Treatment Fidelity in a Music Therapy Multi-site Cluster Randomized Controlled Trial for People Living With Dementia: The MIDDEL Project Intervention Fidelity Protocol

How does group music therapy help in combating the anxiety and depression of dementia patients? A quasi-experimental investigation

This study looked at the effect of group music therapy on dementia patients' levels of feelings of depression and anxiety. Quasi-experiment was carried out (N = 121) in which patients were randomly divided into a control (N = 61) and an experimental group (N = 60). Following a six-weeks, twelve-sessions trial involving both passive and active music therapy, it was discovered that the music group therapy intervention decreased the anxiety and depression levels of dementia patients in the experimental group as compared to the control group, which did not receive any music therapy. It was also noted that after three months of follow-up, participants in the experimental group still maintained a low level of anxiety and depression, but the control group's level remained high, therefore, substantiating the effect of music in lowering anxiety and depression among older ones. We urge the nursing descipline, medical professionals, carers, and care homes to include music therapy in the care they provide for patients with dementia.

Exploring fidelity of enactment in a cluster randomised controlled trial testing the effectiveness of 'gatekeeper' training for pesticide vendors in reducing self-poisoning in rural Sri Lanka: protocol for a multimethod qualitative study

INTRODUCTION

Pesticide self-poisoning causes severe health and socioeconomic hardship in low- and middle-income countries, including Sri Lanka. A stepped-wedge cluster randomised controlled trial (cRCT) has been designed to test whether 'gatekeeper' training for pesticide vendors reduces pesticide self-poisoning in rural Sri Lanka (Vendor cRCT). Ensuring intervention fidelity in RCTs is essential for consistently replicating interventions, accurately assessing their impact and improving outcomes. Thus, the overarching goal of this proposed study is to explore to what extent the pesticide vendors use the 'gatekeeper' strategies.

METHODS AND ANALYSIS

A multimethod qualitative research design is being used to explore the pesticide-selling behaviours of vendors after the 'gatekeeper' training. A subsample of the Vendor cRCT Study population is being recruited using a stratified purposive sampling method in all six intervention districts in Sri Lanka to ensure that the sample is representative of the pesticide vendors in the study area. Participant diaries, observations and focus group discussions are being adopted to collect data. Data triangulation will be performed and data will be analysed thematically.

ETHICS AND DISSEMINATION

The study was approved by the Ethics and Research Committee, Faculty of Medicine and Allied Sciences, at the Rajarata University of Sri Lanka (ERC/2023/09). All participants will provide informed consent. Findings will be disseminated in scientific peer-reviewed journals and conference presentations.

Exploring the usability and feasibility of a mobile music listening application for people living in the community with post-stroke aphasia

PURPOSE

Language and communication disorders can inhibit participation in activities that have potential therapeutic benefits for recovery. This exploratory research examined the usability and feasibility of a purpose-built music listening mobile application for people living in the community with post-stroke aphasia, and examined relationships between useability and participant age, aphasia severity and time post-stroke.

METHODS

Nineteen participants with chronic aphasia tested the application for two weeks. Prior to use, music preferences, technology use and confidence, self-efficacy and music engagement questionnaires were completed. System usability scale, music listening data and a satisfaction rating were completed following use.

RESULTS

Overall, the application was perceived as being usable and feasible with a high system usability rating and moderate effectiveness, efficiency and satisfaction. The system usability scores were not associated with aphasia severity, age, years post-stroke, self-efficacy or music engagement. Technology confidence was positively associated with system usability.

CONCLUSION

The music listening application is a feasible and usable option for listening to music in people with chronic post-stroke aphasia. This study provides a foundation for the rigorous examination of the usability of music listening technology for people with post-stroke aphasia and the potential investigation of use in acute care facilities and other clinical populations.IMPLICATIONS FOR REHABILITATIONMusic listening has potential therapeutic benefits for people with post-stroke aphasia.Applications for music listening require customisation to enable people with post-stroke aphasia opportunity to listen to their preferred music.Music listening applications that are perceived as usable and feasible by people with post-stroke aphasia may have potential application within rehabilitation and community settings.

Implementing NIH Behavior Change Consortium Treatment Fidelity Recommendations in a Multi-Site Randomized Controlled Trial of an Active Music Engagement Intervention for Young Children with Cancer and Parents

Treatment fidelity is the use of methodological strategies to monitor and enhance reliability and validity of behavioral intervention trials. Despite availability of guidelines and checklists, treatment fidelity remains underreported, hindering evaluation, interpretation, and cross-study comparisons. Treatment fidelity is particularly important for music interventions given the inherent complexity of musical stimuli and flexibility required for tailored delivery. The purpose of this paper is to define and describe treatment fidelity strategies for our trial of a music-based play intervention for young children with cancer and parents grounded in the NIH Behavior Change Consortium Treatment Fidelity Recommendations. We report strategies for all 5 areas: study design, training providers, delivery of treatment, receipt of treatment, and enactment of treatment skills. We also discuss 4 challenges our team encountered, including: (1) standardizing live music delivery, (2) defining boundaries for tailored intervention delivery, (3) managing extended time between participants, and (4) minimizing risk for bias. This paper expands on current fidelity literature and may provide a working model for other investigators examining dyadic and/or active music interventions.

Music-based interventions in community settings: Navigating the tension between rigor and ecological validity

Empirical research of community-based music interventions has advanced to investigate the individual, social, and educational implications of arts-for-wellbeing practices. Here, we present the motivations, aims, hypotheses, and implications of this complex field of inquiry. We describe examples of recent large-scale investigations to reflect on the major methodological challenges. Community-based music interventions strike a balance between the empirical rigor of clinical trials and the demands of ecological validity. We argue that this balance should be viewed as an asset rather than a mere pragmatic compromise. We also offer some perspectives on best-practice models for effectively engaging in this type of work.

Putting music to trial: Consensus on key methodological challenges investigating music-based rehabilitation

Major advances in music neuroscience have fueled a growing interest in music-based neurological rehabilitation among researchers and clinicians. Musical activities are excellently suited to be adapted for clinical practice because of their multisensory nature, their demands on cognitive, language, and motor functions, and music's ability to induce emotions and regulate mood. However, the overall quality of music-based rehabilitation research remains low to moderate for most populations and outcomes. In this consensus article, expert panelists who participated in the Neuroscience and Music VII conference in June 2021 address methodological challenges relevant to music-based rehabilitation research. The article aims to provide guidance on challenges related to treatment, outcomes, research designs, and implementation in music-based rehabilitation research. The article addresses how to define music-based rehabilitation, select appropriate control interventions and outcomes, incorporate technology, and consider individual differences, among other challenges. The article highlights the value of the framework for the development and evaluation of complex interventions for music-based rehabilitation research and the need for stronger methodological rigor to allow the widespread implementation of music-based rehabilitation into regular clinical practice.

Dialectical Behavior Therapy Skills Training With Music Therapy Interventions for Adults With Serious Mental Illness: A Quasi-Experimental Nonequivalent Control-Group Pilot Study

Dialectical behavior therapy (DBT) improves emotion regulation by building skills in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. The purpose of this pilot study was to compare a DBT skills group with a combined DBT skills and music therapy (MT) group on participant outcomes of attendance, participation, skill practice, and skill knowledge, as well as determine feasibility of study procedures. We used a quasi-experimental nonequivalent control-group design with all groups co-led by a psychologist and a music therapist. Clinicians facilitated twice weekly 45-min groups in 12-week cycles for a total of eight groups over 2 years. The groups alternated DBT-only and DBT+MT; participant data were analyzed for their first cycle attended. The DBT-only group followed a standard DBT skills training format, whereas the DBT+MT group included music therapy interventions as group exercises. Participants (N = 26) were adults with serious mental illness referred to the inpatient psychosocial rehabilitation group (PSR) at a state psychiatric hospital. Participants completed a demographic form, diary cards, and exit interview; clinicians recorded attendance and session participation. Participants in the DBT+MT condition had significantly higher participation levels, slightly higher average attendance, submitted more diary cards, and included more feeling statements than the DBT-only condition. Although interpretations should be approached with caution, the pilot study intervention shows promise. Overall, this study could be implemented as intended under close monitoring, with minor modifications to assist with recruitment and data collection. Modifications, clinical implications, and recommendations for future research are discussed.

Music therapy for autistic people

BACKGROUND

Social interaction and social communication are among the central areas of difficulty for autistic people. Music therapy uses music experiences and the relationships that develop through them to enable communication and expression, thus attempting to address some of the core problems of autistic people. Music therapy has been applied in autism since the early 1950s, but its availability to autistic individuals varies across countries and settings. The application of music therapy requires specialised academic and clinical training which enables therapists to tailor the intervention to the specific needs of the individual. The present version of this review on music therapy for autistic people is an update of the previous Cochrane review update published in 2014 (following the original Cochrane review published in 2006).

OBJECTIVES

To review the effects of music therapy, or music therapy added to standard care, for autistic people.

SEARCH METHODS

In  August 2021, we searched  CENTRAL, MEDLINE, Embase, eleven other databases and two trials registers. We also ran citation searches, checked reference lists, and contacted study authors to identify additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trials and controlled clinical trials comparing music therapy (or music therapy alongside standard care) to 'placebo' therapy, no treatment, or standard care for people with a diagnosis of autism spectrum disorder were considered for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Four authors independently selected studies and extracted data from all included studies. We synthesised the results of included studies in meta-analyses. Four authors independently assessed risk of bias (RoB) of each included study using the original RoB tool as well as the certainty of evidence using GRADE.   MAIN RESULTS: We included 16 new studies in this update which brought the total number of included studies to 26 (1165 participants). These studies examined the short- and medium-term effect of music therapy (intervention duration: three days to eight months) for autistic people in individual or group settings. More than half of the studies were conducted in North America or Asia. Twenty-one studies included children aged from two to 12 years. Five studies included children and adolescents, and/or young adults. Severity levels, language skills, and cognition were widely variable across studies. Measured immediately post-intervention, music therapy compared with 'placebo' therapy or standard care was more likely to positively effect global improvement (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.06 to 1.40; 8 studies, 583 participants; moderate-certainty evidence; number needed to treat for an additional beneficial outcome (NNTB) = 11 for low-risk population, 95% CI 6 to 39; NNTB = 6 for high-risk population, 95% CI 3 to 21) and to slightly increase quality of life (SMD 0.28, 95% CI 0.06 to 0.49; 3 RCTs, 340 participants; moderate-certainty evidence, small to medium effect size). In addition, music therapy probably results in a large reduction in total autism symptom severity (SMD -0.83, 95% CI -1.41 to -0.24; 9 studies, 575 participants; moderate-certainty evidence). No clear evidence of a difference between music therapy and comparison groups at immediately post-intervention was found for social interaction (SMD 0.26, 95% CI -0.05 to 0.57, 12 studies, 603 participants; low-certainty evidence); non-verbal communication (SMD 0.26, 95% CI -0.03 to 0.55; 7 RCTs, 192 participants; low-certainty evidence); and verbal communication (SMD 0.30, 95% CI -0.18 to 0.78; 8 studies, 276 participants; very low-certainty evidence). Two studies investigated adverse events with one (36 participants) reporting no adverse events; the other study found no differences between music therapy and standard care immediately post-intervention (RR 1.52, 95% CI 0.39 to 5.94; 1 study, 290 participants; moderate-certainty evidence).  AUTHORS' CONCLUSIONS: The findings of this updated review provide evidence that music therapy is probably associated with an increased chance of global improvement for autistic people, likely helps them to improve total autism severity and quality of life, and probably does not increase adverse events immediately after the intervention. The certainty of the evidence was rated as 'moderate' for these four outcomes, meaning that we are moderately confident in the effect estimate. No clear evidence of a difference was found for social interaction, non-verbal communication, and verbal communication measured immediately post-intervention. For these outcomes, the certainty of the evidence was rated as 'low' or 'very low', meaning that the true effect may be substantially different from these results. Compared with earlier versions of this review, the new studies included in this update helped to increase the certainty and applicability of this review's findings through larger sample sizes, extended age groups, longer periods of intervention and inclusion of follow-up assessments, and by predominantly using validated scales measuring generalised behaviour (i.e. behaviour outside of the therapy context). This new evidence is important for autistic individuals and their families as well as for policymakers, service providers and clinicians, to help in decisions around the types and amount of intervention that should be provided and in the planning of resources. The applicability of the findings is still limited to the age groups included in the studies, and no direct conclusions can be drawn about music therapy in autistic individuals above the young adult age. More research using rigorous designs, relevant outcome measures, and longer-term follow-up periods is needed to corroborate these findings and to examine whether the effects of music therapy are enduring.

Therapeutic music interventions with people with dementia living in residential aged care: Perspectives of residents, family members and care home staff from a cluster randomised controlled trial

BACKGROUND

Despite growing support for the benefits of music interventions in dementia care, the perspectives of people with dementia, their families and carers are often missing from the research. This study explored multiple perspectives and first-person experiences of group music interventions delivered within a large cluster randomised controlled trial examining the effectiveness of group music therapy (GMT) and recreational choir singing (RCS) with people with dementia living in residential-aged care (RAC) settings.

METHODS

Focus group and individual interviews with residents with dementia (n = 4), family members (n = 5) and care home staff (n = 15) were conducted following completion of the 6-month GMT and/or RCS intervention and analysed using inductive thematic analysis.

FINDINGS

Three main themes were identified as follows: (1) direct and indirect intrapersonal benefits, (2) direct and indirect interpersonal benefits and (3) therapeutic music interventions versus entertainment. GMT and RCS supported residents' mood, enjoyment, engagement and connectedness to self and others within and post-sessions, with flow-on effects to family members, care staff and the care home environment. Participants differentiated GMT and RCS from other forms of music engagement in the RAC facilities and described feelings of post-programme loss, highlighting ongoing meaning in active therapeutic music interventions.

CONCLUSION

This research highlights the need for increased access to sustainable and meaningful activities, such as purposefully designed therapeutic music interventions in RAC. Improving knowledge about the distinct benefits of therapeutic music interventions compared with other forms of music engagement in RAC may assist nursing staff to make appropriate treatment planning decisions regarding therapeutic music programmes to meet the complex needs of residents with dementia.

Clinical effectiveness of music interventions for dementia and depression in elderly care (MIDDEL): Australian cohort of an international pragmatic cluster-randomised controlled trial

BACKGROUND

Dementia and depression are highly prevalent and comorbid conditions among older adults living in care homes and are associated with individual distress and rising societal costs. Effective, scalable, and feasible interventions are needed. Music interventions have shown promising effects, but the current evidence base is inconclusive. The present study aimed to determine the effectiveness of two different music interventions on the depressive symptoms of people with dementia living in residential aged care.

METHODS

We implemented a 2 × 2 factorial cluster-randomised controlled trial to determine whether group music therapy (GMT) is more effective than no GMT with standard care, or recreational choir singing (RCS) is more effective than no RCS with standard care, for reducing depressive symptoms and other secondary outcomes in people with dementia with mild to severe depressive symptoms living in residential aged care. Care home units with at least ten residents were allocated to GMT, RCS, GMT plus RCS, or standard care, using a computer-generated list with block randomisation (block size four). The protocolised interventions were delivered by music therapists (GMT) and community musicians (RCS). The primary outcome was Montgomery-Åsberg Depression Rating Scale score at 6 months, assessed by a masked assessor and analysed on an intention-to-treat basis using linear mixed-effects models, which examined the effects of GMT versus no-GMT and RCS versus no-RCS, as well as interaction effects of GMT and RCS. We report on the Australian cohort of an international trial. This trial is registered with ClinicalTrials.gov, NCT03496675, and anzctr.org.au, ACTRN12618000156280.

FINDINGS

Between June 15, 2018, and Feb 18, 2020, we approached 12 RAC facilities with 26 eligible care home units and, excluding six units who could not be enrolled due to COVID-19 lockdowns, we screened 818 residents. Between July 18, 2018, and Nov 26, 2019, 20 care home units were randomised (318 residents). Recruitment ceased on March 17, 2020, due to COVID-19. The primary endpoint, available from 20 care home units (214 residents), suggested beneficial effects of RCS (mean difference -4·25, 95% CI -7·89 to -0·62; p=0·0221) but not GMT (mean difference -0·44, -4·32 to 3·43; p=0·8224). No related serious adverse events occurred.

INTERPRETATION

Our study supports implementing recreational choir singing as a clinically relevant therapeutic intervention in reducing depressive symptoms for people with dementia in the Australian care home context.

FUNDING

National Health and Medical Research Council, Australia.

Strategies for implementing music-based interventions for people with dementia in long-term care facilities: A systematic review

OBJECTIVES

Research has found that music-based interventions can decrease behavioral and psychological symptoms of dementia or behaviors that challenge (BPSD/BtC). However, how to effectively implement these interventions is unclear. This study synthesizes available evidence regarding implementation strategies and outcomes of music-based interventions for people with dementia at residential long-term care facilities.

METHODS

Study registered with PROSPERO (registration number: CRD42020194354). We searched the following databases: PsychInfo, PubMed, MEDLINE, CINAHL, and The Cochrane Library. Inclusion criteria included articles targeting music-based interventions conducted for people with dementia, studies conducted in residential long-term care facilities, and articles that reported implementation strategies and outcomes of the intervention.

RESULTS

Of the included eight studies, half were studies of music therapy and the other half were on individualized music. 49 implementation strategies were reported. The most frequently reported category of strategies was planning (34.7%), followed by education (24.5%), quality management (24.5%), restructuring (12.2%), and finance (4.1%). No strategies under the category of attending to the policy context were reported. The most frequently reported implementation outcomes were appropriateness (27.3%), followed by adoption (22.7%), fidelity (22.7%), acceptability (9.1%), sustainability (9.1%), and cost (9.1%). No studies measured feasibility or penetration.

CONCLUSIONS

Although various effective implementation strategies were identified, we were unable to examine the effectiveness of individual implementation strategies due to the designs of the selected studies. Less attention has been paid to strategies that aim at structural changes of intervention delivery systems. Future studies should investigate facilitators and barriers of implementing music-based interventions especially focusing on structural aspects.

Treatment fidelity in the Tinnitus Retraining Therapy Trial

BACKGROUND

Treatment fidelity, defined as ensuring that the recipient receives the intended intervention, is a critical component for accurate estimation of treatment efficacy. Ensuring fidelity and protocol adherence in behavioral trials requires careful planning during the design phase and implementation during the trial. The Tinnitus Retraining Therapy Trial (TRTT) randomized individuals with severe tinnitus to tinnitus retraining therapy (TRT, comprised of tinnitus-specific educational counseling (TC) and sound therapy (ST) using conventional sound generators (SGs)); Partial TRT (TC and placebo SGs); or standard of care (SOC), using a patient-centered care approach. Study audiologists administered both types of counseling in the TRTT, creating a challenge for managing protocol adherence.

METHODS

We developed methods to enhance treatment fidelity including training, competency assessment, scripts, visual aids, and fidelity monitoring. Protocol monitors identified critical topics and content to be addressed for each type of counseling session, prepared corresponding scripts, and developed training aids and treatment-specific checklists covering those topics. Study audiologists' competency assessment required submission and review by the protocol monitors of an audiotape of one TC and one SOC counseling session. Treatment-specific aids included scripts, a 3-D model of the ear, handouts, and for TC, an illustrated flip-chart with talking points that followed the scripted content. During the trial, audiologists completed treatment-specific checklists during each counseling session, indicating topics covered/discussed and submitted audiotapes of counseling sessions. Protocol monitors reviewed audiotapes using corresponding treatment-specific checklists. Results for individual checklist items were tabulated and proportions calculated.

RESULTS

Twenty-five audiologists were certified for TC and/or SOC counseling and 24 completed at least one counseling session. Adherence to each of 33 critical items on the TC checklist as assessed by the protocol monitor ranged from 70 to 100% across 37 counseling sessions (median 97%), with no difference between adherence for TRT (median, 97%) and partial TRT (median, 100%). Adherence to each of 44 critical items on the SOC checklist across 30 SOC counseling sessions ranged from 42 to 100% (median, 87.5%).

CONCLUSION

The TRTT used multiple methods to address treatment fidelity. The close adherence to each treatment type was critical for evaluating the efficacy of the study interventions in this randomized trial.

TRIAL REGISTRATION

clinicaltrials.gov NCT01177137 . Registered on 5 August 2010.