Running head: REDUCING ANXIETY 1

Music Therapy Effect on Patients in Critical Care Units

Alexis Daubney

University of South Florida

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Abstract

Clinical Problem: Patients in the intensive care unit (ICU) experience increased anxiety and

stress levels due to the acute nature of their prognosis.

Objective: To determine if the alternative therapy of music intervention will reduce anxiety in

ICU patients. CINAHL and PubMed were accessed to compile randomized controlled trials

(RCT) regarding music therapy in the clinical setting. Key search terms include: music therapy,

intensive care, critical care, anxiety, and stress.

Results: The literature demonstrated a support for music therapy’s positive therapeutic affect on

patient anxiety and stress levels. Anxiety and stress levels were determined through various

methods including physiological response, sedation levels, and pain levels.

Conclusion: Patients who received music therapy had a reduced level of anxiety and stress.

However, not all studies display a statistically significant decrease in anxiety with music therapy

implementation. Further research with regards to ICU patients is required to validate the use of

music therapy within the ICU.

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Music Therapy Effect on Patients in Critical Care Units

In the intensive care setting, increased anxiety and stress levels are common among

patients due to the acute nature of their prognosis. Patients in the intensive care unit may receive

sedation to decrease anxiety, promote comfort, and regulate respirations (Chlan et al., 2013).

Music therapy is an alternative intervention that is a non-pharmacological method that may help

to reduce anxiety (Aktas & Karabulut, 2015). This paper evaluates the effect of music therapy on

patients within critical care units. In intensive care unit (ICU) patient populations, how does

music therapy compared with no alternative interventions affect patient anxiety/stress levels

within 30 days?

Literature Search

CINAHL and PubMed were accessed to compile randomized control trials (RCT)

regarding music therapy in the clinical setting. Key search terms include: music therapy, critical

care, intensive care, anxiety, and stress.

Literature Review

Four RCTs were complied to evaluate music therapy interventions in reducing anxiety

and stress levels among ICU patients (see Table 1). Aktas and Karabulut (2015) utilized a RCT

to study the effects of music therapy on patients who require endotracheal suctioning in the

intensive care unit. This RCT measured pain scores, sedation levels, and physiological

parameters after applying the intervention. There were 66 patients randomly assigned to control

group (n=33) and intervention group (n=33). Results of the study included decreased pain scores

during suctioning among the intervention group (t = −4⋅ 94, p < .01), decreased pain scores 20

minutes post suction (t = 1⋅ 23, p > .05), and a sedation level between the two groups during

suctioning (p < .01). Strengths of this study include random assignment, concealment of
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placement to subjects in the study, adequate follow up, subjects were analyzed in their randomly

assigned group, and the control group of routine care was appropriate. The scales were valid and

reliable to measure sedation and pain in non-verbal sedated patients. The MINDRAY BeneView

T5 Critical Care Monitors were used to collect data for physiological parameters. Patients

involved in the study were found to have similar demographic characteristics (p > .05). Some

weaknesses included the study were a single-blind study, not being blind to researchers making

the pain assessments, and the only music utilized in the study was Sufi music, which is

traditional in Turkey, where the study was conducted.

Alipour et al. (2013) designed a RCT to test the physiological and behavioral responses

to recorded lullabies, silence, and usual care in premature infants in the neonatal intensive care

units. There were 90 patients, all within 28-37 weeks and with Apgar scores ≥7 a few minutes

after birth. The patients were divided into a control group (n=30), lullaby intervention group

(n=30), and silence intervention group (n=30). The researchers found no significant difference in

physiological responses between the lullaby music and routine care subjects. However, the

lullaby intervention group had a significant difference in respiratory rate depending on the time

of the intervention (p=0.03). Respiratory rate (RR) is a factor in the physiological depiction of

anxiety or stress on the body. Strengths of the study included all participants were randomly

assigned to the control or intervention groups, this was a double blind study, subjects were

analyzed in the group they were assigned, follow up assessments were recorded in a span that

could study effects of the intervention. Rationale was also presented for the subjects that were

removed from the study. The instruments measuring heart rate (HR), and oxygen saturation were

reliable and valid to measure levels of anxiety and stress. Some weaknesses included no note of

concealment was given when subjects enrolled in to the study. The subjects in the groups were
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similar in regards to gender; however, were varying in caesarian section/vaginal delivery or

breast fed/formula fed infants. This study also lacked ways to measure “ambient noise” and

monitors to record RR.

Chlan et al. (2013) formed a study to assess for potential therapeutic effects of patient

directed music (PDM) in mechanically ventilated patients. This was a single-blinded RCT, with

a sample size of 373 patients in the ICU; all patients were receiving support from mechanical

ventilation for treatment of respiratory failure. Patients were randomized between group of usual

care (n=125) and two intervention groups: one intervention group that received self-initiated

PDM (n=126), and an intervention group that received self-initiated noise canceling headphones

(NCH) (n=122). This study found that anxiety and sedation intensity were reduced comparing

PDM to usual care (p=.01); however, results were not significant with NCH compared to usual

care. Strengths of this study included RCT design, randomization method, and a description of

patients who discontinued in the study. All subjects were similar at the start of the trial, with

frequency and intensity of sedation among the participants being similar 24 hours prior to the

study. There were no patients excluded in the follow-up. The control group of “usual care” was

appropriate for the comparison between the intervention groups. A weakness was the inability to

blind the ICU nurses, and ranges of indications for the participants to require mechanical

ventilation; however, the majority of the patients experienced respiratory failure.

Han et al. (2010) formed a study to assess for effects of music therapy on the stress and

anxiety levels among mechanically ventilated patients in the ICU. This was a placebo based

RCT. 137 mechanically ventilated patients were randomly assigned within the study, and then

divided into music listening (n=44), headphone (n=44), or control group (n=49). Results of the

study found reduction in the stress response of HR and RR, over time among the intervention
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group (p < 0.001 for both); with an increase in HR and RR among the control group (p < 0.001

and p = 0.032). Some strengths of this RCT include its randomized fashion, all patient’s

completed the study, and patients were followed up with directly post intervention. Some

weaknesses include the specific group of people recruited for the study, and there was a limited

follow up with no multiple music therapy sessions.

Synthesis

Aktas and Karabulut (2015) reported decreased pain scores 20 minutes post suction with

music therapy intervention (t = −4⋅ 94, p < .01). Alipour et al. (2013) found no significant

difference among the lullaby music and routine care subjects; however, the lullaby intervention

group had a significantly different RR depending on the time of the intervention (p=0.03). Chlan

et al. (2013) found that among the PDM intervention group anxiety and sedation intensity was

reduced compared to typical care (p=0.01), but no difference was present between NCH and

usual care. Additionally, Han et al. (2010) reported a significant reduction in physiological stress

responses among the music therapy intervention group with decreases in HR and RR (p < 0.001

for both).

These RCTs demonstrated multiple similarities and differences. All of the studies focused

on critical care patients and the use of music therapy. However, different types of music therapy

were used among the studies to compare against typical care including PDM, NCH, lullaby, and

silence. Those these varied there was an overall difference in the physiological response to stress.

The research demonstrates that music therapy does have an affect on patient’s anxiety and stress

levels. Music therapy is able to positively impact patient outcomes. Additional research is

required to determine the length of intervention required, along with specific research for the

ICU patient.
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Clinical Recommendations

Clinical guidelines regarding music therapy among the ICU patients are not currently

available. The research among ICU patients supports the implementation of music therapy to

improve patient outcomes by decreasing anxiety and stress levels, which are expressed in

physiological processes. Further research is required to determine a clinical guideline for the

implementation of music therapy among the ICU population as a whole. Music therapy is an

alternative medicine therapy that can improve patient outcomes within the acute setting of the

ICU.
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References

Aktas, Y. Y., & Karabulut, N. (2015). The effects of music therapy in endotracheal suctioning of

mechanically ventilated patients. British Association of Critical Care Nurses, 21(1), 44-

52.

Alipour, Z., Eskandari, N., Tehran, H. A., Hossaini, S. K. E., & Sangi, S. (2013). Effects of

music on physiological and behavioral responses of premature infants: A randomized

controlled trial. Complementary Therapies in Clinical Practice, 19(3), 128-132.

Chlan, L. L., Weinert, C. R., Heiderscheit, A., Tracy, M. F., Skaar, D. J., Guttormson, J. L., &

Savik, K. (2013). Effects of patient-directed music intervention on anxiety and sedative

exposure in critically ill patients receiving mechanical ventilator support: A randomized

clinical trial. Journal of the American Medical Association, 309(22), 2335-2344.

doi:10.1001 /jama.2013.5670

Han, L., Li, J. P., Sit, J. W. H., Chung, L., Jiao, Z. Y., & Ma, G. W. (2010). Effects of music

intervention on physiological stress response and anxiety level of mechanically ventilated

patients in China: A randomised controlled trial. Journal of Clinical Nursing, 19, 978-

987. doi: 10.1111/j.1365-2702.2009.02845.x