What is the role of music in the intensive care unit?
Phumpattra Chariyawong MD, Samuel Copeland MD, Zachary Mulkey MD
Correspondence to Samuel Copeland MD
Email:samuel.copeland@ttuhsc.edu
SWRCCC 2016;4(16):40-44
doi: 10.12746/swrccc2016.0416.218
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Music has been integral to human development and advancement with the power to
convey powerful emotions. It is not surprising that music is played all across
the globe and that it has been found advantageous in the field of medicine.
Music has been shown to help surgeons perform operations faster and to help in
neurologic recovery following traumatic brain insults.1,2 Music
therapy is also unique in that it is very safe and the cost of implementation is
low. Most hospitals have an easy listening TV channel that couples peaceful
music and imagery.
The intensive care unit is a unique patient care experience. It is an extremely
busy and loud place with frequent alarms and flashing lights where sleep often
eludes patients. Unfortunately, these disturbances in sleep are dramatic and can
lead to multiple co-morbidities, including ICU delirium which is associated with
a 3.2 fold increase in six month mortality.3,4
We wondered if there is evidence to support a beneficial effect of music
in the intensive care setting. Specifically, we wondered whether music therapy
could decrease sedation requirements, improve patients' anxiety ratings, and
improve hemodynamic parameters. Most of the literature discusses patients who
are undergoing mechanical ventilation. These patients are susceptible to
multiple stressful factors which can cause anxiety and in turn increase oxygen
consumption.5
The first question was whether music therapy improves a patient's sleep
quality in the ICU over standard care without the addition of music. Su
developed a randomized controlled trial in which patients were randomized to
non-commercial music for 45 minutes at nocturnal sleep time or usual care with
no music. The music consisted of sedating piano pieces composed by the authors
of the study. Polysomnography was recorded for the first two hours of sleep.
Results showed that stage N2 sleep was shorter by 5.2 minutes and stage N3 sleep
was longer by 6.5 minutes in the first two hours. Patients in the music group
had significantly lower heart rates and reported improved sleep quality over the
control group.6
The second question was whether music is actually beneficial or is it
simply the reduction in background ICU noise that offers benefits. In the
largest music focused clinical trial to date, Chlan found that there are
multiple benefits to music therapy. Experimental patients in the MICU were
recruited and divided into three groups of either patient-driven music (PDM),
noise-cancelling headphones (NCH), or control. Patients in the experimental
group had an anxiety score that was 19.5 points lower than the control group. In
addition, patients in the experimental group also used fewer sedatives, both in
intensity and frequency, than control patients. Both findings were statistically
significant. Their conclusion was that in patients receiving ventilator support
for respiratory failure, PDM and NCH resulted in greater reduction in anxiety
compared with usual care. Interestingly, when PDM is compared to NCH, there was
no statistically significant difference in the reduction in anxiety or sedation
intensity in PDM compared with NCH.7 This study demonstrates that
some type of therapy is preferable to none, but it does not answer the question
of whether music therapy is driving the lower anxiety scores.
Another study by Chlan evaluated the effectiveness of music therapy on
relaxation and anxiety in mechanically ventilated patients. Patients experienced
significantly less anxiety assessed by pretest-posttest state anxiety scores.
Physiologic parameters were also measured. The heart rates and respiratory rates
decreased significantly over time in patients in the study group compared to the
control group, suggesting relaxation and less stress-arousal.8
Positive effects of music on anxiety levels based on patient perception have
been supported by several studies. Wong conducted a study of music therapy on
anxiety in twenty ventilator-dependent Chinese patients. The results suggested
that music therapy was more effective in decreasing state anxiety than an
uninterrupted rest period. Physiologic measures of blood pressure and
respiratory rate were significantly lower by the end of the 30 minutes of music.9
Almerud evaluated qualitative and quantitative measures after mechanically
ventilated patients listened to classical music for 30 minutes. Systolic and
diastolic blood pressures significantly fell during the music therapy session
and rose after the end of the session.10 One randomized controlled
trial of twenty subjects did not support the conclusion that music influences
physiologic parameters. This study indicated that listening to music leads to
higher sedation scores but no significant decrease in blood pressure and heart
rate.11 However, this study collected data from sedated mechanically
ventilated patients whose blood pressures and heart rates might be lower than
patients' baseline secondary to sedative drugs. Music may not have additional
effects when added to pharmacological sedation. In aggregate these studies
indicate that music therapy might improve anxiety using both psychological and
physiological criteria.
Not only patients in medical intensive care units, but patients in
cardiovascular intensive care units seem to benefit from music therapy. Two
studies have reported good outcome of music therapy on cardiovascular disease
patients. White used a three group repeated measures experimental design in
forty-five patients with acute myocardial infarction. Patients were divided into
three groups: 1. music in quiet, restful environment (experimental group), 2.
quiet, restful environment without music (attention group), and 3. treatment as
usual (control group). State anxiety was reduced significantly immediately
during the intervention and for one hour after the intervention in the
experimental group only. Heart rate, respiratory rate and myocardial oxygen
demand were significantly decreased immediately during the intervention and for
one hour after in the experimental group compared to the control group but did
not differ significantly differ from the attention group.12 Barnason
studied effects of music on anxiety in coronary artery bypass graft patients.
Spielberger's state-trait anxiety inventory, patient's verbal ratings of both
mood and anxiety by numeric rating scale, and physiologic parameters were
measured. This study found significant improvement in mood but not in anxiety
scores in these subjects. Heart rate and systolic and diastolic blood pressures
were significantly decreased by the intervention, indicating generalized
physiologic relaxation.13 These two studies indicate that music is
not harmful to patients and may help improve mood, anxiety, and physiologic
responses to stress. However, Elliot did not find any relation between music
therapy and anxiety reduction in a randomized controlled trial. Both psychologic
and physiologic variables were measured but there was no significant reduction
in anxiety in patients exposed to music. The author claimed that these results
may be explained by a type II error.14
Most of the studies have focused on non-invasive measures, such as
subjective state anxiety and physiologic parameters, such as blood pressure,
respiratory rate, and heart rate. The human body also responds to stress with
hormone release. Cortisol, corticotrophin, epinephrine, and norepinephrine
levels increase when patients are under stress. Chlan studied the influence of
music on these biomarkers using a 2-group experimental design with repeated
measures study of 10 patients. The levels of cortisol, corticotrophin,
epinephrine and norepinephrine were measured four times during 60 minutes.
However, there were no significant changes in these four biomarkers in patients
who listened to music and in patients who rested quietly.15 Chlan
also measured 24 hour urinary free cortisol levels as a stress biomarker in 70
patients; music intervention did not significantly reduce urinary free cortisol
levels.16
Our review
of the literature indicates that there were important differences among trials
studying whether music therapy has physiologic benefits. Chan took note of these
differing results and proposed that there may be demographic differences that
would make patients more or less likely to respond to music therapy. In his
randomized trial, he studied Chinese patients admitted to an ICU and was able to
categorize patients into two distinct clusters. He found that older, less
educated females had a greater response to music therapy played over a 30 minute
period with reductions in pulse, blood pressure, and respiratory rate. Those who
were less likely to respond were younger, male, and more educated, with only a
significant reduction in systolic blood pressure noted with music therapy.17
This study suggests that certain population subgroups may be more influenced by
music therapy. The types of music that were offered in the study were limited to
Chinese classical music, religious Tibetan music, Western classical, or Jazz. It
is universally understood that there are different preferences in music. While
one person may enjoy classical music, another person may find the rhythms of
heavy metal to be soothing; this leads us to the questions of whether patients'
personal preferences affect their responses. The general recommendation for
music used to relax patients is soothing music with a sustained melodic quality
and a general absence of strong rhythms, percussions, and lyrics.
To answer whether a specific type of music should be used, Chi performed
a literature review. Her analysis concluded that overall results indicated music
selected on the basis of research yielded better results that music selected
simply on basis of individual preference. The argument was that music that was
selected by an individual could cause stimulation rather than relaxation.
Specifically, she found that music specially designed to enhance relaxation was
effective in treating tension and negative moods. This concept was at least
partly refuted by noting that repetitive exposures to music increased the
listener's comfort level. This finding led them to ask whether patient
preference should play a role in music selection. Their review suggested that
personal preference, familiarity, cultural background, and past experiences
should not be ignored. They suggest that while patient preference should be
considered, the first consideration must always be grounded in research. Their
conclusion was that music chosen by research generally produces more relaxation,
reduces pain or anxiety, and prevents stress induced changes in psychological
responses. Patients should be given options for listening, but each option
should be research driven so that it has the highest chance of achieving the
desired outcome.18
Overall, the evidence suggests that music therapy should routinely be prescribed for patients in the intensive care unit. Nurses have a key role in music implementation. We suggest that music therapy should be triggered by a nursing assessment of either elevated CAM ICU scores, hemodynamic parameters which suggest acute agitation, or patient reported anxiety. Demographics should be considered when implementing music therapy, but demographics should not prevent offering therapy. The type of music should be geared towards relaxation, and patients should be offered music often. Multiple relaxing selections should be offered so that patients can choose which one they feel is most suitable for relaxation and better physiologic outcomes.
Key words- ICU, music therapy, agitation, anxiety
References
1. Siu KC, Suh IH,
Mukherjee M, Oleynikov D, Stergiou N. The effect of music on robot-assisted
laparoscopic surgical performance. Surg Innov 2010; 17, 306-311.
2.
Thaut MH, Gardiner JC, Holmberg D, et al. Neurologic music therapy
improves executive function and emotional adjustment in traumatic brain injury
rehabilitation. Ann N Y Acad Sci 2009; 1169, 406-416.
3.
Trompeo AC, Vidi Y, Locane MD, et al. Sleep disturbances in the
critically ill patients: role of delirium and sedative agents. Minerva
Anestesiol 2011; 77, 604-612.
4.
Jackson P, Khan A. Delirium in critically ill patients. Crit Care Clin
2015; 31, 589-603.
5.
Davis T, Jones P. Music therapy: decreasing anxiety in the ventilated
patient: a review of the literature. Dimens Crit Care Nurs 2012; 31, 159-166.
6.
Su CP, Lai HL, Chang ET, Yiin LM, Perng SJ, Chen PW. A randomized
controlled trial of the effects of listening to non-commercial music on quality
of nocturnal sleep and relaxation indices in patients in medical intensive care
unit. J Adv Nurs 2013; 69, 1377-1389.
7.
Chlan LL, Weinert CR, Heiderscheit A, et al. Effects of patient-directed
music intervention on anxiety and sedative exposure in critically ill patients
receiving mechanical ventilatory support: a randomized clinical trial. JAMA
2013; 309, 2335-2344.
8. Chlan L.
Effectiveness of a music therapy intervention on relaxation and anxiety for
patients receiving ventilatory assistance. Heart Lung 1998 May-Jun;
27(3):169-76.
9.
Wong HL, Lopez-Nahas V, Molassiotis A. Effects
of music therapy on
anxiety in ventilator-dependent patients.
Heart Lung 2001 Sep-Oct; 30(5):376-87.
10.
Almerud S,
Petersson K. Music
therapy--a complementary treatment for
mechanically ventilated intensive care patients.
Intensive
Crit Care Nurs 2003 Feb; 19(1):21-30.
11.
Dijkstra BM,
Gamel C,
van
der Bijl JJ,
Bots ML,
Kesecioglu J. The
effects of music on
physiological responses
and sedation scores
in sedated, mechanically ventilated patients.
J
Clin Nurs 2010 Apr; 19(7-8):1030-9.
12.
White JM. Effects
of relaxing music
on cardiac autonomic balance and anxiety after acute myocardial infarction.
Am
J Crit Care 1999 Jul;8(4):220-30.
13.
Barnason S,
Zimmerman L,
Nieveen J. The
effects of music
interventions on anxiety in the
patient after coronary artery bypass grafting.
Heart Lung 1995 Mar-Apr; 24(2):124-32.
14.
Elliott D. The
effects of music and
muscle relaxation
on patient anxiety
in a coronary care unit.
Heart Lung 1994 Jan-Feb; 23(1):27-35.
15.
Chlan LL,
Engeland WC,
Savik K. Does music influence stress in mechanically ventilated
patients?
Intensive Crit Care Nurs 2013 Jun; 29(3):121-7.
16.
Chlan LL,
Engeland WC,
Anthony A,
Guttormson J.
Influence of music on the
stress response in
patients receiving mechanical ventilatory support: a pilot study. Am
J Crit Care 2007 Mar; 16(2):141-5.
17.
Chan MF, Chung YF, Chung SW, Lee OK. Investigating the physiological
responses of patients listening to music in the intensive care unit. J Clin Nurs
2009; 18, 1250-1257.
18.
Chi GC, Young A. Selection of music for inducing relaxation and
alleviating pain: literature review. Holist Nurs Pract 2011; 25, 127-135.
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Received: 04/27/2016
Accepted: 09/07/2016
Reviewers: Steve Urban MD
Published electronically: 10/15/2016
Conflict of Interest Disclosures: none