Original Article

Effect of Music Therapy on Pain and Anxiety Levels of

Cancer Patients: A Pilot Study
Priyadharshini Krishnaswamy, Shoba Nair
Department of Pain and Palliative Care, St John’s Medical College Hospital, Bengaluru, Karnataka, India

Address for correspondence: Ms. Priyadharshini Krishnaswamy; E‑mail: priya_10000abc@yahoo.co.in

ABSTRACT

Background: The pain associated with cancer is highly detrimental to the quality of life of the affected individuals.
It also contributes to the anxiety of the patient. There is a need for a nonpharmacological approach in addition to
the pharmacological therapy for the management of the pain for a more holistic improvement in the individual.
With this study, we wish to achieve this through music.
Objective: To assess the effect of music therapy on pain scores and anxiety levels of cancer patients with pain.
Study Design: In this quantitative study, a comparative study was done on fourteen cancer patients admitted
for pain relief under the Department of Pain and Palliative Medicine, of a tertiary care hospital, having moderate
to severe pain (numerical pain rating scale [NRS] ‑ of 4 to 10).
Subjects and Methods: Convenience sampling was used. Patients were allocated to test group or control
group nonrandomly. The test group patients were subjected to music therapy for 20 min while the control
group patients were kept occupied by talking to them for 20 min. The NRS scale was used to assess the
pre‑ and post‑interventional pain scores and the Hamilton anxiety rating scale was used to assess the pre‑ and
post‑interventional anxiety scores in the two groups.
Statistics: Student’s t‑test was used for comparing the pre‑ and post‑interventional data. Two sample t‑test was
used to compare the data obtained from the control and study groups.
Results: Statistically significant reduction seen in the pain scores in the test group after music therapy (P = 0.003).
No statistically significant reduction seen in the pain score in the control group  (P = 0.356). There was a
statistically significant reduction in the postintervention pain scores in the test group compared to the control
group (P = 0.034). The reduction in anxiety levels in both groups after intervention was not statistically significant.
Conclusion: Music therapy was found to lower the pain score of a patient who had received standard palliative
care for pain reduction. It was also more effective than the act of talking in reducing the pain score. A study with
a larger sample size should be undertaken to conclude that, music therapy can be used in addition to morphine
and other painkillers to reduce pain as a part of a more holistic approach to palliative care strategies.

Key words: Anxiety, Cancer pain, Music

INTRODUCTION is also impaired.[2,3] Although there have been some

Pain often develops as cancers progress. This pain
increases in severity over time and eventually enhances
the disease associated psychological and physiological
deterioration.[1] The quality of life of the individual
Access this article online
Quick Response Code:
Website:
www.jpalliativecare.com
remarkable advances with respect to the pharmacological
management of pain, there is a need for a more holistic
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as
the author is credited and the new creations are licensed under the identical
terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Krishnaswamy P, Nair S. Effect of music therapy
10.4103/0973-1075.185042 on pain and anxiety levels of cancer patients: A pilot study. Indian J Palliat
Care 2016;22:307-11.

© 2016 Indian Journal of Palliative Care | Published by Wolters Kluwer - Medknow 307
 Krishnaswamy and Nair: Pain and symptom control

approach in pain management which will help integrate

all aspects of health‑physical, mental, spiritual, and
emotional.[4,5,6]

Music has for a long time been believed to have therapeutic

effects.[7] It is also believed to reduce pain and anxiety. If
this music therapy can also reduce cancer‑associated pain
and anxiety, then it can serve as a cost‑effective approach
to palliation in addition to pharmacological measures.[6‑19]
However, the studies done to this effect had all been done
overseas in developed countries such as the United States
and the United Kingdom.[6‑19] Hence, it was necessary to do
Figure 1: Numerical pain rating scale
a study regarding music therapy in India as the perceptions
of the people regarding healthcare and music would be 0 (not present) to 4 (severe), with a total score range of
different here compared to the developed countries due 0–56, where <17 indicates mild severity, 18–24 mild to
to cultural, economic factors, and social factors.[20] Thus, moderate severity, and 25–30 moderate to severe.[28,29]
there was a need to look into effect and the application of
this form of therapy in reducing the pain and anxiety levels Sampling method ‑ convenience sampling used.
of Indian cancer patients. We aimed to do this through
our study. An informed consent was taken from the subjects after
which they were allocated into two groups ‑ the study group
Thus, the primary objective of our study was to assess and control group nonrandomly.
the effect of music therapy on pain relief in patients with
cancer pain. The preintervention (baseline) NRS and HAM‑A scores
were recorded in both the groups.
Our secondary objective was to assess the effect of music
therapy on anxiety levels of patients with cancer pain. The intervention
The subjects in the study group were then subjected to
SUBJECTS AND METHODS 20  min of music which was administered by means of
headphones connected to an MP3 player in which the music
The study design was a comparative study. The inclusion was stored. All the subjects were made to listen to the same
criteria for selection of subjects were cancer patients pieces of music. The subjects in the control group were
admitted for pain relief under the Department of kept occupied for 20 min by the act of talking to them.
Pain and Palliative Medicine, of a tertiary care hospital
having moderate to severe pain  (numerical pain rating The postintervention NRS and HAM‑A scores were
scale [NRS] ‑ 4–10) administered morphine 3 h prior to the recorded in both groups.
intervention. The exclusion criteria (having included) were
all patients with hearing deficits and those with metastases The data obtained was analyzed.
to the brain.

The music that was selected was instrumental music ‑ Veena RESULTS

and Flute, which had a combination of the traditional
Indian raga Anandabhairavi  (which is believed to have Demographics
therapeutic effects) and modern contemporary tunes.[21,22] A total of 14 subjects were included of whom 7 were
allocated to the study group and 7 into the control group.
The scales used for the assessment of pain and anxiety
The study group had 5  females and 2  males while the
were:
control group had 3 females and 4 males.
• NRS  ‑  To assess the pain level on a scale of 1–10
[Figure 1].[23‑27] Analysis
• Hamilton anxiety rating scale  (HAM‑A)  –  Used to
assess the anxiety levels based on scores obtained from Student’s t‑test was used for comparing the pre‑  and
14 different criteria. Each item is scored on a scale of post‑interventional data. Two sample t‑test was used to
308 Indian Journal of Palliative Care / Jul-Sep 2016 / Vol 22 / Issue 3
 Krishnaswamy and Nair: Pain and symptom control

compare the data obtained from the control and study
groups.
In the study group
The mean preintervention pain score was 5.43 ± 1.27 and
the postintervention (music) pain score was 4.00 ± 1.29.
The decrease in the pain scores was by 1.43 ± 0.78 with a
P = 0.003 which was statistically significant [Table 1 and
Graph 1].
The difference between the postintervention pain score
of the study group  (music) and control group  (talking)
was − 1.71 ± 0.71 with a P = 0.034 which was statistically
significant [Table 2 and Graph 2].
Table  1: Postmusic pain score compared to
preintervention pain score
Mean pain score
Preintervention 5.43±1.27 0.003
Postintervention 4.00±1.29 Mean difference=1.43±0.78
The mean preintervention HAM‑A score was 17.14 ± 1.38
and the postintervention HAM‑A score was 12.86 ± 0.95.
The decrease in the HAM‑A score was 4.28 ± 0.53 with
a P = 0.078 which was not statistically significant [Table 3
and Graph 3].
In the control group
The mean preintervention pain score in the control group
was 5.86 ± 1.21 and the mean postintervention (talking)
pain score was 5.71 ± 1.38. The decrease in the pain score
was 0.14 ± 0.38 with a P = 0.356 which was not statistically
significant [Table 4 and Graph 4].
The mean preintervention HAM‑A score was 25.71 ± 1.51
and the mean postintervention (talking) HAM‑A score was
Table  3: Anxiety levels after music therapy
P compared to before intervention
Mean anxiety score P
Preintervention 17.14±1.38 0.078
Postintervention 12.86±0.95 Mean difference=4.28±0.53

Table  2: Pain scores in the test group  (music) Table  4: Post-talk pain score compared to
compared to the control group preintervention
Intervention Mean pain score P Mean pain score P
Test 4.00±1.29 0.034 Preintervention 5.86±1.21 0.356
Control 5.71±1.38 Mean difference=−1.71±0.71 Postintervention 5.71±1.38 Mean difference=0.14±0.38

6 6 5.71
5.43

4
PRE INTERVENTION 4
4 4

CONTROL

2
2 TEST
POST INTERVENTION

0
MUSIC THERAPY 0
POST INTERVENTION
Graph 1: Post music pain score compared to preintervention
Graph 2: Pain scores in the test group (music) compared to the
control group
20
17.14
6 5.86 5.71
12.86 PRE INTERVENTION
10 4 PRE INTERVENTION

POST INTERVENTION
2
POST INTERVENTION
0
MUSIC THERAPY 0
TALKING
Graph 3: Anxiety levels after music therapy compared to before
intervention Graph 4: Post-talk pain score compared to preintervention

Indian Journal of Palliative Care / Jul-Sep 2016 / Vol 22 / Issue 3 309

 Krishnaswamy and Nair: Pain and symptom control
21.43 ± 1.21. The decrease in the score postintervention
was 4.28 ± 0.30 with a P = 0.200 which was not statistically
significant [Table 5 and Graph 5].
DISCUSSION
Our study has shown that music therapy caused a significant
reduction in the pain score of patients already on morphine.
The reduction in pain was significantly more after music
therapy than after the act of talking to the patients. Neither
music therapy nor the act of talking significantly reduced
the anxiety levels of the patients. Our pilot study, therefore,
has shown that music therapy can reduce cancer pain.
Our results are in concurrence with the below‑mentioned
studies. However, unlike the other studies, in our study, no
statistically significant reduction in the anxiety levels of
patients in both groups post the intervention was found.
A positive effect with music therapy was found by
Horne‑Thompson and Grocke, through a randomized
control trial involving twenty‑five participants, where the
anxiety levels of the subjects were measured after a single
session using the Edmonton Symptom Assessment System
(ESAS). The investigators found a significant reduction
in anxiety in the experimental group  (P  =  0.005) and
significant reductions in other measurements on the ESAS
in the experimental group, specifically pain (P = 0.019),
tiredness (P = 0.024), and drowsiness (P = 0.018).[8]
Gallagher et al. reported the effects of music therapy
on two hundred patients as a significant improvement
in the facial expressions, mood and verbalization of
the patients (P < 0.001). Most patients and families had
Table  5: Anxiety levels after talking compared
to before intervention
Mean anxiety score P
Preintervention 25.71±1.51 0.200
Postintervention 21.43±1.21 Mean difference=4.28±0.30
30
25.71
25 PRE INTERVENTION
21.43
20
POST INTERVENTION
15
TALKING
Graph 5: Anxiety levels after talking compared to before intervention
310 Indian Journal of Palliative Care / Jul-Sep 2016 / Vol 22 / Issue 3
a positive subjective and objective response to music
therapy.[9]
In another randomized trial (performed by Huang et al.) in
which the patients were made to listen to music of their
own choice, a significant reduction in pain experienced by
the patients was seen postmusic therapy (P < 0.001).[10]
Hilliard showed that there was a significant improvement in
the quality of life among the terminally ill who were subjected
to a single session of music therapy through a randomized
control trial on eighty. Furthermore, the more music therapy
sessions participants received, the higher the quality of life,
even as their physical health declined. This was not the case
in the control group, where the quality of life declined as
physical status declined. The study supports the idea that
live music therapy sessions increase perceived quality of life
for people with terminal cancer, and that sessions should be
provided with a relatively high frequency since the quality of
life increased with each music therapy session.[11]
Music therapy, therefore, should be further looked into
using studies with a larger sample size with randomization
in its application in the management of cancer pain in
addition to morphine and other painkillers, as a part of a
more holistic approach to palliative care strategies. Future
studies exploring the effect of more number of music
sessions, different durations of music and different types
of music on cancer pain can be done. Furthermore, the
acceptability of this form of therapy among patients and
the methods by which this therapy can be incorporated into
routine palliative cancer care should be explored.
CONCLUSION
A single session of music therapy is effective in significantly
reducing cancer pain when used along with standard
palliative care in cancer patients with moderate to severe
pain. Music therapy can, therefore, be considered as a
nonpharmacological method of reducing cancer pain.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Strang P. Cancer pain – A provoker of emotional, social and existential
distress. Acta Oncol 1998;37:641‑4.
 Krishnaswamy and Nair: Pain and symptom control
2. Ferrell BR. The impact of pain on quality of life. A decade of research.
Nurs Clin North Am 1995;30:609‑24.
3. Padilla GV, Ferrell B, Grant MM, Rhiner M. Defining the content domain
of quality of life for cancer patients with pain. Cancer Nurs 1990;13:108‑15.
4. Cassileth BR. Psychiatric benefits of integrative therapies in patients with
cancer. Int Rev Psychiatry 2014;26:114‑27.
5. Breivik H, Cherny N, Collett B, de Conno F, Filbet M, Foubert AJ, et al.
Cancer‑related pain: A pan‑European survey of prevalence, treatment, and
patient attitudes. Ann Oncol 2009;20:1420‑33.
6. Myskja A, Lindbaek M. Examples of the use of music in clinical medicine.
Tidsskr Nor Laegeforen 2000;120:1186‑90.
7. McClean S, Bunt L, Daykin N. The healing and spiritual properties of music
therapy at a cancer care center. J Altern Complement Med 2012;18:402‑7.
8. Horne‑Thompson A, Grocke D. The effect of music therapy on anxiety
in patients who are terminally ill. J Palliat Med 2008;11:582‑90.
9. Gallagher LM, Lagman R, Walsh D, Davis MP, Legrand SB. The clinical
effects of music therapy in palliative medicine. Support Care Cancer
2006;14:859‑66.
10. Huang  ST, Good  M, Zauszniewski  JA. The effectiveness of music in
relieving pain in cancer patients: A randomized controlled trial. Int J Nurs
Stud 2010;47:1354‑62.
11. Hilliard RE. The effects of music therapy on the quality and length of life
of people diagnosed with terminal cancer. J Music Ther 2003;40:113‑37.
12. Burns  SJ, Harbuz  MS, Hucklebridge  F, Bunt  L. A  pilot study into the
therapeutic effects of music therapy at a cancer help center. Altern Ther
Health Med 2001;7:48‑56.
13. Mansky PJ, Wallerstedt DB. Complementary medicine in palliative care and
cancer symptom management. Cancer J 2006;12:425‑31.
14. Richards T, Johnson J, Sparks A, Emerson H. The effect of music therapy
on patients’ perception and manifestation of pain, anxiety, and patient
satisfaction. Medsurg Nurs 2007;16:7‑14.
15. Nilsson U. The anxiety‑ and pain‑reducing effects of music interventions:
A systematic review. AORN J 2008;87:780‑807.
16. Bradt J, Potvin N, Kesslick A, Shim M, Radl D, Schriver E, et al. The impact
of music therapy versus music medicine on psychological outcomes and
pain in cancer patients: A mixed methods study. Support Care Cancer
Indian Journal of Palliative Care / Jul-Sep 2016 / Vol 22 / Issue 3 311
2015;23:1261‑71.
17. Wang JZ, Li L, Pan LL, Chen JH. Hypnosis and music interventions (HMIs)
inactivate HIF‑1: A potential curative efficacy for cancers and hypertension.
Med Hypotheses 2015;85:551‑7.
18. Burrai  F, Micheluzzi  V, Bugani  V. Effects of live sax music on various
physiological parameters, pain level, and mood level in cancer patients: A
randomized controlled trial. Holist Nurs Pract 2014;28:301‑11.
19. Burns DS, Perkins SM, Tong Y, Hilliard RE, Cripe LD. Music therapy is
associated with family perception of more spiritual support and decreased
breathing problems in cancer patients receiving hospice care. J  Pain
Symptom Manage 2015;50:225‑31.
20. Green CR, Anderson KO, Baker TA, Campbell LC, Decker S, Fillingim RB,
et al. The unequal burden of pain: Confronting racial and ethnic disparities
in pain. Pain Med 2003;4:277‑94.
21. Gupta U, Gupta BS. Psychophysiological responsivity to Indian instrumental
music. Psychol Music 2005;33:363‑72.
22. Kumar  TS, Muthuraman  M, Krishnakumar  R. Effect of the Raga
Ananda Bhairavi in post operative pain relief management. Indian J Surg
2014;76:363‑70.
23. Paice JA, Cohen FL. Validity of a verbally administered numeric rating scale
to measure cancer pain intensity. Cancer Nurs 1997;20:88‑93.
24. Jensen MP. The validity and reliability of pain measures in adults with cancer.
J Pain 2003;4:2‑21.
25. Breivik  H, Borchgrevink  PC, Allen  SM, Rosseland  LA, Romundstad  L,
Hals EK, et al. Assessment of pain. Br J Anaesth 2008;101:17‑24.
26. Jones  KR, Vojir  CP, Hutt  E, Fink  R. Determining mild, moderate, and
severe pain equivalency across pain‑intensity tools in nursing home residents.
J Rehabil Res Dev 2007;44:305‑14.
27. Caraceni  A, Brunelli  C, Martini  C, Zecca  E, De Conno  F. Cancer pain
assessment in clinical trials. A review of the literature (1999‑2002). J Pain
Symptom Manage 2005;29:507‑19.
28. Schneider  H, Esbitt  S, Gonzalez  JS. Hamilton Anxiety Rating Scale.
Encyclopedia of Behavioral Medicine. New York: Springer; 2013. p. 886‑7.
29. Yazici  MK, Demir  B, Tanriverdi  N, Karaagaoglu  E, Yolac  P. Hamilton
Anxiety Rating Scale: Interrater reliability and validity study. Turk Psikiyatri
Derg 1998;9:114‑7.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.
 Complementary Therapies in Medicine 30 (2017) 1–9

Contents lists available at ScienceDirect

Complementary Therapies in Medicine

journal homepage: www.elsevierhealth.com/journals/ctim

Effect of Turkish classical music on prenatal anxiety and satisfaction:

A randomized controlled trial in pregnant women with pre-eclampsia
Eylem Toker (Assistant Professor Doctor (PhD)) a,∗ , Nuran Kömürcü (Professor Doctor) b
a
Department of Midwifery, Kahramanmaras High School of Health, Kahramanmaras Sutcu İmam University, Kahramanmaras, Turkey
b
Department of Nursing, School of Health Sciences, İstanbul Aydın University, İstanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The present study aimed to evaluate the effect of music therapy on anxiety and satisfaction
Received 25 February 2016 in pregnant women with preeclampsia.
Received in revised form 20 October 2016 Design, setting and subjects: A randomized controlled trial was performed on 70 pregnant women with pre-
Accepted 17 November 2016
eclampsia hospitalized in the research and application hospital of Kahramanmaras Sütcü İmam University
Available online 18 November 2016
between December 2012 and February 2014. The subjects were allocated to experimental or control
groups in a random manner (n = 35 each).
Keywords:
Interventions: Pregnant women in the experimental group were subject to a 30 min Turkish classical
Pre-eclampsia
Anxiety
music therapy trial each day for a period of 7 days (5 days before and 2 days after labor) whereas those in
Satisfaction the control group received routine care and also were assigned to 30 min of bed rest a day. The Personal
Music therapy Information Form, State-Trait Anxiety Inventory, and Newcastle Satisfaction with Nursing Scale were
administered to participants. Data were analyzed using descriptive statistics, student t-test, and Mann-
Whitney U test where appropriate.
Main outcome measures: Outcome measures were anxiety scale scores, satisfaction scale scores, vital
signs, fetal movement and fetal heart rate.
Results: The differences between anxiety scores were not statistically significant (p > 0.05). On the other
hand, Newcastle Satisfaction with Nursing Scale scores of the experiment group were higher than the
control group (p < 0.01). Finally, when considering fetal movement counts, a significant increase was
determined in the experiment group, whereas Music Therapy had a minimalizing effect on fetal heart
rate and a lowering effect on blood pressure (p < 0.05).
Conclusion: It may be suggested that nurses and midwives can utilize music therapy in the care and
follow-up of pregnant women with preeclampsia in obstetrics units.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Music therapy is a type of treatment performed with a struc-
tured method by arranging the physiological and psychological
effect of musical sounds and melodies.1 Scientific studies proved
years ago that music affects spiritual and mental well-being, and
the body, positively.2,3 Music therapy is thus one of the methods
that is as old as the history of medicine itself. There are many studies
showing that music therapy is beneficial to the anxiety experienced
by the ill and pregnant.4–8 Specifically, a type of music called Med-
ical Resonance Therapy (MRT) is known to have various beneficial
∗ Correspondence to: Kahramanmaraş Sütçü İmam Üniversitesi Sağlık
Yüksekokulu, Bahçelievler Kampüsü, İsmetpaşa mah., 46100 Dulka-
diroğlu/Kahramanmaraş Turkey.
E-mail addresses: eylem7@yahoo.com, tokereylem@gmail.com (E. Toker).
effects in high risk pregnancies and to reduce stress.9 In this con-
text, music therapy, which is a cognitive behavioral therapy type
with high effect on anxiety, can be used as a complementary and
alternative treatment method.10
Pre-eclampsia, which is categorized as hypertension
(≥140/90 mmHg) caused by pregnancy and can be seen alongside
proteinuria after the 20th week of pregnancy classically,11 causes
fear and anxiety in pregnant individuals regarding themselves
or their babies, and presents as anxiety during pregnancy.12,13 In
addition to a subjective feeling of expectation and anxiety charac-
terized by horror, worrying, or the feeling that a disaster is closing
in,14 pre-eclampsia, if not treated throughout pregnancy, may
cause negative outcomes such as babies with low birth weights
(SGA), variational APGAR scores, fetal hemodynamics, movement
disorders, increase in the risk of pre-eclampsia, early membrane
rupturing, or caesarean sections.15

http://dx.doi.org/10.1016/j.ctim.2016.11.005
0965-2299/© 2016 Elsevier Ltd. All rights reserved.
2 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9
Pre-eclampsia and eclampsia, also known as toxemia, present
as a pregnancy complication in 2.8% of pregnancies in developing
countries and 0.4% of pregnancies in developed countries. Accord-
ing to the World Health Organization 2005 report (WHO), 12% of all
direct mother deaths are caused by eclampsia and this cause comes
third among the reasons for such deaths.16 In addition to this report,
in a report published in 2010, 18% of direct mother deaths were
stated to be caused by hypertension and the cause was stated to be
ranked second among causes for such deaths.17 In Turkey, 18.4% of
mother deaths are caused by oedema, proteinuria, and hyperten-
sive disorders, and 13.7% are caused by eclampsia, with eclampsia
coming second among reasons for such deaths.18
Music therapy is used today in many fields of medicine, espe-
cially in reducing anxiety caused by dental treatments, cardiac
procedures, medical and surgical procedures, obstetrics, and oncol-
ogy treatments, reducing stress, pain management, and reducing
hypertension.5–7,19–24
On the other hand, the use of music therapy on pregnant indi-
viduals is limited and studies on high risk pregnant women are
especially insufficient. In literature, music therapy was found to be
used on normal physiological pregnancies, in pregnancies where
transvaginal ultrasonography was performed, in pregnant woman
at delivery, and in pregnant women to whom the Non Stress Test
(NST) was applied in the reduction of anxiety.4,8,25,26 Although
among high risk pregnancies, studies on using the method on high
risk pregnant women who were suggested bed rest and pregnant
women with hypertension were present 7,9 no studies on pregnant
women with pre-eclampsia were found.
In literature, there are no studies investigating the effect of Clas-
sical Turkish Music presented before and after birth to pregnant
women with pre-eclampsia on anxiety, physiological parameters,
well-being of the fetus, and satisfaction. There are a limited num-
ber of research studies in our country regarding music therapy in
the field of obstetrics,4,8 and no clinical or experimental studies on
the effect of music therapy on satisfaction and anxiety of pregnant
women with pre-eclampsia were found in the literature. From this
aspect, the current study is original.
It was thought that Classical Turkish Music would have a posi-
tive effect on pregnant women with pre-eclampsia.2–9,24–26 For this
reason, the aim of this study is to investigate whether music ther-
apy performed with classical Turkish music would have positive
effects on the anxiety and physical symptoms of the mothers and
the fetuses, as well as investigating the general satisfaction of the
pregnant women with music therapy.
2. Methods
2.1. Study design
This was a parallel group, randomized controlled trial (RCT).
The study was conducted with pregnant women who were present
at the maternity unit of Kahramanmaras Sutcu Imam University
Research and Application Hospital and were diagnosed with pre-
eclampsia.
The hospital where the study was conducted was the only pub-
lic hospital which offers third step medical services in the city,
and all of the complicated cases such as pre-eclampsia were being
forwarded to this hospital. In the 12 bed Obstetrics Service, three
separate rooms for women with pre-eclampsia were present, and
these rooms were designed for three people or a single person.
2.2. Permissions for the study
Official permissions from Kahramanmaras Sutcu Imam Uni-
versity Medical School Research and Application Hospital Chief
Physician’s Office and Obstetrics Department through Kahra-
manmaras Sutcu Imam University Rector’s Office and written
permission from the Marmara University Ethical Board were taken
(Institution permission: 26.11.2012-9660; Ethic Board Permission:
14.09.212-1). Additionally, before the study, all of the participants
were informed about the study and an informed consent form was
given to each participant (Informed Consent Form). All participants
completed a consent form before the study.
2.3. Participants
The criteria of The American Congress of Obstetricians and
Gynecologists and the National High Blood Pressure Education Pro-
gram (NHBPEP) 11,27 were used in the study, and according to the
criteria, 126 hospitalized pregnant women who stayed at the hospi-
tal between the dates of December 1st 2012 and February 1st 2014
with a diagnosis of pre-eclampsia formed the population of the
study. Before sample selection, the whole population was planned
to be included in the study, however, only 84 women met the inclu-
sion criteria.
Inclusion criteria were:
(1) Being an inpatient for at least five days with a diagnosis of pre-
eclampsia,
(2) Being in the 30th week of pregnancy or above (Because Non
Stress Test would be taken during observation and the music
would continue until birth and after birth);
In this study, in order to measure the Fetal Health and reaction
of the fetus on music, we used the Electronic Fetal Monitoring and
measured the fetal heart rate and fetal movements before and after
music by non-stress test (NST). NSTs are generally performed after
28 weeks of gestation. Before 28 weeks, the fetus is not developed
enough to respond to the test protocol. Additionally, pre-eclampsia
usually depends on at third trimester in the pregnancy. In addition,
at third trimester of the pregnancy fetus can hear the extrauterine
voices and music and reflect the music more than second trimester.
Due to these reasons, the pre-tests were given in the 30th week of
pregnancy or above.
(3) Being at or above 18 years of age (for detailed Informed Consent
Form),
(4) Having a live, single, healthy fetus.
Exclusion criteria were:
(1) Having hearing deficiencies, (2) Not agreeing to participate,
(3) Being illiterate, (4) Having communication problems, (5) Being
admitted with severe pre-eclampsia, (6) The newborn not being
alive.
2.4. Study protocol
Out of 126 pregnant women who were hospitalized were eval-
uated with regard to how appropriate they were for the study and
84 of those women were included in the study. After second evalu-
ation, for reasons such as infant deaths and staying at the clinic for
less than five days, 14 women were excluded and 70 women were
included in the study (Fig. 1).
Using a computer program module designed for randomized
controlled studies (http://www.randomizer.org/form.htm), a ran-
domization list was formed and participants were accordingly
assigned to the study and control groups. Participants were num-
bered according to their order of admittance to the hospital, and
they were assigned randomly to the study and control groups in
two equal groups (experimental group n = 35, control group n = 35).
According to the results of the randomization, there could be two
 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9 3

Assessed for eligibility (n=126)

Excluded (n=42)
§ Not meeting inclusion criteria (n=32)
§ Declined to participate (n=0)
§ Other reasons (n=10)

Randomization (n=84)

Measurements prior to study

§ Personal Information Form
§ State Trait Anxiety Inventory (STAI TX-I)

Music group (7 days) (n=42) Control group (7 days) (n=42)

§ Music exposure, 30 min § Music exposure, 30 min
§ Pre-test and post-test § Pre-test and post-test
o SBP/DBP o SBP/DBP
o Pulse and respiratory rate o Pulse and respiratory rate
o Non-stress test, fetal movements, o Non-stress test, fetal movements,
fetal heart rate (the first 5 days) fetal heart rate (the first 5 days)

§ Lost to follow-up (Hospitalized fewer than § Lost to follow-up (Hospitalized fewer than
five days at the clinic) (n=6) five days at the clinic) (n=6)
§ Discounted intervention (newborn ex) § Discounted intervention (newborn ex)
(n=1) (n=1)

Measurements following the study

§ State Trait Anxiety Inventory (STAI TX-I)
(retest on the 5th day before labor)
§ New Castle Satisfaction with Nursing Scale
(NNCS) (on the 2nd day following labor)

Analyzed (n=35) Analyzed (n=35)

Fig 1. Flow-chart of the study (SBP, systolic blood pressure; DBP, diastolic blood pressure).

experimental group participants, two control group participants, The power analysis of the study, for ␣ = 0,05 significance level
or one of each in each day. Data was collected together until the ␤ = 0,20, 0,80 test power in the experimental and control group
sample size was reached. based on equal exemplify ∼
= 0,70 for each group n = 35, respectively.
4 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9
3. Measurements
The following scales were used in the study.
3.1. Personal information form
The personal information form prepared by the researcher con-
sisted of 29 questions including socio demographic characteristics
(age, education, health insurance in area lived), obstetrics infor-
mation (obstetric history, history of present pregnancy and birth,
information on the infant) and the relationship of the participants
with music (if they enjoy listening to music, what kind of music
they like, and usually when they listened to music). The form was
applied to both groups before the study.
3.2. State trait anxiety inventory (STAI TX-I)
The scale was developed by Spielberger et al. 1970 in order to
measure State and Continuous Anxiety levels, consisting of two
scales,28 and was tested for validity and reliability in Turkish by
Öner and Le Compte.28 The State Trait Anxiety Scale used in this
study determines how an individual feels in a certain environ-
ment under certain conditions, consisting of 20 straight and inverse
scored terms, and is scored between 20 and 80 in a likert type scor-
ing between 1 and 4. High scores show high anxiety levels while
low scores indicate low anxiety levels.28
For STAI, the Cronbach’s alpha for the total scores was ␣ = 0,81,28
in the study for STAI, the Cronbach’s alpha for the total scores was
0.86.
The scale was applied to both groups before (the intervention)
and after (in the fifth day of the intervention) the study.
The post-tests timing on STAI on the fifth day of the inter-
vention before birth, because we would like to measure and find
the effect of music therapy on anxiety levels of pregnancy period
of pre-eclamptic women which is at last five days before the
delivery during hospitalization on the clinic, when anxiety levels
were expected very high. Normally after birth, anxiety levels were
expected to decrease.
3.3. The newcastle satisfaction with nursing scale (NNCS)
The scale was tested for validity and reliability in Turkish in 2007
by Akın and Erdogan. The total score is converted into 100 before
evaluation, and the maximum and minimum scores that can be
taken from the scale are 95 and 19 respectively. An increase in the
total score taken from the scale shows high satisfaction with the
nursing care received.29
For NNCS, the Cronbach’s alpha for the total scores was
␣ = 0,81,29 also in the study for NNCS the Cronbach’s alpha for the
total scores was 0.95.
The NNCS is a scale about nursing satisfaction and since the
nursing care continued while the participants were staying at the
hospital. As a result, the NNCS was applied on the last day of hos-
pitalization, and it was recommended in such way. With this scale,
in the study we would like to measure of satisfaction scores at pre
and postpartum period holistically, which is not effected by deliv-
ery, so it was applied after the birth. The scale was applied to the
participants in both groups after birth (in the 7th day of the inter-
vention). Because in our country the women at postpartum period
were usually hospitalized optimal two days in the hospital.
3.4. Vital findings
The systolic and diastolic blood pressures of each participant
were measured with a newly calibrated classical manual blood
pressure monitor (the same monitor was used in all participants),
and their pulse and respiratory rates were assessed and recorded
by the researcher.
3.5. Non stress test (NST)
The Fetal Non-Stress test is a non-invasive, simple test per-
formed in pregnancies over 28 weeks gestation. Fetal heart rate
(FHR) and Fetal Movements (FM) were recorded by applying 15 min
of NST through Electronic Fetal Monitoring preferred in the clinic
where the study was conducted.
4. Interventions
4.1. Classical Turkish music presentation
The “Nihavend” and “Buselik” modes of Turkish music suggested
by the Turkish Music Research and Promotion Group (TUMATA)
that have relaxing properties were used by taking expert views.
Participants in the study group listened to the mode of music they
selected from between the Nihavend and Buselik modes regularly
30 min a day for seven days through an MP3 player and headphones
whilst lying down.
The participants in the study group arranged the sound level of
the music according to their desires, and the steps taken care of
during application included the bladder of the participants being
empty, starting the music presentation by taking three deep breaths
for concentration, repeating the breathing exercise in case of lost
concentration, closing cell phones, and not having any medical
interventions during the presentation.
4.2. Bed rest
Both the experimental and control groups received routine care
of assessment of vital signs, drug administration, etc., but while
the experimental group received music therapy, the control group
had 30 min of bed rest a day. Before bed rest, special care was
given to the bladder of the participants being empty, the partici-
pants not being hungry, cell phones being closed, and no medical
interventions being performed during bed rest.
4.3. Data collection
In the literature, music therapy was used consecutively, at least
three days and at most 15 days. Researcher advices music therapy
should be used consecutively, so in this study we would like to
search effects of music therapy on participants before birth and
after birth.
The participants listened to music five days before birth and two
days after birth during they were in the hospital. They did not listen
to music during labor.
The participants were monitored for seven days, five before and
two after birth. During this time, the participants in the study group
had 30 min presentations of Classical Turkish Music (the music
therapy group), and the participants in the control group received
30 min of daily bed rest. The systolic blood pressures and diastolic
blood pressures of each participant were measured with a newly
calibrated separate manual blood pressure device, and their pulse
and respiratory rate were directly assessed and recorded by the
researcher (7 days total).
Additionally, FHR and FM were recorded by applying 15 min
of NST through Electronic Fetal Monitoring preferred in the clinic
where the study was conducted (only the 5 days before birth). The
participants in the control group were asked to perform bed rest
30 min daily, and their vital and fetal findings were also recorded
before and after rest, but they did not listen to music. In this study
 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9
the music therapy was given by the researcher only at the hospital
during they were hospitalized.
4.4. Statistics
Data was defined as averages ± standard deviations and per-
centages. For statistical analysis, the NCSS (Number Cruncher
Statistical System) 2007&PASS (Power Analysis and Sample Size)
2008 Statistical Software (Utah, USA) program, and the G*Power
(v3.1.7) program were used. In data analysis, tests such as the Paired
and unpaired Student t-tests, the Wilcoxon signed-rank and Mann-
Whitney U tests, the Pearson Chi squared test, Pearson-correlation
test, Spearman-correlation test, and Post-hoc power analysis were
used. All evaluations were performed for a 95% confidence interval;
significance threshold was set at a p-value of 0.05 and a p < 0.01 was
considered highly significant.
5. Results
The participants in the study were found to have an average
age of 30.64 ± 5.81, with most being elementary school graduates
and unemployed (Table 1). The average number of pregnancies was
found to be 3.16 ± 1.77, with 24.2% having their first pregnancy,
the women giving an average of 2.26 ± 1.19 births, 9.4% having a
history of stillbirth, and 49.1% having a history of miscarriage. The
participants included in the study were found to give their births in
an average of 36.20 ± 2.40 weeks (Table 2). With regard to the socio
demographic characteristics and other obstetric characteristics, no
statistically significant difference between the groups was found
(p > 0.05) (Tables 1 and 2).
According to the STAI TX-I applied before the interventions, anx-
iety in the participants included in the context of the study was
found to be on an average level, and no statistically significant dif-
ference between the anxiety starting levels were found between
the groups (Table 3). According to the STAI TX-I scale applied on
the 5th day after 5 days of interventions before birth, anxiety lev-
els were again found to be average. In the comparison performed
between the groups before and after five days, no statistically sig-
nificant differences in anxiety levels were found (Table 3).
When the NNCS scores obtained on the 2nd day after birth were
evaluated, the scores of the study group were found to be higher
on a significant level compared to the control group (Table 4).
When the first measurements performed in the beginning of
the study were taken into consideration, no significant difference
between the groups regarding average systolic blood pressure was
found (Table 5). Similarly, no difference was found in the mea-
surements obtained after the application (Table 5). On the other
hand, when the groups were compared according to the difference
between these two values, the music group was seen to have a
larger reduction, and this significant difference was seen between
the groups (Table 5). In the study, the effects of music therapy in
both the prenatal and postnatal period were shown not to cause
significant differences with regard to pulse and respiratory rate in
or between groups (Not given in Tables).
The diastolic blood pressure average values were found to be
similar between the groups in the beginning. The blood pressure
measurements performed after the applications, diastolic blood
pressure values were found to decrease significantly in both the
prenatal and postnatal periods, and this significant difference was
seen within the groups, with no sustainable significant decrease in
the control group. This significant difference was also seen between
the groups in the prenatal period. Especially in the postnatal period,
music therapy was found to cause significant differences between
the groups (Table 6).
5
The fetal health related data (FM, FKH) were found to be simi-
lar in the beginning, with no differences between the groups. The
music therapy applied to the study group was found to increase FM
and FKH values, and this seemed to bring a significant difference
within the group.
Between the groups, these values were found to cause signifi-
cant differences in FM (Table 7) and no statistical differences were
found in FKH (Table 8).
6. Discussion
With regard to the socio demographic characteristics and
other obstetric characteristics, no statistically significant difference
between the groups that could affect the results of the study was
found.
As a result of our study, music therapy was not found to have
a significant decreasing effect on anxiety in pregnant women with
pre-eclampsia. This result is considered to have arisen from the
facts that the participants in our sample were high risk, each of the
situations such as pre-eclampsia bringing risks regarding fetal and
maternal health and hospitalization causing pregnancy anxiety to
increase. Minimal changes occurring in the anxiety scores of the
participants and the anxiety levels not being higher than average
at the end of five days are also seen as positive results. Some stud-
ies report no significant effect or minimal effect for music therapy
on anxiety.24,26,30–33 but in some studies performed with pregnant
women, music was found to be effective on the anxiety of preg-
nant women, differing from our results 4,7,8,25,34 Additionally, music
therapy was used as a complementary and alternative treatment in
the removal of anxiety, and that in most of the studies, music ther-
apy was used to remove status anxiety seen in individuals before
medical and operative interventions.3,5,6,19–21,23 Although it seems
not to have an effect on anxiety levels in our study, participants
tended to close their eyes and mostly sleep while listening to music.
Music may create a feeling of peace. When it is considered that
pre-eclampsia is a medical condition that creates anxiety on its
own, participants relaxing while listening to music is an expected
situation.
Music therapy applied to pregnant women with pre-eclampsia
as a complementary care method in our study has increased satis-
faction with nursing care in pregnant women.
This situation is realized through a certain selected type of music
reducing neuroendocrine and sympathetic nervous system stimuli,
causing an increase in endorphin release and peace and satisfaction
feelings to form in the individual.33,35
Many studies have shown that music therapy increases patient
satisfaction and these results support our study.34,36,37 Addi-
tionally, compared to some other studies evaluating patient
satisfaction, the appeasement scores in our study were especially
higher.38–41
On the other hand, the fact that we found the effect of music to
decrease blood pressure is thought to have arisen from the fact that
music therapy affects the autonomous and central nervous system,
having a positive effect on physiological parameters. Chlan 22 stated
that musical stimuli, especially rhythm and tempo, could be used to
change the physiological responses of the body (heart rate, respira-
tion, blood pressure) through synchronization, and that music has
a positive effect on vital findings and the psychological and phys-
iological well-being of an individual. Parallel to our study, studies
showing that music has a decreasing effect on blood pressure are
present 3,7,9,24,42
Even though there are studies in literature showing that music
has a decreasing effect on blood pressure,3,7,24,42 only a single study
performed with pregnant women with hypertension was found.9
In this study performed by Sideronko9 Medical Resonance Therapy
6 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9

Table 1
Comparison of Socio Demographic Characteristics according to groups.

Study Group (n = 35) Control Group (n = 35) Total (n = 70) ta p

X̄ ± SD X̄ ± SD X̄ ± SD

Age (years) 30.69 ± 5.60 30.60 ± 6.10 30.64 ± 5.81 0.061 0.951

n (%) n (%) n (%) 2 p

Education level
Literate 3 (8.6) 6 (17.1) 9 (12.8) 1.403b 0.548
Elementary 26 (74.3) 25 (71.4) 51 (72.9)
High-College. 6 (17.1) 4 (11.5) 10 (14.3)

Employment status
Employed 3 (8.6) 3 (8.6) 6 (8.6) 0.000c 1.000
Unemployed 32 (91.4) 32 (91.4) 64 (91.4)
a
Student’s t test.
b
Fisher-Freeman-Halton test.
c
Fisher’s exact test.

Table 2
Comparison of Findings regarding Obstetrics Characteristics according to groups.

Study Group (n = 35) Control Group (n = 35) Total (n = 70) td /ze p

X̄ ± SD X̄ ± SD X̄ ± SD

Birth Week 35.76 ± 2.00 36.64 ± 2.69 36.20 ± 2.40 −1.560d 0.123
Number of Births (n = 53)1 2.10 ± 1.06 2.45 ± 1.34 2.26 ± 1.19 −1.110e 0.267

n (%) n (%) n (%) 2a.b.f p

Number of pregnancies
f
1 5 (14.3) 12 (34.3) 17 (24.3) 5.208 0.074
2–3 12 (34.3) 13 (37.1) 25 (35.7)
≥4 18 (51.4) 10 (28.6) 28 (40.0)

Number of stillbirths (n = 53)1

No 26 (86.7) 22 (95.7) 48 (90.6) 1.230b 0.374
Yes 4 (13.3) 1 (4.3) 5 (9.4)

Number of miscarriages (n = 53)1

No 13 (43.3) 14 (60.9) 27 (50.9) 1.676a 0.464
1 12 (40.0) 7 (30.4) 19 (35.8)
≥2 5 (16.7) 2 (8.7) 7 (13.3)
1
was calculated by removing first births from n.
d
Student’s t test.
e
Mann Whitney U test.
a
Fisher-Freeman-Halton test.
b
Fisher’s exact test.
f
Pearson Ki-kare test.

Table 3
Comparison of State Trait Anxiety Inventory (STAI TX-I) scores.

Study Group Control Group Total (n = 70) td p

(n = 35) (n = 35)

PREN Pre Application Min-Mak 32–57 32–64 32–64 −0.522d 0.603

1. day STAI TX-1 X̄ ± SD 42.03 ± 5.92 42.83 ± 6.86 42.43 ± 6.37
PREN Post application Min-Mak 36–54 30–64 30–64 1.008d 0.317
5. day STAI TX-I X̄ ± SD 43.86 ± 4.69 42.34 ± 7.55 43.10 ± 6.29
tg ; p −1.776; 0.085 0.504; 0.617

Change evaluation ze p
Difference1 X̄ ± SD 1.83 ± 6.09 −0.49 ± 5.70 −1.910e 0.056
(median) −1.00 0.00

PREN.: Prenatal.
1
STAI TX-I score difference between the 5th and 1st day before birth.
d
Student’s t test.
g
Paired samples t test.
e
Mann Whitney U test.

Table 4
Comparison of Newcastle Satisfaction with Nursing Scale (NHNS) scores.

Study Group (n = 35) Control Group (n = 35) Total (n = 70) t p

NHNS Min-Mak 69.74–100.00 35.53–100.00 35.53–100.00 2.920t 0.005**

X̄ ± SD 86.54 ± 10.42 74.62 ± 21.78 80.58 ± 17.98
t
Student’s t test.
**
p < 0.01.
 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9 7

Table 5
Comparison of Systolic blood pressure measurements and differences according to groups.

Average Systolic Blood pressure Study Group (n = 35) Control Group (n = 35) td /ze p
X̄ ± SD X̄ ± SD

PREN Pre app1 133.49 ± 12.17 131.17 ± 11.09 0.831d 0.409

Post app2 128.74 ± 11.24 129.46 ± 11.79 −0.261d 0.795
Difference (2-1) tg ; p 4.703g ; 0.001** 1.462g ; 0.153 −2.171e 0.030*
POSN Pre app3 127.71 ± 11.67 126.64 ± 9.29 0.425d 0.672
Post app4 125.14 ± 11.16 126.14 ± 10.49 −0.386d 0.701
Difference (4-3) tg ; p 1.823g ; 0.077 0.407g ; 0.687 −1.264e 0.206

PREN.: Prenatal POSN.:Postnatal App.: Application.

d
Student’s t test.
e
Mann Whitney U test.
g
Paired samples t test.
*
p < 0.05.
**
p < 0.01.
1
Prenatal period Pre application 5 day averages.
2
Prenatal period Post application 5 day averages.
3
Postnatal period Pre application 2 day averages.
4
Postnatal period Post application 2 day averages.

Table 6
Comparison of Diastolic blood pressure measurements and differences according to groups.

Average Diastolic Blood pressure Study Group (n = 35) Control Group (n = 35) td /ze p
X̄ ± SD X̄ ± SD

PREN Pre app1 83.81 ± 9.16 83.07 ± 8.59 0.347d 0.730

Post app2 80.00 ± 6.68 83.09 ± 7.75 −1.784d 0.079
Difference (2-1) tg ; p 3.711g ; 0.001*, * −0.021g ; 0.984 −3.211e 0.001**
POSN Pre app3 79.00 ± 11.62 82.36 ± 8.72 −1.367d 0.176
Post app4 76.00 ± 8.73 81.07 ± 8.75 −2.428d 0.018*
Difference (4-3) tg ; p 2.569g ; 0.015* 1.704g ; 0.290 −0.909e 0.364

PREN.: Prenatal POSN.:Postnatal App.: Application.

d
Student’s t-test.
e
Mann Whitney U test.
g
Paired samples t test.
*
p < 0.05.
**
p < 0.01.
1
Prenatal period Pre application 5 day averages.
2
Prenatal period Post application 5 day averages.
3
Postnatal period Pre application 2 day averages.
4
Postnatal period Post application 2 day averages.

Table 7
Comparison of Fetal Movement Number (FM) measurements and differences according to groups.

Average FM Number Study Group (n = 35) Control Group (n = 35) ze p

X̄ ± SD (median) X̄ ± SD (median)

Pre app1 4.36 ± 3.45 (3.40) 3.57 ± 1.60 (3.40) −0.600e 0.549
Post app2 5.43 ± 3.93 (4.20) 3.72 ± 1.62 (4.00) −1.996e 0.046*
Difference (2-1) th ; p −3.089h ; 0.002** −0.422h ; 0.673 −2.348e 0.019*

FM: Fetal Movement Number.

e
Mann Whitney U test.
h
Wilcoxon signed ranks test.
*
p < 0.05.
**
p < 0.01.
1
Prenatal period Pre application 5 day averages.
2
Prenatal period Post application 5 day averages.

Table 8
Comparison of Fetal Heart Rate (FKH) measurements and differences according to groups.

Average FKH Number Study Group (n = 35) Control Group (n = 35) td /ze p
X̄ ± SD X̄ ± SD

Pre app1 140.15 ± 7.04 141.42 ± 6.89 −0.762d 0.449

Post app2 141.26 ± 7.27 141.34 ± 6.60 −0.048d 0.962
Difference (2-1) tg ; p −2.437g ; 0.020* 0.076g ; 0.940 −1.111e 0.266

FKH: Fetal Heart Rate.

d
Student’s t test.
e
Mann Whitney U test.
g
Paired samples t test.
*
p < 0.05.
1
Prenatal period Pre application 5 day averages.
2
Prenatal period Post application 5 day averages.
8 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9
(MRT) was used as the music type and there is no study evaluating
the effect of Classical Turkish Music on anxiety and blood pressure
in pregnant women with pre-eclampsia. This study is thus unique.
On the other hand, studies similar to ours showing that music ther-
apy causes no differences in pulse and respiratory rates are also
present.34,43
Alongside these changes seen in pregnant women with
pre-eclampsia, the positive and significant differences in fetal
parameters obtained during fetal evaluation are also similar to
studies in literature on the subject.7–9 This result is thought to have
arisen from the response given by the fetus to the music listened
to. The fact that it was already reported that fetuses close to term
would show increased movement as a response to music 44 also
supports our finding.
6.1. Study limitations
When the limitations of the study are considered, the type of
music selected seems to be the first limitation of our study. Differ-
ent results may be obtained with different types of music. However,
it should be taken into consideration that the efficiency of Classi-
cal Turkish Music was found in other studies and that the type of
music was selected by the participants. The researcher knowing
the groups and taking care of the participants during the inter-
ventions and measurements may have affected the results. This
may have prevented more and more significant results obtained
between the groups. The facts that satisfaction was found to be
high in the control group as well and the control group also having
changes in blood pressure show there is no bias. However, a third
group in addition to those listening to music and receiving bed rest
could be added for comparison. However since the study was per-
formed with pregnant women with pre-eclampsia, which is a high
risk pregnancy group, this fact brought along the additional bar-
rier of not having sufficient cases in the clinic. Also the number of
cases is another limitation of the study. Additionally, more compre-
hensive studies with larger samples on the effectiveness of music
therapy on pregnant women with pre-eclampsia would verify the
effectiveness of Classical Turkish Music.
6.2. Recommendations for clinical practice
The study found significant differences between the groups and
the music therapy is suggested for use in the clinical environment
by obstetrics nurses/midwives after they received some training in
regard to education about music therapy. Steps of using the music
therapy may be:
– Maternity units and hospitals facilities could be designed
for music therapy in the clinical environment by obstetrics
nurses/midwives (such as specific areas for music therapy, and
allowance of listening music through loudspeaker or an MP3
player and headphones).
– The pregnant women with pre-eclampsia may be taken in a sep-
arate room.
– The steps before music therapy mentioned in the study should be
taken into considerations such as −the bladder of the participants
being empty, etc.
– The pregnant women should listen to the music selected among
different types of therapeutic musics according to their taste
regularly 30 min daily through an MP3 player and headphones
whilst lying down.
6.3. Suggestions for further studies
– Further studies may be performed with pregnant women with
pre-eclampsia, during prenatal, intrapartum and postpartum
period in order to test its and do research of the effectiveness
of music therapy on women.
– Another study may be performed on women with high risk of
pre-eclampsia and search of effectiveness of music therapy on
prevention of developing pre-eclampsia.
– More comprehensive studies with larger samples (qualitative or
quantitative studies), different measurements on the effective-
ness of music therapy on pregnant women with pre-eclampsia,
fetus and newborn would verify the effectiveness of Classical
Turkish Music.
7. Conclusion
In conclusion, through the findings obtained by applying music
therapy to pregnant women with pre-eclampsia, music therapy
was found to increase satisfaction with nursing care in pregnant
women, decrease blood pressure, the positive effect on fetal move-
ment counts, and minimalizing effect on fetal heart rate. Although
it seems not to have an effect on anxiety levels in our study, par-
ticipants relaxed while listening to music. The participants’ pulse
and respiratory rates were normal before the study so there were
no differences in pulse and respiratory rates before and after the
study.
Briefly, music therapy was found to have positive effects and
help provide a supportive and humane environment as well as
improve the experience and environment of the pregnant women,
and it may be suggested that nurses and midwives can utilize music
therapy in the care and follow-up of pregnant women with pre-
eclampsia in maternity units.
Conflict of interest statement
We, the authors of the present study, declare that there is no
conflict of interest regarding the paper entitled “Effect of Turk-
ish Classical Music on Prenatal Anxiety and Satisfaction: A RCT in
Pregnant Women with Pre-eclampsia”.
Acknowledgment
The TUMATA Association was consulted in every step of this
study from planning to application, and complete cooperation was
received from the team working at the obstetrics clinic where the
application was performed.
The present study is a dissertation completed in the Department
of Obstetrics and Gynecology Nursing, Faculty of Health Sciences,
Marmara University, İstanbul, Turkey.
This manuscript has been presented orally at the Complemen-
tary and Supportive Care Applications Congress, held in Kayseri,
Turkey, 27–29 May 2015.
References
1. Gençel Ö. Treatment with music. Kastamonu J Educ. 2006;14:697–706.
2. Schmidt LA, Trainor LJ. Frontal brain electrical activity (EEG) distinguishes
valence and intensity of musical emotions. Cognit Emot. 2001;15:487–500.
3. Lee D, Henderson A, Shum D. The effect of music on preprocedure anxiety in
Hong Kong chinese day patients. J Clin Nurs. 2004;13:297–303.
4. Kömürcü N. The effect of music presented during labor on anxiety in pregnant
women. J Nurs Forum. 1999;2:89–96.
5. Lai HL, Hwang MJ, Chen CJ, Chang KF, Peng TC, Chang FM. Randomised
controlled trial of music on state anxiety and physiological indices in patients
undergoing root canal treatment. J Clin Nurs. 2008;17:2654–2660.
6. Nilsson U. The anxiety- and pain-reducing effects of music interventions: a
systematic review. AORN J. 2008;87:780–807.
7. Yang M, Li L, Zhu H, et al. Music Therapy to relieve anxiety in pregnant
women on bedrest: a randomized, controlled trial. MCN Am J Maternal Child
Nurs. 2009;34:316–323.
8. Kafali H, Derbent A, Keskin E, Simavli S, Gözdemir E. Effect of maternal
anxiety and music on fetal movements and fetal heart rate patterns. J
Maternal-Fetal Neonatal Med. 2011;24:461–464.
 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9
9. Sidorenko VN. Clinical application of Medical Resonance Therapy music in
high-risk pregnancies. Integr Physiol Behav Sci. 2000;35:199–207.
10. Gürkan A, Bilge A. Alternative therapies and psychiatric nursing. Ege Univ J
Nurs High School. 2006;22:225–232.
11. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY.
Hypertension during pregnancy. In: Cunningham FG, Leveno KJ, Bloom SL,
eds. Williams Obstetrics. 23rd ed. İstanbul: Nobel Tıp Publishing Ltd.;
2010:706–757. Trans: Ceylan Y, Yıldırım G, Gedikbaşı A, Aslan H, Gül A.
12. Coşar B. Pregnancy and psychiatric illnesses. In: Yamaç K, Gürsoy R, Çakır N,
eds. Pregnancy and Systemic Diseases. 1st ed. İstanbul: MN Medikal & Nobel
Tıp Publishing Ltd.; 2002:891–892.
13. Vural G. Hypertensive disorders. In: Gilbert ES, Harmon JS, eds. Manual for
High Risk Pregnancy and Labor. 2nd ed. Ankara: Palme Publishing;
2002:488–533. Trans: Taşkın L.
14. Yüksel N. Anxiety disorders. In: Yüksel N, ed. Mental Disorders. 3rd ed. Ankara:
MN Medikal & Nobel; 2006:143–182.
15. Kocabaşoğlu N, Başer Z. Pregnancy and psychiatric illnesses triggered by
labor: psychiatric illnesses common in Turkey. I.U. Cerrahpasa Faculty of
Medicine Continuing Medical Education Activities Symposium Series.
2008;62:349–354.
16. The World Health Report 2005. Make Every Mother and Child Count Geneva,
World Health Organization. Genova: WHO Press; 200545–65.
17. Countdown to 2015 Decade Report (2000–2010). Taking Stock of Maternal,
Newborn and Child Survival. World Health Organization and UNICEF. Geneva:
WHO Press; 201011–12.
18. Hacettepe University School of Population Research, Reproductive Health
Program National Turkish Mother Deaths Study, 2005. Main Report. Ministry
of Health Directory of Mother Infant Health and Family Planning and
European Commission Turkish Delegation. Ankara, Elma Technical Publishing,
2005; 9–70.
19. Clark M, Isaacks-Downton G, Wells N, et al. Use of preferred music to reduce
emotional distress and symptom activity during radiation therapy. J Music
Ther. 2006;43:247–265.
20. Ferrer AJ. The effect of live music on decreasing anxiety in patients
undergoing chemotherapy treatment. J Music Ther. 2007;44:242–255.
21. Rudin D. Frequently overlooked and rarely listened to: music therapy in
gastrointestinal endoscopic procedures. World J Gastroenterol: WJG.
2007;13:4533.
22. Chlan L. A Review of the evidence for music ıntervention to manage anxiety in
critically ill patients receiving mechanical ventilatory support. Arch Psychiatr
Nurs. 2009;23:177–179.
23. Moradipanah F, Mohammadi E, Mohammadil AZ. Effect of music on anxiety,
stress, and depression levels in patients undergoing coronary angiography.
East Mediterr Health J. 2009;15:639–647.
24. Bekiroglu T, Ovayolu N, Ergun Y, Ekerbicer HC. Effect of Turkish classical
music on blood pressure: a randomized controlled trial in hypertensive
elderly patients. Complement Ther Med. 2013;21:147–154.
25. Chang M-Y, Chen C-H, Huang K-F. Effects of music therapy on psychological
health of women during pregnancy. J Clin Nurs. 2008;17:2580–2587.
26. Shin HS, Kim JH. Music therapy on anxiety stress and maternal-fetal
attachment in pregnant women during transvaginal ultrasound. Asian Nurs
Res. 2011;5:19–27.
9
27. National High Blood Pressure Education Program (NHBPEP). Working Group
Report on High Blood Pressure in Pregnancy. National Institues of Health
National Heart, Lung, and Blood Institute. NIH Publication; 2000. No: 00-3029.
28. Aydemir Ö, Köroğlu E. Clinical Scales Used in Psychiatry. 4th ed. Ankara:
Hekimler Yayın Birliği (Publishing Association for Doctors); 2009:221–232.
29. Akın S, Erdoğan S. The Turkish version the Newcastle Satisfaction with
Nursing Care Scale used on medical and surgical patients. J Clin Nurs.
2007;16:646–653.
30. Domar AD, Eyvazzadeh A, Allen S, et al. Relaxation techniques for reducing
pain and anxiety during screening mammography. AJR Am J Roentgenol.
2005;184:445–447.
31. Kimber L, McNabb M, Mc Court C, Haines A, Brocklehurst P. Massage or music
for pain relief in labour: a pilot randomised placebo controlled trial. Eur J Pain.
2008;12:961–969.
32. Laopaiboon M, Lumbiganon P, Martis R, Vatanasapt P, Somjaivong B. Music
during caesarean section under regional anaesthesia for improving maternal
and infant outcomes. Cochrane Database Syst Rev. 2009;15:CD006914.
33. Tseng YF, Chen CH, Lee CS. Effects of listening to music on postpartum stress
and anxiety levels. J Clin Nurs. 2010;19:1049–1055.
34. Chang SC, Chen CH. Effects of music therapy on Women’s physiologic
measures, anxiety, and satisfaction during cesarean delivery. Res Nurs Health.
2005;28:453–461.
35. Lai HL, Chen CJ, Peng TC, et al. Randomized controlled trial of music during
kangaroo care on maternal state anxiety and preterm infants’ responses. Int J
Nurs Stud. 2006;43:139–146.
36. Uçan Ö, Ovayolu N, Savaş MC. The effects of music presented during upper
gastrointestinal system endoscopy on some patient values, patient
satisfaction, and success of the procedure. Atatürk Univ J Nurs High School.
2007;10:16–25.
37. Wu J, Chaplin W, Amico J, et al. Music for surgical abortion care study: a
randomized controlled pilot study. Contraception. 2012;85:496–502.
38. Eker A, Yurdakul M. The effect of care provided after C-section on patient
satisfaction. Mersin Univ J Health Sci. 2008;1:26–35.
39. Geçkil E, Dündar Ö, Şahin T. Evaluation of patient satisfaction with nursing
care in the city center of Adiyaman. Hacettepe Univ Nurs J Fac Health Sci.
2008;4:41–51.
40. Koç Z, Sağlam Z, Şenol M. Patient satisfaction with the nursing care in
hospital. Turkiye Klinikleri J of Med Sci. 2011;31:629–640.
41. Tuğut N, Gölbaşı Z. Level of satisfaction with nursing services and affecting
factors in patients staying at the gynecology and labor service of a university
hospital. J Nurs Educ Res. 2013;10:38–44.
42. Zanini CR, Jardim PC, Salgado CM, et al. Music therapy effects on the quality of
life and the blood pressure of hypertensive patients. Arq Bras Cardiol.
2009;93:534–540.
43. Gillen E, Biley F, Allen D. Effects of music listening on adult patients’
pre-procedural state anxiety in hospital. Int J Evid Based Healthc.
2008;6:24–49.
44. Kisilevsky S, Hains SM, Jacquet AY, Granier-Deferre C, Lecanuet JP. Maturation
of fetal responses to music. Dev Sci. 2004;7:550–559.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.
 23 (2015) 714–718

Contents lists available at ScienceDirect

Complementary Therapies in Medicine

journal homepage: www.elsevierhealth.com/journals/ctim

Effects of music therapy on pain, anxiety, and vital signs in patients

after thoracic surgery
Yang Liu ∗ , Marcia A. Petrini
HOPE School of Nursing, Wuhan University, Wuhan, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To examine the effectiveness of music listening on pain, anxiety, and vital signs among patients
Received 8 November 2014 after thoracic surgery in China.
Received in revised form 15 July 2015 Design and setting: A randomized controlled clinical trial was conducted in the thoracic surgery depart-
Accepted 1 August 2015
ment of two tertiary hospitals in Wuhan, China. 112 patients were recruited and randomly assigned to
Available online 4 August 2015
either experimental (n = 56) or control (n = 56) group respectively.
Intervention: The experimental group received standard care and a 30-min soft music intervention for
Keywords:
3 days, while the control group received only standard care. Measures include pain, anxiety, vital signs
Anxiety
China (blood pressure, heart rate and respiratory rate), patient controlled analgesia, and diclofenac sodium
Music therapy suppository use.
Pain Results: The experimental group showed statistically significant decrease in pain, anxiety, systolic blood
Thoracic surgery pressure and heart rate over time compared to the control group, but no significant difference were
Vital signs identified in diastolic blood pressure, respiratory rate, patient controlled analgesia and diclofenac sodium
suppository use.
Conclusion: The findings provide further evidence to support the practice of music therapy to reduce
postoperative pain and anxiety, and lower systolic blood pressure and heart rate in patients after thoracic
surgery in China.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction
Thousands of patients undergo surgery everyday throughout the
world and experience pain.1 Postoperative pain, a kind of acute
pain, is an anticipated but unwanted outcome of all surgeries.2
Pain after thoracotomy is a severe acute traumatic pain result-
ing from incision3 and has been reported to be a most painful
clinical experience.4 Literature yielded that postoperative pain in
patients undergoing thoracotomy is still an important problem
attracts attention of numerous studies.5
Anxiety usually accompanies pain,6 patients have a high level of
anxiety when they are in the hospital.7 Anxiety is a psychological
disorder that can cause many adverse effects. Patients may experi-
ence fatigue, have difficulty sleeping and digesting, lose appetite
and weight, have elevated heart rate, develop more stress, feel
∗ Corresponding author at: 115 Donghu Road, HOPE School of Nursing, Wuhan
University, Wuhan, China.
E-mail addresses: 1041407891@qq.com (Y. Liu), 2845map@gmail.com
(M.A. Petrini).
helpless and pessimistic, lose confidence to fight against disease, all
are adverse effect that harm the patient and delay their recovery.8,9
Thus much more attention is required to find an effective way to
reduce patient anxiety.7
Music therapy as a nonpharmacological adjuvant has been
widely used in clinical practice.10 In 2005, the American Music
Therapy Association defines music therapy as “music interventions
that are both clinically and evidence- based. The goal of music inter-
ventions by nurses or therapists, educated in an approved music
therapy program is to develop a therapeutic relationship”. Music
therapy can be implemented as a nursing procedure.11 Research
determined that listening to music can increase comfort and relax-
ation, relieve pain, lower distress, reduce anxiety, improve positive
emotions and mood, and decrease psychological symptoms.8,12–14
Although there are growing studies of music therapy in China
in recent years, the quantity and quality of the studies are sparse
and inadequate,15 and inconsistent findings were reported. This
study was conducted to investigate the effectiveness of music on
patients’ postoperative pain, anxiety, and vital signs after thoracic
surgery and to provide further evidence to support the practice of
music therapy for patients in China.

http://dx.doi.org/10.1016/j.ctim.2015.08.002
0965-2299/© 2015 Elsevier Ltd. All rights reserved.
 Y. Liu, M.A. Petrini / 23 (2015) 714–718
Fig. 1. Flowchart of the study.
2. Methods
2.1. Study design and participants
A randomized controlled trial with repeated measures design
(Fig. 1). The experimental group received a 30-min music inter-
vention for three days plus standard care while the control group
received only standard care. Two tertiary hospitals in Wuhan,
China, provided the setting from November 2013 to March 2014
for the clinical trial.
A convenience sample of 112 patients was recruited. Inclusion
criteria for participants included: (a) inpatients scheduled for tho-
racic surgery; (b) aged 18 or older; (c) able to understand, read and
speak Chinese, so they may complete the informed consent and
questionnaires; (d) conscious, oriented to person, place, time and
situation. Patients with vision and hearing deficits and inability to
complete questionnaires, not willing to participate, or underwent
emergency surgeries were excluded.
2.2. Randomization and sample size
Participants with odd admission day numbers were assigned
to the experimental group while those with even numbers were
assigned to the control group. There was no blinding as the
researcher and participants knew the allocation.
The sample size was determined with GPower3.1.9.16 Alpha
value was set at 0.05 and a power of 0.95; the resulting minimum
sample size was 92 patients. Considering an attrition rate of 20%,
therefore the total sample size required was 112 subjects.
2.3. Measurements
The pain was measured using faces pain scale.17 Patients can
choose the face that best represents their pain intensity ranging
715
from “no hurts” to “hurts the worst”. Although faces pain scale is
widely used to assess children’s pain, a study determined it was the
most accurate, easy to understand, and with highest response rate
among five commonly used pain scales in patients with vascular
surgery.18 The faces pain scale has a strong positive correlation with
other pain scales (r = 0.81–0.95; p < 0.001), and it is valid, reliable
and easy to use for clinical pain assessment of mature adults or
very ill patients.19
The state-trait anxiety inventory (STAI) is widely used for mea-
suring anxiety. It has 20 items for state anxiety; all items are
rated on a 4-point scale from “1 = almost never” to “4 = almost
always”. Higher scores indicate higher anxiety level, low anx-
iety ranges from 20 to 39, the moderate anxiety ranges from
40 to 59, and high anxiety ranges from 60 to 80.7 The STAI’s
internal consistency coefficients have ranged from 0.86 to 0.95
with test-retest reliability coefficients ranging from 0.65 to 0.75.20
STAI is also used expansively in Chinese populations21,22 and has
been applied to many studies, the test-retest coefficient of SAI is
0.88.23
Vital signs (systolic blood pressure [SBP], diastolic blood pres-
sure [DBP], heart rate [HR], and respiratory rate [RR]) were
measured at each test point. Patient controlled analgesia (PCA) use
was counted, and the consumption (mg) of diclofenac sodium sup-
pository (DSS) use was recorded each day for three days. A survey
was also conducted with the music group to ascertain participants’
opinions of the music intervention.
2.4. Procedures
After ethical approval was obtained, the researcher
invited eligible patients, introduced the study protocol to
them, had the informed consent signed, asked participants
716 Y. Liu, M.A. Petrini / 23 (2015) 714–718

Table 1
Demographic characteristics of participants.

Variables Experimental group (n = 47) Control group (n = 51) t/2 P Value

n % n %

Age (years) [mean ± SD] 54.45 ± 15.90 52.02 ± 15.62 t = − 0.76 0.45

Gender  = 0.13
2
0.72
- Male 33 64.7 32 68.1
- Female 18 35.3 15 31.9

Education 2 = 0.93 0.63

- Primary school or below 22 43.1 19 40.4
- Middle school 20 39.2 16 34.0
- College or above 9 17.7 12 25.6

Marital status 2 = 0.70 0.87

- Single 8 15.7 7 14.9
- Married 38 74.5 33 70.2
- Divorced 1 2.0 2 4.3
- Widow 4 7.8 5 10.6

Job 2 = 1.02 0.31

- Yes 28 54.9 21 44.7
- No 23 45.1 26 55.3

Hospitalization payment 2 = 0.39 0.53

- Own expense 26 51.0 21 44.7
- Health insurance 25 49.0 26 55.3

Religious belief 2 = 0.55 0.46

- No 47 92.2 45 95.7
- Yes 4 7.8 2 4.3

Previous surgery 2 = 0.16 0.69

- No 35 68.6 34 72.3
- Yes 16 31.4 13 27.7

to complete demographic data, and then assigned them to
groups.
The experimental group were visited by the researcher on
post-operative day 1, collected pre-test data (pain, anxiety, and
vital signs), and then provided 30-min music session, after that,
post-tests (pain, anxiety, and vital signs) were recorded. On post-
operative day 2 and 3, after the 30-min music intervention, the
same post-tests were conducted. Soft music with 60–80 beats per
minute or less was offered24 because melodious music with pleas-
ant rhythms has shown to yield a calming effect and a sense of
well-being.25 Music was transferred to the MP3 players before
the intervention, with earphones connected, and volume was con-
trolled by participants. In preparation for the intervention, the
researcher prepared the patient and environment well (turned off
cell phones, shut the door, and eliminated distractions), and tried
to keep the patients from being disturbed.26 The researcher guided
patients to keep their breathing smooth, relaxed, and focused on the
music.27 After all data had been collected, a survey was conducted
to collect participants’ opinions about the music intervention.
For the control group, music intervention was absent, partici-
pants received only standard care, and same pre-test and post-tests
were conducted regard to the experimental group. After all data had
been collected, the same music was provided if the participants
wanted.
2.5. Ethical considerations
The Human Ethical Committee of Wuhan University HOPE
School of Nursing and the two tertiary hospitals approved the study.
The research protocol was explained to participants, and they were
told that participation is voluntary. Also, if they wanted to drop
out at any time throughout the study, no harm to them would be
experienced. Prior to study participation, all subjects gave informed
consent.
2.6. Statistical analysis
Data was analysed using SPSS (version 21.0 for Windows). Par-
ticipant characteristics and the survey results were analyzed with
descriptive statistics. Chi-square tests were utilized to identify any
significant difference between groups regarding demographic data.
Independent t-test was used to detect any significant differences
in the baseline anxiety, SBP, DBP, HR, and RR. Repeated measures
of analysis of variance (RENOVA) were used to examine anxiety,
SBP, DBP, HR, and RR through the study. The marginal modeling
approach (GEE analysis) was used to detect any significant differ-
ence in pain over time.28 Significance was <0.05.
3. Results
3.1. Demographic and baseline characteristics of participants
Tables 1 and 2 present the demographic and baseline character-
istics of participants.
3.2. Pain, anxiety, and vital signs (Table 3)
After the intervention, a significant difference between groups
regarding pain (Wald 2 = 5.498, p = 0.019), anxiety, SBP, and HR
was noted. No significant difference existed in respect to DBP, RR,
DSS use, and PCA use (2 = 0.29, p = 0.59) ().
89.4% (n = 42) of participants like the music, 68.1% (n = 32)
thought the music alleviated their pain, and 76.6% (n = 36) thought
the music decreased their anxiety.
4. Discussion
This study examined the effectiveness of a 3-days music
intervention on patients’ pain, anxiety, and vital signs after tho-
racic surgery. Major findings are congruent with other studies
 Y. Liu, M.A. Petrini / 23 (2015) 714–718 717

Table 2
The baseline assessment of major study variables.

Variables Group (mean ± SD) z/t P Value

Experimental (n = 47) Control (n = 51)

Pain – – z = −0.167 0.867

Anxiety 50.92 ± 6.02 51.04 ± 6.68 t = 0.094 0.925
SBP 132.92 ± 14.73 132.51 ± 15.05 t = −0.137 0.892
DBP 83.76 ± 7.81 83.06 ± 8.27 t = −0.431 0.667
HR 87.59 ± 11.04 88.79 ± 12.37 t = 0.507 0.613
RR 20.24 ± 3.58 20.28 ± 3.48 t = 0.058 0.954

Table 3
Repeated measures ANOVA on major study variables.

Variables Group (mean ± SD) F P Value

Experimental (n = 47) Control (n = 51)

Anxiety 5.560 0.020*

[-] - 1st Post-test 50.10 ± 5.50 50.79 ± 6.72
[-] - 2nd Post-test 42.73 ± 4.92 46.62 ± 6.51
[-] - 3rd Post-test 35.53 ± 5.08 41.43 ± 5.49

SBP 4.495 0.037*

[-] - 1st Post-test 129.31 ± 12.28 132.02 ± 14.67
[-] - 2nd Post-test 122.63 ± 10.18 128.68 ± 12.33
[-] - 3rd Post-test 114.29 ± 7.67 125.02 ± 8.45

DBP 0.670 0.415

[-] - 1st Post-test 81.55 ± 7.99 82.77 ± 7.83
[-] - 2nd Post-test 75.86 ± 6.68 77.30 ± 6.60
[-] - 3rd Post-test 71.61 ± 7.51 73.91 ± 6.70

HR 4.379 0.039*
[-] - 1st Post-test 85.61 ± 10.71 88.62 ± 10.86
[-] - 2nd Post-test 80.63 ± 9.22 86.57 ± 8.89
[-] - 3rd Post-test 76.92 ± 9.31 82.21 ± 8.92

RR 0.710 0.402
[-] - 1st Post-test 19.49 ± 2.99 20.21 ± 3.22
[-] - 2nd Post-test 18.51 ± 3.18 19.19 ± 2.43
[-] - 3rd Post-test 17.53 ± 2.53 17.62 ± 2.15

DSS use (mg) 0.011 0.918

[-] - 1st Post-day 62.73 ± 18.26 62.91 ± 20.72
[-] - 2nd Post-day 36.67 ± 21.51 37.93 ± 22.78
[-] - 3rd Post-day 14.17 ± 14.21 14.66 ± 15.69

Note: post-day = postoperative day.

*
p < 0.05.

identified that music may help to relieve postoperative pain,29,30
help subjects feel less anxious and more relaxed,31 decrease SBP,32
and lower HR.33 The results did not reveal a significant impact on
DBP and RR. This finding was similar to other studies in RR,24,29 but
inconsistent with previous studies in DBP,32 RR.33 A study reported
that subjects required fewer opioids or analgesics after listening to
music,34 but no such impact was detected regarding PCA use and
DDS use in this study, which is similar to previous studies.24,35
Music therapy is safe, inexpensive, simple to learn, and may
be used easily by nurses in hospitals.36 In nursing practice,
music may be used alone, or combined with other methods
like jaw relaxation29 and therapist guidance26 ; it may be prac-
ticed in various settings, situations and populations for different
purposes.13,24,26,29,37–39 Studies suggested that 20–90 min of music
therapy is an adequate treatment period.40,41 The kinds of
music included: Sedative music,39 researcher-provided music and
subject- preferred music,38 smoothing music,42 and easy-listening
music.24
A Balance between analgesia and side effects43,44 was used as
the conceptual framework for this study that proposes that nurses
can use a combination of pharmacological and nonpharmacological
measures to relieve acute pain and avoid side effects. This theory
provided a very good theoretical foundation for the management
of acute pain in clinics. It is imperative for health care professionals
to know that there are other methods, such as music, to relieve
clinical pain and anxiety.
4.1. Limitations and implications
There are several limitations: first, independent variables (the
type of surgery, health status, and diagnosis) often influence the
dependent variables. Second, the music choice was limited and
was chosen by the researcher, which may have hindered the effect
of music. Third, the music therapy group received special atten-
tion (music intervention) from the researcher. While the control
group did not receive the same attention, the effect of special atten-
tion on the results cannot be ruled out. Therefore, the results may
not be exclusively attributed to the music intervention. Fourth, the
research was only conducted for 3 days. Future studies may provide
more music choices to participants based on their preferences. A
study of the long term benefits and other outcome measures, as well
as conduct similar studies in other settings and groups is advised.
5. Conclusion
This study provides further evidence to support the practice of
music therapy to reduce postoperative pain and anxiety, and lower
systolic blood pressure and heart rate in patients after thoracic
718 Y. Liu, M.A. Petrini / 23 (2015) 714–718
surgery in China. Additionally, the study learned that the majority
of patients with the music therapy thought that music may alleviate
pain and decrease anxiety.
Conflict of interests
None declared.
Funding
No funding.
Authors’ contribution
Study design YL, M.A.P; data collection and analysis: YL;
manuscript preparation: YL, M.A.P.
Acknowledgements
Sincere gratitude to the patients who participated in this study;
and to the two thoracic surgery departments for their support is
given.
References
1. Kuhn S, Cooke K, Collins M, Jones JM, Mucklow JC. Perceptions of pain relief
after surgery. BMJ Br Med J. 1990:1687–1690.
2. Rosenquist RW, Rosenberg J. Postoperative pain guidelines. Reg Anesth Pain
Med. 2003;28(4):279–288.
3. Soto RG, Fu ES. Acute pain management for patients undergoing thoracotomy.
Ann Thorac Surg. 2003;75(4):1349–1357.
4. Furrer M, Rechsteiner R, Eigenmann V, Signer C, Althaus U, Ris HB.
Thoracotomy and thoracoscopy: postoperative pulmonary function, pain and
chest wall complaints. Eur J Cardiothorac Surg. 1997;12(1):82–87.
5. Kol E, Alpar ŞE, Erdoğan A. Preoperative education and use of analgesic before
onset of pain routinely for post-thoracotomy pain control can reduce pain
effect and total amount of analgesics administered postoperatively. Pain
Manage Nurs. 2014;15(1):331–339.
6. Bernatzky G, Presch M, Anderson M, Panksepp J. Emotional foundations of
music as a non- pharmacological pain management tool in modern medicine.
Neurosci Biobehav Rev. 2011;35(9):1989–1999.
7. Barnason S, Zimmerman L, Nieveen J. The effects of music interventions on
anxiety in the patient after coronary artery bypass grafting. Heart Lung.
1995;24(2):124–132.
8. Li XM, Zhou KN, Yan H, Wang DL, Zhang YP. Effects of music therapy on
anxiety of patients with breast cancer after radical mastectomy: a
randomized clinical trial. J Adv Nurs. 2012;68(5):1145–1155,
http://dx.doi.org/10.1111/j.1365-2648.2011.05824.x.
9. Sharpley CF, Bitsika V, Christie DR. Helping prostate cancer patients
understand the causes of anxiety and depression: comparing cancer-cansed
vs. patient response events. J Men’s Health. 2009;6(4):
345–353.
10. Agwu KK, Okoye IJ. The effect of music on the anxiety levels of patients
undergoing hysterosalpingography. Radiography. 2007;13(2):
122–125.
11. Aldridge D. Music therapy references relating to cancer and palliative care. Br
J Music Ther. 2003;17(1):17–25.
12. Bruscia K, Dileo C, Shultis C, Dennery K. Expectations of hospitalized cancer
and cardiac patients regarding the medical and psychotherapeutic benefits of
music therapy. Arts Psychother. 2009;36(4):239–244.
13. Chaput-McGovern J, Silverman MJ. Effects of music therapy with patients on a
post-surgical oncology unit: a pilot study determining maintenance of
immediate gains. Arts Psychother. 2012;39(5):417–422.
14. Cooke M, Chaboyer W, Schluter P, Hiratos M. The effect of music on
preoperative anxiety in day surgery. J Adv Nurs. 2005;52(1):
47–55.
15. Ma L, Yu LJ. The status of nursing research using music therapy in pain
management in China. Chin J Nurs. 2008;43(3):268–270.
16. Faul F, Erdfelder E, Lang A-G, Buchner A. G*power 3: a flexible statistical
power analysis program for the social, behavioral, and biomedical sciences.
Behav Res Methods. 2007;39(2):175–191.
17. Wong DL, Baker CM. Pain in children: comparison of assessment scales.
Pediatr Nurs. 1988;14(1):9–17.
18. Liu Y, Li ZY, Li H. Comparison on usability of 5 different pain intensity
assessment rating scales for patients in vascular surgery department. Chin
Nurs Res. 2009;23(10C):2764–2767.
19. Stuppy DJ. The faces pain scale: reliability and validity with mature adults.
Appl Nurs Res. 1998;11(2):84–89.
20. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the
State-Trait Anxiety Inventory. Palo Alto. CA: Consulting Psychologists Press;
1983.
21. Shek DT. The Chinese version of the state-trait anxiety inventory: its
relationship to different measures of psychological well-being. J Clin Psychol.
1993;49(3):349–358.
22. Taylor-Piliae RE, Chair SY. The effect of nursing interventions utilizing music
therapy or sensory information on Chinese patients’ anxiety prior to cardiac
catheterization: a pilot study? Eur J Cardiovasc Nurs. 2002;1(3):203–211.
23. Lin CD, Yang ZL, Huang TX. Dictionary of Psychology. Shanghai Educational
Press: Shanghai; 2003.
24. Allred KD, Byers JF, Sole ML. The effect of music on postoperative pain and
anxiety. Pain Manage Nurs. 2010;11(1):15–25.
25. MacClelland DC. Therapeutic communication through music. Point View.
1982;19:4–5.
26. Gutgsell KJ, Schluchter M, Margevicius S, et al. Music therapy reduces pain in
palliative care patients: a randomized controlled trial. J Pain Symptom
Manage. 2012;5(8):1–10.
27. Roykulcharoen V, Good M. Systematic relaxation to relieve postoperative
pain. J Adv Nurs. 2004;48(2):140–148.
28. Aghaie B, Rejeh N, Heravi-Karimooi M, et al. Effect of nature-based sound
therapy on agitation and anxiety in coronary artery bypass graft patients
during the weaning of mechanical ventilation: a randomized clinical trial. Int J
Nurs Stud. 2014;51(4):526–538.
29. Good M, Anderson GC, Ahn S, Cong X, Stanton-Hicks M. Relaxation and music
reduce pain following intestinal surgery. Res Nurs Health.
2005;28(3):240–251.
30. Nilsson U, Unosson M, Rawal N. Stress reduction and analgesia in patients
exposed to calming music postoperatively. Eur J Anaesthesiol.
2005;22(02):96–102.
31. Brunges MJ, Avigne G. Music therapy for reducing surgical anxiety. AORN J.
2003;78(5):816–818.
32. Almerud S, Petersson K. Music therapy–a complementary treatment for
mechanically ventilated intensive care patients. Intensive Crit Care Nurs.
2003;19(1):21–30.
33. Lai HL. Music preference and relaxation in Taiwanese elderly people. Geriatr
Nurs. 2004;25(5):286–291.
34. Nilsson S, Kokinsky E, Nilsson U, Sidenvall B, Enskär K. School-aged children’s
experiences of postoperative music medicine on pain, distress, and anxiety.
Pediatric Anesthesia. 2009;19(12):1184–1190.
35. Voss JA, Good M, Yates B, Baun MM, Thompson A, Hertzog M. Sedative music
reduces anxiety and pain during chair rest after open-heart surgery. Pain.
2004;112(1–2):197–203.
36. Wang CF, Sun YL, Zang HX. Music therapy improves sleep quality in acute and
chronic sleep disorders: a meta-analysis of 10 randomized studies. Int J Nurs
Stud. 2014;51(1):51–62.
37. Lai HL, Good M. Music improves sleep quality in older adults. J Adv Nurs.
2005;49(3):234–244.
38. Siedliecki SL, Good M. Effect of music on power, pain, depression and
disability. J Adv Nurs. 2006;54(5):553–562.
39. Huang ST, Good M, Zauszniewski JA. The effectiveness of music in relieving
pain in cancer patients: a randomized controlled trial. Int J Nurs Stud.
2010;47(11):1354–1362.
40. Guzzetta CE. Effects of relaxation and music therapy on patients in a coronary
care unit with presumptive acute myocardial infarction. Heart Lung.
1989;18(6):609–616.
41. Henry LL. Music therapy: a nursing intervention for the control of pain and
anxiety in the ICU: a review of the research literature. Dimens Crit Care Nurs.
1995;14(6):295–304.
42. Good M, Stanton-Hicks M, Grass JA, Anderson GC, Choi C, Schoolmeesters LJ,
Salman A. Relief of postoperative pain with jaw relaxation, music and their
combination. Pain. 1999;81(1–2):163–172.
43. Good M. A Middle-range theory of acute pain management: use in research.
Nurs Outlook. 1998;46(3):120–124.
44. Good M, Moore SM. Clinical practice guidelines as a new source of
middle-range theory: focus on acute pain. Nurs Outlook. 1996;44(2):74–79.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.
Dai et al. Journal of Cardiothoracic Surgery (2020) 15:81
https://doi.org/10.1186/s13019-020-01141-y

RESEARCH ARTICLE Open Access

The effect of music therapy on pain,

anxiety and depression in patients after
coronary artery bypass grafting
Wang-Sheng Dai1†, Shu-Ting Huang1,2†, Ning Xu1,2, Qiang Chen1,2* and Hua Cao1*

Abstract
Objective: The purpose of this study was to explore the effects of music therapy on pain, anxiety and depression
in patients after coronary artery bypass grafting.
Methods: A retrospective study of 99 patients after coronary artery bypass from January 2017 to January 2019 was
conducted in a cardiac center in China. According to the different interventions, all the participants were divided
into 3 groups: group A: music therapy; group B: rest without music therapy; and group C: conventional treatment.
The Numerical Rating Scale (NRS), Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) were used
to measure the patient’s pain, anxiety and depression before and after 30 min of the intervention.
Results: There were no significant differences in the NRS, SDS and SAS scores between the three groups of
patients before the intervention. After 30 min of music therapy, the NRS, SDS and SAS scores of patients in group A
were significantly lower than those before music therapy, and the differences were statistically significant. However,
before and after the intervention in groups B and C, the NRS, SDS and SAS scores were not statistically significant.
By comparison among the three groups after 30 min of intervention, the NRS, SDS and SAS scores in patients in
group A were significantly lower than those in groups B and C, and the differences were statistically significant. The
scores were not significantly different between groups B and C.
Conclusion: Music therapy can effectively alleviate the pain, anxiety and depression of patients after coronary
artery bypass grafting.
Keywords: Music therapy, CABG, Pain, Anxiety, Depression

Introduction grafting with a small left anterior lateral thoracotomy,

Coronary atherosclerotic heart disease is one of the most
common heart diseases in elderly individuals. With the
development of minimally invasive technology and
equipment, many coronary heart diseases can be treated
with minimally invasive treatment, including percutan-
eous coronary intervention, coronary artery bypass
* Correspondence: chenqiang2228@163.com; caohua0791@163.com
†
Wang-Sheng Dai and Shu-Ting Huang contributed equally to this work.
1
Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital,
Affiliated Hospital of Fujian Medical University, Fuzhou, China
Full list of author information is available at the end of the article
robotic off-pump coronary artery bypass grafting, etc.
However, coronary artery bypass grafting with median
thoracotomy is still the main surgical method for the
treatment of severe and multiple coronary artery disease
[1]. Surgery requires midline splitting of the sternum, a
large incision and an indwelling drainage tube; thus, pa-
tients usually suffer from obvious postoperative pain [2].
Studies have shown that more than 80% of patients suf-
fer from moderate to severe postoperative pain [3]. Post-
operative patients need to be placed in an unfamiliar
environment with 24 h of artificial lighting with possible

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Dai et al. Journal of Cardiothoracic Surgery (2020) 15:81
accompanying medical instrument monitoring, no family
support, and worries about the success of the operation,
all of which can easily make the patients feel anxious
and depressed. Although the problems of postoperative
pain, anxiety and depression have been taken seriously,
the management and treatment are still incomplete [4,
5]. This study summarized our experience in implement-
ing music therapy for patients after coronary artery by-
pass grafting and evaluated its effects on improving
patients’ postoperative pain, anxiety, and depression.
Information and methods
Normal information
According to the pain of the three groups of patients in
the pilot test, assuming a difference of 10% between the
three independent populations, α = 0.05, β = 0.2, it was
calculated that 30 participants were required for each
group. Assuming a 10% dropout rate, the total sample
size required was 99 cases (33 cases per group), which
were some of the cases at the hospital at this period.
The study was approved by the ethics committee of our
university, and written informed consent was obtained
from each participant.
This study was a retrospective study conducted by a
cardiac hospital. The clinical data of 99 patients who
underwent coronary artery bypass graft from January
2017 to January 2019 were collected and divided into 3
groups according to the selected different types of inter-
vention: group A: music therapy group; group B: rest
without music therapy group; and group C: conventional
treatment group. All of the patients underwent routine
surgery with or without cardiopulmonary bypass. The
following inclusion criteria were used: tracheal intub-
ation was removed on same the day as the surgery or
the next day, hemodynamics were stable, the patient was
transferred to the general ward 1 to 2 days after surgery,
the analgesia pump was stopped, the patient suffered no
hearing impairment, and the patient was able to cooper-
ate with the treatment and this research. The exclusion
criteria were as follows: 1, the patient had a history of
chronic pain, mental disorders, or hearing impairment,
2, the patient’s condition was combined with other im-
portant organ dysfunction, 3, the patient experienced se-
vere complications during the perioperative period, 4,
the patient was unable to cooperate with this research or
was unwilling to sign the informed consent, and 5, the
patient used any painkillers or other methods to reduce
pain before our intervention.
Methods
The patients were lying on their bed in the general ward
at 20:00. The surrounding environment was quiet, com-
fortable, safe, and the light was soft. The bed curtains
were pulled closed, and the patients had no interference
Page 2 of 5
from the medical staff or researchers. All patients wore
binaural headphones. Music was chosen and played in
group A for 30 min. Patients could choose their favorite
music with the volume based on the their comfort.
There was no restriction on the type of music, but
mostly light music and relaxing music. The patients had
just a quiet rest for 30 min without playing music in
group B. The patients in group C were given routine
treatment with wearing headphones for 30 min, and nor-
mal activities were performed.
Research tool
Numerical Rating Scale (NRS): This scale has been
widely used in pain-related studies with good reliability
and validity [6]. The scale uses numbers instead of text
to indicate the degree of pain, segmented on a straight
line, with the degree of pain expressed with 11 numbers
from 0 to 10. 0 means no pain, 1–3 points means mild
pain (1 point: no pain in a quiet supine position, pain
when turning over and coughing; 2 points: pain when
coughing, no pain in deep breathing; 3 points: no pain in
a quiet supine, pain with deep breathing and coughing),
4–6 points means moderate pain (4 points: gap pain
when in a quiet supine position; 5 points: persistent pain
when in a quiet supine position; 6 points: severe pain
when in a quiet supine position), 7–10 points means sig-
nificant pain (7 points: heavier pain, upset, unable to fall
asleep; 8 points: persistent, intolerable pain, sweating
throughout the body; 9 points: severe, intolerable pain;
10 points: the most painful, life was worse than death).
Self-Rating Depression Scale (SDS): The Zung Self-
Rating Depression Scale was used. The SDS has been
widely used in clinical practice and has high reliability
and validity [7]. The scale consists of 20 items with 4
scoring grades and includes 10 negative symptoms and
10 positive symptoms. Each question represents the
characteristics of depression. All of the items reflect
mood, physical discomfort, mental activity, behavior and
psychological symptoms. According to the frequency of
positive symptoms, numbers from 1 to 4 are used for
scoring. Based on the frequency of negative symptoms, a
rough score is obtained using the reverse score method
(4 to 1). The standard score is the score multiplied by
1.25 and is rounded off. The upper limit score is 41, and
the standard score is 53. The higher the score, the more
pronounced the depression tendency.
Self-Rating Anxiety Scale (SAS): The Zung Self-Rating
Anxiety Scale was used. The SAS has been widely used
in clinical practice and has high reliability and validity
[8]. Fifteen items are expressed as negative words, and
scores are based on the frequency of symptoms (1 to 4).
Affirmative terms are used to indicate 5 items, and ac-
cording to the frequency of symptoms, the reverse scor-
ing method (4 to 1) is used for scoring. The scores of all
Dai et al. Journal of Cardiothoracic Surgery (2020) 15:81 Page 3 of 5

items are summed to obtain the total score. The stand-
ard score is multiplied by 1.25 and rounded off. The
standard score average is 50. Score description: < 50
means normal, 50 ~ 59 means mild anxiety, 60 ~ 69
means moderate anxiety, and ≥ 70 means severe anxiety.
Data collection
The SAS, SDS and NRS scores were recorded separately
before and after 30 min of the intervention to measure
the patient’s pain, anxiety and depression. Participants
completed the questionnaire independently; the re-
searchers were not allowed to interfere with the partici-
pants’ decisions but were able to explain the questions
to the participants or provided language translation.
After all questionnaires were completed, the data were
statistically analyzed by specialized independent
researchers.
Statistical analysis
Quantitative data are expressed as the means ± standard
deviations, and continuous data were compared between
groups by analysis of variance; qualitative data were
compared between groups by chi-square test; P < 0.05
was considered statistically significant.
Results
The general information of all patients is shown in
Table 1. There were no significant differences among
the three groups of patients. The NRS, SAS and SDS
scores before the intervention were also not statistically
significant. These results indicated that the three groups
of patients were homogeneous; thus, the data were com-
parable between groups. After 30 min of music therapy,
the NRS, SDS and SAS scores of patients in group A
were significantly lower than those before music therapy,
and the differences were statistically significant (P <
0.05). However, before and after intervention in groups
B and C, the NRS, SDS and SAS scores were not statisti-
cally significant. After 30 min of intervention, the NRS,
SDS, and SAS scores in patients in group A were signifi-
cantly lower than those in groups B and C, and the dif-
ferences were statistically significant (P < 0.05). The
scores were not significantly different between groups B
and C. These results indicated that music therapy could
significantly reduce the NRS, SDS and SAS scores of pa-
tients after coronary artery bypass grafting (Table 2).
Discussion
Pain is an unpleasant feeling and emotional experience
related to tissue damage or potential tissue damage. It is
one of the most common symptoms of surgical patients

Table 1 Comparison of general information of the three groups of patients

Variable Group A Group B Group C P value
Age 53.4 ± 12.6 55.8 ± 10.9 53.1 ± 14.8 0.547
Male/female 18/15 17/16 19/14 0.885
Number of bridging vessels
one 5 4 3 0.932
two 8 7 9
three or more 20 22 21
NYHA
I 0 0 0 0.563
II 23 25 21
III 10 8 12
IV 0 0 0
LVEF 56.9 ± 11.5 58.2 ± 9.3 55.8 ± 12.7 0.612
Incision length 13.1 ± 2.8 14.8 ± 2.1 14.5 ± 2.8 0.886
Marriage
married 30 31 30 0.906
spinsterhood 1 1 2
widowed 2 1 1
Education
Middle school and below 16 18 15 0.719
High school and technical secondary school 14 10 15
College and above 3 5 3
Dai et al. Journal of Cardiothoracic Surgery (2020) 15:81
Table 2 Comparison of NRS, SDS, and SAS scores between the
three groups of patients before and after intervention
Scores Group A Group B Group C
NRS
pretest 7.3 ± 1.9 7.1 ± 1.6 7.2 ± 2.0
# #
posttest 4.2 ± 2.1* 7.2 ± 1.8 7.4 ± 1.9
SDS
pretest 58.6 ± 10.4 60.8 ± 12.8 62.2 ± 13.6
posttest 46.3 ± 9.3* 59.3 ± 14.1# 62.9 ± 11.8#
SAS
pretest 64.6 ± 13.8 63.2 ± 14.9 62.1 ± 12.7
# #
posttest 54.3 ± 11.6* 60.5 ± 15.5 62.6 ± 13.9
# means P < 0.05 compared with group A
* means P < 0.05 compared with before music therapy
and affects the recovery of local or overall functions,
which can even threaten the patient’s life [9, 10]. Espe-
cially for patients with severe coronary heart disease,
coronary artery bypass grafting must be performed with
a median sternal incision. As the chest cavity moves with
breathing and coughing, the cut edges of the sternum
will rub against each other, causing severe pain. If the
pain cannot be effectively controlled, the patient’s con-
centrations of catecholamines will increase, which will
lead to increased blood pressure, a faster heartbeat, in-
creased peripheral vascular resistance, and increased in-
cidence of postoperative bleeding and will affect the
patient’s breathing, cough, mood, and appetite. The cor-
responding results can delay the patient’s time to get out
of bed, affect the patient’s postoperative recovery, and
even increase the incidence of complications. Prolonged
pain can also easily cause patients to have negative emo-
tions, such as anxiety, anxiety, nervousness and even de-
pression [11, 12]. These effects are more pronounced in
older people with weak constitutions who undergo cor-
onary artery bypass grafting. In recent years, increasing
amounts of attention have been paid to pain manage-
ment in these types of older patients. Thus, how to ef-
fectively reduce postoperative pain and improve the
psychological state of postoperative patients has become
a research hotspot.
Although the current treatment of postoperative pain
is mainly focused on drug treatment, increasing numbers
of nondrug treatment methods have also begun to be
widely used [13, 14]. Music therapy is an innovative
nondrug treatment that can stimulate the cerebral cortex
to reduce stress-related hormones and can have a posi-
tive effect on improving emotions through neuroendo-
crine pathways [15]. It can also have a direct impact on
the brain edge and the brainstem reticular structure of
the nervous system, reducing sympathetic nervous sys-
tem activity and increasing parasympathetic neural activ-
ity, reducing the body’s physiological response to stress
Page 4 of 5
and lowering the cortisol level in the patient’s body,
thereby stabilizing the patient’s blood pressure and heart
P value rate under stress [16]. Music therapy relieves pain by
distraction and improves the emotional dimension of
0.832 pain by affecting emotions and feelings. Many domestic
and overseas research reports have confirmed that music
0.013
intervention can have significant effects on pain relief
and emotional stability and can relieve stress and anx-
0.761 iety. A clinical randomized controlled trial conducted by
0.022 Ko SY and his colleagues showed that relaxed music
could improve the pain and anxiety of patients undergo-
0.846 ing colonoscopy and improve treatment satisfaction [17].
A study by Yaman Aktaş et al. showed that music ther-
0.034
apy could be used as a nondrug therapy to reduce pain
in patients with mechanical ventilation [18]. Ernsten and
his teams found that perioperative music therapy could
effectively relieve acute pain associated with surgery
[19]. Rohilla et al. showed that music therapy could help
reduce anxiety, pain and the use of opioids during surgi-
cal dressing changes in burn patients [20]. Music therapy
can relieve the degree of postoperative pain in surgical
patients and can be beneficial in stabilizing the patient’s
heart rhythm and maintaining the hemodynamic bal-
ance, as shown in a study by Chen and her colleagues
[21]. Music can adjust and balance people’s emotions. It
can slow down the heart rate and dilate the blood ves-
sels, thereby improving the blood circulation, reducing
the heart load, removing the metabolic products pro-
duced by myocardial hypoxia, and consequently alleviat-
ing angina pectoris [22]. In this study, the pain score of
patients in the music therapy group was significantly
lower than that of patients who did not receive music
therapy and that of the preintervention status; this study
also confirmed that music therapy could relieve pain in
patients after coronary artery bypass grafting.
In addition, music also had a good sedative effect [23,
24]. Music stimulated the right hemisphere limbic sys-
tem, which manages emotions, feelings and sensory cen-
ters to bring about a sedation effect and improve the
patient’s negative emotions. When patients listen to
comfortable and sweet-sounding music, they produce
pleasant associations, which can create a comfortable
and satisfied mood to relieve anxiety. This study also
showed that the SAS and SDS scores of the music ther-
apy group after music therapy were significantly lower
than those before the music therapy, and the SAS and
SDS scores of the music therapy group were significantly
lower than those of the non-music therapy group. Such
results indicated that listening to comfortable and pleas-
ant music could significantly relieve the patients’ anxiety
and depression.
The study still had some shortcomings. First, this was
a single-center retrospective study, not a randomized
controlled study; thus, there was a certain deviation in
Dai et al. Journal of Cardiothoracic Surgery (2020) 15:81
the selection of cases, but the findings still had certain
clinical significance. In addition, this was a single-center
study with a relatively small sample size. A multicenter
and large-sample study will be performed in the future.
Third, this study was only limited to specific patients
undergoing coronary artery bypass surgery. Whether
music therapy had the same effect in other patients
undergoing other types of surgery will require further
study.
Conclusion
Music therapy as a nondrug treatment method is very
safe, simple and economical to implement and can ef-
fectively alleviate the pain, anxiety and depression of pa-
tients undergoing coronary artery bypass grafting. Thus,
it is worthy of clinical promotion and application.
Abbreviations
NRS: Numerical Rating Scale; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating
Depression Scale
Acknowledgements
We highly acknowledge the contribution by the participating doctors: Dao-
Zhong Chen, Liang-Wan Chen, Feng Lin, Qi-Min Wang, Han-Fan Qiu, Xue-
Shan Huang, Dong-Shan Liao, Xiao-Fu Dai, Zeng-Chun Wang.
Authors’ contributions
Qiang Chen and Hua Cao designed the study and submitted the manuscript.
Wang-Sheng Dai, Shu-Ting Huang and Ning Xu collected and analyzed data
together. Wang-Sheng Dai drafted the article. All authors read the final ver-
sion of this article and approved for publication.
Funding
No.
Availability of data and materials
Data sharing not applicable to this article as no data sets were generated or
analyzed during the current study.
Ethics approval and consent to participate
The present study was approved by the ethics committee of Fujian Medical
University, China and adhered to the tenets of the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
All authors declare that they have no competing interests.
Author details
1
Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital,
Affiliated Hospital of Fujian Medical University, Fuzhou, China. 2Department
of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou,
China.
Received: 24 January 2020 Accepted: 4 May 2020
References
1. Head SJ, Milojevic M, Daemen J, Ahn JM, Boersma E, Christiansen EH,
Domanski MJ, Farkouh ME, Flather M, Fuster V, Hlatky MA, Holm NR, Hueb
WA, Kamalesh M, Kim YH, Mäkikallio T, Mohr FW, Papageorgiou G, Park SJ,
Rodriguez AE, Sabik JF 3rd, Stables RH, Stone GW, Serruys PW, Kappetein
AP. Mortality after coronary artery bypass grafting versus percutaneous
coronary intervention with stenting for coronary artery disease: a pooled
analysis of individual patient data. Lancet. 2018;391(10124):939–48.
Page 5 of 5
2. Goodwin MJ, Bissett L, Mason P, Kates R, Weber J. Early extubation and early
activity after open heart surgery. Crit Care Nurse. 1999 Oct;19(5):18–26.
3. Allred KD, Byers JF, Sole ML. The effect of music on postoperative pain and
anxiety. Pain Manag Nurs. 2010;11(1):15–25.
4. Sendelbach SE, Halm MA, Doran KA, Miller EH, Gaillard P. Effects of music
therapy on physiological and psychological outcomes for patients
undergoing cardiac surgery. J Cardiovasc Nurs. 2006;21(3):194–200.
5. Mueller XM, Tinguely F, Tevaearai HT, Revelly JP, Chioléro R, von Segesser
LK. Pain location, distribution, and intensity after cardiac surgery. Chest.
2000;118(2):391–6.
6. Gagliese L, Weizblit N, Ellis W, Chan VW. The measurement of postoperative
pain: a comparison of intensity scales in younger and older surgical
patients. Pain. 2005;117(3):412–20.
7. Zung WW. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63–
70.
8. Zung WW. A rating instrument for anxiety disorders. Psychosomatics. 1971;
12(6):371–9.
9. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience:
results form a national survey suggest postoperative pain continues to be
undermanaged. Anesth Analg. 2003;97(2):534–40.
10. Tse MMY, Chan MF, Benzie IF. The effect of music therapy on postoperative
pain, heart rate, systolic blood pressures and analgesic use following nasal
surgery. J Pain Palliat Care Pharmacother. 2005;19(3):21–9.
11. Evangelism JA, Parsons M, Renneburg AK. Chest pain in children: diagnosis
through history and physical examination. J Pediatr Health Care. 2000;14(1):
3–8.
12. Kehletc H. The stress response to surgery: release mechanisms and the
modifying effect of pain relief. Acta Chir Scand Suppl. 1989;550:22–8.
13. Zimmerman L, Nieveen J, Barnason S, Schmaderer M. The effects of music
interventions on postoperative pain and sleep in coronary artery bypass
graft (CABG) patients. Sch Inq Nurs Pract. 1996;10(2):153–70 discussion 171-
4.
14. Nilsson U, Rawal N, Enqvist B, Unosson M. Analgesia following music and
therapeutic suggestions in the PACU in ambulatory surgery; a randomized
controlled trial. Acta Anaesthesiol Scand. 2003;47(3):278–83.
15. Stegemann T, Geretsegger M, Quoc EP, Riedl H, Smetana M. Music therapy
and other music-based interventions in pediatric health care: an overview.
Medicines (Basel). 2019;6(1):25.
16. Twiss E, Seaver J, McCaffrey R. The effect of music listening on older adults
undergoing cardiovascular surgery. Nurs Crit Care. 2006;11(5):224–31.
17. Ko SY, Leung DY, Wong EM. Effcets of easy listening music intervention on
satisfaction, anxiety, and pain in patients undergoing colonoscopy: a pilot
randomized controlled trial. Clin Interv Aging. 2019;14:977–86.
18. Yaman Aktas Y, Karabulut N. Relief of procedural pain in critically III patients
by music therapy: a randomized controlled trial. Complement Med Res.
2019;26(3):156–65.
19. Ernsten L, Hepp P, Fehm T, Schaal NK. Perioperative music-induced
analgesia: comparison of the effect of music on pain between preoperative,
intraoperative and postoperative application. Schmerz. 2019;33(2):100–5.
20. Rohilla L, Agnihotri M, Trehan SK, Sharma RK, Ghai S. Effect of music therapy
on pain perception, anxiety, and opioid use during dressing change among
patients with burns in India: a quasi-experimental, cross-over pilot study.
Ostomy Wound Manage. 2018;64(10):40–6.
21. Chan MF, Wong OC, Chan HL, Fong MC, Lai SY, Lo CW, Ho SM, Ng SY,
Leung SK. Effects of music on patients undergoing a C-clamp procedure
after percutaneous coronary interventions. J Adv Nurs. 2006;53(6):669–79.
22. McCaffrey R, Taylor N. Effective anxiety treatment prior to diagnostic cardiac
catheterization. Holist Nurs Pract. 2005;19(2):70–3 Review.
23. Voss JA, Good M, Yates B, Baun MM, Thompson A, Hertzog M. Sedative
music reduces anxiety and pain during chair rest after open-heart surgery.
Pain. 2004;112(1–2):197–203.
24. Ortega A, Gauna F, Munoz D, Oberreuter G, Breinbauer HA, Carrasco L.
Music therapy for pain and anxiety Management in Nasal Bone Fracture
Reduction: randomized controlled clinical trial. Otolaryngol Head Neck Surg.
2019;161(4):613–9.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
 © 2020. This work is licensed under
http://creativecommons.org/licenses/by/4.0/ (the “License”). Notwithstanding
the ProQuest Terms and Conditions, you may use this content in accordance
with the terms of the License.
 Original Article

The Effects of Music Therapy on Anxiety and Depression

of Cancer Patients
Madineh Jasemi, Sanaz Aazami1, Roghaieh Esmaili Zabihi
Faculty of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, 1Faculty of Nursing and
Midwifery, Ilam University of Medical Sciences, Ilam, Iran

Address for correspondence: Miss. Roghaieh Esmaili Zabihi; E‑mail: esmaeili.r@gmail.com

ABSTRACT

Background and Purpose: Cancer patients often suffer from anxiety and depression. Various methods are
used to alleviate anxiety and depression, but most of them have side effects. Music therapy can be used as a
noninvasive method to reduce anxiety and depression. This study aimed to examine the effect of music therapy
on anxiety and depression in patients with cancer.
Materials and Methods: This quasi‑experimental study was conducted attaching hospitals in Urmia city. A total
number of sixty patients with depression and anxiety were recruited using random sampling method and divided
into two groups of control and intervention. Patients in intervention group listened to light music at least 20 min
per day for 3 days. The degree of patients’ anxiety and depression was assessed by Hospital Anxiety and
Depression Scale at baseline and 3 days after music therapy. Data were analyzed by SPSS version 13 using
t‑test, Pearson, and ANOVA tests.
Results: The results showed no significant differences between demographic variable of intervention and control
groups. Our findings indicated a significant decrease in the level of depression and anxiety among intervention
group. There were significant relationships between anxiety, depression, and sex (P < 0.001, r = 0.42) as well
as education (P = 0.003, r = 0.37).
Conclusion: This study revealed positive effects of music therapy on decreasing level of depression and anxiety
in patients with cancer. Therefore, it is recommended to include music therapy in the nursing care.

Key words: Anxiety, Cancer, Depression, Music

INTRODUCTION
Nowadays, human life expectancy has increased by
improvement of public nutrition, social, and individual
hygiene; prevention, control, and treatment of infectious
diseases which was considered as the highest cause of
mortality rates during the 19th century.[1]
Along with increasing life expectancy, chronic diseases
such as cancer and its mortality were increased.
Access this article online
Quick Response Code:
Website:
www.jpalliativecare.com
[2]
It is estimated to have more than 482,543 deaths
due to cancer in America during the first decade of
21st century, and the trend continues to raise.[3] In
Iran, there were 20,665 cancer cases during 2001 and
22,351 of those cancer patients died within 2 years.
[4]
Cancer has many side effects, and the most notable
consequences are anxiety and depression. It is reported
that 75% of patients at the final stage of cancer,
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as
the author is credited and the new creations are licensed under the identical
terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Jasemi M, Aazami S, Zabihi RE. The effects of
10.4103/0973-1075.191823 music therapy on anxiety and depression of cancer patients. Indian J Palliat
Care 2016;22:455-8.

© 2016 Indian Journal of Palliative Care | Published by Wolters Kluwer - Medknow 455
 Jasemi, et al.: The effects of music therapy on anxiety and depression
experience anxiety and depression[5] and between 50%
and 85% of them suffer from anxiety and depression
simultaneously.[6] The previous studies in Iran indicated
that 20% of cancer patients suffer from anxiety and 40%
suffer from depression. Anxiety and depression adversely
affect the progression of cancer treatment, progress of
cancer disease, treatment efficiency, and the patients’
quality of life.[7] Furthermore, cancer may cause feelings
of displeasure, stay away from friends or family, lack
of motivation and defeat intolerance, decreased libido,
decrease or increase in appetite and weight, decreased
energy and cause fatigue, sleep disturbances, menstrual
disorder, constipation, dry mouth, and headache.[8]
Medication and behavioral therapies are implemented to
alleviate the level of patients’ anxiety and depression.[9]
Most of these methods have side effects on patient’s body
and minds such as addiction, drug dependency, blood
pressure, weakening of vital signs, drowsiness, nausea,
vomiting, and even shock. In addition, these routine
therapeutic methods are time‑consuming for nurses and
impose heavy cost to the health‑care systems.[10] Drugs for
reducing anxiety and depression are not without side effects
and at the same time, there is the possibility of recurring
symptoms in case of dose reduction. Therefore, use of
nondrug methods privileged to overcome depression
and anxiety in patients with cancer. Accordingly, several
nonpharmacological methods are encouraged to decrease
anxiety and depression in patients with cancer including
communication therapy.[11,12]
One of the methods used to relieve anxiety and depression
is pleasant voice stimulant that is called music therapy. The
use of music as a therapeutic approach has an old history.
As the inscriptions in ancient Egypt, Greece, China, India,
and Rome talked of music as a healer with a relaxing effect
that reduces anxiety and creates relaxation.[13] Therapeutic
effect of music on physical and psychological aspects of
patients undergoing cardiac surgery and Alzheimer disease
in various studies is confirmed.[14-16] Nevertheless, few
studies have investigated the effect of music therapy on
reducing the level of anxiety and depression in patients
with cancer.
This study aims to assess the effects of music therapy
on anxiety and depression among cancer patients
through Hospital Anxiety and Depression Scale (HADS)
questionnaire. In addition, the present study seeks to examine
the correlation between demographic characteristics with
levels of patients’ anxiety and depression. We hope that
the results of this study can improve the nurses’ quality of
care in cancer patients.
456 Indian Journal of Palliative Care / Oct-Dec 2016 / Vol 22 / Issue 4
MATERIALS AND METHODS
This quasi‑experimental study was conducted at Imam
Khomeini Hospital of Urmia city in 2014. Samples for each
group was considered 30 persons using a preliminary study
on 12 persons and considering the results of confidence
interval 95% and power of test 80%, and total number of
sixty patients aged 18–65 years old were included in this
study. Patients with following criteria were eligible to be
included in this study: Stages 1, 2, and 3 of cancer, ability
to read and write, being able to communicate, no history
of serious problems, no development of other malignancy,
and at least 3 months passed from diagnosis. In this study,
the two groups were matched for age, sex, education level,
and stage of the disease. Permission to conduct this study
was obtained from dean of hospital and wards. Patients
received adequate information regarding aim, benefits, and
risks of the study before data collection. On obtaining
written permission, participants were randomly allocated
to two groups of controls and experiments using simple
random sampling method.
HADS questionnaire was used to measure the level of
patients’ anxiety and depression. This questionnaire
has high sensitivity compared to other questionnaires
in the measurement of anxiety and depression which
has been widely used. Validity and reliability of the
HADS questionnaire have been confirmed previously.
The questionnaire included 14 items with 4 Likert‑type
response. Each item’s score can vary from minimum of
0 and maximum of 3 which yield a total score ranging from
0 to 21. Scores from 0 to 7 represents natural anxiety and
depression level, 8–10 mild, 11–14 moderate level, and
15–21 will be considered as severe anxiety and depression
level.[17]
Baseline levels of depression and anxiety were assessed
using the HADS questionnaire 24 h before the onset
of intervention. Then, patients listened to music at
least 20 min per day for 3 consecutive days and HADS
questionnaire administrated at the end of each day. The
intervention tools included a Walkman and a headphone of
Sony Company. Type of music was selected after obtaining
5 expert’s opinion, and the tape was recorded in the form of
relaxing light music like the sea, rain, and water sound. Data
was analyzed using SPSS version 13 (South Wacker Drive,
Chicago, United States of America). Kolmogorov–Smirnov
test was used to test normality of sample which revealed a
normal distribution (P = 0.09). Therefore, parametric tests
were used to analyze the data. Mean and standard deviation
were used to describe data. Independent t‑test, Pearson, and
ANOVA tests were used to analyze and compare the means.
 Jasemi, et al.: The effects of music therapy on anxiety and depression

RESULTS Table 1: Demographic characteristics of control

and intervention group
Results from this study showed that 57.2% of experiment Demographic Percentage Demographic Percentage
group were male, and 61.8% were aged 30–45 years old. characteristics in characteristics in
control group intervention group
In terms of education, 68.2% of intervention group
Sex
did not have diploma and 93.3% of them were married.
Male 51.2 Male 57.2
In control group, the prevalence of male samples was Female 48.8 Female 42.8
51.2%and 60% were aged 30–50 years old, 63% had no Age
diploma, and 87.4% were married. Regarding type of 18-30 9.3 18-30 10.2
cancer, 48% of interventions and 54% of controls had 31-45 60 31-45 61.8
soft tissue cancer. The majority of our subjects were in 46-55 11.7 46-55 21.4
Stage 3 of cancer [Table 1]. No statistically significant 56-65 19 56-65 6.6
difference was found between any of the demographic Material status
variables of two groups. Independent t‑test showed Single 12.6 Single 6.7

no significant difference in mean score of anxiety, Married 87.4 Married 93.3

depression between control and intervention groups Educational level

Under diploma 63 Under diploma 68.2
before the study. There was no significant difference
University 37 University 31.8
in mean score of anxiety and depression between four
Type of disease
times intervals (P = 0.67) among controls. While there
Soft tissue cancer 54 Soft tissue cancer 48
was a significant reduction in the mean scores of anxiety Bone cancer 16.4 Bone cancer 32
and depression (P < 0.001) in the intervention group Leukemia 29.4 Leukemia 20
[Table 2]. Stage of disease
Stage 1 28.8 Stage 1 25.2
Re s u l t s o f c o r r e l a t i o n b e t we e n d e m o g r a p h i c Stage 2 31.2 Stage 2 30.8
characteristics with anxiety and depression showed Stage 3 40 Stage 3 44
higher mean scores among women as well as educated
individuals [Table 3]. Findings from Pearson test showed
significant and positive association between anxiety and Table 2: Comparing the mean of anxiety and
depression in intervention and control groups
depression with gender (r = 0.42, P < 0.001) and level
in the four times interval
of education (r = 0.37, P = 0.003). However, we found Groups anxiety 24 h before 1st day 2nd day 3rd day Test
no significant association between anxiety, depression and depression intervention result (P, F)
and marital status (P = 0.21), type of cancer (P = 0.76), Music therapy 14.46±2.13 11.36±2.9 9.53±1.34 8.63±2.57 <0.001, 2.80
group
cancer stages (P = 0.32), and age (P = 0.42).
Control group 14.72±2.06 13.78±3.04 14.67±2.12 14.34±2.48 0.67, 8.45

DISCUSSION sample. A study in America in 2006 also showed the effect

The findings of this study show the effect of music
therapy on the anxiety and depression of patients
with cancer. Several studies showed a beneficial effect
of music on reducing anxiety in patients undergoing
cesarean,[18] abdominal surgery,[19] and patients admitted
in critical care unit.[20] Our findings are consistent with
Horne‑Thompson and Grocke[21] study that showed the
beneficial effect of music therapy on reducing the level
of anxiety among patients with cancer.
of music on depression.[24]
We also found significant relationships between the level
of anxiety, depression, sex, and education. Our finding
is consistent with Mohamadi Zeidi et  al.[25] study that
showed anxiety is higher among women. In contrast,
results of the present study reversed a positive relationship
between anxiety and education.[25] That is, highly educated
individuals experience a higher level of anxiety compared
to their counterparts.

Another finding from this study includes the effect of

music on the reduction of depression in patients with CONCLUSION
cancer. A study at China in 2011 also showed that music
reduces depression in cancer patients.[22] Sheiban et al.[23] According to the findings of this study, use of music
showed the effect of music on depression among Iranian therapy is an easy, inexpensive, and safe method to reduce

Indian Journal of Palliative Care / Oct-Dec 2016 / Vol 22 / Issue 4 457

 Jasemi, et al.: The effects of music therapy on anxiety and depression

Table 3: The relationship between demographic REFERENCES

characteristics with anxiety and depression 1. Rahmani A, Ferguson C, Jabarzadeh F, Mohammadpoorasl A, Moradi N,
Demographic variables SD±mean P Pakpour V. Supportive care needs of Iranian cancer patients. Indian J Palliat
Gender Care 2014;20:224‑8.
Male 13.78±2.34 0.003 2. Rezvani M. Cancer, endless suffering. Mashhad: Astane Gods Razavi; 2004.
Female 14.72±2.04 3. Hanington A, Berrelly O. Pychiatric management of cancer pain. London:
Mosby; 2003.
Marital status
4. Valizadeh L, Zamanzadeh V, Rahmani A, Howard F, Nikanfar AR,
Single 13.89±2.39 0.21 Ferguson C. Cancer disclosure: Experiences of Iranian cancer patients.
Married 14.07±1.92 Nurs Health Sci 2012;14:250‑6.
Type of cancer 5. Ilkhani M. Effects of relaxation on pain in cancer patients hospitalized
Soft tissue cancer 14.27±2.41 0.76 cancer in selected Tehran hospitals. Tehran: Medical Sience University of
Shahid Beheshti; 2002.
Bone cancer 14.23±2.74
6. Zabora J, Hofe B, Szok K. The prevalence of psychological distress by
Leukemia 13.65±2.56 cancer site. Psychooncology 2001;10:19‑28.
Cancer stages 7. Mystakidou K, Tsilika E, Parpa E, Katsouda E, Galanos A, Vlahos L.
Stage 1 13.94±1.33 0.32 Assessment of anxiety and depression in advanced cancer patients and
Stage 2 14.09±2.33
their relationship with quality of life. Qual Life Res 2005;14:1825‑33.
8. Chen ML, Chang HK, Yeh CH. Anxiety and depression in Taiwanese cancer
Stage 3 14.24±2.56
patients with and without pain. J Adv Nurs 2000;32:944‑51.
Age 9. Johnson B. Physiology of pain. London: Bailliere Tineall; 2001.
18-30 14.57±2.73 0.42 10. Hagger SP. The effect of relaxation on postoperative muscle tension and
31-45 13.61±2.19 pain. Cancer Res 2002;22:244‑8.
46-55 11. Stark DP, House A. Anxiety in cancer patients. Br J Cancer 2000;83:1261‑7.
56-65 14.18±2.07 12. Rodin G, Lloyd N, Katz M, Green E, Mackay JA, Wong RK; Supportive
Care Guidelines Group of Cancer Care Ontario Program in Evidence‑Based
Education level
Care. The treatment of depression in cancer patients: A systematic review.
Primary school 9.83±2.52 0.008 Support Care Cancer 2007;15:123‑36.
Guidance school 11.34±1.21 13. Shaban M, Rasoolzadeh N, Mehran A, Moradalizadeh F. Effects of
High school 12.92±2.56 non‑pharmacological methods (PMR and music therapy) on pain in cancer
patients. Haiat 2006;12:63‑72.
University 14.04±2.42
14. Sheard T, Maguire P. The effect of psychological interventions on anxiety
and depression in cancer patients: Results of two meta‑analyses. Br J Cancer
anxiety and depression. Therefore, it is recommended to 1999;80:1770‑80.
15. Guétin S, Portet F, Picot MC, Pommié C, Messaoudi M, Djabelkir L,
implement music therapy as a part of nursing care services. et al. Effect of music therapy on anxiety and depression in patients with
Alzheimer’s type dementia: Randomised, controlled study. Dement Geriatr
There are some limitations in this study which need to be Cogn Disord 2009;28:36‑46.
16. Sendelbach SE, Halm MA, Doran KA, Miller EH, Gaillard P. Effects of
addressed. The first limitation is low number of sample music therapy on physiological and psychological outcomes for patients
size. Another limitation of the current study is mere undergoing cardiac surgery. J Cardiovasc Nurs 2006;21:194‑200.
attention to anxiety and depression as the outcome in 17. Kaviani H, Seyfourian H, Sharifi V, Ebrahimkhani N. Reliability and validity
patients with cancer. However, future studies may benefit of Anxiety and Depression Hospital Scales (HADS): Iranian patients with
anxiety and depression disorders. Tehran Univ Med J 2009;67:379‑85.
from investigating effects of music therapy on other health 18. Rafian Z, Azarbarzin M, Safarifard S. Determine the effect of music therapy
problems of cancer patients. on anxiety, pain, nausea and vital signs of patients undergoing cesarean
section at Shariati Hospital. Azad Univ J 2009;19:25‑30.
19. Mirbagher Ajorpaz N, Aghajani M, Shahshahani M. The effects of music and
Acknowledgment Holy Quran on patient’s anxiety and vital signs before abdominal surgery.
Evid Base Care J 2012;1:1‑7.
We would like to thank the anonymous participants and 20. Siavash Vahabi Y. Effects of relaxation and music therapy on anxiety in
the staffs working at the Urmia Imam Khomeini Hospital patients admitted to the cardiac intensive care units. Nurs Midwifery J
and colleagues who collaborated with researchers during Tehran 2013;19:1‑8.
21. Horne‑Thompson A, Grocke D. The effect of music therapy on anxiety
data collection. in patients who are terminally ill. J Palliat Med 2008;11:582‑90.
22. Zhou KN, Li XM, Yan H, Dang SN, Wang DL. Effects of music therapy
Financial support and sponsorship on depression and duration of hospital stay of breast cancer patients after
radical mastectomy. Chin Med J (Engl) 2011;124:2321‑7.
This research was financially supported by Urmia University 23. Sheiban F, Pakdaman SH, Dadkhah A, Hasannejad M. Effects of
music therapy on depression and loneliness of the elderly. Iran J Aging
of Medical Sciences. 2011;5:54‑60.
24. Siedliecki SL, Good M. Effect of music on power, pain, depression and
Conflicts of interest disability. J Adv Nurs 2006;54:553‑62.
25. Mohamadi Zeidi A, Heidarnia A, Hajizadeh A. Study the lifestyle in patients
There are no conflicts of interest. with heart disease. Dneshvar J 2004;61:49‑56.

458 Indian Journal of Palliative Care / Oct-Dec 2016 / Vol 22 / Issue 4

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.