European Journal of Oncology Nursing 17 (2013) 436e441

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European Journ...
L.-C. Chen et al. / European Journal of Oncology Nursing 17 (2013) 436e441

music therapy into a pediatric radiotherapy wa...

L.-C. Chen et al. / European Journal of Oncology Nursing 17 (2013) 436e441

researchers followed the same procedure a...
L.-C. Chen et al. / European Journal of Oncology Nursing 17 (2013) 436e441

observed in the music and control groups. Howe...

L.-C. Chen et al. / European Journal of Oncology Nursing 17 (2013) 436e441

accelerates breathing rate and increases ...
L.-C. Chen et al. / European Journal of Oncology Nursing 17 (2013) 436e441
O’Callaghan, C., Sexton, M., Wheeler, G., 2007....
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Fifteen minute music intervention reduces pre-radiotherapy anxiety


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Fifteen minute music intervention reduces pre-radiotherapy anxiety

  1. 1. European Journal of Oncology Nursing 17 (2013) 436e441 Contents lists available at SciVerse ScienceDirect European Journal of Oncology Nursing journal homepage: Fifteen-minute music intervention reduces pre-radiotherapy anxiety in oncology patients Lee-Chen Chen a, Tze-Fang Wang b, *, Yi-Nuo Shih c, Le- Jung Wu d a Department of Nursing, Far Eastern Memorial Hospital, Taipei, Taiwan School of Nursing, National Yang Ming University, No. 155, Section 2, Li-Nong St, Beu-Tou District, Taipei 112, Taiwan c Department of Occupational Therapy, College of Medicine, Fu Jen Catholic University, Xinzhuang City, Taipei County, Taiwan d Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei, Taiwan b a b s t r a c t Keywords: Anxiety Music therapy Oncology Radiotherapy State-Trait Anxiety Inventory Purpose: Oncology patients may respond to radiation treatment with anxiety expressed as stress, fear, depression, and frustration. This study aimed to investigate effects of music intervention on reducing pre-radiotherapy anxiety in oncology patients. Methods: Quasi-experimental study with purposeful sampling was conducted in the Department of Radiation Oncology, at Far Eastern Memorial Hospital, Taipei, Taiwan. Subjects were assigned into a music group (n ¼ 100) receiving 15 min of music therapy prior to radiation and a control group (n ¼ 100) receiving 15 min rest prior to radiation. Both groups were evaluated for pre- and post-test anxiety using the State-Trait Anxiety Inventory. Physiological indicators of anxiety were measured pre- and post-test. Results: Baseline State/Trait scores and vital signs were comparable between groups (P > 0.05). Mean change in pre- and post-test State/Trait scores showed significant decreases from baseline to post-test in both groups (all P < 0.05). A statistically significant difference was observed between music therapy and control groups in mean change of State anxiety scores (mean decreases 7.19 and 1.04, respectively; P < 0.001) and Trait anxiety scores (mean decreases 2.77 and 1.13, respectively; P ¼ 0.036). In vital signs, both groups had significant decreases in pre- and post-test heart rate and respiration rate (P < 0.05). A statistically significant difference in mean change of systolic pressure was found between music and control groups (À5.69 Æ 0.41 mmHg vs. À0.67 Æ 1.29 mmHg, respectively; P ¼ 0.009). Conclusions: Music therapy decreased State anxiety levels, Trait anxiety levels and systolic blood pressure in oncology patients who received the intervention prior to radiotherapy. Ó 2012 Elsevier Ltd. All rights reserved. Introduction Oncology patients often respond to their cancer diagnosis and treatment, including chemotherapy (Lin et al., 2011) and radiation (Chaturvedi et al., 1996; Clark et al., 2006), with emotional symptoms such as anxiety, depression and stress, as well as fear, frustration, loneliness and feelings of loss of control (Magill, 2006). Music therapy is an evidence-based complementary therapy commonly used in integrative oncology treatment programs (Magill, 2006; Hilliard, 2006). Music therapy has been applied successfully in various clinical settings to help reduce anxiety. Music has improved mood and decreased anxiety and pain associated with surgery, medical procedures, and chronic conditions, as * Corresponding author. Tel.: þ886 2 28267907; fax: þ886 2 28262487. E-mail address: (T.-F. Wang). 1462-3889/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. well as helping to improve quality of life during end-of-life care (Kemper and Danhauer, 2005). In integrative oncology, music therapy has been introduced to treat multiple symptoms such as pain, mood disturbances, and communication issues; besides ameliorating pain and anxiety symptoms, it specifically reduced effects of noxious stimuli and enhanced mood and overall feelings of comfort and sense of control (Magill, 2006). Music therapy has also effectively reduced chemotherapy-induced anxiety (Bulfone et al., 2009; Ferrer, 2007; Lin et al., 2011). Acknowledging the high level of fear and anxiety that may be present before and during radiation treatments, Smith et al. (2001) suggested that modifying the treatment environment is one way to address the psychological well-being of patients with cancer, and further suggested that music therapy was an effective therapeutic intervention to moderate treatment-related anxiety (Smith et al., 2001). Music therapy significantly reduced anxiety, current distress and weekly distress in response to radiotherapy (Clark et al., 2006). Introducing
  2. 2. L.-C. Chen et al. / European Journal of Oncology Nursing 17 (2013) 436e441 music therapy into a pediatric radiotherapy waiting area reduced patients’ anxiety and stress as well as that of family members and staff involved in their healthcare program (O’Callaghan et al., 2007). In a mixed-methods analysis, measured effects of a computerbased music CD created by pediatric oncology patients undergoing initial radiotherapy revealed that 67% of children receiving standard care used social withdrawal as a coping mechanism for treatment-related distress but no children in the music therapy group withdrew socially (Barry et al., 2010). Although both quantitative results (Smith et al., 2001; Clark et al., 2006) and qualitative outcomes (O’Callaghan et al., 2007) of music therapy were promising in terms of reducing anxiety and stress for patients receiving radiation treatments, the music therapy procedures described in these previous studies were diverse. The timing of receiving music therapy in relationship to radiation was also not consistent with the various methods in previous studies. O’Callaghan offered music therapy when the patients were waiting for medical consultations and radiotherapy treatments, Smith’s group allowed the patients to listen to the music during their radiation therapy simulation appointment and also during their daily radiation treatments, and Clark’s group directed the music therapist to instruct participants to listen to the music at any time during the course of therapy. We hypothesized that music therapy received in the Radiology waiting room may be able to reduce anxiety and improve anxietyrelated physiological parameters in oncology patients prior to undergoing radiotherapy. Therefore, we aimed to evaluate the physiological (e.g., blood pressure) and psychological effects (e.g., anxiety) of a single music intervention delivered to patients prior to a single radiation treatment. Patients and methods Design A quasi-experimental study was conducted. Pre- and post-test data were collected from a purposeful sample between April 1, 2011 and October 31, 2011 at the Department of Radiation, Oncology, at Far Eastern Memorial Hospital, Taipei, Taiwan. The internal review board of the hospital reviewed the study protocol and approved the study. 437 Main outcome measures Primary outcomes Scores from the self-reported State-Trait Anxiety Inventory (Speilberger et al., 1983) were the primary outcome measures applied in the experimental and control groups. Secondary outcomes Blood pressure, heart rate, respiratory rate, and fingertip oxygen saturation (determined from peripheral circulation) were measured in experimental and control groups using a Philips SureSignsÒ VM6 patient monitor (Philips Medical Systems, Inc., Cleveland, OH, USA). State-Trait Anxiety Inventory (STAI) The State-Trait Anxiety Inventory (STAI) (Speilberger et al., 1983) is a self-reported questionnaire, Form Y, which is divided into two sections of 20 statements each based on two categories of anxiety: State anxiety (S-Anxiety) or Trait anxiety (T-Anxiety). State-Anxiety refers to the subjective and transitory feeling of tension, nervousness, and worry experienced at a given time. Trait-Anxiety refers to a relatively general experience of anxiety as the individual’s tendency to perceive and respond to stressful situations with increased intensity (Speilberger et al., 1983). Form Y, which replaces the pre-1983 STAI Form X (Spielberger et al., 1970) clearly differentiates temporary State anxiety from the more general and longstanding Trait anxiety in measuring anxiety in adults. Each of the 40 statements has four possible responses: The STAI is languageappropriate for individuals with at least a sixth grade reading level. The median Cronbach’s alpha reliability coefficients for the State and Trait scales (Form Y) are 0.92 and 0.90, respectively. Item remainder correlation coefficients for both scales (Form Y) have consistently been above 0.90 (Tluczek et al., 2009). A Chinese version of the STAI was developed and tested on junior high school students (Chung and Long, 1984). It had a test-retest reliability of 0.74 (n ¼ 259) and 0.76 (n ¼ 256) for STAI-state (S-anxiety) and STAI-trait (T-anxiety), respectively. In another validation study of the Chinese version of STAI among 737 and 725 junior high school students, Cronbach’s alpha for S-Anxiety and T-Anxiety were 0.86 (n ¼ 737) and 0.90 (n ¼ 725), respectively. Procedure of musical intervention Participants Patients who were scheduled to receive a treatment protocol of radiation therapy lasting about 5 weeks or more and who were at least 18 years old, were purposefully sampled by physicians from the Radiation Oncology Department of Far Eastern Memorial Hospital, Taipei, Taiwan, and were then referred to our research team and invited to participate in this study. Inclusion criteria were: patients with sufficient literacy to respond to a written questionnaire. Patients with prior diagnosis of anxiety or psychological disorder, those receiving anti-anxiety or anti-depressant medications, or those with hearing deficit were excluded. A total of 209 patients who met the inclusion criteria were enrolled. Nine of these patients withdrew at the early stage for reasons of severe clinical condition or personal reasons, and 200 patients were retained for analysis. No data were collected from the Radiation Oncology Department regarding chemotherapy or surgical treatment that patients may have received before radiotherapy. The 200 patients were randomly assigned by simple random sampling (every other patient) into two groups, a music therapy group (n ¼ 100) and a control group (n ¼ 100). After the study was explained thoroughly for each group (separately since instructions were different) by a research assistant, all included participants provided signed informed consent. The intervention was conducted by two investigators from our research team, one a clinical practitioner and the other a psychological testing professional, who measured patients’ physiological conditions (blood pressure, heart rate, respiratory rate, and blood oxygen concentration) and conducted the State-Trait Anxiety Inventory test, respectively. Patients decided individually on which day of their radiation treatment schedules their music intervention should be conducted. Patients were asked to fill out the personal information form (demographics) and the State-Trait Anxiety Inventory Form Y with two scales prior to receiving the first measurement of physiological conditions. Then patients were instructed to sit comfortably on a couch in the radiology waiting room and to wear headphones and listen to slow-paced, soft, melodic music at low volume with consistent tempo and dynamics and an average 60e80 beats per minute. Subjects chose their own favorite music tracks from a selection of old songs in Mandarin, Mandarin pop, traditional Taiwanese songs, Western music (country and western), and classical music (e.g., chamber music with string instruments). Patients were able to adjust the volume and then listen to 15 min of music. Researchers again measured patients’ physiological conditions, and asked the patient to fill out the STAI anxiety scales once again. For the control group,
  3. 3. 438 L.-C. Chen et al. / European Journal of Oncology Nursing 17 (2013) 436e441 researchers followed the same procedure as above but without providing music therapy. Instead patients were instructed to sit comfortably on the radiology waiting room couch (a separate room from the music therapy group but similar facility) and to rest for 15 min. These participants were not aware if they were in the intervention or control group until after the 15-min rest period in which they may have anticipated receiving music but did not; i.e., they were blinded to the assignment, thereby avoiding Hawthorne effect. Measurement of patients’ physiological conditions and the STAI test were both done before and after a 15-min rest period. Power consideration Based on G*Power 2 software, an effect size of 0.40 was used for power analysis (power 0.80, alpha 0.05), and sample size requirement was 199. We estimated a dropout rate of 5% and therefore aimed to recruit 209 patients. Statistical analysis Categorical variables were analyzed by Chi-square analysis/ Fisher’s exact test. Paired t tests in both groups were employed to analyze pre- and post-test differences in primary and secondary endpoints. Independent two-sample t tests were used to detect between-group differences in baseline to post-intervention changes in primary and secondary endpoints. Continuous data were presented as mean Æ standard deviation, while categorical data were represented by a number and percentage. All statistical assessments were two-tailed and considered significant at the 0.05 level. Statistical analyses were performed using SPSS 15.0 statistics software (SPSS Inc, Chicago, IL). Results Demographic data and baseline characteristics of music group and control group subjects were comparable (Table 1). No significant differences were found between groups in the pre-test (baseline) STAI-S/STAI-T scores and vital signs before intervention (P > 0.05). However, a significant difference was found in oxygen saturation between the two groups (P ¼ 0.005). Mean changes in STAI-S and STAI-T scores from baseline to posttest are shown in Table 2. Significant decreases were observed in STAI-S and STAI-T scores from baseline to post-test in both groups (all P < 0.05) after intervention. Also, statistically significant differences were observed in mean change of STAI-S and STAI-T scores between the music and control groups (P < 0.05). A mean decrease of 7.19 for STAI-S score was found in the music intervention group, compared to a mean decrease of 1.04 in the control group. Also, a mean decrease of 2.77 for STAI-T score was found in the music intervention group compared to a mean decrease of 1.13 in the control group. Mean changes in pre- and post-test vital signs are also shown in Table 2. Significant decreases in heart rate and respiration rate from baseline to post-test were observed in both groups (P < 0.05). In addition, a statistically significant difference in mean change of systolic pressure was noted between the music therapy and control groups (À5.69 Æ 0.41 mmHg vs. À0.67 Æ 1.29 mmHg, respectively; P ¼ 0.009) after the intervention. No significant difference between two groups was found in mean change of oxygen saturation before and after the music intervention (Table 2). Discussion In this study, we investigated the effects of music intervention on reducing pre-radiotherapy anxiety in oncology patients. A music Table 1 Basic demographic parameters and baseline characteristics of study population (n ¼ 200). Music group (n ¼ 100) Age (Years)1 Gender, n (%)2 Male Female Education, n (%)2 Elementary school High school University Type of cancer, n (%)3 Head and neck Gynecological Breast Digestive tract Lung Prostate Tumor stage, n (%)2 I II III IV Medication history, n (%)2 Hypertension Heart disease Radiotherapy4 STAI1 S-Anxiety T-Anxiety Heart rate (beat/min)1 Systolic pressure (mmHg)1 Diastolic pressure (mmHg)1 Respiration rate (breaths/min)1 Oxygen saturation (%)1 Control group (n ¼ 100) P-valuea 55.06 Æ 13.50 55.66 Æ 11.41 0.735 64 (64.0) 36 (36.0) 57 (57.0) 43 (43.0) 0.311 31 (31.0) 54 (54.0) 15 (15.0) 37 (37.0) 58 (58.0) 5 (5.0) 0.218 34 6 17 21 6 13 (34.0) (6.0) (17.0) (21.0) (6.0) (13.0) 33 17 21 16 6 5 (33.0) (17.0) (21.0) (16.0) (6.0) (5.0) 0.111 18 29 35 18 (18.0) (29.0) (35.0) (18.0) 17 16 36 31 (17.0) (16.0) (36.0) (31.0) 0.064 23 (23.0) 10 (10.0) 5 (3, 9) 24 (24.0) 12 (12.0) 5 (3, 9) 0.868 0.651 0.867 42.63 Æ 11.01 41.94 Æ 10.74 85 Æ 13 125.9 Æ 18.5 73.8 Æ 14.2 18 Æ 2 98.0 Æ 1.2 42.03 Æ 10.41 42.35 Æ 9.24 84 Æ 12 126.8 Æ 20.4 74.8 Æ 12.6 19 Æ 2 97.5 Æ 1.2 0.693 0.773 0.970 0.753 0.615 0.050 0.005* Data presented as 1mean Æ S.D., 2,3number (percentage) and 4median (IQR). STAI: State-Trait Anxiety Inventory. * Indicates a significant difference between music and control groups, P < 0.05. a P-values based 1independent two-sample t test, 2Chi-square test, 3Fisher’s exact test and 4ManneWhitney U test. group received 15 min of music therapy prior to undergoing one radiation treatment and a control group only had 15 min of rest before radiation. Significant differences were shown in pre- to posttest State and Trait scores in both the music group and the control group. More importantly, a significant increase in mean change was observed in the music group in STAI-S and STAI-T scores from baseline to post-test, indicating that music therapy was effective in reducing anxiety symptoms. In terms of vital signs, significant preto post-test decreases in heart rate and respiration rate were Table 2 Comparative primary endpoint (mean change of anxiety score from baseline) and secondary endpoints (mean change in vital signs from baseline) between the two groups (n ¼ 200).a Mean change from baseline Primary endpoint STAI-S STAI-T Secondary endpoints Heart rate (beat/min) Systolic pressure (mmHg) Diastolic pressure (mmHg) Respiration rate (breaths/min) Oxygen saturation (%) Music group (n ¼ 100) Control group (n ¼ 100) P-value À7.19 Æ 0.94** À2.77 Æ 0.66** À1.04 Æ 0.41** À1.13 Æ 0.42** <0.001* 0.036* À4.40 À5.69 À1.71 À0.65 À0.01 À3.28 À0.67 À1.41 À0.46 À0.06 Æ Æ Æ Æ Æ 0.77** 0.41** 0.89 0.13** 0.13 Æ Æ Æ Æ Æ 1.10** 1.29 0.86 0.14** 0.13 0.405 0.009* 0.809 0.319 0.779 * Significant difference between two groups using independent two-sample t test, P < 0.05. ** Significant difference between pre and post intervention using paired t test, P < 0.05. STAI: State-Trait Anxiety Inventory. a Data are presented as mean Æ S.E.
  4. 4. L.-C. Chen et al. / European Journal of Oncology Nursing 17 (2013) 436e441 observed in the music and control groups. However, a statistically significant difference between groups was only noted in mean change of systolic blood pressure, which was markedly reduced in subjects receiving music therapy compared to controls. These findings were consistent with a previous report in Taiwan that music therapy was more effective in reduction of postchemotherapy anxiety than verbal relaxation, and the reduction in anxiety was associated with a significant increase in skin temperature. Patients with higher State anxiety also responded more to therapy (Lin et al., 2011). The conditions of music intervention may result in different outcomes. A self-selected music listening intervention among patients undergoing radiation therapy showed a significant correlation between the dose of music therapy (i.e., number of times per week music was used) and changes in treatment-related distress (Clark et al., 2006). Based on our preliminary study, multiple interventions usually resulted in considerable missing data. Besides, in this study, it was not possible to follow all 200 study subjects at every appointment of radiotherapy. Therefore, we decided to perform the intervention once prior to radiotherapy. This agreed with a comprehensive review study showing that the majority of music therapy studies provided only one music session to participants with pre- and post-intervention evaluation (Bradt and Dileo, 2009). In the present study, each participant listened to music for 15 min prior to one of their scheduled radiation treatments; although participants could have their music therapy conducted at different stages of their treatment, all measurements (physiological and STAI tests) were done pre- and post- a single treatment, avoiding any impact on overall results. The 15-min timing also agrees with the intervention times applied in previous studies. In one study, patients received music intervention during their daily radiation treatments, which lasted an average of 15 min each (Smith et al., 2001). A 15-min self-selected music intervention significantly reduced patients’ anxiety prior to gastrointestinal procedures (Hayes et al., 2003). In addition, in the present study, all patients received the 15-min listening period without interruption by other people or medical staff and without falling asleep during the intervention session. Exploring and comparing the effects of longer music exposure at different time points may be valuable in future study. A recent review of music therapy studies suggested that more research is needed that examines relationships between frequency and duration of music interventions and differences in effects obtained (Bradt et al., 2011). The STAI Form Y (Speilberger et al., 1983) clearly differentiates between the temporary, current condition of “State-anxiety” (Sanxiety) and the more general and long-standing “Trait-anxiety” (Tanxiety). Argstatter et al. (2006) demonstrated that patients with high levels of state and trait anxiety have much greater benefits from music interventions than those with low levels of anxiety (Argstatter et al., 2006). In the present study and others (Lin et al., 2011; Smith et al., 2001), S-anxiety responded more to the effects of music therapy and anxiety levels were reduced significantly. However, differences between intervention and control groups were less in the T-anxiety scores as a result of music intervention. Sanxiety refers to the subjective and transitory feeling of tension, nervousness, and worry (Fountoulakis et al., 2006), factors that may be more sensitive to the music intervention. T-anxiety refers to relatively stable individual differences in anxiety proneness as a personality trait (Fountoulakis et al., 2006) and may be less affected by the music intervention. These preliminary impressions suggest a need for additional study of the effects of music therapy in terms of differential effect between S-anxiety and T-anxiety. Our State anxiety results are also similar to those of a study on early music therapy intervention for patients with high levels of 439 anxiety before and during radiotherapy (Smith et al., 2001). In that study, experimental group patients listened to their preferred music before and during simulation and daily treatments over the planned course of therapy. Trends in State anxiety scores suggested the benefit of music therapy delivered pre-treatment, although lack of significance in between-group differences indicated that music did not moderate anxiety levels during treatment. Still, the authors suggested that music therapy is a simple, low-cost intervention that may help to moderate high levels of State anxiety during simulation and the early part of radiation therapy (Smith et al., 2001). The timing of music therapy and anxiety measurement may also be an important factor. In the present study, we only provided 15 min of music therapy once to subjects prior to radiotherapy. Measures of anxiety and vital signs, as physiological indicators of anxiety, were evaluated pre- and post-test, but not during or after radiotherapy. However, music intervention applying 30 min of music prior to radiation only slightly reduced patients’ anxiety scores and physiological indices after radiation without statistical significance (Zhao et al., 2008). Smith et al. (2001) found no benefit of music therapy when measuring anxiety during radiation (Smith et al., 2001), but another study conducted by Clark et al. (2006) found significant between-group differences in anxiety, current distress (i.e., State anxiety), and weekly distress measured at baseline, mid-treatment, and post-treatment in subjects who listened to self-selected music weekly for the course of radiotherapy (Clark et al., 2006). In that study, anxiety and treatmentrelated distress were reduced but physical symptoms such as fatigue and pain were not affected during the course of radiotherapy. Music therapy provided during the therapy also had a positive effect on post-chemotherapy anxiety; patients with initial high State anxiety scores who received music therapy had a greater drop in post-chemotherapy anxiety than did normal State anxiety subjects (Lin et al., 2011). These results suggest a need for further evaluation of the effectiveness of music therapy received pre-, during and post-treatmentdnot just evaluation of postmusic-intervention. Dileo and Bradt (2007) clearly distinguished between music interventions conducted by medical professionals, or so-called “music medicine,” and those conducted by trained music therapists. Music medicine is typically passive listening to pre-recorded music, while music therapy requires a therapeutic process and the use of live music experiences (Dileo and Bradt, 2007). According to professional music therapists, many types of music therapy may be applied, including active (e.g., participation in chime or drum circles, music meditation, sing-along or song writing) and passive (e.g., recorded music or live performance); these techniques are guided by music therapists and include feedback and measurements such as vital signs and self-reported changes in distress levels (Mahon and Mahon, 2011). The particular type of music therapy may produce different responses in different situations. Differences in study results may be attributable to study design, type and frequency of music intervention, and outcome measurements (Bradt and Dileo, 2009). Other influences on the response to music, and subsequently to music therapy effects on anxiety and physical parameters, may include age, gender, music preference, personal associations with music, prior musical training and culture, and patients’ emotional state (Bradt and Dileo, 2009). The mechanism behind the effects of music intervention on anxiety levels is still unclear. Clinical research findings suggest that music may facilitate reduced anxiety levels, decreased blood pressure and heart rate, and changes in plasma stress hormone levels (Watkins, 1997). Music induces an arousal effect, predominantly related to the tempo. Slow or meditative music can induce a relaxing effect (Bernardi et al., 2006). Passive listening to music
  5. 5. 440 L.-C. Chen et al. / European Journal of Oncology Nursing 17 (2013) 436e441 accelerates breathing rate and increases blood pressure, heart rate, and the LF:HF ratio in proportion to the tempo and perhaps also related to the complexity of the rhythm (Bernardi et al., 2006). Bernardi et al. (2009) also found significant correlations between cardiovascular or respiratory signals and music profiles, especially skin vasoconstriction and blood pressure responses produced by vocal and orchestral crescendos compared to uniform emphasis (Bernardi et al., 2009). Outcomes of a systematic review conducted by Bradt and Dileo (2009) found that listening to music reduced heart rate, respiratory rate and blood pressure. Those physiological changes associated with music intervention may facilitate a reduction in the stress response, including decreased anxiety levels (Bradt and Dileo, 2009). A recent review found that selection of the primary music for music intervention is first based on research and then a variety of selections can be presented to subjects for choice on the basis of personal preferences (Chi and Young, 2011). However, they suggested that using patient-selected music may have more heterogeneous results than trials using researcher-selected music (Bradt and Dileo, 2009). Clark et al. (2006) also suggested using patients’ preferred music in pre-radiation music interventions; however, although anxiety levels and treatment-related distress were reduced in those who self-selected music, differences were not significant when compared to controls not receiving music therapy (Clark et al., 2006). Also, individual preferences in music style have been found to be less important to physiological response than music characteristics such as tempo (Bernardi et al., 2006). In the present study, researchers selected and organized types of music randomly without any rationale except for constant tempo (beats per minute) and volume. To maintain a fairly consistent style of music, including consistent tempo and dynamics, we (and most previous researchers) selected music that had a relatively constant speeddslow-paced, soft, melodic music at low volume with an average of 60e80 beats per minute. Thus, we can expect that the slow tempo and consistent style of music in our intervention would produce mild and uniform responses, inducing a relaxing effect and reduction of pre-treatment anxiety. Limitations This study is limited by the collection of data in only one medical center in northern Taiwan, which precludes generalizing results to all Taiwanese radiation oncology patients. In addition, subjects’ cancer types and stages were heterogeneous, which affects the type and intensity of radiotherapy and limits generalizability to the cancer population. Also, the present study only performed music intervention once in participating subjects prior to radiotherapy, and collected only one set of pre- and postintervention measurements of the STAI scales and vital signs rather than repeating either music therapy or measurements, that is, no testeretest was conducted immediately after the intervention. Anxiety levels were not measured during or after radiotherapy as in some other trials (Clark et al., 2006) to evaluate duration of effects. We also did not conduct a double-blind experiment, and therefore cannot rule out experimenter bias. Future study should adopt a randomized controlled study design and recruit a larger sample in multiple institutions and locations. Longer-term music intervention may also be important in future study; although our results showed a beneficial effect on outcomes related to short-term physiologic changes and anxiety levels, this study provided no evidence of long-term outcomes. Many studies of music therapy suffer from small sample size, which may make it difficult to achieve statistically significant results (Bradt and Dileo, 2009). Multiple and possibly longer music therapy sessions should be included for comparison and verification of data. It may also be valuable to measure music therapy effects after radiation treatment and to determine anxiety-related factors that may respond to music therapy. Conclusions and implications for nursing practice Music therapy provided prior to radiation treatment decreases State-Trait anxiety levels and systolic blood pressure in oncology patients receiving radiotherapy. Nursing staff at radiation treatment centers can provide a choice of music for patients to listen to in the waiting room before treatment to help reduce anxiety. Patient education may instruct patients about practicing music therapy at home, helping to ease symptoms of anxiety and enhance comfort levels prior to radiation therapy. Music intervention and nurse-guided education also may enhance the quality of nursing care and patients’ satisfaction with nursing. Conflict of interest statement None declared. References Argstatter, H., Haberbosch, W., Bolay, H.V., 2006. Study of the effectiveness of musical stimulation during intracardiac catheterization. Clinical Research in Cardiology 95 (10), 514e522. Barry, P., O’Callaghan, C., Wheeler, G., Grocke, D., 2010. Music therapy CD creation for initial pediatric radiation therapy: a mixed-methods analysis. Journal of Music Therapy 47, 233e263. Bernardi, L., Porta, C., Sleight, P., 2006. Cardiovascular, cerebrovascular, and respiratory changes induced by different types of music in musicians and nonmusicians: the importance of silence. Heart 92 (4), 445e452. Bernardi, L., Porta, C., Casucci, G., Balsamo, R., Bernardi, N.F., Fogari, R., et al., 2009. Dynamic interactions between musical, cardiovascular, and cerebral rhythms in humans. Circulation 119 (25), 3171e3180. Bradt, J., Dileo, C., 2009. Music for stress and anxiety reduction in coronary heart disease patients. Cochrane Database of Systematic Reviews 15 (2), CD006577. Bradt, J., Dileo, C., Grocke, D., Magill, L., 2011. Music interventions for improving psychological and physical outcomes in cancer patients (review). Cochrane Database of Systematic Reviews, CD006911. Bulfone, T., Quattrin, R., Zanotti, R., Regattin, L., Brusaferro, S., 2009. Effectiveness of music therapy for anxiety reduction in women with breast cancer in chemotherapy treatment. Hospital Nursing Practice 23 (4), 238e242. Chaturvedi, S.K., Chandra, P.S., Channabasavanna, S.M., Anantha, N., Reddy, B.K.M., Sharma, S., 1996. Levels of anxiety and depression in patients receiving radiotherapy in India. Psycho-Oncology 5 (4), 343e346. Chi, G.C., Young, A., 2011. Selection of music for inducing relaxation and alleviating pain: literature review. Holistic Nursing Practice 25 (3), 127e135. Chung, S.K., Long, C.F., 1984. 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