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DOI: 10.1177/1099800411413259

2012 14: 277 originally published online 27 June 2011Biol Res NursYen-Ju Lin, Kuo-Cheng Lu, Ching-Min Chen and Chia-Chi Chang

HemodialysisThe Effects of Music as Therapy on the Overall Well-Being of Elderly Patients on Maintenance

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The Effects of Music as Therapy on theOverall Well-Being of Elderly Patients onMaintenance Hemodialysis

Yen-Ju Lin, RN1, Kuo-Cheng Lu, MD2,3, Ching-Min Chen, RN, DNS4, and

Chia-Chi Chang, RN, PhD5

Abstract

In this study, the authors explored the use of music during hemodialysis (HD) as a complementary therapy to improve overallwell-being in elderly patients. The authors recruited a convenience sample of 88 patients on maintenance HD from a teachinghospital in northern Taiwan and randomly assigned them to either an experimental group (n 44) or a control group (n 44). In the first week, participants in the experimental group created their own music playlists. During the second week, theseparticipants listened to music from their own playlists during each HD session (three times/week). The authors evaluated the

effects of music as therapy by assessing its impact on perceived stressors and adverse reactions during HD (HD Adverse Reac-tions Self-Assessment Scale and HD Stressor Scale [HSS]) and measuring changes in physiological indices during the course of themusic listening. After 1 week of the use of music as therapy during HD, the authors noted significant reductions in the frequency

and severity of adverse reactions during dialysis and in scores on the HSS, p < .001. The authors also observed significantlydecreased respiratory rate and significantly increased finger temperature and oxygen saturation, p < .001, during the same period.In conclusion, listening to music during HD may promote overall patient well-being. It may thus serve as a complementary form oftherapy that facilitates care and delivery of adequate dialysis and thus improves overall patient well-being in the long run.

Keywords

music, hemodialysis, adverse reactions, end-stage renal disease (ESRD)

Taiwan currently holds the dubious honor of having the highest

incidence and prevalence of chronic kidney disease requiringlong-term hemodialysis (HD) worldwide (United States Renal

Data System, 2010). Of these end-stage renal disease (ESRD)

patients on HD, 44.65% are over 65 years of age (Taiwan

Bureau of National Health Insurance, 2011). Older patients

often have multiple comorbidities and are more likely to

experience greater degrees of physical and psychological func-

tional decline. Elderly patients are also more likely to develop

adverse reactions during HD, such as hypotension, muscle

cramping, nausea, vomiting, headache, and chest pain (Tan

& Yang, 2005). HD treatment is thus often a source of stress

and anxiety for these patients; they are more inclined than

younger patients to ask for earlier termination of treatment or

to skip scheduled HD treatments altogether, frequently com-promising the adequacy of dialysis therapy.

Management of adverse reactions during HD usually only

provides symptomatic relief and cannot fully prevent patients

from having recurrent reactions during subsequent HD ses-

sions. Current recommended strategies to manage and prevent

these adverse reactions may have unintended consequences as

well. Thus, alleviating the physical discomfort and emotional

distress, these patients experience remains a major concern in

clinical practice.

Previous studies have shown that unique characteristics in

the melody and rhythm of certain types of music can relievestress and help receptive patients relax, with investigators

observing lower levels of blood pressure (BP) as well as

decreased respiratory and basal metabolic rates in these

patients (Glynn, 1986; Kemper & Danhauer, 2005). Research-

ers and clinicians have used music therapy for the treatment of

stress and depression, as well as for sleep induction, pain alle-

viation, muscle relaxation, and attempts to enhance immune

function against infection (Burns, Harbuz, Hucklebridge, &

1 Dialysis Center, Department of Nursing, Cardinal Tien Hospital, New Taipei

City, Taiwan, Republic of China2

School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan,Republic of China3 Division of Nephrology, Cardinal Tien Hospital, New Taipei City, Taiwan,

Republic of China4 Department of Nursing, College of Medicine, National Cheng-Kung

University, Tainan, Taiwan, Republic of China5 School of Geriatric Nursing and Care Management, College of Nursing, Taipei

Medical University, Taipei, Taiwan, Republic of China

Corresponding Author:

Chia-Chi Chang, No. 250, Wu-Xing St. Taipei 110, Taiwan, Republic of China

Email: [email protected]

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Bunt, 2001; Chang & Sung, 2005). Music therapy may also

serve as a distraction for patients and decrease awareness of the

passage of time during HD sessions, which may improve

treatment outcomes.

We hypothesized that listening to music during HD would

decrease the level of anxiety and stress that many older patients

experience during these sessions, thus facilitating patient adjust-

ment to and acceptance of HD treatment. In the present study,

we explored the effects of music therapy on the incidence and

severity of adverse reactions during HD treatment and

measured changes in biophysical parameters during treatment.

Background

Factors Associated With Adverse Reactions During HDSessions

The adverse reactions patients most commonly experience

during HD are hypotension (2550%), muscle spasm (520%),

nausea and vomiting (515%), headache (5%), chest pain(25%), back pain (25%), pruritus (5%), fever and chills (1%;

M. S. Wu, 2007). Though there are current recommended

guidelines for the prevention and management of these adverse

reactions, elderly patients with ESRD often have comorbidities

such as cardiovascular disease and autonomic dysfunction which

limit their ability to cope with physiological stressors and main-

tain hemodynamic stability during the HD procedure (Li, Jiang,

& Xu, 2008). Elderly diabetic patients with ESRD, who comprise

the largest group of patients on long-term HD, are particularly at

risk and have significantly higher morbidity and mortality rates

(Wang, 2007). Thus, effective prevention and management of

these potentially life-threatening adverse reactions are needed

to improve patient safety and well-being (Sulowicz & Radzis-

zewski, 2007), as well as to improve adherence to therapy.

The Physiological, Psychological, Social, and Spiritual

Aspects of Music Therapy

Music is perceived by the cochlear nerve, which subsequently

transmits neural signals to the cortex, activating the limbic sys-

tem. The limbic system then relays signals to the pituitary

gland, which releases endorphins that possess analgesic proper-

ties, thus causing decreased perception of pain signals (Beck,

1991). Music also has the ability to decrease pressure-

dependent adrenocorticotropic hormone (ACTH) stimulationand cortisol release, resulting in decreased catecholamine

secretion from the adrenal medulla. The consequent changes

in BP, heart rate, respiratory rate, temperature, and serum free

fatty acids have beneficial effects on the cardiovascular,

respiratory, musculoskeletal, and nervous systems as well as

the bodys metabolism, such as the alleviation of migraine

headache and hypertension and easing of muscle tension, and

may lower the risks associated with coronary heart disease and

stroke (Cook, 1986; Mockel et al., 1994). Research has also

shown that music increases the rhythmicity of alpha brain

waves, which is associated with improvements in memory and

creativity during conscious meditation (Wang, 2002).

In addition, investigators have reported that music therapy

makes receptive individuals feel a sense of peace and comfort,

eliminating negative, hostile, and anxious thoughts and

increasing motivation (Beck, 1991; Brown, Martinez, & Par-

sons, 2004; Prinsley, 1986). Menon and Levitin (2005) demon-

strated that listening to music regularly increases dopamine

release, producing positive thoughts, and a sense of well-

being. Other researchers have shown that music therapy pro-

motes social interactions, reducing avoidance behavior and

increasing the chance of participation in social organizations

(Prinsley, 1986; Wang, Yeh, & Chang, 2003).

Principles of Implementation of Music Therapy

Gerdner (2000) and Lai (2004) found that, prior to the imple-

mentation of music therapy, researchers or clinicians must ade-

quately assess patients personal background and information

regarding their preferences in music to maximize the potentialeffects of treatment. The characteristics of relaxing music

appropriate for music therapy include a slow tempo (60*80

crotchet beats per minute), low-to-medium pitch, low volume,

and melodious rhythms comprised mostly of wind instruments

(OSullivan, 1991). Staum and Brotons (2000) reported that

keeping the volume at 6070 dB maximizes relaxation and

reduces psychological stress. During the course of music ther-

apy, which is best conducted individually in a quiet room, the

clinicians or researchers encourage the patient to assume a

relaxed and comfortable position and listen to the music for

2045 min (Wang et al., 2003). They might also provide

patients with headphones to reduce ambient and background

noise and set playlists on automatic replay to minimize inter-ruptions during sessions and maximize treatment effects (Beck,

1991; S. Lee, Lieu, & Chen, 1999).

Effects of Music Therapy in the Clinical Setting

Researchers have studied music therapy as a complementary

treatment in a variety of medical fields. Midwives have used

music therapy to reduce stress and anxiety during labor,

increase concentration, and facilitate positive experiences for

the mother and her relatives (Chang & Chen, 2005). Richard-

son, Babiak-Vazquez, and Frenkel (2008) likewise reported

that music therapy effectively reduced pain, discomfort, and

anxiety in the palliative care of cancer patients. Hilliard(2005) showed that music therapy facilitates the building of

patient relationships with caregivers and other patients and

improves patients quality of life. Among patients with chronic

psychosis, Wang et al. (2003) demonstrated that music therapy

reduces negative symptoms associated with these chronic con-

ditions and improves social interaction and levels of interest in

patients surroundings. In pediatrics, L. Lee, Chan, Ho, Cheng,

and Su (2005) found that music therapy improves learning

motivation in autistic children, increasing cognitive and con-

versational abilities.

278 Biological Research for Nursing 14(3)


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Patients on HD often present with acute complaints that need

immediate attention. In maintenance HD patients, music ther-

apy has had beneficial effects on stress, anxiety, and depression.

Investigators have also noted increased blood oxygen saturation

in these patients (Kim, Lee, & Sok, 2006; Lin, Chen, Kuo,

Wang, & Huang, 2007). To date, however, there is little evi-

dence in the literature regarding the effects of music therapy

on the well-being of patients on HD, especially the elderly.

Method

Design and Setting

The Ethics Committee on Human Studies at Cardinal Tien

Hospital, Taipei, Taiwan, approved the study protocol. We

obtained written informed consent from each patient who par-

ticipated. We recruited a convenience sample of 88 HD patients

and randomly assigned them to the experimental (n 44) or

control group (n 44) by flipping a coin. Patients deemed eli-

gible for enrollment in the study were aged 60 years and over,

known to have ESRD for at least 3 months, on maintenance

HD three times every week (4 hr/per session) and able to

communicate effectively in Mandarin or Taiwanese. Patients

with severe cognitive or hearing impairments and those with

pacemakers were excluded from this study.

In the first week, patients in the experimental group selected

and created their own music playlists. During the second week,

the experimental group listened to music from their own play-

list during each HD session (three times/week). We evaluated

the effects of the music therapy by assessing its impact on stres-

sors and adverse reactions during HD (HD Adverse Reactions

Self-Assessment Scale and HD Stressor Scale [HSS]) and mea-

suring changes in physiological indices during the course of thetreatment (Figure 1). We checked the physiological indices

every 30 min for the entire HD treatment and averaged data

from eight time points (30, 60, 90, 120, 150, 180, 210, and

240 min after HD initiation) to obtain the postintervention mea-

sures for each patient.

InstrumentsDemographic data. To account for possible confounding fac-

tors during analysis, we recorded and controlled for the

A subject is deemed eligible for enrollment

and qualified based on sample criteria

Subjects are randomly assigned to experimental

or control group by coin flip

Informed consent is secured for enrollment in study

Experimental group Control group

Pretest data collection:

First HD session, Week 1: Demographics

Sheet and HSS.

Last HD session, Week 1:

- During HD: physiological monitoring

- After HD: HD Adverse Reactions Self-

Assessment Scale and music selection.

Pretest data collection:

First HD session, Week 1: Demographics

Sheet and HSS.

Last HD session, Week 1:

- During dialysis: physiological monitoring


Assessment Scale

Regular clinical care with music therapy Regular clinical care only

Posttest data collection:

Last HD session, end of week 2:



Assessment Scale and HSS

Posttest data collection:

Last HD session, end of week 2:



Assessment Scale and HSS

Data processing and analysis

Figure 1. Data-collection process. Note. HD

hemodialysis; HSS

HD Stressor Scale. Coin flip results: subjects on Mon-Wed-Fri HDschedule were assigned to the experimental group; subjects on Tue-Thu-Sat HD schedule were assigned to the control group.

Lin et al. 279


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following demographic data: age, sex, education level, marital

status, time on HD, comorbidities, and musical preferences.

Hemodialysis Adverse Reactions Self-Assessment Scale. Adapted

from relevant literature and clinical nursing management expe-

rience, the self-assessment scale contained 17 common adverse

reactions that may occur during HD (Tan & Yang, 2005;

Tanimu et al., 2000; M. S. Wu, 2007). We used 4-point

Likert-type scales to quantify symptom frequency (0 none,

1 once or twice, 2 35 times, and 3 more than 5 times)

and severity (1 only mildly ill, 2 moderately ill, 3 seri-

ously ill, and 4 extremely ill). Frequency scores ranged

between 0 and 51, with higher scores indicating a higher fre-

quency. Severity scores ranged between 17 and 68, with higher

scores likewise representing a greater severity. Cronbachs a of

the scale was .662 and coefficient of variation (CVI) was .91.

Hemodialysis Stressor Scale. The HSS (Chou, 2002) is a 32-

item scale used to rate the incidence and severity of stressors

associated with HD. Subjects rated the extent of being troubledby each of the 32 stressors using a 4-point scale (0 not at all,

1 slightly, 2 moderately, and 3 a great deal). We

obtained a subtotal score for each construct by summing the

ratings for each; the higher the score, the greater the stress.

We used the HSS for both longer-term recall (i.e., 12 months

prior to study) and more immediate recall (during the Week 2

of the study period). Cronbachs a of this scale was .905 in the

current study.

Physiological indicators. We used a biological monitoring sys-

tem (GE Medical Systems Information Technologies, Inc.,

Milwaukee, WI) to monitor and record data regarding BP, heart

rate, respiratory rate, and oxygen saturation. The Departmentof Health, Executive Yuan and the Bureau of Standards

(2010), Metrology and Inspection approved this system. A cer-

tified engineer made any necessary adjustments.

When individuals are in a state of relaxation, parasympathetic

effects are enhanced, leading to capillary expansion and an

increase in the surface temperature of the fingers. Investigators

can measure this physiological change and use it as an indicator

of emotional state (P. H. Chen, 2003; Kistler,Mariauzouls,& von

Berlepsch, 1998). For the current study, we measured finger

surface temperature using the TEMPviewTemperature Feedback

Monitor,with an accuracy within 0.1 C (TM-903A, Ronmac Int.

Corp, Taipei, Taiwan, manufactured in 2009).

Intervention

In the first week, we encouraged participants in the experimen-

tal group to choose their favorite musical styles by listening to

the first 30 s of each of the songs on the complete playlist with 5

s intervals between songs. There were three songs to choose

from in each music category and participants had free rein to

select and eliminate songs and music categories to create their

own personal playlists, which we then recorded for each

participant. All available selections were melodic instrumental

music with a tempo of 6080 beats per min.

During the second week, participants in the experimental

group received music as therapy during every HD session.

They wore earphones to eliminate background noise and

selected music from their own playlists. Participants could lis-

ten to music for the first 20 min of every hour for the first 3 hr

of HD. For the fourth hour, we asked participants to listen to

music during the last 20 min of HD treatment. We did not pro-

vide the control group with any music at all during HD.

Statistical Analysis

We express continuous variables as means + SD and catego-

rical values as percentages. We tested normal distribution of

samples using the KolmogorovSmirnov test and performed

comparisons between groups using Students t test or Mann

Whitney U test (according to data characteristics). We used

Fishers exact test or chi-square analysis to analyze categorical

data, Wilcoxons signed ranks test to analyze the differences

between pretest and posttest in the experimental group, and

Spearman rank correlation coefficient test to examine the cor-

relations between age, the habit of listening to music, and other

indices. We consider a p value < .05 to be statistically signifi-

cant. We used the Statistical Package for the Social Sciences

(SPSS/PC, SPSS, Inc., Chicago, IL) for our statistical analyses.

Results

Baseline Data and Physiological Parameters

We cross-referenced patient demographic data with currently

available nationwide research data (Chang, 2005; L. H. Lee,2003; Sung, Chang, & Abbey, 2006). We found no statistically

significant differences between the experimental and control

groups with regard to sex, level of education, marital status,

religion, annual income, living arrangement, length of time

on HD and duration of each session, average frequency and

severity of adverse reactions, HSS scores during HD, or phy-

siological indices (Table 1). The experimental group had a

lower mean age (69.11 + 7.88 versus 75.55 + 9.16, p

.001) and its members were more likely to have a habit of lis-

tening to music (w2 19.17, p < .001) compared to the control

group.

Since we noted significant differences between the two

groups with respect to age and the habit of listening to music,we used the Spearmans rank correlation coefficient to analyze

the relationships between these two demographic variables and

the physiological parameters in all the patients (Table 2). We

found a negative correlation between age and diastolic BP (r

.332, p .002), which might be due to the decreased elas-

ticity and compliance of arteries that occurs with age (M. F.

Chen, 2009). We found no statistically significant correlation

between the habit of listening to music and any of the physio-

logical parameters or with respect to sources of stress and the

frequency and severity of adverse reactions during HD.



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Analysis of Variables Before and After Music Therapy

The frequency and severity of adverse reactions as well as scores

on the HSS decreased significantly after three sessions (1 week)

of music as therapy (see Table 3). Respiratory rate and finger

temperature also significantly decreased, and oxygen saturation

significantly increased. We found no significant differences with

respect to heart rate, systolic and diastolic BP (DBP), including

the percentage of systolic BP (SBP) below 100 mmHg.

Table 1. Demographic and Baseline Variables of the Two Groups (N 88)

Variable Experimental (n 44) Control (n 44) p

Age 69.11 + 7.881 75.55 + 9.156 .001a**SexFemale 22 (50) 29 (65.9) .131b

Educational level .389c

Uneducated (illiterate) 7 (15.9) 13 (29.5)

Elementary school 19 (43.2) 18 (40.9)Junior high school 6 (13.6) 7 (15.9)High school 6 (13.6) 4 (9.1)College, university, and above 6 (13.6) 2 (4.5)

Marital status .113c

Single 3 (6.8) 2 (4.5)Married 28 (63.6) 18 (40.9)Divorced 0 1 (2.3)Separated 0 1 (2.3)Widowed 13 (29.5) 22 (50.0)

Religion .588c

None 2 (4.5) 4 (9.1)Chinese traditional religion 38 (86.4) 37 (84.1)Christianity 4 (9.1) 2 (4.5)Catholicism 0 1 (2.3)

Annual income .300c

Insufficient 5 (11.4) 10 (22.7)Enough 23 (52.3) 24 (54.5)Good 12 (27.3) 6 (13.6)Very good 4 (9.1) 4 (9.1)

Lives with familyNo 5 (11.4) 7 (15.9) .379b

Length of time on hemodialysis (years) 6.80 + 5.290 4.42 + 3.584 .054a

Duration of hemodialysis sessions .183c

< 4 hr 2 (4.5) 4 (9.1)4 hr 39 (88.6) 40 (90.9)> 4 hr 3 (6.8) 0

Number of other chronic diseases .461c

0 6 (13.6) 1 (2.3)1 7 (16.0) 13 (29.5)

2 21 (47.7) 21 (47.7) 3 10 (22.7) 9 (20.5)

Habit of listening to musicNo 17 (38.6) 37 (84.1) .000b***Frequency of adverse reactions score 2.36 + 2.934 1.93 + 2.491 .415a

Severity of adverse reactions score 2.45 + 3.605 1.77 + 2.144 .505a

Hemodialysis Stressor Scale score 27.00 + 17.032 28.18 + 15.919 .573a

SBP (mmHg) 134.60 + 18.992 133.66 + 18.570 .815a

DBP (mmHg) 70.05 + 9.665 66.26 + 9.492 .081a

% of SBP < 100 mmHg 5.52 + 11.2 7.79 + 17.82 .952a

Heart rate (beats/min) 71.59 + 15.345 71.50 + 10.582 .611a

Respiratory rate (breaths/min) 18.52 + 1.944 18.87 + 1.903 .537a

Finger temperature (C) 31.85 + 1.912 31.31 + 1.988 .163a

Oxygen saturation (%) 98.43 + 1.022 98.16 + 0.938 .125a

Note. Continuous variables are expressed as mean + SD; categorical variables are expressed as n (%).

DBP diastolic blood pressure; SBP systolic blood pressure.a Chi-square test.b Fishers exact test.c MannWhitney U test.** p < .01.*** p < .001.

Lin et al. 281


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Comparison of Change in Variables After Music

Therapy Between the Two Groups

The incidence and severity of adverse reactions as well as

scores on the HSS significantly decreased after 1 week of

music therapy compared to the control group (see Table 4).

Subsequent analysis of the 32 items in the HSS showed signif-

icant alleviation of stress after music therapy with regard to

nine stressors: poor/inadequate A-V fistula function, itch-

ing, hypotension, loss of bodily function, limitation

of activity, sleep disturbances, coping with family

responsibilities, vacation limitations, and frequency of

hospitalizations. Respiratory rate decreased significantly and

oxygen saturation increased significantly in the experimental

group compared to the control group after 1 week of music

therapy.

Discussion

The Effects of Music as Therapy in Reducing theFrequency and Severity of Adverse Reactions During HD

Our results show significantly reduced frequency and severity

of adverse reactions after music therapy in the experimental

group compared to the control group. Pothoulaki et al. (2008)found that music therapy attenuated the perception of pain in

patients undergoing HD. Investigators have also observed

improved BP control, reduced respiratory rate, muscle rel-

axation, and alleviation of nausea and vomiting after music

therapy (Beck, 1991; Brown et al., 2004; Cook, 1986; Menon

& Levitin, 2005). Thus, music therapy may help improve

patient compliance with HD treatment and promote adequacy

of dialysis, especially among elderly patients, who are more

likely to both experience adverse reactions during HD and to

ask to discontinue treatment because of them (Inrig, 2010).

Listening to Music and Sources of Stress

Our results also show that music therapy can mitigate the

effects of stress in HD patients. These results are consistent

with the results of Giedts (1999) study, which evaluated the

psychoneuroimmunological effects of guided imagery, and Lin

et al.s (2007) observations regarding the effects of music ther-

apy on anxiety and stress.We compared participants scores on the HSS measuring the

level of stress related to HD in the 12 months prior to the study

to their scores after the 2-week study period and noted a signif-

icant attenuation of stress. In particular, we observed significant

improvement in 9 items on the scale, as described in Results,

above, which implies that some stressors may be amenable to

treatment with short-term music therapy, while other sources

of stress may require a longer period of intervention.

Music therapy may create a sense of comfort by gradually

eliciting hormonal and physiological changes and indirectly

influencing emotional states. Music may also eliminate nega-

tive emotions, stimulate motivation, and decrease levels of

anxiety and hostility (Beck, 1991; Brown et al., 2004; Cook,1986; Menon & Levitin, 2005). Since stress may be due to a

chronic accumulation of negative feelings, music therapy may

help mitigate stress by allowing patients to focus less on their

problems or physical discomforts and decreasing their aware-

ness of time; thus helping patients to relax and facilitate effec-

tive delivery of treatment during HD.

Effects of Music Therapy on Physiological Indicators

Several studies have observed reduced respiratory rates in

patients receiving music therapy (Chan, Chan, Mok, & Kwan

Tse, 2009; Glynn, 1986; Lai, 2004). Chlan (1998) observed thatheart rate, in patients receptive to music, slowed down and syn-

chronized with the tempo of the music. These patients reported

a reduced sense of anxiety. Thus, patients listening to music

during HD treatment may be more able to relax and, thus, help

to reduce rapid respiratory and heart rates.

Our results showed significantly increased oxygen satura-

tion in the experimental group. As the sympathetic nervous sys-

tem becomes less active with relaxation, respiratory and basal

metabolic rates decrease and oxygen saturation levels increase

(Kemper & Danhauer, 2005; C. C. Wu, 1994). We also

observed a significant increase in finger temperature in patients

after music therapy (Table 3), which is consistent with results

from previous studies (Hwang, Chang, Lee, Ko, & Chu,1996; Lai, 2004; D. F. Lee & Hwang, 1997). In a state of calm

and relaxation, a change in finger temperature is mediated by a

reduction in autonomic nervous system activity and reduced

muscle tension, which leads to expansion of superficial capil-

laries and greater blood flow (P. H. Chen, 2003). In a study

of the effects of music therapy on 60 patients on HD, Lin

et al. (2007) also observed a slight increase in the subjects

body temperature. However, the sample size was quite small

(effect size 0.68, power < 0.9) and their results were not sta-

tistically significant.

Table 2. Correlations Between Age and the Habit of Listening toMusic and Physiological and Hemodialysis-Related Variables (n 88)

Variable AgeHabit of Listening to

Music

Frequency of adverse reactionsScore

.055 .155

Severity of adverse reactionsScore

.001 .136

Hemodialysis Stressor ScaleScore

.167 .034

Systolic blood pressure (mmHg) .150 .104Diastolic blood pressure (mmHg) .332** .154Heart rate (beats/min) .020 .087Respiratory rate (breaths/min) .208 .069Finger temperature (C) .047 .077Oxygen saturation (%) .121 .178

Note. Spearmans rank correlation coefficient analysis was used to determinecorrelations.** p < .01.



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The HD procedure constitutes an extracorporeal circulation,

which can often lead to hemodynamic instability in elderly

patients. The most common reaction is an activation of the

autonomic nervous system, which increases the heart rate and

causes peripheral vasoconstriction (M. S. Wu, 2007). During

HD, a patient who experiences a 25% decline in BP or greater

from previous readings needs immediate intervention to pre-

vent the development of excessive hypotension and more seri-

ous complications (Prakash, Garg, Heidenheim, & House,

2004). Thus, though we observed no significant differences

in heart rate, SBP, DBP, or the percentage of SBP less than100 mmHg, we cannot exclude the possibility of effects of

music therapy on autonomic nervous system activity.

Limitations

We did not assess plasma hormone levels in the present study.

Measurement of levels of cortisol or other hormones in blood or

saliva as an additional indicator of stress may be a future research

goal. Monitoring of heart rate variability (HRV) may also be a

reliable method of detecting autonomic dysfunction, which is a

frequent problem in HD patients (Schubert, Palazzolo, Brum,

Ribeiro, & Tan, 1997). Thus, measurement of HRV, which

involves a relatively simple and noninvasive method, could be

used to monitor physiological changes during music therapy in

future studies.

Conclusions

Providing music during HD may be an effective complemen-

tary therapy to improve overall patient well-being. Since music

therapy alleviates the frequency and severity of adverse reac-tions associated with HD, improves physiological parameters,

and reduces patient stress and anxiety, it may increase patient

adherence to therapy and promote adequacy of dialysis. The

use of music as therapy during HD may also facilitate patient

care by allowing patients to participate in their own health care

and help create a more harmonious relationship between

patient and caregivers.

Though it is not in widespread use among nurses at this

time, the provision of music therapy as a clinical treatment tool

could provide further avenues for nursing care in the future.

Table 3. Mean + SD for Variables Before and After Music Therapy in the Experimental Group (n 44)

Variable Before Therapy After Therapy p

Frequency of adverse reactions score 2.36 + 2.934 0.59 + 1.263 .000***Severity of adverse reactions score 2.45 + 3.605 0.55 + 1.247 .000***Hemodialysis Stressor Scale Score 27.00 + 17.032 21.11 + 15.680 .000***SBP (mmHg) 134.60 + 18.992 131.83 + 18.229 .137

DBP (mmHg) 70.05 + 9.665 68.78 + 8.810 .178% SBP < 100mmHg 5.52 + 11.2 3.25 + 8.072 .106Heart rate (beats/min) 71.59 + 15.345 71.51 + 13.458 .566Respiratory rate (breaths/min) 18.52 + 1.944 16.08 + 1.552 .000***Finger temperature (C) 31.85 + 1.912 32.38 + 1.485 .008**Oxygen saturation (%) 98.43 + 1.022 99.27 + 0.685 .000***

Note. Wilcoxons signed ranks test was used for analysis.DBP diastolic blood pressure; SBP systolic blood pressure.** p < .01.*** p < .001.

Table 4. Comparison of Changes in Variables From Premusic to Postmusic Therapy Between the Two Groups (n 88)

Variable Experimental Group (n 44) Control Group (n 44) p

Frequency of adverse reactions score 1.77 + 2.281 0.14 + 3.739 .000***Severity of adverse reactions score 1.91 + 2.675 0.32 + 2.924 .000***Hemodialysis Stressor Scale Score 5.89 + 4.785 1.59 + 7.212 .000***SBP 2.77 + 12.865 0.38 + 14.391 .282DBP 1.26 + 6.212 0.28 + 5.18 .234% SBP < 100 mmHg 2.27 + 9.214 0.65 + 13.413 .362Heart rate (beats/min) 0.08 + 7.514 1.18 + 5.668 .187Respiratory rate (breaths/min) 2.44 + 1.435 0.08 + 1.579 .000***Finger temperature (C) 0.53 + 1.573 0.31 + 1.32 .280Oxygen saturation (%) 0.83 + 0.802 0.08 + 0.843 .000***

Note. Data are described as mean + SD. The MannWhitney U test was used for this analysis.DBP diastolic blood pressure; SBP systolic blood pressure.*** p < .001.

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Findings from the current and prior research indicate that HD

patients could likely benefit from the clinical use of music ther-

apy. Further research into the benefits of music therapy will

likely reveal additional applications and provide an increased

understanding of the mechanisms at work.

Authors NoteThe authors Yen-Ju Lin and Kuo-Cheng Lu contributed equally to this

work.

Acknowledgments

The authors would like to thank all participants for their assistance in

conducting this research. The authors are also grateful for grants from

the National Science Council, Taiwan R.O.C. and Cardinal Tien

Hospital.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the

research, authorship, and/or publication of this article: This work was

partly supported by grants from the National Science Council

(NSC 97-2314-B-038-017-MY2) and Cardinal Tien Hospital (CTH-

99-1-2A02).

References

Beck, S. L. (1991). The therapeutic use of music for cancer-related

pain. Oncology Nursing Forum, 18, 1327-1337.

Brown, S., Martinez, M. J., & Parsons, L. M. (2004). Passive music

listening spontaneously engages limbic and paralimbic systems.NeuroReport, 15, 2033-2037.

Burns, S. J., Harbuz, M. S., Hucklebridge, F., & Bunt, L. (2001). A pilot

study into the therapeutic effects of music therapy at a cancer help

center. Alternative Therapies in Health and Medicine, 7, 48-56.

Chan, M., Chan, E., Mok, E., & Kwan Tse, F. Y. (2009). Effect of

music on depression levels and physiological responses in

community-based older adults. International Journal of Mental

Health Nursing, 18, 285-294.

Chang, F. Y. (2005). The effectiveness of music therapy on agitation in

the elderly with dementia in institutions (Unpublished masters

thesis). National Taipei College of Nursing, Taipei. [Chinese].

Chang, S. C., & Chen, C. H. (2005). Effects of music therapy on

womens physiologic measures, anxiety, and satisfaction duringcesarean delivery. Research in Nursing & Health, 28, 453-461.

Chang, S. M., & Sung, H. C. (2005). Music therapy and child care.

Journal of Nursing, 52, 71-75. [Chinese].

Chen, M. F. (2009). Cardiovascular system health maintenance.

Retrieved October 5, 2009, from http://www.alum.ntu.edu.tw/

wordpress/?p1291 [Chinese].

Chen, P. H. (2003). Application of thermography for measuring the

effect on skin temperature of listening to music (Unpublished mas-

ters thesis). National Cheng Kung University, Tainan, Taiwan.

[Chinese].

Chlan, L. (1998). Effectiveness of a music therapy intervention on

relaxation and anxiety for patients receiving ventilatory assistance.

Heart & Lung, 27, 169-176.

Chou, H. C. (2002). Study for stressors and coping methods among

chronic hemodialysis patients (Unpublished masters thesis).

National Sun Yat-sen University, Kaohsiung, Taiwan. [Chinese].

Cook, J. D. (1986). Music as an intervention in the oncology setting.

Cancer Nursing, 9, 23-28.

Department of Health, Executive Yuan. (2010). Statistics on causes of

death. Retrieved March 3, 2010, from http://www.doh.gov.tw/

CHT2006/DisplayStatisticFile.aspx?d73104&s1 [Chinese].

Gerdner, L. A. (2000). Effects of individualized versus classical

relaxation music on the frequency of agitation in elderly persons

with Alzheimers disease and related disorders. International

Psychogeriatrics, 12, 49-65.

Giedt, J. F. (1999). The psychoneuroimmunological effects of guided

imagery in patients on hemodialysis for end-stage renal disease

(Unpublishedmasters thesis).Wayne State University, Michigan.

Glynn, N. J. (1986). The therapy of music. Journal of Gerontological

Nursing, 12, 6-10.Hilliard, R. E. (2005). Music therapy in hospice and palliative care:

A review of the empirical data. Evidence-based Complementary

and Alternative Medicine, 2, 173-178.

Hwang, S. L., Chang, Y., Lee, M. B., Ko, W. J., & Chu, S. H. (1996).

Effect of music therapy on reducing stress for post-open heart sur-

gery patients in the intensive care unit. TZU CHI Medical Journal,

8, 47-54. [Chinese].

Inrig, J. K. (2010). Intradialytic hypertension: A less-recognized

cardiovascular complication of hemodialysis. American Journal

of Kidney Diseases, 55, 580-589.

Kemper, K. J., & Danhauer, S. C. (2005). Music as therapy. Southern

Medical Journal, 98, 282-288.

Kim, K. B., Lee, M. H., & Sok, S. R. (2006). The effect of musictherapy on anxiety and depression in patients undergoing hemo-

dialysis. Taehan Kanho Hakhoe Chi, 36, 321-329.

Kistler, A., Mariauzouls, C., & von Berlepsch, K. (1998). Fingertip

temperature as an indicator for sympathetic responses. Interna-

tional Journal of Psychophysiology, 29, 35-41.

Lai, H. L. (2004). Music preference and relaxation in Taiwanese

elderly people. Geriatric Nursing, 25, 286-291.

Lee, D. F., & Hwang, S. L. (1997). Effects of music therapy on pain

for burn patients during dressing change. Taiwanese Journal of

Psychiatry, 11, 27-39. [Chinese].

Lee, L., Chan, N. Y., Ho, H. J., Cheng, J. G., & Su, C. (2005). To

explore the efficiency of music therapy for the development of

a group of autistic children. Journal of Special Education, 21,1-21. [Chinese].

Lee, L. H. (2003). The effects of music therapy on depressed elderly

adults (Unpublished masters thesis). Tzu Chi University, Hualien,

Taiwan. [Chinese].

Lee, S., Lieu, L. F., & Chen, S. L. (1999). Clinical applications of

music therapy in the nursing profession of Taiwan. Journal of

Nursing, 46, 25-30. [Chinese].

Li, S. H., Jiang, X. L., & Xu, P. (2008). Clinical observation and nursing

intervention for elderly hemodialysis patients with hypotension.

Journal of Hainan Medical College, 14, 461-461. [Chinese].



7/30/2019 Biol Res Nurs 2012 Lin 277 85

10/10

Lin, H. H., Chen, H. M., Kuo, T. F., Wang, C. Y., & Huang, C. H.

(2007). Effects of music on anxiety and stress in hemodialysis

patients. Kaohsiung Journal of Nursing, 24, 1-16. [Chinese].

Menon, V., & Levitin, D. J. (2005). The rewards of music listening:

Response and physiological connectivity of the mesolimbic

system. NeuroImage, 28, 175-184.

Mockel, M., Rocker, L., Stork, T., Vollert, J., Danne, O., Eichstadt, H.,

. . . Hochrein, H. (1994). Immediate physiological responses of

healthy volunteers to different types of music: Cardiovascular,

hormonal and mental changes. European Journal of Applied

Physiology, 68, 451-459.

OSullivan, R. J. (1991). A musical road to recovery: Music in inten-

sive care. Intensive Care Nursing, 7, 160-163.

Pothoulaki, M., Macdonald, R. A., Flowers, P., Stamataki, E.,

Filiopoulos, V., Stamatiadis, D., & Stathakis, ChP. (2008). An

investigation of the effects of music on anxiety and pain perception

in patients undergoing haemodialysis treatment. Journal of Health

Psychology, 13, 912-920.

Prakash, S., Garg, A. X., Heidenheim, A. P., & House, A. A. (2004).

Midodrine appears to be safe and effective for dialysis-inducedhypotension: A systematic review. Nephrology, Dialysis, Trans-

plantation, 19, 2553-2558.

Prinsley, D. M. (1986). Music therapy in geriatric care. Australian

Nurses Journal, 15, 48-49.

Richardson, M. M., Babiak-Vazquez, A. E., & Frenkel, M. A. (2008).

Music therapy in a comprehensive cancer center. Journal of the

Society for Integrative Oncology, 6, 76-81.

Schubert, A., Palazzolo, J. A., Brum, J. M., Ribeiro, M. P., &

Tan, M. (1997). Heart rate, heart rate variability, and blood

pressure during perioperative stressor events in abdominal sur-

gery. Journal of Clinical Anesthesia, 9, 52-60.

Staum, M. J., & Brotons, M. (2000). The effect of music amplitude on

the relaxation response. Journal of Music Therapy, 37, 22-39.Sulowicz, W., & Radziszewski, A. (2007). Dialysis induced

hypotensionA serious clinical problem in renal replacement

therapy. Medicinski Pregled, 60, 14-20.

Sung, H. C., Chang, A. M., & Abbey, J. (2006). Application of music

therapy for managing agitated behavior in older people with

dementia. Journal of Nursing, 53, 58-62. [Chinese].

Taiwan Bureau of National Health Insurance. (2011). 2011 Q1 Annual

global budgets on hemodialysis. Retrieved April 19, 2011, from

http://www.nhi.gov.tw/webdata/webdata.aspx?menu 17&menu_

id661&WD_ID685&webdata_id3627

Tan, Z. G., & Yang, W. C. (2005). Artificial kidney. Taipei:

LeaderBook. [Chinese].

Tanimu, D., Huraib, S.,Shaheen,F., Hejaili, F.,Giles,C., & Pagayon, V.

(2000). The effect of vitamin E-modified dialyzers on acute intra-

dialytic symptoms: A comparative crossover study. Saudi Journal

of Kidney Diseases and Transplantation, 11, 543-547.

United States Renal Data System. (2010). International comparisons.

In USRDS 2010 annual data report: Vol. 2. Atlas of end-stage

renal disease in the United States (chap. 12). Retrieved from

http://www.usrds.org/atlas.htm

Wang, H. Y. (2002). Impact of acoustic stimulus on the brain wave a

frequency. Vanung Commercial Journal, 7, 301-318. [Chinese].

Wang, L. H. (2007). Blood pressure management in hemodialysis. InTaiwan Nephrology Nurses Association, Discussion of clinical care

in HD patients (2)The management of bloodpressureduring hemo-

dialysis. Symposium conducted at the meeting of the Taiwan

Nephrology Nurses Association, Taipei City, Taiwan. [Chinese].

Wang, S. M., Yeh, M. Y., & Chang, L. Y. (2003). The effects of music

therapy for chronic psychotic patients. Chang Gung Nursing, 14,

342-352. [Chinese].

Wu, C. C. (1994). Respiration. In T. J. Fang (Ed.), Review of med-

ical physiology (15th ed., pp. 665-718). Taipei: Yi Hsien.

[Chinese].

Wu, M. S. (2007, May). Hemodynamic changes and their management

during hemodialysis. In Taiwan Nephrology Nurses Association,

Discussion of clinical care in HD patients (2)The managementof blood pressure during hemodialysis. Symposium conducted at

the meeting of the Taiwan Nephrology Nurses Association, Taipei

City, Taiwan. [Chinese].

Lin et al. 285

biol res nurs 2012 lin 277 85

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