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Music and Music Therapy in the Medical Radiation Sciences

2018; Elsevier BV; Volume: 49; Issue: 4 Linguagem: Inglês

10.1016/j.jmir.2018.09.009

1939-8654

Johnathan Hewis,

Hearing Loss and Rehabilitation

It's a wintry day in 2005. It's my first day as a senior magnetic resonance imaging (MRI) radiographer in a busy teaching hospital. Our patient is a 14-year-old male who presented for a follow-up MRI brain examination. My new colleague quickly explains the procedure and soon has the patient comfortably inside the bore of the magnet. He then clicks on the CD player and instantly the distinct, rough voice of Bruce Springsteen permeates the control room and our patient's headphones. Maybe our young patient loves listening to aged American rockers? Or, perhaps he would prefer the Arctic Monkeys who happen to be at number 1 this particular week in the UK? “Music to one's ear” certainly can be noise to one of our neighbors. Music is an integral part of our life and the human condition. It is also universal in all cultures [[1]Trappe H.J. Role of music in intensive care medicine.Int J Crit Illn Inj Sci. 2012; 2: 27-31Crossref PubMed Google Scholar]. Within our everyday lives, it can arouse, may enhance our concentration or executive skills, may enhance perceived enjoyment of exercise, can improve our sleep quality, and is an important component of our social and cultural identity and connectedness [[2]Koelsch S. Brain correlates of music-evoked emotions.Nature. 2014; 15: 170-180Google Scholar]. Equally in health care and our departments, sound can be heard in every corner. We play music in our waiting rooms and use music during our procedures, and many of our cutting-edge technologies produce a cacophony of unique, rhythmic sounds. Surgeons in our operating theaters even saw, dissect, or suture to it. But, how much do we really think about music or sound and the potential positive or detrimental effects it may have on our clients or ourselves? This commentary briefly explores the neural correlates and biological and physical effects of music stimuli and aims to provide a snapshot of current music therapy within the medical radiation sciences and the broader health care setting. In ancient Greece, Pythagoras believed that harmonic music had the capacity to soothe individuals with a potential to cure physical and spiritual ailments [[3]Pratt R.R. Jones R.W. Music and medicine: a partnership in history. Springer, Berlin1987: 377-388Google Scholar]. Pythagoras had sufficient insight to understand that music had the power to incite an array of emotions [[3]Pratt R.R. Jones R.W. Music and medicine: a partnership in history. Springer, Berlin1987: 377-388Google Scholar]. Aristotle deduced that music could have a cathartic effect [[4]Ford A. Catharsis: the power of music in Aristotle’s politics.in: Murray P. Wilson P. Music and the Muses: the culture of ‘Mousike’ in the classical Athenian City. 2004Google Scholar], and Plato affirmed that the intrinsic qualities of music had innate but potent spiritual or psychological properties [[5]Whitfield S. Music: its expressive power and moral significance.Music Off. 2010; 1: 11-19Google Scholar]. Modern science continues to grapple with the evolutionary, psychological, cognitive, biochemical, emotional, behavioral, and therapeutic effects of music. From an anthropological perspective, music and human evolution is intimately intertwined. The social functions of music are complex with many theories, but central to all is that music promotes socialization and therefore enhances well-being with evolutionary benefits. Music is part of our rituals, religions, and social events; which is not by accident, but perhaps due to adaptation and natural selection. Darwin believed that songs evolved alongside language and are intimately linked to the function of communication, infant bonding, and sexual selection [[6]Schulkin J. Raglan G.B. The evolution of music and human social capability.Front Neurosci. 2014; 8: 292Crossref PubMed Scopus (31) Google Scholar]. Music is also strongly linked to movement, which is why we cannot help but be physiologically aroused [[2]Koelsch S. Brain correlates of music-evoked emotions.Nature. 2014; 15: 170-180Google Scholar] and covertly tap our foot to that catchy beat. Music can be something very personal and subjective but is typically social; it is communicative, expressive, and created for others. Social behavior and collaboration is therefore a premium cognitive adaptation of humanity enabled in part by music. The creative capability inherent in music is also considered unique to humans due to the required expansion in brain function that has enabled musical instrumentalism [[6]Schulkin J. Raglan G.B. The evolution of music and human social capability.Front Neurosci. 2014; 8: 292Crossref PubMed Scopus (31) Google Scholar]. In turn, musical instruments are an extension of our expression, which help to facilitate social bonds and coordinated behaviors [[7]Brown S. Martinez M.J. Hodges D.A. et al.The song system of the human brain.Cogn Brain Res. 2004; 20: 363-375Crossref PubMed Scopus (154) Google Scholar]. In the modern society, adults are principally motivated to engage with music to experience and regulate emotions and moods [2Koelsch S. Brain correlates of music-evoked emotions.Nature. 2014; 15: 170-180Google Scholar, 8Nightingale C.L. Rodriguez C. Carnaby G. The impact of music interventions on anxiety for adult cancer patients: a meta-analysis and systematic review.Integr Cancer Ther. 2013; 12: 393-403Crossref PubMed Scopus (35) Google Scholar]. Music can evoke changes in activity within core brain structures underlying emotions, which is demonstrated consistently across a broad range of studies [[2]Koelsch S. Brain correlates of music-evoked emotions.Nature. 2014; 15: 170-180Google Scholar]. Research in this area is extensive and diverse. It includes exploration of the effects of auditory stimulus to music, imagining music, and music creation or performance. Listening to music for pleasure and in particular “preferred music” is emotionally arousing. Seminal research by Goldstein [[9]Goldstein A. Thrills in response to music and other stimuli.Physiol Psychol. 1980; 8: 126-129Crossref Scopus (312) Google Scholar] is acknowledged as providing evidence of a definitive link between music and emotion. In controlled experiments, Goldstein was able to elicit thrills by using “moving” music to evoke an emotional response. The neural correlates of music span many cognitive domains including audition, speech, language, memory, and motor expression [[6]Schulkin J. Raglan G.B. The evolution of music and human social capability.Front Neurosci. 2014; 8: 292Crossref PubMed Scopus (31) Google Scholar]. Significant advancement in this field has been enabled by developments in functional and molecular imaging. Positron emission tomography and functional MRI studies demonstrate that listening to music modulates the limbic and paralimbic structures to include the amygdala, nucleus accumbens, hypothalamus, insula, hippocampus, cingulate, and orbitofrontal cortex [2Koelsch S. Brain correlates of music-evoked emotions.Nature. 2014; 15: 170-180Google Scholar, 10Koelsch S. Towards a neural basis of musicevoked emotions.Trends Cogn Sci. 2010; 14: 131-137Abstract Full Text Full Text PDF PubMed Scopus (395) Google Scholar]. These regions are highly associated with emotion and arousal. The superficial amygdala helps process basic social-affective information. The amaygdala is pivotal in emotion regulation. The hippocampus is involved in generation of attachment-related emotions [[2]Koelsch S. Brain correlates of music-evoked emotions.Nature. 2014; 15: 170-180Google Scholar]. Music-evoked pleasure is associated with activation of the dopaminergic mesolimbic reward pathway, a phylogenetically old reward network that functions to ensure the survival of the individual and species. In recent research by Behroozi et al [[11]Behroozi M. Billings B.K. Helluy X. Manger P.R. Gunturkun O. Strockens F. Functional MRI in the Nile crocodile: a new avenue for evolutionary neurobiology.Proc Biol Sci. 2018; 285https://doi.org/10.1098/rspb.2018.0178Crossref Scopus (10) Google Scholar], they performed functional MRI on Nile crocodile brains while listening to sounds and music. They discovered that playing complex patterns such as classical music composed by Johann Sebastian Bach triggered activation patterns similar to that of both birds and mammals. This further supports an ancient evolutionary beginning of the neuronal cognitive processing mechanism of music. The regions of brain activated are influenced by musical characteristics such as tempo and tone and also by factors such as familiarity. Several studies indicate that different areas of the brain are selectively activated as a function of tonality or the character of music. Nemoto et al [[12]Nemoto I. Fujimaki T. Wang L.Q. fMRI measurement of brain activities to major and minor chords and cadence sequences.Conf Proc IEEE Eng Med Biol Soc. 2010; 2010: 5640-5643Google Scholar] observed that minor keys activated larger regions of the brain compared to music in a major key. Trost et al [[13]Trost W. Ethofer T. Zentner M. et al.Mapping aesthetic musical emotions in the brain.Cereb Cortex. 2012; 22: 2769-2783Crossref PubMed Scopus (176) Google Scholar] suggested that high-arousing joyful music engages the insula and left striatum, whereas the right striatum and orbitofrontal cortex is activated by low-arousal nostalgic sad music. Physiologically, research demonstrates that auditory stimulation through music can evoke emotions resulting in changes to hormone secretion, skin properties, and heart and respiratory rate. Dopamine, serotonin, cortisol, and oxytocin are just some important neurotransmitters affected by listening to music. Positron emission tomography imaging has demonstrated that dopamine secretion increases at peak emotional arousal when listening to music [[14]Salimpoor V.N. Benovoy M. Larcher K. et al.Anatomically distinct dopamine release during anticipation and experience of peak emotion to music.Nat Neurosci. 2011; 14: 257-262Crossref PubMed Scopus (928) Google Scholar]. Dopamine is a “mood-enhancing” neurotransmitter associated with “reward” and is deficient in conditions such as depression, schizophrenia, and Parkinson's disease [[15]Kraus N. Chandrasekaran B. Music training for the development of auditory skills.Nat Rev Neurosci. 2010; 11: 599-605Crossref PubMed Scopus (671) Google Scholar]. Similar to food and sex, listening to your favorite music can be very pleasurable. It has also been found that listening to music results in lower secretion of the “stress hormone” cortisol, thereby reducing anxiety [[2]Koelsch S. Brain correlates of music-evoked emotions.Nature. 2014; 15: 170-180Google Scholar]. Cortisol has wide reaching effects on the nervous, circulatory, immune, digestive, and skeletal systems [[6]Schulkin J. Raglan G.B. The evolution of music and human social capability.Front Neurosci. 2014; 8: 292Crossref PubMed Scopus (31) Google Scholar]. Elevated cortisol levels can negatively impact on learning and memory; reduce your immunity levels and bone density; result in weight gain, increased blood pressure, and cholesterol levels; and increase your risk of heart disease. Other physiological changes induced by auditory music stimuli include enhanced, albeit temporarily spatial reasoning, information processing, attention, and memory. Musician brains are also distinctly different compared with those of nonmusicians. Musical training can enhance auditory capability, and early musical training has been found to improve linguistic expression in children [[16]Marin M.M. Effects of early musical training on musical and linguistic syntactic abilities.Ann N Y Acad Sci. 2009; 1169: 187-190Crossref PubMed Scopus (12) Google Scholar]. Structural and functional abnormities in the limbic and paralimbic brain structures are common characteristics of several neurological and psychiatric disorders including depression, schizophrenia, neurodegenerative disease, posttraumatic stress disorder, and Parkinson's disease [[2]Koelsch S. Brain correlates of music-evoked emotions.Nature. 2014; 15: 170-180Google Scholar]. The neurobiological correlates of listening to music demonstrate changes to these structures, which provide supporting evidence for the therapeutic effects of music. Hillecke et al [[17]Hillecke T. Nickel A. Bolay H.V. Scientific perspectives on music therapy.Ann N Y Acad Sci. 2005; 1060: 271-282Crossref PubMed Scopus (84) Google Scholar] proposed five modulating factors that contribute to the effects of music therapy. These include modulation of attention thus distracting from other negative stimuli such as pain; emotion modulation through activation of limbic and paralimbic brain structures; modulation of cognition including how memory is processed in relation to music; and behavioral or communication modulation [[2]Koelsch S. Brain correlates of music-evoked emotions.Nature. 2014; 15: 170-180Google Scholar]. Villarreal et al [[18]Villarreal E.A. Brattico E. Vase L. et al.Superior analgesic effect of an active distraction versus pleasant unfamiliar sounds and music: the influence of emotion and cognitive style.PLoS One. 2012; 7: e29397Crossref PubMed Scopus (48) Google Scholar] theorized that familiarity with music drives emotional mechanisms to help modulate negative stimuli, whereas in unfamiliar music, any analgesic mechanism may be more cognitive than emotional. The literature provides extensive and diverse examples of therapeutic effects of music therapy. A small selection of recent studies are discussed in the following sections as exemplars. van der Heijden et al [[19]van der Heijden M.J.E. Jeekel J. Rode H. et al.Can live music therapy reduce distress and pain in children with burns after wound care procedures? A randomized controlled trial.Burns. 2018; 44: 823-833Crossref Scopus (16) Google Scholar] conducted a blinded randomized controlled trial evaluating live music therapy in children with burns receiving wound care. The intervention group received 3–5 minutes of live music therapy immediately after their wound care procedure. Self-reported distress was significantly reduced in children older than 5, although the intervention was not found to be effective in reducing distress or pain in younger children. Listening to preferred (favorable) music during colonoscopy among an elderly population was found to reduce the perception of pain during the procedure [[20]Jangsirikul S. Patcharatrakul T. Ridtitid W. et al.The effects of music therapy in the patients with functional bowel symptoms undergoing colonoscopy.Gastrointest Endosc. 2018; 87: AB513-AB514Google Scholar]. Wang et al [[21]Wang C.F. Sun Y.L. Zang H.X. Music therapy improves sleep quality in acute and chronic sleep disorders: a meta-analysis of 10 randomized studies.Int J Nurs Stud. 2014; 51: 51-62Crossref PubMed Scopus (78) Google Scholar] performed a metal-analysis of 10 randomized music therapy studies. They found that music therapy can assist in improving sleep quality for acute and chronic sleep disorders. Chronic sleep disorders are associated with adverse health issues such as cardiovascular disorders, and pharmacological therapy is widely used but with potential side effects. A more recent systematic review by Feng et al [[22]Feng F. Zhang Y. Hou J. et al.Can music improve sleep quality in adults with primary insomnia? A systematic review and network meta-analysis.Int J Nurs Stud. 2018; 77: 189-196Crossref Scopus (58) Google Scholar] also concluded that music therapy is a suitable first-line nonpharmacological intervention for insomnia in adults. McCaffrey [[23]McCaffrey T. Evaluating music therapy in adult mental health services: Tuning into service user perspectives.Nordic J Music Ther. 2018; 27: 28-43Google Scholar] used an interpretive phenomenological qualitative approach to evaluate service user perspective of music therapy in adult mental health services. The study found that music therapy provided an opportunity to be “meaningfully occupied” and that “group music therapy fosters reciprocity.” The study also highlighted that lack of music instruction was a cause of frustration for some participants. Meaningful occupation has been identified as a key component of recovery in mental health. In a randomized controlled trial reviewing music-supported therapy in subacute stroke patient rehabilitation, Grau-Sanchez et al (2018) [[24]Grau-Sanchez J. Duarte E. Ramos-Escobar N. et al.Music-supported therapy in the rehabilitation of subacute stroke patients: a randomized controlled trial.Ann N Y Acad Sci. 2018; 1423: 318-328Google Scholar] found that mood and quality of life were improved for participants receiving music intervention. Music therapy also significantly increased patient's intrinsic motivation to engage with associated improvements in motor outcomes. Gallagher et al [[25]Gallagher L. Lagman R. Rybicki L. Outcomes of music therapy interventions on symptom management in palliative medicine patients.Am J Hosp Palliat Med. 2018; 32: 250-257Google Scholar] conducted a large retrospective study of the effects of music on symptom management in palliative medicine patients using observational behavioral data. Study findings include improvements in pain, anxiety, depression, shortness of breath, and mood. It is important to note several limitations in the study design that decrease internal validity. Anxiety may amplify pain levels and prolong cast room procedures with additional reductions in comfort, willingness, and pleasure. Tolunay et al [[26]Tolunay T. Bicici V. Tolunay H. et al.Rhythm and orthopedics: the effect of music therapy in case room procedures, a prospective clinical trial.Injury. 2018; 49: 593-598Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar] found music therapy to be a safe, noninvasive intervention that decreased anxiety and anxiety-related cardiac arrhythmia and increased patient satisfaction during cast room procedures in adult orthopedic patients. The volume of research is far more limited within our own field. In a nuclear medicine context, Tan et al [[27]Tan Y.Z. Ozdemir S. Temiz A. Celik F. The effect of relaxing music on heart rate and heart rate variability during ECG GATED-myocaridal perfusion scintigraphy.Complement Ther Clin Pract. 2015; 21: 137-140Crossref PubMed Scopus (22) Google Scholar] conducted an observational study evaluating whether there was an effect on heart rate and heart rate variability due to listening to relaxing music during electrocardiography-gated myocardial perfusion scintigraphy compared with a control group. Owing to the prolonged scan position and the need for immobilization, patients can frequently feel uncomfortable and anxious, which can adversely impact the gating. Tan et al found a statistically significant reduction in heart rate in the music-receiving cohort that improved gating in this study. Walworth [[28]Walworth D. Effect of live music therapy for patients undergoing magnetic resonance imaging.J Music Ther. 2010; XLVII: 335-350Google Scholar] investigated the effect of live music therapy on 88 patients undergoing MRI. This study found a significant improved perception of satisfaction for patients who received live music intervention. Additional benefits included a reduction in scan repeats due to movement with a subsequent reduction in the overall scan time. Ma et al [[29]Ma D. Pierre E.Y. Jiang Y. et al.Music-based magnetic resonance fingerprinting to improve patience comfort during MRI examinations.Magn Reson Med. 2016; 75: 2303-2314Google Scholar] developed a novel approach to mitigating the acoustic noise created by MRI gradients during scanning by reverse engineering pulse sequences from a recording of Yo-Yo Ma playing Bach's cello suite. This technique uses and adapts the relatively recent acquisition method MR fingerprinting. The MRI scanner reproduces the cello music as an integral component of the noises created by the gradients during the MRS-Music scan. Satisfaction was reportedly improved; however, this was conducted in a very small and healthy volunteer sample. This technique demonstrates how emerging technology and approaches can be combined with strategies to potentially improve patient experience and acceptance. Ryu et al [[30]Ryu M. Park J.S. Park H. Effect of sleep-inducing music on sleep in persons with percutaneous transluminal coronary angiography in the cardiac care unit.J Clin Nurs. 2012; 12: 728-735Google Scholar] investigated the effects of sleep-inducing music on sleep patterns in percutaneous transluminal coronary angiography recipients in the cardiac care unit compared with a control group who wore ear plugs only. Sleep-inducing music significantly improved both sleep quantity and quality over the control group. Sleep and absolute bed rest is an important requirement after the procedure, and the study found that music therapy helped negate the use of often addictive medication to control sleeping problems that can also have undesirable effects on this particular population. Anxiety is a common side issue for many patients who undergo radiation therapy. Hanedan [[31]Hanedan U. Influence of music therapy on the state of anxiety during radiotherapy.Turkish J Oncol. 2017; 32: 141-147Google Scholar] evaluated the effect of patient's preferred music therapy on their anxiety state during radiotherapy. The nonrandomised Turkish cohort study compared the music intervention to a control cohort who received no music therapy during their treatment. Anxiety was assessed quantitatively using Spielberg's State Anxiety Inventory. Patients receiving the music therapy had a lower anxiety level after treatment than before treatment compared with the control group who had a higher anxiety level after radiotherapy than before commencement of the treatment. A recent randomized control trial [[32]Alacantara-Silva T.R. de Freitas-Junior R. Freitas N.M.A. et al.Music therapy reduces radiotherapy- induced fatigue in patients with breast or gynecological cancer: a randomized trial.Integr Cancer Ther. 2018; 17: 628-635Google Scholar] investigated the influence of music therapy on fatigue, depression, and life quality for women undergoing radiotherapy for malignant breast or gynecological neoplasia. Fatigue is a frequent symptom in cancer and radiotherapy. The music therapy was administered in 30–40 minute sessions, bi-weekly, by a trained music therapist using a repertoire of baroque, classical, and romantic period music. As a consequence of music therapy, the study found that the intervention cohort had decreased fatigue and significantly reduced depression that was likely associated with an increase in quality of life. These corroborate a previous published meta-analysis that suggests music therapy can reduce fatigue and increase quality of life for cancer patients [[33]Bradt J. Dileo C. Magill L. Teague A. Music inteventions for improving psychological and physical outcomes in cancer patients.Cochrane Database Syst Rev. 2016; : CD006911Google Scholar]. Both of these radiation therapy studies demonstrate potential benefits of including music therapy as an integrative intervention that can be included as part of holistic patient care to help alleviate anxiety, depression, and fatigue, and increase quality of life. It is important to note that both the studies were nonblinded as an important methodological limitation. The quality and size of MRS dedicated music therapy studies are currently somewhat limited. Wider health care research using music therapy interventions would indicate that there is significant potential for further research and practice within the MRS field. There would also appear to be a methodological gap with limited literature using qualitative research methods to explore patient experience in relation to music therapy. Within the MRS profession, there is extensive and diverse opportunity for further research and practice in relation to the use of music and sound. I am not suggesting that all radiation therapy departments suddenly go out and buy a selection of floor toms and start an adjunct therapy drumming circle or that every MRI department pays for a concert violinist to sit in the corridor bowing out soothing, classical tones. Sarcasm aside, a growing body of knowledge indicates that there is a significant potential to incorporate aspects of music therapy within our environments for the benefits of both our clients and the workforce. Herein lies a dichotomy of sorts. Cutting-edge advances in functional and molecular imaging techniques continue to help define and elucidate our understanding of the neurobiological effects of music. Yet, for the everyday clients visiting our departments, are they all benefitting from this wealth of emerging knowledge and understanding? Enabling individuals to have a choice so our clients can listen to “preferred music” is one easy, everyday piece of good practice that we can all adopt immediately. Music is far from a simple construct; it is a pervasive, core human experience intertwined with key basic human needs resulting directly from thousands of years of evolution. Music therapy is no panacea, but has a great deal to offer. It is important to use trained and experienced music therapists for formalized music-based interventions. In the context of a modern patient-centered health care system with a movement toward personalized medicine, we should contemplate how we use this deeply human and cost-effective intervention to help increase well-being and satisfaction. Download .xml (.0 MB) Help with xml files Data Profile