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The Effects of Music as Therapy on the Overall Well-Being of Elderly Patients on

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 Biological Research For Nursing
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The Effects of Music as Therapy on the Overall Well-Being of Elderly Patients on Maintenance
Hemodialysis
Yen-Ju Lin, Kuo-Cheng Lu, Ching-Min Chen and Chia-Chi Chang
Biol Res Nurs published online 27 June 2011
DOI: 10.1177/1099800411413259

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 Biological Research for Nursing
000(00) 1-9
The Effects of Music as Therapy on the ª The Author(s) 2011
Reprints and permission:
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Overall Well-Being of Elderly Patients on DOI: 10.1177/1099800411413259
http://brn.sagepub.com
Maintenance Hemodialysis

Yen-Ju Lin, RN1, Kuo-Cheng Lu, MD2,3, Ching-Min Chen, RN, DNS4, and
Chia-Chi Chang, RN, PhD5

Abstract
In this study, the authors explored the use of music during hemodialysis (HD) as a complementary therapy to improve overall
well-being in elderly patients. The authors recruited a convenience sample of 88 patients on maintenance HD from a teaching
hospital in northern Taiwan and randomly assigned them to either an experimental group (n ¼ 44) or a control group (n ¼
44). In the first week, participants in the experimental group created their own music playlists. During the second week, these
participants listened to music from their own playlists during each HD session (three times/week). The authors evaluated the
effects of music as therapy by assessing its impact on perceived stressors and adverse reactions during HD (HD Adverse Reac-
tions Self-Assessment Scale and HD Stressor Scale [HSS]) and measuring changes in physiological indices during the course of the
music listening. After 1 week of the use of music as therapy during HD, the authors noted significant reductions in the frequency
and severity of adverse reactions during dialysis and in scores on the HSS, p < .001. The authors also observed significantly
decreased respiratory rate and significantly increased finger temperature and oxygen saturation, p < .001, during the same period.
In conclusion, listening to music during HD may promote overall patient well-being. It may thus serve as a complementary form of
therapy that facilitates care and delivery of adequate dialysis and thus improves overall patient well-being in the long run.

Keywords
music, hemodialysis, adverse reactions, end-stage renal disease (ESRD)

Taiwan currently holds the dubious honor of having the highest
incidence and prevalence of chronic kidney disease requiring
long-term hemodialysis (HD) worldwide (United States Renal
Data System, 2010). Of these end-stage renal disease (ESRD)
patients on HD, 44.65% are over 65 years of age (Taiwan
Bureau of National Health Insurance, 2011). Older patients
often have multiple comorbidities and are more likely to
experience greater degrees of physical and psychological func-
tional decline. Elderly patients are also more likely to develop
adverse reactions during HD, such as hypotension, muscle
cramping, nausea, vomiting, headache, and chest pain (Tan
& Yang, 2005). HD treatment is thus often a source of stress
and anxiety for these patients; they are more inclined than
younger patients to ask for earlier termination of treatment or
to skip scheduled HD treatments altogether, frequently com-
promising the adequacy of dialysis therapy.
Management of adverse reactions during HD usually only
provides symptomatic relief and cannot fully prevent patients
from having recurrent reactions during subsequent HD ses-
sions. Current recommended strategies to manage and prevent
these adverse reactions may have unintended consequences as
well. Thus, alleviating the physical discomfort and emotional
distress, these patients experience remains a major concern in
clinical practice.
Previous studies have shown that unique characteristics in
the melody and rhythm of certain types of music can relieve
stress and help receptive patients relax, with investigators
observing lower levels of blood pressure (BP) as well as
decreased respiratory and basal metabolic rates in these
patients (Glynn, 1986; Kemper & Danhauer, 2005). Research-
ers and clinicians have used music therapy for the treatment of
stress and depression, as well as for sleep induction, pain alle-
viation, muscle relaxation, and attempts to enhance immune
1
Dialysis Center, Department of Nursing, Cardinal Tien Hospital, New Taipei
City, Taiwan, Republic of China
2
School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan,
Republic of China
3
Division of Nephrology, Cardinal Tien Hospital, New Taipei City, Taiwan,
Republic of China
4
Department of Nursing, College of Medicine, National Cheng-Kung
University, Tainan, Taiwan, Republic of China
5
School of Geriatric Nursing and Care Management, College of Nursing, Taipei
Medical University, Taipei, Taiwan, Republic of China
Corresponding Author:
Chia-Chi Chang, RN, PhD, No. 250, Wu-Xing St. Taipei 110, Taiwan, Republic
of China
Email: cchang@tmu.edu.tw

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2 Biological Research for Nursing 000(00)
function against infection (Burns, Harbuz, Hucklebridge, &
Bunt, 2001; Chang & Sung, 2005). Music therapy may also
serve as a distraction for patients and decrease awareness of the
passage of time during HD sessions, which may improve
treatment outcomes.
We hypothesized that listening to music during HD would
decrease the level of anxiety and stress that many older patients
experience during these sessions, thus facilitating patient adjust-
ment to and acceptance of HD treatment. In the present study,
we explored the effects of music therapy on the incidence and
severity of adverse reactions during HD treatment and
measured changes in biophysical parameters during treatment.
Background
Factors Associated With Adverse Reactions During HD
Sessions
The adverse reactions patients most commonly experience
during HD are hypotension (25–50%), muscle spasm (5–20%),
nausea and vomiting (5–15%), headache (5%), chest pain
(2–5%), back pain (2–5%), pruritus (5%), fever and chills (1%;
M. S. Wu, 2007). Though there are current recommended
guidelines for the prevention and management of these adverse
reactions, elderly patients with ESRD often have comorbidities
such as cardiovascular disease and autonomic dysfunction which
limit their ability to cope with physiological stressors and main-
tain hemodynamic stability during the HD procedure (Li, Jiang,
& Xu, 2008). Elderly diabetic patients with ESRD, who comprise
the largest group of patients on long-term HD, are particularly at
risk and have significantly higher morbidity and mortality rates
(Wang, 2007). Thus, effective prevention and management of
these potentially life-threatening adverse reactions are needed
to improve patient safety and well-being (Sulowicz & Radzis-
zewski, 2007), as well as to improve adherence to therapy.
The Physiological, Psychological, Social, and Spiritual
Aspects of Music Therapy
Music is perceived by the cochlear nerve, which subsequently
transmits neural signals to the cortex, activating the limbic sys-
tem. The limbic system then relays signals to the pituitary
gland, which releases endorphins that possess analgesic proper-
ties, thus causing decreased perception of pain signals (Beck,
1991). Music also has the ability to decrease pressure-
dependent adrenocorticotropic hormone (ACTH) stimulation
and cortisol release, resulting in decreased catecholamine
secretion from the adrenal medulla. The consequent changes
in BP, heart rate, respiratory rate, temperature, and serum free
fatty acids have beneficial effects on the cardiovascular,
respiratory, musculoskeletal, and nervous systems as well as
the body’s metabolism, such as the alleviation of migraine
headache and hypertension and easing of muscle tension, and
may lower the risks associated with coronary heart disease and
stroke (Cook, 1986; Möckel et al., 1994). Research has also
shown that music increases the rhythmicity of alpha brain
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waves, which is associated with improvements in memory and
creativity during conscious meditation (Wang, 2002).
In addition, investigators have reported that music therapy
makes receptive individuals feel a sense of peace and comfort,
eliminating negative, hostile, and anxious thoughts and
increasing motivation (Beck, 1991; Brown, Martinez, & Par-
sons, 2004; Prinsley, 1986). Menon and Levitin (2005) demon-
strated that listening to music regularly increases dopamine
release, producing positive thoughts, and a sense of well-
being. Other researchers have shown that music therapy pro-
motes social interactions, reducing avoidance behavior and
increasing the chance of participation in social organizations
(Prinsley, 1986; Wang, Yeh, & Chang, 2003).
Principles of Implementation of Music Therapy
Gerdner (2000) and Lai (2004) found that, prior to the imple-
mentation of music therapy, researchers or clinicians must ade-
quately assess patients’ personal background and information
regarding their preferences in music to maximize the potential
effects of treatment. The characteristics of relaxing music
appropriate for music therapy include a slow tempo (60*80
crotchet beats per minute), low-to-medium pitch, low volume,
and melodious rhythms comprised mostly of wind instruments
(O’Sullivan, 1991). Staum and Brotons (2000) reported that
keeping the volume at 60–70 dB maximizes relaxation and
reduces psychological stress. During the course of music ther-
apy, which is best conducted individually in a quiet room, the
clinicians or researchers encourage the patient to assume a
relaxed and comfortable position and listen to the music for
20–45 min (Wang et al., 2003). They might also provide
patients with headphones to reduce ambient and background
noise and set playlists on automatic replay to minimize inter-
ruptions during sessions and maximize treatment effects (Beck,
1991; S. Lee, Lieu, & Chen, 1999).
Effects of Music Therapy in the Clinical Setting
Researchers have studied music therapy as a complementary
treatment in a variety of medical fields. Midwives have used
music therapy to reduce stress and anxiety during labor,
increase concentration, and facilitate positive experiences for
the mother and her relatives (Chang & Chen, 2005). Richard-
son, Babiak-Vazquez, and Frenkel (2008) likewise reported
that music therapy effectively reduced pain, discomfort, and
anxiety in the palliative care of cancer patients. Hilliard
(2005) showed that music therapy facilitates the building of
patient relationships with caregivers and other patients and
improves patient’s quality of life. Among patients with chronic
psychosis, Wang et al. (2003) demonstrated that music therapy
reduces negative symptoms associated with these chronic con-
ditions and improves social interaction and levels of interest in
patients’ surroundings. In pediatrics, L. Lee, Chan, Ho, Cheng,
and Su (2005) found that music therapy improves learning
motivation in autistic children, increasing cognitive and con-
versational abilities.
Lin et al. 3

A subject is deemed eligible for enrollment

and qualified based on sample criteria

Subjects are randomly assigned to experimental

or control group by coin flip

Informed consent is secured for enrollment in study

Experimental group Control group

Pretest data collection: Pretest data collection:

First HD session, Week 1: Demographics
Sheet and HSS.
Last HD session, Week 1:
- During HD: physiological monitoring
- After HD: HD Adverse Reactions Self-
Assessment Scale and music selection.
First HD session, Week 1: Demographics
Sheet and HSS.
Last HD session, Week 1:
- During dialysis: physiological monitoring
- After HD: HD Adverse Reactions Self-
Assessment Scale

Regular clinical care with music therapy Regular clinical care only

Posttest data collection: Posttest data collection:

Last HD session, end of week 2: Last HD session, end of week 2:
- During dialysis: physiological monitoring - During dialysis: physiological monitoring
- After HD: HD Adverse Reactions Self- - After HD: HD Adverse Reactions Self-
Assessment Scale and HSS Assessment Scale and HSS

Data processing and analysis

Figure 1. Data-collection process. Note. HD ¼ hemodialysis; HSS ¼ HD Stressor Scale. Coin flip results: subjects on Mon-Wed-Fri HD
schedule were assigned to the experimental group; subjects on Tue-Thu-Sat HD schedule were assigned to the control group.

Patients on HD often present with acute complaints that need
immediate attention. In maintenance HD patients, music ther-
apy has had beneficial effects on stress, anxiety, and depression.
Investigators have also noted increased blood oxygen saturation
in these patients (Kim, Lee, & Sok, 2006; Lin, Chen, Kuo,
Wang, & Huang, 2007). To date, however, there is little evi-
dence in the literature regarding the effects of music therapy
on the well-being of patients on HD, especially the elderly.
Method
Design and Setting
The Ethics Committee on Human Studies at Cardinal Tien
Hospital, Taipei, Taiwan, approved the study protocol. We
obtained written informed consent from each patient who par-
ticipated. We recruited a convenience sample of 88 HD patients
and randomly assigned them to the experimental (n ¼ 44) or
control group (n ¼ 44) by flipping a coin. Patients deemed eli-
gible for enrollment in the study were aged 60 years and over,
known to have ESRD for at least 3 months, on maintenance
HD three times every week (4 hr/per session) and able to
communicate effectively in Mandarin or Taiwanese. Patients
with severe cognitive or hearing impairments and those with
pacemakers were excluded from this study.
In the first week, patients in the experimental group selected
and created their own music playlists. During the second week,
the experimental group listened to music from their own play-
list during each HD session (three times/week). We evaluated
the effects of the music therapy by assessing its impact on stres-
sors and adverse reactions during HD (HD Adverse Reactions
Self-Assessment Scale and HD Stressor Scale [HSS]) and mea-
suring changes in physiological indices during the course of the
treatment (Figure 1). We checked the physiological indices
every 30 min for the entire HD treatment and averaged data
from eight time points (30, 60, 90, 120, 150, 180, 210, and
240 min after HD initiation) to obtain the postintervention mea-
sures for each patient.
Instruments
Demographic data. To account for possible confounding fac-
tors during analysis, we recorded and controlled for the

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4 Biological Research for Nursing 000(00)
following demographic data: age, sex, education level, marital
status, time on HD, comorbidities, and musical preferences.
Hemodialysis Adverse Reactions Self-Assessment Scale. Adapted
from relevant literature and clinical nursing management expe-
rience, the self-assessment scale contained 17 common adverse
reactions that may occur during HD (Tan & Yang, 2005;
Tanimu et al., 2000; M. S. Wu, 2007). We used 4-point
Likert-type scales to quantify symptom frequency (0 ¼ none,
1 ¼ once or twice, 2 ¼ 3–5 times, and 3 ¼ more than 5 times)
and severity (1 ¼ only mildly ill, 2 ¼ moderately ill, 3 ¼ seri-
ously ill, and 4 ¼ extremely ill). Frequency scores ranged
between 0 and 51, with higher scores indicating a higher fre-
quency. Severity scores ranged between 17 and 68, with higher
scores likewise representing a greater severity. Cronbach’s a of
the scale was .662 and coefficient of variation (CVI) was .91.
Hemodialysis Stressor Scale. The HSS (Chou, 2002) is a 32-
item scale used to rate the incidence and severity of stressors
associated with HD. Subjects rated the extent of being troubled
by each of the 32 stressors using a 4-point scale (0 ¼ not at all,
1 ¼ slightly, 2 ¼ moderately, and 3 ¼ a great deal). We
obtained a subtotal score for each construct by summing the
ratings for each; the higher the score, the greater the stress.
We used the HSS for both longer-term recall (i.e., 1–2 months
prior to study) and more immediate recall (during the Week 2
of the study period). Cronbach’s a of this scale was .905 in the
current study.
Physiological indicators. We used a biological monitoring sys-
tem (GE Medical Systems Information Technologies, Inc.,
Milwaukee, WI) to monitor and record data regarding BP, heart
rate, respiratory rate, and oxygen saturation. The Department
of Health, Executive Yuan and the Bureau of Standards
(2010), Metrology and Inspection approved this system. A cer-
tified engineer made any necessary adjustments.
When individuals are in a state of relaxation, parasympathetic
effects are enhanced, leading to capillary expansion and an
increase in the surface temperature of the fingers. Investigators
can measure this physiological change and use it as an indicator
of emotional state (P. H. Chen, 2003; Kistler, Mariauzouls, & von
Berlepsch, 1998). For the current study, we measured finger
surface temperature using the TEMPview Temperature Feedback
Monitor, with an accuracy within 0.1  C (TM-903A, Ronmac Int.
Corp, Taipei, Taiwan, manufactured in 2009).
Intervention
In the first week, we encouraged participants in the experimen-
tal group to choose their favorite musical styles by listening to
the first 30 s of each of the songs on the complete playlist with 5
s intervals between songs. There were three songs to choose
from in each music category and participants had free rein to
select and eliminate songs and music categories to create their
own personal playlists, which we then recorded for each
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participant. All available selections were melodic instrumental
music with a tempo of 60–80 beats per min.
During the second week, participants in the experimental
group received music as therapy during every HD session.
They wore earphones to eliminate background noise and
selected music from their own playlists. Participants could lis-
ten to music for the first 20 min of every hour for the first 3 hr
of HD. For the fourth hour, we asked participants to listen to
music during the last 20 min of HD treatment. We did not pro-
vide the control group with any music at all during HD.
Statistical Analysis
We express continuous variables as means + SD and catego-
rical values as percentages. We tested normal distribution of
samples using the Kolmogorov–Smirnov test and performed
comparisons between groups using Student’s t test or Mann–
Whitney U test (according to data characteristics). We used
Fisher’s exact test or chi-square analysis to analyze categorical
data, Wilcoxon’s signed ranks test to analyze the differences
between pretest and posttest in the experimental group, and
Spearman rank correlation coefficient test to examine the cor-
relations between age, the habit of listening to music, and other
indices. We consider a p value < .05 to be statistically signifi-
cant. We used the Statistical Package for the Social Sciences
(SPSS/PC, SPSS, Inc., Chicago, IL) for our statistical analyses.
Results
Baseline Data and Physiological Parameters
We cross-referenced patient demographic data with currently
available nationwide research data (Chang, 2005; L. H. Lee,
2003; Sung, Chang, & Abbey, 2006). We found no statistically
significant differences between the experimental and control
groups with regard to sex, level of education, marital status,
religion, annual income, living arrangement, length of time
on HD and duration of each session, average frequency and
severity of adverse reactions, HSS scores during HD, or phy-
siological indices (Table 1). The experimental group had a
lower mean age (69.11 + 7.88 versus 75.55 + 9.16, p ¼
.001) and its members were more likely to have a habit of lis-
tening to music (w2 ¼ 19.17, p < .001) compared to the control
group.
Since we noted significant differences between the two
groups with respect to age and the habit of listening to music,
we used the Spearman’s rank correlation coefficient to analyze
the relationships between these two demographic variables and
the physiological parameters in all the patients (Table 2). We
found a negative correlation between age and diastolic BP (r
¼ .332, p ¼ .002), which might be due to the decreased elas-
ticity and compliance of arteries that occurs with age (M. F.
Chen, 2009). We found no statistically significant correlation
between the habit of listening to music and any of the physio-
logical parameters or with respect to sources of stress and the
frequency and severity of adverse reactions during HD.
Lin et al. 5

Table 1. Demographic and Baseline Variables of the Two Groups (N ¼ 88)

Variable Experimental (n ¼ 44) Control (n ¼ 44) p

Age 69.11 + 7.881 75.55 + 9.156 .001a**

Sex—Female 22 (50) 29 (65.9) .131b
Educational level .389c
Uneducated (illiterate) 7 (15.9) 13 (29.5)
Elementary school 19 (43.2) 18 (40.9)
Junior high school 6 (13.6) 7 (15.9)
High school 6 (13.6) 4 (9.1)
College, university, and above 6 (13.6) 2 (4.5)
Marital status .113c
Single 3 (6.8) 2 (4.5)
Married 28 (63.6) 18 (40.9)
Divorced 0 1 (2.3)
Separated 0 1 (2.3)
Widowed 13 (29.5) 22 (50.0)
Religion .588c
None 2 (4.5) 4 (9.1)
Chinese traditional religion 38 (86.4) 37 (84.1)
Christianity 4 (9.1) 2 (4.5)
Catholicism 0 1 (2.3)
Annual income .300c
Insufficient 5 (11.4) 10 (22.7)
Enough 23 (52.3) 24 (54.5)
Good 12 (27.3) 6 (13.6)
Very good 4 (9.1) 4 (9.1)
Lives with family—No 5 (11.4) 7 (15.9) .379b
Length of time on hemodialysis (years) 6.80 + 5.290 4.42 + 3.584 .054a
Duration of hemodialysis sessions .183c
< 4 hr 2 (4.5) 4 (9.1)
4 hr 39 (88.6) 40 (90.9)
> 4 hr 3 (6.8) 0
Number of other chronic diseases .461c
0 6 (13.6) 1 (2.3)
1 7 (16.0) 13 (29.5)
2 21 (47.7) 21 (47.7)
≥ 3 10 (22.7) 9 (20.5)
Habit of listening to music—No 17 (38.6) 37 (84.1) .000b***
Frequency of adverse reactions score 2.36 + 2.934 1.93 + 2.491 .415a
Severity of adverse reactions score 2.45 + 3.605 1.77 + 2.144 .505a
Hemodialysis Stressor Scale score 27.00 + 17.032 28.18 + 15.919 .573a
SBP (mmHg) 134.60 + 18.992 133.66 + 18.570 .815a
DBP (mmHg) 70.05 + 9.665 66.26 + 9.492 .081a
% of SBP < 100 mmHg 5.52 + 11.2 7.79 + 17.82 .952a
Heart rate (beats/min) 71.59 + 15.345 71.50 + 10.582 .611a
Respiratory rate (breaths/min) 18.52 + 1.944 18.87 + 1.903 .537a
Finger temperature ( C) 31.85 + 1.912 31.31 + 1.988 .163a
Oxygen saturation (%) 98.43 + 1.022 98.16 + 0.938 .125a
Note. Continuous variables are expressed as mean + SD; categorical variables are expressed as n (%).
DBP ¼ diastolic blood pressure; SBP ¼ systolic blood pressure.
a
Chi-square test.
b
Fisher’s exact test.
c
Mann–Whitney U test.
** p < .01.
*** p < .001.

Analysis of Variables Before and After Music Therapy temperature also significantly decreased, and oxygen saturation
The frequency and severity of adverse reactions as well as scores significantly increased. We found no significant differences with
on the HSS decreased significantly after three sessions (1 week) respect to heart rate, systolic and diastolic BP (DBP), including
of music as therapy (see Table 3). Respiratory rate and finger the percentage of systolic BP (SBP) below 100 mmHg.

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6 Biological Research for Nursing 000(00)

Table 2. Correlations Between Age and the Habit of Listening to Listening to Music and Sources of Stress
Music and Physiological and Hemodialysis-Related Variables (n ¼ 88)
Our results also show that music therapy can mitigate the
Habit of Listening to effects of stress in HD patients. These results are consistent
Variable Age Music with the results of Giedt’s (1999) study, which evaluated the
Frequency of adverse reactions .055 .155 psychoneuroimmunological effects of guided imagery, and Lin
Score et al.’s (2007) observations regarding the effects of music ther-
Severity of adverse reactions .001 .136 apy on anxiety and stress.
Score We compared participants’ scores on the HSS measuring the
Hemodialysis Stressor Scale .167 .034 level of stress related to HD in the 1–2 months prior to the study
Score to their scores after the 2-week study period and noted a signif-
Systolic blood pressure (mmHg) .150 .104
Diastolic blood pressure (mmHg) .332** .154
icant attenuation of stress. In particular, we observed significant
Heart rate (beats/min) .020 .087 improvement in 9 items on the scale, as described in ‘‘Results,’’
Respiratory rate (breaths/min) .208 .069 above, which implies that some stressors may be amenable to
Finger temperature ( C) .047 .077 treatment with short-term music therapy, while other sources
Oxygen saturation (%) .121 .178 of stress may require a longer period of intervention.
Note. Spearman’s rank correlation coefficient analysis was used to determine
Music therapy may create a sense of comfort by gradually
correlations. eliciting hormonal and physiological changes and indirectly
** p < .01. influencing emotional states. Music may also eliminate nega-
tive emotions, stimulate motivation, and decrease levels of
anxiety and hostility (Beck, 1991; Brown et al., 2004; Cook,
1986; Menon & Levitin, 2005). Since stress may be due to a
Comparison of Change in Variables After Music
chronic accumulation of negative feelings, music therapy may
Therapy Between the Two Groups help mitigate stress by allowing patients to focus less on their
The incidence and severity of adverse reactions as well as problems or physical discomforts and decreasing their aware-
scores on the HSS significantly decreased after 1 week of ness of time; thus helping patients to relax and facilitate effec-
music therapy compared to the control group (see Table 4). tive delivery of treatment during HD.
Subsequent analysis of the 32 items in the HSS showed signif-
icant alleviation of stress after music therapy with regard to
nine stressors: ‘‘poor/inadequate A-V fistula function,’’ ‘‘itch- Effects of Music Therapy on Physiological Indicators
ing,’’ ‘‘hypotension,’’ ‘‘loss of bodily function,’’ ‘‘limitation
Several studies have observed reduced respiratory rates in
of activity,’’ ‘‘sleep disturbances,’’ ‘‘coping with family
patients receiving music therapy (Chan, Chan, Mok, & Kwan
responsibilities,’’ ‘‘vacation limitations,’’ and ‘‘frequency of
Tse, 2009; Glynn, 1986; Lai, 2004). Chlan (1998) observed that
hospitalizations.’’ Respiratory rate decreased significantly and
heart rate, in patients receptive to music, slowed down and syn-
oxygen saturation increased significantly in the experimental
chronized with the tempo of the music. These patients reported
group compared to the control group after 1 week of music
a reduced sense of anxiety. Thus, patients listening to music
therapy.
during HD treatment may be more able to relax and, thus, help
to reduce rapid respiratory and heart rates.
Our results showed significantly increased oxygen satura-
Discussion tion in the experimental group. As the sympathetic nervous sys-
tem becomes less active with relaxation, respiratory and basal
The Effects of Music as Therapy in Reducing the
metabolic rates decrease and oxygen saturation levels increase
Frequency and Severity of Adverse Reactions During HD (Kemper & Danhauer, 2005; C. C. Wu, 1994). We also
Our results show significantly reduced frequency and severity observed a significant increase in finger temperature in patients
of adverse reactions after music therapy in the experimental after music therapy (Table 3), which is consistent with results
group compared to the control group. Pothoulaki et al. (2008) from previous studies (Hwang, Chang, Lee, Ko, & Chu,
found that music therapy attenuated the perception of pain in 1996; Lai, 2004; D. F. Lee & Hwang, 1997). In a state of calm
patients undergoing HD. Investigators have also observed and relaxation, a change in finger temperature is mediated by a
improved BP control, reduced respiratory rate, muscle rel- reduction in autonomic nervous system activity and reduced
axation, and alleviation of nausea and vomiting after music muscle tension, which leads to expansion of superficial capil-
therapy (Beck, 1991; Brown et al., 2004; Cook, 1986; Menon laries and greater blood flow (P. H. Chen, 2003). In a study
& Levitin, 2005). Thus, music therapy may help improve of the effects of music therapy on 60 patients on HD, Lin
patient compliance with HD treatment and promote adequacy et al. (2007) also observed a slight increase in the subjects’
of dialysis, especially among elderly patients, who are more body temperature. However, the sample size was quite small
likely to both experience adverse reactions during HD and to (effect size ¼ 0.68, power < 0.9) and their results were not sta-
ask to discontinue treatment because of them (Inrig, 2010). tistically significant.

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Lin et al. 7

Table 3. Mean + SD for Variables Before and After Music Therapy in the Experimental Group (n ¼ 44)

Variable Before Therapy After Therapy p

Frequency of adverse reactions score 2.36 + 2.934 0.59 + 1.263 .000***

Severity of adverse reactions score 2.45 + 3.605 0.55 + 1.247 .000***
Hemodialysis Stressor Scale Score 27.00 + 17.032 21.11 + 15.680 .000***
SBP (mmHg) 134.60 + 18.992 131.83 + 18.229 .137
DBP (mmHg) 70.05 + 9.665 68.78 + 8.810 .178
% SBP < 100mmHg 5.52 + 11.2 3.25 + 8.072 .106
Heart rate (beats/min) 71.59 + 15.345 71.51 + 13.458 .566
Respiratory rate (breaths/min) 18.52 + 1.944 16.08 + 1.552 .000***
Finger temperature ( C) 31.85 + 1.912 32.38 + 1.485 .008**
Oxygen saturation (%) 98.43 + 1.022 99.27 + 0.685 .000***
Note. Wilcoxon’s signed ranks test was used for analysis.
DBP ¼ diastolic blood pressure; SBP ¼ systolic blood pressure.
** p < .01.
*** p < .001.

Table 4. Comparison of Changes in Variables From Premusic to Postmusic Therapy Between the Two Groups (n ¼ 88)

Variable Experimental Group (n ¼ 44) Control Group (n ¼ 44) p

Frequency of adverse reactions score 1.77 + 2.281 0.14 + 3.739 .000***

Severity of adverse reactions score 1.91 + 2.675 0.32 + 2.924 .000***
Hemodialysis Stressor Scale Score 5.89 + 4.785 1.59 + 7.212 .000***
SBP 2.77 + 12.865 0.38 + 14.391 .282
DBP 1.26 + 6.212 0.28 + 5.18 .234
% SBP < 100 mmHg 2.27 + 9.214 0.65 + 13.413 .362
Heart rate (beats/min) 0.08 + 7.514 1.18 + 5.668 .187
Respiratory rate (breaths/min) 2.44 + 1.435 0.08 + 1.579 .000***
Finger temperature ( C) 0.53 + 1.573 0.31 + 1.32 .280
Oxygen saturation (%) 0.83 + 0.802 0.08 + 0.843 .000***
Note. Data are described as mean + SD. The Mann–Whitney U test was used for this analysis.
DBP ¼ diastolic blood pressure; SBP ¼ systolic blood pressure.
*** p < .001.

The HD procedure constitutes an extracorporeal circulation,
which can often lead to hemodynamic instability in elderly
patients. The most common reaction is an activation of the
autonomic nervous system, which increases the heart rate and
causes peripheral vasoconstriction (M. S. Wu, 2007). During
HD, a patient who experiences a 25% decline in BP or greater
from previous readings needs immediate intervention to pre-
vent the development of excessive hypotension and more seri-
ous complications (Prakash, Garg, Heidenheim, & House,
2004). Thus, though we observed no significant differences
in heart rate, SBP, DBP, or the percentage of SBP less than
100 mmHg, we cannot exclude the possibility of effects of
music therapy on autonomic nervous system activity.
Limitations
We did not assess plasma hormone levels in the present study.
Measurement of levels of cortisol or other hormones in blood or
saliva as an additional indicator of stress may be a future research
goal. Monitoring of heart rate variability (HRV) may also be a
reliable method of detecting autonomic dysfunction, which is a
frequent problem in HD patients (Schubert, Palazzolo, Brum,
Ribeiro, & Tan, 1997). Thus, measurement of HRV, which
involves a relatively simple and noninvasive method, could be
used to monitor physiological changes during music therapy in
future studies.
Conclusions
Providing music during HD may be an effective complemen-
tary therapy to improve overall patient well-being. Since music
therapy alleviates the frequency and severity of adverse reac-
tions associated with HD, improves physiological parameters,
and reduces patient stress and anxiety, it may increase patient
adherence to therapy and promote adequacy of dialysis. The
use of music as therapy during HD may also facilitate patient
care by allowing patients to participate in their own health care
and help create a more harmonious relationship between
patient and caregivers.
Though it is not in widespread use among nurses at this
time, the provision of music therapy as a clinical treatment tool
could provide further avenues for nursing care in the future.

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8 Biological Research for Nursing 000(00)
Findings from the current and prior research indicate that HD
patients could likely benefit from the clinical use of music ther-
apy. Further research into the benefits of music therapy will
likely reveal additional applications and provide an increased
understanding of the mechanisms at work.
Acknowledgments
The authors would like to thank all participants for their assistance in
conducting this research. The authors are also grateful for grants from
the National Science Council, Taiwan R.O.C. and Cardinal Tien
Hospital.
Authors’ Note
The authors Yen-Ju Lin and Kuo-Cheng Lu contributed equally to this
work.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: This work was
partly supported by grants from the National Science Council
(NSC 97-2314-B-038-017-MY2) and Cardinal Tien Hospital (CTH-
99-1-2A02).
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