Effectiveness of Music Therapy on Pain, Anxiety, Depression and Quality of Life among Patients with Cancer - a Systematic Review of Randomized Controlled Trials

on Pain, Anxiety, Depression and Quality of Life among Patients with Cancer - a Systematic Review of Randomized Controlled Trials.


Introduction
Cancer is the most serious non-communicable disease, causing stress in both patients and their families. It affects a person's physical, physiological, emotional, and social well-being. Music therapy is a simple and cost-effective method for cancer survivors to reduce stress, anxiety, pain, and despair while also increasing their quality of life. Because as cancer progress pain increases which cause psychological and physiological deterioration [1].
Music and sound are used in music therapy to help people express their emotions and promote their emotional and physical well-being [2]. Music therapy includes listening to music or playing simple instruments. When cancer patients listen to music, they feel a lot better because it is tranquil and relaxing. Music stimulates the release of dopamine, which helps patients with cancer feel good, and endorphins, which induces happy moods and relieves pain. It also stimulates the release of oxytocin and leads to a positive and happy feeling. Music therapy is usually offered for 30-60 minutes per day for weeks or months at a time.
Objective: Examine the effects of music therapy on pain, anxiety, depression, exhaustion, and quality of life among patients with cancer.

Materials and Methods
Data Sources: The investigators selected the research studies by search strategy using the phrases such as "music treatment for cancer, music therapy in patients with cancer and influence of music on cancer patients". The databases included studies published between 2011 and 2020 from CINAHL, MEDLINE, Cochrane, and PubMed. In order to ensure specificity and replicability, the databases were reviewed over a period of 3 months. Later a librarian validated it. A three-step search procedure was used. 1) a limited search of CINAHL, MEDLINE, and PubMed; 2) a thorough search of all included databases using all selected keywords; and 3) a manual search of the reference lists of included articles.

Criteria for selection: Inclusion criteria:
• All randomized-controlled studies among adult patients with cancer.
• Studies focused on the effects of music therapy on anxiety, pain, pain and anxiety, anxiety and depression, improving psychological outcomes that included anxiety, pain and fatigue, depression, exhaustion, and quality of life.
• Studies published in English from peer-reviewed journals.

Exclusion criteria:
• The studies on effectiveness of music therapy combined with other complimentary therapies such as naturopathy, acupuncture and aromatherapy.

Results:
The flow chart ( Figure 1) represents the selection and reasons for deletion. 20 studies that met the inclusion criteria were included in this review. Out of 20 included articles, 45% (n=9) were RCTs; 50% (n=10) were SRs and 5% (n=1) were mixed methods. Note, about 90% of these studies were on the effects of music therapy on pain, anxiety, depression and exhaustion and 10% were on effects of music therapy on quality of life among cancer patients. When comparing the test group to the control group, there was a statistically significant reduction in postintervention pain scores (P = 0.034). The reduction in anxiety levels after intervention was not statistically significant in either group [10].   There was a significant reduction in depression and anxiety among the intervention group (p=0.001). Anxiety, depression, and sex (P = 0.001, r = 0.42) were found to have significant relationships, as was education (P = 0.003, r = 0.37) [8].
A mixed methods study on impact of music therapy versus music medicine on psychological outcomes and pain among patients with cancer .

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According to the quantitative data, both interventions were equally effective in improving target outcomes. MT sessions, on the other hand, were preferred by 77.4 percent of participants. According to the qualitative data, music improves symptom management, embodies hope for survival, and aids in connecting to a pre-illness self [2]. The study included 102 female participants (51 with and 51 without music).
Prior to RT, 48 percent of patients using the STAI and 58 percent of patients using the SDT had a high anxiety score. The percent decrease in mean STAI (State-Trait Anxiety Inventory) score with music was 16 percent versus 10% without music (P =.2197).
The mean SDT (Symptom Distress Thermometer) percent changes with music were a 13% decrease versus a 2% increase without music (P =0.3298) [15]. In the third Chemotherapy therapy session, the group music had a lower incidence of depression (P < .001) and anxiety scores (P < .001) and vomiting (P < .01). In the Subjective Impression of the Subject questionnaire, all of the group music participants reported positive changes in their lives, as well as less fatigue and stress [17].

11
Tereza Raquel Alcântara-Silva, Ruffo de Freitas-Junior et al Music Therapy on Radiotherapy-Induced Fatigue among Patients with Breast or Gynecological Cancer.

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FACT-F results were significant for the MTG (music therapy group) in terms of Trial Outcome Index ( P =.011), FACT-G ( P =.005), and FACT-F ( P = 0.001) when compared to the CG (control group) [18]. 68 percent of the participants responded that music therapy was "helpful." Positive associations were found with singing regularly (p = 0.003), living in a partnership (p = 0.017), having children (p = 0.035), psycho-oncologic therapy (p = 0.043), experience with music therapy (p = 0.007), the role of music in life (p = 0.035), playing an instrument (p = 0.021), and living in a partnership (p = 0.017) [9].

13 Burns DS, Perkins SM(2015)
Effect of Music Therapy on Family Perception of More Spiritual Support and Breathing Problems among Cancer Patients Receiving Hospice Care.

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Between patients who received music therapy and those who did not, there were no differences in pain, anxiety, or overall satisfaction with care. Music therapy patients were more likely to report spiritual dialogues (OR = 1.59, P = 0.01), had marginally less problem in breathing (OR = 0.77, P = 0.06), and were marginally more likely to receive appropriate spiritual support (OR = 1.59, P = 0.06).Music therapy was linked to feelings of meaningful spiritual support and less difficulty breathing [5].

14 Gencer D, Diel A et al., (2019)
Prospective survey to evaluate the potential complementary treatment approaches: music interventions among patients with cancer.

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A total of 187 patients expressed an interest in complementary music interventions. In the univariate and multivariate analyses, patients with non-somatic complaints and patients actively playing or making music showed significantly higher interest in complementary music interventions, presumably in the hope of a relaxing therapeutic effect. Instrumentalists would prefer more active forms of music interventions [6].

15
Li XM Yan H,  Effects of music therapy on pain among patients subjected to radical mastectomy. 120 Music therapy was found to significantly(p<0.05) lower the (Pain Rating Index) PRI-total score in the intervention group compared to the control group, with a mean difference (95 percent CI) of -2.38 (-2.80, -1.95), -2.41 (-2.85, -1.96), and -1.87 (-2.33, -1.42) for the first, second, and third post-tests, respectively. The study's findings provide some evidence that music therapy has both short-and long-term positive effects on pain relief in breast cancer patients after a radical mastectomy. [ A randomized clinical trial on effects of music therapy on anxiety among breast cancer patients .

18 Hsieh FC, Miao NF(2019)
A feasibility study in Taiwan on effect of home-based music intervention versus ambient music among breast cancer survivors.

19
Lima TU, Moura ECR(2020) A Randomized Clinical Trial on impact of Music Intervention on Quality of Life among patients with Breast Cancer subjected to Chemotherapy.

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To compare qualitative variables, the Student's t test and chi-squared test were used. Results revealed that in the first and third CT sessions, the GM had higher QoL scores on functional scales than the GC. In the third CT session, the GM had a lower incidence of depression (P= 0.001), anxiety (P=0.001), and vomiting (P=0.01). In the Subjective Impression of the Subject questionnaire, all of the GM participants reported positive changes in their lives, as well as less fatigue and stress [13].
20. 20 Bro ML, Johansen C et al., A randomized controlled, multicenter trial on effects of live music during chemotherapy among patients with lymphoma.

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When age, gender, diagnosis, number of sessions, and baseline anxiety were all controlled for, the linear mixed model revealed a borderline statistically significant reduction in primary outcome anxiety in the live music group compared to standard care. (7% (95% CI, -14% to 0%, p = 0.05), while the effect of pre-recorded music was non-significant (5% (95% CI, -12% to + 3%, p = 0.18). Secondary outcomes revealed no intervention effects. Live music that patients prefer reduces anxiety in patients with malignant lymphomas undergoing chemotherapy [4].

Discussion
This study reviewed systematically the effects of music therapy on variables such as pain, anxiety, depression, exhaustion and quality of life. The overall findings revealed that music therapy has a positive effect in reduction of pain, anxiety, depression and exhaustion in patients with cancer. The Spielberger State Anxiety Inventory-State Anxiety (STAI-S) was used to measure anxiety reduction, while FACT was used to measure quality of life (Functional assessment of chronic illness therapy). Music therapy had minimized the need for anesthetics and analgesics, as well as recovery time and hospitalization duration, according to the findings of a single study, but additional research is needed to support these findings. Many studies did not disclose the information on various domains of quality of life, including physical health, emotional, social and spiritual well-being. However, the study participants of two articles included in this review reported positive changes in terms of reduction of anxiety and depression, which may be associated with better quality of life of patients with cancer.

Strengths
The findings of the present study, strengthens the professional role of nurses as direct care providers and policy makers in caring for cancer patients. It was a comprehensive search strategy across multiple database. The results suggests that music therapy has a positive effect over pain, depression, anxiety and quality of life among cancer patients.

Limitations
The current study has few limitations that must be acknowledged. The relevant databases, a hidden source of bias in this review may involve the failure to include all relevant original trials. Pertinent bias occurs when full text of studies not available. The side effects of music therapy were not studied, furthermore there were no standardized music therapy administered for pain, depression, anxiety and quality of life.

Implications
Oncology and palliative care nurses are uniquely positioned to step into new roles in giving care to cancer patients. The results of this review provides evidence based practice to utilize music interventions to reduce pain, depression and anxiety among patients receiving chemotherapy, radiotherapy and palliative care. The concept of incorporating music therapy must be emphasized in the undergraduate as well as i n postgraduate nursing curricula. Cancer care centers must be equipped with facilities for music therapy.

Recommendations
The long-term effects on the characteristics of music therapy upon the pain, depression, anxiety and quality of life can be studied. The framework of music therapy such as type, frequency, duration and time for each type of cancers can be further researched. The description of cost analysis of the intervention with the outcome of various cancers can be conducted.

Conclusion
This systematic review found that music therapy is an active intervention to reduce anxiety, pain and fatigue, and improves the quality of life in cancer patients. Though it is harmless, cost effective and can be implemented easily, further studies and metaanalyses should be conducted to enhance evidence-based practice.