Methodological challenges for music therapy controlled clinical trials in palliative care

Music Therapy Interventions in Palliative Care: A Systematic Review

BACKGROUND

Palliative care is an interdisciplinary medical approach for people with illnesses that are unresponsive to curative treatment. Music therapy has been gaining ground in this field since the 1970s, with a not-always-standardized range of interventions and musical techniques.

OBJECTIVE

The purpose of this systematic review is to analyze interventions with music therapy and new developments in this area in the field of palliative care.

METHODS

The primary source of data for this review was the online database Web of Science (WOS). We also used other databases such as Medline and Scopus. A systematic search was performed of the past 6 years following the PRISMA criteria.

RESULTS

From a selection of 310 documents, we reviewed 54 completed articles and included 19 studies in the review. The percentage of agreement in the selection of articles was 87.5% and the Cohen Kappa index of inter-rater reliability was 0.727. In 5 of the articles, the musical interventions were not specified. However, in the remaining 14 they were, including new developments such as use of the monochord and the body tambura, and adaptation of the RBL (Rhythm, Breath & Lullaby) method.

CONCLUSIONS

There has been notable improvement in the specification of musical interventions during music therapy sessions in palliative care. However, articles in this field need to describe how these techniques are carried out and any new developments. All this without forgetting that the patient's musical preferences are a fundamental aspect when performing music therapy sessions.

Brief psychosocial interventions improve quality of life of patients receiving palliative care: A systematic review and meta-analysis

Background:

Patients with a terminal disease report a high need for psychosocial and spiritual support. Previous literature reviews on psychosocial interventions in palliative care were restricted to certain subtypes of techniques, included a wide range of patients, conditions, and settings, or required a number of sessions unrealistic to be achieved in patients nearing the end of their lives.

Aim:

The aim of this study was to review and synthesize the evidence on brief psychosocial interventions (i.e. four sessions or less and less than 21 days) for patients receiving palliative treatment.

Design:

We performed a systematic review and meta-analysis in accordance with standard guidelines and a pre-registered protocol (PROSPERO: CRD42018082713).

Data sources:

Electronic databases, journals, and references were searched for controlled clinical trials. We used the Cochrane criteria to assess the risk of bias within studies.

Results:

In total, 15 studies met the eligibility criteria and reported the effects of 17 interventions and a total of 1248 patients. The most frequently used techniques were life review techniques and music therapy. After exclusion of outliers, psychosocial interventions showed to be superior with regard to the improvement of quality of life (effect size = 0.36, confidence interval = 0.08 to 0.64), and the reduction of emotional (effect size = −0.51, confidence interval = −0.77 to −0.26) and existential distress (effect size = −0.40, confidence interval = −0.71 to −0.07) compared to the control groups.

Conclusion:

Brief psychosocial interventions can improve clinically relevant health outcomes and should therefore be made available for patients receiving palliative care.

A randomised controlled pilot and feasibility study of music therapy for improving the quality of life of hospice inpatients

BACKGROUND

Evidence about the effectiveness of music therapy for improving the quality of life of palliative care patients is positive but weak in terms of risk of bias.

METHODS

This study aimed to determine the feasibility of a randomised controlled trial to evaluate the effectiveness of music therapy for improving the quality of life of hospice inpatients, as measured by the McGill Quality of Life questionnaire. Objectives included recruitment of 52 participants over 12 months and provision of data to support the calculation of the required sample size for a definitive randomised trial, taking into account the retention rates of recruited participants; and evaluation of the viability of the intervention and the acceptability of the assessment tool. The design was a single-centre, researcher-blinded randomised pilot and feasibility study involving two parallel groups. Participants were recruited from one inpatient hospice unit in Northern Ireland. Eligibility criteria were an Eastern Cooperative Oncology Group performance status of two or lower and an Abbreviated Mental Test score of seven or more. Consenting patients were randomly allocated to the intervention or control group using a 1:1 allocation ratio. The intervention group received up to six individual music therapy sessions over 3 weeks in addition to usual care. The control group received usual care only.

RESULTS

Fifty one participants were recruited over 12 months. Twenty five were allocated to the intervention group and 26 to the control group. Seventy one percent of participants were lost to follow up by week 3, the proposed primary endpoint. The primary endpoint was moved from week 3, when 71% were lost to follow up to week 1, when 33% were lost. The McGill Quality of Life questionnaire was generally acceptable to participants. In order to detect a small to moderate effect size of 0.3, a fully powered study would require the recruitment of 698 participants.

CONCLUSIONS

A Phase III randomised controlled trial to evaluate the effectiveness of music therapy in improving the quality of life of hospice inpatients is feasible.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02791048 . Registered 6 June 2016.

The analgesic effect of music on cold pressor pain responses: The influence of anxiety and attitude toward pain

OBJECTIVE

The analgesic effect of music has been recognized for pain relief, but individual differences and adjuvant methods are poorly understood. This study employed a cold-pressor task (CPT) to observe the effects of music (without considering personal preferences) on pain experience and how this is affected by individuals' general (and pain-specific) anxiety symptomology.

METHODS

Fifty participants were each presented with three conditions (randomized into different orders): music-listening, news-listening, and no sound (control). Pain responses, including pain tolerance time (PT), pain intensity (PI), and pain unpleasantness (PU), were assessed using CPT and compared with a 3x3 crossover design. Participants also completed the anxiety sensitivity index (ASI-16) and pain anxiety symptom scale (PASS-20).

RESULTS

CPT pain responses during the music intervention were significantly different from responses during the news intervention and control conditions, respectively. Among participants with normal anxiety levels, pain responses during the music condition differed significantly from the news and control groups; this was not the case for the anxiety risk group. Pain responses during the music condition for those with normal levels of pain-specific anxiety differed significantly from the control, but this was not the case for the risk group.

CONCLUSIONS

Music appears to influence diminished pain responses relative to the absence of an intervention. However, this was not the case when individuals listened to news stories. These effects were more robust for individuals experiencing normal levels of general and pain-specific anxiety. Thus, music (even outside one's own preferences) was an effective adjuvant method for managing pain, especially among those without significant anxiety symptomology.

'Song of Life': music therapy in terminally ill patients with cancer

OBJECTIVES

Music therapy (MT) holds a promising potential to meet emotional and existential needs in palliative care patients. The aim of the present pilot study was to assess the feasibility, acceptance and potential effectiveness of a novel MT intervention to improve life closure and spiritual well-being of terminally ill patients with cancer receiving palliative care.

METHODS

The 'Song of Life' (SOL) intervention was provided on two consecutive sessions containing a biographical interview and a live performance of a song with high biographical relevance to the patient in a lullaby style. Pre-to-post intervention assessments comprised brief self-report measures on life closure, well-being, stress, worry and pain.

RESULTS

13 out of 15 patients were able to complete the protocol as intended. The chosen songs were associated with a close person, an important place or event or with a religious belief. The results showed medium-sized improvements with regard to life closure, well-being, relaxation, worry and pain.

CONCLUSION

'SOL' proved to be a feasible and highly accepted intervention for patients approaching the end of their lives. Further consideration with regard to the procedures and outcomes is necessary before implementation of a randomised trial.

Trajectories of Terminally Ill Patients' Cardiovascular Response to Receptive Music Therapy in Palliative Care

CONTEXT

Relaxation interventions are frequently used to promote symptom relief in palliative care settings, but little is known about the underlying mechanisms.

OBJECTIVES

The present analysis aimed at examining the psychophysiological pathways of terminally ill patients' cardiovascular response to a live music therapy vs. prerecorded mindfulness exercise.

METHODS

Eighty-four patients of a palliative care unit were randomly assigned to either of the two interventions. Multilevel modeling was used to analyze trajectories of physiological change. Vagally mediated heart rate variability (VM-HRV) and blood volume pulse amplitude (BVP-A) served as indices of autonomic nervous system response. Participants' gender, age, baseline scores, self-rated pain, and assignment to treatment were entered to the models as predictors.

RESULTS

Both VM-HRV and BVP-A showed significant linear and quadratic trends over time, as well as substantial heterogeneity among individuals' trajectories. Baseline scores, pain, and treatment significantly accounted for random variation in VM-HRV intercepts. BVP-A levels were significantly higher in women than in men. Moreover, assignment to treatment significantly accounted for differences in the linear slopes of peripheral blood flow.

CONCLUSION

Higher levels of VM-HRV in the music therapy group highlight the importance of a therapeutic relationship for the effectiveness of relaxation interventions in end-of-life care settings. Music therapy caused significantly stronger reductions of vascular sympathetic tone and, therefore, may be indicated in the treatment of pain and stress-related symptoms in palliative care. Initial self-ratings of pain moderated patients' physiological response and need to be taken into account in clinical practice and future theory building.

Effects of vibroacoustic stimulation in music therapy for palliative care patients: a feasibility study

Background

The present study aimed at examining whether methodological strategies from a previously implemented study design could be transferred to the evaluation of the psychological and physiological effects of a music therapy intervention working with vibroacoustic stimulation in palliative care.

Method

Nine participants suffering from advanced cancer took part in single-sessions of music therapy, lasting for 30 min. The live music therapy intervention utilized singing chair sounds and vocal improvisation. Visual analogue scales (VAS) were used to assess self-ratings of pain, relaxation, and well-being before and after each session. During the intervention, we continuously recorded heart rate variability (HRV) as a measure of autonomic functioning. Data collection was complemented by a semi-structured interview to explore subjective experiences in more detail. Feasibility was defined as the ability to complete 80 % of the sessions in accordance with the study protocol.

Results

In 5 out of 9 sessions (55 %) it was possible to deliver the intervention and obtain all data as intended. VAS assessment was feasible, although graphical and statistical examination revealed only marginal mean changes between pre and post. HRV recordings were subject to artifacts. While HRV parameters differed between individuals, mean changes over time remained relatively constant. Interview data confirmed that the individual perception was very heterogeneous, ranging from “calming” to “overwhelming”.

Conclusion

The criterion of feasibility was not met in this study. Physiological data showed high attrition rates, most likely due to movement artifacts and reduced peripheral blood flow in some participants’ extremities. Examination of individual-level trajectories revealed that vibroacoustic stimulation may have an impact on the autonomic response. However, the direction and mechanisms of effects needs to be further explored in future studies.

Trial registration

German Clinical Trials Register – DRKS00006137 (July 4^th, 2014).

Music therapy to promote psychological and physiological relaxation in palliative care patients: protocol of a randomized controlled trial

BACKGROUND

Music therapy is one of the most frequently used complementary therapies in different palliative care settings. Despite its long tradition and high acceptance by other health-care professionals, evidence on the effectiveness of music therapy interventions for terminally ill patients is rare. Recent reviews and health-care reports consistently point out the need of music therapists to provide an evidence-based rationale for their clinical treatments in this field. Therefore, the present study evaluates the psychological and physiological response of palliative care patients to a standardized music therapy relaxation intervention in a randomized controlled trial.

METHODS/DESIGN

A sample of 84 participants from a palliative care unit in Heidelberg is randomized to either two sessions of music therapy or two sessions of a verbal relaxation exercise, each lasting 30 minutes. The music therapy sessions consist of live played monochord music and a vocal improvisation, the control group uses a prerecorded excerpt from the mindfulness-based stress reduction program containing no musical elements. Outcome measures include self-report data on subjective relaxation, well-being, pain intensity, and quality of life, as well as continuous recording of heart rate variability and blood volume pulse as indicators of autonomous nervous system functioning.

DISCUSSION

To our knowledge, this study is the first clinical trial in Europe and one of very few randomized controlled trials worldwide to systematically examine the effects of music therapy in palliative care.

TRIAL REGISTRATION

German Clinical Trials Register - DRKS00006137.