Impact of Music Therapy on Hospitalized Patients Post-elective Orthopaedic Surgery Review
Introduction
Stress is a well-known chance cistron for the onset and progression of a range of physical and emotional problems, such equally cardiovascular diseases, cancers, anxiety disorders, low, and burnout (American Psychological Association [APA], 2017; Australian Psychological Society [APS], 2015; Steptoe & Kivimäki, 2012). To cope with stress and the demands of today's society, millions of people over the world utilize tranquilizing medications, which have a lot of negative contraindications and side furnishings, including substance dependence and corruption (Bandelow et al., 2015; Olfson et al., 2015; Puetz et al., 2015; World Health Organization [WHO], 2010). Therefore, information technology is important to examine the furnishings of not-pharmacological therapeutic interventions for the prevention and management of stress (de Witte et al., 2020a; Kamioka et al., 2014; Martin et al., 2018; Raglio et al., 2015).
For decades and all over the world music has been used to provide calmness and relaxation. These stress reducing qualities are the most widely studied effects of music (Chanda & Levitin, 2013; de Witte et al., 2020a; Juslin & Västfjäll, 2008; Koelsch, 2015; Mehr et al., 2019). Therefore, music therapy interventions are increasingly being used to reduce stress and enhance the well-existence of clients beyond a variety of clinical populations (Agres et al., 2020; Bainbridge et al., 2020; Juslin & Västfjäll, 2008; Kemper & Danhauer, 2005; Koelsch, 2012, 2015; Landis-Shack et al., 2017; Thaut & Hoemberg, 2014).
Music therapy is specifically characterized past using the specific qualities of music in a therapeutic relationship with a music therapist. This distinguishes music therapy from other music interventions, mostly offered past medical or healthcare professionals and referred to every bit music medicine (Agres et al., 2020; Bradt et al., 2013b; de Witte et al., 2020a; Gilded et al., ; Magee, 2019). The torso of research on music therapy is much smaller compared to the amount of research on music listening interventions. Our previous meta-analytic review (de Witte et al., 2020a) was focused on the effects of music interventions in general and included mainly music listening interventions. In none of these studies a trained music therapist was involved.
In order to integrate the bachelor cognition on the furnishings of music therapy on stress, we conducted a systematic review and meta-analysis of quantitative studies testing the effects of music therapy on both physiological and psychological stress-related outcomes in mental and medical healthcare settings.
The influence of music on the stress response
Stress tin be regarded every bit the quality of an experience, produced through a person-surroundings transaction that may result in physiological or psychological distress (Aldwin, 2007). Responses to stress tin be related to both increased physiological arousal and specific emotional states, while the underlying systems of those responses regulate and bear upon each other during stress (east.chiliad., de Witte et al., 2020a; Linnemann et al., 2017; McEwen & Gianaros, 2010). The stress reducing effect of music therapy interventions is explained past music itself as well as the continuous attunement of music by the music therapist to the individual needs of a patient.
Music listening is strongly associated with stress reduction by the decrease of physiological arousal as indicated by reduced cortisol levels, lowered heart rate, and decreases in hateful arterial pressure (east.1000., Burrai et al., 2016; Koelsch et al., 2016; Kreutz et al., 2012; Linnemann et al., 2015). Music tin can also reduce negative emotions and feelings, such every bit subjective worry, state anxiety, restlessness or nervousness (Akin & Iskender, 2011; Cohen et al., 1983; Pittman & Kridli, 2011; Pritchard, 2009), and increase positive emotions and feelings, such as happiness (Jäncke, 2008; Juslin & Västfjäll, 2008). This is in line with studies showing that music modulates activity in brain structures, such equally the amygdala and the mesolimbic reward brain organization, which are known to be involved in emotional and motivational processes (Claret & Zatorre, 2001; Koelsch, 2015; Koelsch et al., 2016, 2016; Levitin, 2009; Moore, 2013; Salimpoor et al., 2013; Zatorre, 2015). Furthermore, it is causeless that the systematic application of music in therapy in response to the needs of the patient(south) can strengthen the bear on of music (Agres et al., 2020; Bradt & Dileo, 2014). In improver, empirical bear witness shows that music activities in a group may result in synchronization among grouping members, which leads to positive feelings of togetherness and bonding (Linnemann et al., 2016; Tarr et al., 2014). These feelings of togetherness and bonding may be explained past the release of the neurotransmitters endorphin and oxytocin, which both play an of import role in the defensive response to stress (e.g., Amir et al., 1980; Dief et al., 2018; Myint et al., 2017). Lastly, music listening can help to lower stress levels through its quality to provide 'distraction' from stress-increasing feelings or thoughts (Bernatzky et al., 2011; Chanda & Levitin, 2013).
Music therapy
Music therapy tin be defined as the clinical and evidence-informed apply of music interventions to accomplish individualized goals inside a therapeutic relationship in club to achieve physical, emotional, mental, social and cognitive needs (Aalbers et al., 2019; Agres et al., 2020; American Music Therapy Clan [AMTA], 2018; de Witte et al., 2020a). Music therapy has been applied equally a therapeutic intervention in a wide spectrum of health care contexts, such as mental health care, forensic care, nursing homes, rehabilitation, and oncology (eastward.grand., Agres et al., 2020; Kamioka et al., 2014; Martin et al., 2018). Although the term 'music therapy' sometimes refers to whatever kind of use of music every bit an intervention in health care settings, music therapy should be offered by a trained music therapist, who is a licensed and qualified therapist with the required knowledge in psychology, medicine, and music (Agres et al., 2020; AMTA, 2018; Bradt et al., ; Magee, 2019).
Music therapists use the unique qualities of music (e.one thousand., tune, rhythm, tempo, dynamics, pitch) within the therapeutic relationship to access patient's emotions and memories, to address social experiences or influence behavior (Bruscia, 1987; Wheeler, 2015). This specific kind of responsivity to the patient'south needs can exist regarded equally the key competencies of the music therapist, referring to the processes that take identify between therapist and patient supporting coordination, empathy and shared perspectives (Agres et al., 2020). More specifically, during music therapy the music therapist attunes to the patient by adjusting the music created as an immediate response to the patient's needs (Aalbers et al., 2019; Magee, 2019).
To work on patient-therapist attunement, the music therapist synchronizes with the patient moment-past-moment, which may be considered as a mirroring technique. This means that the (musical) deportment of the music therapist and the patient tin can go simultaneous and regulated through time, yielding a similar expression in motion, matching pulse, rhythm, dynamics and/or melody (Aalbers et al., 2019; Bruscia, 1987; Schumacher & Calvet, 2008). For case, the music therapist may influence patients' perceived stress during musical improvization by synchronizing with the patient'southward music-making, later on irresolute the musical expression by playing slower and less loudly. This specific way of patient-therapist attunement is unremarkably used in music therapy practice and refers to the so-chosen Iso Principle (eastward.one thousand., Altshuler, 1948; Heiderscheit & Madson, 2015). Literature shows that the tempo and loudness are important for the experienced intensity of the music (Gabrielsson & Lindström, 2010), and music with a irksome steady rhythm may provide stress reduction past altering inherent body rhythms, such every bit middle charge per unit (Thaut et al., 1999; Thaut & Hoemberg, 2014). The music therapist uses several types of interventions, which can be offered to a grouping of patients as well every bit individually. The number, frequency, and duration of the music therapy session may vary widely, and depend on the targeted upshot, patients' preferences, and/or the setting in which the music therapy is offered (Agres et al., 2020; AMTA, 2018). Furthermore, music therapy interventions tin can be subdivided in two broad categories: agile and receptive interventions (Magee, 2019; Magee et al., 2017; Wheeler, 2015).
Active interventions involve the patient doing something with the music during the music therapy sessions, such equally musical improvization, composing music or songs, motility to music, or singing or vocalizing. According to both literature and clinical practice, it seems that musical improvization is the nigh used intervention inside music therapy, meaning that patient(s) and therapist improvize on musical instruments they have chosen and play together freely or with a given structure (Gilded et al., 2009; Wigram, 2004). In receptive music therapy interventions, the patient is not actively making music, but rather responds to music provided by the music therapist, such equally listening to alive or prerecorded music (Bruscia, 1998; Magee, 2019; Wheeler, 2015). The patient listens to the music and may procedure verbally their ain emotions and/or experiences. During both active and receptive music interventions music therapists brand specific apply of the unique qualities of music (also known as 'musical components'), such as rhythm, pitch, tempo, dynamics, melody and harmony, to facilitate and promote personal contact, advice, learning, mobilization, expression and other relevant goals (Agres et al., 2020; Câmara et al., 2013; Taets et al., 2019; Thaut & Hoemberg, 2014; Wheeler, 2015).
Summarized, whereas music medicine does not involve a personal therapeutic process, music therapy requires such a process, characterized by personally tailored music interventions initiated by a trained/qualified music therapist (de Witte et al., 2020a; Leubner & Hinterberger, 2017). These music therapy interventions tin can be divided in receptive music therapy interventions (music listening) or active music therapy interventions (live music-making), and are specifically characterized past musical attunement, facilitated by the music therapist, which distinguishes music therapy from other music interventions.
Music therapy versus music medicine
Research on music therapy is fast-growing (de Witte et al., 2020a). The effects of music listening interventions, such equally 'music medicine', are mainly caused past the general influence of music on the stress response, whereas the effects of music therapy may also be explained by the therapeutic relationship through patient-therapist attunement past the use of music. Dileo (2006) stated that music therapy is more than effective than 'music medicine' interventions, and attributed this difference to the fact that music therapists individualize their interventions to meet patients' specific needs (Bradt et al., 2010; Dileo, 1999, 2006).
In a Cochrane review of Bradt et al. (2016) it was shown that 'music medicine' interventions and music therapy were every bit constructive in decreasing (state) anxiety. Bradt et al. () compared 'music medicine' with music therapy, and as well plant that both types of interventions were equally effective for feet and stress reduction, although 77.4% of the participants expressed a preference for music therapy for future treatments. This patient's preference for music therapy was related to quality of therapeutic relationships, interactive music making and the possibility of emotional expression, which is precisely what music therapy distinguishes from music listening interventions (Bradt et al., ; Gutgsell et al., 2013).
In our previous meta-analytic review on Randomized Controlled Trials (RCTs) examining the effects of music interventions on stress-related outcomes (de Witte et al., 2020a), we showed that music therapy did take at least as much effect on physiological stress-related outcomes (d = .423) every bit 'music medicine' (d = .379). However, just 7 studies on music therapy were included against 54 studies examining music medicine. Therefore, findings on music therapy were compromised past low generalizability and lack of statistical power to examine factors that might affect the effectiveness of music therapy by means of moderator analyses. Notably, about effectiveness studies on music therapy are quasi-experimental, because it is often difficult to meet the requirements for randomization and/or masking procedures (Bradt et al., 2013b; de Witte et al., 2020a; Magee et al., 2017).
The present written report
The present study is a systematic review and meta-analysis on the effects of music therapy on both physiological stress-related arousal (e.m., blood force per unit area, heart charge per unit, hormone levels) and psychological stress-related experiences (east.grand., state anxiety, restlessness or nervousness) in clinical wellness intendance settings. In our previous meta-analysis, nosotros examined the effect of music interventions on stress-related outcomes. The included studies primarily used prerecorded music offered by medical professionals, whereas music therapy involves a trained music therapist who is responsive to the needs of the patient and can influence emotions and/or beliefs of the patient by the utilise of music.
In the nowadays meta-assay, we included both RCTs and quasi-experimental designs with a control condition (Clinical Controlled Trials [CCT]), accounting for the event of study design and quality in moderator analyses. The inclusion of quasi-experimental studies, which accept been conducted nether clinically representative weather condition, increases external validity of meta-analytic findings and substantially increases statistical power of a meta-assay (Shadish et al., 2002; Shadish et al., 2008).
The methodology of the nowadays meta-analytic written report is in line with our contempo three-level meta-analysis (de Witte et al., 2020a), in which 104 randomized controlled trials were included. Results showed a significant pocket-sized-to-medium result of music interventions on physiological stress-related outcomes (d = .380; 61 trials), and a medium effect of music interventions on psychological stress-related outcomes (d = .545; 79 trials), indicating that groups receiving music intervention benefited more than than the comparing groups. In the present meta-analysis, we examine the overall effect of music therapy on stress reduction, bookkeeping for differences in physiological and psychological stress-related outcomes, and nosotros aim to gain more than insight into written report, sample, consequence and intervention characteristics that might moderate the effects of music therapy on stress reduction.
Methods
Inclusion criteria
For the current meta-analysis, multiple inclusion criteria were formulated. First, merely Randomized Controlled Trials (RCTs) and Clinical Controlled Trials (CCTs) that examined the effect of music therapy on the feel of stress and/or land anxiety were included. The type of intervention concerned of import inclusion criteria for this meta-analysis. Merely studies that offered music therapy past an educated and certified music therapist were included in this meta-analysis. Outcome measures related to quality of life (QoL) or pain were excluded, because in this study only the primary outcome measures of stress were included. The physiological effects of stress had to be measured by middle rate (Hr), center rate variability (HRV), claret pressure and hormone levels. The psychological effects of stress had to be measured by cocky-report instruments aiming at 'stress' or 'country anxiety'. Second, studies examining people with dementia or participants younger than 18 years of age were excluded. Although many studies showed cognitive and emotional benefits in dementia patients when they sing or listen to familiar songs (Särkämö et al., 2008, 2014), these findings are non directly related to 'stress reduction'. In addition, the stress measurement instruments which are used in the included studies are not used in studies examining people with dementia or immature participants.
Selection of the studies
All randomized controlled trials (RCTs) and clinical controlled trials (CCTs) bachelor until the 8th of May 2019 that met the inclusion criteria were included in this meta-analytic review. Multiple systematic searches were performed with the help of an independent medical librarian, every bit librarian engagement is significantly associated with college quality of reported search strategies (Rethlefsen et al., 2015). Nosotros conducted a reckoner-based search of the psychological and medical electronic literature databases, including Medline, Academic Search Complete, Cochrane Library, Web of Science, Embase, Wiley Online Library, Springerlink, PubMed, PiCarta, Academic Search Premier, ScienceDirect, PsycINfo and Google Scholar. The search string comprised three elements: a music therapy element, a stress-related issue element and a report blueprint element. For the music therapy element, the following keywords were used: 'music therapy', 'musical therapy' or 'music-based therapy'. For the stress-related outcome element, the following keywords were used: 'stress', 'anxiety', 'arousal', 'psychological stress,' 'occupational stress', 'physiological stress', 'mental endure', 'anguish', 'hypertension,' 'relaxation', 'centre rate,' 'claret pressure', 'nervousness', 'cortical vigilance', 'distress', 'cortisol', 'intravascular pressure', 'vascular pressure' or 'STAI'. Concerning the study blueprint element, the keywords: 'randomized controlled trial', 'randomised controlled trial', 'clinical controlled trial', 'randomised', 'randomized', ' RCT', 'review' or 'meta-analysis' were used. Furthermore, reference sections of review – and meta-analytic manufactures about the effect of music (therapy) interventions on stress-related outcomes were inspected for qualifying studies. The search protocol of this meta-analytic review is registered at the international prospective register of systematic reviews (ref.no. CRD42020160222).
The initial search resulted in 2.182 individual studies and was conducted by an independent librarian and the start author. The first option on championship and abstract resulted in 317 individual studies that were, posteriorly, total text screened based on the inclusion criteria. Finally, 47 studies met all the inclusion criteria (run into Figure i). All the steps of the selection process were conducted past two dissimilar authors, who selected the studies blindly from each other. Concerning the selection conflicts, a third author was involved and made the final determination. Table A1 provides an overview of the included studies and their main characteristics (encounter Appendix 1).
Music therapy for stress reduction: a systematic review and meta-analysis
Published online:
27 November 2020
Effigy 1. Flow chart of the search results.
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Coding and moderators
The included studies were coded by the beginning and 2d author using a coding sheet according to the guidelines of Lipsey and Wilson (2001). Stress can be considered as the dependent variable and was coded into physiological or psychological stress-related outcomes, resulting in one meta-assay. Multiple variables with a potential moderating effect on the relation between music therapy and stress were identified. These moderators were divided into outcome-, study-, sample-, and intervention characteristics.
Regarding the psychological stress-related outcomes, it was coded whether the psychological outcomes were assessed past means of questionnaires measuring stress or (land) anxiety. Country anxiety can be seen equally a psychological stress-related outcome, because many studies (eastward.thou., de Witte et al., 2020a; Claw et al., 2008; Ng et al., 2016; Zhang et al., 2014) considered state feet to be a issue of stress and outcome measures related to state feet or stress. Therefore, in the literature these concepts are used interchangeably (Bradt & Dileo, 2014; Lazarus & Folkman, 1984; Ozer et al., 2013; Pittman & Kridli, 2011; Wetsch et al., 2009). This is in line with the results of our previous meta-analysis, which showed no significant differences in effect sizes between state-anxiety self-written report scales (d = .553) and stress cocky-study scales (d = .512). In the present report, xxx% of the studies used Visual Analog Scales (VAS) to measure perceived stress or state anxiety. Overall, stress is often measured by the Perceived Stress Scale (PSS) (Cohen et al., 1983), the Quick Mood Scale (Woodruffe-Peacock et al., 1998), and the Profile of Mood States (POMS) (McNair et al., 1981), which instruments are used in nineteen% of the included studies. State feet is predominantly measured by the land version of the Spielberger Land-Trait Anxiety Inventory (STAI) (Spielberger et al., 1983) and the anxiety version of the Infirmary Anxiety and Depression Scale (HADS-A), which are used in 45% of the included studies.
Regarding the written report characteristics, we coded the design, study quality, type of setting, type of control condition and whether the report was conducted in Western- or non-Western countries. Studies with prospective group design, such as RCTs and CCTs were considered relevant for the current research. Therefore, we coded study design every bit RCT when participants were allocated to handling weather condition through randomization (eastward.m., computer-generated randomization lists), and CCT design when authors did not explicitly mention randomization, or quasi-randomized studies. The quality of the study was coded as potent, moderate or weak after cess with the 'Quality Assessment Tool for Quantitative Studies' (Effective Public Health Practise Project [EPHPP], 2009). This tool measures the quality of a study by providing a comprehensive and structured cess of written report quality (Armijo-Olivo et al., 2012). The EPHPP has been reported to accept high content and construct validity (Jackson & Waters, 2005; Thomas et al., 2004). Low quality studies negatively affect the internal (causal decision) validity, which can lead to a biased interpretation of the overall outcome guess (Higgins & Greenish, 2011; Zeng et al., 2015).
Regarding the setting in which the written report was conducted, we coded whether the report was conducted in a mental healthcare setting or in a medical setting (e.g., during polyclinic treatments, before or after surgery, palliative intendance). Furthermore, the type of control condition was coded, considering different control atmospheric condition tin yield different result sizes (Finney, 2000; Karlsson & Bergmark, 2015). We coded care every bit usual (CAU) when no stress-reducing intervention was offered, but patients did receive regular care within medical or mental healthcare, waiting list when there was no intendance or intervention offered, or stress intervention when another stress-reducing intervention was delivered, such as listening to prerecorded music, verbal support, or mindfulness-based therapy. Farther, we coded whether the study was conducted in Western countries (European countries, Australia, Usa, Canada, New Zealand) or whether the written report was conducted in countries designated as non-Western countries (mainly Asiatic countries). The cultural surroundings has been shown to influence the mode people respond to and cope with stress (Lonner, 2007; Tweed et al., 2004), which could influence the result of music on stress. In our previous meta-analysis, the land in which the study was conducted but failed to reach the conventional level of statistical significance (p = 0.089), indicating that not-Western studies yielded larger furnishings on physiological stress-related outcomes than studies conducted in Western countries.
Sample characteristics were also coded, such as the per centum of men in each study. There are indications that men and women react differently to stress, both psychologically and physiologically, leading to substantiated gender differences in measured stress levels (Galanakis et al., 2009; Kajantie & Phillips, 2006; Verma et al., 2011). Nosotros also coded the average age of the participants per report, because research on occupational stress revealed several differences in stress levels betwixt different age groups (Galanakis et al., 2009).
Additionally, nosotros coded nine music therapy characteristics. Commencement, nosotros coded whether the music therapy was offered to an individual patient or whether it concerned a group music therapy. Empirical evidence shows that during group music therapy interventions people synchronize with each other, which evokes positive feelings of togetherness and bonding, and decreases stress levels (Linnemann et al., 2016; Tarr et al., 2014). Second, we coded music therapy interventions equally 'protocolized' or 'non-protocolized'. Music therapy protocols not only enable researchers to compare and replicate studies, but also to understand consistencies and strategies used past music therapists across sessions with participants (de Witte et al., 2020a; Vink & Hanser, 2018). Both structure as well as strategies used during the therapy session may take affect on participants' outcomes, such as stress levels. Third, the quality of the intervention clarification was coded in reported detailed or reported briefly and poor. We considered the description of the therapy equally detailed if authors mentioned or elaborated on components of a session of music therapy, such equally the number or duration of the sessions, listening to live or recorded music, or which musical instruments or music therapeutic techniques were used. If authors did non explicitly written report on most of the characteristics of the delivered music therapy (as mentioned above), the description was regarded as brief/poor.
Quaternary, music style was divided into three categories: classical music offered by the music therapist, relaxation music, and choice of own-preference music by patient. 5th, we fabricated a distinction between the way the music was offered: whether the music therapist used live music solitary, pre-recorded music lonely or both. Sixth, with regard to music choice, we coded whether the music was selected based on the preferences of the patient, on the choice of the music therapist himself, or whether a pre-selected option of music was offered. In some studies, in which the effects of music listening on stress-related outcomes was examined, information technology was advised to allow the subjects to choose the music themselves, considering this may have a greater stress reducing bear on (Brannon & Fiest, 2007; Juslin et al., 2008). However, our previous meta-analytic review showed that the term 'self-selected music' is used both in studies where the patient could bring her/his ain preference music and in studies where the patient had to choose from a pre-selected list of music styles or songs (de Witte et al., 2020a). Therefore, we coded every bit such in the present report.
Seventh, nosotros coded whether the tempo of the music was lx–90 bpm or whether the music had some other tempo. Tempo tin can be considered equally 1 of the about pregnant moderators of music-related arousal and relaxation effects. In the previous meta-analytic review (de Witte et al., 2020a) of the effects of music interventions on stress-related outcomes, larger consequence sizes were found in music with a tempo of lx–90 bpm compared to music with another tempo. Music with a boring tempo, such as meditative music, has often been demonstrated to initiate reductions in heart rate, resulting in greater relaxation (e.k., Bernardi et al., 2005; Bringman et al., 2009; Chlan, 2000; Hilz et al., 2014; Nomura et al., 2013). Lastly, nosotros coded the number of music intervention sessions and the frequency of the sessions per calendar week. The number of interventions has been shown to be positively correlated with stress and anxiety regulation (Cassileth et al., 2003; Gilded et al., 2009; Robb et al., 2011).
Calculation and analyses
The effect sizes were transformed into Cohen'due south d by using the calculator of Wilson (2013) and formulas of Lipsey and Wilson (2001). Negative effect sizes indicate that music therapy had a negative upshot on stress-related outcomes. Most d-values were calculated based on reported means and standard deviations. To correct for pre-treatment differences, pre-test effects were subtracted from post-examination effects. The effect size was coded as nil when a report reported that an upshot was non significant without providing whatever statistics (Lipsey & Wilson, 2001). For both meta-analyses, the continuous moderators (age of the participants, gender of the participants, duration of the music intervention and frequency of the music intervention) were centered on their means. For categorical variables, dichotomous dummy variables were created. Extreme outliers in effect sizes were identified using box plots (Tabachnick & Fidell, 2013), and were winsorized (i.e., replaced by the highest or lowest adequate score falling within the normal range) for both meta-analyses. Standard errors were estimated using formulas of Lipsey and Wilson (2001).
In some of the studies, information technology was possible to summate more than one effect size, every bit nigh studies reported on multiple stress-related outcome variables, multiple scales or measurement instruments. It is possible that the effect sizes from the same study are more akin than effect sizes from other studies. The assumption of contained consequence sizes underlying traditional meta-analytic methods was therefore violated (Hox, 2010; Lipsey & Wilson, 2001). We practical a multilevel approach to meta-assay in order to account for the interdependency of effect sizes (run into Assink et al., 2015; Cheung, 2014; de Witte et al., 2020a; Houben et al., 2015; Spruit et al., 2016).
A three-level meta-analytic model was used to calculate the combined consequence sizes and to perform the moderator analyses. Three sources of variance were modeled, including the sampling variance for each effect sizes (level-i), the variance between effect sizes within studies (level-2), and the variance between studies (level-three) (Assink & Wibbelink, 2016). The meta-analysis was conducted in R (version iii.4.3) with the metafor-bundle, employing a multilevel random effects model (Houben et al., 2015; Van den Bussche et al., 2009; Viechtbauer, 2010). This model is frequently used for multilevel meta-analyses and, in general, information technology is superior to the fixed-effects approaches used in traditional meta-analyses (Van Den Noortgate & Onghena, 2003). We used likelihood-ratio-tests to compare the deviance scores of the full model and the models without variance parameters on level ii or three to determine if the level-2 and -iii variances were significant, indicating heterogeneity of effect sizes. A heterogeneous consequence size distribution indicates that the consequence sizes cannot be treated every bit estimates of a common overall consequence size. In that case, we conducted moderator analyses, because the differences among effect sizes may be explained by outcome, written report, sample, and/or intervention characteristics.
Publication bias
A common trouble in conducting a meta-analysis is that studies with not-significant or negative results are less likely to be published than studies with positive and significant results. The studies included in this meta-analysis may therefore not be an adequate representation of all studies that have been conducted, which is called the 'file drawer trouble' (Rosenthal, 1995).
In lodge to check the presence of publication bias in the electric current meta-assay, a trim and fill up procedure was performed (Duval & Tweedie, 2000a, 2000b). In case of publication bias, the funnel plot of the distribution of effect sizes is disproportionate. We tested if issue sizes were missing on the left and right side of the distribution. Publication bias would simply exist likely to occur in case of non-meaning or unfavorable (i.e., negative) results, resulting in left-sided funnel plot disproportion. Right-sided funnel plot disproportion is indicative of selection bias. We imputed estimations of effect sizes of missing studies through trim and make full analyses in the case of left or correct-sided disproportion, and afterward computed an overall effect size that would accept the influence of publication bias or selection bias into account (Duval & Tweedie, 2000a, 2000b), providing an estimate of the degree to which publication bias or selection bias might have afflicted the overall mean effect size.
Results
Overall effect of music therapy on stress-related outcomes
The present meta-analytic review on the effects of music therapy on both physiological and psychological stress-related outcomes, included 47 contained studies (s), reporting on 76 effect sizes (m), and a total sample of N = 2.747 subjects, of which n = 1.405 subjects in the music therapy groups, and n = 1.342 subjects in the comparison groups. Tabular array A1 (see Appendix 1) shows an overview of the most important characteristics of the included studies. Tabular array 1 shows the overall effect of music therapy on both physiological stress-related outcomes and psychological stress-related outcomes. We found a significant medium-to-stiff result (d = .723, [.51–.94]) of music therapy on stress-related outcomes in mental healthcare and medical settings.
Table 1. Overall furnishings of music therapy on stress-related outcomes.
According to the trim-and-fill plot, the presence of publication bias was unlikely (see Figure A1, Appendix 2), considering studies were lacking on the right side of the funnel instead of the left side of the funnel. A trim and fill analysis yielded a marginally larger effect size of d = .783 compared to the observed consequence size of d = .723. The likelihood ratio examination showed that significant variance was nowadays at the between-written report level (level 3) and the inside study level (level ii). Nosotros therefore conducted moderator analyses on type of consequence, study, sample, and music intervention characteristics to examine the upshot of music intervention on physiological stress-related outcomes. The results are presented in Tabular array 2.
Table 2. Moderator effects of music therapy on stress-related outcomes.
Results of moderator analyses of music therapy on stress-related outcomes
Consequence characteristics. Both the domain of outcomes (physiological or psychological stress-related outcomes) and the type psychological measure (stress or state-feet measurements) did non influence the effects of music therapy on stress-related outcomes.
Report characteristics. Firstly, the strongest furnishings of music therapy on stress-related outcomes were measured past CCTs (d = 1.449, [1.01–1.89]) compared to RCTs (d = .555, [.35–.76]). Secondly, the continent in which the study was conducted did also moderate the overall effect. Studies from non-Western countries had a stronger influence on the overall effect of music therapy on stress-related outcomes (d = ane.306, [.79–one.82]) compared to studies from Western countries (d = .611, [.39–.83]). Thirdly, a meaning moderating event was found for type of command condition. Studies with a waiting list control status yielded a larger effect (d = 1.415, [.95–i.88]) than studies with CAU (d = .561, [.33–.79]) or another stress-reducing intervention (d = .594, [.29–.90]). The clinical setting in which the study was conducted, did non moderate the effect. No meaning differences were establish between the effects of music therapy on stress-related outcomes in mental wellness intendance settings and medical settings. Furthermore, we observed that study quality chastened the overall effect with depression quality studies (d = one.056, [.71–1.forty]) yielding larger effects compared to studies with a moderate (d = .589, [.28–.90]) or stiff (d = .444, [.02–.87]) report quality.
Sample characteristics. The age (d = .718, [.50–.94]) and gender (d = .728, [.51–.94]) of the samples did non show to take a moderating consequence on stress symptoms.
Intervention characteristics. Music tempo betwixt 60 and 90 bpm yielded a larger effect (d = .900 [.54–one.26]) compared to music with no specific tempo (d = .631 [.37–.90]). Similarly, more than than one session of music therapy had a larger effect (d = .894 [.56–1.23]) than ane session (d = .594 [.17–1.02]). The effect size of preselected choice was larger (d = 1.059 [.66–1.46]) than music choice by the music therapist (d = .695 [.37–one.02]) and by the patient (d = .766 [.47–1.06]). With respect to music manner, relaxation had a greater effect (d = .826 [.49–1.xvi]) compared to own preference music (d = .688 [.40–.97]) and classical music (d = .562 [−.07 to 1.xix]). Additionally, group music therapy yielded a larger result (d = .927 [.54–i.32]) than individual music therapy (d = .679 [.41–.95]). However, due to the small number of studies in sure categories (run across Table 2), these differences were non statistically significant, and further studies are necessary to estimate these differences with more than precision. Other differences had like effect sizes (e.g., treatment protocol (d = .683 [.33–ane.04]) or not (d = .747 [.48–ane.02]); detailed intervention description (d = .775 [.52–1.03]) or brief/poor description (d = .637 [.31–96]); and the way the music therapist induced the music – live music (d = .726 [.46–.99]), prerecorded music (d = .664 [.26–1.07]) and both (d = .767 [.37–1.16]). Lastly, the effect of frequency of sessions per week (d = .746 [.49–1.01]) was non pregnant.
Discussion
Overall effects
Overall, nosotros found a meaning medium-to-stiff result (d = 0.723, [0.51, 0.94]) of music therapy on stress-related outcomes, indicating that participants receiving music therapy benefited more controls. We conclude that music therapy is constructive in reducing stress-related symptoms in both mental healthcare and medical settings. In our previous meta-analytic review, we found positive small-to-medium effects of music interventions on stress-related outcomes (meet for more than details: de Witte et al., 2020a), while the findings of the nowadays study demonstrate that music therapy yields a medium-to-potent issue on stress reduction. The divergence in the strength of overall effect sizes may exist explained by the unlike way both types of interventions are offered. The active involvement of a music therapist who is specifically trained to tailor interventions to the needs of patients and their musical preferences might requite a reasonable explanation for the larger upshot size for music therapy compared to music interventions (Bradt & Dileo, 2014; Dileo, 1999, 2006; Magee, 2019; Magee et al., 2017; Stegemann et al., 2019). Music therapists are especially trained to evangelize music therapy sessions to come across participants/patients' needs at the individual or group level (Rafieyan & Ries, 2007).
The overall findings of the present meta-assay are consequent with the findings of previous reviews and/or meta-analyses on the effects of music therapy on stress- and anxiety-related outcomes (Bradt & Dileo, 2014; Bradt et al., 2013a; Bradt et al., 2013b; Bradt et al., 2016; Carr et al., 2013; de Witte et al., 2020a; Aureate et al., 2009; Kamioka et al., 2014). In addition, the promising results of music therapy established in the current meta-analysis are in line with the findings of previous systematic reviews and meta-analyses on the effects of music interventions on the reduction of stress and/or (state) feet (Bradt & Dileo, 2014; Bradt et al., 2013a; Bradt et al., 2013b; Bradt et al., 2016; de Witte et al., 2020a; Gillen et al., 2008; Kim et al., 2015; Pelletier, 2004; Rudin et al., 2007).
Both the present meta-analysis and previous reviews show a growth in controlled clinical studies testing the effects of music therapy and/or music interventions on stress-related outcomes, which is important in social club to codify valid conclusions on the effects of non-pharmaceutical interventions for stress reduction (Casey, 2017; de Witte et al., 2020a). The need for more not-pharmaceutical interventions, such every bit music therapy, may exist explained past the increasing sensation of the negative side effects of tranquilizing medication, such every bit substance dependence and abuse (Casey, 2017; Globe Health Arrangement [WHO], 2010). Although a considerable number of people around the world utilize tranquilizing medications to cope with daily life stressors or anxiety (e.g., Bandelow et al., 2015; Olfson et al., 2015; Puetz et al., 2015), previous studies evidence no convincing bear witness for the curt-term effectiveness of pharmacological treatment in the reduction of stress-related problems (Donovan et al., 2019; Olfson et al., 2015).
Effect moderating variables
Results of the present meta-analysis betoken that moderators explain differences in the strength of the effect size. Meaning larger effects were found for studies using quasi-experimental CCTs compared to RCTs. Regardless of ethical concerns nigh the randomization of patients, the results of RCTs are still considered to provide the most robust evidence, because RCT designs can better exclude alternative explanations for established intervention effects than not-randomized designs. Selection bias in non-randomized effect studies can lead to overestimations of treatment effects (Page et al., 2018; Valentine & Thompson, 2013)
The overall effect size proved to be strongly moderated by the land in which the study was conducted (i.due east., not-Western versus Western countries). Larger furnishings were found in non-Western studies (northward = 8), including studies conducted in Asian countries, such equally China, Korea, and Taiwan, but also studies conducted in Iran, Brazil and Nigeria. It has been shown that the cultural surroundings influences how people respond to stress (Lonner, 2007; Tweed et al., 2004), which might explain differences betwixt Western and not-Western countries. On the other manus, the not-Western countries show great heterogeneity in culture, socioeconomic characteristics or topographical region. Moreover, Western countries with large proportions of immigrants – such equally the USA, Canada, and Australia – make it difficult to equate land with culture (Morales & Ladhari, 2011). Additionally, mail service-hoc analyses showed a weak correlation between Non-Western countries and study blueprint (r = .34, p = <.01), which indicates that the CCT blueprint was more frequently used in Non-Western countries than in Western studies. Further research is needed to exam detail explanations for cultural differences in effects betwixt studies in Western and non-Western countries. Non only civilisation should be taken into account in futurity inquiry, only also socioeconomic characteristics of study samples and the delivery of care in different wellness care systems, because of great heterogeneity both within and between countries.
Contrary to our expectations, nosotros did non notice show for a moderating effect of studies using a specific therapy protocol compared to studies without such a protocol. This tin be explained by the fact that well-nigh studies included in our meta-assay did not written report on the use of such a therapy protocol, just notwithstanding showed an adequate and rich description of the content of music therapy interventions. From the perspective of the music therapist, who is trained to tune in to the patient past adjusting the style of music-making as an immediate response to the patient's needs (Aalbers et al., 2019; Magee, 2019), music therapy protocols might often equal the flexibility of non-protocolled handling in order to deliver personalized treatment, which increases the comparability or sameness of protocolled and non-protocolled treatment.
Notwithstanding we believe that there is a need for developing music therapy protocols and intervention descriptions that facilitate further replication of music therapy interventions and, later on, volition amend inform clinicians and practitioners in both mental health care and medical settings (de Witte et al., 2020a). In addition, in future trials we strongly recommend examining handling integrity too, considering music therapists may choose not to offer some of the elements specified in the protocol or to add new handling elements. Having data on treatment integrity allows for the exam of the degree to which the implemented intervention approximates the intended intervention, and possible effects of treatment integrity on client outcomes (Perepletchikova, 2011; Vermilyea et al., 1984).
Study quality only failed to reach the conventional level of statistical significance, which indicates that low quality studies may yield larger furnishings compared to studies with a moderate or potent study quality. An caption for this result could be that the caste of 'masking' was an important factor in assessing study quality. Masking of participants in music therapy studies is ordinarily not possible unless 2 types of music therapy interventions are compared, such as receptive music therapy versus active music therapy (Bradt et al., 2013b). Masking procedures in which but the investigator is masked to the resource allotment of the intervention is much more feasible in music therapy trials (Mean solar day & Altman, 2000). Yet, the present meta-analysis contained several studies in which the way of masking was not reported at all (n = 12), which is in line with the findings of Magee et al. (2017), who conclude in their Cochrane review that in hereafter research reporting on the masking of participants and outcome assessors requires improvement. The lack of participant masking is problematic when studies examine subjective outcomes, such as mood or quality of life. Masking of therapists is often not possible in music therapy studies when active music-making is examined. When due to setting constrains the interventions cannot assure masking procedures, they should at least be masked to the purpose of the study where possible. In either case, masking procedures should be reported or discussed (Bradt et al., 2013b; Magee et al., 2017).
Statistical analyses showed that the selected music therapy characteristics practise not seem to moderate the overall effects of music therapy on stress-related outcomes. This could be explained by the variety of the music therapeutic approaches and/or the applied interventions of the included music therapy studies, which is also mentioned in several previous reviews (Carr et al., 2013; Gold et al., 2009; Mössler et al., 2011; Silverman, 2003). On the other hand, this diverseness in the content of music therapy can too be related to the core competence of a qualified music therapist, which ways that the interventions are often tailored to what the patient needs or shows at that moment. Precisely this attribute of music therapy is the main difference with music interventions without a music therapist and could therefore take resulted in a larger upshot size.
The selected intervention characteristics did not take a statistically significant impact on the effectiveness of music therapy. However, some substantial differences in effect sizes were constitute (d = .thirty or larger) in moderator analyses that did non reach the conventional level of significance due to lack of statistical power, mostly caused by an unequal distribution of studies (and consequence sizes) among moderator categories (encounter Tabular array ii). Nosotros discuss some of these findings because they may be of particular theoretical interest, and probably should be addressed in future research.
Commencement, at that place was a difference of d = .xxx between the bear on of only one session of music therapy (d = .594, [.17–ane.02]) and more than i session (d = .894, [.56–1.23]), indicating that the outcome of music therapy on stress-related outcomes increases with the use of multiple sessions. The larger result size for more than one session is in line with the report of Gilded et al. (2009), which showed more than substantial benefits in patients who took a longer course of music therapy or more frequent sessions. However, Aureate's report examined the effects of music therapy in patients with severe mental disorders, whereas the present meta-analysis mostly included studies with patients suffering from much milder mental issues or patients with stress due to medical conditions. This does not diminish the importance of stress reduction, since stress is globally recognized as a major risk cistron for the evolution of serious wellness problems (American Psychological Association [APA], 2017; Australian Psychological Society [APS], 2015).
Notably, the issue of the number of sessions seems to be related to the type of setting (medical healthcare versus mental healthcare). In our meta-analysis, only studies conducted in medical healthcare settings measured ane-session furnishings of music therapy on stress-related outcomes, which of course does not exclude the possibility that positive effects can merely as well be measured within mental healthcare settings afterwards just one session of music therapy. Nevertheless, our meta-analysis establish empirical evidence for the curt-term effectiveness of music therapy (i.e., a single session of music therapy) in reducing stress, and therefore puts the assumption that pharmacological treatment should be started due to its immediate and rapid effect in a critical lite (Bandelow et al., 2015; de Witte et al., 2020a; Fedoroff & Taylor, 2001). Moreover, the shown efficacy of simply i single session may facilitate the implementation of music therapy in cases where for logistic reasons or in more complicated settings (due east.yard., during chemotherapy in the treatment of cancer, before or later surgery, or in palliative care) multiple sessions of music therapy would not exist possible.
Second, the large consequence of music with a tempo of sixty–ninety bpm (d = .900, n = sixteen) is worth mentioning. It is larger than the effect obtained in our previous meta-analytic review (de Witte et al., 2020a), showing a medium upshot (d = .625, n = 36). The larger issue size found in the current meta-analysis may be ascribed to a lower amount of studies using prerecorded music than in our previous meta-assay, which included mostly 'music medicine' interventions. Interestingly, a post-hoc analysis showed a significant strong correlation between music tempo of lx–90 bpm and prerecorded music (r = .61, p = <.01). Unfortunately, several studies did not report on the tempo used due to the fact that (1) interventions could vary across the music therapy session depending on participants' needs, and (two) the utilize of musical instruments varied considerably inside and across the music therapy sessions. Moreover, the music tempo is usually not measured during a music therapy session of live improvised music are. We strongly recommend to investigate the influence of music tempo as a component of music therapy interventions, especially when targeting stress reduction. Moreover, literature also shows that music with a ho-hum tempo and steady rhythm may provide stress reduction by altering inherent trunk rhythms, such every bit heart rate (Thaut et al., 1999; Thaut & Hoemberg, 2014).
Lastly, the moderator 'therapy setting' revealed a big outcome for group music therapy (d = .927, [.54–1.32]). There is empirical prove showing that group music activities stimulate the release of the stress-reducing neurotransmitters endorphin and oxytocin equally a result of positive feelings of togetherness and bonding amongst group members (Linnemann et al., 2016; Tarr et al., 2014). In grouping music therapy, feelings of togetherness and bonding may be the result of not-exact synchronization with each other by making music or listening to music, which offers a different feel of communicating and relating to others in a medium that has been shown to exist motivating for people who otherwise find it hard to share or engage (Carr et al., 2017; Aureate et al., ; Stern, 2010). Moreover, enquiry shows that achieving synchronization past musical attunement is considered 1 of the almost of import (pre-)conditions in music therapy for eventually reaching stress reduction (Aalbers et al., 2019; de Witte et al., 2020b). Facilitating synchronization every bit the basis for further interventions in music therapy is therefore regarded as one of the cardinal competencies of a music therapist (e.g., Aalbers et al., 2019; Bruscia, 1987; Schumacher & Calvet, 2008; Wheeler, 2015). Finally, a post-hoc analysis showed a significant moderate correlation (r = .45, p = <.01) between individual music therapy and medical settings, which indicates that individual music therapy is relatively more used in medical setting compared other settings.
Limitations of the nowadays study
The current report has some limitations that need to be mentioned. Firstly, a meaning number (n = sixteen) of the studies included in this meta-analysis had a small sample size (10–25 participants). Studies with modest sample sizes are fairly common in meta-analyses (Davey et al., 2011), particularly when studies are conducted in medical or palliative settings where time and logistic constraints occur. It is important to highlight that small sample sizes in primary studies may result in great heterogeneity in treatment effects due to relatively large standard errors. Studies with small samples may also testify greater clinical heterogeneity among patients compared to studies with large sample sizes, which may affect the issue of the experimental treatment (IntHout et al., 2015; Schwarzer et al., 2015). Furthermore, the findings from small sample size studies tend to be less generalizable compared to studies with large number of participants. Furthermore, a limitation of any meta-assay is that there is not a completely satisfactory way to exam the presence of publication bias (Carter et al., 2019). The presence of publication bias can therefore never be ruled out, even if formal tests indicate that publication bias is unlikely. In fact, information technology is imperative that all clinical trials be preregistered in effectiveness research, including publication of the research protocols. In the present study, we chose to comport a funnel-plot-based trim and fill method (Duval & Tweedie, 2000a, 2000b), which is usually used in three-level meta-analyses in the domain of psychological studies (run across Assink et al., 2019; Assink & Wibbelink, 2016; Zeegers et al., 2017), which seems a sufficiently sensitive method to observe publication bias in the current meta-assay given the substantial number of studies and upshot sizes, the magnitude of the effect sizes, and the degree of level 2 (within studies) and level 3 (between studies) heterogeneity of the overall effect size (Run into Assink & Wibbelink, 2016; Carter et al., 2019).
Although a articulate search strategy to place relevant studies has been performed, by for instance excluding observational and retrospective studies, most studies included in our meta-analysis lack masking procedure to participants. This particularly occurred in medical settings where due to the clinical condition of the participants the treatment grouping was disclosed. The majority of studies with pocket-sized sample sizes and without a masking process were conducted in medical care. This might accept influenced some of the study outcomes. Specifically, the lack of masking may have contributed to therapist expectancy (leading to therapist bias) and/or a patient expectancy-effect (also known every bit placebo effect), eliciting a desirable therapeutic result (Tambling, 2012). In future studies, efforts need to be made to reduce expectancy or placebo effects, for example, by measuring expectation and/or adopting alternative experimental designs to control for these effects (Atwood et al., 2020; Boot et al., 2013). Nevertheless the ethical reasons to refrain from a masking procedure and waiting-list design in feet and stress studies, information technology is important to farther amend written report quality and use larger samples. Side by side, we strongly recommend that future trials written report on ability analyses.
Concluding remarks
The current meta-analytic review provides evidence that music therapy can be effective in reducing stress and provides justifications for the increasing use of music therapy carried out past a qualified music therapist in both mental health care practice and medical settings. Given the added value of the presence of a well-trained and qualified music therapist who offers music therapy, it is advisable to carefully consider whether music therapy is needed, or whether music listening interventions, more often than not offered by healthcare professionals, are sufficient. In addition, low costs and lack of side furnishings of music therapy, and the moderate-to-strong stress-relieving effects of music therapy are very important for the prevention and treatment of stress-related problems. Nevertheless, with respect to the methodology of hereafter trials, we strongly recommend reducing the hazard of selection bias by adjustment with the atmospheric condition of RCTs. Finally, the development of standardized music therapy protocols is necessary to bear more robust research on the effects of music therapy, and to proceeds more insight into the moderating effects of characteristics of music therapy for stress reduction.
Source: https://www.tandfonline.com/doi/full/10.1080/17437199.2020.1846580
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