Assessment of Use of Music by Patients Participating in Cardiac Rehabilitation
Metzger, L Kay
The primary cause of morbidity and mortality in the United States is heart disease. It is a costly and pervasive group of disorders that effect all ages, races, and genders. Behavioral medicine and health psychology have focused on prevention and psychosocial influences of cardiovascular diseases for the past 30 years. Music therapy is a viable collaborative method in the psychosocial arena for alleviating risks and motivating rehabilitation from cardiac events. There is research to support the use of music to modulate heart health measurements such as heart rate and blood pressure, to enhance exercise programs, and to relieve stress symptoms. However, inconsistencies in the results of this research warrant continued collaboration of social scientists to find scientific means of establishing interventions with measurable outcomes. This project involved administering a music therapy survey in order to determine current use and preference for music in a cardiac rehabilitation program. Patients who were attending rehabilitation sessions in a large city hospital completed a survey on which they rated their level of use of music for exercise, relaxation, and enjoyment. The researcher also gathered information about musical preferences, musical experiences, and pertinent demographics. Patients, mostly white males over the age of 60, showed positive responses to the aesthetically pleasurable aspects of music. The use of music as a stimulus cue for exercise was decidedly absent. Nursing staff members were receptive to the project, and both staff and patients showed some interest for learning about music for therapeutic purposes. The results suggest that education about and development of music therapy in a cardiac rehabilitation program is warranted.
According to numerous sources, heart disease is the primary cause of mortality and morbidity in the United States (American Heart Association, 2001). More people in the United States die every year from heart problems than from cancer, chronic lung disease, pneumonia, influenza, diabetes, and all accidents combined (Martin, 2002). Although there are some genetic predispositions for heart disease, there are preventable risk factors such as sedentary behavior, obesity, consuming foods high in fat and sodium, and cigarette smoking (Levi, Lucchini, Negri, & La Vecchia, 2002; Luepker, Perry, et al., 1996; Vale, 2000). Community education programs have helped the general public become aware of risk factors and the seriousness of heart disease. (Luepker, Rastam, et al., 1996). Some of these programs have only moderate results. Prevention programs for young adults and school-aged children have been the most successful (Luepker, Perry, et al., 1996). Perhaps because of a growing awareness of the need for healthier lifestyles, the rate of mortality from heart disease has declined in the United States since 1970 (Kaplan, Patterson, & Sallis, 1993; Levi et al., 2002). However, cardiovascular disease still remains the leading cause of mortality and morbidity in the United States (Kaplan et al., 1993; Luepker, Perry, et al., 1996; Vale, 2000).
Kaplan et al. (1993) emphasize that cardiovascular diseases are not just a problem for older people. At least 20% of deaths from cardiovascular disease are people who are below the age of 65. The American Heart Association reported in 2001 that over $100 billion is spent each year in the United States for lost productivity, medical care, or disability payments resulting from heart disease (Smith & Ruiz, 2002). In addition, 23% of men and 30% of women who survive a heart attack (myocardial infarction) will have a recurrence within 6 months (Mason, 2002). These facts show that cardiovascular disease is a primary health care concern.
Music therapy may serve as an adjunct to medical treatment for cardiovascular disease. Ai and Boiling (2002) showed that 81% of 246 patients who were scheduled for cardiac surgery confirmed use of complementary or alternative therapies. A research review conducted at Stanford University revealed that music therapy was among the mind-body practices that were efficacious for cardiovascular conditions (Luskin et al., 1998). Kreitzer and Snyder (2002) emphasize that complementary therapies such as music can help reduces stress and anxiety especially if the underlying holistic philosophy is honored. Even though the anecdotal evidence is compelling, there is a high need for controlled research and evidence of cost effectiveness for complementary and alternative treatments such as music therapy (Luskin et al., 1998).
Both traditional allopathic medicine and complementary medicine are exploring research with a holistic perspective in mind (Aldridge, 1990). Observations regarding physiological changes such as heart rate can be correlated with musical changes. Aldridge (1990) refers to a hospital in Western Germany that embraces music and the arts as part of its holistic setting. In addition, during the past twenty years, medical practitioners, particularly nurses, have tended to see the presence of music in the medical setting as an antidote to a highly technological environment (Aldridge, 1993).
In the United States music has been used as a specialty to help address patient needs for over 100 years (Washco, 1933; Weldin & Eagle, 1991). Since 1950, music therapy has developed as a formalized profession. The American Music Therapy Association, Inc., documents several prominent physicians who endorse the role of music therapy as essential in patient rehabilitation in the medical setting (Music Therapy and Medicine, 2002). Research attests to the viability of music therapy in areas vital for cardiovascular well being; for example, stress management, alteration of physiological measures such as heart rate and blood pressure, and positive changes in mood and emotional states. However, studies done during the last 50 years with college students as subjects show inconsistent results (Metzger, in press). Although generally speaking, stimulative or excitative music will increase heart rate, blood pressure, and hormonal responses and sedative music will calm the physiological responses, further research is needed using a collaborative approach among medical personnel and scientifically trained music therapists (Edwards, Eagle, Pennebaker, & Tunke, 1991).
Bonny (1983) demonstrated the use of music therapy in the Intensive Coronary Care Unit. She administered a study of the effects of researcher designed musical tapes, which were intended to reduce stress and anxiety. Results showed significant decreases in heart rate, lessened anxiety and depression, and increased tolerance of pain. Webster (1973) studied the effects of twice daily music and relaxation therapy for patients with myocardial infarction over a 2 week period. She found a significant decrease in heart rate for the music condition and subjects reported feeling placid and at rest. The nursing profession has conducted studies regarding the effectiveness of music therapy in Coronary Care Units (CCU) over the last 15 years with mixed results (Elliot, 1994). Some showed significant results in reduction of heart rate, respiratory rate, blood pressure, or skin temperature (Barnason, Zimmerman, & Nieveen, 1995; Guzzetta, 1989; Lueders-Bolwerk, 1990; White, 1992). Other studies indicated significant improvement in mood or anxiety states (Barnason et al., 1995; Davis-Rollans & Cunningham, 1987; Lueders-Bolwerk, 1990; White, 1992). Elliot (1994) found that there were no significant differences in anxiety or physiologic measures for the music condition, although he stated this could have been due to a type II error. Reduction of anxiety and concern over safety of using music in a coronary care unit were motivators for most of these studies and all concluded that at the very least music is not harmful and has a positive effect on mood (Barnason et al., 1995; Davis-Rollans & Cunningham, 1987). Subject reports and qualitative data showed that most patients enjoyed and preferred listening to music while relaxing and recuperating (Bonny, 1983; White, 1992).
While research on the use of music in the CCU rendered important information, there are inherent inconsistencies. Some of the diagnoses are suspected Myocardial Infarction (MI), some are confirmed MI, others are Ischemic, recent heart bypass surgery, or unknown diagnosis. Measures of anxiety as well as the pre-intervention level of anxiety vary, and it was difficult to maintain consistent frequency and duration of musical stimulus. In addition, the process of musical selection ranged from investigator’s choice, to patient preference, to music previously used in the hospital. Because of the difficulties with controlling conditions in the CCU and the success for recovery with utilization of cardiac rehabilitation, music therapy research in a cardiac rehabilitation setting may be more salient.
The American Heart Association and American College of Cardiology emphasize the importance of cardiovascular rehabilitation and give guidelines for patients who have experienced an Acute Myocardial Infarction (McEntee et al., 1999). They state that the majority of patients need to change behaviors surrounding diet, smoking, stress, exercise, and medication adherence. Denial, insufficient motivation, emotional distress, and physical deconditioning thwart positive goals. Studies show that cardiac rehabilitation programs can improve health status, self-efficacy, and diastolic blood pressure (Mason, 2002). Rodgers’ (2000) study showed a significant improvement for patients in a cardiac rehabilitation program in the areas of sleep quality and mental and physical health. Those who participated in rehabilitation demonstrated some gains in depression scores (Rodgers, 2000) and participated in significantly more exercise, meditation, and healthy nutrition (Buselli, 1998). Cardiac rehabilitation programs are effective in extending the life of patients (Buselli, 1998; Kaplan et al., 1993) and can even lead to a reversal of artery blockage due to atherosclerosis thus preventing further damage to the coronary system (Kaplan et al., 1993). Even though formal rehabilitation programs provide marked benefits for recovery, only a small percentage of patients participate. Motivational and alternative methods of behavioral management need to be explored.
Music can enhance motivational and behavioral management needs. It can be used as an energizing stimulus for exercise performance, can serve as a positive reinforcer, can change mood states, and is effective for stress management. Exercising to music may effect perceived exertion, physiological measures, and mood state. Subjects showed enhancement of mood when music accompanied exercise in two studies (MacNay, 1995; Murrock, 2002). MacNay (1995) demonstrated that a preferred music condition elicited perceived decrease in exertion and a decrease in time estimation of exercise. A study often men during treadmill running showed that music during exercise significantly changed perceived effort, lactate levels, and norepinephrine (Bacharach, 1998). There is some evidence that music could be both a motivating and reinforcing element for participation in exercise in a cardiovascular rehabilitation program.
Music therapy can be effective in a stress management program for cardiovascular rehabilitation. Mandel (1996) conducted individual and group music sessions for patients and family members or close friends. These sessions documented the importance of psychosocial as well as physiological variables in restoring cardiac health and convinced the staff cardiologist of the benefits of music therapy. Many of the clients chose to continue to use music therapy as an adjunct treatment. Watkins (1997) reiterates from a nursing perspective that music therapy can be an effective intervention for reducing stress through decreasing anxiety levels, blood pressure, heart rate, or hormone levels. Other nursing studies affirm that music therapy is a safe modality for modulating psychophysiologic symptoms of stress for coronary patients (Fitzsimmons, Shively, & Verderber, 1991). Stress inducing behaviors that contribute to cardiac risks such as Type A behaviors can also be assessed through music improvisation. The musical improvisation can discover new levels of flexibility and help develop coping skills for stress management (Aldridge, 1991).
Since cardiac rehabilitation is an effective means of increasing cardiac health and decreasing recurrence of heart disease incidents, health care providers can improve patient success by maximizing services in cardiac rehabilitation. Psychosocial interventions including music therapy have been shown to effect pertinent heart health physiological measures, quality of life, emotional well-being, and stress levels. Music therapy interventions can maximize success in reaching cardiac rehabilitation goals in a cost-effective manner. However, before designing music therapy interventions, it is necessary to assess current needs and uses of music by those participating in cardiac rehabilitation programs. Currently, this information is not readily available. As Fowler (1988) suggests, such information must be collected by administering a music therapy survey that measures how patients use music for exercise, for relaxation, for stress reduction, or for enjoyment. Survey results can be used to develop music therapy interventions that will, in turn, evaluate the effectiveness of music therapy in achieving a higher rate of medically acceptable progress for patients in cardiovascular rehabilitation.
A survey questionnaire and an informed consent letter were developed according to guidelines presented in a university music research class and by Floyd Fowler, Jr. in Survey Research Methods (1988). The design followed guiding principles for a self-administered questionnaire such as brevity, clarity, uncluttered look, ease of use, and minimal need for directions (Fowler, 1988). Two music therapy professors and about 15 graduate students in music research reviewed the letter and survey. Their feedback contributed to helpful revisions for clarity and ease of use. The following research questions were used for developing twelve items about how participants in a cardiovascular rehabilitation program might be using music for exercise, stress management, or aesthetic enjoyment:
1. Do patients in cardiovascular rehabilitation programs
a. Use music as a distraction while exercising?
b. Use music as a motivator to energize their exercise routine?
c. Use music to reduce stress symptoms that may be related to heart disease?
d. Use music in their daily life for recreation or enjoyment?
2. Would patients in cardiovascular rehabilitation programs be interested in learning more about how to use music to reach their rehabilitation goals?
3. What are the demographics of those answering Questions 1 and 2? Demographics include musical training and preference, age, gender, ethnicity, marital status, heart condition, spiritual orientation, and number of weeks in rehabilitation.
Subjects were 33 patients who were participating in a cardiac rehabilitation program at a local hospital. These patients were primarily Caucasian males over the age of 65. This sample is typical for a patient with heart disease in a rehabilitation program. Those of other ethnicity or gender (females) may respond differently to cardiovascular diseases and rehabilitation. All subjects read an informational consent letter assuring confidentiality, completed the survey independently on site, and returned it to the researcher as soon as they were finished.
The survey was conducted at St. Joseph Health Center in Kansas City, Missouri. St. Joseph Health Center is a large private, not-for-profit, acute-care facility and is a division of Carondelet Health Systems, Inc. It was founded in 1874 by the Sisters of St. Joseph of Carondelet and had since become part of a larger network of Catholic health services. It has an acute cardiopulmonary unit as well as a large cardiovascular rehabilitation facility. The researcher consulted with the nursing director of cardiac rehabilitation and reviewed the research protocol and methods, which were approved by the departmental administration. The nursing director and music therapist agreed on a date for the research. The survey was conducted on site by the music therapist/researcher from about 8:30 a.m. to 3:00 p.m. The nursing staff referred some patients to the researcher, who was sitting at a desk in the cardiac rehabilitation room, to fill out the questionnaire prior to or immediately following their exercise sessions. In addition, there were two educational classes and one support group meeting taking place on the day of the survey research. The nursing coordinator suggested these would be viable settings for more distribution of the survey. Before each class the researcher met briefly with the patients, explained the source of the project, and passed out the letters and survey forms. All participants were invited to place their name in a basket for a drawing for a music therapy relaxation audiotape. The drawing for the tape took place at the end of the research project day and the audiotapes were left with the nursing staff to distribute to the patients. An effort was made so that the solicitation to fill out the survey was nonintrusive and nonimplicative of any consequences for nonparticipation. The majority of the patients attending the rehabilitation sessions participated in filling out the survey.
Patients gave individual ratings to 12 questions, which were collated into the respective research questions. Percentages were tabulated for the five research questions on the ratings of 5 (always), 4 (a lot), 3 (sometimes), 2 (rarely), and 1 (never). Results regarding research questions are as follows:
Table one shows the mean ratings for the survey items related to the research questions. The means as expected follow the pattern of percentages, which shows most ratings in the midrange. The expected value of 3 for the means of a normal distribution is approximated except for the ratings for musical enjoyment or pleasure (4.06). It is of interest to note the other two mean ratings over 3.5-music used as a distracter while exercising (3.67) and willingness to learn about music therapy (3.60). Some subjects gave verbal comments that indicated their hesitation for learning about or using music as part of their rehabilitation came from not knowing exactly how music could be used as a therapeutic modality. These data show that the subjects value music as a pleasurable activity, may consider using it to enhance exercise, and have no strong opposition to music therapy as part of their cardiovascular rehabilitation program.
Demographic information revealed that out of 33 respondents, 25 were male, 6 female, (2 left blank); 26 were married, 2 divorced, 2 single, and 1 widowed, (2 left blank). Christian (27 marked) was the predominate spiritual orientation with Jewish, Buddhist, and Other each mentioned once (3 left blank). Race and ethnicity were distinguished as White (Non-Hispanic), 26; Native American, 4; Asian American, 4; and African American, 2 (2 left blank). Most subjects (88%) were in rehabilitation as the result of a recant heart surgery such as a bypass or angioplasty.
Ages of the subjects ranged from 50-83 (M = 67; SD = 9.59). The number of weeks in rehabilitation ranged from 1.5 to 18 (M = 9; SD = 4.73). In summary of the demographics, we can state that the largest majority of participants in this cardiac rehabilitation program were white males in their 60s or 70s who were married, of Christian faith, had recent heart surgery, and been in rehab for a few weeks. See Table 2 and Table 3 for a summary of musical preferences and experiences. Subjects were instructed to “mark all that apply” in these sections.
These subjects were people who had strong preferences for the Big Band era of music but also showed some interest in Country Western and Classical. Three subjects remarked that they would listen to almost anything but Rap music.
Out of the 31 subjects that answered the section about musical experience, 9 expressed that they had no previous or current experience. The remaining 22 subjects had a total of 45 musical experiences in music groups or in study about music. Two people verbalised that they still enjoyed their participation in country and folk dancing; three others mentioned that they were still singing in a choir. One commented that she facilitated and supported the use of music therapy when she was the medical director of an agency. The average difference between mean ratings for those with or without musical experiences on the five research questions was 0.44. This was interpreted as minimal.
The purpose of this survey was to discover current needs and uses of music by those participating in a cardiac rehabilitation program. This discovery can lead to designing methods and techniques of music therapy for enhancing success in rehabilitation. The participants in this survey were typical of many patients recovering from a serious heart event. White males over 65 in large metropolitan areas have the highest rates of recorded heart disease. However, as mentioned earlier, it is important to note that females and those with other racial/ethnic origins may have different symptom or treatment needs. This study is limited in that respect in its external validity. Results show that subjects gained pleasure in listening to music, enjoyed participating in musical activities, and used music some as a distracter during their exercise routines. Two representative comments support the aesthetic enjoyment: “Music, for me, is medicinal” and “I love music; it is relaxing.”
However, their use of music as a specific stimulus cue for exercise was not present to a large degree. This was indicated not only by their answers to the questions but by the researcher’s observations. The music played during exercise is not cued to any particular rhythmic pattern or beats per minute. It was chosen for nursing staff preference as well as an individual patient preference. The patients were rarely, if ever, synchronizing their movements to the music. Since the patients are in a large exercise room as a group yet each performing at their own pace and level of perceived exertion, they would need individual earphones to listen to effective music stimulus for exercise. Their heart rate is monitored continuously and their blood pressure is taken before, during, and after their sessions. There was also only a moderate awareness of the specific effects of music as a stress management or relaxation stimulus as indicated by survey results, comments, and observation.
The nursing staff as well as the patients showed some enthusiasm for the researcher’s presence and several patients showed eagerness to share their opinions on music preferences with the music therapist. One stated, “I am enthusiastic about music therapy.” The majority of the patients (92%) would attend music therapy at least sometimes. It is not clear, however, how much enthusiasm was due to the novelty of the presence of a music therapist.
Smith and Ruiz (2002) point out that behavioral medicine and health psychology have focused on heart disease as a major concern for the last 30 years. Health psychologists particularly focus on prevention, psychosocial influences (such as stress and negative emotions) on the development and course of heart disease, and psychosocial interventions for managing medical care. Psychosocial interventions that address hostility, depression, anxiety, social isolation, interpersonal conflicts, and job stress can help reduce morbidity and mortality for cardiovascular diseases (Clay, 2001 ). Although there are some inconsistencies and methodological limitations, there is growing evidence regarding the efficacy of adjunctive psychosocial interventions (Smith & Ruiz, 2002). It is precisely in the area of psychosocial and behavioral interventions that music therapy can become a collaborative health service in cardiac health and rehabilitation programs. Increased knowledge in this area could contribute to the clinical practice of music therapy and benefit those seeking cardiovascular well being. This study helped illustrate the need to carefully assess musical preferences, specific patient needs, and treatment conditions before designing an individualized and effective music therapy intervention for cardiovascular rehabilitation.
The levels of musical experience were generalized, into two broad categories of “with” or “without.” Future assessments could be designed to discern the effects of frequency and type of musical experiences on specific outcomes (e.g., level of motivation or hedonic effects of music). Further areas of study could explore the interaction of music therapy preferences or needs with occupation, educational level, gender, or ethnicity.
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L. Kay Metzger, MME, MT-BC
University of Missouri-Kansas City
Copyright American Music Therapy Association Spring 2004
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