Music Therapy Research and

Applications in Pediatric
Oncology Treatment
and
Jayne M. Standley, PhD, RMT,
Suzanne B. Hanser, EdD, RMT-BC

Music therapy is a profession which meets multiple physical, social, and psy-
chological needs. Music therapists can facilitate health objectives by reducing
the intensity or duration of pain, alleviating anxiety, and decreasing the amount
of analgesic medication needed. Rehabilitative objectives can include activities
which incorporate exercise, range of motion therapy, or gait training. Reduction
of fear, anxiety, stress, or grief are common psychological objectives. Music
therapy is particularly effective in promoting social objectives such as increased
interaction, verbalization, independence, and cooperation; enhanced relation-
ships with health care personnel and family members; and increased stimulation
during long-term hospitalization or isolation. Counseling techniques are often
paired with music to achieve emotional objectives such as expression, adjust-
ment, stability, or locus of control. The purpose of this article is to synthesize the
extant music/medical research literature and clarify how music therapy can pro-
vide a quintessential combination of physical, social, and psychological benefits
to enhance the health care of pediatric oncology patients.
© 1995 by Association of Pediatric Oncology Nurses.

IS WIDELY used in health care
M USIC
1 1 tings, and it is generally perceived as ex-
tremely beneficial. For many years professional
music therapists have provided health care ser-
vices in diverse specialties from obstetrics’ to
hospice programs for the terminally i11.~~2 Re-
cently, health care personnel have begun play-
ing recorded music for patients during painful
procedures or to relieve anxiety,3-5 and perform-
ing artists have been invited into health agencies
to provide concerts 6 The latter two types of mu-
sic activities are certainly beneficial to patients,
but are distinctly different from the first type, the
provision of professional music therapy services.
From the Center for Music Research, Florida State Uni-
versity, Tallahassee, FL; and the National Association for
Music Therapy, Inc, Silver Spring, MD.
Address reprint requests to Jayne M. Standley, PhD,
RMT, Professor of Music Therapy, Center for Music Re-
search, The Florida State University, Tallahassee, FL
32306-2098.
© 1995 by Association of Pediatric Oncology Nurses.
1043-4542/95/0201-0002$03.00/0
set- The purpose of this article is to clarify that dis-
tinction.
Purpose of Music Therapy
Music therapy is a discipline involving the
complex interaction between a qualified thera-
pist and one or more patients. Music activities
are used to establish relationships and trust with
patients and to achieve and facilitate a priori ob-
jectives related to the diagnosis, the treatment
situation, or the medical protocols used. The
music therapy setting accommodates individual
and group work with patients of all abilities and
family members of all ages
Music Therapy Training and Services
A music therapist meets stringent training cri-
teria culminating in a bachelor’s degree in the
field. The 4-year curriculum is comprised of a
major in music therapy in an accredited music
program, a minor in psychology, and courses in
anatomy and the behavioral sciences. A

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4
6-month internship in an approved clinical set-
ting required after completion of coursework.
is
The music therapy professional courses pro-
vide the Registered Music Therapist (RMT) with
the expertise and skills to assess patient needs
as indicated by the medical diagnosis, treat-
ment, and setting and to select and provide ther-
apeutic music therapy activities (such as music
listening, music performance, song composi-
tion, song selection, lyric substitution, lyric dis-
cussion, music-guided imagery/relaxation tech-
niques, music combined with art activities,
movement/exercise/dancing to music, music
improvisation, etc). Music and assessment abil-
ities are combined with counseling, therapeutic,
and teaching skills to facilitate specific health or
rehabilitative objectives.
Selecting music for a particular patient with a
specific diagnosis is a complex science based
on comprehensive knowledge of a vast reper-
toire of music selections and styles (classical,
pop, jazz, rock, easy listening, etc) and training in
research-based psychology of music principles.
Psychology of music is the study of the effect of
music on human behavior and includes the
study of the separate elements of music com-
position (tempo, volume, texture, instrumenta-
tion, form), the style of the music (classical, con-
temporary, rock, etc), the perceived emotional
response to the music (stimulation versus seda-
tion, sadness versus happiness), and the over-
riding variables of patient preferences and re-
sponsiveness.8
Research has shown that the effects of music
are mitigated by the above factors and other
principles inherent in the processing of music by
the brain. Entrainment? is the ability of music
tempo to affect the heart rate or circadian
rhythms of an individual. &dquo;Iso mood&dquo; effects 10
dictate the selection and variation of music ele-
ments across time (tempo, rhythm, volume, tex-
ture, etc) to increase the probability and ease of
patient mood changes to music. Patient mem-
ory can be increased by pairing the desired in-
formation with familiar music because this mu-
sic information seems to be retrieved from the
brain more easily. Focus of attention to music
I
can forestall or blunt the perception of pain.&dquo;
of
A11 effects music are influenced by the age,
sex, and cultural background of the patient
combined with the degree of pain, intensity of
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psychological trauma, the type of medical treat-
ment, the outcome desired, and the perceived
stress experienced by the individual.’ 1.12 The
music therapist assesses these variables with the
knowledge of vast amounts of music literature.
Selection of music for patient listening, then, in-
volves a sophisticated process and professional
competence. When the therapist also has the
skill to provide that music in live performance
versus recorded performance, the health bene-
fits are enhanced. 13 A comprehensive meta-
analysis of music research in medical treatment
has determined that the provision of live music
was more effective than recorded music when
selected and performed by trained music ther-
apists according to the above professional crite-
ria.&dquo; Such benefits have not been documented
for other types of live music performance in
medical settings, ie, live concerts in hospitals by
performing artists.
Nursing personnel are intimately aware that
children hospitalized with serious illnesses and
their family members may be at risk for psycho-
social problems. 14.1 -5 The difficulties of dealing
emotionally with a life-threatening illness may be
compounded by having to endure aggressive
and invasive treatments such as lumbar punc-
tures, bone marrow aspirations, and intramus-
cular or intravenous (IV) injections. Music ther-
apy interventions are designed to help pediatric
oncology patients to cope with the pain and anx-
iety associated with health care as well as the
additional distress arising from hospitalization,
eg, separation from family, loss of familiar sur-
roundings and comforts, restriction of activity,
bondage to aversive machines and N lines, and
stimulus deprivation due to isolation.’ 6-18
From the initial diagnosis throughout the
course of the disease, treatment, and rehabilita-
tion to the cure or end of life, music therapy is a
service that addresses both the medical and
psychosocial needs of the patient. It can be pro-
vided to the pediatric patient alone or with the
family and in the home, hospital, clinic, or hos-
pice setting. Thus, the music therapist can re-
main involved with the pediatric patient and
family throughout the entire health care process.
Selected Research Review .
Research has documented that music therapy
activities are indicated for a variety of health ob-

jectives. Caine demonstrated that daily music
listening to female vocalists singing lullabies
shortened the length of hospitalization by an av-
erage of 5 days for low birth-weight neonates in
intensive care.19 Chetta reduced distress and
crying by singing familiar children’s songs with
pediatric patients during preoperative injec-
tions. 20 Ammon played recorded background
music for 1 hour and significantly decreased re-
spiratory rates of 2- to 24-month old patients in
intensive care 2’
Collins and Kuck played music for 20 minutes
and demonstrated an increase in oxygen satu-
ration levels of aroused, premature neonates in
intensive care.22 Standley and Moore extended
the 20-minute music sessions for premature ne-
onates over 3 days and demonstrated that oxy-
gen saturation increases became greater and
more stable over time
Frank showed that listening to preferred mu-
sic during a single chemotherapy treatment re-
duced nausea duration from a mean of 10.4
hours to a mean of 7.1 hours. 24 To ascertain
whether this reduction was merely a Hawthorne
effect, Standley expanded the use of music over
four treatments and conducted follow-up inter-
views at 1- and 2-week intervals after each che-
motherapy application. Oncology patients
ceiving music had less nausea after each
treatment and also had delayed onset of nausea
after each treatmenl 25 .
Sanderson showed that music defivered ~via
earphones throughout the stay in the recovery
room reduced postsurgical nausea for orthope-
dic patients. 26 Steinke’s music listening sessions
began in the recovery room and continued as
desired throughout the surgical patients’ stay.
Again, music resulted in reduced postoperative
pain for these adolescent scoliosis patients 2’
Wolfe paired music with gross motor rehabil-
itation exercises across several sessions after
surgery and showed that patients with chronic
pain increased their endurance and pain toler-
ance.28 Gait training and physical rehabilitation
objectives of child and adult neurologically im-
paired patients were substantially increased with
the addition of music matching the tempo of
their exercises. 29,30
Music therapy can enhance specific treatment
objectives and also relieve the emotional dis-
tress of the patient Gross and Swartz demon-
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5
strated this by using music activities and coun-
seling for 8 weeks to reduce anxiety of adult
chronic and terminally ill patients?1
Music listening has been used in a variety of
settings to facilitate cooperation during painful
diagnostic techniques. Pediatric patients under-
going cardiac catheterization with music had re-
duced pain, especially those less than 1 year and
between 7 and 12 years of age.32 Pediatric can-
cer patients received music throughout bone
marrow aspirations and received benefits in pain
reduction. 33 Adult patients undergoing bron-
choscopy accompanied by music listening
throughout also showed significantly reduced
levels of pain and anxiety. 34
Several investigators have described effective
music therapy techniques for helping seriously
ill patients deal with their pain?5-37 In all pain
reduction procedures it has been shown that the
initiation of the music stimulus must precede
the initiation of the pain stimulus. Barker used
this principle to reduce pain during debridement
of severely burned adolescent and adult pa-
tients. These patients received music during ev-
ery debridement treatment for 14 days and
found nonvocal, instrumental music to be the
most effective in assisting them to manage the
re- pain. Barker also suggested that music paired
with physical therapy to reduce muscle contrac- .
tures from burns would be an effective tech-
nique in this setting 3a
The fact that music can draw attention away
from the health treatment can result in diverse
physiological benefits. Two hours of music lis-
tening during hemodialysis reduced blood pres-
sure fluctuations and subsequent discomfort, in-
cluding nausea, for adult patients. 39 More recent
research has shown that music listening may
increase immune response. Lane conducted a .
live 30-minute music therapy session with pedi-
atric inpatients and showed that a significant in-
crease in salivary immunoglobulin A occurred
pretest and posttest. Patients in the control
group who did not receive music therapy did not
show this increase after 30 minutes .40 Tsao et al
had similar findings in their study with college
students after 20 minutes of quiet music 4’
Music Therapy with Pediatric Patients
The overall techniques of music therapy for
pediatric patients are amply described in the
6
current clinical literature. Fagan has provided a
comprehensive discussion of a music therapy
program for terminally ill children incorporating
personalized confrontations with death, accept-
ing the deaths of friends in the hospital, dealing
with medical crises, isolation, sensitivity to hos-
pital routines as indicative of crisis, and reduc-
tion of anxiety related to drug-induced halluci-
nations. Her procedures proved effective in
promoting serenity and emotional adjustment
to debilitating illness for even the youngest
patients .42 Brodsky demonstrated the power-
ful benefits of music therapy stimulation for
children in medical isolation due to decreased
immunity from treatment side effects. Music
helped these children to experience a more nor-
malized environment with age-appropriate activ-
ities and opportunities for expression, relaxation,
control, and anxiety reduction. 43 Marley’s article
describes procedures for and benefits from the
musical stimulation and sedation of hospitalized
infants and toddlers44 whereas McDonnell and
Rudenberg and Royka describe music activities
for traumatized children with burns and their
families ~5.46
Music therapy is similar in concept to the idea
and principles of play therapy in that diversion
from aversive stimuli is afforded by focus of at-
tention on a preferred activity. Similarly, self-
expression and self-concept can be enhanced in
successful, fun, age-appropriate activities. It is
interesting to note that one study contrasted
music and play therapy techniques and found
that music therapy was slightly more effective
than play therapy in promoting verbalizations of
pediatric patients about what they were experi-
encing 47 Slivka and Magill, therefore, developed
a program which combines music therapy with
social work techniques to maximize counseling
benefits.48
Pediatric Oncology
goals of music therapy in pediatric on-
The
cology include anxiety and pain reduction, ten-
sion release and relaxation, provision of oppor-
tunities to exercise control of an aversive
environment, expression of feelings, facilitation
ofhope, nurturing, normalization and improve-
ment of thequality of life, development of trust,
improvement in parent/child relationships, pro-
motion of self-esteem, and celebration of the
healthy/positive aspects of the child’s life. 43
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Family members are regularly integrated into
music therapy activities to assist children with
cancer in bonding with parents during times of
medical crisis .49 By participating actively in mu-
sic therapy, family members are also empow-
ered at a time when they may feel that they lack
control.
’The lyurse’s Role
This article has attempted to demonstrate
why the simple addition of taped music to the
health care environment, although beneficial, is
not synonymous with music therapy5o (although
music therapists may use this activity as one
option in an array of sophisticated professional
techniques). The following suggestions are of-
fered to nursing researchers and pediatric on-
cology nurse practitioners who wish to include
music in their health protocols: (1) differentiate
among music listening, music performance,
and music therapy procedures in the health care
setting, especially in written documentation of
the procedures; (2) investigate the rich database
of music therapy research literature and exper-
tise ; (3) consult a qualified, professional music
therapist in the provision of music for patients, in
the selection of music for research purposes,
and in the review of music research articles be-
fore publication; and (4) integrate professional
music therapy services with other treatments
and therapies received by pediatric oncology pa-
tients.
Nurses are particularly aware of special needs
of their patients. Referral to music therapy for
pediatric patients would be indicated for the fol-
lowing problems: when the patient is in pain, has
a terminal illness, is distressed by the medical
environment or treatment, is withdrawn or non-
responsive to medical personnel, is deprived of
stimulation due to isolation restrictions, is devel-
opmentally regressing, has a poor relationship
with family members, has recently become
aware of the death of a special friend in the med-
ical setting, or has difficulty sleeping. The refer-
ring nurse could expect the RMT to provide a
music therapy session designed to relieve the
specific symptom and provide written docu-
mentation and evaluation of the results.
At the end of life, music therapists assist pa-
tients to cope with pain and assist families to
deal with this painful transition by creating an
environment for warm, intimate sharing of a per-

sonal, creative experience .51 -52 Live music per-
formance for sedation and song composition
based on personal patient experiences are par-
ticularly powerful at this time. Often, nursing
personnel join the music therapist, the patient,
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