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Support Care Cancer (2006) 14: 859866

DOI 10.1007/s00520-005-0013-6 ORIGINAL ARTI CLE


Lisa M. Gallagher
Ruth Lagman
Declan Walsh
Mellar P. Davis
Susan B. LeGrand
Received: 13 October 2005
Accepted: 15 December 2005
Published online: 15 March 2006
# Springer-Verlag 2006
The clinical effects of music therapy
in palliative medicine
Abstract Goal: This study was to
objectively assess the effect of music
therapy on patients with advanced
disease. Patients and methods: Two
hundred patients with chronic and/or
advanced illnesses were prospec-
tively evaluated. The effects of music
therapy on these patients are re-
ported. Visual analog scales, the
Happy/Sad Faces Assessment Tool,
and a behavior scale recorded pre-
and post-music therapy scores on
standardized data collection forms. A
computerized database was used to
collect and analyze the data.
Results: Utilizing the Wilcoxon
signed rank test and a paired t test,
music therapy improved anxiety,
body movement, facial expression,
mood, pain, shortness of breath, and
verbalizations. Sessions with family
members were also evaluated, and
music therapy improved families
facial expressions, mood, and ver-
balizations. All improvements were
statistically significant (P<0.001).
Most patients and families had a
positive subjective and objective re-
sponse to music therapy. Objective
data were obtained for a large
number of patients with advanced
disease. Conclusions: This is a
significant addition to the quantita-
tive literature on music therapy in
this unique patient population. Our
results suggest that music therapy is
invaluable in palliative medicine.
Keywords Music therapy
.
Palliative
medicine
.
Cancer
.
Symptoms
Introduction
Music and medicine have been interrelated in many
cultures throughout history. Music is experienced through-
out the entire life cycle particularly at seminal events, i.e.,
birth, marriage, and death. It has been used to celebrate and
honor special occasions and milestones. It has the ability to
communicate in a way that transcends language. Music is
capable of transforming and moving individuals emotion-
ally. It has been used to heal individuals physically,
psychologically, socially, emotionally, and spiritually.
The literature regarding the use of music with the
terminally and/or chronically ill has continued to grow.
Music has been used therapeutically in hospice [8, 11, 10],
in palliative care [5, 1419, 24, 25], while receiving
radiation therapy [27], during chemotherapy [17, 23, 27
29], and undergoing medical procedures (such as port
placement/removal or tissue biopsy) [12, 20]. Music has
been used in symptom management such as for pain [2, 10
14, 16, 30, 34] and anxiety [1, 2, 11, 12, 14, 16, 23, 27, 30]
and has been associated with improved quality of life [5, 9]
and spiritual healing [14, 19, 21, 25, 30].
L. M. Gallagher
.
R. Lagman
.
D. Walsh
.
M. P. Davis
.
S. B. LeGrand
The Harry R. Horvitz Center for
Palliative Medicine (A World Health
Organization Demonstration Project),
Cleveland Clinic Taussig Cancer
Center, Cleveland Clinic Foundation,
9500 Euclid Avenue, M76,
Cleveland, OH 44195, USA
L. M. Gallagher
The Cleveland Music
School Settlement,
11125 Magnolia Drive,
Cleveland, OH, USA
D. Walsh (*)
The Harry R. Horvitz Chair in
Palliative Medicine,
Cleveland Clinic Foundation,
Cleveland, OH, USA
e-mail: lagmanr@ccf.org
Tel.: +1-216-4447793
Fax: +1-216-4455090
Most published studies are qualitative and/or case
studies. Quantitative trials measuring the benefits of
music therapy are less common. In reviewing the literature,
only 15 studies [1, 3, 4, 6, 7, 9, 10, 12, 20, 23, 24, 2730]
included objective measurement of music therapy effec-
tiveness with cancer patients. Therefore, we have sought to
add this to the quantitative literature in this study. For this
study, data were prospectively gathered from 200 patients
and are reported.
Methods
Patient selection
This study was approved by the Institutional Review Board
(IRB) at The Cleveland Clinic Foundation. Patients
admitted to The Harry R. Horvitz Center for Palliative
Medicine and those patients followed by the Palliative
Medicine consult service on other acute units at Cleveland
Clinic Foundation (CCF) were eligible to participate in this
study. Some patients were offered music therapy services
but declined them.
Referrals for music therapy were directly requested by a
physician on a standardized physicians order sheet or by
verbal request from the social worker, physician assistant,
nurses, or other members of the interdisciplinary team.
Indirect referrals involved inquiries based on information
provided in daily morning report. Brochures on music
therapy were routinely included within the admission
packet patients received during their stay on the unit, and
on occasion, patients and families directly requested
services themselves.
Sessions
Music therapy was done by a board-certified music
therapist or a music therapy intern under the direction of
the board-certified music therapist. Each session included
assessment and intervention. The goals of music therapy
were determined based on the patients subjective needs, as
well as those perceived by the therapist [6]. A variety of
patient goals were derived (see results in Table 9 for a list),
with multiple goals being addressed within the same
session. Goals were also designed to address the needs of
family members present during the session. As with the
patient goals, these were individualized and multiple goals
were addressed as needed within the same session. Once
goals were established, the therapist individualized inter-
ventions designed to meet these goals. A description of
these interventions (in order of frequency) can be found in
Table 1. The patients comfort and fatigability level were
taken into consideration, and the patient was encouraged to
participate as he/she was able. Family members present in
the room were also encouraged to participate in the session.
Multiple interventions were often presented within the
same session.
Data collection
During the first meeting with a patient, a music therapy
assessment was completed. This included information on
the patients musical background (played instrument, sang,
type of performing group) and musical preferences (styles,
favorite songs, and favorite artists/groups). Demographic
information was collected.
At the beginning of each session and immediately
after the completion of all music therapy interventions,
the patient was presented with the Rogers Happy/Sad
Faces Assessment Tool [22], a scale of five faces that
was used to identify mood before and after music
therapy. Visual analog scales were used to measure
symptoms before and after music therapy. Symptoms
were anxiety, depression, pain, and shortness of breath.
A behavioral scale adapted from the Riley Infant Pain
Scale [26] and the Nursing Assessment of Pain Intensity
[26] was utilized by the music therapist involving
patients facial expression, body movement, sleep, and
verbalizations/vocalizations.
Data were recorded on a standardized data collection
form, approved and copyrighted by the Cleveland Clinic
Forms Committee for inclusion in the patients chart. In
addition to the before/after data listed above, other
information recorded included the following: date, time
spent, goals, interventions, type of participation, style of
music and songs used, status of goals (met, unmet, unable
to determine), patient consenting to a repeat session with
therapist, family member(s) present, patients verbal
response, and family member(s) verbal response. A
narrative comment section was also provided so that any
pertinent information not fitting in the other sections could
be included.
A computerized database was designed for standardized
collection of data. FileMaker Pro (Santa Clara, CA) was
used to maintain this database. These data were then
downloaded into Microsoft Excel (Microsoft Redmond,
Washington) and statistical analysis was performed. The
Wilcoxon signed rank test and a paired t test were used to
determine if patient (or family) assessment and therapist
assessment scores significantly changed following music
therapy, with P<0.05 indicating statistical significance.
The Wilcoxon rank sum test was used to study score
changes between variables such as gender and being a
musician. Spearmans correlation was calculated between
age and score changes, and between age and percentage of
goals met.
860
Results
Patients
An ex post facto study of the data gathered from September
2000 to August 2002 was completed. During this time, 345
patients were seen, for a total of 396 sessions. For this
particular study, however, it was decided that only the data
gathered in the initial sessions would be analyzed. In 199 of
200 sessions, music therapy services were in the patients
room on the Harry R. Horvitz Center for Palliative
Medicine, and the other session was provided in a patient
room on the Colorectal Surgery Unit. This patient was
being seen by the Palliative Medicine consult team, and the
music therapist was also asked to see the patient. Of 200
patients, 159 sessions took place in private rooms and 41 in
double occupancy rooms. There were 200 initial sessions
performed that involved a patient and music therapist
planned intervention and postintervention evaluation. Of
these 200 patients, 59% were female. The median age was
62 years (range 2487 years). Diagnoses included
malignancies, nonmalignant syndromes, pain disorders,
sickle cell disease, aortic aneurysm, Gardners syndrome,
acquired immune deficiency syndrome (AIDS), amyotro-
phic lateral sclerosis (ALS), CreutzfeldtJakob disease
(CJD), other neurodegenerative disorders, and other life-
limiting illnesses. Only 29% of patients had a musical
background (former or current singer or player of an
instrument).
The results of score changes during the music therapy
session are in Table 2. Patient-rated scores for anxiety,
mood, pain, and shortness of breath improved significantly
(Tables 3 and 4). Facial expression, movement, and
verbalizations all improved significantly (P<0.001) follow-
ing music therapy (Tables 5 and 6). Although sleep was
included in the behavioral scale, it was not investigated as
assisting the patient in relaxing and falling asleep was only
addressed in 12 sessions.
Table 1 Interventions presented
Intervention presented Description
Music listening (live) Live music played by music therapist
Singing Singing alone or with therapist
Participation Engaging in clapping, humming, tapping foot, etc.
Musical life review Sharing memories elicited by the music
Song choices Requesting songs from memory or list
Instrument playing Playing keyboard, guitar, percussion instruments, etc.
Verbal processing Engaging in discussion with therapist, not elicited by music
Lyric analysis Discussing song lyrics and their meaning/significance
Music-assisted relaxation Participating in breathing, muscle relaxation, and/or imagery
Song-writing Writing song lyrics to original or familiar music
Musical entrainment Matching tempo of music to breathing and gradually slowing
Music listening (recorded) Providing recorded music (tape or CD)
Planning funeral music Selecting songs to be performed/played at funeral
Table 2 Patient categorical assessment of score change
a
Score/type of change Number %Change
Pain
Better 38 30.2
Same 84 66.7
Worse 4 3.2
Depression
Better 16 31.4
Same 34 66.7
Worse 1 2.0
Anxiety
Better 36 29.0
Same 87 70.2
Worse 1 0.8
Shortness of breath
Better 13 10.3
Same 112 88.9
Worse 1 0.8
Mood
Better 100 81.3
Same 22 17.9
Worse 1 0.8
Facial
Better 104 52.0
Same 94 47.0
Worse 2 1.0
Movement
Better 20 10.0
Same 179 89.5
Worse 1 0.5
Verbal
Better 121 60.5
Same 76 38.0
Worse 3 1.5
a
These findings are descriptive in nature; thus, no P values are
attached to this table
861
Results following music therapy were compared be-
tween female and male patients, and the only significant
difference was changes in the facial score. In looking at
other variables of musicianship and age, there were no
Table 4 Patient assessment: statistical results (Wilcoxon signed rank test)
Score/timing Number Mean SD Median Min Max P value
Mood
Before 123 1.8 1.1 2 0 4
After 123 0.7 0.8 0.5 0 4
Difference 123 1.1 0.8 1 3 1 <0.001
a
Pain
Before 126 2.7 3.3 0 0 10
After 126 2.1 2.8 0 0 10
Difference 126 0.6 1.4 0 8 2.9 <0.001
a
Anxiety
Before 124 2.1 3.1 0 0 10
After 124 1.2 2.2 0 0 10
Difference 124 0.9 1.8 0 8.5 1.5 <0.001
a
Depression
Before 51 2.0 3.1 0 0 10
After 51 1.1 2.3 0 0 10
Difference 51 0.8 1.7 0 8.2 0.5 <0.001
a
SOB
Before 126 0.8 2.0 0 0 8
After 126 0.6 1.6 0 0 8
Difference 126 0.3 1.0 0 7 1 <0.001
a
a
Significant (P<0.05)
Table 3 Patient assessment: statistical results (paired t test)
Score/timing Number Mean SD 95% CI P value
Mood
Before 123 1.8 1.1 1.6 to 2.0
After 123 0.7 0.8 0.5 to 0.8
Absolute difference 123 1.1 0.8 1.2 to 0.9 <0.001
a
Pain
Before 126 2.7 3.3 2.1 to 3.3
After 126 2.1 2.8 1.6 to 2.6
Absolute difference 126 0.6 1.4 0.8 to 0.4 <0.001
a
Anxiety
Before 124 2.1 3.1 1.6 to 2.7
After 124 1.2 2.2 0.8 to 1.6
Absolute difference 124 0.9 1.8 1.2 to 0.6 <0.001
a
Depression
Before 51 2.0 3.1 1.1 to 2.8
After 51 1.1 2.3 0.5 to 1.8
Absolute difference 51 0.8 1.7 1.3 to 0.4 <0.001
a
SOB
Before 126 0.8 2.0 0.5 to 1.2
After 126 0.6 1.6 0.3 to 0.8
Absolute difference 126 0.3 1.0 0.4 to 0.1 <0.001
a
SOB Shortness of breath
a
Statistically significant (P<0.05)
862
differences between patients with musical background and
those who did not have a musical background, and
percentage of goals met was the only variable correlated
with age. Reasons for referral (Table 7), styles of music
used (Table 8), goals addressed (Table 9), interventions
presented (Table 10), and patient response to the interven-
tion were also investigated.
Families
Family members were present in 68 of the 200 sessions.
The median number of family members present was 1
(range of 14). Family members also benefited. Mood
scores of family members improved significantly
(P<0.001). The only family rating that did not improve
postintervention was anxiety (P=0.50).
Facial expression and verbalization improved signifi-
cantly (P<0.001), but body movement did not improve
(P=1.00). Sleep was not investigated in family members.
Styles of music used (Table 8), goals addressed (Table 9),
interventions presented (Table 10), and family response to
the intervention are also reported.
Discussion
To the best of our knowledge, this is the first study to
objectively assess music therapy for such a large number of
patients with advanced disease. This will add to the
quantitative and objective data in the study of this unique
patient population. The computerized database has been
invaluable, as it has enabled the music therapist to maintain
and analyze large amounts of data.
Individual symptoms such as anxiety, depression, pain,
and shortness of breath were clinically better after music
therapy intervention. Statistical analysis of the data was
performed twice using two different tests, and statistical
significance was still found. Although the percentage of
goals met was correlated with age, the correlation was very
Table 6 Therapist assessment: statistical results (Wilcoxon signed rank test)
Score/timing Number Mean SD Median Min Max P value
Facial
Before 200 1.1 0.4 1 0 3
After 200 0.5 0.6 1 0 2
Difference 200 0.5 0.6 1 2 1 <0.001
a
Movement
Before 200 0.1 0.4 0 0 2
After 200 0.0 0.2 0 0 1
Difference 200 0.1 0.4 0 2 1 <0.001
a
Verbal
Before 200 1.0 0.5 1 0 2
After 200 0.4 0.5 0 0 2
Difference 200 0.6 0.6 1 2 1 <0.001
a
a
Significant (P<0.05)
Table 5 Therapist assessment: statistical results (paired t test)
Score/timing Number Mean SD 95% CI P value
Facial
Before 200 1.1 0.4 1.0 to 1.1
After 200 0.5 0.6 0.5 to 0.6
Absolute difference 200 0.5 0.6 0.6 to 0.5 <0.001
a
Movement
Before 200 0.1 0.4 0.1 to 0.2
After 200 0.0 0.2 0.01 to 0.05
Absolute difference 200 0.1 0.4 0.15 to 0.06 <0.001
a
Verbal
Before 200 1.0 0.5 0.9 to 1.0
After 200 0.4 0.5 0.3 to 0.4
Absolute difference 200 0.6 0.6 0.7 to 0.5 <0.001
a
a
Statistically significant (P<0.05)
863
weak. Therefore, even though it was statistically signifi-
cant, it may not be very clinically meaningful. It is possible
that as individuals mature, goals are more specific and
defined. Also, there was no statistical difference with
patient scores whether they had a musical or non-musical
background. This proves that music is a universal
language, and individuals need not have special training
to appreciate or benefit from it.
The results for families regarding movement and anxiety
were not as statistically significant as those for patients. In
the future, anxiety should be consistently evaluated in
family members. The anxiety scale was evaluated in only
seven family members. Such a small number would make
results insignificant. In general, few family members were
Table 7 Reasons for referral
a
Reason for referral Percentage of referrals (N=200)
Providing enjoyment 25.5
Decreasing anxiety 14
Decreasing depression 11.5
Decreasing perception of pain 11
Providing family interaction 7
Providing coping skills/support 6.5
Improving mood 5.5
Providing distraction 4.5
Being with actively dying 3.5
Providing relaxation/comfort 3.5
Decreasing agitation/restlessness 3
Addressing end of life issues 2.5
Decreasing confusion 2
Decreasing loneliness 1
Decreasing shortness of breath 1
Other 49
a
More than one reason for referral may have been received per
patient
Table 8 Styles of music used within sessions
a
Style of music Patients (N=200) Family (N=83)
Gospel 57 23
Classical 35 13
Big band/1940s and 1950s 27 13
Jazz 25 8
Musicals 24 6
Popular (1980s, 1990s,
and 2000s)
22 7
Country 18 3
Christmas 12 5
1950s and 1960s 9 3
1970s and 1980s 7 3
Polka 4 1
Relaxation 3 0
Irish 2 2
Latin 2 0
Easy listening 1 1
Folk 1 1
Improvisation 1 0
a
More than one style may have been used per session
Table 10 Interventions presented (N=200)
Intervention Number of applications
a
Patient Family
Music listening (live music) 424 75
Singing 144 30
Participation (clapping, foot tapping,
humming, etc.)
50 6
Musical life review 44 6
Song choices 35 16
Instrument playing 33 5
Therapeutic use of self/verbal processing 25 0
Lyric analysis 19 1
Music-assisted relaxation 18 2
Song-writing 14 0
Musical entrainment 4 0
Music listening (recorded music) 3 1
Planning funeral music 1 0
Memory sharing 0 1
a
More than one intervention may have been used per session
Table 9 Goals addressed (N=200)
Goal Number of times addressed
a
Patient Family
Improve mood 128 26
Decrease pain 68 0
Increase participation/interaction 59 18
Decrease stress/provide distraction 55 37
Decrease anxiety 53 2
Relaxation 40 2
Self-expression 39 3
Decrease depression 25 0
Decrease shortness of breath 23 0
Comfort and solace 14 3
Increase acceptance of music therapy 14 3
Increase decision-making 10 0
Maintain level of comfort 6 0
Decrease nausea 3 0
Decrease restlessness 3 0
Decrease agitation 2 0
Increase self-esteem 1 0
Increase leisure skills 1 0
Increase positive family interaction 1 5
Bereavement 0 1
a
More than one goal may have been addressed per session
864
present and therefore participated in music therapy
sessions. Therapist perceived benefits defined by body
movement did not improve. Further investigation into the
benefits of music therapy on depression and mood among
family members may also be worthwhile.
This study also demonstrated that music therapy had a
positive effect on patients and families mood, as well as
benefit confirmed through facial expression and verbaliza-
tions of both. A key element to the music therapy session is
that of presence, having someone with the ability to listen
to the patient. Factors that may contribute to this include
the following: (1) the music itself, (2) the fact that someone
is attending to the patient, (3) the therapeutic relationship
between patient and therapist, or (4) a combination of any
of these factors. Future studies can be designed and
separate these factors to determine which variable
contributed to the effectiveness of the interventions.
There are some limitations to this study. The music
therapist was also the collector of data, and thus, the
findings could have been biased. While the therapist
attempts to remain objective, it is possible that patients may
respond favorably to please the therapist. To avoid this
bias, it is recommended that whenever possible, someone
other than the music therapist present the scales before and
after the intervention for data collection. Although all eight
parameters were found to be statistically significant, there
were overlapping standard deviations. The behavioral
scales were a category scale with only four divisions.
The validity (clinical significance) of differences is yet to
be determined. It is possible that a score improvement by
one point is relevant, but further study is needed to define
statistical and clinical significance. Reliability (test and
retest consistency) may also be a bias since this may
influence results. More importantly, the duration of the
effect of music therapy is also unknown, presenting another
opportunity for future investigation.
As reported in a previous article [6], a similar database
has been used at our Hospice (of Cleveland Clinic), and it is
hoped that a future study will include a comparison of the
impact of music therapy between hospice and palliative
medicine patients. Future research should investigate the
data from multiple sessions for the same patient to
determine if the benefit of music therapy increases with
experience over time. Evaluating the impact of music
therapy against placebo is being considered for a future
research project. The effectiveness of specific interventions
when addressing specific goals should also be investigated.
This would help determine the most effective interventions
to utilize when addressing specific problems.
Conclusion
Most patients and families who participated had a positive
response to music therapy, and the results demonstrated the
effectiveness of music therapy. Since music therapy had a
significant effect on common symptoms of patients with
chronic and/or terminal illness, such as pain, anxiety,
depression, and shortness of breath, it is suggested that
music therapy would be an asset to palliative medicine
programs.
Acknowledgements We gratefully acknowledge the support of
The Kulas Foundation and The Music Therapy Program Fund. We
thank Lisa Rybicki, MS, for performing the statistical analysis and
Becky Michel and Lisa McKelvey, music therapy interns, for their
contributions to the sessions.
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