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EFFECTS OF MUSIC THERAPY VS. MUSIC MEDICINE ON PHYSIOLOGICAL AND PSYCHOLOGICAL PARAMETERS OF INTENSIVE CARE PATIENTS: A

RANDOMIZED CONTROLLED TRIAL

A Dissertation

Submitted to

the Temple University Graduate Board in Partial Fulfillment of the Requirements for the Degree

DOCTOR OF PHILOSOPHY

by

Carol L Shultis

May, 2012

Examining Committee Members:

Cheryl Dileo, Advisory Chair, Music Therapy

Darlene Brooks, Music Therapy

Cynthia Folio, Music Studies

Edward Flanagan, Boyer College of Music & Dance

ii

ABSTRACT

This randomized controlled trial examined the effects of Music Therapy (MT), Music Medicine (MM), or Attention Control (AC) on physiological and psychological parameters of stress for adult and older adult patients receiving care in the Intensive Care Unit of a community general hospital. Previous studies have indicated effectiveness of music therapy or music medicine for these medical patients, but few data are available for music therapy interventions. This study was an attempt to add to available information about the effects of music therapy compared to the effects of music medicine or attention control for this patient population. Participants (twenty-eight adults, ranging in age from

37-83 years; not mechanically ventilated at the time of session) were randomly assigned

to music therapy, music medicine or the attention control group. Repeated measures of heart rate, blood pressure, respiratory rate, oxygen saturation, and anxiety and pain levels were collected before the session, immediately after the session and at 60 minutes post- session. Anxiety was measured using the Faces Anxiety Scale, and pain was self- reported via a Visual Analog Scale. Post-session length of stay was collected from the groups and outcome measures. There was a statistically significant difference between length of stay for music therapy participants and attention control. Over time from pre- session to post-session, statistically significant decreases in anxiety scores were measured for both music medicine and music therapy groups. Pain scores decreased for both music medicine and music therapy groups, however not significantly. Some medically beneficial effects of music therapy or music medicine were evident in the data. iii

ACKNOWLEDGEMENTS

With sincere thanks from the depths of my heart and soul to all who journeyed with me - To Dr. Cheryl Dileo, for her wisdom and sustained support throughout this project; this work would not have been completed without her advice, guidance and perseverance. To Dr. Darlene Brooks, Dr. Cynthia Folio and Dr. Edward Flanagan for valuable feedback and perspective which expanded my thinking about this project. To Temple music therapy faculty: Dr. Kenneth Bruscia for his on-going support and wise counsel, to Dr. Kenneth Aigen for his questions and to Dr. Wendy Magee for her advice. To Dr. Michael Hansen, Debra Bayer, RN and the staff of the Intensive Care Unit of Western Pennsylvania Hospital, Forbes Regional Campus in Monroeville, PA, for your openness to having music therapy research on your unit. Your support and input were an integral part of my learning. To Melyssa Weller and Michelle Muth, for your assistance as data collectors for this research; I could not have done this without you. Your assistance in providing music therapy treatment to other ICU patients was appreciated as well. To the thousands of medical patients I have been privileged to treat over the past 30 years, I offer my deepest gratitude and appreciation. You allowed me to share in your struggles and triumphs and taught me about the power of music and my role as a music therapist. Special thanks to Dr. Jennifer Cromley, Temple University College of Education, for sharing her knowledge and teaching me to appreciate and understand statistical analysis. iv To Eric Ruggieri for his statistical advice and patient listening ear as I found my way along the analytic path. I acknowledge with gratitude my fellow travels on this PhD journey, both the doctoral d my thinking and exchanged ideas all while helping me to maintain balance in the face of many academic and research responsibilities. Thanks also to my music therapy colleagues and friends who served as cheerleaders acles and responsibilities threatened to sidetrack my efforts. Most importantly, I am thankful for my husband Gary, for sustaining our family through these years of academic work, doing the laundry and making the phone calls and offering his unique perspective on the work I faced. v

TABLE OF CONTENTS

ABSTRACT ...................................................................................................................... II

ACKNOWLEDGEMENTS ........................................................................................... III

TABLE OF CONTENTS ................................................................................................ V

LIST OF TABLES ........................................................................................................ XII

LIST OF FIGURES ....................................................................................................... XV

CHAPTER 1 ...................................................................................................................... 1

HEALTH, STRESS AND MUSIC .................................................................................. 1

Understanding the Mind/Body Connection .................................................................... 1

Stress and Illness ............................................................................................................... 3

Stress and Intensive Care Unit Treatment ..................................................................... 4

Non-Pharmacologic Treatment of ICU Stress ............................................................... 5

Music in the ICU ............................................................................................................... 6

CHAPTER 2 .................................................................................................................... 13

REVIEW OF LITERATURE ........................................................................................ 13

vi

Understanding Stress in Intensive Care Treatment .................................................... 13

ICU Cost Factors........................................................................................................... 13

Prevalence and Causes of Stress in the ICU ................................................................. 14

Psychological Impact ...................................................................................................... 19

Adverse Outcomes .......................................................................................................... 19

Music Medicine for Stress Management ....................................................................... 21

Music and Heart Rate.................................................................................................... 28

Music and Blood Pressure ............................................................................................ 29

Music and Respiration Rate .......................................................................................... 30

Music and Oxygen Saturation ....................................................................................... 30

Music and Pain Management ........................................................................................ 31

Music and Anxiety Management .................................................................................. 31

Music and Length of Stay in ICU ................................................................................. 32

Music Therapy Studies ................................................................................................... 32

Music Therapy and Heart Rate ..................................................................................... 32

Music Therapy and Blood Pressure .............................................................................. 33

Music Therapy and Respiration Rate ............................................................................ 33

Music Therapy and Oxygen Saturation ........................................................................ 33

Music Therapy and Pain Management ......................................................................... 33

Music Therapy and Anxiety Management .................................................................... 34

vii

Music Therapy and Length of Stay in ICU ................................................................... 34

Rationale for Current Study .......................................................................................... 34

Research Questions ......................................................................................................... 35

CHAPTER 3 .................................................................................................................... 37

RESEARCH METHOD ................................................................................................. 37

Participants ...................................................................................................................... 37

Setting and Recruitment ................................................................................................ 37

Procedure ......................................................................................................................... 38

........................................................................................................................... 38

Procedures for Study Approval ..................................................................................... 39

Procedures for Random Assignment ............................................................................ 39

Procedures for Implementation ..................................................................................... 40

Session Procedures........................................................................................................ 41

Music Medicine Group (MM) .................................................................................. 41

Music Listening Selections ....................................................................................... 42

Music Therapy Group (MT) ..................................................................................... 44

Befriending/Attention Control Group (AC).............................................................. 48

Measures .......................................................................................................................... 49

Dependent Variables ..................................................................................................... 49

viii

Data Collection ................................................................................................................ 51

Equipment ....................................................................................................................... 53

CHAPTER 4 .................................................................................................................... 55

RESULTS ........................................................................................................................ 55

DATA ANALYSIS .......................................................................................................... 55

Randomized Allocation .................................................................................................. 57

Follow-Up......................................................................................................................... 57

Analysis ............................................................................................................................ 57

Analysis ............................................................................................................................ 57

Musical Demographics ................................................................................................... 58

Decision Tree Procedures ............................................................................................... 59

Physiological Measures ................................................................................................... 61

Heart Rate Data Analysis .............................................................................................. 63

Blood Pressure Data Analysis ....................................................................................... 65

Respiratory rate data analysis. ...................................................................................... 68

Oxygen Saturation Data Analysis ................................................................................. 70

Psychological Measures .................................................................................................. 72

ix

Anxiety Scores Data Analysis ...................................................................................... 72

Pain Scores Data Analysis ............................................................................................ 75

Pain level was measured using a Visual Analog scale. These data were collected by the researcher immediately prior to the research condition and repeated by a student research assistant after the research condition and at 60 minutes post session. ........... 75

Length of Stay Data Analysis ......................................................................................... 77

CHAPTER 5 ................................................................................................................... 81

DISCUSSION .................................................................................................................. 81

Description of Participants............................................................................................. 81

Heart Rate Discussion..................................................................................................... 83

Blood Pressure Discussion .............................................................................................. 84

Respiratory Rate Discussion .......................................................................................... 85

Oxygen Saturation Discussion ....................................................................................... 86

Anxiety Scores Discussion .............................................................................................. 87

Pain Scores Discussion .................................................................................................... 89

Length of Stay as a Dependent Variable....................................................................... 90

Music Choices and Interventions .................................................................................. 91

x

Methodological considerations ...................................................................................... 93

Potential Intervening Variables ..................................................................................... 93

Practical Problems ........................................................................................................ 94

Limitations of the Study ................................................................................................. 97

Implications for Research .............................................................................................. 99

Implications for Clinical Practice ................................................................................ 100

Implications for Education and Training ................................................................... 101

Recommendations for Future Research ..................................................................... 104

REFERENCES .............................................................................................................. 109

APPENDIX A ................................................................................................................ 151

REQUEST FOR PROTOCOL REVIEW .................................................................. 151

APPENDIX B ................................................................................................................ 162

RESEARCH SUBJECT INFORMATION CONSENT FORM ............................... 162

APPENDIX C ................................................................................................................ 169

DEMOGRAPHIC/MUSIC QUESTIONNAIRE ........................................................ 169 xi

APPENDIX D ................................................................................................................ 170

MUSIC THERAPY GROUP PARTICIPANT SONG LYRICS .............................. 170 xii

LIST OF TABLES

Table 1 ................................................................................................................................ 9

Sampling of experimental use of music with medical patients. .................................... 9

Table 2 .............................................................................................................................. 23

Effect Size for Cardiology/ICU Studies from Dil-Analysis (2005)

................................................................................................................................... 23

Table 3 .............................................................................................................................. 25

Music Medicine Research 2004 and beyond Cardiology/ICU and Surgical

specializations only.................................................................................................. 25

Table 4 .............................................................................................................................. 44

Music programs used for music medicine intervention .............................................. 44

Table 5 .............................................................................................................................. 53

Data Collection Points .................................................................................................... 53

Table 6 .............................................................................................................................. 59

Music Genre Preferences by Group .............................................................................. 59

Table 7 .............................................................................................................................. 60

Music Therapy Interventions......................................................................................... 60

Table 8 .............................................................................................................................. 61

Baseline Analysis of Variance ........................................................................................ 61

Table 9 .............................................................................................................................. 62

Multivariate ANOVA for Physiological Dependent Variables a................................ 62

Table 10 ............................................................................................................................ 63

xiii

Repeated Measures ANOVA for Heart Rate a ............................................................. 63

Table 11 ............................................................................................................................ 64

Mean Heart Rate Scores by Treatment Group ............................................................ 64

Table 12 ............................................................................................................................ 66

Repeated Measures ANOVA for Blood Pressure Means a .......................................... 66

Table 13 ............................................................................................................................ 67

Mean Arterial Blood Pressure Scores by Treatment Group ...................................... 67

Table 14 ............................................................................................................................ 68

Repeated Measures ANOVA for Respiratory Rate a ................................................... 68

Table 15 ............................................................................................................................ 69

Mean Respiratory Rate Scores by Treatment Group ................................................. 69

Table 16 ............................................................................................................................ 70

Repeated Measures ANOVA for Oxygen Saturation a ................................................ 70

Table 17 ............................................................................................................................ 71

Mean Oxygen Saturation Scores by Treatment Group ............................................... 71

Table 18 ............................................................................................................................ 73

Repeated Measures ANOVA for Faces Anxiety Scores a ............................................ 73

Table 19 ............................................................................................................................ 73

Student t-test comparisons of pre-session to post session anxiety score changes ...... 73

Table 20 ............................................................................................................................ 74

Mean Anxiety Scores by Treatment Group.................................................................. 74

Table 21 ............................................................................................................................ 75

xiv

Repeated Measures ANOVA for Pain Scores a ............................................................ 75

Table 22 ............................................................................................................................ 77

Mean Pain Scores by Treatment Group ....................................................................... 77

Table 23 ............................................................................................................................ 77

Student t-test comparisons of pre-session to post session pain score changes........... 77

Table 24 ............................................................................................................................ 78

One-way ANOVA length of stay a ................................................................................. 78

Table 25 ............................................................................................................................ 80

Kruskal-Wallis One-way ANOVA of Ranks for length of stay .................................. 80

Table 26 ............................................................................................................................ 80

Mean Length of Stay (in hours) by Treatment Group ................................................ 80

xv

LIST OF FIGURES

Figure 1 Session Protocol .............................................................................................. 47

Figure 2 Participant Recruitment and Allocation ...................................................... 57

Figure 3 Heart Rate Scores ............................................................................................ 64

Figure 4 Mean Arterial Blood Pressure ........................................................................ 67

Figure 5 Respiratory Rates ............................................................................................ 69

Figure 6 Oxygen Saturation ........................................................................................... 71

Figure 7 Anxiety Scores .................................................................................................. 74

Figure 8 Pain Scores ....................................................................................................... 76

Figure 9 Length of Stay .................................................................................................. 78

CHAPTER 1

HEALTH, STRESS AND MUSIC

Understanding the Mind/Body Connection

Modern day understanding of health has changed. Over the past 30 years, research and writings have altered the knowledge of what is required to maintain or restore health. After decades of dependence on the medical model, professionals have begun to acknowledge the contributions of psychosocial factors to both health and illness. Perhaps the most striking change is the current understanding of the linkages between -body, complementary, alternative or integrative medicine or psychoneuroimmunology, this movement is based on scientific research that supports knowledge of the interrelationships among thoughts, emotions, social support, spiritual factors and physical well-being (National Institutes of Health, 2007). A central focus of past and current research has been the impact of stress on mind, body and spirit, making stress a major health risk factor (Van Itallie, 2002). Stress has been examined from many perspectives, including attitude, anxiety, sleep disorders, social relationships, support networks and loss (Karren, Hafen, Smith & Frandsen, 2002). This research has shifted the traditional understanding of illness and medicine, producing evidence that mind, body and spirit may play as significant a role in health as do bacteria, viruses and physical changes. 2 In 1985, neuroscientist Candace Pert introduced her ground-breaking research, which demonstrated a link between emotions and cellular activity throughout the body.

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