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Abstract
Purpose: The aim of the study was to determine if listening to music may reduce anxiety experienced by stroke patients during
acute rehabilitation.
Design: A prospective, nonblinded, randomized study in an inpatient rehabilitation setting.
Methods: Fifty participants were randomized into two groups: (1) 1 hour of music (intervention) or (2) no music (control). All
participants completed pretest anxiety and depression screening and 44 completed the posttest anxiety screening. Differences
between groups were determined using chi-square and t tests.
Findings: After listening to music for 1 hour, participants who completed the posttest (n = 44) reported significantly less anxiety
(p < .0001) compared to before the intervention. The control group showed no difference in their pre- and posttest anxiety scores
(p = .84). No differences were determined among age, gender, or diagnostic groups.
Conclusions: These findings demonstrate that music intervention may help lessen anxiety in rehabilitation patients poststroke.
Clinical Relevance: Offering musical intervention to stroke patients in rehabilitation may lessen symptoms of anxiety.
Copyright © 2017 by the Association of Rehabilitation Nurses. Unauthorized reproduction of this article is prohibited.
2 Music in Stroke Rehab M. Le Danseur et al.
to treat anxiety but have side effects that may hinder the Methods
ability of the patient to receive the full benefit of PM&R This was a prospective, nonblinded, investigator-initiated,
therapy sessions. randomized study. All study procedures were reviewed
Music, as a therapeutic intervention, was first de- and approved by the institutional review board. Physical
scribed in Dunton (1946). Pacchetti et al. demonstrated medicine and rehabilitation patients admitted for inpatient
that patients with Parkinson’s disease that were involved rehabilitation and diagnosed with an ischemic or hemor-
in music therapy also displayed increased engagement in rhagic stroke, who were able to provide self-consent, were
physical therapy (Pacchetti et al., 2000). Magee and considered eligible for the study. Prisoners and patients
Davidson (2002) concluded that music therapy may be who were deaf or very hard of hearing were excluded from
beneficial in increasing mood states for neurologically in- the study. Following consent, participants (N = 50) were
jured patients who are undergoing rehabilitation therapy. randomized by random number assignment to the No-
Music improves mood and arousal through the dopami- Music (control) or Music (intervention) group. A random
nergic mesolimbic system, improves memory by stimulat- number generator was used based on the target sample size
ing glutamatergic neurotransmission, alleviates stress and of 50; then, the group assignments were placed into sealed
anxiety by reducing cortisol levels, and increases cerebral envelopes and were opened after participant consent. Par-
blood flow surrounding the ischemic or hemorrhagic le- ticipants and providers were not blinded to group assign-
sion, thereby stimulating neuroplastic recovery (Peretz ment. The target sample was based on an assumption
& Zatorre, 2005; Särkämö & Soto, 2012; Zatorre & that power is set at 0.80 and alpha is .05, with an estimated
McGill, 2005). effect size of 0.60 (24 subjects per group; Lipsey, 1990).
Research involving music therapy and stroke patients
has been multifaceted (Särkämö, Tervaniemi, & Huotilainen,
Measures
2013). Jun, Roh, and Kim (2013) combined music and move-
ment. It included stretching to music, followed by a ses- Demographic data were collected at baseline via chart ab-
sion of playing various instruments and singing, ending straction. Anxiety was measured with the State–Trait
with listening to music while patients shared their experi- Anxiety Inventory (STAI) and the Hospital Anxiety De-
ences with respect to the session. The results suggested an pression Score (HADS). The original STAI consists of
improved mood state and increased range of motion of two sets of 20 questions to assess both state anxiety and
the upper extremities (Jun et al., 2013). Forsblom, Särkämö, trait anxiety levels in adults. The STAI-State (STAI-S) ex-
Laitinen, and Tervaniemi (2010) supported the premise that amines current level anxiety: How anxious is the subject
music therapy could enhance recovery of the stroke patient. at this moment? The STAI-Trait (STAI-T) anxiety refers
Their population listened to both music and audiobooks. to a characteristic of personality that one endures over
They demonstrated that music directly correlated to im- time. The STAI self-evaluation tests have a 4-point scale
proved mood and increased relaxation (Forsblom et al., rated from “almost never” to “almost always.” The STAI
2010). Kim et al. (2011) focused on depressive mood can be easily read by an adult with at least a sixth-grade
and anxiety and the effects of music with the stroke pop- level of education. The STAI has been used previously
ulation in the outpatient setting. The population had ex- with stroke patients in rehabilitation. The results showed
perienced a stroke within the last 6 months. The results that the scale had high correlation with other mental
showed a decrease in depression scores that were stati- health scales used at a .05 level of significance (Torkia,
cally significant. However, the generalizability of the Best, Miller, & Eng, 2016). Evidence supports using six
study was limited with recommendations to repeat the questions in each part of the STAI to score state anxiety
study in other settings (Kim et al., 2011). (Fioravanti-Bastos, Cheniaux, & Landeira-Fernandez, 2011).
Current research supports the use of music as an in- Therefore, participants received six questions from STAI-S
tervention to benefit patients with stroke and brain injury and 20 questions from STAI-T to measure their levels
(Bradt, Magee, Dileo, Wheeler, & McGilloway, 2010; of anxiety.
Särkämö & Soto, 2012). Music has also been found to The HADS is a validated 14-item rank scale that can be
be beneficial in acute PM&R (Thaut et al., 2009). There- used to score anxiety and depression (Bjelland, Dahl, Haug,
fore, the literature supports a testable assumption that & Neckelmann, 2002; Zigmond & Snaith, 1983). Seven
incorporating music in a PM&R setting may reduce anx- items relate to anxiety and seven to depression, and HADS
iety. The purpose of this study was to examine the impact scores have been found valid for poststroke screening
of 1-hour of music listening on anxiety scores in a cohort (Sagen et al., 2009). The HADS measure has been previ-
of inpatient PM&R patients who recently sustained ously tested with patients admitted to a stroke unit, show-
a stroke. ing sensitivity of 100% and specificity of 99.17% (Pedroso,
Copyright © 2017 by the Association of Rehabilitation Nurses. Unauthorized reproduction of this article is prohibited.
Month 2017 • Volume 00 • Number 0 www.rehabnursingjournal.com 3
Vieira, Brunoni, Lauterbach, & Teixeira, 2016). HADS scores paired t test to examine difference between the Music and
were included to provide concurrent validity for trait anxiety. No-Music groups.
The HADS anxiety and depression scores were calcu-
lated as standardized; eight questions were reverse-coded.
Study Procedures The odd questions addressed symptoms of anxiety, whereas
Following randomization, all participants completed three self- the even numbered questions addressed symptoms of depres-
report forms: (1) STAI-S, (2) STAI-T, and (3) HADS to provide sion. For subgroup analysis, patients were dichotomized
baseline data. The study period lasted 1 hour. Participants ran- based on the primary diagnosis of either embolic or hemor-
domized to the music intervention group listened to music of rhagic stroke. Patients with incomplete questionnaire re-
their choice (participants chose from one of five music genres: sponses were excluded from subgroup analysis for that
Christian/gospel, classical, classic rock, country western, or questionnaire. All statistics were calculated in SAS v9.3.
pop/modern) for 1 hour. Participants randomized to the con-
trol arm were asked to carry on with their daily routine for Results
1 hour (e.g., watching TV, walking, reading, eating). At the Of 50 patients enrolled in the study, two withdrew after
end of 1 hour, all participants (control and intervention) com- randomization (1 Music, 1 No-Music), and four were ex-
pleted the poststudy self-report form (STAI-S). cluded for missing data in STAI-S self-report (2 Music, 2
No-Music); therefore, 44 completed the study. Demo-
graphic data showed similar distributions between partic-
Statistical Analysis
ipants assigned to either intervention arm (Table 1). A
Baseline group characteristics were examined using a chi- difference was seen between the Music and No-Music
square test among categorical variables (gender, race) or t group in the HADS anxiety score (p = .02). A paired t
test for continuous variables (age). Participants were ex- test demonstrated a statistically significant difference in
cluded from analysis if any answers in the primary out- STAI-S scores before (pre)listening to music compared
come measures (STAI-S initial and final scores) were to after (post)listening to music (3.18, 95% CI, [2.0,
missing. The six questions from STAI-S were given nu- 4.4], p < .0001); there was no significant difference for
meric values for their four answer choices, with the most in pre- versus post-STAI scores among the No-Music
negative answer being given a 1 and the most positive an- group (−0.16, 95% CI [1.8, 1.4], p = .8374).
swer being a 4, the total STAI-S was the summation of the Multivariate modeling, displayed in Table 2, was used
six questions (minimum 6 for high-state anxiety, maxi- to examine the relationship between predictor variables
mum 24 for low-state anxiety). Initial and final total STAI and the outcome variable (anxiety). After adjusting for
scores were compared using a t test to examine differences STAI-S (pre), age, gender, primary diagnosis group, STAI-T,
among the Music and No-Music groups, followed by a HADS-A, and HADS-D, a multivariable model used to
Table 1 Demographic and primary variables of interest
No Music Music
n Mean (SD) or % n Mean (SD) or % p
Age 22 62.4 (13.5) 22 54.3 (15.3) .07
Gender .99
Female 9 40.9% 9 40.9%
Male 13 59.1% 13 59.1%
Race .22
Caucasian 7 31.8% 15 68.2%
African American 2 9.1% 1 4.5%
Asian 1 4.5% 0 0%
Unknown 12 54.5% 6 27.3%
Primary diagnosis group .61
Acute ischemic stroke 17 77.3% 19 86.4%
Hemorrhagic stroke 5 22.7% 3 13.6%
STAI-Trait 20 40.8 (11.0) 18 34.6 (10.0) .08
HADS-Depression 20 7.3 (2.5) 21 6.3 (2.4) .20
HADS-Anxiety 20 8.1 (4.8) 21 4.7 (3.6) .02
STAI-State (pre) 22 17.6 (3.9) 22 18.7 (4.8) .43
STAI-State (post) 22 17.5 (4.5) 22 21.84 (2.9) .0004
Copyright © 2017 by the Association of Rehabilitation Nurses. Unauthorized reproduction of this article is prohibited.
4 Music in Stroke Rehab M. Le Danseur et al.
predict post STAI-S scores demonstrated a decrease of 2.2 not affected by age, gender, and type of stroke (ischemic
points in anxiety scores for the Music group (p = .039). To vs. hemorrhagic), demonstrating that music intervention
confirm this difference was not originally present in the two may be helpful for men and women of all ages undergo-
groups, a multivariable model to predict pre-STAI-S ing inpatient stroke rehabilitation. Interventions aimed
scores was constructed. The values that significantly pre- at decreasing anxiety may improve overall mood and en-
dicted pre STAI-S scores were as follows: STAI-T (p = .003), hance the environment for better rehabilitation.
HADS-A (p = .026), and HADS-D (p = .025). Race was not Rehabilitation professionals have all felt the pull to
included as variable in the final model because of the large improve and individualize patient care. Alleviation of
number of missing values (41% of the study sample), which poststroke anxiety during rehabilitation is an elusive but
would not yield a useful sensitivity analysis in this small, important goal (Campbell Burton et al., 2013). Beyond
single site study for confounding. pharmacotherapy, several alternative interventions such
as relaxation techniques, cognitive therapy, art therapy,
Discussion and massage have recently been explored to reduce post-
stroke anxiety during rehabilitation (Ali, Gammidge, &
The difference in pre- versus post-STAI scores for the Mu-
Waller, 2014; Bowen, Hazelton, Pollock, & Lincoln, 2013;
sic group, where no such differences were found in the
Kneebone, Walker-Samuel, Swanston, & Otto, 2014;
No-Music group, supports the hypothesis that the inter-
Thanakiatpinyo et al., 2014). This study helps build a plat-
vention was associated with a significant decrease in anx-
form to add an intervention (music) for patients experiencing
iety (measured by STAI). Music has been employed as an
anxiety. This may represent a viable nonpharmacologic
ambient or adjunct tool during medical procedures and
option for anxiety reduction, depression reduction, and
for chronic pain management (Supnet, Crow, Stutzman,
mood enhancement.
& Olson, 2016). However, there is no consensus in the
literature regarding protocols for listening to music, its ef-
Limitations
ficacy in certain procedures, and which type of music is
most effective. Our results showed that a 1-hour music in- The first limitation of the study was that all participants
tervention had a significant effect on the anxiety levels of were recruited from one university hospital setting and
participants. The group that listened to 1 hour of music, data were not recorded for the number of days since they
regardless of the genre, reported significantly lower levels first experienced a stroke; therefore, the data may not be
of anxiety than the group that did not listen to music. generalizable to all stroke patients in rehabilitation. Sec-
There were several novel aspects of this study that ond, the study allowed participants to choose their own
presented new information on the direct impact of music music because adequate research identifying the most ef-
on anxiety in poststroke patients in inpatient rehabilita- fective types of music to decrease anxiety was lacking.
tion. One unique aspect of this study was that the partic- Music was used, in this study, only as a one-time interven-
ipants in the music intervention group were allowed to tion, and additional research is required to determine if
pick between five different music genres, increasing the the impact of this intervention is sustained, amplified,
chances that the patient would enjoy the experience of or reduced if the intervention is delivered more often or
the music. Within a clinical setting, using the type of mu- for longer sessions. The time of the intervention was
sic that the patient prefers to listen to may provide less- based on convenience and patient preference, and the
ened anxiety. Furthermore, the statistical analyses timing of therapy sessions was not recorded. Thus, asso-
confirmed that the benefits of the music intervention were ciations between pre- and posttherapy anxiety, as well
Copyright © 2017 by the Association of Rehabilitation Nurses. Unauthorized reproduction of this article is prohibited.
Month 2017 • Volume 00 • Number 0 www.rehabnursingjournal.com 5
Key Practice Points benefit from examining different music genres and the op-
•
Acknowledgments
The patient’s ability to choose the music genre may
The University of Texas Southwestern Medical Center Hospi-
maximize this benefit.
tal and the Department of Neurology and Neurotherapeutics
• The data suggest that this noninvasive holistic approach provided financial support. The authors declare no conflict
to decreasing anxiety should become part of our practice. of interest.
Copyright © 2017 by the Association of Rehabilitation Nurses. Unauthorized reproduction of this article is prohibited.
6 Music in Stroke Rehab M. Le Danseur et al.
Survey Replication. Archives of General Psychiatry, 62(6), 617–627. inpatient rehabilitation. South African Medical Journal = Suid-
doi:10.1001/archpsyc.62.6.617. Afrikaanse tydskrif vir geneeskunde, 102(6), 545–548.
Kim, D. S., Park, Y. G., Choi, J. H., Im, S. H., Jung, K. J., Cha, Y. A., Sagen, U., Vik, T. G., Moum, T., Mørland, T., Finset, A., &
… Yoon, Y. H. (2011). Effects of music therapy on mood in Dammen, T. (2009). Screening for anxiety and depression after
stroke patients. Yonsei Medical Journal, 52(6), 977–981. doi:10. stroke: Comparison of the hospital anxiety and depression
3349/ymj.2011.52.6.977 scale and the Montgomery and Asberg depression rating scale.
Kneebone, I., Walker-Samuel, N., Swanston, J., & Otto, E. (2014). Journal of Psychosomatic Research, 67(4), 325–332. doi:10.1016/
Relaxation training after stroke: Potential to reduce anxiety. j.jpsychores.2009.03.007.
Disability and Rehabilitation, 36(9), 771–774. doi:10.3109/ Särkämö, T., & Soto, D. (2012). Music listening after stroke:
09638288.2013.808275. Beneficial effects and potential neural mechanisms. Annals of
Jones, A. L., Charlesworth, J. F., & Hendra, T. J. (2000). Patient the New York Academy of Sciences, 1252, 266–281. doi:10.1111/
mood and carer strain during stroke rehabilitation in the j.1749-6632.2011.06405.x.
community following early hospital discharge. Disability and Särkämö, T., Tervaniemi, M., & Huotilainen, M. (2013). Music per-
Rehabilitation, 22(11), 490–494. doi:10.1080/096382800413970. ception and cognition: Development, neural basis, and rehabilitative
Lipsey, M. W. (1990). Design sensitivity: Statistical power for use of music. Wiley Interdisciplinary Reviews. Cognitive Science, 4(4),
experimental research. Newbury Park, CA: Sage Publications. 441–451. doi:10.1002/wcs.1237.
Lucassen, P. J., Pruessner, J., Sousa, N., Almeida, O. F., Van Dam, A. M., Schöttke, H., & Giabbiconi, C. M. (2015). Post-stroke depression and
Rajkowska, G., … Czéh, B. (2014). Neuropathology of stress. Acta post-stroke anxiety: Prevalence and predictors. International
Neuropathologica, 127(1), 109–135. doi:10.1007/s00401-013-1223-5 Psychogeriatrics, 27(11), 1805–1812. doi:10.1017/s1041610215000988.
Magee, W. L., & Davidson, J. W. (2002). The effect of music
Supnet, C., Crow, A., Stutzman, S., & Olson, D. (2016). Music as
therapy on mood states in neurological patients: A pilot study.
medicine: The therapeutic potential of music for acute stroke
Journal of Music Therapy, 39(1), 20–29.
patients. Critical Care Nurse, 36(2), e1–e7. doi:10.4037/ccn2016413.
Masskulpan, P., Riewthong, K., Dajpratham, P., & Kuptniratsaikul,
V. (2008). Anxiety and depressive symptoms after stroke in 9 Thanakiatpinyo, T., Suwannatrai, S., Suwannatrai, U., Khumkaew,
rehabilitation centers. Journal of the Medical Association of P., Wiwattamongkol, D., Vannabhum, M., … Kuptniratsaikul,
Thailand = Chotmaihet thangphaet, 91(10), 1595–1602. V. (2014). The efficacy of traditional Thai massage in decreasing
National Institutes of Mental Health. (2014). Anxiety disorders. spasticity in elderly stroke patients. Clinical Interventions in
Retrieved from http://www.nimh.nih.gov/health/topics/anxiety- Aging, 9, 1311–1319. doi:10.2147/cia.s66416
disorders/index.shtml Thaut, M. H., Gardiner, J. C., Holmberg, D., Horwitz, J., Kent, L.,
Pacchetti, C., Mancini, F., Aglieri, R., Fundarò, C., Martignoni, E., Andrews, G., … McIntosh, G. R. (2009). Neurologic music
& Nappi, G. (2000). Active music therapy in Parkinson's disease: therapy improves executive function and emotional adjustment
An integrative method for motor and emotional rehabilitation. in traumatic brain injury rehabilitation. Annals of the New York
Psychosomatic Medicine, 62(3), 386–393. Academy of Sciences, 1169, 406–416. doi:10.1111/j.1749-
Pedroso, V. S., Vieira, É. L., Brunoni, A. R., Lauterbach, E. C., & 6632.2009.04585.x
Teixeira, A. L. (2016). Psychopathological evaluation and use Torkia, C., Best, K. L., Miller, W. C., & Eng, J. J. (2016). Balance
of the Hospital Anxiety and Depression Scale in a sample of confidence: A predictor of perceived physical function, perceived
Brazilian patients with post-stroke depression. Archives of Clinical mobility, and perceived recovery 1 year after inpatient stroke
Psychiatry (São Paulo), 43(6), 147–150. rehabilitation. Archives of Physical Medicine and Rehabilitation,
Peretz, I., & Zatorre, R. J. (2005). Brain organization for music 97(7), 1064–1071.
processing. Annual Review of Psychology, 56, 89–114. doi:10. Zatorre, R., & McGill, J. (2005). Music, the food of neuroscience?
1146/annurev.psych.56.091103.070225. Nature, 434(7031), 312–315. doi:10.1038/434312a.
Rouillard, S., De Weerdt, W., De Wit, L., & Jelsma, J. (2012). Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and
Functioning at 6 months post stroke following discharge from depression scale. Acta Psychiatrica Scandinavica, 67(6), 361–370.
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