Arts and Music in Healthcare:

1














Arts
and
Music



in
Healthcare:



An
overview
of
the
medical
literature:
2004‐2011


Rosalia
Staricoff
&
Stephen
Clift





































July
2011





CONTENTS








Page


Foreword






Summary











3








4


1
Introduction





6


2
Method





10


3
Findings





12


3.1
Maternity





3.2
Neonatal
and
intensive
care





3.3
Children





3.4
Cardiovascular
conditions





3.5
Surgery
and
pain
management





3.6
Lung
diseases





3.7
Oncology








4
Conclusions





21








5
References





24


3


Foreword
and
acknowledgements




I
am
very
pleased
to
introduce
this
review
of
the
medical
literature
on
arts
and
health
 published
since
2004.
 The
Hospital
Arts
programme
of
Chelsea
and
Westminster
Health
Charity
helps
to
create
a
 healing
environment
within
Chelsea
and
Westminster
Hospital,
where
visual
and
performing
 arts
are
combined
to
help
relieve
anxiety
and
assist
in
recovery.

In
1995,
the
hospital
was
 the
first
in
Britain
to
provide
weekly
live
performances
for
patients,
staff
and
visitors,
and
 the
first
to
carry
out
any
significant
research
on
the
impact
the
arts
can
have
on
patient
 wellbeing.
 This
review
is
the
second
piece
of
research
completed
by
Rosalia
Staricoff
on
behalf
of
 Chelsea
and
Westminster
Health
Charity.
Between
1999
and
2002,
Dr
Staricoff
conducted
a
 pioneering
research
programme
in
Chelsea
and
Westminster
Hospital,
which
provided
 evidence
that
the
integration
of
performing
and
visual
arts
into
the
healthcare
environment
 induce
psychological,
physical
and
biological
outcomes
which
could
have
clinical
 significance.

This
research
has
provided,
and
will
continue
to
provide,
the
basis
of
all
the
 work
that
the
Hospital
Arts
team
carry
out,
from
the
maintenance
of
the
art
collection
to
 the
provision
of
music‐based
interactions
with
a
huge
range
of
patients.


 I
would
like
to
thank
Rosalia
Staricoff
and
Stephen
Clift
for
their
committed
and
thorough
 work
in
preparing
this
review.
 


Christian
Brodie


Chairman,
Chelsea
and
Westminster
Health
Charity





SUMMARY


Introduction



 This
report
is
an
update
of
the
review
of
arts
in
health
research
conducted
for
Arts
Council
 England
which
appeared
in
2004
(Staricoff,
2004).

 


Method



 A
search
strategy
to
identify
relevant
research
reports
was
based
upon
Staricoff
(2004).
The
 vast
majority
of
studies
identified
were
concerned
with
music
interventions,
and
this
review
 focuses
on
these.
The
present
review
is
not
‘systematic’
as
it
covers
a
wide
range
of
health
 issues,
and
time
and
resources
precluded
the
application
of
quality
screens
and
data
 extraction.
 


Findings



 One
hundred
and
three
studies
were
identified
which
offer
evidence
of
the
effect
of
music
 interventions
on
psychological
and
physiological
outcomes
of
patients
in
a
hospital
 environment.
Studies
are
organised
under
the
following
headings:
 
 Maternity
 The
intervention
of
music
on
prenatal
care
and
childbirth
has
been
studied
with
increasing
 interest
in
the
last
decade
mainly
addressing
the
state
of
anxiety
and
depression
of
the
 mothers‐to‐be.
The
beneficial
effect
achieved
promotes
early
mother‐child
contact
and
 reduces
length
of
stay
in
hospital.

 
 Neonatal
and
intensive
care
 The
special
care
of
premature
infants
is
the
subject
of
a
number
of
research
studies
 exploring
the
influence
that
music,
mother
singing
and
lullabies
can
have
in
their
 development.
They
have
shown
evidence
of
beneficial
effect
on
weight
gain,
oxygen
 saturation
improvements,
feeding
and
crying.

The
intervention
of
music
was
well
accepted
 by
medical
staff
and
supported
by
a
positive
attitude
of
the
parents.
 
 Children
 
The
psychological
and
physiological
responses
of
children
to
art
interventions
in
hospital
 care
have
been
addressed
in
many
studies.
Research
has
shown
beneficial
effects
of
music
 intervention
on
behaviour
and
clinical
outcomes.
 
 Cardiovascular
conditions
 Music
interventions
can
have
an
important
role
during
a
number
of
procedures
for
 screening
and
diagnosis,
reducing
significantly
the
level
of
stress
and
anxiety,
blood
pressure
 and
heart
rate.
The
use
of
music
delivered
by
headphones
or
tapes
has
been
shown
to
be
 very
effective
in
reducing
levels
of
anxiety
and
stabilizing
vital
signs.
 
 
 
 


5



 Surgery
and
pain
management
 Music
can
have
a
positive
role
during
the
pre‐operative
stage,
during
surgery
and
for
post‐
 operative
recovery.
It
significantly
reduces
anxiety
and
stress
and
helps
to
normalize
vital
 signs.
Of
great
importance
are
the
findings
on
the
significant
reduction
of
anaesthetics,
 medication
for
sedation
and
analgesics.
These
results
also
showed
that
music
interventions
 can
contribute
to
achieve
cost‐benefits
effects.
 
 Lung
diseases
 Music
and
singing
play
an
important
role
in
the
functional
activities
of
the
respiratory
 system,
significantly
benefiting
patients
with
breathing
problems.
 
 Oncology
 Music
intervention
in
cancer
care
has
been
shown
to
have
an
effect
of
reducing
the
levels
of
 high
anxiety
and
depression,
and
it
could
also
help
to
control
some
of
the
side
effects
of
the
 treatment.

 
 


1


INTRODUCTION


This
report
is
an
update
of
the
review
of
arts
in
health
research
conducted
for
Arts
Council
 England
which
appeared
in
2004
(Staricoff,
2004).
It
was
commissioned
by
Chelsea
and
 Westminster
Health
Charity
with
two
principal
objectives:
 a)
To
identify
relevant
literature
published
between
2004
and
2011
on
the
effects
of
 arts
interventions
in
the
context
of
healthcare,
and

 b)
To
provide
a
basis
for
the
Charity
to
plan
further
research
to
build
upon
the
 research
programme
conducted
in
Chelsea
and
Westminster
Hospital
between
1999‐ 2002
(Staricoff,
2003).
 The
field
of
arts
and
health
practice
and
research
has
expanded
considerably
over
the
last
 twenty
years
across
the
UK.

There
is
also
considerable
interest
in
the
value
of
the
arts
for
 health
care
and
health
promotion
internationally.

‘Arts
&
Health:
An
international
journal
 for
research,
policy
and
practice’
has
published
a
series
of
articles
on
the
state
of
arts
and
 health
in
England,
the
US,
Canada,
Australia
and
Norway/Sweden.

These
papers
highlight
 the
creative
vitality
of
this
field
and
document
a
wide
range
of
practical
activities.

They
also
 emphasise
the
need
for
robust
evaluation
and
research
if
the
role
of
arts
in
health
is
to
 continue
to
develop
and
be
mainstreamed
in
the
context
of
health
service
delivery.
 The
development
of
Maggie’s
Centres
for
cancer
care
has
stimulated
further
debates
about
 the
importance
of
hospital
architecture,
and
all
aspects
of
interior
space
and
design
in
 promoting
healing
in
a
holistic
sense.
In
their
contributions
to
‘Architecture
of
Hope’,
Jencks
 and
Heathcote
(2010)
write
movingly
about
the
personal
circumstances
of
people
with
life‐ threatening
illnesses,
and
the
sometimes
negative
impacts
of
being
cared
for
in
soulless,
 dreary
and
noisy
hospital
environments.
They
remind
us
of
the
need
to
remember
the
 patient’s
perspective
in
any
discussions
of
arts
and
health
practice
and
the
process
of
 evaluation
and
research.

 Chelsea
and
Westminster
Hospital
has
been
at
the
forefront
of
developments
in
arts
and
 health
in
the
UK,
and
particularly
in
pioneering
an
original
programme
of
research
to
assess
 the
clinical
contributions
of
visual
and
performing
arts
in
the
context
of
on‐going
healthcare
 within
the
hospital.
The
research
provided
evidence
from
small
controlled
studies
in
a
range
 of
clinical
settings
in
the
hospital
of
positive
benefits
on
clinical
measures
from
visual
art
 being
displayed
and
music
performed.
The
findings
attracted
considerable
attention
and
are
 widely
quoted
by
practitioners
in
the
field
of
hospital
arts.

Nevertheless,
the
small‐scale
of
 the
studies
undertaken
meant
that
the
work
could
not
achieve
the
recognition
it
deserved
 through
publication
in
mainstream
peer‐reviewed
medical
journals,
which
have
a
bias
 towards
publication
of
large‐scale
randomised
controlled
trials
and
epidemiological
 research.




7


The
consequences
of
this
lack
of
peer‐reviewed
publications
are
clearly
revealed
by
a
 Google
Scholar
search
based
on
the
Arts
Council
England
review
and
the
Chelsea
and
 Westminster
research
report.

As
of
April
2011
these
reports
had
been
cited,
respectively,
in
 78
and
16
subsequently
published
reports
and
papers.1
Very
few
of
the
sources
identified
 through
these
searches
were
reporting
findings
from
subsequent
research
studies
on
arts
in
 healthcare
settings,
and
certainly
none
reported
research
which
built
upon
and
extended
 the
nature
of
the
work
undertaken
in
Chelsea
and
Westminster.

 A
recent
report
from
the
British
Medical
Association
(2011)
on
the
‘Psychological
and
Social
 Needs
of
Patients’
should
also
be
mentioned.

The
aim
of
the
report
is
to
identify
the
key
 needs
of
patients
and
to
explore
ways
in
which
they
can
be
met
in
healthcare
environments
 beyond
the
provision
of
appropriate
clinical
care.

They
draw
upon
the
findings
from
 Staricoff
(2003)
in
the
following
passage:
 Creating
a
therapeutic
healthcare
environment
extends
beyond
the
elimination
 of
boredom.
Arts
and
humanities
programmes
have
been
shown
to
have
a
 positive
effect
on
inpatients.
The
measured
improvements
include:
 • inducing
positive
physiological
and
psychological
changes
in
clinical
 outcomes
 • reducing
drug
consumption
 • shortening
length
of
hospital
stay
 • promoting
better
doctor‐patient
relationships
 • improving
mental
healthcare

 (BMA,
2011,
p.9)
 The
report
goes
on
to
identify
the
following
range
of
activities
which
may
contribute
to
 meeting
patients’
psychological
and
social
needs:
recreational
activities;
humour;
creative
 writing,
storytelling
and
poetry;
music;
visual
art;
dancing
and
singing
(BMA,
2011,
pp.9‐11).
 None
of
the
research
sources
drawn
upon
post‐date
the
Staricoff
review
for
Arts
Council
 England.


The
current
review


The
current
review
followed
the
procedures
employed
for
the
Arts
Council
England
review,
 and
searched
for
empirical
studies
of
arts
interventions
in
healthcare
settings
from
2004
 onwards.

The
details
of
the
method
employed
are
given
in
the
following
section.
It
was
 clear
from
the
results
of
the
searches
undertaken
that
the
very
large
majority
of
studies
 identified
were
concerned
with
musical
interventions
in
healthcare,
and
very
few
studies
 meeting
the
inclusion
criteria
were
found
concerned
with
the
impact
of
visual
arts
in
 healthcare
settings.

 This
is
an
area
that
deserves
more
research.
A
survey
conducted
in
the
waiting
room
of
a
 follow‐up
renal
clinic,
showed
that
magazines,
puzzle
books,
plasma
screens
and
paintings
 on
the
walls
were
given
higher
scores
than
window
views,
computers
or
potted
plants.

 





 






 1_{These
figures
under‐estimate
the
extent
to
which
these
reports
have
been
cited
as
the
search
process
relies} upon
the
exact
form
of
the
citation
given,
and
does
not
include
grey
literature
which
is
not
reflected
in
existing
 research
databases.


Patients
expressed
their
preference
for
landscapes,
animals
and
birds,
but
very
few
wished
 abstract
paintings
or
portraits
(Cusack,
2010).
Belver
(2010)
explore
the
value
of
arts
in
 ‘humanising’
the
environment
in
children’s
hospitals.
 Colour
and
lighting
in
hospital
environments
also
have
an
impact
on
patients
and
staff.
A
 well
designed
hospital
improves
the
quality
of
patient/staff/visitor
experience
and
it
could
 have
an
influence
on
time
of
recovery
and
sense
of
wellbeing
(Dalke,
2006).
A
recent
study
 on
the
effects
of
an
improved
primary
care
environment
showed
that
an
enhanced
 environment
resulted
in
improvements
in
patients’
perception
of
patient‐doctor
 communication,
reduction
in
anxiety
and
patient
and
staff
satisfaction
(Rice,
2008).
 Given
the
preponderance
of
studies
concerned
with
music,
the
current
review
focuses
on
 musical
interventions
in
the
context
of
healthcare.
The
importance
of
music
in
health
 interventions
is
increasingly
widely
recognized,
and
studies
exploring
the
effects
of
music
on
 cardiovascular
and
respiratory
functions
provide
evidence
for
the
importance
of
type
of
 music,
tempo,
rhythm,
and
indeed
pauses
in
music,
in
medical
care
(Larsen,
2011;
Lippi,
 2010).
 A
systematic
review
on
the
evidence
of
the
effect
of
introducing
music
for
hospital
patients
 has
been
recently
published
(Evans,
2011).
This
study
refers
solely
to
recorded
music,
and
 excludes
studies
involving
live
music.
The
author
found
that
music
reduces
anxiety,
but
its
 use
is
more
controversial
in
the
context
of
invasive
procedures,
and
there
is
a
need
for
 further
research
on
this
issue.


9


2


METHOD


This
study
focuses
on
studies
published
in
peer‐reviewed
publications,
covering
randomized
 and
non‐randomized
controlled
trials
and
also
systematic
and
non‐systematic
reviews.

It
is
 important
to
note
that
the
current
review
was
undertaken
rapidly
to
gain
an
overview
of
 developments
since
the
2004
review
undertaken
for
Arts
Council
England.
It
is
not
a
 systematic
review.

Such
reviews
are
more
focused,
time
consuming
and
expensive
and
 require
a
team
of
people
to
carry
out.
No
independent
quality
screening
and
data
extraction
 processes
were
carried
out
with
respect
to
the
studies
reviewed.
This
would
be
an
essential
 next
step
in
the
development
of
research
protocols
for
further
research
in
the
hospital.
 The
initial
strategy
for
identifying
relevant
research
on
arts
in
healthcare
environments
 involved
identifying
citations
for
Staricoff
(2004)
and
Staricoff
(2003)
in
Google
Scholar.

The
 advantage
of
starting
with
Google
Scholar
is
that
it
draws
upon
a
comprehensive
range
of
 existing
academic
bibliographic
databases,
and
also
very
rapidly
identifies
all
sources
citing
 papers
and
reports
which
are
considered
key
publications
in
the
field
to
be
reviewed.

The
 next
step
was
to
follow
the
search
procedure
originally
adopted
for
the
Arts
Council
review.

 The
following
electronic
databases
were
searched:
 Medline:

for
papers
on
the
effects
of
the
arts
on
medical
conditions
treated
within
the
 healthcare
environment
 EMBASE:

for
arts
and
clinical
outcomes
 CINAHL:
for
studies
on
nursing
and
allied
nursing
literature
 Cochrane
Library:
for
reviews
on
subjects
relevant
to
this
review
 
 The
following
internet
sites,
amongst
many
others,
were
consulted:
 www.tandf.co.uk/journals
 www.impact.arts.gla.ac.uk
 www.biomedcentral.com/singing
 
 A
number
of
sources
were
identified
from
hand‐searching
of
references
of
relevant
 publications.
 Keywords
 Arts
and
clinical
outcomes,
music
and
childbirth,
arts
and
pregnancy,
music
and
intensive
 care
units,
music
and
pain
management,
singing
and
health,
dance
and
health,
creativity
and
 health,
music
and
surgery,
amongst
many
others.
 
 


Research
studies
included
 The
criteria
followed
in
this
study
were:
 • Randomized
and
non‐randomized
controlled
trials
 • Evaluation
studies
with
data
collected
before
and
after
an
arts/music
intervention
 • Peer‐reviewed
studies
and
reports
from
other
reputable
sources
 • Survey
and
qualitative
studies
on
arts/music
interventions
carried
out
in
hospital
and
 healthcare
settings
 • Arts
and
music
in
healthcare
settings
and
arts
and
music
therapy
interventions
 • Studies

published
in
English
from
2004
onwards
 In
addition,
systematic
and
non‐systematic
reviews
of
existing
literature
on
arts
and
health
 which
covered
arts
interventions
in
healthcare
settings
were
drawn
upon.
 Studies
concerned
with
the
role
of
the
arts
in
the
treatment
of
mental
health
issues
were
 not
considered
in
this
review.
 One
thousand
and
hundred
and
fifty
references
were
identified,
and
one
hundred
and
three
 were
selected
for
inclusion
in
this
review.


11


3


FINDINGS


The
research
studies
identified
are
organised
according
to
the
principal
focus
of
the
 research.

The
following
headings
were
chosen
as
being
most
relevant
to
Chelsea
and
 Westminster
Health
Charity
in
considering
priorities
for
future
research
in
the
hospital:
 maternity,
neonatal/intensive
care,
children,
cardiovascular
conditions,
surgery
and
pain
 management,
lung
diseases,
and
oncology.
Inevitably,
there
is
some
overlap
in
the
issues
 addressed
in
these
different
sections.

As
noted
earlier,
this
review
is
focused
on
musical
 interventions
and
provides
an
overview
of
principal
findings
as
reported
by
the
researchers.

 Further
more
detailed
and
critical
reviews
of
specific
bodies
of
literature
would
be
needed
 in
the
development
of
research
protocols.


3.1
Maternity





Maya
Waldman
leads
a
Womb
Song
workshop
with
pregnant
women
at
Chelsea
and
Westminster
Hospital,
2011.
 The
influence
of
music
in
childbirth
has
been
the
subject
of
interest
for
decades,
however,
 there
are
few
well
designed
studies
showing
the
physiological
and
psychological
nature
of
 its
effects.
The
use
of
headphones
providing
previously
selected
music
by
a
group
of
women
 during
caesarean
delivery
showed
a
significant
decrease
in
the
level
of
anxiety,
and
a
higher
 level
of
satisfaction
regarding
the
procedure
experience
than
the
control
group
having
no
 music
intervention
(Chang,
2005).
A
review
evaluating
the
benefits
of
listening
to
music
 during
caesarean
section
under
regional
anaesthesia
(Laopaiboon,
2009)
showed
an
 improvement
on
pulse
rate
and
birth
satisfaction,
however
other
parameters
like
 respiration
rates
and
anxiety
levels
were
not
different
between
the
groups
receiving
or
not
 preferred
music
by
earphones.

 Another
study
explored
the
use
of
music
sessions
over
three
consecutive
days
for
mothers
 hospitalized
at
the
end
of
a
high‐risk
pregnancy
(Yang,
2009)
compared
to
those
in
similar
 situations
but
not
exposed
to
music.
The
authors
reported
a
significant
decrease
in
the
 levels
of
anxiety
which
was
reflected
in
reduced
heart
rates
and
stable
respiratory
rates.




The
effect
of
patient‐selected
music
was
investigated
on
early
postoperative
pain,
anxiety,
 blood
pressure
or
heart
rate
(Ebneshahidi,
2008;
Liu,
2010)
and
showed
that
pain
score
and
 consumption
of
analgesics
were
significantly
lower
among
patients
in
the
music
group,
 whereas
no
differences
were
found
on
anxiety
scores,
blood
pressure
or
heart
rate.
These
 findings
are
relevant
in
terms
of
improving
recovery
and
allowing
early
contact
between
 mother
and
child
during
the
time
in
hospital,
but
it
appears
that
the
effects
become
non‐ significant
in
the
post‐partum
period
at
home
(Tseng,
2010).



3.2
Neonatal
/
Intensive
Care





Copyright
NHS
Choices,
photographer
Vicki
Couchman
 There
are
different
opinions
of
whether
the
perception
and
ability
to
respond
to
music
is
 innate
or
learned;
studies
performed
in
a
number
of
healthy
neonates
(Winkler,
2009)
 strongly
support
the
view
that
an
interest
in
music
is
an
innate
ability
of
the
newborn
infant.
 This
understanding
has
motivated
a
number
of
investigations
on
the
value
of
music
 stimulation
for
preterm
infants
in
the
neonatal
intensive
care
unit
environment.
A
study
of
 the
effects
of
live
music,
recorded
music
or
no
music
therapy
over
three
consecutive
days,
 with
strict
control
of
environmental
noise
level
(Arnon,
2006),
showed
that
no
physiological
 and
behavioural
parameters
were
modified
during
the
30
minutes
of
music
intervention;
 however,
measurements
taken
at
intervals
after
the
therapy
ended
showed
a
significant
 decrease
in
heart
rate,
and
improved
behavioural
score.

Interestingly,
these
positive
results
 were
only
found
after
the
intervention
of
live
music.
Recorded
music
and
no
music
had
no
 significant
effect
in
those
parameters
(Arnon,
2006).

 Exposure
to
music
over
a
range
of
decibels
levels
(Dureau,
2005)
on
one‐day‐old
infants
 showed
no
significant
differences
in
heart
rate
or
behavioural
state
during
three
loudness
 levels.
An
analysis
of
clinical
records
after
discharging
pre‐term
infants
from
a
unit
that
 provided
a
program
of
multi‐modal
stimulation,
pacifier‐activated‐
lullaby
treatment
and
 parents
trained
stimulation
of
the
infants,
showed
that
those
infants
included
in
the
 program
gained
more
weight/day
and
were
discharged
earlier
than
those
not
included
in
it
 (Standley,
2010).
The
effect
of
music
in
growing
pre‐term
infants
showed
improved
weight
 gain.
A
potential
mechanism
could
be
an
increased
metabolic
efficiency
which
the
authors
 related
mainly
to
the
exposure
of
music
by
Mozart
(Lubetzky,
2010).



13


Another
aspect
to
consider
is
the
management
of
pain
in
neonatology.
Non‐pharmacological
 methods
are
increasingly
discussed
with
regard
to
pain
prevention
and
relief
either
alone
or
 in
combination
with
pharmacological
treatment.
A
review
was
carried
out
studying
13
 randomised
controlled
studies
and
two
meta‐analyses
(Cignacco,
2007).
Among
different
 types
of
non‐pharmacological
interventions,
the
study
examined
the
effects
of
different
 forms
of
music,
such
as
music
with
intrauterine
sounds,
instrumental
music
or
a
capella
 singing.

These
two
last
interventions
were
effective
only
in
preterm
infants
older
than
31
 weeks,
and
the
authors
recommended
that
music
should
not
be
provided
for
more
than
15
 minutes
due
to
the
risk
of
sensory
overload.
A
more
recent
review
(Hartling,
2009)
of
 randomised
controlled
trials
on
the
effects
of
music
for
medical
procedures
in
neonates
 showed
preliminary
evidence
of
some
therapeutic
benefit
of
music
intervention
for
specific
 medical
indications.

Those
trials
measured
pain
scores,
physiological
and
behavioural
 parameters
following
the
use
of
classical
music,
lullabies,
intra‐uterine
music,
and
compared
 the
results
with
similar
groups
not
receiving
this
type
of
intervention.

 A
pilot
study
designed
to
understand
whether
music
enhances
weight
gain
in
premature
 infants
on
fixed
feeding
regimens
assessed
the
levels
of
salivary
cortisol
and
heart
 variability,
in
groups
exposed
or
not
to
live
harp
music
(Kemper,
Hamilton,
2008).
The
 authors
reported
preliminary
encouraging
results
which
deserve
a
larger
study.

 It
has
been
found
that
neonates
responded
to
music
with
a
preference
for
lullabies
over
 adult
songs,
and
harmonic
music
over
dissonant
music.
It
is
also
interesting
to
explore
their
 preference
for
instrumental
and/or
instrumental
plus
vocal
music.
The
response
of
the
 newborn
to
music
is
evident
by
changes
in
heart
rate,
and
it
has
different
effects
on
 neonates
of
depressed
mothers
versus
non‐depressed
mothers
(Hernandez‐Reif,
2006)
 Neonates
of
depressed
mothers
showed
slower
processing
and
delayed
attention
compared
 to
neonates
of
non‐depressed
mothers.

 The
psychotherapeutic
influence
of
infant‐directed
singing
by
parents
promotes
and
support
 demonstrations
of
empathy
facilitating
development
and
bonding
in
the
parent‐infant
 relationship
(O’Gorman,
2006;
Neal,
2008).
The
effect
of
mother’s
singing
was
studied
in
a
 trial
using
pre‐recorded
singing
songs
by
the
mothers
of
full‐term
and
preterm
infants
 (Cevasco,
2008).
Although
the
results
did
not
reach
significant
difference,
it
is
interesting
 that
the
preterm
infants
who
listened
to
the
CD
recording
of
their
mothers’
singing
left
 hospital
an
average
of
two
days
earlier
than
those
in
the
control
group.

 A
pilot
study
(Blumenfeld,
2006;
Austin,
2010)
on
the
effects
of
mother’s
singing
during
 feeding,
did
not
find
significant
benefits,
but
the
overall
impact
of
music
in
premature
 neonates
was
shown
in
reduced
symptoms
of
stress,
faster
weight
gain,
and
shorter
stays
in
 the
neonatal
intensive
care
unit.
The
intervention
of
music
and
the
use
of
pacifier‐activated‐ lullaby
has
shown
a
maximum
benefit
when
applied
30
minutes
before
feeding
(Cevasco,
 2005;
Whipple,
2008;
Standley,
2010)
resulting
in
a
definite
trend
of
greater
weight
gain.

 Another
aspect
in
which
the
intervention
of
music
and
maternal
voice
has
produced
 significant
benefits
is
on
inconsolable
crying
of
premature
babies
(Keith,
2009).
This
study
 showed
a
significant
reduction
in
the
frequency
and
duration
of
this
episode,
and
also
had


significant
effect
on
improving
heart
and
respiratory
rate,
oxygen
saturation
and
blood
 pressure.

 The
attitude
of
medical
and
nursing
staff
in
a
neonatal
care
unit
towards
the
introduction
of
 live/recorded
music
was
very
favourable,
recorded
music
was
preferred
to
live
music
and
its
 value
was
recognised
regarding
the
reduction
of
stress,
crying
and
improved
sleep
in
 premature
babies
(Kemper,
2004).
Similar
results
were
found
by
other
authors
(Bouhairie,
 2006)
when
they
investigated
staff
attitudes
and
expectations
towards
music
in
a
paediatric
 oncology
unit
versus
a
neonatal
intensive
care
unit.
They
were
strongly
associated
with
prior
 musical
training
and
experience.
Staff
attitudes
are
not
barriers
to
providing
music
therapy
 in
neonate
intensive
care
units.








3.3
Children





Ian
and
Friends
puppet
show
at
the
Chelsea
and
Westminster
Hospital
Open
Day,
2011.
 Art
plays
a
very
important
role
in
creating
a
humanized
hospital
environment,
especially
in
 children’s
hospitals
where
the
relationship
between
art
and
artists
with
patients,
parents,
 carers
and
medical
staff
leads
to
improvements
in
children’s
management
and
beneficial
 clinical
and
emotional
outcomes
(Belver,
2010;
Belver,
2011).
The
authors
of
these
papers
 emphasized
the
importance
of
paying
attention
to
the
diversity
of
cultures,
parent’s
 opinions
and
patients
and
staff
participation
in
the
creative
processes.

 Music
interventions,
as
a
listener
or
as
an
active
music
making,
have
been
the
subject
of
 extensive
work.
However,
the
heterogeneity
of
interventions,
measurements
applied
and
 outcomes
found,
make
it
difficult
to
reach
definite
conclusions.
A
recent
review
(Naylor,
 2011)
of
seventeen
studies
showed
the
impact
of
music
intervention
on
clinical
outcomes
 such
as
reduction
in
migraine
frequency,
motor
impulsivity,
and
decreased
levels
of
salivary
 cortisol.
A
most
significant
effect
is
reported
with
respect
to
coping
behaviours,
especially
 those
related
to
grief
and
distress.
The
authors
concluded
that
there
is
an
urgent
need
of
 high
quality
research,
consensus
on
priorities
and
standardized
interventions.

 Practice
guidelines
for
music
interventions
in
children’s
hospitals
have
been
attempted


15


example:
on
analgesia,
distraction,
relaxation
or
sensory
stimulation.

It
is
also
important
 that
realistic
therapeutic
goals
and
clear
outcomes
are
specified.
Music
selection
and
 methods
of
delivery
are
essential,
and
the
responsibilities
of
medical
staff
in
recording
the
 physiological
and
psychological
effects
should
be
outlined.

 A
review
of
twenty
two
studies
on
the
intervention
of
music
in
paediatrics
(Robb,
2009)
has
 identified
gaps
in
planning
and
reporting
and
the
need
for
improving
the
evidence‐based
 practice.
A
systematic
review
for
pain
and
anxiety
in
children
undergoing
medical
 procedures
and
the
efficacy
of
music
therapy
found
that
this
intervention
was
effective
and
 promising,
but
concluded
that
it
should
be
taken
as
provisional
due
to
the
poor
quality
of
 the
studies
analysed
(Klassen,
2008).

 More
recently
(Irons,
2010a)
explored
the
issue
of
research
on
singing
intervention
for
 children
and
adults
with
bronchiestasis.
This
is
a
common
respiratory
disease
with
a
lung
 function
that
may
decline
with
time.
Singing
may
support
lung
function
and
enhance
quality
 of
life,
but
controlled‐randomized
studies
have
not
been
undertaken
as
yet
and
are
 necessary
to
establish
the
value
of
this
intervention.
The
same
methodology
was
followed
 and
similar
conclusions
reached
from
a
search
for
research
on
the
influence
of
singing
on
 lung
function
and
quality
of
life
for
children
and
adults
with
cystic
fibrosis
(Irons,
2010b).


 Authors
studying
the
effect
of
music
on
pain,
distress
and
anxiety
after
day‐surgery
found
 that
children
exposed
to
soft
and
relaxing
music
delivered
by
headphones
consumed
fewer
 analgesics
than
the
group
of
children
on
similar
circumstances
but
with
their
headphones
 turned
off
(Nilsson,
S.,
2009).
They
also
reported
less
distress,
but
there
were
not
changes
 on
other
aspects
of
the
post‐operative
process.
A
randomized
trial
studied
the
effect
of
 music
on
children
with
cancer
undergoing
lumbar
puncture
(Nguyen,
2010).
The
 measurements
included
pain
scores,
heart
rate,
blood
pressure,
respiratory
rate
and
oxygen
 saturation
taken
before,
during
and
after
the
procedure.
The
results
showed
that
listening
 to
music
through
earphones
reduced
pain
scores,
heart
and
respiratory
rates
and
levels
of
 anxiety
when
compared
to
the
control
group.
A
previous
randomized
controlled
trial
of
the
 active
music
engagement
on
children
with
cancer
(Robb,
2008)
found
that
this
intervention
 significantly
improved
coping‐related
behaviours
in
hospitalized
children
receiving
cancer
 treatment.
An
interesting
initiative
(Barry,
2010)
involved
children
creating
a
music
CD
prior
 to
their
first
radiation
treatment
for
cancer,
and
then
listening
during
treatment.
The
control
 group
received
standard
care.
The
authors
showed
that
this
intervention
was
engaging
and
 appropriate
and
the
trend
for
effective
coping
strategy
approached
significant
result.
The
 intervention
of
music
was
also
effective
in
controlling
anxiety
in
mechanically
ventilated
 patients
(Han,
2010)
and
in
children
following
cardiac
surgery
(Hatem,
2006).
Music
therapy
 was
also
beneficial
for
the
sedation
of
children
undergoing
different
medical
procedures
 (Loewy,
2006).

 
 
 


3.4
Cardiovascular
conditions



 Opus
IV
performing
at
Chelsea
and
Westminster
Hospital,
2006.
 A
recent
study
addresses
the
subject
of
the
effect
of
music
on
clinical
outcomes
(Bernardi,
 2011).
The
authors
aimed
to
assess
the
potential
clinical
intervention
of
different
types
of
 music
on
the
cardiovascular,
cerebrovascular
and
respiratory
systems,
as
well
as
in
the
 modulation
of
stress.
They
have
found
that
music
produced
an
increase
in
focused
attention
 of
the
listener,
and
it
was
proportional
to
the
speed
of
the
music
and
rhythm.
Pauses
or
 slower
rhythms
induced
a
relaxing
effect.
Measurements
of
ventilation,
blood
pressure
and
 heart
rate
showed
an
increase
with
faster
tempi,
while
pauses
induced
a
decrease
of
heart
 rate
and
blood
pressure.
The
choice
of
the
right
type
of
music
could
be
useful
in
the
 management
of
cardiovascular
diseases.


 A
study
found
the
greatest
benefit
on
health
with
classical
and
meditation
music
(Trappe,
 2010)
whereas
heavy
metal
or
techno
music
could
even
be
dangerous
leading
to
stress
and
 arrhythmias.
They
identified
the
music
by
Bach,
Mozart
and
some
Italian
composers
as
the
 more
beneficial.

A
previous
review
(Bradt,
2009)
concluded
that
listening
to
music
may
 have
a
beneficial
effect
on
blood
pressure,
heart
rate,
respiratory
rate,
anxiety
and
pain
in
 individuals
with
coronary
heart
disease,
but
more
research
is
needed
in
order
to
improve
 the
evidence.

 The
use
of
music‐assisted
relaxation
was
shown
to
be
effective
(Niet,
2011)
in
its
capacity
of
 inducing
and
improving
quality
of
sleep
in
patients
with
various
conditions.
The
 physiological
responses
of
patients
listening
to
music
in
the
intensive
care
unit
(Chan,
2009)
 showed
that
preferred
music
selected
by
the
patient,
induces
beneficial
physiological
 outcomes
mostly
in
female
groups
and
those
using
a
ventilator.
This
effect
of
music
therapy
 was
investigated
in
palliative
care
(Horne‐Thompson,
2008).
The
authors
found
a
significant
 reduction
of
anxiety,
pain,
tiredness
and
drowsiness
measurements.

 A
number
of
studies
focused
their
aims
in
evaluating
the
effects
of
music
listening
and
music
 therapy
as
a
useful
intervention
to
provide
stress
and
pain
relief
during
different
medical
 procedures.
Providing
patients
with
headphones
and
their
preferred
choice
of
music
in
the
 endoscopy
suite
has
resulted
in
a
reduction
of
sedation
amounts
compared
to
control
 groups,
with
results
approaching
significance,
and
a
29.7%
decrease
in
analgesia


17


those
patients
receiving
the
intervention
of
music.
Two
meta‐analysis
studies
followed
the
 last
paper
(Wilson,
2008;
Bechtold,
2009).
The
authors
were
able
to
confirm
that
listening
to
 music
during
a
colonoscopy
procedure
is
effective
in
reducing
the
time
and
amount
of
 sedation,
and
its
use
should
be
promoted.
The
intervention
of
listening
to
music
during
 colposcopy
reduced
significantly
the
levels
of
anxiety
of
women
undergoing
this
procedure
 (Galaal,
2009).


As
a
result
of
a
review
of
randomised
and
quasi
randomised
controlled
trials
 they
concluded
that
the
intervention
of
music
also
induced
a
significant
reduction
in
pain
 scores
(Cepeda,
2010).



3.5
Surgery
and
pain
management





Connaught
Opera
performing
on
a
surgical
ward
at
Chelsea
and
Westminster
Hospital,
2004
 The
intervention
of
music
in
surgery
has
been
addressed
by
a
number
of
authors
who
have
 evaluated
the
benefits
during
day
surgery,
anaesthesia
requirements,
pre‐operative
and
 post‐operative
measurements
(Leardi,
2007).
Patients
selected
music
delivered
through
 headphones
during
surgery
for
skin
cancer
(Perischetti,
2009;
Shenefelt,
2010)
resulted
in
a
 very
positive
response
of
first
time
patients,
with
increased
willingness
of
using
music
in
 repeated
surgical
procedures.


 The
impact
of
music
on
anxiety
levels
during
short
waiting
periods
in
day
surgery
(Cooke,
 2005)
was
reviewed,
showing
cost‐effective
benefits
after
implementation,
although
more
 research
is
needed.

 The
use
of
music
during
paediatric
laceration
repair
did
not
increase
the
proportion
of
 parents
who
were
involved
in
this
strategy
of
distraction
(Sobieraj,
2009).

 Anther
type
of
surgery,
which
mainly
affects
elderly
people,
is
total
knee
replacement.
 These
patients
have
a
slow
and
painful
time
of
recovery
which
induces
anxiety
and
 depression.
Music
therapy
and
singing,
as
a
non‐pharmacological
intervention
have
 significantly
improved
the
psychological
distress
of
these
patients
(Giaquinto,
2006;
 McCaffrey,
2006)
and
induced
a
reduction
of
perceived
pain
(Simcock,
2008).


 The
use
of
music
in
operating
theatres
has
taken
place
for
decades;
however,
the
 understanding
of
its
effects
on
sedation
and
amounts
or
anaesthesia
required
is
a
more
 recent
development.
A
study
to
determine
whether
the
decrease
in
sedative
requirements


was
the
result
of
music
or
the
elimination
of
operating
room
noise
(Ayoub,
2005)
concluded
 that
when
controlling
for
room‐noise,
the
use
of
a
favourite
CD
by
the
patient
resulted
in
 almost
significantly
less
requirement
of
sedative,
such
as
propofol.

Other
studies
(Zhang,
 2005;
Bringman,
2009)
have
not
only
confirmed
the
results,
but
found
a
significant
 reduction
in
mean
induction
of
sedation
and
amount
of
intraoperative
propofol
during
 combined
spinal‐epidural
anaesthesia
in
the
group
that
listen
to
music
compared
to
control.

 Ten
journal
articles
were
reviewed
regarding
the
use
of
music
in
the
operating
theatre
 during
monitored
anaesthesia
care
(Newman,
2010).
The
conclusions
of
this
review
showed
 that
the
intervention
of
music
is
highly
beneficial;
significantly
reducing
the
amount
of
 sedation
required,
reduces
recovery
time,
and
prevents
in
many
cases
the
need
for
 converting
to
general
anaesthesia.

 A
protocol
for
evaluating
the
use
of
music
for
pre‐operative
anxiety
identifies
the
main
 points
to
take
into
consideration,
such
as:
the
effects
of
music
therapy
versus
patient
 selected
music;
the
efficacy
of
patient‐preferred
music
versus
researcher‐selected
music,
 and
the
overall
effect
of
music
on
pre‐operative
anxiety
(Dileo,
2010b;
Ganidagli,
2005).
The
 intervention
of
music
has
been
shown
to
be
very
effective
in
the
post‐operative
 management
of
pain
(Tse,
2005;
Good,
2005;
Good,
2010).
This
strategy
induced
significant
 decreases
in
pain
intensity
over
time;
patients
had
a
lower
systolic
blood
pressure
and
heart
 rate,
and
needed
fewer
doses
of
analgesics.

 A
randomized
clinical
trial
was
conducted
to
analyse
the
effect
of
music
in
stress
response
 to
cardiac
surgery
(Nilsson,
2009a;
Hatem,
2006)
on
the
first
post‐operative
day
after
 cardiac
surgery.
Measurements
of
vital
signs
and
cortisol
levels
have
indicated
the
clinical
 value
of
listening
to
music
while
resting
in
bed
after
open
heart‐surgery.
In
the
same
type
of
 patients
the
introduction
of
soothing
music
increased
oxytocin
(a
hormone
with
anti‐stress
 effects)
levels,
as
demonstrated
by
another
randomized
controlled
trial
(Nilsson,
2005;
 Nilsson,
2009b).
Older
people
undergoing
cardiovascular
surgery
who
listen
to
music
 showed
less
anxiety
and
shorter
time
of
intubation
(Twiss,
2006;
Chan,
2006).

 A
study
exploring
a
different
type
of
surgery
such
as
solid
organ
transplant
(Madson,
2010)
 found
that
music
therapy
is
a
valuable
psychosocial
intervention
indicating
significant
 improvements
in
self‐reporting
levels
of
anxiety,
pain,
and
nausea.
In
a
study
regarding
 post‐operative
pain
after
different
types
of
surgery,
the
inclusion
of
music
as
a
nursing
 intervention
showed
a
lower
use
of
analgesics
(Engwall,
2009;
Camara,
2008).
The
 requirement
of
morphine
consumption
after
surgery
in
school‐aged
children
(Nilsson,
S.,
 2009)
was
reduced
in
the
music
group
compared
to
the
control
group.

However,
another
 study
does
not
support
the
use
of
music
during
surgery
due
to
the
lack
of
conclusive
results
 (Szmuk,
2008).
An
exploratory
study
(Sand‐Jecklin,
2010)
has
found
a
positive
impact
of
live
 music
on
patients
admitted
to
hospital.
The
therapeutic
effect
of
this
intervention
showed
a
 reduction
on
the
level
of
pain,
anxiety
scores
and
muscle
tension
levels.
The
post‐operative
 analysis
in
the
quality
of
indicators,
such
as
length
of
stay
and
level
of
medication
on
 patients
after
brain
surgery
(Walworth,
2008)
showed
a
clear
improvement
after
live
music


19


A
systematic
review
on
the
anxiety
and
pain‐reducing
effects
of
music
interventions
 (Nilsson,
2008)
included
42
randomized
controlled
trials
in
perioperative
settings.
More
than
 half
of
the
reviewed
studies
showed
a
positive,
low
cost
potential
of
implementation
of
this
 intervention
addressing
patients’
distress.
Another
review
(Cepeda,
2010)
on
the
effect
of
 music
on
acute,
chronic
or
cancer
pain
relief
concluded
that
listening
to
music
reduces
pain
 intensity
levels
and
opioid
requirements,
but
the
effects
were
not
always
significant,
and
its
 use
in
clinical
practice
remains
unclear.
The
need
for
more
research
on
the
clinical
effects
of
 music
intervention
is
emphasized
in
a
review
(Bradt,
2010)
of
studies
on
mechanically
 ventilated
patients.
The
findings
suggested
that
music
listening
may
have
a
beneficial
effect
 on
heart
and
respiratory
rates
and
anxiety
levels.


3.6
Lung
diseases





Phoene
Cave
leads
a
Singing
for
Breathing
workshop
at
Royal
Brompton
&
Harefield
NHS
Foundation
Trust.
 Non‐pharmacological
interventions
for
alleviating
shortness
of
breath
due
to
terminal
 cancer
or
respiratory
diseases
were
reviewed
(Bausewein,
2010).
Among
others,
music
 induced
breathing
training
appear
to
be
effective,
but
there
is
currently
not
enough
data
to
 judge
the
evidence
and
its
benefits.
Singing
classes
as
a
therapy
for
chronic
respiratory
 disease
(Lord,
2010)
have
shown
to
have
a
beneficial
effect
in
reducing
anxiety
and
had
no
 adverse
consequences.
Measurements
of
pulmonary
function
and
quality
of
life
were
 conducted
after
weekly
classes
of
singing
practice
(Bonilha,
2009).
The
authors
found
a
 significant
difference
on
changes
of
one
of
the
functional
respiratory
tests,
maximal
 expiratory
pressures
contributing
to
a
better
quality
of
life
and
respiratory
improvement.
A
 very
interesting
study
on
the
mechanisms
of
breathing
patterns
and
respiratory
muscle
used
 by
subjects
with
spinal
cord
injury
(Tamplin,
2011)
found
that
the
application
of
therapeutic
 singing
training
resulted
in
functional
improvements
in
those
patients.
The
evidence
base
to
 support
the
inclusion
of
music
and
singing
in
treatments
and
care
of
older
people
is
 increasing
(Skingley,
2010)
but
more
research
is
needed
to
support
the
findings
and
 elaborate
a
strategy
for
implementation.



3.7
Oncology





Sun
by
Lucy
Algar,
2003,
commission
for
The
Macmillan
Centre
at
Chelsea
and
Westminster
Hospital.
 A
protocol
for
investigating
the
effects
of
music
intervention
on
psychological
and
 physiological
outcomes
on
patients
with
cancer
(Dileo,
Bradt,
Grocke,
et
al.,
2010)
has
been
 outlined.
Their
objectives
include
the
identification
of
randomised
controlled
trials,
the
 comparison
between
music
therapy
and
standard
care
and
music
therapy
versus
other
types
 of
music
delivery.
A
review
will
follow
to
address
these
objectives.
Previous
reviews
and
 studies
on
the
subject
(Pothoulaki,
2006;
Hanser,
2006;
O’Callaghan,
2006)
concluded
that
 more
evidence
is
needed
to
validate
the
benefits
of
music
intervention
in
cancer
care.
A
 group
of
patients
who
listened
to
music
during
bone
marrow
biopsy
aspiration
(Shabanloei,
 2010)
had
lower
anxiety
and
pain
levels
than
those
who
did
not
have
music.
A
cross‐ sectional
survey
was
carried
out
during
two
years
in
a
paediatric
oncology
clinic
(Kemper,
 2008)
in
order
to
understand
parents’
attitudes
and
expectations
about
music
intervention
 on
paediatric
leukaemia
patients.
The
results
showed
that
parents
and
clinicians
have
 positive
attitudes
and
posed
no
barriers
for
the
use
of
music
in
children
units.



21


4


CONCLUSIONS



This
review
of
the
literature
on
arts
in
health
has
identified
one
hundred
and
three
studies
 offering
strong
evidence
of
the
effect
of
music
interventions
on
psychological
and
 physiological
outcomes
of
patients
in
healthcare
environments.
This
positive
contribution
is
 described
for
a
number
of
different
areas
within
the
healthcare
setting,
but
also
discusses
 studies
which
found
controversial
or
unclear
results.

The
findings
of
this
review
show
that
 the
contribution
of
music
to
healthcare
is
of
a
great
importance
in
creating
a
humanized
 environment,
decreasing
levels
of
stress,
anxiety
and
depression,
reducing
drugs
 consumption,
and
shortening
length
of
stay
in
hospital.
 Future
research
should
incorporate
and
analyse
rigorously
the
contribution
of
a
wider
 spectrum
of
arts
intervention.
Visual
art:
landscapes,
portraits
or
abstract
paintings?
A
 research
project
considering
which
type
of
paintings/photographs
are
the
most
appropriate
 for
different
areas
of
the
hospital
evaluating
the
emotional
and
physiological
response
on
 patients
is
important.

There
are
few
studies,
however
the
confirmation
of
their
contribution
 to
a
reduction
on
drugs
consumption
and
length
of
stay
in
hospital
requires
further
 research.
It
is
accepted
that
patients
with
neurological
diseases
are
benefited
by
the
 contribution
of
literature,
poetry
and
singing.
A
research
showing
conclusive
clinical
 outcomes
should
provide
valuable
evidence,
beyond
anecdotal
information.

The
 contribution
of
creative
writing,
dance
and
drama/theatre
is
still
waiting
to
be
evaluated
in
 relation
to
the
psychological
and
physiological
responses
of
patients
in
a
hospital
 environment.
The
evaluation
of
the
effect
of
integrating
different
art
forms
into
the
 healthcare
culture
requires
new
and
challenging
ideas
which
could
induce
unforeseen
 benefits
for
patients
and
the
National
Health
Service.
 Finally,
an
important
aspect
to
be
considered
when
establishing
a
research
project
in
a
 hospital
environment
is
the
strategy
for
recruiting
patients
and
staff.
It
is
important
to
tailor
 the
objectives
and
measurements
to
each
participating
unit,
considering
the
diversity
of
 gender
and
cultures
in
the
development
of
strategies
(Chlan,
2009).









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