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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 4  |  Page : 320-325

The effect of music therapy in critically ill patients admitted to the intensive care unit of a tertiary care center


1 Department of Cardiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
2 Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
3 Department of Opthalamology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission20-Nov-2019
Date of Decision30-Nov-2019
Date of Acceptance20-Dec-2019
Date of Web Publication16-Jul-2020

Correspondence Address:
Dr. Nitin Raisinghani
Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_41_20

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  Abstract 


Introduction: The role of music in medicine, and specifically, Intensive care medicine is still unclear; however, its role in affecting vital parameters is well known. Thus, in recent years, music has been increasingly used as a therapeutic tool in the treatment of different diseases and in intensive care medicine. Neural plasticity has been believed to explain some of the sensorimotor and cognitive enhancements that have been associated with music therapy. Thus, a study was conducted to see if it can serve as complementary method for treating perioperative stress and for acute and chronic pain management in a critical care setting. Aim and Objectives: The aim is to evaluate the effect of music therapy on clinical parameters in critically ill patients, its role in causation of biochemical parameters, and its effect on the overall outcome in critical care patients. Materials and Methods: The study was a cross-sectional study conducted in the intensive care unit (ICU) of the medicine department, AVBRH, Sawangi, from September 2018 to February 2019. The study involved 120 adult patients aged 18–85 years categorized into 60 cases and 60 controls. Reasons for hospitalizations primarily included sepsis, congestive cardiac failure, acute respiratory distress syndrome, cerebrovascular episodes with complications, and chronic kidney disease with concurrent complications. Cases were administered music therapy in the form of classical piano pieces composed by Mozart, played for 20 min in the morning, afternoon, and evening, while controls received only protocol-based management. Data were entered in Microsoft Office Excel 2010 and analyzed using the IBM SPSS software version 22.0 (Chicago, Illinois, USA). Results: Case category patients were found to have a statistically significant reduction in Glasgow Coma Scale, heart rate, blood pressure, and Hamilton anxiety scale rating on day 1 versus day 5 and in comparison to the control group as well. Case patients were also noted to have a lesser duration of hospital stay and lesser mean morbidity in the ICU compared to controls. Conclusion: Thus, authors believe that music therapy can be a crucial adjuvant to protocol-based management that already exists across critical care settings, and strongly feel that further studies, including a greater number of patients and follow-up evaluations, are needed to confirm promising results observed in this study.

Keywords: Critical care, Glasgow coma scale, Hamilton anxiety scoring, heart rate, music therapy


How to cite this article:
Jawaharani A, Acharya S, Kumar S, Gadegone A, Raisinghani N. The effect of music therapy in critically ill patients admitted to the intensive care unit of a tertiary care center. J Datta Meghe Inst Med Sci Univ 2019;14:320-5

How to cite this URL:
Jawaharani A, Acharya S, Kumar S, Gadegone A, Raisinghani N. The effect of music therapy in critically ill patients admitted to the intensive care unit of a tertiary care center. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Aug 11];14:320-5. Available from: http://www.journaldmims.com/text.asp?2019/14/4/320/289858




  Introduction Top


The role of music in medicine, and specifically, Intensive care medicine is still unclear. However, it is well known that music may not only improve quality of life but also effect changes in heart rate (HR) and HR variability (HRV).[1] Music is considered a universal language and has influenced human existence at all levels. Neurologists, psychologists, and comparative musicologists have been one of the earliest pioneers of this field of research, such as Carl Stumpf, who studied the effect of music in terms of multiple levels of sensory processing and mental representation. Neurologists such as August Knoblauch also discussed multiple levels of music processing, as early as in the Nineteenth Century. Knoblauch and others attempted to localize music function in the brain. Other neurologists, such as John Hughlings Jackson, discussed the relation between music as an emotional system and language as an intellectual system. Richard Wallaschek used ideas from psychology to explain music processing and audience reactions and also used case studies from neurology to support arguments about the nature of music. In recent years, music has been increasingly used as a therapeutic tool in the treatment of different diseases and in intensive care medicine.[2],[3],[4],[5],[6]

Research today has shown that repeatedly practicing the association of motor actions with a specific sound and visual patterns (musical notation), while receiving continuous multisensory feedback will strengthen connections between auditory and motor regions (e.g., arcuate fasciculus) as well as multimodal integration regions. Furthermore, the plasticity of this system as a result of long-term and intense interventions suggest the potential for music making activities (e.g., forms of singing) as an intervention for neurological and developmental disorders to learn and relearn associations between auditory and motor functions such as vocal motor functions. Music plays an important role in intensive care medicine.[7] It is well known that soft, silent, or quiet classical or mediation music is associated with the reduced need for sedative drugs and reduced perception of pain. Despite the well-known effects of music in intensive care medicine this kind of “therapy” is observed rarely in daily practice. Furthermore, there are many psychological effects: Music from the youth of the patient will lead to improved mood, concentration, and motivation, all of which are essential for the intensive care patient.[4],[8] However, music is inexpensive, easily administered, and free of adverse effects, and as such, and thus, this study was conducted to see if it can serve as complementary method for treating perioperative stress and for acute and chronic pain management in a critical care setting.

Aim and objectives

To study the effect of music therapy as an adjunct in critically ill patients.

Objectives

  • To evaluate the effect of music therapy on clinical parameters in critically ill patients
  • To evaluate the effect of music therapy in biochemical parameters
  • To study the effect of music therapy on overall outcome in critically care unit patients.



  Materials and Methods Top


This cross-sectional interventional study was carried out in critically ill patients admitted in medicine intensive care unit (ICU) of AVBRH Sawangi (Meghe), Rural hospital.

Duration of study: September 2018–February 2019

Setting

Department of Internal Medicine ICU, AVBRH Sawangi (Meghe) Wardha.

Type of study

Cross-sectional interventional study.

Study subjects

Study participants were 120 adult male and female patients aged between 18 and 85 years admitted to the medicine ICU of AVBRH, Sawangi, Meghe. participants by random categorization, were grouped into 60 patients considered as the category of Cases, who were given primary intervention with Music therapy in the form of classical piano pieces composed by Mozart for 20 min every day in the morning, afternoon,[9] and evening along with therapy using the routine protocol, and 60 patients who acted as the control group, and were not administered music therapy, and were treated only with protocol management.

Definition of cases

Definition of sepsis

A diagnosis of bacterial sepsis was based on the protocol of quick Sequential Organ Failure Assessment (qSOFA) scoring introduced in 2016,[10] which allowed for quick bedside analysis of organ dysfunction in patients with suspected or documented infection. The qSOFA score included a respiratory rate of 22 breaths/min or more, systolic blood pressure of 100 mm Hg or less, and altered level of consciousness. For completeness, severe sepsis was defined as sepsis complicated by organ dysfunction, i.e., progressive organ dysfunction in a severely ill patient, with failure to maintain homeostasis without intervention. Patients suffering from septicemia (with or without shock), irrespective of cause, are the cases were taken. Management of patients was carried out as per conventional guidelines.

SCCM APACHE SCORE[11] was calculated for all patients, and then the patients were randomized into two groups;

  • Group 1: Received music therapy in the form of classical piano pieces composed by Mozart based on international recommendations of studies conducted in music therapy, which were played for 320 min sessions each in the morning, afternoon, and night, apart from the normal conventional therapy[9]
  • Group 2: Included patients from the control group who were treated using only conventional therapy.


Primary endpoint

Effects of music therapy in the form of daily clinical examination pertaining to physiological parameters including response in temperature, pulse rate, HRV, blood pressure, and overall well-being were noted and tabulated over a duration of 5 days.

Laboratory and biochemical parameters such as changes in complete blood count and total leukocyte count were assessed by the bedside. Changes in Xray chest, kidney function test, liver function test, and serum electrolytes (wherever applicable) were compared in the two groups on day 1 and day 5.

Secondary endpoint

Duration of ICU stay and mortality was further studied and compared amongst the two groups.

Definition of congestive cardiac failure

Congestive cardiac failure (CCF) was defined according to the Framingham criteria[12] for the diagnosis of heart failure, which consists of the concurrent presence of either two major criteria or one major and two minor criteria. Major criteria comprised of paroxysmal nocturnal dyspnea, weight loss of 4.5 kg in 5 days in response to treatment, neck vein distention, rales, acute pulmonary edema, hepatojugular reflux, S 3 gallop, central venous pressure >16 cm water, circulation time of 25 s or longer, radiographic cardiomegaly, pulmonary edema, visceral congestion, or cardiomegaly at autopsy. The minor criteria (accepted only if they cannot be attributed to another medical condition) comprising of the following nocturnal cough, dyspnea on ordinary exertion, a decrease in vital capacity by one third the maximal value recorded, pleural effusion, tachycardia (rate of 120 bpm), hepatomegaly, or bilateral ankle edema. CCF was then categorized on the basis of the New York Heart Association classification system on a scale of I to IV,[2] as follows:

  • Class I: No limitation of physical activity
  • Class II: Slight limitation of physical activity
  • Class III: Marked limitation of physical activity
  • Class IV: Symptoms occur even at rest; discomfort with any physical activity.


Further management was started based on the recommended protocol, appropriate to the severity of symptoms and class obtained.

Definition of acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) was diagnosed on the basis of the American-European Consensus Conference (AECC) definition[13] which characterizes it as an acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia in the absence of evidence for cardiogenic pulmonary edema. The severity of hypoxemia necessary to make the diagnosis of ARDS was defined by the ratio of the partial pressure of oxygen in the patient's arterial blood (PaO2) to the fraction of oxygen in the inspired air (FiO2), based on AECC recommendations. ARDS was defined by a PaO2/FiO2 ratio of <200, and in acute lung injury, <300. The Berlin definition for ARDS was also taken into account, and was categorized by timing (within 1 weak of clinical insult or onset of respiratory symptoms); radiographic changes (bilateral opacities not fully explained by effusions, consolidation, or atelectasis); the origin of edema (not fully explained by cardiac failure or fluid overload); and severity based on the PaO2/FiO2 ratio on 5 cm of continuous positive airway pressure. The three categories of ARDS thus obtained were taken to be mild (PaO2/FiO2 200–300), moderate (PaO2/FiO2 100–200), and severe (PaO2/FiO2 ≤ 100).

Definition of a cerebrovascular event

A diagnosis of common vulnerabilities and exposures (CVE) was made on the basis of neuro-imaging, which is essential for the evaluation of acute ischemic/hemorrhagic stroke, using any appropriate radio imaging modality. Appropriate management was started based on protocol considering area of vascular involvement, the severity of symptoms, and progressive course of signs in the patient population. Critically ill patients having suffered a CVE and diagnosed with concurrent comorbid complications, including raised intracranial tension or significant intra-cerebral bleed, were included in the study.

Diagnosis of chronic kidney disease

Diagnosis of chronic kidney disease (CKD) was based on updated Kidney Disease: Improving Global Outcomes guidelines, and critically ill patients with concurrent complications including metabolic acidosis, shock, or malignant hypertension, were especially focused on as cases in the study.

Exclusion criteria

Patients excluded from the study comprised:

  • Patients/relatives who did not agree to consent for the study
  • Patients on mechanical ventilator due to any other cause (myocardial infarction),
  • Disoriented or comatose patients,
  • Paralyzed patients and
  • Patients who were heavily sedated, were not included in the study.


Calculation of sample size

The incidence of sepsis found across Indian studies was estimated to be 10%–15%. Thus, sample size was calculated by using the formulae:



where Z (1−α/z) = Is the standard normal variant at 5% type 1 error (P < 0.05) it is 1.96.

p = Expected proportion in population -based studies

d = Absolute error, i.e., 0.05

So minimum sample size obtained by the formulae was found to be: 120

Statistical analysis

The data was collected and stored in an electronic spreadsheet (Microsoft Excel 2007, Microsoft Inc., Redmond, Washington, USA). Statistical analysis was done using Chi-square test, Student's t-test and multiple regression analysis, after data collection, and P < 0.05 was taken to be statistically significant.

Ethical clearance

Ethical clearance was obtained from the Institutional Ethical Committee of JNMC, Sawangi (Meghe), Wardha, on 20nd October 2019. With ethical clearance no DMIMS(DU)/IEC/2019-20/360.


  Results Top


The study was a prospective case–control study conducted in the Medicine ICU of AVBRH, Sawangi, Meghe, from the period of September 2018–February 2019. Study subjects were 120 adult male and female patients aged between 18 and 85 years, grouped into 60 patients considered as the category of cases, who were given primary intervention in the form of music therapy followed by therapy with routine protocol, and 60 patients who acted as the control group, and were not administered music therapy, and were treated only with protocol management. A comparison of basic patient demographics between cases and controls was carried out first. The P values obtained for this comparison was found to be statistically insignificant, data for which is represented in [Table 1].
Table 1: Basic patient demographics

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Next, an analysis of reasons for ICU Hospitalization among case patients and control group was carried out, and data obtained were as follows. There was no statistical significance noted, as is documented in [Table 2].
Table 2: Comparison of reasons of hospitalization

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A day 1 versus day 5 comparison of laboratory parameters amongst case patients was carried out next, which showed that there was statistically significant decline in four parameters, namely Glasgow Coma Scale (GCS), HR, blood pressure and Hamilton anxiety scale rating among the case group compared to the control group. This data is represented in [Table 3].
Table 3: Comparison of case group parameters on day 1 and day 5

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A day 1 versus day 5 comparison of laboratory parameters among control group patients was carried out next but revealed no significant changes. Then, Day 5 parameters between case patients and the control group were analyzed. Results showed that there was a statistically significant decline in four parameters, namely GCS, HR, blood pressure, and Hamilton anxiety scale rating among the case group compared to the control group. This data are represented in [Table 4].
Table 4: Comparison of Case Group day 5 parameters versus Control Group day 5 parameters

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Finally, patient outcomes were assessed between the two groups, which revealed a significantly lesser mean duration of ICU stay and mean morbidity in the ICU among case patients, as compared to controls. This data are represented in [Table 5].
Table 5: Comparison of patient outcomes amongst Case and Control group patients

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  Discussion Top


The study was a prospective case–control study conducted in the Medicine ICU of AVBRH, Sawangi, Meghe, from the period of September 2018–February 2019. Study participants were 120 adult male and female patients aged between 18 and 85 years, grouped into cases and controls having 60 patients each.

Chan et al.[7] performed a randomized study in 47 people under the age of 65 who underwent music therapy compared to 24 controls. Data from this study suggested that in the case group-administered music therapy, there was a statistically significant decrease in depression scores (P < 0.001), blood pressure (P < 0.001), and HR (P < 0.001) after 1 month (P < 0.001), data similar to which was obtained in this study as well. The implication of this observation is that music can be an effective intervention for older and/or patients suffering from depressive syndromes. Therefore, music plays an important role in this situation, and music from the patient's youth has the most impact.[14],[15]

In a study by Mary et al.,[16] out of the 44 patients studied, 23 demonstrated a decrease in HR after a music session. Respiratory rates in 24 of the patients studied decreased after a music session. Of the 13 patients able to rate their pain, 23% of those studied reported a decrease in pain after listening to music, findings which were quite similar to the ones obtained in the current study as well. Other factors were also assessed by Mary et al., including sedation scale scores for 16% of patients in the study, which demonstrated movement toward the midpoint rating of 3, which describes the patient as calm and cooperative. Of 8 patients in physical restraints upon initiation of music, 2 had their restraints removed after administration of music, factors that were not assessed in our study.

Bernardi et al.[17] studied 24 young, healthy subjects (12 chorists and 12 nonmusician control subjects) who listened in random order to music with vocal (Puccini's “Turandot”) or orchestral (Beethoven's Ninth Symphony adagio) progressive crescendos, more uniform emphasis (Bach's Cantata BWV 169 “Gott Soll Allein Mein Herz haben”), 10-s period rhythmic phrases (Verdi's Arias “Va Pensiero” and “Libiam Nei Lieti Calci”) or silence while HR, respiration, blood pressure, middle cerebral artery flow velocity, and skin vasomotion were recorded. Vocal and orchestral crescendos produced significant correlations between cardiovascular or respiratory signals and musical profile, particularly skin vasoconstriction and blood pressures, proportional to crescendo, in contrast to uniform emphasis, which induced skin vasodilation and reduction in blood pressure.

Grewe et al.[18] observed that some subjects occasionally experienced the sensation of chills during sudden crescendi, together with cardiovascular changes. Yoshie et al.[19] and Nakahara et al.[20] state that music will have beneficial effects on HR, HRV, and anxiety levels in not only skilled pianists but also nonmusicians during both performance of and listening to music. Studies conducted by Bringman et al., and Chan et al. suggests, that musical performance has a greater effect on emotion-related modulation in cardiac autonomic nerve activity than musical perception.[21],[22] Morley and other authors have researched the multi-modal use of music across various fields of Medicine and its implications,[23],[24] while the neuropsychiatric role of music in current times has been critically reviewed by Solanki et al.,[25] a similar conclusion being proposed by authors Heise et al. in their assessment of the role of music in other psychiatric scenarios,[26] parameters different from what were studied in the current research.

Authors Porter et al. have worked on a critical realist evaluation of a music therapy intervention in palliative care, and concluded that music therapy contains multiple mechanisms that can provide physical, psychological, emotional, expressive, existential and social support, which as noted in the current study as well,[27] while its role in postop patients was noted by authors Ames et al., who measured pain, distress, and anxiety scores immediately before and after music listening or controlled resting periods, and recorded total opioid intake every 24 h and during each intervention. After approximately 50-min music listening interventions which were offered 4 times per day (every 4–6 h) during the 48 h of patients' ICU stays, they found no significant difference in pain, opioid intake, distress, or anxiety scores between the control and music listening groups during the first 4 time points of the study. However, a mixed modeling analysis examining the pre-and post-intervention scores at the first time point revealed a significant interaction in the numeric rating scale for pain between the music and the control groups (P = 0.037). The Numeric Rating Score decreased in the music group but remained stable in the control group.[28] Similar results were obtained by authors Vaajoki et al.[29] who documented a decrease in HR and respiratory rate on the second postop day following administration of music therapy to patients.

Authors Bauer et al. conducted an intervention along the same lines and found that the music group also showed lower anxiety and increased satisfaction overall, but these differences were not statistically significant. No major barriers to using the therapy were identified by the authors, similar to our study.[30] Schlaug has given insightful work on how neural plasticity in this network can explain some of the sensorimotor and cognitive enhancements that have been associated with the administration of music.[31] Thus, music therapy assessment has shown a significant improvement of patient outcomes in a critical care setting. Future studies, including a greater number of patients and follow-up evaluations, are needed to confirm promising results observed in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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