic process, and the use of personally tailored music experiences. These music experiences may include listening to live, therapist-composed, improvised, or prerecorded music, performing music on an instrument, improvising music spontaneously using voice or instruments, composing music, and music combined with other modalities (e.g. movement, imagery, art). Results indicate that music therapy may have a beneficial effect on the quality of life of people in end-of-life care. However, the results stem from a limited number of studies and the quality of the evidence is not strong. More research is needed. No evidence of effect was found for pain or anxiety. This may be due to the fact that only two studies with very small samples examined the effects of music therapy on these outcomes. There were insufficient data to examine the effect of music therapy on other physical, psychological, or social outcomes. More research is needed.
BACKGROUND Music therapy is increasingly used in end-of-life care, with a growing number of music therapists being employed in hospices and hospital-based palliative care programs each year (Hilliard 2005). Data from a survey study of 300 randomly selected hospices in the U.S. indicated that the most popular forms of complementary therapies were massage therapy and music therapy (Demmer 2004). This is also true for use of complementary therapies in Canadian hospices, according to a recently completed survey (Oneschuk 2007). Music therapists in end-of-life care work with a broad range of populations with many types of illnesses including cancer (Hanser 2005; Hilliard 2003; Magill 2001), HIV/AIDS (Lee 1996; Neugebauer 1999), congestive heart failure (Dileo 2005c), dementia (Patrick 2005) and neurodegenerative disorders (Magee 2004; Scheiby 2005). The primary aim of music therapy in this context is to improve a person's quality of life by helping relieve symptoms, addressing psychological needs, offering support and comfort, facilitating communication, and meeting spir-
itual needs. In addition, music therapists assist family and caregivers with coping, communication, and grief/bereavement (Dileo 2005b). Research on the effects of music and music therapy in healthcare has grown rapidly during the past 20 years and has included a variety of outcome measures in a wide range of specialty areas including medical care, geriatric care, and rehabilitation (Dileo 2005a). It is important, however, to make a clear distinction between music interventions administered by medical or healthcare professionals (music medicine) and those implemented by trained music therapists (music therapy). A substantive set of data (Dileo 2005a) indicates that music therapy interventions are more effective than music medicine interventions for improving physiological as well psychological outcomes in medical patients. This difference might be attributed to the fact that music therapists individualize their interventions to meet patients' specific needs, more actively engage the patients in the music making, make use of the therapeutic
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relationship established with the patient to meet clinical goals and employ a systematic therapeutic process that includes assessment, treatment, and evaluation. As defined by Dileo 1999, interventions are categorized as 'music medicine' when passive listening to pre-recorded music is offered by medical personnel. In contrast, music therapy requires the implementation of a music intervention by a trained music therapist, the presence of a therapeutic process, and the use of personally tailored music experiences. These music experiences include:
conducted with cancer, terminally ill and AIDS patients (Dileo 2005a). However, this meta-analysis did not examine terminally ill patients as a separate group. In addition, differences in factors such as study designs, methods of interventions, and intensity of treatment have led to varying results. A systematic review is needed to more accurately gauge the efficacy of music therapy in endof-life care as well as to identify variables that may moderate its effects.
1. listening to live, therapist-composed, improvised, or prerecorded music;
OBJECTIVES
2. performing music on an instrument; 3. improvising music spontaneously using voice or instruments, or both; 4. composing music; and 5. music combined with other modalities (e.g., movement, imagery, art) (Dileo 2007). In end-of-life care, receptive approaches, i.e. listening to live or pre-recorded music, are common due to the physical limitations of many patients. An example of a receptive intervention aimed at providing psychoSocial Support is song choice in which the patient selects a song according to specific criteria, e.g., how he or she is feeling (Dileo 2005b). For terminally ill patients, verbally expressing their emotions may be too difficult or threatening. In advanced stages of cancer, for example, speech impairments due to brain damage may prevent patients from verbally expressing their emotions, thoughts, and needs. Other patients may be hesitant to openly express their emotions because of the intensity of the feelings or the need to protect their loved ones. These patients may benefit from song choice as it gives them an "alternative, creative, and non-threatening medium through which to experience and express their emotions" (Hogan 1999). If the patient is able to engage in music making, active music therapy methods such as songwriting, instrumental improvisation and vocal improvisations are used to improve sense of empowerment, enhance self-esteem, facilitate expression of ideas and emotions, increase socialization, facilitate creativity, and find meaning and hope (O'Callaghan 1997). Music listening, as well as active music making, is also used to help manage physical symptoms such as labored breathing, pain, agitation, and insomnia. Finally, music therapists play an important role in addressing the spiritual needs of patients as music can offer the "creative, lyrical, and symbolic means to address existential and spiritual needs during the process of dying" (Magill 2002, p. 996). Several research studies on the use of music in end-of-life care have reported positive results. For example, positive effects of music on pain, nausea/vomiting, anxiety, depression, mood and sense of well-being were reported in a meta-analysis combining studies
1. To investigate the effectiveness of music therapy in end-oflife care. 2. To compare the effects of music therapy combined with standard care with: i) standard care alone, or ii) standard care and other therapies. 3. To compare the effects of different types of music therapy interventions (e.g. music listening, songwriting, improvisation). METHODS Criteria for considering studies for this review Types of studies We included all randomized controlled trials (RCTs), published or unpublished, in any language. Due to the limited number of studies that used proper methods of randomization, we also included studies with quasi-randomized or systematic methods of treatment allocation (for example, alternate allocation of treatments). Types of participants This review included participants in specialist palliative care or hospice settings (inpatient or community) or participants in any care setting with a diagnosis of advanced life-limiting illness being treated with palliative intent and with a life expectancy of less than two years (Hancock 2007). There were no restrictions as to age, gender, or ethnicity.
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Types of interventions This review included all studies in which standard care combined with music therapy was compared with: 1. standard care alone, or 2. standard care combined with other therapies. In addition, studies were considered only if: 1. music therapy was delivered by a formally trained music therapist or by trainees in a formal music therapy program; 2. a therapeutic process was present, and 3. one of the following personally tailored music therapy interventions was used in an individual or group setting: i) listening to live, therapist-composed, patientcomposed, therapist and patient-composed, improvised, or prerecorded music; ii) performing music on an instrument; and iii) improvising music spontaneously using voice or instruments, or both.
4. CINAHL (1982 to September 2009); 5. PsycINFO (1967 to September 2009); 6. LILACS ( 1982 to September 2009); 7. CancerLit (1983 to September 2009); 8. CAIRSS for Music (retrieved on September 23 2009); 9. Proquest Digital Dissertations (1861 to September 2009); 10. ClinicalTrials.gov (www.clinicaltrials.gov) (retrieved on September 23 2009); 11. Current Controlled Trials (www.controlled-trials.com) (retrieved on September 23 2009); 12. National Research Register (www.update-software.com/ National) (retrieved on September 23 2009); 13. www.musictherapyworld.de (retrieved on May 8 2009). Please see the Appendices (Appendix 1; Appendix 2; Appendix 3; Appendix 4; Appendix 5; Appendix 6; Appendix 7; Appendix 8; Appendix 9; Appendix 10; Appendix 11; Appendix 12; Appendix 13) for the search strategies that were employed for each database.
Types of outcome measures The following outcome measures were included in this review: 1. symptom relief (e.g. of nausea, fatigue, pain); 2. psychological outcomes (anxiety, depression, fear); 3. physiological outcomes (e.g. respiratory rate, heart rate, IgA levels); 4. relationship and social support (e.g. family support, isolation); 5. communication (e.g. verbalization, facial affect, gestures); 6. quality of life; 7. spirituality; and 8. participant satisfaction. In addition, this review considered the following outcome measures for family members and caregivers: 1. psychological outcomes (e.g. depression, distress, coping, grief ); 2. relationship and social support; 3. communication with participant; 4. quality of life. Search methods for identification of studies Electronic searches We searched the Cochrane Cancer Network Register and the Cochrane Pain, Palliative & Supportive Care Register. In addition, we searched the following electronic databases and trials registers: 1. Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2009, issue 3); 2. MEDLINE (1950 to September 2009); 3. EMBASE (1980 to October 2009);
Searching other resources Handsearching We handsearched the following journals from their first available date: 1. Australian Journal of Music Therapy 2. Australian Music Therapy Association Bulletin 3. Canadian Journal of Music Therapy 4. The International Journal of the Arts in Medicine 5. Journal of Music Therapy 6. Musik-,Tanz-, und Kunsttherapie (Journal for Art Therapies in Education, Welfare and health care) 7. Musiktherapeutische Umschau 8. Music Therapy 9. Music Therapy Perspectives 10. Nordic Journal of Music Therapy 11. Music Therapy Today (online journal of music therapy) 12. Voices (online international journal of music therapy) 13. New Zealand Journal of Music Therapy 14. The Arts in Psychotherapy 15. British Journal of Music Therapy 16. Journal of Society for Integrative Oncology 17. Evidence Based complementary and alternative medicine 18. Japanese Journal of Music Therapy In an effort to identify further published, unpublished and ongoing trials, we searched the bibliographies of relevant studies and reviews, contacted experts in the field, and searched available proceedings of music therapy conferences. Music therapy association websites were consulted to help identify music therapy practitioners and conference information (e.g., American Music Therapy Association (www.musictherapy.org), The British Society for Music Therapy (www.bsmt.org), The Association of Professional Mu-
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sic Therapists (APMT) (www.apmt.org), Music Therapy World ( http://musictherapyworld.de)) . Data collection and analysis
could not be rejected with certainty, the full article was retrieved and the two review authors independently inspected the article. Both review authors used an inclusion criteria form to assess the study's eligibility for inclusion. If a study was excluded, we kept a record of both the article and the reason for its exclusion.
Selection of studies One review author (JB) conducted the electronic searches. One review author (JB) and a research assistant scanned the titles and abstracts of each record retrieved from the search. If information in the abstract clearly indicated that the study did not meet the inclusion criteria, we rejected the study. When a title or abstract
Data extraction and management Both review authors independently extracted data from the selected studies using a standard coding form. We discussed any differences in the data extraction. The data that was extracted from the included studies is outlined in Additional Table 1. Where data was unavailable from the studies identified, we contacted the study author for clarification.
Table 1. Data extraction information from included studies
General info
Study info
Intervention info Participant info Outcome info
Stats outcome info
· Author
· Study design
· Year of
(parallel group,
publication
cross-over)
· Title
· Journal (title, · Randomization:
volume, pages)
yes/no
· If
unpublished, source· Randomization
· Duplicate
method
publications
· Allocation
· Country
concealment: yes/
· Language of no
publication
· Allocation
concealment
method
· Level of
blinding
· Type of intervention (e.g. singing, songwriting, music listening, music improvisation) · Music selection (detailed information on music selection in case of music listening) · Music preference (patientpreferred versus researcher-selected in case of music listening) · Length of intervention · Frequency of intervention · Comparison intervention
· Total sample size · Number of experimental group · Number of control group · Gender · Age · Ethnicity · Diagnosis · Illness stage · Setting · Study-specific inclusion criteria
Statistical informa- Statistical informa-
tion for the follow- tion on the follow-
ing outcomes (if ap- ing
outcome
plicable):
measures for family
1. symptom
members and care-
relief (e.g. nausea, givers (if applicable)
fatigue, pain)
:
2. psychological 1. psychological
outcomes (anxiety, outcomes (e.g.
depression, fear) depression, distress,
3. physiological coping, grief )
outcomes (e.g.
2. Relationship
respiratory rate, and social support
heart rate, IgA
levels)
3. communication
4. relationship with patient
and social support 4. quality of life
(e.g. family
support, isolation)
5. communication (e.g. verbalization, facial affect, gestures) 6. quality of life 7. spirituality and 8. patient satisfaction
Assessment of risk of bias in included studies
Both review authors, blinded to each other's assessment, assessed all included studies for quality, using the following criteria.
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1. Method of randomization: · was the study reported as randomized? Yes or no; · was the method of randomization appropriate? Yes, no, or unclear. We rated randomization as appropriate if every participant had an equal chance to be selected for either intervention. We regarded the use of date of birth, date of admission, or alternation as inappropriate. 2. We used allocation concealment ratings of: A (adequate), B (unclear), and C (inadequate) in accordance with section 6.3 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2006). A: adequate, where methods to conceal allocation included 1. central randomization; 2. serially-numbered, opaque, sealed envelopes; or 3. other descriptions with convincing concealment. B: unclear, where authors did not adequately report on method of concealment. C: inadequate, where allocation was not adequately concealed (e.g., alternation methods were used). 3. Blinding: yes, no, or unclear With music therapy studies it is not possible to blind participants and those providing the music therapy interventions. However, outcome assessors can be blinded. In studies that used self-report measures, blinded outcome assessment was, of course, not possible. In this review, we marked blinding as yes, no, or unclear as it pertains to blinding of outcome assessors for objective outcomes. 4. Incomplete outcome data addressed: adequate, inadequate, unclear We gave a rating of adequate when numbers of dropouts and reasons for drop-out were reported or if we were able to obtain this information from the study author. If there were no withdrawals and this was indicated in the study, the study received a rating of adequate. The above four criteria were used to give each article an overall quality rating (based on section 6.7.1 of the Cochrane Handbook for Systematic Reviews of Interventions) (Higgins 2006). A. Low risk of bias: all four criteria met. B. Moderate risk of bias: one or more of the criteria only partly met. C. High risk of bias: one or more criteria not met. We did not exclude studies based on a low quality score.
(available case analysis). It was not assumed that participants who dropped out after randomization had a negative outcome. Assessment of heterogeneity Heterogeneity was investigated using the I-squared test with I2 > 50% indicating significant heterogeneity. Assessment of reporting biases We had planned to examine publication bias visually in the form of funnel plots. However, this was not possible because of the limited number of studies per outcome. It needs to be noted though that three out of the five studies are unpublished studies. Data synthesis JB entered the data of included studies into Review Manager (RevMan 2008). CD checked data entry for errors. We presented the main outcomes in this review as continuous variables. Where studies used different instruments to measure the same conceptual phenomenon (for example, quality of life) we reported the standardized mean difference (SMD) with 95% confidence intervals (CI). When there were sufficient data available from various studies using the same measurement instrument (for example, The Hospice Quality of Life Index-Revised) we computed a weighted mean difference (MD) with 95% CI. We calculated pooled estimates using the fixed-effect model. In case of significant heterogeneity (I-squared value > 50%), we used the random-effects model. We determined the levels of heterogeneity by I-squared (I 2) (Higgins 2002). The following treatment comparisons were made: 1. standard care and music therapy versus standard care alone; 2. standard care and music therapy versus standard care combined with other treatment. Subgroup analysis and investigation of heterogeneity The following sub-analyses were planned a priori as described by Deeks et al (Deeks 2001) and as recommended in section 8.8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2006), but could not be carried out because of an insufficient number of studies. These sub-analyses would have compared: 1. different types of music therapy interventions; 2. different duration and frequency of music therapy; 3. different diagnoses.
Dealing with missing data Data were analyzed on an endpoint basis, including only participants for whom final data point measurement was obtained
Sensitivity analysis We had planned to examine the influence of study quality using a sensitivity analysis where the results including and excluding lower-quality studies are compared. Because all studies received a
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high risk of bias quality rating, we could not conduct the planned sensitivity analysis for impact of high risk studies. RESULTS Description of studies See: Characteristics of included studies; Characteristics of excluded studies. Results of the search The database searches and handsearching of conference proceedings and journals resulted in 2964 citations. One review author (JB) and a research assistant examined the titles and abstracts, and 23 references were retrieved for possible inclusion. These were then independently screened by the two review authors resulting in five studies that met all the inclusion criteria. Where necessary we contacted chief investigators to obtain additional information on study details and data. Included studies Five studies with a total of a 175 participants (experimental and control) were included. One study provided music therapy in in-home hospice care (Hilliard 2003) and four studies conducted the music therapy sessions in an inpatient hospice setting (Horne-Thompson 2008; Lee 2005; Nguyen 2003; Wlodarczyk 2007). All study participants were adults with an average age of 68 years. The gender distribution in these studies was balanced with 51% female and 49% male participants. For three studies, ethnicity of the participants was not reported (Horne-Thompson 2008; Lee 2005; Nguyen 2003). For those studies that did report on ethnicity (Hilliard 2003; Wlodarczyk 2007), the majority of the participants were Caucasian (average of 82.5%). Trial sample size ranged from 10 to 80 participants (see 'Characteristics of included studies' table for sample size of each study). One study provided services exclusively to terminal cancer patients in in-home hospice care (Hilliard 2003) whereas the other studies offered music therapy sessions to inpatient participants with various diagnoses including cancer, congestive heart failure, renal failure, AIDS, amyotrophic lateral sclerosis (ALS). Four studies used parallel group designs, whereas one study (Wlodarczyk 2007) used a cross-over design. Various music therapy interventions were used to meet the individual needs of the participants during the music therapy sessions: song choice, music-prompted reminiscence, singing, listening to live music, lyric analysis, instrument playing, song parody, singing with accompaniment using the Iso-principle, planning of funerals or memorial services, song gifts, music-assisted supportive counseling, music and relaxation, music and imagery, improvisation,
songwriting, life review, sing-alongs with family and friends, and music for prayer. One study exclusively used live music based on the Iso-principle (Lee 2005). To establish a musical iso, music that matches the patient's current mood is played, after which the music is gradually changed in the therapeutic direction (e.g., a gradual change from music that has a lot of harmonic tension to music that sounds relaxing and peaceful). The music therapy interventions were aimed at developing a rapport with the patient or family, facilitating family interaction, providing support, enabling reminiscence, providing opportunities for spiritual exploration and validation, addressing feelings of anticipatory mourning and grief, and reducing anxiety and pain. The studies offered the following control conditions: standard care (Hilliard 2003; Nguyen 2003), a visit by a volunteer who engaged the participant in a conversation, read to the participant, or provided emotional support (Horne-Thompson 2008), a visit by the researcher to engage the participant in a conversation about a patient-preferred topic (Wlodarczyk 2007), and a music session where the participant listened to pre-recorded music without a music therapy process or interaction with a music therapist (Lee 2005). Two studies offered one music therapy session (Horne-Thompson 2008; Lee 2005), two studies offered two music therapy sessions (Nguyen 2003; Wlodarczyk 2007). In the Hilliard 2003 study, participants received a minimum of two sessions with some participants receiving up to 13 sessions. However, Hilliard 2003 only included data of the second session in his data analysis. Not all studies measured all outcomes identified for this review. The studies were conducted in two different countries: USA ( Hilliard 2003; Lee 2005; Nguyen 2003; Wlodarczyk 2007) and Australia (Horne-Thompson 2008). Further details of the studies included in the review are shown in the table of 'Characteristics of included studies'. Excluded studies We identified 18 additional experimental research studies. However, these were excluded because of the following reasons: (a) no control group or control condition (Brown 2006; Calovini 1993; Kitawaki 2007; Krout 2001; Nakayama 2009; Segall 2007; Whittall 1989; Whittsitt 2006), (b) no random or pseudo-random (i.e. alternate group allocation) assignment to groups or conditions (Abbott 1995; Okamoto 2005; Patrick 2004), (c) ex post facto research without randomization (Gallagher 2006), and not an end-of-life care study (Martinez 2007; Mihara 2006). Four studies were excluded because the intervention was not a music therapy intervention (as defined by the authors in the background section) even though the study was conducted by a music therapist (Curtis 1986) or music therapy student (Choi 2007; Kerr 2004; Kim 2006). In these studies, the participants listen to pre-recorded music without the implementation of a therapeutic process.
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Details of the excluded trials are listed in the 'Characteristics of excluded studies' table. Risk of bias in included studies We included studies that used appropriate methods of randomization (e.g. computer-generated table of random numbers, draw of lots, flip of coins) (Horne-Thompson 2008; Nguyen 2003) as well as studies that used alternate group assignment as allocation method (Lee 2005; Wlodarczyk 2007). One study stated that random assignment was used, but the randomization method was not specified. Attempts to receive this information from the author were unsuccessful (Hilliard 2003). Only one study used allocation concealment (Horne-Thompson 2008). All studies used self-report measures. Blinding of outcome assessors for these measures was, therefore, not possible. Two studies included additional physiological and physical outcomes, but blinding of outcome assessors did not take place (Lee 2005) or was unclear (Hilliard 2003). This inevitably introduced potential for biased assessment and, subsequently, overestimation of the effect size. Blinding of intervention allocation is not possible in music therapy interventions, adding another layer of possible bias. For two studies, the drop-out rate was unclear (Hilliard 2003; Nguyen 2003). Two studies reported a drop-out rate of less than 20% (Horne-Thompson 2008; Lee 2005). One study had a very high drop out rate (51%), but this was likely due to the fact that the data collection was spread over seven days. The authors reported that within that time frame, many of the participants passed away or became non-responsive. High drop-out rates are to be expected in end-of-life studies. As a result, all studies were rated to have a high risk of bias. Risk of bias is detailed for each study in the risk of bias tables included in the 'Characteristics of included studies' table. As all studies were rated as high risk, sensitivity analysis on the basis of overall quality rating was not carried out. Effects of interventions
based on the Iso-principle (posttest M = 3.02, SD = 1.86) was more effective (P = 0.025) in reducing pain than the use of prerecorded music (posttest M = 4.63, SD = 2.34). Horne-Thompson and Grocke (Horne-Thompson 2008) investigated the effects of music therapy on other symptomatic issues common for patients in end-of-life care. Participants were asked to rate the severity of their symptoms using the Edmonton Symptom Assessment System (ESAS) (0 to 10 scale for each symptom). The authors reported that music therapy was effective in reducing tiredness (P = 0.024) and drowsiness (P = 0.018), but not in improving nausea (P = 0.2), appetite (P = 0.09), and shortness of breath (P = 0.07). One study (Nguyen 2003) found a statistically significant difference (P = 0.006) between post-intervention levels of discomfort (as measured on a 100 mm visual analogue scale (VAS)) in hospice patients receiving standard care and music therapy (n = 10, M = 11.1, SD = 14.34) and hospice patients receiving standard care alone (n = 10, M = 52.1, SD = 41.82). Finally, Hilliard 2003 included physical status as measured by the Palliative Performance Scale (PPS), but found no statistically significant difference between the music therapy group (M = 35.8, SD = 13.7) and the standard care group (M = 32.5, SD = 16.9). The PPS is a nursing assessment scale which includes measurement of the patient's conscious level, nutritive intake, self-care, ambulation, activity, and evidence of disease, with 0% indicating death and 100% indicating full functioning and no evidence of disease (Hilliard 2003). Psychological outcomes Two studies included anxiety as an outcome measure and had a homogeneous SMD of -0.31 (95% CI -0.90 to 0.28, P = 0.30) (Analysis 1.2). However, this effect was not statistically significant. Two studies (Horne-Thompson 2008; Nguyen 2003) reported on the effect of music therapy on depression or sadness in participants who were terminally ill. Their data resulted in a homogeneous SMD of -.51 (95% CI -1.11 to 0.10, P = 0.10), but this was not statistically significant (Analysis 1.3).
Primary outcomes Symptom relief Two studies (Horne-Thompson 2008; Nguyen 2003) examined the effect of music therapy on pain in hospice patients. Their pooled estimate indicated no strong evidence of effect of music therapy (SMD = -0.33, 95% CI -0.92 to 0.26, P = 0.27) (Analysis 1.1). Lee 2005 compared the effects of live music therapy with listening to pre-recorded music on patients' self-reported pain (using a 10-point graphic rating scale) and found that live music therapy
Physiological outcomes Only two studies included a physiological outcome, namely pulse rate. However, because one study used a volunteer visit as the control condition (Horne-Thompson 2008), and the other study used listening to prerecorded music as the control condition (Lee 2005), their estimates could not be pooled. Neither of the studies found a statistically significant effect of music therapy on pulse rate. Relationship and social support None of the studies included relationship and social support outcomes such as family support or isolation. Two studies used the
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Hospice Quality of Life Index - Revised (HQLI-R) which includes a social/spiritual well-being subscale, but social well-being was not considered separate from spiritual well-being. Results of these two studies are discussed below under the quality of life outcome. Communication We did not find any studies that examined the effect of music therapy on communication variables such as verbalization, facial affect, and gestures.
Spirituality One study (Wlodarczyk 2007) considered spirituality as an outcome. Even though two other studies reported results on social/ spiritual well-being on the HQLI-R, this subscale did not separate spiritual well-being from social well-being and, therefore, their results could not be pooled with the Wlodarczyk study. Wlodarczyk 2007 reported that music therapy was significantly more effective (P = 0.01) than a non-music visit in enhancing spiritual well-being (M = 78.5, SD = 20.93 and M = 73.95, SD = 20.76, respectively) in hospice patients.
Quality of life The pooled effect of two studies (Hilliard 2003; Nguyen 2003) indicated that music therapy has a beneficial effect (MD = 37.08, 95% CI 22.45 to 51.72, P < 0.00001) on quality of life in patients in end-of-life care and results were consistent between the two studies (IІ = 0%). Both studies used the Hospice Quality of Life Index-Revised (HQLI-R). Horne-Thompson and Grocke (Horne-Thompson 2008) used the Edmonton Symptom Assessment Scale (ESAS) to examine the effects of music therapy on several symptomatic issues in palliative care patients, including wellbeing (measured on a 0-10 scale); they did not find statistically significant differences between the music therapy group and the control group. Pooling the results of their study with the Hilliard 2003 and Nguyen 2003 study resulted in a moderate but heterogeneous effect size (SMD = 0.69, 95% CI 0.11 to 1.27, P = 0.02; IІ = 51%) (Analysis 1.4). The HQLI-R is a self-report questionnaire using a Likert scale of 0 to 10 with a total of 28 items designed for hospice patients with cancer. It includes three subscales: functional well-being (i.e. daily activities, concentration ability) (total possible score of 70), psychophysiological well-being (i.e. anger, pain, nausea) (total possible score of 130), and social/spiritual well-being (i.e. meaning in life, family support, relationship with God) (total possible score of 80). The results of two studies (Hilliard 2003; Nguyen 2003) suggest that music therapy has a positive effect on psychophysiological well-being (MD = 17.41, 95% CI 9.10 to 25.72, P < 0.0001; IІ = 0%) (Analysis 1.6), functional well-being (MD = 13.40, 95% 7.25 to 19.54, P < 0.0001; IІ = 0%) (Analysis 1.5), and social/ spiritual well-being (MD = 6.02, 95% 1.67 to 10.37, P = 0.007; IІ = 0%) (Analysis 1.7). In one study (Hilliard 2003), it was found that even though the physical status of participants receiving music therapy declined over time, as indicated by their scores on the Palliative Performance Scale, their quality of life scores increased. In the standard care group, both physical status and quality of life declined over time. Hilliard 2003 also included length of life as an outcome variable. The average length of life (in days) for the music therapy participants was 69.5 (SD = 60.5) days and 57.8 (SD = 45.5) days for the control group. More studies are needed to examine the impact of music therapy interventions on length of life.
Participant satisfaction None of the studies compared satisfaction of experimental group participants with satisfaction of control group participants. One study included a family satisfaction questionnaire for the music therapy participants. In this questionnaire, participants were asked how beneficial music therapy was for them and their loved ones. The following ratings (10-point scale) were obtained: (a) The use of music therapy within end-of-life celebration is beneficial for me: M = 9.4, SD = 0.97, (b) The use of music therapy within end-of-life celebration is beneficial for my loved one: M = 9.7, SD = 0.48, (c) I enjoy the use of music therapy within the hospital setting: M = 9.7, SD = 4.2, (d) I believe that music therapy with an end-of-life celebration has or will bring closure for me: M = 8.9, SD = 1.55, and (e) I believe that music therapy with an endof-life celebration has or will bring closure for my loved ones: M = 8.6, SD = 1.7. DISCUSSION Summary of main results The results of this review show that there is insufficient evidence to reliably conclude a beneficial effect of music therapy on the quality of life of patients at the end of life. These results are based on a few studies with small sample sizes (125 participants combined). More studies are needed to strengthen the evidence. There was no strong evidence for effect of music therapy on pain and anxiety. Unfortunately, only two studies included these outcomes and their total sample size was very small (45 participants combined). Clearly, more studies are needed to further evaluate the effects of music therapy on these outcomes. Single studies reported that music therapy was effective for enhancing spirituality (Wlodarczyk 2007), reducing tiredness and drowsiness (Horne-Thompson 2008), and alleviating discomfort and sadness (Nguyen 2003), but no support was found for effects of music therapy on nausea, appetite, shortness of breath, depression (Horne-Thompson 2008) or decreasing heart rate (Horne-Thompson 2008; Lee 2005).
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None of the studies included communication, social support, or physiological outcomes other than pulse rate. Only one study (Wlodarczyk 2007) evaluated patient satisfaction with music therapy services. Results indicated that most patients found music therapy to be highly beneficial to themselves and their loved ones, and that music therapy greatly contributed to bringing closure.
aspect of culture), the majority of the participants were Caucasian. Persons' cultures may strongly influence their music preferences, their views of music as a therapeutic agent and its use at end of life, as well as their attitudes towards therapy in general. It can be assumed that the culture will influence individuals' expectations of music and music therapy at the end of life and consequently study outcomes.
Overall completeness and applicability of evidence This review included five controlled trials. The strength of our review is that we searched all available databases and a large number of music therapy journals (English, German, French, and Japanese language), checked reference lists of all relevant studies, contacted relevant experts for identification of unpublished trials, and reviewed publications for eligibility without restricting language. In spite of such a comprehensive search, it is still possible we missed some published and unpublished trials. We requested additional data where necessary for all studies we considered for inclusion. This allowed us to get accurate information on the trial quality and data for most studies and helped us make well-informed study selection decisions. There is insufficient evidence of high quality to support the effect of music therapy on quality of life of people in end-of-life care. Even though many clinical reports and data from non-controlled trials indicate beneficial effects of music therapy for palliative care and hospice patients and their families (e.g. Hanser 2005; Hilliard 2005; Gallagher 2006; Krout 2001; Magill 2001; O'Callaghan 1996), it is clear that more RCTs are needed before conclusions can be drawn. Because only two small studies investigated the effect of music therapy on pain and anxiety, the evidence is not clinically applicable at this time. More research is needed. Given the high chance for participant loss due to death or rapid cognitive decline, the studies in this review included a limited number of music therapy sessions. Because multiple sessions allow for the development of a therapeutic relationship and deepening of the therapeutic process through the music, it is possible that providing more than two sessions could result in larger effects. Because not all studies in this review addressed all main outcome variables, it was not possible to conduct a subgroup analysis to examine frequency and duration of sessions as moderator variables. All studies provided music therapy interventions by a trained music therapist and used live music. Studies that used listening to pre-recorded music without a therapeutic process were excluded. Therefore, the results of this review are only applicable to music therapy interventions as defined by the authors in the background section. One can question the generalizability of these results to various cultural groups since little information was provided in these studies about the cultural make-up of the samples. For those studies that did include information about ethnicity specifically (as one
Quality of the evidence The quality of reporting in general was poor with only one study (Horne-Thompson 2008) detailing the method of randomization, allocation concealment, and level of blinding. The lead authors of most studies needed to be contacted to provide additional methodological and statistical information. All studies in this review received a high risk of bias rating. The studies included were generally small (average n = 35, range: 10 to 80) resulting in a lack of precision of treatment effects as evidenced by the rather large confidence intervals. This, combined with the high risk of bias, requires that the results of this review be interpreted with caution. We are confident that our detailed search strategy combined with extensive handsearching of journals and some conference proceedings identified all relevant published studies. We were able to identify several unpublished studies. It is possible that we did not identify some grey literature, however, it is doubtful that this would have a significant impact on our results. Grey literature tends to include studies with relatively small numbers of participants and inconclusive results (McAuley 2000). AUTHORS' CONCLUSIONS Implications for practice There is limited evidence to support or refute the effectiveness of music therapy for enhancement of quality of life in end-oflife care. Some studies with high risk of bias indicate that music therapy may be beneficial for quality of life, however, these results need to be interpreted with caution. No evidence of effect was found for pain and anxiety. However, only two studies with a total of 45 participants investigated the effects of music therapy on these outcomes. Because of the many clinical reports and data from non-RCTs about the pain and anxiety-reducing effects of music therapy, it is clear that more research is needed before conclusions can be drawn regarding clinical implications of these results. More research is needed to strengthen the available evidence before recommendations for clinical practice can be made.
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Implications for research Carrying out RCTs with this population creates several challenges. First and perhaps foremost, time is precious and guarded for patients and their families at the end of life, and engaging in research is not a priority for the time remaining. It may be particularly difficult to recruit research participants because of this. Researchers should consider encouraging family members to participate in the sessions, if they so desire. At the same time, the treatment offered should be flexible to the amount of time patients and their families are willing to commit to the sessions. Similarly, the outcome measurements selected for a study need to be short.
occur. To address this issue, studies should utilize a standardized treatment that will also allow for flexibility in the music therapy methods used to address the needs of each patient. Despite these challenges, the studies in this review clearly demonstrate that it is feasible to conduct RCTs with this population, and they can be used as models for future studies. One should not ignore, however, the importance of qualitative research and nonRCT research to gain a better understanding of the qualitative aspects of the experiences of patients and their loved ones as well as to identify factors that may contribute to or limit the effectiveness of music therapy interventions.
When conducting studies with people in end-of-life care, it may be unethical to withhold treatment for even short periods of time when death is imminent. This needs to be carefully considered in research designs. One can opt to use a very brief intervention period or employ a cross-over design in which both conditions are offered within a short timeframe. When life expectancy is several weeks or more, a longer timeframe can be adopted for treatment implementation. Ex post facto research trials with random selection of patients may offer a valuable alternative.
Future studies need to include other outcomes as listed in the method section of this review. In addition, studies need to continue to include quality of life as the results of this review show promising results. Researchers should furthermore examine the effects of music therapy on pediatric patients in end-of-life care as well as family members and caregivers. Finally, formal evaluation of the cost & benefit of music therapy is needed.
In addition, when determining the sample size for adequately powered studies, researchers need to consider the potential for extensive participant loss due to death as well a rapid cognitive decline. Future studies need to include power analysis so that adequate sample sizes are used. A final problem in conducting research with those in end-of-life care is the conflict between the requirement of providing an intervention that is sufficiently standardized so as to be adequately evaluated versus the imperative to tailor the intervention to the particular needs of each participant. This conflict is of utmost concern in persons who are dying because of the urgency of providing appropriate and meaningful treatment while the patients are still alive as well as the lack of predictability regarding when death may
ACKNOWLEDGEMENTS The authors would like to thank the Cochrane Pain, Palliative, and Supportive Care Group editorial base for their excellent advice and support. We would also like to acknowledge Cassandra Mulcahy, Patricia Gonzalez and Andi McGraw Hunt, graduate assistants, for their help in the handsearching of journals and retrieval of articles. The following peer reviewers were contacted for comment on the development of this full review: Soledad Cepeda, Edzard Ernst, Sosie Kassab, R Andrew Moore, John Plummer; as well as the following consumers: Clare Jeffrey, Sai Janani, Ann Fonfa and Kathie Godfrey.
REFERENCES
References to studies included in this review Hilliard 2003 {published and unpublished data} Hilliard RE. The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer. Doctoral dissertation, Florida State University, USA 2002. Hilliard RE. The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer. Journal of Music Therapy 2003;40(2):113­37. [MEDLINE: 14505443] Horne-Thompson 2008 {published and unpublished data} Horne-Thompson A, Grocke D. The effect of music therapy on anxiety in patients who are terminally ill. Journal of Palliative Care 2008;11(4):582­90. [MEDLINE: 18454611]
Lee 2005 {unpublished data only} Lee HJ. The effect of live music via the Iso-principle on pain management in palliative care as measured by self-report using a graphic rating scale and pulse rate. Master's Thesis, Florida State University, USA 2005. Nguyen 2003 {unpublished data only} Nguyen JT. The effect of music therapy on end-of-life patients' quality of life, emotional state, and family satisfaction as measured by self-report. Master's Thesis, Florida State University. Florida, 2003. Wlodarczyk 2007 {unpublished data only} Wlodarczyk N. The effect of music therapy on the spirituality of persons in an in-patient hospice unit as measured by self-report. Master's Thesis, Florida State University. Florida.
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References to studies excluded from this review Abbott 1995 {unpublished data only} Abbott E. The effects of music therapy on the perceived quality of life of patients with terminal illness in a hospice setting. Master's thesis, Western Michigan University 1995. Brown 2006 {unpublished data only} Brown JL. Comparison of the effects of music and conversation on hospice patients' predisposition to communicate and communication behaviors. Master's thesis, Florida State University 2006. Calovini 1993 {unpublished data only} Calovini BS. The effect of participation in one music therapy session on state anxiety in hospice patients. Master's thesis, Case Western Reserve University 1993. Choi 2007 {unpublished data only} Choi YK. The effect of music and progressive muscle relaxation on anxiety, fatigue, and quality of life in family caregivers of hospice patients. Master's thesis, University of Kansas 2007. Curtis 1986 {published data only} Curtis SL. The effect of music on pain relief and relaxation of the terminally ill. Journal of Music Therapy 1986;23(1):10­24. Gallagher 2006 {published data only} Gallagher LM, Lagman R, Walsh D, Davis MP, Legrand SB. The clinical effects of music therapy in palliative medicine. Supportive Care in Cancer 2006;14(8):859­66. [MEDLINE: 16538499] Kerr 2004 {unpublished data only} Kerr SE. The effect of music on non-responsive patients in a hospice setting. Master's Thesis, Florida State University. Florida, 2004. Kim 2006 {unpublished data only} Kim, SA. The effect of music listening on mood state and relaxation of hospice patients and caregivers. Master's Thesis, Florida State University. Florida, 2006. Kitawaki 2007 {unpublished data only} Kitawaki A. The effectiveness of music therapy involving family members of terminally ill patients in hospice on quality of life of the patient and stress levels of family members. Master's thesis, Michigan State University, USA. 2007. Krout 2001 {unpublished data only} Krout RE. The effects of single-session music therapy interventions on the observed and self-reported levels of pain control, physical comfort, and relaxation of hospice patients. American Journal of Hospice & Palliative Care 2001;18(6):383­90. Martinez 2007 {unpublished data only} Martinez JB. Effects of Singing in Chronic Obstructive Pulmonary Disease. University of Sao Paulo. ClinicalTrials.gov 2007. [: NCT00500526] Mihara 2006 {published data only} Mihara B, Mihara Y, Fujimoto M, Nagashima H, Tomita Y, Takao M. The effect of music therapy for patients with amyotrophic lateral sclerosis-evaluation by neuropsychologic and physiological tests. Japanese Journal of Music Therapy 2006;6(1):23­32. [: 1346­6119]
Nakayama 2009 {published data only} Nakayama H, Kikuta F, Takeda H. A pilot study on effectiveness of music therapy in hospice in Japan. Journal of Music Therapy 2009; 46(2):160­72. Okamoto 2005 {unpublished data only} Okamoto M. The effects of music therapy interventions on grief and spirituality of family members of patients in a hospice setting. Master's Thesis, Florida State University. Florida, 2005. Patrick 2004 {unpublished data only} Patrick L. The effects of music therapy entrainment on perceived pain in hospice patients: A pilot study. Master's Thesis, Temple University. Philadelphia: Temple University, 2004. Segall 2007 {unpublished data only} Segall LE. The effects of patient-preferred live versus recorded music on non-responsive patients in the hospice setting as evidenced by physiological and behavioral states. Master's Thesis, Florida State University. Florida, 2007. Whittall 1989 {published data only} Whittall J. The impact of music therapy in palliative care: A quantitative pilot study. In: Martin JA editor(s). The next step forward: Music therapy with the terminally ill. Bronx, NY: Calvary Hospital, 1989:69­72. Whittsitt 2006 {unpublished data only} Whittsitt SG. Music as a mood state inducer for hospice/palliative care patients and its effect on perceived pain. Master's Thesis, Florida State University. Florida, 2006. Additional references Deeks 2001 Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta-analysis. In: Egger M, Davey Smith G, Altman DG editor (s). Systematic Reviews in Health Care: Meta-analysis in Context. 2nd Edition. London: BMJ Publication Group, 2001. Demmer 2004 Demmer C. A survey of complementary therapy services provided by hospices. Journal of Palliative Medicine 2004;7:510­6. Dileo 1999 Dileo C. A classification model for music and medicine. In: Dileo C editor(s). Applications of Music in Medicine. American Music Therapy Association, 1999:1­6. Dileo 2005a Dileo C, Bradt J. Medical Music Therapy: A Meta-Analysis & Agenda for Future Research. Cherry Hill: NJ: Jeffrey Books, 2005. Dileo 2005b Dileo C, Dneaster D. Introduction: state of the art. In: Dileo C, Loewy JV editor(s). Music Therapy at the End of Life. Cherry Hill: NJ: Jeffrey Books, 2005. Dileo 2005c Dileo C, Zanders M. In-between: Music therapy with inpatients awaiting a heart transplant. In: Dileo C, Loewy JV editor(s). Music Therapy at the End of Life. Cherry Hill: NJ: Jeffrey Books, 2005: 65­76.
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Dileo 2007 Dileo C, Bradt J. Music therapy: applications to stress management. In: Lehrer P, Woolfolk R editor(s). Principles and Practice of Stress Management. 3rd Edition. New York: Guilford Press, 2007. Hancock 2007 Hancock K, Clayton JM, Parker SM, et al.Discrepant perceptions about end-of-life communication: A systematic review. Journal of Pain and Symptom Management 2007;34(2):190­200. Hanser 2005 Hanser SB. Music therapy to enhance coping in terminally ill adult cancer patients. In: Dileo C, Loewy JV editor(s). Music Therapy at the End of Life. Cherry Hill: NJ: Jeffrey Books, 2005. Higgins 2002 Higgins JPT, Thompson SG. Quantifying heterogeneity in a metaanalysis. Statistics in Medicine 2002;21:1539­58. Higgins 2006 Higgins JPT, Green S (eds). Cochrane Handbook for Systematic Reviews of Interventions 4.2.6 [updated September 2006]. The Cochrane Library, Issue 4 2006. Chichester, UK: Wiley-Blackwell, 2006. Hilliard 2005 Hilliard R. Music therapy in hospice and palliative care: a review of the empirical data. Evidence-Based Complementary and Alternative Medicine 2005;2:173­8. Hogan 1999 Hogan B. Music therapy at the end of life: Searching for the rite of passage. In: Aldridge D editor(s). Music Therapy in Palliative Care. London: Jessica Kingsley, 1999:68­81. Lee 1996 Lee C. Music at the Edge. Routledge, 1996. Magee 2004 Magee WL, Davidson JW. Singing in therapy: monitoring disease process in chronic degenerative illness. British Journal of Music Therapy 2004;18:65­78. Magill 2001 Magill L. The use of music therapy to address the suffering in advanced cancer pain. Journal of Palliative Care 2001;17:167­72.
Magill 2002 Magill L, Luzzato P. Music therapy and art therapy. In: Berger A, Portenoy R, Weissman D editor(s). Principles and Practice of Palliative Care and Supportive Oncology. 2nd Edition. Philadelphia, PA: Lippincott, Williams and Wilkins, 2002:993­1006. McAuley 2000 McAuley L, Pham B, Tugwell P, Moher D. Does the inclusion of grey literature influence estimates of intervention effectiveness reported in meta-analyses?. Lancet 2000;356:1228­31. Neugebauer 1999 Neugebauer L. Music therapy with HIV positive and AIDS patients. In: Aldridge D editor(s). Music Therapy in Palliative Care. London: Jessica Kingsley, 1999:126­34. O'Callaghan 1996 O'Callaghan. Music and well-being: Music therapy in palliative care. Annual Journal of the New Zealand Society for Music Therapy 2006:4­19. O'Callaghan 1997 O'Callaghan CC. Therapeutic opportunities associated with music when using song writing in palliative care. Music Therapy Perspectives Music Therapy Perspectives 1997;15:32­8. Oneschuk 2007 Oneschuck D, Balneaves L, Verhoef M, Boon H, Demmer C, Chiu L. The status of complementary therapy services in Canadian palliative care settings. Supportive Care in Cancer 2007;15:939­47. Patrick 2005 Patrick L, Avins K. Music therapy approaches for patients with dementia at end of life. In: Dileo C, Loewy J editor(s). Music Therapy at the End of Life. Cherry Hill: NJ: Jeffrey Books, 2005. RevMan 2008 The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan) [Computer program]. Version 5.0 for Windows. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008. Scheiby 2005 Scheiby BB. Dying alive - A transpersonal, analytical music therapy approach for adults with chronic, progressive neurological diseases. In: Dileo C, Loewy JV editor(s). Music Therapy at the End of Life. Cherry Hill: NJ: Jeffrey Books, 2005. Indicates the major publication for the study
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CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID] Hilliard 2003
Methods Participants Interventions Outcomes Notes Risk of bias Item Adequate sequence generation?
Quasi-randomized trial 2-arm parallel group design Adults with one of the following terminal cancers: lung (n = 25), colon (n = 7), kidney (n = 3), nasopharynx (n = 1), prostate (n = 3), liver (n = 2), esophagus (n = 3), breast (n = 5) , pancreas (n = 5), brain (3), oral cavity (1), ovary (n = 2), stomach (n = 2), endometrium (n = 1), sinus (n = 1), larynx (n = 1), leukemia (n = 2), melanoma (n = 3), multiple myeloma (n = 1), lymphoma (n = 1), head, neck and face (n = 1) and unspecified cancer (n = 3) N music therapy group: 40 N control group: 40 Mean age: 65.5 Sex: 40 F, 40 M Ethnicity: 25% Black, 75% Caucasian Setting: in-home hospice care Music therapy group: individual music therapy sessions were provided by the author, other board-certified music therapists, or music therapy interns under supervision of a board-certified music therapist. The music therapists individualized the music therapy interventions according to clients' needs. Techniques often used: song choice, musicprompted reminiscence, singing, live music listening, lyric analysis, instrument playing, song parody, singing with accompaniment using the Iso principle, planning of funerals or memorial services, song gifts, and music-assisted supportive counseling. The music therapists used live, subject-preferred music. Control group: home visit by family support counselor as part of routine care. Number of sessions: minimum of 2 sessions; some participants received up to 13 sessions Length of session: not reported · Quality of life (Hospice Quality of Life Index-Revised): total score and subscale scores of second session · Physical status (Palliative Performance Scale): score of second session · Length of life (in days)
Authors' judgement Unclear
Description The author stated that random assignment was used but the randomization method was not specified. Attempts to receive this information from the author were unsuccessful
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Hilliard 2003 (Continued)
Allocation concealment?
Unclear
Blinding? Objective outcomes Incomplete outcome data addressed? All outcomes
No Unclear
Attempts to receive this information from the author were unsuccessful Subjective outcomes (self-report): blinding not possible Based on descriptions in the text, there appear to be no withdrawals. However, there is a discrepancy between total number reported in data analyses (N = 80) and number of participants reported per diagnosis (N = 76)
Horne-Thompson 2008 Methods Participants Interventions Outcomes Notes Risk of bias Item Adequate sequence generation?
RCT 2-arm parallel group design Adult inpatients receiving palliative care service due to a diagnosis of terminal illness (24 cancer, 1 end stage heart failure) N music therapy group: 13 N control group: 12 Mean age: 73.9 (13.32) Sex: 11F, 14 M Ethnicity: not reported Setting: in-patient facility Music therapy: individual music therapy session. Specific music therapy intervention was determined on a case-by-case basis by the music therapist. The following interventions were used: live familiar music, singing, music and relaxation, music and imagery, improvisation, music-assisted counseling, reminiscence, and listening to recorded music. Control: a visit by a volunteer who read to the patient, engaged the patient in conversations, or provided emotional support Number of sessions: 1 Length of session: 20-40 minutes Symptomatic issues on Edmonton Symptom Assessment Scale (ESAS)): posttest scores (posttest means and SD received from the author) Pulse: posttest value
Authors' judgement Yes
Description computer-generated number list
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Horne-Thompson 2008 (Continued)
Allocation concealment?
Yes
Blinding?
No
Objective outcomes
Incomplete outcome data addressed?
Yes
All outcomes
Serially numbered opaque envelopes Blinding for pulse readings was attempted but author reported (personal communication) that the nurses could still hear the music on the unit and therefore knew which patient was receiving music therapy services. Five patients died or were discharged
Lee 2005 Methods Participants Interventions Outcomes Notes Risk of bias Item Adequate sequence generation?
Quasi-randomized trial 2-arm parallel group design Adults in in-patient palliative care. N music therapy group: 20 N control group: 20 Mean age: not reported Sex: 20 F, 20 M Ethnicity: not reported Setting: in-patient facility Music therapy: live music based on the Iso principle, played for 20-30 minutes. A limited selection of live music from 1920s to 1980s was offered. Control: recorded music, played for 20-30 minutes. The recorded music included classical excerpts: (a) Mozart, WA, "Andante from Piano Concerto N. 21," (b) Bach, JS, "Air On The G-String," (c) Bach, JS, "Arioso from Cantata N. 156," (d) and Morisod, A. "Et Les Oiseaux Chantaient." These selections were recommended as relaxing music because these are based on slow and steady rhythm, long phrases, little dynamic variation, and emotional components Number of sessions:1 Length of session: 20-30 minutes Pulse: posttest value (SD were computed by JB from the raw data provided in the Appendix of the thesis) Pain (Graphic rating scale): posttest value (SD were computed by JB from the raw data provided in the Appendix of the thesis)
Authors' judgement No
Description Alternate assignment
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Lee 2005 (Continued)
Allocation concealment? Blinding? Objective outcomes Incomplete outcome data addressed? All outcomes Nguyen 2003 Methods Participants Interventions Outcomes
No
No allocation concealment was used
No
No blinding was used
Yes
Three withdrawals due to refusal to partic-
ipate or excessive interruptions by hospital
staff
RCT Posttest only control group design End-of-life adults in palliative care. Most frequent diagnoses: Congestive Heart Failure (N = 4), Chronic Renal Failure (N=2), and different types of Cancer (N = 8). Other diagnoses included: Syncope and Collapse, Septicemia NOS, Multi-Cranial Nerve Palsy, Hypertension, Intestinal Obstruction, and Respiratory Abnormalities. N music therapy group: 10 N control group: 10 Mean age: 64.5 Sex: 10 F, 10 M Ethnicity: not reported Setting: in-patient facility Music therapy: received two music therapy sessions: First session included singing patient preferred music, seeking information about patient's favorite songs, and assessing patient and family levels of coping. Second session was an end of life celebration. Control group: standard care, no music therapy services Number of sessions: 2 Length of sessions: not reported Quality of life (Hospice Quality of Life Index-Revised): posttest total score and subscale scores (SD were computed by JB from the raw data provided in the Appendix of the thesis) Anxiety (VAS): posttest scores of second session (SD were computed by JB from the raw data provided in the Appendix of the thesis) Pain (VAS): posttest scores of second session (SD were computed by JB from the raw data provided in the Appendix of the thesis) Sadness (VAS): posttest scores of second session (SD were computed by JB from the raw data provided in the Appendix of the thesis) Stress (VAS): posttest scores of second session (SD were computed by JB from the raw data provided in the Appendix of the thesis) Hope (VAS):posttest scores of second session (SD were computed by JB from the raw data provided in the Appendix of the thesis) Discomfort (VAS): posttest scores of second session (SD were computed by JB from the raw data provided in the Appendix of the thesis)
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Nguyen 2003 (Continued)
Notes Risk of bias Item Adequate sequence generation? Allocation concealment? Blinding? Objective outcomes Incomplete outcome data addressed? All outcomes Wlodarczyk 2007 Methods Participants Interventions Outcomes Notes Risk of bias
Authors' judgement Yes No No Yes
Description Computer-generated list of numbers (personal communication with author) No allocation concealment was used Subjective outcomes (self-report): blinding not possible Subject loss because of death (personal communication with author)
Cross-over trial Counterbalanced repeated measures design Adult hospice in-patients. Diagnoses: lymphoma, renal failure, stomach cancer, ovarian cancer, pancreatic cancer, rectal cancer, AIDS, ALOS, cardiomyopathy, CHF. Total N = 10 Mean age = 67.6 Sex = 8F, 2 M Ethnicity: 90% Caucasian, 10% African-American Setting:in-patient hospice Music therapy condition: music therapist playing guitar and singing patient-preferred music, facilitating patient song choice via printed song book, leading the patient in music-making such as singing and improvising on a variety of percussion, pitched and unpitched instruments, songwriting, music as life review, sing-a-longs with family and friends, music for prayer, and song dedication. Control condition: nonmusic visit consisting of conversations regarding patient-preferred topics. Number of sessions: 2 music therapy and 2 nonmusic visits Length of sessions: 30 min. Spiritual well-being (adapted version of the Spiritual Well-being Scale): posttest score of second session (SD were computed by JB from the raw data provided in article)
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wlodarczyk 2007 (Continued)
Item Adequate sequence generation?
Authors' judgement No
Allocation concealment?
No
Blinding?
No
Objective outcomes
Incomplete outcome data addressed?
Yes
All outcomes
Characteristics of excluded studies [ordered by study ID]
Description Alternate assignment (personal communication with author) No allocation concealment was used Subjective outcomes (self-report): blinding not possible 21 participants enrolled, only 10 completed the 4-day data collection. Subject loss due to death or patients becoming nonresponsive
Study
Reason for exclusion
Abbott 1995
Group assignment was based on whether the participants had already received music therapy services or not. No random or alternate group allocation
Brown 2006
One group pretest-posttest design; no control group
Calovini 1993 One group pretest-posttest design; no control group
Choi 2007
Not music therapy intervention. Participants listened to pre-recorded music and progressive muscle relaxation tape without a therapeutic process
Curtis 1986
Not music therapy intervention. Participants listened to prerecorded music without a therapeutic process
Gallagher 2006 Not a RCT; ex post facto research
Kerr 2004
Not music therapy intervention. Participants listened to prerecorded music without a therapeutic process
Kim 2006
Not music therapy intervention. Participants listened to prerecorded music without a therapeutic process
Kitawaki 2007 Not a RCT, two case studies
Krout 2001
One group pretest-posttest design; no control group
Martinez 2007 Not end-of-life care Mihara 2006 Not end-of-life care
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Nakayama 2009 One group pretest-posttest design; no control group
Okamoto 2005 No random or alternate assignments to groups
Patrick 2004 Participants served as own control. No random assignment to treatment sequence
Segall 2007
One group pretest-posttest design; no control group
Whittall 1989 One group pretest-posttest design; no control group
Whittsitt 2006 One group pretest-posttest design; no control group
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES
Comparison 1. Music therapy versus standard care
Outcome or subgroup title 1 Pain 2 Anxiety 3 Depression 4 Quality of Life 5 Functional well-being 6 Psychophysiological well-being 7 Social/spiritual well-being
No. of No. of studies participants
Statistical method
2
45
Std. Mean Difference (IV, Fixed, 95% CI)
2
45
Std. Mean Difference (IV, Fixed, 95% CI)
2
45
Std. Mean Difference (IV, Fixed, 95% CI)
3
125
Std. Mean Difference (IV, Random, 95% CI)
2
100
Mean Difference (IV, Fixed, 95% CI)
2
100
Mean Difference (IV, Fixed, 95% CI)
2
100
Mean Difference (IV, Fixed, 95% CI)
Effect size -0.33 [-0.92, 0.26] -0.31 [-0.90, 0.28] -0.51 [-1.11, 0.10] 0.69 [0.11, 1.27] 13.40 [7.25, 19.54] 17.41 [9.10, 25.72] 6.02 [1.67, 10.37]
WHAT'S NEW Last assessed as up-to-date: 1 October 2009.
Date
Event
Description
24 September 2010 Amended Contact details updated.
HISTORY Protocol first published: Issue 2, 2008 Review first published: Issue 1, 2010
Date
Event
Description
24 April 2008 Amended Protocol converted to new review format.
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CONTRIBUTIONS OF AUTHORS Draft the protocol: JB and CD Develop search strategy: JB Search for studies: JB Obtain copies of studies: JB and graduate assistant Select which studies to include: JB and CD Extract data from studies: JB and CD Enter data into RevMan: JB Carry out the analysis: JB Interpret the analysis: JB and CD Draft the final review: JB and CD Update the review: JB and CD DECLARATIONS OF INTEREST Both review authors are music therapists SOURCES OF SUPPORT Internal sources · No sources of support supplied External sources · State of Pennsylvania Formula Fund, USA. DIFFERENCES BETWEEN PROTOCOL AND REVIEW The following journals were added for the handsearching: The Japanese Journal of Music Therapy and the Canadian Journal of Music Therapy.
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INDEX TERMS Medical Subject Headings (MeSH) Music Therapy; Terminally Ill; Randomized Controlled Trials as Topic; Terminal Care [methods] MeSH check words Humans
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