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Music, Health, and Wellbeing$

Raymond MacDonald, Gunter Kreutz, and Laura Mitchell

Print publication date: 2012

Print ISBN-13: 9780199586974

Published to Oxford Scholarship Online: May 2012

DOI: 10.1093/acprof:oso/9780199586974.001.0001

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The Use of Music in Chronic Illness: Evidence and Arguments

The Use of Music in Chronic Illness: Evidence and Arguments

Chapter:
Chapter 18 The Use of Music in Chronic Illness: Evidence and Arguments
Source:
Music, Health, and Wellbeing
Author(s):

Maria Pothoulaki

Raymond MacDonald

Paul Flowers

Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780199586974.003.0018

Abstract and Keywords

This chapter presents a review of the current literature addressing the therapeutic use of music among those affected by: chronic illness, cancer, and cardiac disease. It includes a systematic analysis of each of these areas, highlighting music listening (both music therapy and other types of music listening) as the most prevalent type of music activity reported. Results suggest beneficial effects of music listening upon a range of physiological (e.g., blood pressure, heart rate, enzyme production, respiration) and psychological variables (e.g., anxiety, mood, relaxation, pain). Theoretical integration and synthesis is then explored, with three mechanisms presented as possible explanations for the positive effects of music listening: musical communication as a form of social support; emotional engagement with music; and increased levels of perceived control.

Keywords:   music therapy, music listening, cancer, heart disease, musical communication, emotional engagement, perceived control

According to the World Health Organization (WHO), cardiovascular disease and cancer are two of the main causes of death worldwide, being responsible for 30% and 13% respectively, of the total deaths in 2005 (WHO 2005). The impact of cancer and chronic illness is likely to grow over the next century, particularly in the developed world where the morbidity and mortality associated with acute and infectious disease is still decreasing (National Center for Health Statistics 2006). Chronic diseases are varied, including cancer and neoplasms, cardiovascular diseases, respiratory diseases, autoimmune diseases, renal failure, diabetes, hepatitis, arthritis, osteoporosis, psychiatric disorders, mental health disorders, chronic fatigue syndrome, and chronic pain. Music interventions have been applied to many of these health conditions, addressing the needs of individuals with cancer (Pothoulaki et al. 2005; Joske et al. 2006), mental illness (Gold et al. 2009; Silverman 2009), renal failure (Schuster 1985; Pothoulaki et al. 2008) multiple sclerosis (Aldridge et al. 2005), traumatic brain injury (Guetin et al. 2009), chronic pain (McCaffrey 2008; Siedliecki 2009), cardiac disease (Barnason et al. 2006; Bruscia et al. 2009), and those in rehabilitation suffering from diverse muscular and neurological diseases (Batt-Rawden 2006). In a meta-analysis by Dileo (2006), 12 different clinical settings were identified examining the effects of music and/or music therapy, with five of them referring to chronic illness; cardiology intensive care units, HIV, rehabilitation-neurological diseases and chronic pain, Alzheimer’s disease, and cancer. This chapter presents a current review of the literature addressing the therapeutic use of music among those affected by: (1) chronic illness, (2) cancer, and (3) cardiac disease. The chapter includes a systematic analysis of each of these areas, highlighting music listening (both music therapy and other types of music listening) as the most prevalent type of music activity reported. Results suggest beneficial effects of music listening upon a range of physiological (e.g. blood pressure, heart rate, enzyme production, respiration) and psychological variables (e.g. anxiety, mood, relaxation, pain). Theoretical integration and synthesis is then explored, with three mechanisms presented as possible explanations for the positive effects of music listening: (1) musical communication as a form of social support; (2) emotional engagement with music; (3) increased levels of perceived control.

Systematic literature review

Taking into consideration the diverse clinical settings that have utilized music interventions, the following section presents a systematic literature review conducted in three stages, focusing on chronic illness, cancer, and cardiac disease. Searches were conducted using four electronic databases: PSYCHINFO, WEB OF SCIENCE, SCIENCEDIRECT, and EBSCO (including AMED, (p.240) CINAHL, Health Source and MEDLINE databases). Selection criteria involved research reports of journal articles from empirical quantitative and/or qualitative studies published within the period 2006–2009 and written in English; building on earlier reviews by Pothoulaki et al. (2005, 2006). Information on the applied systematic process for all three thematic stages can be found in Table 18.1.

Music and chronic illness

The first stage of the search involved the terms ‘music’ and ‘chronic illness’ that initially revealed 821 papers. The term ‘music’ was utilized in order to include all types of music activity, both listening and participation. The 821 papers represent the total number of papers initially identified from all databases regardless of keywords included in papers. After the initial identification, all papers were examined in terms of keywords and title relevance. So, for instance, papers that involved the above keywords were included in the search as well as papers that did not involve the above keywords but their title was relevant to the search topic. Further to this stage, papers were then examined in order to identify empirical research reports, quantitative and/or qualitative, published in scientific journals. All the above stages took place for each of the thematic sections presented below. In terms of ‘music and chronic illness’, the above stages revealed 10 papers examining music interventions in relation to chronic illness. The search also revealed one literature review and one meta-analysis of extant research. Table 18.2 provides a summary of the 10 identified studies, in terms of location, sample type, research design, and dependent variables when applicable.

Findings indicate that seven out of the 10 reported studies were randomized controlled trials (RCTs); experimental protocols viewed as the most scientifically robust way of investigating the efficacy of interventions within healthcare contexts (Schulz et al. 2010). In addition, six studies were conducted in the USA, one in Germany, one in Norway, one in China, and one in Taiwan. The underlying health conditions that were addressed in relation to music were: mental disorders (Silverman 2009), cancer and cardiac disease (Bruscia et al. 2009), chronic pain (Siedliecki and Good 2006; Siedliecki 2009), paediatric patients with sleep apnoea (Smith et al. 2009), migraine (Oelkers-Ax et al. 2007), and cerebral palsy (Yu et al. 2009), rehabilitation patients with different types of diseases, such as muscular diseases, chronic fatigue, neurological diseases, etc. (Batt-Rawden 2006), and lastly, dementia patients (Sung et al. 2006; Yu et al. 2009). In addition, with reference to sample characteristics (when available), female participants outnumbered male participants. This is in keeping with previous literature reviews (Pothoulaki et al. 2005). The above

Table 18.1 Information on the applied systematic process

Literature reviews

Databases

Time period

Keywords used

Selection criteria

Music and chronic illness

PSYCHINFO, WEB OF SCIENCE, SCIENCEDIRECT and EBSCO (including AMED, CINAHL, Health Source and MEDLINE databases)

2006–2009

Music and Chronic Illness

Research reports of journal articles from empirical quantitative and/or qualitative studies written in English

Music and cancer

Music and Cancer

Music and cardiac disease

a) Music and cardiac disease

b) Music and heart disease

(p.241)

Table 18.2 Summary of relevant identified studies ‘music and chronic illness’

Study

Sample details

Research design

Dependent variables

Silverman ( 2009 ) USA

n=105

(psychiatric patients)

RCT

Satisfaction with life

Knowledge of illness

Treatment perceptions

Response type and frequency

Bruscia et al. ( 2009 ) USA

n=182 (f=57%, m=43%)

(cancer patients=55)

(cardiac patients=127)

b) mean age=59.8

Survey

*Siedliecki ( 2009 ) USA

n=60 (f=46, m=14)

(African American and Caucasian patients with chronic pain)

b) 21–65 years

RCT—secondary analysis of data

Racial variation in response to music

Racial variation in post-treatment pain scoring

Smith et al. ( 2009 ) USA

n=97 (f=44, m=53)

(sleep apnoea patients)

RCT

Adherence to CPAP

Physical health

Mental health

Depression

Patient satisfaction

Park ( 2009 ) USA

n=15 (f=11, m=4)

(dementia patients)

b) 60–100 years

Quasi-experimental design—pilot study

(within-subjects/repeated measures design)

Pain

Yu et al. ( 2009 ) China

n=60

(children patients with cerebral palsy undergoing acupuncture)

RCT

Anxiety

Blood pressure

Heart rate

Oelkers-Ax et al. ( 2008 ) Germany

n=58

(paediatric migraine patients)

8–12 years

RCT

Headache frequency

Depression

Stress

Behavioural and emotional problems

Batt-Rawden ( 2006 ) Norway

n=22 (f=13, m=9)

(rehabilitation patients)

34–65 years

Qualitative study

(ethnography and grounded theory)

*Siedliecki and Goood ( 2006 ) USA

n=60 (f=46, m=14)

(African American and Caucasian patients with chronic pain)

b) 21–65 years

RCT

Pain

depression

disability

power

Sung et al. ( 2006 ) Taiwan

n=36 (f=10, m=26)

(institutionalized elders with dementia)

76–79 years

RCT

Agitation

F, female; m, male, RCT, randomized controlled trial.

(p.242) finding could have epidemiological foundations, relating to specific disease prevalence and gender. Alternatively females are perhaps more inclined to engage with in complementary therapies than men.

Music utilized in these studies involved predominantly music listening interventions that did not include a music therapist, with the exception of the studies by Silverman (2009) and Oelkers-Ax et al. (2008). Listening interventions were varied, e.g. Siedliecki and Good (2006) utilized both self-selected music and pre-selected music whereas Yu et al. (2009) and Park (2009) employed preferred music listening. Other studies applied alternative types of music listening, such as music-based audiotape with instructions for continuous positive airway pressure (CPAP) and instructions for muscle relaxation (Smith et al. 2009), group music with movement interventions (Sung et al. 2006), and CD listening in combination with patients’ narratives (Batt-Rawden 2006). Studies mainly examined psychological variables such as anxiety, pain, agitation, perception of power, mood, depression, disability, and other parameters related to health and quality of life, in addition to physiological variables, such as sleep, headaches, blood pressure, and heart rate. These variables are concurrent with the 40 outcome variables presented in the meta-analysis of Dileo (2006) focusing on the effects of music and music therapy in medical patients.

Findings of the above studies revealed that the use of music and music therapy significantly influenced many of the outcome measures and positively enhanced standard care. More specifically, in the study by Siedliecki and Good (2006) with patients suffering from chronic non-malignant pain, researchers reported that participants in both music groups experienced and perceived significantly more power, less pain, less depression and disability than the control group. In addition, Yu et al. (2009) reported that preferred music listening significantly reduced anxiety for children undergoing acupuncture, with supporting physiological measures showing reduced blood pressure and heart rate. Park (2009) reported a significant post-test (after music listening) pain decrease and Smith et al. (2009) reported a significant increase of patients adhering to CPAP procedures at the end of the first month. Sung et al. (2006) reported a significant reduction in the occurrence of agitated behaviour in older adults with dementia over time. A qualitative study by Batt-Rawden (2006) reported an increase in self-awareness, consciousness, and quality of life and a motivation for social interaction with direct implications for recovery and healing. With reference to the studies that applied music therapy as an intervention, Oelkers-Ax et al. (2008) reported a significant reduction of headache frequency during treatment period. Finally Silverman (2009) suggested that music therapy can be successfully used in psychoeducational contexts with psychiatric patients.

Music and cancer

Before presenting the current literature review it is worth outlining our previous review (Pothoulaki et al. 2005), which reviewed 24 papers published between 1985–2002 investigating music and cancer. Key positive effects reported were the reduction in side effects of chemotherapy (Frank 1985; Standley 1992) such as reduction in patients’ perceived degree of vomiting, reported (p.243) nausea, and reported anxiety (Frank 1985; Palakanis et al. 1994; Sabo and Michael 1996) as well as reductions in state anxiety and psychological effects such as emotional changes, improvement in wellbeing and quality of life (Pfaff et al. 1989; Bunt and Marston-Wyld 1995; Weber et al. 1997; Burns et al. 2001; O’Callaghan 2001; Barrera et al. 2002); physiological effects (Bartlett et al. 1993; Burns et al. 2001; Kuhn 2002) with particular reference to the enforcement of the immune system; behavioural improvements (Pfaff et al. 1989; Robb 2000; Burns 2001; Waldon 2001; Barrera et al. 2002) and communication and expression improvements (Bunt and Marston-Wyld 1995; O’Callaghan 1996; Weber et al. 1997; Tobia et al. 1999; Gallagher and Steele 2001).

Critical design and methodology issues were also identified, including the questionable reliability and validity of assessment tools used as well as the method of administration, limited description of the actual process of the music intervention, and limited follow-up data (Pothoulaki et al. 2006). These are important hurdles to overcome if the results of studies are to be viewed as reliable in term of developing evidence based music interventions.

The present literature review initially revealed 1612 papers. Following a thorough analysis by applying the previously mentioned search criteria (please see Table 18.1), a total of 26 distinct research reports were identified as directly relevant to the topic of music and cancer. Table 18.3 provides methodological details of the studies in terms of location, sample type, research design, and dependent variables when applicable.

Table 18.3 Summary of relevant identified studies ‘music and cancer’

Study

Sample details

Research design

Dependent variables

Bulfone et al. ( 2009 ) Italy

a) n=60 (female breast cancer patients during adjuvant post-surgical chemotherapy treatment)

RCT

Anxiety

Nakayama et al. ( 2009 ) Japan

a) n=10 (Hospice residents)

Quantitative study (within-subjects design)

Mood

stress

Burns et al. ( 2009 ) USA

a) n=12 (f=5, m=7) (adolescents and young adults hospitalized receiving stem cell transplantation)

b) 13–24 years

RCT

Anxiety

Pain

Mood

Defensive and courageous Coping

Derived meaning

Resilience

Quality of life

O’Callaghan et al. ( 2009 ) Australia

a) n=27 (f=20, m=7) (cancer patients/parents)

Qualitative study

Wan et al. ( 2009 ) China

a) n=136 (cancer patients)

RCT

Anxiety

depression

pain

Horne-Thompson and Grocke ( 2008 ) Australia

a) n=25 (hospice residents)

RCT

Anxiety

Symptoms (pain, tiredness, drowsiness)

Magill and Berenson ( 2008 ) USA

Qualitative study—case study reports

Magill et al. ( 2008 ) USA

a) n=39 (critically ill cancer patients)

Mixed-methods

Cancer distress

Lu et al. ( 2008 ) China

a) n=38 (cancer patients)

Quantitative study (within-subjects design)

Quality of life

O’Callaghan ( 2008 ) Australia

Qualitative analysis—grounded theory

Robb et al. ( 2008 ) USA

a) n=83 (paediatric oncology patients)

b) 4–7 years

RCT

Coping related behaviours (positive facial affect, active engagement, initiation)

Burns et al. ( 2008 ) USA

a) n=49 (f=30, m=19)

(patients receiving intensive myelosuppressive chemotherapy)

b) mean age=55.5

RCT

Positive and negative affect

Fatigue

Anxiety

Cooper and Foster (2008) UK

a) n=250

(patients waiting to undergo chemotherapy or radiotherapy)

Quantitative study

Anxiety

Wlodarczyk ( 2007 ) USA

a) n=10 (f=8, m=2) (hospice residents)

b) 26–75 years

Within-subjects design

Spiritual wellbeing

Oneschuk et al. ( 2007 ) Canada

a) 136 (Canadian palliative care settings)

Online survey

O’Callaghan et al. ( 2007 ) Australia

a) n=102 (paediatric radiotherapy patients=39, family members and friends= 63)

b) ≥14 years

Qualitative study—Case study reports

O’Callaghan and Dermott ( 2007 ) Australia

a) n=257 (patients who experienced MT=128, patients who overheard=27, hospital visitors=41, staff=61)

Qualitative study—discourse analysis

Daykin et al. ( 2007 ) UK

a) n=23 (cancer patients in a CAM centre)

Qualitative study—grounded theory

Windich-Biermeier et al. ( 2007 ) USA

a) n=50 (children and adolescents cancer patients)

Intervention-comparison group design (between-subjects design)

Pain

fear

distress

Gallagher et al. ( 2006 ) USA

a) n=200 (f=59%, m=41%) (patients with chronic and advanced illnesses)

b) 24–87 years

Quantitative study (within-subjects design)

Mood

Anxiety

Depression

Pain

Shortness of breath

Daykin et al. ( 2006 ) UK

a) 80 UK cancer care organizations (hospices, hospitals, and cancer help centres)

Survey

Nelson ( 2006 ) USA

a) n=15 (f=8, m=7) (hospice residents)

b) 26–83 years

Qualitative study—ethnography

Hanser et al. ( 2006 ) USA

a) n= 70 (female patients with metastatic breast cancer)

26–77 years

RCT (longitudinal)

Psychological functioning

Quality of life

Physiological stress arousal

Shaban et al. ( 2006 ) Iran

a) n=100 (cancer patients)

Quantitative study (between-subjects design)

Pain relief

Clark et al. ( 2006 ) USA

a) n=63 (patients undergoing radiation therapy)

RCT

Emotional distress (anxiety, depression and treatment related distress)

Symptoms (fatigue, pain)

Bozcuk et al. ( 2006 ) Turkey

a) –

(breast cancer patients during chemotherapy)

Within-subjects design

Quality of life and parameters (insomnia, appetite)

F, female; m, male, RCT, randomized controlled trial.

(p.244)

(p.245) In terms of location, most studies were conducted in the USA (n=11), five studies in Australia, five in Asia and Middle East (including countries such as Japan, China, Iran, and Turkey), four studies in Europe, and one in Canada. Location of studies provides a geographical ‘mapping’ of relevant research; for instance, the USA and Australia have increased research activity in music therapy, and an active music therapy ‘corpus’. In addition, studies conducted in Asia mainly derive from the medical field.

A total of 1619 patients participated in the above identified studies. Most studies involved cancer patients, with various types and stages of cancer, although there were studies that involved also other types of patients such as HIV patients and those with pain disorders, Gardner’s syndrome, sickle cell diseases and other chronic and advanced illnesses (Gallagher et al. 2006; Wlodarczyk 2007). Furthermore, four studies involved paediatric cancer patients such as children and adolescents and in some cases young adults (O’Callaghan et al. 2007; Windich-Biermeier et al. 2007; Robb et al. 2008; Burns et al. 2009).

(p.246) With reference to study design, 18 studies were quantitative, out of which the majority described their design as an RCT. The remaining quantitative studies involved five studies using within-subjects design, three studies using between-subjects design, and two surveys. Seven studies were qualitative in nature. Three of the studies involved case study reports, two involved grounded theory analysis, one involved discourse analysis, and one ethnography. Finally, only one study applied a mixed-methods approach by using both quantitative and qualitative methods.

Although most studies (n=15) reported using music therapy as an intervention, they did not specify the types of music therapy utilized. Two studies applied preferred music listening, four studies applied pre-selected music listening, and two studies involved music with other techniques and/or interventions with the involvement of a music therapist.

Most quantitative studies applied measures for anxiety or distress either as a distinct outcome variable or these were combined with other psychological outcome variables such as depression, pain, mood and fatigue (Clark et al. 2006; Gallagher et al. 2006; Hanser et al. 2006; Horne-Thompson and Grocke 2008; Magill et al. 2008; Bulfone et al. 2009; Burns et al. 2009; Nakayama et al. 2009; Wan et al. 2009). Other studies measured quality of life as a single outcome variable or in addition to other dependent variables (Bozcuk et al. 2006; Lu et al. 2008; Burns et al. 2009; Hanser et al. 2006). Two studies also applied physiological measures in addition to psychological, namely cortisol levels (Nakayama et al. 2009) and heart rate measurements (Hanser et al. 2006).

Music and cardiac disease

Cardiac disease is a major area under the broader spectrum of chronic illness, and as such it is the third topic of investigation of this literature review. In terms of providing an overview of the extant research, previous research literature on music and cardiac disease published within 1985–2004 focused primarily on music’s physiological effects in relation to cardiac disease. It is of interest that all relevant studies identified within this period were quantitative in nature. Suggested evidence supported the effectiveness of music in a variety of psychosocial outcome measures: anxiety reduction (Robichaud-Ekstrand 1999; Knight and Rickard 2001; Tsai 2004); mood changes (MacNay 1995; Mockel et al. 1995; Cadigan et al. 2001); relaxation increase (Robichaud-Ekstrand 1999; Tsai 2004); psychological parameters such as reduction in ‘fear’ and ‘worries’, reported sleep improvement and perceived exertion (MacNay 1995; Vollert et al. 2003; Metzger 2004; Tsai 2004); and physiological parameters such as blood pressure, heart rate, and hormones in patients and healthy individuals (Guzzetta 1989; Mockel et al. 1995; Escher and Evequoz 1999; Robichaud-Ekstrand 1999; Cadigan et al. 2001; Knight and Rickard 2001; Schein et al. 2001; Vollert et al. 2002; Vollert et al. 2003; Chafin et al. 2004).

Across this corpus of work there were noticeable methodological limitations, such as issues related to study design and uncontrollable factors/confounding variables, issues related to the rationale for the selection of music interventions, reliability, validity and appropriate administration of assessment tools and limited follow-up data. Unfortunately this raises questions regarding the credibility of the evidence and implies the need for a more thorough approach, with particular reference to research design and the appropriate use of psychometric instruments.

The present search provides additional evidence on the body of literature reviewed above. Keywords used for this search involve: ‘music’ and ‘cardiac disease’ and in cases where there were no results, ‘cardiac disease’ was replaced by the words ‘heart disease’ (see Table 18.1). The search initially revealed 558 papers. Following a thorough analysis of the identified papers involving the previously mentioned stages 551 papers were excluded and a total of seven journal articles were deemed relevant to this chapter. These studies are presented in Table 18.4. (p.247)

Table 18.4 Summary of relevant identified studies ‘music and cardiac disease’

Study

Sample details

Research design

Dependent variables

Twiss et al. ( 2009 ) USA

a) n=60 (patients admitted for surgery)

b) 〈65 years

RCT

Postoperative anxiety

Intubation time

Nilsson ( 2009 ) Sweden

a) n=58 (patients who had undergone open coronary artery bypass grafting or aortic valve replacement surgery)

b) mean age=66.5

RCT

Stress physiological response

Pain

Anxiety

Tang et al. ( 2009 ) USA

a) n=41 (f=35, m=6) (older adults with hypertension)

b) mean age=85

RCT

Blood pressure (systolic, diastolic)

Okada et al. ( 2009 ) Japan

a) n=87 (patients with CVD)

Between-subjects design

Cardiac autonomic activity (heart rate)

Plasma cytokine

Catecholamine levels

Buffum et al. ( 2006 ) USA

a) n=170 (f=4, m=166) (patients waiting to undergo vascular angiography)

b) mean age=66.8

Quasi-experimental design—RCT

Anxiety

Sendelbach et al. ( 2006 ) USA

a) n=86 (f=30.2%, m=69.8%) (patients undergoing cardiac surgery)

b) mean age=63.3

RCT

Pain intensity

Anxiety

Physiological parameters (systolic and diastolic blood pressure, heart rate)

Opioid consumption

Hatem et al. ( 2006 ) Brazil

a) n=84 (children in paediatric cardiac intensive care unit)

b) day 1–16 years

RCT

Heart rate

Blood pressure and mean blood pressure

Respiratory rate

Temperature

Oxygen saturation

Pain

F, female; m, male, RCT, randomized controlled trial.

Studies identified were conducted in the USA (n=4), Japan (n=1), Sweden (n=1), and Brazil (n=1). Participants in these studies involved individuals with some type of cardiovascular problems (e.g. hypertension), individuals who had undergone cardiovascular surgery, and one study involved paediatric cardiac patients. With the exception of a pediatric patients study, all participants were older adults of a similar age range.

(p.248) Most of the studies applied an RCT design and examined the effects of music in both physiological and psychological parameters. In particular, in terms of music interventions, most studies used music listening, with one study using preferred music (Buffum et al. 2006) and two (Sendelbach et al. 2006; Okada et al. 2009) utilizing music therapy.

Outcome measures were both physiological and psychological. However, greater emphasis tended to be placed upon physiological variables, possibly due to the fact that the majority of researchers/authors were coming from medical disciplines. Physiological measures involved heart rate, parameters of heart rate variability (e.g. rMSSD and pNN50), plasma cytokine and catecholamine levels, respiratory rate, mean arterial pressure, systolic blood pressure, diastolic blood pressure, arterial oxygen pressure, arterial oxygen saturation, and opioid consumption. Psychological variables examined were anxiety and pain. Two studies indicated that the use of music was beneficial for a number of physiological parameters (Hatem et al. 2006; Okada et al. 2009) while others did not find any significant differences between groups with reference to physiological variables (Sendelbach et al. 2006).

Towards a synthesis

To summarize, studies focused upon cancer patients tend to utilize music therapy as a music intervention. However, studies focusing on cardiac patients and other types of chronic illnesses tended to use mostly music listening interventions without the input of a music therapist. Although methodological shortcomings can be identified in a number of studies across conditions, such as the assertion of using of a RCT design with a convenience sample and/or small sample of participants and the incorrect administration of psychometrics, the methodological quality of the above studies is considerably improved compared to methodological issues raised in preceding studies identified in previous literature review (Pothoulaki et al. 2006). In the present selection of studies the increased use of RCT designs should be highlighted as a major improvement within the reported literature compared to previous years, where RCT designs were rarely used. In addition, qualitative studies reported theoretical frameworks such as ethnography, discourse analysis, and grounded theory whereas earlier qualitative studies existing in the literature tended not to report theoretical approaches and analysis details.

With reference to the above issues, the examination of both physiological and psychological outcome variables related only to short-term aspects of wellbeing. The outcome measures indicate an increased interest in short-term effects, due to the nature of illness, the related symptoms and the notion and sense of ‘future’. More specifically, in life-threatening illnesses such as cancer, the ‘future’ perspective and consequently long-term outcomes may not be as critical as short-term outcomes and references to the ‘present’ (Pothoulaki et al. under review). Still, the reported research context, regardless of the adopted methodology and outcome differences, does share with previously identified studies in the literature (Pothoulaki et al. 2005) the research interest in the ‘musical presence and process’ in clinical settings. As such, differing evidence, settings and methodologies can be linked by an underlined theoretical framework. Studies supporting the effects of music interventions and music therapy rely upon different psychological outcome variables and suggest fragmentary explanations for their findings. In the section that follows we synthesize and integrate these diverse findings and draw upon three distinct theoretical perspectives which together illuminate the emerging consensus regarding the relevancy and effectiveness of music interventions in chronic illness.

Implications for theory

Music may have no direct effect in terms of the underlying physiological causes of chronic disease; however, this chapter provides evidence that music can affect components that are related to (p.249) perceived quality of life as well as psychological wellbeing. Three main theoretical arguments can be provided in order to contextualize the above findings and support the role of music interventions in the course of chronic illness. These arguments refer to: musical communication and support, emotional engagement, and, locus of control (perceived control).

Musical communication as social support

Many authors have suggested that musical communication and musical interaction can provide social support and positive social interaction (Neugebauer and Aldridge 1998; Trevarthen and Malloch 2000; MacDonald and Miell 2002; Ansdell and Pavlicevic 2005; Miell et al. 2005). More specifically, the concept of ‘communication’ and ‘connectivity’ is an underlying premise in most studies. With reference to this issue, primary importance can be placed not only on the musical communication but also on the group interaction and the desire for communication through the musical expression. As a result, musical communication, as a creative means of self-expression, serves to establish and develop a ‘connective’ bond between patients/participants, relatives and healthcare staff. The group context or the ‘musical companionship’, as described by Ansdell and Pavlicevic (2005), is of essential importance when looking at group music therapy processes. Cancer is an illness with serious physical symptoms that change the everyday life of patients and often creates feelings of isolation. Therefore, the formation of a group, offers participants the opportunity to constructively interact, establish strong social bonds and receive social support in an atypical, but nevertheless, fundamental and ‘holistic’ context. Furthermore, when relating these concepts to health and social support, a number of studies have outlined in the past the importance of social support in perceiving and coping with illness (Heitzmann and Kaplan 1984; Peterson and Seligman 1984; Groarke et al. 2004; Pattenden et al. 2002). Consequently, it can be argued that if musical communication and musical interaction is a form of social support and ‘companionship’, then the application of music interventions is of direct relevance to the clinical and healthcare services.

Emotional engagement with music

Emotional engagement with music is the second theoretical argument that supports the relevance of music interventions in healthcare settings. For instance, researchers relating the musical experience with emotional responses have suggested that emotional responses to music can be shaped by ‘iconic relationships… between a musical structure and some event or agent carrying emotional tone’ (Sloboda and Juslin 2001, p. 93). ‘Iconic relationships’ (Sloboda and Juslin 2001) are also related to associative theories of musical communication (Davies 1978; Hargreaves et al. 2005). Associative theories refer to the relationship of experienced musical stimuli and non-musical events that are attributed emotional meaning. For example, a particular piece of music maybe reminiscent of a family holiday or a past relationship. While this approach suggests that feelings and emotional responses to music are individual and distinctive, there are examples of cultural influences leading to collective emotional responses (Sloboda and Juslin 2001), such as lyrical themes in Christian religious ceremonies.

This theoretical argument provides a basis for studies that have utilized participants’ preferred music as an intervention (Clark et al. 2006; Buffum et al. 2006; Bulfone et al. 2009; Mitchell et al. 2007; Park 2009; Yu et al. 2009), in that the reported effects can be related to participants’ musical choices and the emotional meaning that they attributed to the particular musical stimuli that they chose. Based on this argument, particular interest would lie on the investigation of the effects of preferred versus pre-selected music to patients (Mitchell et al. 2008; Pothoulaki et al. 2008). Related to the emotionally engaging aspects of music listening is the possibility that music provides a means for listeners to be distracted from other stimuli that may have negative effects (MacDonald et al. 2003; Mitchell et al. 2007).

(p.250) Music and perceived control

Locus of control and perceived control is a major issue for patients suffering from chronic illnesses. Models of illness representations have outlined the importance of perceived control and locus of control in relation to patients’ illness representations (Wallston et al. 1976; Bandura 1980; Leventhal et al. 1984; Turnquist et al. 1988). Most patients suffering from diverse types of chronic illnesses experience lack of control due to physical and psychological symptoms that restrict their activities and their lifestyle. As a result, patients can feel a reduced sense of control over their illness and over their life in general which means that interventions that help to regain a sense of control have considerable utility within a healthcare context.

Studies which involved preferred music and focused on pain, have indicated that music interventions can be effective in modifying the perception of pain and increasing participants’ coping abilities (Brown et al. 1989; Mitchell et al. 2008). With reference to the findings of qualitative studies outlined in this literature review, the issue of control constitutes a strong theoretical basis for explaining these results. More specifically, Magill et al. (2008) reported that preferred music is important in terms of sense of control and emotional coping. Furthermore, the issue of control can also be traced in themes that are related to identity, self-expression and self-awareness (Daykin et al. 2007; O’Callaghan and McDermott 2007; O’Callaghan et al. 2007). Such findings are in line with Aldridge (1991) suggesting that interventions involving creative forms of expression are applicable to individuals with chronic illness because they can help them regain a sense of control and autonomy.

In light of this argument, it should also be noted that most hospitalized patients suffering from chronic illnesses experience a reality based on ‘loss of control’. They do not have control of their treatment and of their everyday activities and more importantly sometimes, they do not have control of their physical activities due to the side effects of medication and illness symptoms.

In conclusion, this chapter has presented an overview of research investigating the efficacy of music interventions for individuals with chronic illness with a particular focus on cancer and cardiac disease. A number of positive outcomes were highlighted relating to psychological and physiological measures. Musical interaction in all its manifestations elicits human reactions that address wider and topical research questions in healthcare. Further research can continue these advances to highlight how music interventions can complement the biomedical management of the healing process within chronic illness. For example, the evidence presented here does not suggest that all music listening will produce beneficial effects and further studies investigating under what conditions music may be beneficial are required. Also, there is much work to be done on the nature of both the music and the social context within the musical activities take place. The extent to which structural features such as tempo and melodic contour interact with psychological features such as preference and familiarity needs to be understood in more detail. In addition, within the context of music and health, ‘iconic relationships’ should be further examined with reference to musical events and health ‘moments/memories’. If a musical stimulus has emotional connotations and can be associated to an experienced life moment/memory, then is it possible that ‘preferred’ musical stimuli may be associated to individual health moments/memories in life? And if so, what effect do these reminiscences have on chronically ill patients and to what extend is this related to wellbeing within the context of chronic illness? Future research could shed light on the recollection and emotional revival of health memories. Other questions to be investigated include to what extent music is a unique intervention and can other interventions produce similar effects. It may be that the capacity of music listening to distract and engage the listener both cognitively and emotionally and to produce these effects with relatively little effort from the listener does indeed make it a unique stimulus. However, what is clear is that theories of musical communication, (p.251) emotional engagement with music, and perceived control provide a framework to contextualize and explain why music can produce beneficial effects in the contexts presented. These explanations bind musical experiences to wider psychological principles of healing. This also highlights the inextricable link that exists between music listening and psychological and social variables related to health and wellbeing. These factors make investigating the relationship between music, health and wellbeing both timely and urgent.

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