Music Interventions For Improving Psychological and Physical Outcomes in Cancer Patients (Review)

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Cochrane Database of Systematic Reviews

Music interventions for improving psychological and physical
outcomes in cancer patients (Review)
Bradt J, Dileo C, Magill L, Teague A
Bradt J, Dileo C, Magill L, Teague A.

Music interventions for improving psychological and physical outcomes in cancer patients.
Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD006911.
DOI: 10.1002/14651858.CD006911.pub3.
www.cochranelibrary.com

Music interventions for improving psychological and physical outcomes in cancer patients (Review)
Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.

Library Better health. Cochrane Database of Systematic Reviews
TABLE OF CONTENTS
HEADER......................................................................................................................................................................................................... 1
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 6
OBJECTIVES.................................................................................................................................................................................................. 7
METHODS..................................................................................................................................................................................................... 7
RESULTS........................................................................................................................................................................................................ 10
Figure 1.................................................................................................................................................................................................. 11
Figure 2.................................................................................................................................................................................................. 13
Figure 3.................................................................................................................................................................................................. 15
Figure 4.................................................................................................................................................................................................. 16
Figure 5.................................................................................................................................................................................................. 17
Figure 6.................................................................................................................................................................................................. 18
Figure 7.................................................................................................................................................................................................. 19
Figure 8.................................................................................................................................................................................................. 20
DISCUSSION.................................................................................................................................................................................................. 26
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 28
ACKNOWLEDGEMENTS................................................................................................................................................................................ 29
REFERENCES................................................................................................................................................................................................ 30
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 38
DATA AND ANALYSES.................................................................................................................................................................................... 120
Analysis 1.1. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 1 Anxiety (STAI)........... 123
Analysis 1.2. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 2 Anxiety (non-STAI 124
(full version) measures)........................................................................................................................................................................
Analysis 1.3. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 3 Anxiety (intervention 124
subgroup)...............................................................................................................................................................................................
Analysis 1.4. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 4 Anxiety (music 125
preference).............................................................................................................................................................................................
Analysis 1.5. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 5 Anxiety (music-guided 126
relaxation)..............................................................................................................................................................................................
Analysis 1.6. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 6 Depression............... 127
Analysis 1.7. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 7 Depression 127
(intervention subgroup).......................................................................................................................................................................
Analysis 1.8. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 8 Depression (music 128
preference).............................................................................................................................................................................................
Analysis 1.9. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 9 Mood........................ 128
Analysis 1.10. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 10 Mood (intervention 129
subgroup)...............................................................................................................................................................................................
Analysis 1.11. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 11 Pain...................... 129
Analysis 1.12. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 12 Pain (music 130
preference).............................................................................................................................................................................................
Analysis 1.13. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 13 Fatigue................. 130
Analysis 1.14. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 14 Physical 131
functioning.............................................................................................................................................................................................
Analysis 1.15. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 15 Heart rate............. 131
Analysis 1.16. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 16 Heart rate (music 132
preference).............................................................................................................................................................................................
Analysis 1.17. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 17 Respiratory rate..... 133
Analysis 1.18. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 18 Systolic blood 133
pressure.................................................................................................................................................................................................
Analysis 1.19. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 19 Systolic blood 134
pressure (music preference).................................................................................................................................................................
Music interventions for improving psychological and physical outcomes in cancer patients (Review) i
Informed decisions.

Analysis 1.20. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 20 Diastolic blood 134
pressure.................................................................................................................................................................................................
Analysis 1.21. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 21 Diastolic blood 135
pressure (music preference).................................................................................................................................................................
Analysis 1.22. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 22 Oxygen 135
Saturation..............................................................................................................................................................................................
Analysis 1.23. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 23 Quality of Life....... 136
Analysis 1.24. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 24 Quality of life 136
(intervention subgroup).......................................................................................................................................................................
Analysis 2.1. Comparison 2 Music therapy plus standard care versus music medicine plus standard care, Outcome 1 Anxiety...... 137
Analysis 3.1. Comparison 3 Music interventions plus standard care versus standard care plus placebo control, Outcome 1 137
Distress...................................................................................................................................................................................................
Analysis 3.2. Comparison 3 Music interventions plus standard care versus standard care plus placebo control, Outcome 2 138
Spiritual well-being...............................................................................................................................................................................
APPENDICES................................................................................................................................................................................................. 138
WHAT'S NEW................................................................................................................................................................................................. 151
HISTORY........................................................................................................................................................................................................ 153
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 153
DECLARATIONS OF INTEREST..................................................................................................................................................................... 153
SOURCES OF SUPPORT............................................................................................................................................................................... 153
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 153
INDEX TERMS............................................................................................................................................................................................... 154
Music interventions for improving psychological and physical outcomes in cancer patients (Review) ii
Informed decisions.

[Intervention Review]
Music interventions for improving psychological and physical outcomes

in cancer patients
Joke Bradt1, Cheryl Dileo2, Lucanne Magill3,4, Aaron Teague1
1Department of Creative Arts Therapies, College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA.
2Department of Music Therapy and The Arts and Quality of Life Research Center, Boyer College of Music and Dance, Temple University,
Philadelphia, USA. 3Creative Arts Therapy Department, Mount Sinai Hospital, New York, NY, USA. 4Department of Music and Performing
Arts Professions, New York University, New York, NY, USA
Contact address: Joke Bradt, Department of Creative Arts Therapies, College of Nursing and Health Professions, Drexel University, 1601
Cherry Street, room 7112, Philadelphia, PA, 19102, USA. [email protected].
Editorial group: Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group.

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 8, 2016.
Citation: Bradt J, Dileo C, Magill L, Teague A. Music interventions for improving psychological and physical outcomes in cancer patients.
Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD006911. DOI: 10.1002/14651858.CD006911.pub3.
ABSTRACT
Background
Having cancer may result in extensive emotional, physical and social suffering. Music interventions have been used to alleviate symptoms
and treatment side effects in cancer patients.
Objectives
To assess and compare the effects of music therapy and music medicine interventions for psychological and physical outcomes in people
with cancer.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 1), MEDLINE, Embase, CINAHL, PsycINFO, LILACS,
Science Citation Index, CancerLit, CAIRSS, Proquest Digital Dissertations, ClinicalTrials.gov, Current Controlled Trials, the RILM Abstracts of
Music Literature, http://www.wfmt.info/Musictherapyworld/ and the National Research Register. We searched all databases, except for the
last two, from their inception to January 2016; the other two are no longer functional, so we searched them until their termination date.
We handsearched music therapy journals, reviewed reference lists and contacted experts. There was no language restriction.
Selection criteria
We included all randomized and quasi-randomized controlled trials of music interventions for improving psychological and physical
outcomes in adult and pediatric patients with cancer. We excluded participants undergoing biopsy and aspiration for diagnostic purposes.
Data collection and analysis

Two review authors independently extracted the data and assessed the risk of bias. Where possible, we presented results in meta-analyses
using mean differences and standardized mean differences. We used post-test scores. In cases of significant baseline difference, we used
change scores.
Main results
We identified 22 new trials for inclusion in this update. In total, the evidence of this review rests on 52 trials with a total of 3731 participants.
We included music therapy interventions offered by trained music therapists, as well as music medicine interventions, which are defined
as listening to pre-recorded music, offered by medical staff. We categorized 23 trials as music therapy trials and 29 as music medicine trials.
Music interventions for improving psychological and physical outcomes in cancer patients (Review) 1
Informed decisions.

The results suggest that music interventions may have a beneficial effect on anxiety in people with cancer, with a reported average anxiety
reduction of 8.54 units (95% confidence interval (CI) −12.04 to −5.05, P < 0.0001) on the Spielberger State Anxiety Inventory - State Anxiety
(STAI-S) scale (range 20 to 80) and −0.71 standardized units (13 studies, 1028 participants; 95% CI −0.98 to −0.43, P < 0.00001; low quality
evidence) on other anxiety scales, a moderate to strong effect. Results also suggested a moderately strong, positive impact on depression
(7 studies, 723 participants; standardized mean difference (SMD): −0.40, 95% CI −0.74 to −0.06, P = 0.02; very low quality evidence), but
because of the very low quality of the evidence for this outcome, this result needs to be interpreted with caution. We found no support for
an effect of music interventions on mood or distress.
Music interventions may lead to small reductions in heart rate, respiratory rate and blood pressure but do not appear to impact oxygen
saturation level. We found a large pain-reducing effect (7 studies, 528 participants; SMD: −0.91, 95% CI −1.46 to −0.36, P = 0.001, low quality
evidence). In addition, music interventions had a small to moderate treatment effect on fatigue (6 studies, 253 participants; SMD: −0.38,
95% CI −0.72 to −0.04, P = 0.03; low quality evidence), but we did not find strong evidence for improvement in physical functioning.
The results suggest a large effect of music interventions on patients' quality of life (QoL), but the results were highly inconsistent across
studies, and the pooled effect size for the music medicine and music therapy studies was accompanied by a large confidence interval (SMD:
0.98, 95% CI −0.36 to 2.33, P = 0.15, low quality evidence). A comparison between music therapy and music medicine interventions suggests
a moderate effect of music therapy interventions for patients' quality of life (QoL) (3 studies, 132 participants; SMD: 0.42, 95% CI 0.06 to
0.78, P = 0.02; very low quality evidence), but we found no evidence of an effect for music medicine interventions. A comparison between
music therapy and music medicine studies was also possible for anxiety, depression and mood, but we found no difference between the
two types of interventions for these outcomes.
The results of single studies suggest that music listening may reduce the need for anesthetics and analgesics as well as decrease recovery
time and duration of hospitalization, but more research is needed for these outcomes.
We could not draw any conclusions regarding the effect of music interventions on immunologic functioning, coping, resilience or
communication outcomes because either we could not pool the results of the studies that included these outcomes or we could only
identify one trial. For spiritual well-being, we found no evidence of an effect in adolescents or young adults, and we could not draw any
conclusions in adults.
The majority of studies included in this review update presented a high risk of bias, and therefore the quality of evidence is low.
Authors' conclusions
This systematic review indicates that music interventions may have beneficial effects on anxiety, pain, fatigue and QoL in people with
cancer. Furthermore, music may have a small effect on heart rate, respiratory rate and blood pressure. Most trials were at high risk of bias
and, therefore, these results need to be interpreted with caution.
PLAIN LANGUAGE SUMMARY
Can music interventions benefit cancer patients?
The issue
Cancer may result in extensive emotional, physical and social suffering. Current cancer care increasingly incorporates psychosocial
interventions to improve quality of life. Music therapy and music medicine interventions have been used to alleviate symptoms and
treatment side effects and address psychosocial needs in people with cancer. In music medicine interventions, the patient simply listens
to pre-recorded music that is offered by a medical professional. Music therapy requires the implementation of a music intervention by a
trained music therapist, the presence of a therapeutic process and the use of personally tailored music experiences.
The aim of the review

This review is an update of a previous Cochrane review from 2011, which included 30 studies and found support for an effect of music
interventions on several psychological and physical outcomes. For this review update, we searched for additional trials studying the effect
of music interventions on psychological and physical outcomes in people with cancer. We searched for published and ongoing studies up
to January 2016. We considered all studies in which music therapy or music medicine was compared with standard treatment alone or
standard care combined with other treatments or placebo.
What are the main findings?

We identified 22 new studies, so the evidence in this review update now rests on 52 studies with 3731 participants. The findings suggest
that music therapy and music medicine interventions may have a beneficial effect on anxiety, pain, fatigue, heart rate, respiratory rate
and blood pressure in people with cancer. Because of the very low quality of the evidence for depression, it is unclear what impact music
interventions may have. Music therapy but not music medicine interventions may improve patients' quality of life. We did not find evidence
that music interventions improve mood, distress or physical functioning, but only a few trials studied these outcomes. We could not
draw any conclusions about the effect of music interventions on immunologic functioning, coping, resilience or communication outcomes
because there were not enough trials looking at these aspects. Therefore, more research is needed.
Informed decisions.

No adverse effects of music interventions were reported.
Quality of the evidence

Most trials were at high risk of bias, so these results need to be interpreted with caution. We did not identify any conflicts of interests in
the included studies.
What are the conclusions?

We conclude that music interventions may have beneficial effects on anxiety, pain, fatigue and quality of life (QoL) in people with cancer.
Furthermore, music may have a small positive effect on heart rate, respiratory rate and blood pressure. Reduction of anxiety, fatigue
and pain are important outcomes for people with cancer, as they have an impact on health and overall QoL. Therefore, we recommend
considering the inclusion of music therapy and music medicine interventions in psychosocial cancer care.
Informed decisions.

SUMMARY OF FINDINGS

Summary of findings for the main comparison. Music interventions compared to standard care for psychological
and physical outcomes in cancer patients
Music interventions versus standard care for psychological and physical outcomes in cancer patients
Patient or population: cancer patients

Setting: inpatient and outpatient cancer care
Intervention: music interventions
Comparison: standard care
Out- Relative effect (95% CI) No of par- Quality of Comments

comes ticipants the evi-
(studies) dence
(GRADE)
Anxiety The mean anxiety in the music intervention group was 8.54 units 1028 ⊕⊕⊝⊝ —
assessed less (12.04 less to 5.05 less) than in the standard care group (13 RCTs) Lowa,b
with:
Spielberg-
er State
Anxiety In-
dex
Scale
from: 0 to
40
Depres- The mean depression in the music intervention group was 0.40 723 ⊕⊝⊝⊝ An SMD of 0.40 is
sion standard deviations less (0.74 less to 0.06 less) than in the standard (7 RCTs) Very considered a low to
care group lowa,c moderate effect size
Mood The mean mood in the music intervention group was 0.47 standard 236 ⊕⊕⊝⊝ An SMD of 0.47 is
deviations better (0.02 worse to 0.97 better) than in the standard (5 RCTs) Lowa,d considered a moder-
care group ate effect size
Pain The mean pain in the intervention group was 0.91 standard devia- 528 ⊕⊕⊝⊝ An SMD of 0.91 is
tions less (1.46 less to 0.36 less) than in the standard care group (7 RCTs) Lowa,e considered a large ef-
fect size
Fatigue The mean fatigue in the music intervention group was 0.38 stan- 253 ⊕⊕⊝⊝ An SMD of 0.38 is
dard deviations less (0.72 less to 0.04 less) than in the standard care (6 RCTs) Lowa considered a small to
group moderate effect size
Quality of The mean quality of life in the music intervention group was 0.98 545 ⊕⊕⊝⊝ An SMD of 0.98 is
life standard deviations more (0.36 less to 2.33 more) than in the stan- (6 RCTs) Lowa,f considered a large ef-
dard care group fect size
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the
relative effect of the intervention (and its 95% CI).
CI: confidence interval; SMD: standardized mean difference.
GRADE Working Group grades of evidence

High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the ef-
fect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the
effect
Informed decisions.

Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the
estimate of effect
a The majority of the trials were at high risk of bias.

b Results were inconsistent across studies as evidenced by I2 = 93%, but all treatment effects were in the desired direction.
c Results were inconsistent across studies as evidenced by I2 = 77%, but all treatment effects were in the desired direction.
d Results were inconsistent across studies as evidenced by I2 = 70%, but all treatment effects were in the desired direction.
e Results were inconsistent across studies as evidenced by I2 = 88%, but all treatment effects were in the desired direction.
f Results were inconsistent across studies as evidenced by I2 = 98% ,but all treatment effects were in desired direction and large
heterogeneity was mostly due to outlying values of one study.

Informed decisions.

BACKGROUND • combining music with other therapeutic modalities (e.g.

movement, imagery, art) (Dileo 2007).
Description of the condition
How the intervention might work
The lifetime risk of developing any type of cancer is 44% for
men and 38% for women (NCI 2010), and a diagnosis of cancer Music interventions have been used in different medical fields to
may result in extensive emotional, physical and social suffering. meet patients' psychological, physical, social and spiritual needs.
Many symptoms and treatment side effects have an impact on Research on the effects of music and music therapy for medical
cancer patients' physical well-being and quality of life (QoL), patients has burgeoned over the past 20 years, examining a variety
including appetite disturbance, difficulty swallowing, nausea, of outcome measures in a wide range of specialty areas (Dileo
vomiting, constipation, diarrhea, dyspnea or difficulty breathing, 2005). For both adult and pediatric cancer patients, music has been
fatigue, insomnia, muscle weakness and numbness (King 2003). In used to decrease anxiety prior to or during surgical procedures
addition, study findings clearly indicate that people with cancer (Burns 1999; Haun 2001; Pfaff 1989), to decrease stress during
experience elevated levels of psychological distress and depression chemotherapy or radiation therapy (Clark 2006; Weber 1996), to
in response to diagnosis and treatment (van't Spijker 1997; Massie lessen treatment side effects (Bozcuk 2006; Ezzone 1998; Frank
2004; Norton 2004; Parle 1996; Raison 2003; Sellick 1999). The 1985), to improve mood (Bailey 1983 Barrera 2002; Burns 2001a;
actual experience of chemotherapy-induced side effects, such as Cassileth 2003), to enhance pain management (Akombo 2006;
nausea and vomiting, and their influence on psychological well- Beck 1989), to improve immune system functioning (Burns 2001a;
being varies widely in patients receiving the same cytotoxic agents. Camprubi 1999), and to improve quality of life (QoL) (Burns 2001a;
This suggests that non-pharmacological factors possibly play an Hilliard 2003).
important role in how patients experience or interpret physical
symptoms during the treatment phase (Montgomery 2000; Thune- There are inherent elements of music—such as rhythm and
Boyle 2006). It is therefore important that cancer care incorporates tempo, mode, pitch, timbre, melody and harmony—that are known
services that help meet patients' psychological, social and spiritual to influence physiological and psycho-emotional responses in
needs. humans. For example, music has been found to arouse memory
and association, stimulate imagery, evoke emotions, facilitate
Description of the intervention social interaction, and promote relaxation and distraction (Dileo
2006). In cancer settings, music therapists conduct ongoing
The use of music in cancer care can be situated along a assessments and utilize various individualized interventions in
continuum of care, namely from music listening initiated by people with cancer and their families, including pertinent elements
patients, to pre-recorded music offered by medical personnel, of music within the context of therapeutic relationships, to address
to music psychotherapy interventions offered by a trained music prevailing biopsychosocial and spiritual issues, symptoms and
therapist. Therefore, when examining the efficacy of music needs (Magill 2009; McClean 2012). The following music therapy
interventions with cancer patients, it is important to make interventions are common: use of songs (singing, song writing, and
a clear distinction between music interventions administered lyric analysis); music improvisation (instrumental and vocal), music
by medical or healthcare professionals (music medicine) and and imagery, music-based reminiscence and life review, chanting
those implemented by trained music therapists (music therapy). and toning, music-based relaxation, and instrumental participation
A substantive body of evidence suggests that music therapy (O'Callaghan 2015). Based on patient preferences and assessment
interventions provided by medical professionals are significantly outcomes, music therapists adapt and modify music interventions
more effective than music medicine interventions for a wide variety to address symptoms and areas of difficulty; they utilize music
of outcomes (Dileo 2005). This difference might be attributed to the and verbal strategies to provide opportunities for expression and
fact that music therapists individualize their interventions to meet communication, reminiscence, the processing of thoughts and
patients' specific needs, more actively engage the patients in music emotions and improvement of symptom management (Magill
making, and employ a systematic therapeutic process including 2011). Therapist-supported music therapy environments often
assessment, treatment and evaluation. Dileo 1999 categorizes provide the space and time through which patients and families
interventions as music medicine when medical personnel offer pre- may experience social connection, improve self fulfilment and
recorded music for passive listening. For example, they may offer acquire effective coping strategies (Magill 2015).
people a CD for relaxation or distraction; however, no systematic
therapeutic process is present, nor is there a systematic assessment Why it is important to do this review
of the elements and suitability of the music stimulus. In contrast,
music therapy requires the implementation of a music intervention Several research studies on the use of music with cancer patients
by a trained music therapist, the presence of a therapeutic process have reported positive results (Beck 1989; Cassileth 2003; Harper
and the use of personally tailored music experiences. 2001; Hilliard 2003; Robb 2008). The majority of these studies,
however, are compromised by small sample size and lack of
These music experiences include: statistical power. In addition, differences in factors such as methods
of interventions and type and intensity of treatment have led to
• listening to live, improvised or pre-recorded music; varying results. A systematic review is needed to more accurately
• performing music on an instrument; gauge the efficacy of music interventions in cancer patients as well
• improvising music spontaneously using voice, instruments or as to identify variables that may moderate its effects.
both;
• composing music;
Informed decisions.

OBJECTIVES 2. MEDLINE (OvidSp) (1950 to January, week 2, 2016) (Appendix 2);

3. Embase (OvidSp) (1980 to 2016, week 4) (Appendix 3);
To assess and compare the effects of music therapy and music
4. CINAHL (EbscoHost)(1982 to 23 January 2016) (Appendix 4);
medicine interventions for psychological and physical outcomes in
people with cancer. 5. 5. PsycINFO (OvidSp) (1967 to January 15 2016) (Appendix 5);
6. LILACS (Virtual Health Library) (1982 to January 2016) (Appendix
METHODS 6).
7. The Science Citation Index (ISI) (inception to January 2016)
Criteria for considering studies for this review (Appendix 7).
Types of studies 8. CancerLit (1983 to 2003) (http://www.cancer.gov) (Appendix 8).
9. CAIRSS for Music (inception to January 2016) (http://
All randomized controlled trials (RCTs) and studies with quasi-
ucairss.utsa.edu/) (Appendix 9).
randomized methods of treatment allocation (e.g. alternate
allocation of treatments) were eligible for inclusion. 10.Proquest Digital Dissertations (Proquest) (inception to January
2016) (Appendix 10).
Types of participants 11.ClinicalTrials.gov (http://www.clinicaltrials.gov/) (inception to
This review included participants diagnosed with any type of January 2016) (Appendix 11).
cancer. There were no restrictions as to age, sex, ethnicity or type 12.Current Controlled Trials (http://www.controlled-trials.com/)
of setting. We did exclude participants undergoing biopsy, bone (inception to January 2016) (Appendix 12).
marrow biopsy and aspiration for diagnostic purposes. This review 13.National Research Register (http://www.update-software.com/
did not include studies with cancer survivors. National/) (inception to September 2010; the NRR is no longer
active) (Appendix 13).
Types of interventions 14.http://www.wfmt.info/Musictherapyworld/ (database is no
The review included all trials comparing standard treatment plus longer functional) (inception to March 2008) .
music therapy or music medicine interventions with: 15.RILM Abstracts of Music Literature (EbscoHost) (1969 to January
2016) (Appendix 14).
1. standard care alone;
2. standard care plus alternative intervention (e.g. music therapy Searching other resources
versus music medicine); We handsearched the following journals from first available date to
3. standard care plus placebo. January 2016
Placebo treatment can involve the use of headphones for the • Australian Journal of Music Therapy.
patient without provision of music stimuli or with another type of • Australian Music Therapy Association Bulletin.
auditory stimulus (e.g. audiobooks, white noise (hiss), pink noise
• Canadian Journal of Music Therapy.
(sound of ocean waves) or nature sounds).
• The International Journal of the Arts in Medicine.
Types of outcome measures • Journal of Music Therapy.
Primary outcomes • Musik-,Tanz-, und Kunsttherapie (Journal for Art Therapies in
Education, Welfare and Health Care).
1. Psychological outcomes (e.g. depression, anxiety, anger,
• Musiktherapeutische Umschau.
hopelessness, helplessness)
• Music Therapy.
2. Physical symptoms (e.g. fatigue, nausea, pain)
• Music Therapy Perspectives.
Secondary outcomes • Nordic Journal of Music Therapy;
1. Physiological outcomes (e.g. heart rate, respiratory rate, • Music Therapy Today (online journal of music therapy).
immunoglobulin A (IgA) levels) • Voices (online international journal of music therapy).
2. Social and spiritual support (e.g. family support, spirituality, • New Zealand Journal of Music Therapy.
social activity, isolation) • The Arts in Psychotherapy.
3. Communication (e.g. verbalization, facial affect, gestures) • British Journal of Music Therapy.
4. Quality of life (QoL) • Music and Medicine.
• Approaches.
Search methods for identification of studies
There were no language restrictions for either searching or trial In an effort to identify further published, unpublished and ongoing
inclusion. trials, we searched the bibliographies of relevant trials and
reviews, contacted experts in the field, and searched available
Electronic searches proceedings of music therapy conferences. We consulted music
therapy association websites to help identify music therapy
We searched the following electronic databases and trials registers. practitioners and conference information (e.g. the American
Music Therapy Association at www.musictherapy.org and the
1. Cochrane Central Register of Controlled Trials (CENTRAL) (The
British Association for Music Therapy at http://www.bamt.org).
Cochrane Library, 2016, Issue 1) (Appendix 1);
Informed decisions.

We also handsearched the website of the Deutsches Zentrum • Setting

fur Musiktherapieforschung (www.dzm-heidelberg.de/forschung/ • Inclusion criteria
publikationen/) and the research pages of the PhD programs
that are listed on the website of the European Music Therapy Outcomes
Confederation (emtc-eu.com/music-therapy-research/).
We extracted pre-test means, post-test means, standard deviations
Data collection and analysis and sample sizes for the treatment group and the control group for
the following outcomes (if applicable). For some trials only change
Selection of studies scores, instead of post-test scores, were available.
We divided the responsibility of the searches, as outlined in 1. Psychological outcomes (e.g. depression, anxiety, anger,
the search strategy, amongst JB, AT and research assistants. JB, hopelessness, helplessness)
AT and research assistants scanned titles and abstracts of each 2. Physical symptoms (e.g. fatigue, nausea, pain)
record retrieved from the search and deleted obviously irrelevant 3. Physiological outcomes (e.g. heart rate, respiratory rate,
references. When we could not reject a title or abstract with immunoglobulin A (IgA) levels)
certainty, we consulted the other review authors. We used an 4. Social and spiritual support (e.g. family support, spirituality,
inclusion criteria form to assess the trial's eligibility for inclusion social activity, isolation)
(Appendix 15). We kept a record of all excluded trials that initially 5. Communication (e.g. verbalization, facial affect, gestures)
appeared eligible and the reason for exclusion. 6. Quality of life
Data extraction and management Assessment of risk of bias in included studies
JB and AT independently extracted data from the selected trials Two review authors (JB and CD) assessed all included trials for
using a standardized coding form. We discussed differences in data risk of bias for the original review. CD and LM conducted the 'Risk
extraction until reaching a consensus. We extracted the following of bias' assessment for new studies included in this update. All
data. authors were blinded to each other's assessments. We resolved
any disagreements by discussion. The authors used the following
General information
criteria for quality assessment.
• Author
• Year of publication Random sequence generation
• Title • Low risk
• Journal (title, volume, pages) • Unclear risk
• If unpublished, source • High risk
• Duplicate publications
We rated trials to be at low risk for random sequence generation
• Country if every participant had an equal chance to be selected for
• Language of publication either condition and the investigator was unable to predict which
treatment the participant would be assigned to. Use of date of birth,
Intervention information date of admission or alternation resulted in a a judgement of high
• Type of intervention (e.g. singing, song-writing, music listening, risk of bias.
music improvisation)
Allocation concealment
• Music selection (detailed information on music selection in case
of music listening) • Low risk methods to conceal allocation include:
• Music preference (patient-preferred versus researcher-selected • central randomization;
in case of music listening) • serially numbered, opaque, sealed envelopes;
• Level of intervention (music therapy versus music medicine, as • other descriptions with convincing concealment.
defined by the authors in the Background) • Unclear risk - authors did not adequately report on method of
• Length of intervention concealment
• Frequency of intervention • High risk (e.g. trials used alternation methods)
• Comparison intervention
Blinding of participants and personnel
Participant information
• Low risk
• Total sample size • Unclear risk
• Number in experimental group • High risk
• Number in control group
• Sex Since participants cannot be blinded in a music intervention trial,
we did not downgrade studies for not blinding the participants. As
• Age
for personnel, in music therapy studies music therapists cannot be
• Ethnicity blinded because they are actively making music with the patients.
• Diagnosis In contrast, in music medicine studies blinding of personnel is
• Illness stage possible by providing control group participants with headphones
Informed decisions.

but no music (e.g. blank CD). Therefore, downgrading for not scales. When there were sufficient data available from various
blinding personnel was only applied in studies that used listening studies using the same measurement instrument, we computed a
to pre-recorded music. mean difference (MD) with 95% CI.
Blinding of outcome assessors Unit of analysis issues

• Low risk In all studies included in this review, participants were individually
• Unclear risk randomized to the intervention or the standard care control group.
• High risk Post-test values or change values on a single measurement for each
outcome from each participant were collected and analyzed.
When the study included no objective outcomes, we noted this in
the Characteristics of included studies table, and we rated the trial Dealing with missing data
as being at low risk of bias for outcome assessment of objective We did not impute missing outcome data. We analyzed data on
outcomes. The majority of the studies used self report measures an endpoint basis, including only participants for whom final data
for subjective outcomes. We rated these studies as being at high point measurement was available (available case analysis). We did
risk of bias for subjective outcomes, unless study participants were not assume that participants who dropped out after randomization
blinded to the study hypothesis (for comparative studies). had a negative outcome.
Incomplete outcome data Assessment of heterogeneity
We recorded the proportion of participants whose outcomes were We investigated heterogeneity using visual inspection of the forest
analyzed. We coded loss to follow-up for each outcome as: plots as well as the I2 statistic (Higgins 2002).
• low risk: if fewer than 20% of patients were lost to follow-up Assessment of reporting biases
and reasons for loss to follow-up were similar in both treatment
arms; We tested for publication bias visually in the form of funnel plots
(Higgins 2011).
• unclear risk: if loss to follow-up was not reported;
• high risk: if more than 20% of patients were lost to follow-up or Data synthesis
reasons for loss to follow-up differed between treatment arms.
We present all outcomes in this review as continuous variables.
Selective reporting We calculated standardized mean differences (SMD) for outcome
measures using results from different scales. We used mean
• Low risk: reports of the study were free from suggestions of differences (MD) for results using the same scales. We anticipated
selective outcome reporting that some individual trials would have used final scores and
• Unclear risk others change scores and even analysis of covariance (ANCOVA)
• High risk: reports of the study suggest selective outcome in their statistical analyses of the results. We combined these
reporting different types of analyses as MDs. We determined not to pool the
results in case of significant clinical heterogeneity. We calculated
Other sources of bias pooled estimates using the more conservative random-effects
• Low risk model. We calculated 95% confidence intervals (CI) for each effect
size estimate. We interpreted the magnitude of the SMDs using
• Unclear risk
the interpretation guidelines put forth by Cohen 1988). Cohen
• High risk suggested that an effect size of 0.2 be considered a small effect, an
effect size of 0.5 medium, and an effect size of 0.8 large.
We considered information on potential financial conflicts of
interest to be a possible source of additional bias. We made the following treatment comparisons in meta-analyses.
The above criteria were used to give each article an overall 1. Music interventions plus standard care versus standard care
quality rating (based on section 8.7 of the Cochrane Handbook for alone.
Systematic Reviews of Interventions; Higgins 2011).
2. Music therapy versus music medicine interventions (this was
• Low risk of bias - all criteria met. only possible for anxiety).
• Moderate risk of bias - one or more of the criteria only partly met. 3. Music interventions plus standard care versus standard care plus
alternative relaxation interventions
• High risk of bias - one or more criteria not met.
4. Music interventions plus standard care versus standard care plus
Studies were not excluded based on a low quality score. We planned placebo (audiobook control).
to use the overall quality assessment rating for sensitivity analysis.
However, since most trials were at high risk of bias, we could not Several studies compared music interventions with non-music
carry out this analysis. relaxation interventions. However, there was an insufficient
number of trials to allow for a treatment comparison analysis.
Measures of treatment effect These studies are therefore included in the narrative under the third
comparison (music intervention versus alternative intervention)
We present all outcomes in this review as continuous variables.
but not in the meta-analysis of this review.
We calculated standardized mean differences with 95% confidence
intervals (CI) for outcome measures using results from different
Informed decisions.

Subgroup analysis and investigation of heterogeneity RESULTS

We conducted the following subgroup analyses within the music
Description of studies
interventions plus standard care versus standard care alone
comparison for outcomes with a sufficient number of available Results of the search
studies.
For the original review, the database searches and handsearching
1. Music medicine versus music therapy. of conference proceedings, journals and reference lists resulted
in 773 unique citations. One review author (JB) and a research
2. Type of intervention (e.g. music listening alone versus music-
assistant examined the titles and abstracts and identified 101
guided relaxation).
reports as potentially relevant, which we retrieved for further
3. Music preference (patient-preferred music versus researcher- assessment. One review author (JB) and a research assistant then
selected music). independently screened them. We included 30 trials, reported
We planned the following subgroup analyses a priori, but we could in 36 records, in the original review. Where necessary, we
not carry these out because of insufficient numbers of trials per contacted principal investigators to obtain additional details on
outcome for age subgroup analysis and because no separate data trials and data. We identified three ongoing trials (NCT02261558;
were available according to stage of illness. NCT02583126; NCT02583139). We moved two ongoing studies from
the original review to the 'awaiting assessment' classification
1. Different age groups. (NCT00086762; O'Brien 2010). Unfortunately, we could not include
2. Stages of illness. them in this update as their results were not yet available
for inclusion. We classified four additional studies as awaiting
We conducted subgroup analyses as described by Deeks 2001 and assessment because their results were not yet published, and the
recommended in section 9.6 of Higgins 2011. authors could not provide the results for inclusion in this review.
Sensitivity analysis The 2016 update of the search resulted in 1187 unique citations.
Two review authors (JB and AT) and one research assistant
We examined the impact of sequence generation by comparing the examined the titles and abstracts, retrieving full-text articles where
results of including and excluding trials that used inadequate or necessary. This resulted in the addition of 25 references reporting
unclear randomization methods. on 22 trials (Figure 1) and three new ongoing trials (NCT02261558;
NCT02583126; NCT02583139).

Informed decisions.

Figure 1. Study flow diagram.

Included studies This review included 2090 females and 1171 males. Five trials
did not provide information on the distribution between sexes
We included 52 trials with a total of 3731 participants. Seventeen
(Danhauer 2010; Jin 2011; Robb 2008; Shaban 2006; Xie 2001). The
trials included participants who underwent chemotherapy or
average age of the participants was 54.67 years for adult trials and
radiation therapy (Bradt 2015; Bulfone 2009; Burrai 2014; Cai 2001;
10.93 years for pediatric trials. Seventeen studies did not report
Chen 2013; Clark 2006; Ferrer 2005; Gimeno 2008; Jin 2011; Lin 2011;
on the ethnicity of the participants (Burns 2001a; Burns 2008;
Moradian 2015; O'Callaghan 2012; Romito 2013; Smith 2001; Straw
Burrai 2014; Cassileth 2003; Chen 2013; Cook 2013; Duocastella
1991; Xie 2001; Zhao 2008), 20 trials examined the effects of music
1999; Ferrer 2005; Lin 2011; Moradian 2015; O'Callaghan 2012;
during procedures or surgery (Binns-Turner 2008; Bufalini 2009;
Robb 2008; Romito 2013; Straw 1991; Vachiramon 2013; Wang
Burns 2009; Cassileth 2003; Danhauer 2010; Fredenburg 2014a;
2015; Zhou 2015). For trials that did provide information on
Fredenburg 2014b; Kwekkeboom 2003; Li 2004; Li 2012; Nguyen
ethnicity, the distribution was as follows: 50% white, 32% Asian,
2010; Palmer 2015; Pinto 2012; Ratcliff 2014; Robb 2014; Rosenow
7% black, 8% Latino, and 3% other. The trials took place in nine
2014; Vachiramon 2013; Wang 2015; Yates 2015; Zhou 2015), and
different countries: the United States (Bradt 2015; Beck 1989; Binns-
14 trials included general cancer patients (Beck 1989; Burns 2001a;
Turner 2008; Burns 2001a; Burns 2008; Burns 2009; Cassileth 2003;
Burns 2008; Chen 2004; Cook 2013; Duocastella 1999; Hanser 2006;
Clark 2006; Cook 2013; Danhauer 2010; Ferrer 2005; Fredenburg
Harper 2001; Hilliard 2003; Huang 2006; Liao 2013; Robb 2008;
2014a; Fredenburg 2014b; Hanser 2006; Harper 2001; Hilliard 2003;
Shaban 2006; Wan 2009). Five trials examined music interventions
Kwekkeboom 2003; Gimeno 2008; Palmer 2015; Ratcliff 2014;
in pediatric patients (Bufalini 2009; Burns 2009; Duocastella 1999;
Robb 2008; Robb 2014; Rosenow 2014; Smith 2001; Straw 1991;
Nguyen 2010; Robb 2014).
Vachiramon 2013; Yates 2015), China (Cai 2001; Chen 2004; Jin 2011;
Informed decisions.

Li 2004; Li 2012; Liao 2013; Wan 2009; Xie 2001; Zhao 2008), Italy Excluded studies
(Bufalini 2009; Bulfone 2009), Iran (Moradian 2015; Shaban 2006),
In the original review, 27 of the 101 reports that we retrieved
Spain (Duocastella 1999), Taiwan (Chen 2013; Huang 2006; Lin 2011;
for further assessment turned out not to be outcome research
Wang 2015; Zhou 2015), Brazil (Pinto 2012), Australia (O'Callaghan
studies. We identified 38 experimental research studies that
2012) and Vietnam (Nguyen 2010). Trial sample size ranged from 8
appeared eligible for inclusion. However, we excluded these
to 260 participants.
after closer examination or after receiving additional information
We classified 23 trials as music therapy studies (Bradt 2015; from the principal investigators. Reasons for exclusions were:
Bufalini 2009; Burns 2001a; Burns 2008; Burns 2009; Cassileth 2003; not a randomized or quasi-randomized controlled trial (29
Clark 2006; Cook 2013; Duocastella 1999; Ferrer 2005; Fredenburg studies); insufficient data reporting (2 studies); unacceptable
2014a; Fredenburg 2014b; Hanser 2006; Hilliard 2003; Gimeno 2008; methodological quality (3 studies); not a music intervention (1
Palmer 2015; Ratcliff 2014; Robb 2008; Robb 2014; Romito 2013; study); not exclusively cancer patients (1 study); and article could
Rosenow 2014; Stordahl 2009; Yates 2015). Of these trials, nine used not be located (2 studies).
interactive music making with the participants, four used music-
For the update, we retrieved 94 reports for further assessment. We
guided imagery, two used music-guided relaxation, six used live
excluded 60 studies for the following reasons: not a randomized
patient-selected music performed by the music therapist and two
or quasi-randomized controlled trial (36 studies), insufficient data
used music video making. We classified 29 trials as music medicine
reporting (2 studies), not music intervention (12 studies), not
studies, as defined by the authors in the background section, and
population of interest (8 studies), use of healthy controls (1 study),
used listening to pre-recorded music as the intervention.
and use of non-standardized measurement tools (1 study).
Frequency and duration of treatment sessions greatly varied
For studies with insufficient data reporting or those that could
among the trials. The total number of sessions ranged from 1 to
not be located, we attempted to contact the authors on multiple
40 (e.g. multiple music listening sessions per day for length of
occasions.
hospital stay). Most sessions lasted 30 to 45 minutes. We report
details on frequency and duration of sessions for each trial in the Details about reasons for exclusion are provided in the
Characteristics of included studies table. Characteristics of excluded studies table.
Forty-nine trials used parallel group designs, whereas three trials Risk of bias in included studies
used a cross-over design (Bradt 2015; Beck 1989; Gimeno 2008). Not
all trials measured all outcomes identified for this review. We detail the risk of bias for each trial in the 'Risk of bias' tables
included in the Characteristics of included studies table and the
We show details of the trials included in the review in the 'Risk of bias summary' (Figure 2). In addition, readers can consult
Characteristics of included studies table. an overall assessment of risk of bias in Figure 3.

Informed decisions.

Figure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Informed decisions.

Figure 2. (Continued)

Informed decisions.

Figure 2. (Continued)

Figure 3. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages
across all included studies.

Allocation feasible in music therapy and music medicine studies. This may
introduce possible bias.
We included 37 trials that used appropriate methods of
randomization (e.g. computer-generated table of random numbers, Incomplete outcome data
drawing of lots, coin flip), 6 trials that used systematic methods
of treatment allocation (e.g. alternate group assignment, date of The dropout rate was small for most trials, falling between 0%
birth), and 9 trials that reported using randomization but failed to and 17%. Ten trials reported dropout rates of more than 20%.
state the randomization method. For 14 trials, it was unclear whether there were any participant
withdrawals. Most trials reported reasons for dropout. Detailed
Twenty-two trials concealed allocation, whereas 12 trials did not. information on dropout rate and reasons is included in the
For the remainder of the trials, authors did not mention allocation Characteristics of included studies table.
concealment.
Selective reporting
Blinding
We did not find any evidence of selective reporting by the authors.
Fifteen trials included objective outcomes, but only four of them
reported blinding of the outcome assessors. For six trials, the use We examined publication bias visually in the form of funnel plots
of blinding was unclear. The other trials did not use blinding. for several of the included outcomes. Visual inspection suggested
The majority of the trials included subjective outcomes only. It is that there was no publication bias for anxiety (Figure 4), depression
important to point out that blinding of outcome assessors is not (Figure 5), pain (Figure 6), and heart rate (Figure 7). We did detect a
possible in the case of self report measurement tools for subjective possible publication bias for fatigue (Figure 8), but this was based
outcomes (e.g. STAI; Spielberger 1983) unless the participants are on a small number of trials. For this outcome, it is possible that
blinded to the intervention. Blinding of the participants is often not studies that did not result in statistically significant findings may
not have been published.

Informed decisions.

Figure 4. Funnel plot of comparison: 1 Music intervention plus standard care versus standard care alone, outcome:
1.1 Anxiety (STAI).

Informed decisions.

1.6 Depression.

Informed decisions.

1.11 Pain.

Informed decisions.

1.15 Heart rate.

Informed decisions.

1.13 Fatigue.

Other potential sources of bias Effects of interventions
We did not identify any other potential sources of bias in the studies See: Summary of findings for the main comparison Music
included in this review. interventions compared to standard care for psychological and
physical outcomes in cancer patients
As a result, only one trial was at low risk of bias (Bradt 2015). Two
additional trials were at low risk of bias for objective outcomes, Comparison 1: Music intervention plus standard care versus
as they satisfied all criteria used to assess risk of bias (Duocastella standard care alone
1999; Nguyen 2010). Forty-six trials were at high risk of bias. Three
trials were at moderate risk of bias (Binns-Turner 2008; Hilliard Primary outcomes
2003; Palmer 2015). The main reason for receiving a high risk of Psychological outcomes
bias rating was the lack of blinding. As pointed out above, blinding
State anxiety
is often impossible in music therapy and music medicine studies
that use subjective outcomes, unless the studies compare the Twenty-three trials examined the effects of music interventions
music intervention with another active treatment intervention (e.g. plus standard care compared to standard care alone for anxiety in
progressive muscle relaxation). This is especially true for music participants with cancer. Fifteen trials measured anxiety by means
therapy studies that use active music-making. Therefore, it appears of the Spielberger State-Trait Anxiety Inventory - State Anxiety
impossible for these types of studies to receive a low or even form (STAI-S) (Binns-Turner 2008; Bufalini 2009; Bulfone 2009;
moderate risk of bias even if they have adequately addressed Chen 2013; Danhauer 2010; Harper 2001; Jin 2011; Kwekkeboom
all other risk factors (e.g. randomization, allocation concealment, 2003; Li 2012; Lin 2011; O'Callaghan 2012; Smith 2001; Vachiramon
etc.). 2013; Wan 2009; Zhou 2015); one trial used the STAI-short form
(Nguyen 2010); and eight trials reported mean anxiety measured
It is worth noting that the Chinese trials were particularly by other scales, such as a numeric rating scale or a visual
problematic in terms of providing sufficient information regarding analogue scale (Cai 2001; Cassileth 2003; Ferrer 2005; Hanser
risk of bias. It is unclear, however, if this was due to incomplete 2006; Li 2004; Palmer 2015; Yates 2015; Zhao 2008). We could
translations or lack of detail in the original trial reports. not include the data from Burns 2008 because it did not report
post-test or follow-up scores. The author did provide follow-up
Informed decisions.

scores (4 weeks postintervention), but we could not combine First, we compared the treatment benefits of music therapy versus
these with the post-test scores of the other trials. Moreover, Burns music medicine studies for anxiety. We only included studies that
2008 reported a large moderating effect of pre-intervention affect reported post-test scores in this analysis to allow for computation
state scores on post-test scores and follow-up scores. We also of a standardized mean difference across studies. The pooled effect
did not include the data from Kwekkeboom 2003 in the meta- of three music therapy studies (SMD: −0.62, 95% CI −1.01 to −0.24,
analysis because this study was affected by a serious flaw in P = 0.001, I2 = 0%; Bufalini 2009; Ferrer 2005; Yates 2015) was
the implementation of the intervention. Participants in this trial smaller than of the music medicine studies (SMD: −1.00, 95% CI
listened to music while undergoing painful medical procedures. −1.45 to −0.55, P < 0.0001, I2 = 93%; Binns-Turner 2008;Bulfone
However, they reported that the use of headphones prevented 2009; Cai 2001; Danhauer 2010; Jin 2011; Li 2004; Li 2012; Lin 2011;
them from hearing the surgeon, increasing their anxiety. Finally, Nguyen 2010; O'Callaghan 2012; Smith 2001; Vachiramon 2013;
we report the data from Hanser 2006 narratively but do not Wan 2009; Zhao 2008; Zhou 2015). However, this difference was
include them in the meta-analysis because of the high attrition not statistically significant (P = 0.21). It is worth noting that the
rate (40%). In addition, the researchers experienced serious results of the music therapy studies were consistent across studies,
issues with intervention implementation within the predetermined whereas the results of the music medicine studies were highly
implementation timeframe (three sessions were implemented over heterogeneous (Analysis 1.3).
a 15-week period), and the authors concluded that the intervention
was significantly diluted because of this. Second, we compared studies that used patient-preferred music
with studies that used researcher-selected music. For this
A meta-analysis of 13 trials that used the full STAI-S (score range: comparison, we only included studies that used listening to pre-
20 to 80) to examine state anxiety in 1028 participants indicated recorded music as the intervention. Music preference did not
a significantly lower state of anxiety in participants who received appear to impact the treatment benefits for anxiety. The use of
standard care combined with music interventions than those who patient-preferred music resulted in a SMD of −0.86 (95% CI −1.38
received standard care alone ( MD: −8.54, 95% CI −12.04 to −5.05, P < to −0.34, P = 0.001, I2 = 92%) whereas researcher-selected music
0.0001; Analysis 1.1). Statistical heterogeneity across the trials (I2 = resulted in a SMD of −0.89 (95% CI −1.43 to −0.35, P = 0.001, I2 = 71%)
93%) was due to some trials reporting much larger beneficial effects (Analysis 1.4).
of music interventions than others (Binns-Turner 2008; Harper
2001; Wan 2009). In Kwekkeboom 2003, participants in the music Finally, we compared the music medicine studies by type of
listening group reported higher levels of anxiety at post-test (mean: intervention (e.g. music-guided relaxation, music listening alone,
33.45, standard deviation (SD) 1.77) than those in the standard etc.). We could not conduct this subgroup analysis for music
care group (mean: 30.59, SD 1.93), but this difference was not therapy studies because of an insufficient number of trials. The
statistically significant. A sensitivity analysis excluding the trials majority of the music medicine studies used listening to pre-
that used inadequate methods of randomization (Bulfone 2009; recorded music. Four studies, however, embedded relaxation or
Chen 2013), or for which the method of randomization was unclear imagery instructions within the pre-recorded music (Jin 2011; Lin
(Bufalini 2009), had minimal impact on the pooled effect size (MD: 2011; Wan 2009; Zhou 2015). The pooled effect of these four studies
−8.64, 95% CI −12.50 to −4.79, P < 0.0001, I2 = 94%; Analysis 1.1). (SMD: −1.61, 95% CI −2.56 to −0.65, P = 0.0009, I2 = 95%) was much
larger than that of music listening only studies (SMD: −0.71, 95%
The standardized mean difference (SMD) of trials that reported CI −1.16 to −0.26, P = 0.002, I2 = 89%) but because of the large
post-test anxiety scores on measures other than the full-form STAI-S heterogeneity, this difference was not statistically significant (P =
(N = 449) also suggested a moderate to large anxiety-reducing effect 0.10) (Analysis 1.5).
of music (SMD: −0.71, 95% CI −0.98 to −0.43, P <.00001; Analysis
1.2; Cai 2001; Ferrer 2005; Li 2004; Nguyen 2010; Zhao 2008; Yates Depression
2015). The results were consistent across the trials (I2 = 41%). We
Seven trials examined the effects of music plus standard care
did not include the data of two trials in the meta-analysis because
compared to standard care alone on depression in 723 participants
change scores and final scores should not be combined for the
(Cai 2001; Cassileth 2003; Clark 2006; Li 2012; Wan 2009; Yates 2015;
computation of a SMD (Cassileth 2003; Palmer 2015). However, the
Zhou 2015). Their pooled estimate indicated a moderate treatment
data by Cassileth 2003 were consistent with the results of the meta-
effect of music (SMD: −0.40, 95% CI −0.74 to −0.06, P = 0.02; Analysis
analysis, reporting a greater effect of music therapy on anxiety
1.6), but the results were inconsistent across trials (I2 = 77%). A
(mean change score: −2.6, SD 2.5) than standard care alone (mean
sensitivity analysis examining the impact of randomization method
change score: −0.9, SD 3.0) on the POMS-anxiety subscale (score
did not have much impact on the pooled effect size (SMD: −0.37,
range: 0 to 36). Likewise, the data from Palmer 2015 indicated a
beneficial effect of music therapy (mean change score: −30.9, SD 95% CI −0.79 to 0.05, P = 0.08, I2 = 81%; Analysis 1.6).
36.3) versus standard care (mean change score: 0, SD 22.7) on the
A subgroup analysis revealed that there was no statistically
Global Anxiety-VAS (score range: 0 to 100 mm). A sensitivity analysis
significant difference between music therapy and music medicine
to examine the impact of randomization method, excluding the
studies for the outcome of depression (P = 0.12) (Analysis 1.7).
data of Cai 2001, Ferrer 2005 and Li 2004, resulted in a larger SMD of
We also examined the impact of music preference in studies that
−0.80 (95% CI −1.44 to −0.16, P = 0.01; Analysis 1.2), but the results
used listening to pre-recorded music. Although the difference
were no longer consistent across studies (I2 = 66%). between studies that used patient-preferred versus researcher-
selected music was not statistically significant (P = 0.25), allowing
Next, we conducted several a priori determined subgroup analyses
patients to select music from a variety of styles offered by the
as outlined in the Methods.
researcher resulted in a large effect size that was statistically
significant (SMD: −0.88, 95% CI −1.67 to −0.09, P = 0.003, I2 = 89%;
Informed decisions.

Analysis 1.8). In contrast, the use of researcher-selected music data from Beck 1989, Clark 2006 or Moradian 2015 in the meta-
resulted in a small effect size that was not statistically significant analysis because of the use of change scores. Kwekkeboom 2003
(SMD: −0.32, 95% CI −0.84 to 0.19, P = 0.22, I2 = 61%). compared the effects of music listening, audiotape and standard
care on procedural pain and anxiety, finding that participants did
Distress not like wearing the headsets as it prevented them from hearing
Clark 2006 compared standard care plus music-guided relaxation the surgeon, causing greater anxiety. The literature suggests that
versus standard care alone and reported a reduction of −2.03 increased anxiety leads to increased pain perception (McCracken
(SD 2.46) on a 0 to 10 numeric rating scale in the music therapy 2009); therefore, we excluded these data from the meta-analysis.
intervention group. Participants in the control group reported an The pooled effect of the remaining seven studies with 528
average reduction in distress of −2.44 (SD 2.55). participants resulted in a large effect for music on pain perception
(SMD: −0.91, 95%CI −1.46 to −0.36, P = 0.001; Analysis 1.11; Cohen
Mood 1988). There was disagreement between the trials on the size of the
The pooled estimate of five trials (N = 236) resulted in a moderate effect (I2 = 88%), but this was due to Li 2012 reporting much larger
effect of music interventions for mood in participants with cancer treatment benefits than the other trials.
(SMD: 0.47, 95% CI −0.02 to 0.97, P = 0.06; Analysis 1.9; Beck Using a 0 to 10 numeric rating scale, Clark 2006 found that music
1989; Burrai 2014; Cassileth 2003; Moradian 2015; Ratcliff 2014).The therapy resulted in greater pain reduction (mean change score:
results were inconsistent across studies (I2 = 70%), with Burrai 2014 −0.44, SD 2.55) than standard care (mean change score: 0.45, SD
reporting much larger treatment benefits than the other studies. 1.87). Likewise, Beck 1989 reported a greater pain reduction for
A sensitivity analysis based on randomization method slightly the music listening group as measured by a 100mm VAS (mean
increased the pooled effect (SMD: 0.57, 95% CI −0.03 to 1.18, P = change score: −9.27, SD 18.86) than for the control group (mean
0.06, I2 = 74%; Analysis 1.9). We could not include the data from change score: −5.69, SD 17.9). In contrast, Moradian 2015 reported
Burns 2001a in the meta-analysis because the authors did not use similar improvements in pain for the treatment (mean change
a constant in the computation of their scores, as recommended score: −12.96, SD 24.16) and the control group (mean change score:
in the Profile of Mood States (POMS) scoring guide (McNair 1971). −13.58, SD 28.51).
The results of the meta-analysis were robust to Burns 2001a, which
reported a mean post-test score of −48.25 (SD 32.96) for the music For this outcome, we were able to examine the impact of
therapy group and a mean post-test score of 20.75 (SD 30.87) for the music preference on treatment effect (Analysis 1.12). Although
control group. the difference between the use of patient-preferred music and
researcher-selected music was not statistically significant (P =
A subgroup analysis comparing music therapy (SMD: 0.37, 95% CI 0.42), the use of patient-preferred music led to a much larger and
−0.13 to 0.87, P = 0.15) with music medicine (SMD: 0.55, 95% CI statistically significant pooled effect (SMD: −1.06, 95% CI −1.93 to
−0.37 to 1.47, P = 0.24) found no statistically significant differences −0.2, P = 0.02, I2 = 91%) than the use of researcher-selected music
between the two types of studies (P = 0.73), but the results of (SMD: −0.59, 95% CI −1.34 to 0.15, P = 0.12, I2 = 75%). The large
the music therapy studies were consistent across studies (I2 = heterogeneity was due to some studies reporting a much larger
37%), whereas the music medicine studies were inconsistent across beneficial effect than others.
studies (I2 = 82%) (Analysis 1.10).
Fatigue
Resilience
Six trials examined the effects of music interventions on fatigue
One music therapy study in 80 adolescents and young adults in 253 participants (Cassileth 2003; Clark 2006; Ferrer 2005;
undergoing hematopoietic stem cell transplant (HSCT) included Fredenburg 2014b; Moradian 2015; Rosenow 2014). The pooled
resilience as an outcome and reported a small effect for the music estimate of their change scores indicated a small to moderate effect
therapy intervention (SMD: 0.21), although this effect was not for music interventions (SMD: −0.38, 95% CI −0.72 to −0.04, P =
statistically significant (P = 0.35) (Robb 2014). The authors reported 0.03; Analysis 1.13), with consistent results across studies (I2 = 38%).
that the study was underpowered to detect medium and small Burns 2008 also collected data on fatigue; however, investigators
effect sizes. did not report postintervention data. Burns 2008 also provided
Coping
us with four-week postintervention follow-up scores, but could
not provide the immediate post-test scores. This prevented us
Robb 2014 also examined the effect of music therapy on coping. from pooling their data with data from the other three studies.
They reported a moderate effect size for courageous coping A sensitivity analysis based on randomization method suggested
immediately post-transplant. At the same time, they found no that use of proper methods of randomization resulted in a smaller
change in the use of defensive coping strategies, suggesting pooled effect that was no longer statistically significant (SMD:
that adolescents and youth in the music therapy treatment arm −0.20, 95% CI −0.48 to 0.08, P = 0.16, I2 = 0%).
increased their use of positive coping strategies.
Physical functioning
Physical symptoms
Five trials examined the effects of music on participants' physical
Pain functioning (Hanser 2006; Hilliard 2003; Liao 2013; Moradian 2015;
Eleven trials compared the effects of music versus standard care Xie 2001). We could not include the results of Hanser 2006 in the
on pain (Beck 1989; Binns-Turner 2008; Clark 2006; Danhauer pooled estimate because of the use of change scores and the
2010; Fredenburg 2014a; Huang 2006; Kwekkeboom 2003; Li 2012; high attrition rate. The pooled estimate of the remaining studies
Moradian 2015; Nguyen 2010; Wan 2009). We could not include the indicated no evidence for an effect of music on physical status
Informed decisions.

in 493 participants with cancer (SMD: 0.78, 95% CI −0.74 to 2.31, Secondary outcomes
P = 0.31; Analysis 1.14). The results were highly inconsistent (I2 Physiological outcomes
= 98%), with Xie 2001 reporting a much larger beneficial effect.
In Hanser 2006, music therapy led to a greater improvement in Heart rate
physical well-being (FACT-G Physical Well-Being Subscale, score Eight trials examined the effects of music on heart rate in 589
range: 0 to 28)( mean change score: 2.0, SD 4.6) than standard participants (Binns-Turner 2008; Burrai 2014; Chen 2013; Ferrer
care (mean change score: −0.4, SD 3.7), but this difference was not 2005; Harper 2001; Jin 2011; Nguyen 2010; Zhao 2008). All of the
statistically significant. studies except for Ferrer 2005 were music medicine studies.Their
pooled estimate showed a decrease in heart rate, favoring music
Removing Xie 2001 because of improper randomization method
interventions over standard care (MD: −3.32, 95% CI −6.21 to −0.44,
resulted in a small effect that was consistent across studies (SMD:
P = 0.02; Analysis 1.15). However, the results were inconsistent
0.08, 95% CI −0.18 to 0.34, P = 0.54, I2 = 0%; Analysis 1.14)
across studies (I2 = 73%). A sensitivity analysis excluding Ferrer 2005
Anesthetic and analgesic intake and Chen 2013 because of an unknown randomization method and
a lack of proper randomization, respectively, resulted in a larger
Two studies included use of anesthesia and analgesics as an effect with less heterogeneity (MD: −4.63, 95% CI −8.18 to −1.09, P =
outcome. Palmer 2015 examined the amount of propofol needed to 0.01, I2 = 56%; Analysis 1.15).
reach a sedation score of 70 on the Bispectral Index (BIS) in women
undergoing breast surgery. A BIS reading of 70 represents moderate A subgroup analysis for music preference indicated that researcher-
sedation. The average propofol needed in the live music group (n selected music led to greater reductions in heart rate (MD: −7.94,
= 67) was 67.2 mg (SD 53.7), 61.9 mg (SD 34.1) in the recorded 95% CI −15.10 to −0.78, P = 0.03, I2 = 0%) than patient-preferred
music group (n = 65), and 70.5 mg (SD 35.2) in the usual care music (MD: −3.13, 95% CI −6.54 to 0.27, P = 0.07, I2 = 82%; Analysis
group (n = 62). However, the difference between the groups was not 1.16), but this difference was not statistically significant (P = 0.23).
statistically significant. Wang 2015 examined the impact of music-
guided relaxation compared to standard care on postoperative One cross-over trial compared the effect of music and imagery
consumption of the sufentanil, a narcotic medicine, and use of with imagery alone (Gimeno 2008). Both interventions resulted in
a patient-controlled analgesia (PCA) pump. Participants in the statistically significant decreases in heart rate from pre-test to post-
music treatment arm consumed a significantly smaller amount of test: the music and imagery group's mean heart rate dropped from
sufentanil (52.68 µg, SD 7.07) than the standard care treatment arm 89.58 beats per minute (bpm) (SD 17.32) at pre-test to 78.84 bpm
(82.65 µg, SD 6.19). PCA use was also significantly lower in the music (SD 13.46) at post-test; the imagery only group's mean heart rate
treatment arm (19.06, SD 3.49) than in the control group (30.96, SD dropped from 93.31 bpm (SD 15.76) to 81.05 bpm (SD 13.96), but
4.0). the difference between the two interventions was not statistically
significant.
Length of hospital stay and recovery time
Respiratory rate
Palmer 2015 also examined the effect of music on recovery time
following breast surgery. Recovery time was defined as the interval The pooled estimate of four trials (N = 437) did not provide evidence
between surgery end time and the time when the patient had met of an effect for music interventions on respiratory rate (MD: −1.24,
all discharge criteria determined by the recovery nurse. The results 95% CI −2.54 to 0.06, P = 0.06; Analysis 1.17; Chen 2013; Jin 2011;
indicated that there was no statistically significant difference in Nguyen 2010; Zhao 2008), and the studies did not agree on the
recovery time between the two types of music interventions size of effect (I2 = 80%). A sensitivity analysis excluding Chen
(live music by a music therapist and listening to pre-recorded 2013 because of failure to use a proper method of randomization
music) and the usual care group, suggesting that the addition of resulted in a larger pooled effect that was statistically significant
music intervention did not increase patient time commitment. A (MD: −1.83, 95% CI −3.36 to −0.30, P = 0.02, I2 = 52%; Analysis 1.17)
statistically significant difference was found between the live music
group (52.4 minutes, SD 21.6) and the recorded music group (64.8 We could not conduct a subgroup analysis based on music
minutes, SD 35.3), with the live music group getting discharged preference for this outcome due to an insufficient number of trials
approximately 12 minutes faster than the recorded music group. differentiating music type.
However, the authors suggest a careful interpretation of these
results as other factors could have contributed to this difference. Systolic blood pressure
We found a pooled estimate of −5.40 mmHg (95% CI −8.32 to −2.49,

Li 2012 tracked the length of women's hospital stay after radical
P = 0.0003; N = 559; Analysis 1.18) for systolic blood pressure (SBP),
mastectomy. Women in the music listening treatment arm stayed
favoring music interventions (Burrai 2014; Chen 2013; Ferrer 2005;
an average of 13.62 days (SD 2.04), whereas women in the usual
Harper 2001; Jin 2011; Nguyen 2010; Zhao 2008). The results were
care control arm stayed an average of 15.53 days (SD 2.75). This
difference between the treatment arms was statistically significant slightly inconsistent across studies (I2 = 54%). However, excluding
(P < 0.001). Chen 2013 and Ferrer 2005 because of lack of proper randomization
resulted in a larger effect that was consistent across studies (MD:
−7.63 mmHg, 95% CI −10.75 to −4.52, P < 0.00001, I2 = 11%; Analysis
1.18). All of the studies except for Ferrer 2005 were music medicine
studies.
We conducted a subgroup analysis based on music preference

(Analysis 1.19), and in contrast to the findings for heart rate, this
Informed decisions.

analysis suggested that patient-preferred music led to greater SBP Therapy-Spiritual Well-Being subscale (FACIT-Sp, score range: 0
reduction (MD: −6.65, 95% CI −10.07 to −3.23, P = 0.0001, I2 = 64%) to 48) (Hanser 2006). Results indicated no statistically significant
than researcher-selected music (MD: −4.72, 95% CI −10.80 to 1.37, difference between the two groups (music therapy mean change
P = 0.13, I2 = 0%). This difference was not statistically significant (P score: 2.5, SD 8.56; control group mean change score: 0.7, SD
= 0.59). 6.95). Cook 2013 compared music therapy with standard care and
reported a greater improvement in the music therapy treatment
Diastolic blood pressure arm ( mean change score: 4.4, SD 4.84) than the control arm (mean
We found a pooled estimate of −2.35 mmHg (95% CI −5.88 to 1.18; change score: 2.0, SD 6.08) on the FACIT-Sp.
Analysis 1.20) for diastolic blood pressure (DBP) in 559 participants Social support
(Burrai 2014; Chen 2013; Ferrer 2005; Harper 2001; Jin 2011; Nguyen
2010; Zhao 2008).The results were inconsistent across studies (I2 = Robb 2014 examined the effect of music therapy on perceived
91%). Similar to the SBP analysis, excluding Chen 2013 and Ferrer social support in adolescents and young adults during stem
2005 in a sensitivity analysis resulted in a larger MD of −4.94 mmHg cell transplant. At 100 days post-transplant, participants in
(95% CI −7.78 to −2.09) that was statistically significant (P = 0.0007), the music therapy treatment arm reported significantly greater
and less heterogeneous (I2 = 60%; Analysis 1.20). All of the studies improvements in perceived social support (SMD: 0.54, P = 0.028)
except for Ferrer 2005 were music medicine studies. and family environment (i.e. family cohesion, family adaptation,
family communication, and family strength) (SMD: 0.66, P = 0.008)
Patient-preferred music resulted in somewhat greater reductions in than participants in the control group. Qualitative analysis of
DBP (MD: −4.10, 95% CI −8.78 to 0.59, P = 0.09, I2 = 95%; Analysis the music videos that accompanied the songs written by the
1.21) than researcher-selected music (MD: −2.01, 95% CI −6.26 to participants revealed that study participants were "identifying
2.25, P = 0.36, I2 = 0%), but this difference was not statistically peers (i.e., social integration), family members (i.e., family
significant (P = 0.52). environment), and faith/spirituality (i.e., spiritual perspective) as
important sources of support" (p 916).
Mean arterial pressure
Quality of life
Binns-Turner 2008 reported on the effects of music on mean arterial
pressure (MAP) in 30 participants and found a large decrease in MAP Seven trials compared the impact of music interventions to
for the music group (mean change score: −15.1 mmHg, SD 17.1, standard care on QoL (Burns 2001a; Hanser 2006; Hilliard 2003; Liao
95% CI −23.76 to −6.44). In contrast, participants in the standard 2013; Moradian 2015; Ratcliff 2014; Xie 2001). We did not include
care group experienced an increase in MAP (mean change score: 4.5 Hanser 2006 in the meta-analysis for reasons discussed above.
mmHg, SD 15.3, 95% CI −3.25 to 12.25). Meta-analysis of the remaining six trials (N = 545) resulted in a
heterogeneous SMD of 0.98 (95% CI −0.36 to 2.33, P = 0.15, I2 =
Oxygen saturation level 98%; Analysis 1.23; Burns 2001a; Hilliard 2003; Liao 2013; Moradian
2015; Ratcliff 2014; Xie 2001), with Xie 2001 reporting a much
Three trials with 292 participants reported no effects for music
larger beneficial effect than the other trials. Removal of this outlier
listening on oxygen saturation levels (MD: 0.50%, 95% CI −0.18 to
resulted in a small effect size that was homogeneous (SMD: 0.29,
1.18, P = 0.15, I2 = 78%; Analysis 1.22; Burrai 2014; Chen 2013;
95% CI 0.05 to 0.53, P = 0.02, I2 = 0%).
Nguyen 2010).
Immune system functioning We conducted a sensitivity analysis removing all studies that used
improper methods of randomization. This resulted in a moderate
Two trials examined the effects of music on immune system effect size that was statistically significant (SMD: 0.52, 95% CI 0.01
functioning. In one trial in 30 children, Duocastella 1999 found to 1.02, P = 0.04, I2 = 66%; Analysis 1.23).
that live music making with children led to a greater increase
in Immunoglobin A (IgA) levels (mean change score: 7.07 mg/ A subgroup analysis per intervention type resulted in a
l, SD 34.52) than engaging children in activities that did not homogeneous, moderate effect of music therapy on QoL (SMD:
involve music (mean change score: 4.13 mg/l, SD 41.02), but this 0.42 , 95% CI 0.06 to 0.78, P = 0.02, I2 = 4%; Analysis 1.24)
difference was not statistically significant. Another trial compared that was statistically significant and consistent across studies
music listening to standard care in 46 participants and found post- (Cohen 1988). In Hanser 2006, music therapy resulted in a greater
test differences for the following indicators of immune system improvement in QoL (FACT-G, 0-108) (mean change score: 3.5, SD
functioning: CD3 (music: mean 44, SD 12.62; control: mean 36.73, 13.75) than standard care (mean change score: 0.9, SD 15.8), but this
SD 11.01), CD4/CD8 (music: mean 1.67, SD 0.76; control: mean 1.32, difference was not statistically significant. The pooled effect of the
SD 1.01), and natural killer (NK) cell activity (music: mean 25.23, SD music medicine studies was large but very heterogeneous and not
15.20; control: mean 21.36, SD 12.86), indicating a positive effect statistically significant (SMD: 1.33, 95% CI −0.96 to 3.63, P = 0.26, I2 =
of music listening on the immune system in women with breast 99%). The large heterogeneity was due to the outlying values of Xie
cancer (Chen 2004). CD3 and CD4/CD8 are proteins that play a role 2001; removing it from the analysis resulted in a small effect for the
in immune system functioning. music medicine studies that was consistent across studies but not
Social and spiritual support
statistically significant (SMD: 0.20, 95% CI −0.11 to 0.51, P = 0.21, I2 =
0%). The difference in treatment effect between the music therapy
Spiritual well-being studies and the music medicine studies was statistically significant
Two trials under this comparison assessed spiritual well-being when we excluded Xie 2001 from the analysis (P = 0.01). With the Xie
(Cook 2013; Hanser 2006). One trial compared music therapy to study included, the difference was not statistically significant (P =
usual care using the Functional Assessment of Chronic Illness 0.44).
Informed decisions.

Comparison 2: Music therapy plus standard care versus music 5.19) than verbal relaxation instructions (post-test mean = 8.64, SD
medicine plus standard care 6.42).
Only two studies reported on the direct comparison between music Physical symptoms
therapy and music medicine interventions.
Pain
Primary outcomes Shaban 2006 compared the effects of progressive muscle relaxation
Psychological outcomes (PMR) to music listening and found that PMR was more effective in
reducing pain (100mm VAS) (mean post-test score: 6.22, SD 2.45)
Anxiety
than listening to pre-recorded music (mean post-test score: 4.96, SD
Two trials directly compared the effects of music therapy 2.76) in 100 participants.
with music medicine on cancer patients' anxiety using a
100mm visual analogue scale (Bradt 2015; Palmer 2015). Both Secondary outcomes
interventions resulted in reduction of anxiety. Whereas music Quality of life
therapy interventions resulted in a greater average anxiety
reduction than music medicine intervention, this difference was Straw 1991 compared a guided imagery and relaxation intervention
not statistically significant (MD: −3.67, 95% CI −11.68 to 4.35, P = to music listening and found that music listening led to a greater
0.37, I2 = 0%; Analysis 2.1). However, 77.4% of the participants in the increase in QoL (Functional Living Index, score range 22 to 154)
cross-over trial by Bradt 2015 expressed a preference for receiving (mean change score: 16.33, SD 20.73) than the guided imagery and
music therapy sessions for the remainder of their cancer treatment relaxation group (mean change score: 4.6, SD 20.49).
or future treatments. The main reasons cited by participants for this Comparison 4: Music interventions plus standard care versus
preferences were that they felt cared for by the music therapist, standard care plus placebo control
enjoyed the interactive and creative music making, and valued the
opportunity for emotional expression and processing. Only a few trials compared music therapy or music medicine to a
placebo control, The trials examined a limited number of outcomes,
Comparison 3: Music interventions plus standard care versus which we describe below.
standard care plus alternative relaxation interventions
Primary outcomes
Several studies compared music interventions with other
relaxation interventions such as progressive muscle relaxation, Psychological symptoms
guided imagery and relaxation, and verbal relaxation instructions. Distress
At this time, only single studies were identified per outcome. This
precluded meta-analysis is results. Two trials examined the effects of music therapy on reduction of
distress, comparing a music video intervention with an audiobook
Primary outcomes control condition in adolescents and young adults during stem
cell transplantation (Burns 2009; Robb 2014). In the music video,
Psychological outcomes
participants wrote songs and created accompanying music videos
Anxiety in collaboration with a music therapist. The pooled effect of the
Straw 1991 compared music listening to guided imagery and two trials did not provide support for an effect of music therapy
relaxation training and found that both interventions significantly (SMD: −0.08, 95% CI −0.42 to 0.25, P = 0.62, I2 = 0%; Analysis
reduced state anxiety as measured by the STAI-S (score range 20 to 3.1). In Burns 2009, both groups reported an increase in distress
80) (guided imagery post-test mean: 38.6, SD 10.01; music listening post-intervention scores, which were used in the meta-analysis.
post-test mean: 34.22, SD 10.12). An ANCOVA analysis with pre- However, follow-up measures at 100 days after the stem-cell
test anxiety scores as a co-variate indicated that the difference in transplantation indicated a lower mean distress score for the music
effect of the two interventions on state anxiety was not statistically therapy group (mean: 1.67, SD 0.55) than the audiobook group
significant. (mean: 2.00, SD 0.64).
Depression Secondary outcomes
Stordahl 2009 compared music-assisted relaxation with verbal Social and spiritual support
relaxation instructions in 20 women with breast cancer and Spiritual well-being
reported a lower level of depression on the Center for Epidimiologic
Diseases - Depression Scale (CES-D, score range 0 to 60) following Burns 2009 and Robb 2014 also examined the effect of a music video
treatment in the music-assisted relaxation treatment arm (n = 10; intervention versus audiobook control condition on spiritual well-
post-test mean: 6.6, SD 5.02) than in the verbal relaxation treatment being in adolescents and young adults. Their pooled estimate did
arm (n = 10; post-test mean: 9.20, SD 10.96). not find support for an effect of music therapy on spiritual well-
being (SMD: 0.31, 95% CI −0.11 to 0.73, P = 0.15, I2 = 0%; Analysis 3.2).
Mood
Communication
Stordahl 2009 also compared the impact of music-assisted
relaxation with verbal relaxation instructions on mood in women One trial in children with cancer compared the effects of one
with breast cancer and found that music-assisted relaxation session of active music making to music listening and audio
resulted in lower scores (i.e. better mood) on the POMS-SF (score storybooks on levels of active engagement and initiation in 55
range 14 to 70 as reported in this thesis) (post-test mean: 6.5, SD children (Robb 2008). Active music therapy sessions led to higher
Informed decisions.

active engagement (post-test mean: 26.03, SD 4.1) than music It is important that careful consideration is given to the
listening (post-test mean: 15.65, SD 6.2, P < 0.0001) or audio implementation of music listening interventions. The results
storybooks (post-test mean: 15.17, SD 4.9, P < 0.0001). These of Kwekkeboom 2003 indicate that listening to music through
differences were statistically significant. Active music making (post- headphones may be contraindicated during painful procedures
test mean: 14.19, SD 8.3) and music listening (post-test mean: 15.89, because it prevents the patient from hearing the surgeon's
SD 11.2) also increased the child's initiation behaviour compared instructions and comments. This may greatly increase patients'
to the audio storybooks (post-test mean: 7.43, SD 6.6). These anxiety and, consequently, their perceived pain. In this case, it is
differences were also statistically significant (P = 0.04 and P = 0.002, better to listen to music without headphones.
respectively).
Furthermore, results suggest that music interventions may have a
Quality of life beneficial effect on several physiological responses in patients with
Burns 2009 compared music therapy to an audiobook control, cancer. Listening to music may reduce heart rate by an average of
finding a small increase in QoL in the music therapy group (Index of three to four beats per minute and respiratory rate by an average
Well-Being, score range 9 - 63) (mean change score: 0.31, SD 1.73, n of two breaths per minute. These results are consistent with the
= 7) and a small decrease in the control group (mean change score: findings of a Cochrane systematic review on the use of music with
−0.22, SD 1.24, n = 3). However, the sample size was too small to coronary heart disease patients (Bradt 2013a), which reported a
draw any meaningful conclusions. heart rate reduction of 3.4 bpm and a respiratory rate reduction of
2.5 breaths per minute. Similar results were reported in a Cochrane
DISCUSSION review on music interventions for mechanically ventilated patients
(Bradt 2014), namely a mean heart rate reduction of 3.95 bpm and
Summary of main results a mean respiratory rate reduction of 2.87 breaths per minute. In
the case of a resting heart rate within normal range, a reduction
The results of 19 trials suggest that music therapy and music of 4 bpm may not be clinically significant. However, it might
medicine interventions may have a beneficial effect on anxiety in be in the case of a tachycardiac rate. In a study examining the
people with cancer, with a reported anxiety reduction of 8.54 units, quantitative relationship between resting heart rate reduction and
on average, on the STAI-S (score range: 20 to 80) scale and −0.71 clinical benefit, Cucherat 2007 found that each 10 bpm reduction in
standardized units on other anxiety scales which is considered a heart rate is estimated to reduce the relative risk of cardiac death
moderate to large effect. Although the magnitude of the effect by 30%. The results of this review also indicate that listening to
differed across the studies, the trials agreed on the direction of music may have a beneficial effect on SBP, although we found no
the point estimates. These anxiety-reducing results are consistent evidence of an effect for DBP. Trials on music listening with cardiac
with the findings of three other Cochrane systematic reviews on the patients and mechanically ventilated patients have also reported
use of music with coronary heart disease patients (Bradt 2013a), reductions in systolic blood pressure (Bradt 2013a; Bradt 2014).
with mechanically ventilated patients (Bradt 2014), and for pre- The reduction of heart rate, respiratory rate, and blood pressure
operative anxiety (Bradt 2013b). A comparison of music therapy corresponds with the anxiety-reducing effects found by subjective
with music medicine trials for anxiety reduction in people with outcome measures in this review.
cancer suggest a moderate treatment effect for music therapy
studies (SMD: −0.62) that was consistent across studies. Music No evidence of support was found for an effect of music
medicine trials resulted in a larger effect (SMD: −1.0) but results interventions on oxygen saturation level. Single trials included in
were highly inconsistent across studies. Cohen 1988 suggested that this review found support for a beneficial effect of music on mean
an effect size of 0.20 be considered a small effect, an effect size of arterial pressure and immunologic function.
0.50 medium, and an effect size of 0.80 large. A direct comparison
of music therapy with music medicine interventions for anxiety Music therapy interventions had a moderate effect of 0.42
reduction in two studies indicated greater anxiety reduction of standardized units on quality of life, whereas we found no support
music therapy interventions. It is noteworthy that a large majority for an effect for music medicine studies. Two studies that compared
of the patients in one of the comparative studies expressed a music therapy with audiobook control in adolescents and young
preference for the music therapy intervention. adults did not find support for spiritual well-being. Two music
therapy studies with adults reported conflicting results for this
The results of seven studies suggest that music intervention may outcome. Finally, a single study with adolescents and young adults
reduce depression in people with cancer. The results of a single during stem cell transplant reported beneficial effects of music
study suggest that music therapy may help adolescents and therapy on perceived social support and the family environment.
young adults employ positive coping strategies during stem cell
transplant, a high risk and high intensity treatment. We found no Subgroup analyses of treatment effects between music therapy and
evidence of effect for distress or mood. music medicine studies was possible for four outcomes, namely
anxiety, depression, mood and quality of life. There was a difference
As for the effect of music on physical symptoms, the results of seven for quality of life, with music therapy studies contributing to a
trials suggest that music has a large pain-reducing effect of −0.91 larger pooled treatment effect than music medicine studies; we
standardized units. The results of single studies suggest that music found no difference between music therapy and music medicine
listening may reduce the need for anesthetics and analgesics. Music studies for the other outcomes. However, it is worth noting that
interventions also had a small to moderate effect on fatigue (−0.38 for all outcomes, music therapy interventions resulted in consistent
standardized units). We found no evidence for an effect of music on findings across studies whereas the results of music medicine
physical status. Reduction of anxiety, depression, fatigue and pain studies were highly heterogeneous for these outcomes.
are important outcomes for people with cancer, as they have an
impact on health and overall QoL.
Informed decisions.

We could examine the impact of music preference for anxiety, widely, and more detailed information would help clinicians make
depression, pain, heart rate, systolic and diastolic blood pressure. well-informed decisions regarding music selections.
Music preference did not impact the effect of music on anxiety. For
the other outcomes, even though there was no difference between The frequency and duration of the interventions varied widely
the use of patient-preferred versus researcher-selected music, the across the trials. Twelve trials offered a single music session.
results show some interesting trends. For pain, the use of patient- We would like to suggest that offering multiple music listening
preferred music had a much larger impact on pain reduction. sessions allows for the patient to give feedback about the music,
In contrast, no evidence of pain-reducing effect was found for select different music if needed, and become more skilled in
researcher-selected music. For heart rate, researcher-selected using music for relaxation purposes. In the case of music therapy
music resulted in a larger and more consistent treatment effect interventions, multiple sessions allow for the development of
than patient-preferred music. Interestingly, for blood pressure, a therapeutic relationship and deepening of the therapeutic
patient-preferred music resulted in a larger treatment effect, but process through the music. This may lead to greater health
the results were highly inconsistent across studies. In contrast, benefits. At this time, however, the relationship between the
researcher-selected music resulted in smaller effect. frequency and duration of treatment and treatment effect remains
unclear. Further investigation into the optimal frequency and
For all outcomes, the sensitivity analyses were robust to the original duration of music interventions for specific outcomes in people
conclusions. with cancer is needed.
The Summary of findings for the main comparison provides a Presently, we cannot provide data regarding cost or cost-
summary of the main results of this review with associated risks. effectiveness of music therapy or music medicine applications in
the care of cancer patients, as the reviewed trials did not provide
Overall completeness and applicability of evidence these data.
This review included 52 randomized controlled trials and quasi-
Quality of the evidence
randomized trials.
Because of the large number of trials at high risk of bias, readers
Seventeen trials used listening to pre-recorded music, and 13 should interpret the findings of this review with caution. Often
trials used music therapy interventions that actively engaged the blinding of participants is not possible in music medicine or
patients (Characteristics of included studies). We were able to music therapy studies unless a comparative design is used (e.g.
compare the treatment effects of music therapy studies with music Bradt 2015). Many of the trials in this review included subjective
medicine studies for four outcomes. For the other outcomes this outcomes, such as anxiety, pain, mood and quality of life. When
was not possible due to insufficient number of music therapy and participants cannot be blinded to the intervention, there is
music medicine studies per outcome. definitely an opportunity for bias when they are asked to report on
these subjective outcomes.
This review included both music therapy and music medicine
studies, as defined in the Background. Music therapists who For many trials, the principal investigators needed to be contacted
work with cancer patients do not limit their interventions to to provide additional methodological and statistical information,
offering music listening for relaxation purposes. Music therapists which improved the quality of evidence in the review.
are specially trained clinically and academically to carefully select
music interventions to offer emotional and spiritual support, For anxiety and pain, there were moderate to large effects across
support communication with loved ones, enhance a sense of studies. For anxiety, the trials did not agree on the size of effect, with
control, and improve physical well-being in patients with cancer. some reporting much larger beneficial effects than others, resulting
Comparative analyses suggest that music therapy interventions in a large confidence interval. In summary, the quality of evidence
are more effective than music medicine interventions in improving was low for the outcomes (i.e. anxiety, mood, pain, fatigue and
quality of life. We found no differences between music therapy quality of life) and very low for depression (Summary of findings for
and music medicine interventions for other outcomes, but it is the main comparison).
worth noting that the results of music therapy studies were much
less heterogeneous than those of music medicine studies. This is Potential biases in the review process
likely due to the fact that music therapists are trained to meet
The strength of our review is that we searched all available
the individual needs of patients through music interventions (e.g.
databases and a large number of music therapy journals (English,
meeting the patient's in-the-moment needs when offering live
German, and French language), checked reference lists of all
music) rather than offering a limited selection of pre-recorded
relevant trials, contacted relevant experts for identification of
music, which may not be suitable for all patients. Participants
unpublished trials, and included publications without restricting
in a cross-over trial who experienced both music therapy and
language. We requested additional data where necessary for all
music medicine interventions overwhelmingly preferred the music
trials we considered for inclusion. This allowed us to get accurate
therapy sessions because of the personal attention and care, the
information on the trial quality and data for most trials and helped
creativity of the interactive music making, and the opportunity for
us make well-informed trial selection decisions.
emotional expression through singing and playing instruments.
Although we cannot completely rule out the possibility that
In general, the trials that used listening to pre-recorded music
we missed some published and unpublished trials, we are
provided little information about the music selections used, except
confident that our detailed search strategy combined with
for mentioning general music styles (e.g. new age, classical music,
extensive handsearching identified all relevant trials. It is possible
easy listening, etc). Music within each of these styles can vary
that we did not identify some grey literature; however, it is doubtful
Informed decisions.

that this would have had a significant impact on our results. Grey on coping, resilience, mean arterial pressure, immunologic
literature tends to include trials with relatively small numbers of functioning or communication behaviours because the results of
participants and inconclusive results (McAuley 2000). the studies that included these outcomes could not be pooled or
because we could only identify one trial.
One of the included trials (Bradt 2015) was conducted by the lead
author of this review. As for all new studies included in this update, Implications for research
the risk of bias was assessed by CD and LM. Data extraction was
completed independently by AT. This systematic review provides evidence that music interventions
may have beneficial effects on anxiety, pain, fatigue, QoL, heart
Agreements and disagreements with other studies or rate, respiratory rate and blood pressure in patients with cancer.
reviews Comparative analyses between music therapy and music medicine
interventions indicate that music therapy is more effective in
The findings of this review are consistent with the results of a review improving QoL than music medicine interventions. At this time,
(32 RCTs and controlled clinical trials) assessing the effect of music more RCTs are needed to determine the effectiveness of music
interventions on psychological and physical outcomes in cancer medicine versus music therapy for outcomes other than quality of
patients (Zhang 2012). Zhang and colleagues reported a mean life. This can be achieved by including more music medicine as
difference of −12.3 for anxiety (STAI-S, score range 20 to 80), −6.23 well as music therapy RCTs in future reviews, when these become
for depression (Self-Rating Depression Scale, score range 20 to 80), available or, alternatively, future trials could directly compare the
−0.52 for pain (0 to 10 numeric rating scale) and 13.32 for quality effects of these two types of interventions. It is important to note
of life (Quality of Life - Cancer, score range 0-100). The authors also that Bradt 2015 undertook such a comparative study based on
reported that the effects of music on vital signs, especially blood the recommendation of the original systematic review, concluding
pressure, were small. In contrast, Nightingale 2013 (a review of that both music therapy and music medicine interventions were
four RCT studies) evaluated the effects of music on anxiety in adult similarly effective for symptom management. However, the results
cancer patients, reporting no evidence of an effect for music on of their mixed methods research study clearly indicated that even
anxiety. This was likely due to the small number of studies included listening to pre-recorded music can evoke strong emotions and
in this review. In addition, reviewers included Kwekkeboom 2003 existential issues in people with cancer and that the participants
in the meta-analysis, which was a quite problematic trial in terms in this study were grateful for the presence of a music therapist
of the implementation of the music listening interventions, as to process these emotions and fears. Participants furthermore
discussed in the Results section of our review. Study participants emphasized the importance of interactive music making, as it
reported that the use of headphones while undergoing painful allowed them to access their creativity; this is considered an
medical procedures was anxiety-provoking because it prevented important resource for the facilitation of resilience in the face of
them from hearing the surgeon. In addition, Nightingale 2013 life's challenges.
included Hanser 2006 in the meta-analysis, whereas we included
this study in the narrative only. Our decision was based on a very Future research should explore patient characteristics as
high attrition rate (40%) and the inability to implement the music moderators of treatment benefits of music therapy interventions
therapy intervention within the a priori set timeframe, thereby versus listening to pre-recorded music. For example, Bradt 2015
highly diluting the intervention, as reported by the authors. suggested that listening to music may cause distress in patients
who have a negative outlook on life. It is possible that these
AUTHORS' CONCLUSIONS patients are at greater risk for music's powerful capacity to access
sad and traumatic memories, and such patients may be better
Implications for practice served by listening to music in the presence of a music therapist
This systematic review indicates that music interventions may who can help them process their emotions. On the other hand,
have beneficial effects on anxiety, pain, fatigue and QoL in people Bradt and colleagues emphasize that some patients have a great
with cancer. Furthermore, the results suggest that music may need for stability and emotional security during this challenging
reduce heart rate, respiratory rate and blood pressure, though time in their life and may therefore prefer the familiarity of their
this reduction is rather small and therefore may not be clinically own music. Self selected music presents predictable musical and
significant. Results from single trials suggest that music listening emotional content and may therefore provide a much needed
in cancer patients undergoing surgery may reduce anesthetic and holding environment for the patient.
analgesic consumption and reduce the length of hospital stay,
We recommend that future research efforts aim to enhance
but more research is needed before drawing solid conclusions.
understanding of how each of music therapy and music medicine
Results from a single study furthermore suggest that post-surgery
interventions can be optimized for symptom management, how
recovery time may be shortened when a music therapist offers live,
music interventions can best serve patients along the cancer
individualized music before and during surgery. Overall, evidence
treatment trajectory, and what unique aspects of music therapy
of the trials included in this review suggest that music interventions
and music medicine interventions contribute to the care of patients
may be offered as a complementary treatment to people with
(Bradt 2015).
cancer.
As stated in other reviews, it is important that investigators consider
No evidence of effect was found for distress, mood, physical
qualitative and mixed methods research, as these enhance
functioning, spiritual well-being or oxygen saturation. However,
understanding of the qualitative aspects of a patient's experience
only a small number of trials investigated the effects of music on
and identify factors that may contribute to or limit the effectiveness
these outcomes. More research is needed. We cannot draw any
of music therapy or music medicine interventions (Bradt 2013a;
conclusions at this time regarding the effects of music interventions
Bradt 2010; Bradt 2014).
Informed decisions.

Future trials that use listening to pre-recorded music should report ACKNOWLEDGEMENTS
more details related to the music selections made available to
participants and exercise greater care in selecting music that We would like to thank and acknowledge Clare Jess (Managing
reflects the patient's true preference (rather than just giving the Editor), Chris Williams and Jo Morrison (Co-ordinating Editors),
patient the option to select from four or five general genres). Barbara Wheeler, Claudia Lazado-Can, Megan Prictor, Andy Bryant,
In addition, researchers need to carefully consider the potential Lars Ole Bonde (peer reviewers) and Kathie Godfrey (consumer
negative impact of the use of headphones during procedures reviewer) for their help and editorial advice during the preparation
because of hampered communication between the patient and of the protocol and the review. We would also like to acknowledge
medical personnel. Patricia Gonzalez and Andi McGraw Hunt, graduate assistants at
Temple University, for their help in the handsearching of journals
More research is needed that examines the relationship between and retrieval of articles; Patricia Winter, graduate assistant at
frequency and duration of music interventions and treatment Temple University, for her help with data extraction; Minjung Shim,
effects. research assistant at Drexel University, for her help with data input;
and Denise Grocke for her contribution as an author on the original
Many trials used small sample sizes and did not indicate the review. For the review update we would like to thank Kelly L By and
use of power calculations. Future trials need to include power Johanna Dwinells, graduate students at Drexel University, for their
calculations in order to use adequate sample sizes. help with screening of database outputs and Karola Bryl, doctoral
student at Drexel University, for her help with data extraction.
More studies are needed on the use of music interventions in
pediatric patients with cancer. Of the 52 trials in this review, only We'd like to thank the Cystic Fibrosis Group for permission to
four studies focused on outcomes in children and adolescents. modify their data extraction form.
Many studies examined the effects of music interventions on This project was supported by the National Institute for Health
anxiety, but more studies are needed for all other outcomes Research, via Cochrane Infrastructure funding to the Cochrane
included in this review. Gynaecological, Neuro-oncology and Orphan Cancer Group. The
views and opinions expressed therein are those of the authors
Formal cost-benefit evaluations of music medicine and music
and do not necessarily reflect those of the Systematic Reviews
therapy are needed.
Programme, NIHR, NHS or the Department of Health.
Informed decisions.

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thesis]. Taipei: Taipei Medical College, 2000. Pienta 1998 {published data only}
* Pienta D. The effects of guided imagery & music on the self
Jourt-Pineau 2012 {published data only} esteem and well-being of cancer survivors. Unpublished paper
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the effects of music therapy on pain and anxiety in hospitalized
oncology patients [La musicotherapie en oncologie: evalutaion Robinson 2009 {unpublished data only}
des effets de la musicotherapie sur la douleur et l'anxiete chez * Robinson A. Music During Chemotherapy. Effects on
les patients hospitalises et/ou suivis en service d'oncologie]. La Patients with Gynecologic Malignancies with Emphasis on
Revue Francaise de Musicotherapie 2012;32(1):4-108. Physical Symptoms and Coping: Results of a Prospective
Study. [Musik während der Chemotherapie. Effekte auf
Jourt-Pineau 2013 {published data only} Patientinnen mit Gynäkologischen Malignomen unter
* Jourt-Pineau C, Guetin S, Vedrine L, Le Moulec S, Poirier JM, Besonderer Berücksichtigung von Körperlichen Beschwerden
Ceccaldi B. Effects of music therapy on pain and anxiety und Krankheitsverarbeitung: Ergebnisse einer Prospektiven
in treating cancer patients: a feasibility study. Douleurs Studie] [PhD thesis]. Berlin: Universitätsmedizin, Berlin, 2009.
2013;14(4):200-7.
Rose 2008 {published data only}
Karagozoglu 2013 {published data only} * Rose JP, Weis J. Sound meditation in oncological
* Karagozoglu S, TekyasarF, Yilmaz FA. Effects of music rehabilitation: a pilot study of a receptive music therapy group
therapy and guided visual imagery on chemotherapy-induced using the monochord. Forschende Komplementarmedizin
anxiety and nausea-vomiting. Journal of Clinical Nursing 2008;15(6):335-43.
2013;22(1-2):39-50.
Sadat 2009 {published data only}
Kemper 2008 {published data only} * Sadat Hoseini AAS. Effect of music therapy on chemotherapy
* Kemper KJ, Hamilton CA, McLean TW, Lovato J. Impact of nausea and vomiting in children with malignancy. Journal of
music on paediatric oncology outpatients. Pediatric Research Hayat 2009;15(2):5-14.
2008;64(1):105-9.
Informed decisions.

Sahler 2003 {published data only} Washington 1990 {unpublished data only}
NCT00032409. The effects of music therapy-based stress * Washington DR. The Effect of Music Therapy on Anxiety Levels
reduction on bone marrow transplant recipients. http:// of Terminally Ill Cancer Patients: A Pilot Atudy [Master's thesis].
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of patients undergoing bone marrow transplantation: a pilot influence of receptive music listening on cancer patients
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Schur 1987 {published data only} Whitney 2013 {unpublished data only}
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Lamaze pant-blow breathing in children undergoing bone free Survival Rates in Pediatric Neuroblastoma [Master's thesis].
marrow aspirations and lumbar punctures. Dissertation Ithaca, NY: Weill Medical College of Cornell University, 2013.
Abstracts International, 48(3-B)889 1987.
Wurr 2000 {unpublished data only}
Sedei 1980 {unpublished data only}
* Wurr CJ. Evaluation of music therapy in pediatric oncology - a
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Yildirim 2007 {published data only}
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CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Beck 1989
Methods RCT
Cross-over trial
Participants Adults with documented cancer-related pain
Type of cancer: breast (n = 7, 46.5%), multiple myeloma (n = 4, 26.5%), rectal (n = 1, 6.75%), prostate (n
= 1, 6.75%), sarcoma (n = 1, 6.75%), lymphoma (n = 1, 6.75%)
Total N randomized: 15
Total N analyzed: 15
Mean age: 55.6 years
Sex: 12 (80%) females, 3 (20%) males
Ethnicity: 15 (100%) white
Setting: patients' home
Country: USA
Interventions 2 study groups
1. Music condition: listening to music via headphones

2. Control condition: listening to 60-cycle hum via headphones
Music provided: the researcher asked a registered music therapist to select relaxing music in 7 cate-
gories including classical, jazz, folk, rock, country and western, easy listening and new age. Participants
were asked to select from these music options.
Number of sessions: 3
Length of sessions: 45 min
Categorized as music medicine trial
Outcomes Mood (Visual Analogue Scale, VAS), pain (VAS): change scores
Notes Because of significant pre-test differences, JB used data provided in Beck's dissertation to compute
change scores
Risk of bias
Informed decisions.

Beck 1989 (Continued)
Bias Authors' judgement Support for judgement
Random sequence genera- Low risk Quote: "Using a coin flip for a random start, assignment was alternated be-
tion (selection bias) tween the 2 groups which differed on the order of the intervention"
Allocation concealment Low risk Cross-over trial; all participants received both conditions
(selection bias)
Blinding of participants Unclear risk It is unclear whether personnel were blinded

and personnel (perfor-
mance bias)
All outcomes
Blinding of outcome as- Low risk The study did not address objective outcomes
sessment (detection bias)
Objective outcomes
Blinding of outcome as- High risk Self report measures were used for subjective outcomes
Subjective outcomes
Incomplete outcome data High risk 6 dropouts (28.6%) because of hospitalisation (n = 1), deterioration (n = 2), in-
(attrition bias) adequate baseline (n = 2), or withdrawal during baseline (n = 1)
All outcomes
Selective reporting (re- Low risk No evidence of selective reporting

porting bias)
Other bias Low risk No conflict of interest reported

Binns-Turner 2008
Methods RCT
2-arm parallel group design
Participants Women undergoing mastectomy
Type of cancer: breast cancer
N randomized to music group: 15
N randomized to control group: 15
N analyzed in music group: 15
N analyzed in control group: 15
Ethnicity: 24 (80%) white, 6 (20%) black
Setting: inpatient
Informed decisions.

Binns-Turner 2008 (Continued)
Country: USA
Interventions 2 study groups
1. Music group: music listening during mastectomy via iPod and headphones
2. Control group: iPod and headphones but no music or sounds
(Note: iPod case concealed the function status of the iPod to ensure blinding of medical personnel)
Music selections provided: 4 h of continuous non-repeating music in genre selected by the participant
from the following genres: classical, easy listening, inspirational or new age
Length of sessions: duration of mastectomy (music was begun after the participant received midazo-
lam preoperatively)
Categorized as music medicine
Outcomes Anxiety (Spielberger State-Trait Anxiety Inventory - State Anxiety form, STAI-S), pain (VAS): post-test
scores
Heart rate (HR), mean arterial pressure (MAP): change scores
Notes —
Risk of bias
Random sequence genera- Low risk Quote: "[T]he participants were assigned by the investigator to experimental
tion (selection bias) or control groups by selecting numbers from an envelope which contained pa-
pers numbered 1 to 30 (odd numbers were assigned to the experimental group
and even numbers to the control group)" (p. 53).
Allocation concealment Low risk Not reported. We assumed that the participants were present when the lot was
(selection bias) drawn therefore assuring allocation concealment.
Blinding of participants Unclear risk Personnel were blinded. Quote: "the iPOD was placed in a carrying case which
and personnel (perfor- concealed the function of the player; participants were not blinded." We de-
mance bias) cided to assign 'unclear risk' because it is unlikely that the participants' knowl-
All outcomes edge of group allocation influenced their physiological responses (objective
outcome measures). However, this knowledge may have influenced their re-
porting on subjective outcomes.
Blinding of outcome as- Low risk Outcome assessors were blinded for HR and MAP (iPod function was con-
sessment (detection bias) cealed from medical personnel who obtained the HR and MAP data).
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk No dropouts

(attrition bias)
All outcomes

porting bias)
Informed decisions.

Binns-Turner 2008 (Continued)
Other bias Low risk No report of conflict of interest

Bradt 2015
Methods RCT
Cross-over trial
Participants Adults receiving cancer treatment
Type of cancer: breast (n = 6, 19.4%), head and neck (n = 3, 9.7%), gastrointestinal (n = 3, 9.7%), gyneco-
logical (n = 3, 9.7%), hematologic (n = 7, 22.6%), lung (n = 4, 12.9%), other (n = 5, 16%)
Total N randomized: 39 with 5 patients lost prior to initiation of treatment
Age: 53.8 years
Sex: 21 (67.7%) females, 10 (32.3%) males
Ethnicity: 23 (74.2%) black, 1 (3.2%) Asian, 6 (19.4%) white, 1 (3.2%) other
Setting: inpatient and outpatient
Country: USA
Interventions 2 study conditions:
1. Music therapy condition: music therapist offered live and interactive music making based on patient
needs
2. Music medicine condition: participants listed to iPod with the patient's playlist
Number of sessions: 2 of each condition
Length of sessions: 30-45 min
Categorized as music therapy
Outcomes Anxiety (VAS), mood (VAS), relaxation (VAS), pain (NRS): post-test scores
Notes —
Risk of bias
Random sequence genera- Low risk "Using a list of random numbers, participants were randomized to one of two
tion (selection bias) treatment sequences consisting of two MT sessions followed by two MM ses-
sions or vice versa" (p.1262)
Allocation concealment Low risk "The use of sequentially numbered, opaque, sealed envelopes ensured alloca-
(selection bias) tion concealment" (p.1262).
Blinding of participants Low risk Study participants were blinded: "We minimized expectation effects of partici-
and personnel (perfor- pants throughout the study by referring to both treatment conditions as music
mance bias) sessions rather than referring to one intervention as music therapy" (p1263).
All outcomes The music therapist could not be blinded.
Informed decisions.

Bradt 2015 (Continued)
Blinding of outcome as- Low risk No objective outcomes were included in this study.
Objective outcomes
Blinding of outcome as- Low risk Self report measures were used for subjective outcomes but participants were
sessment (detection bias) blinded to the study hypotheses.
Subjective outcomes
Incomplete outcome data Low risk Attrition rate: 13% (p.1264)

(attrition bias)
All outcomes
Selective reporting (re- Low risk No indication of selective reporting

porting bias)
Other bias Low risk Study was funded by Drexel University's College of Medicine

Bufalini 2009
Methods Controlled clinical trial (CCT) (randomization method unclear)
Participants Children with cancer who had previously undergone more than 2 painful, invasive procedures (e.g. os-
teomedullar biopsy, lumbar puncture) and who were scheduled to undergo a painful medical proce-
dure
Type of cancer: acute lympathic leukemia (n = 18, 47% of music group, n = 25, 65% of control group),
non-Hodgkin's lymphoma (n = 12, 32% of music group, n = 8, 20% of control group), neuroblastoma (n
= 4, 11% of music group, n = 4, 10% of control group), osteosarcoma (n = 2, 5% of music group, n = 2, 5%
of control group), medulloblastoma (n = 2, 5% of music group, 0% of control group)
Total N randomized: unclear
Ethnicity: 39 (100%) white (Italian)
Setting: inpatient
Country: Italy
Interventions 2 study groups:
1. Music therapy group: conscious sedation and music listening phase followed by an interactive music
therapy phase
2. Control group: conscious sedation alone
Music selections provided: during the initial music listening phase, the following music was used: lul-
labies (e.g. Brahms); children's songs (Walt Disney); folk songs (Italian/non-Italian), ethnic songs (Alba-
nia, Romania, Latin America), pop (Italian /non-Italian), classical music (e.g. Bach), other music (Celtic
music, Simon and Garfunkel, etc.). This phase was followed by active music making with the child using
small percussion instruments and vocal and body percussion.
Informed decisions.

Bufalini 2009 (Continued)
Length of sessions: 15 min for phase 1 (music listening); length of active music making is not specified
Outcomes Anxiety (STAI-S): post-test scores
Induction compliance (not used in this review)
Notes —
Risk of bias
Random sequence genera- Unclear risk Not reported

tion (selection bias)
Allocation concealment Unclear risk Not reported

(selection bias)
Blinding of participants Low risk Music therapist and participants could not be blinded as this trial used an in-
and personnel (perfor- teractive music therapy intervention
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Unclear risk It is unclear whether number of participants analyzed equals the number of
(attrition bias) participants recruited
All outcomes

porting bias)

Bulfone 2009
Methods CCT
Participants Women with breast cancer waiting for adjuvant chemotherapy
Type of cancer: breast (n = 60, 100%)
Informed decisions.

Bulfone 2009 (Continued)
Sex: 60 (100%) females
Ethnicity: 60 (100%) white (Italian)
Setting: inpatient
Country: Italy
1. Music group: listening to pre-taped music themes with WalkmanⓇ and earphones while waiting for
chemotherapy
2. Control group: standard care
Music selections provided: participants were asked to select from new age music, nature music, film
soundtracks, Celtic melodies, or classical music
Notes The principal investigator provided us with standard deviations as these were not given in the study re-
port
Risk of bias
Random sequence genera- High risk Alternate assignment using order of admission (personal communication with
tion (selection bias) principal investigator)
Allocation concealment High risk Alternate assignment prohibited allocation concealment

(selection bias)
Blinding of participants Unclear risk It is unclear whether personnel were blinded; participants were not blinded
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk No attrition

(attrition bias)
Informed decisions.

Bulfone 2009 (Continued)
All outcomes

porting bias)

Burns 2001a
Methods RCT
Participants Adult patients with cancer
Diagnosis: ovarian (n = 1, 13%), breast (n = 7, 87%)
Mean age: 48 (SD 6.56) years
Ethnicity: no information provided
Setting: outpatient
Country: USA
1. Music therapy group: 10 weekly sessions of the Bonny Method of Guided Imagery and Music
2. Control group: wait-list control group
Music selections provided: Quote from study report (p. 55): "The Bonny Method of Guided Imagery and
Music is an in depth music psychotherapy that utilizes specially sequenced Western Art music to elicit
imagery and emotional expression."
Outcomes Mood (Profile of Mood States, POMS): could not be included because constant of 100 was not used in
total score computation by the authors
Quality of Life (QoL-Cancer Scale): change scores were computed by JB to allow for computation of
pooled effect size (SMD) with other studies that reported change scores
Notes —
Informed decisions.

Burns 2001a (Continued)
Risk of bias
Random sequence genera- Low risk Computer-generated number list (personal communication with principal in-
tion (selection bias) vestigator)
Allocation concealment Low risk Statisticalprogram Aleator (personal communication with principal investiga-
(selection bias) tor)
Blinding of participants Low risk Blinding of participants and music therapist was not possible given the inter-
and personnel (perfor- active nature of the music therapy sessions
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk No subject loss

(attrition bias)
All outcomes

porting bias)
Other bias Low risk Study was supported by Trustees of the Paul Jenkins fund

Burns 2008
Methods CCT
Participants Adults with acute leukemia
Diagnosis: acute leukemia, high-grade non-Hodgkin's lymphoma
Mean age: 54 years
Ethnicity: not provided
Setting: inpatient
Informed decisions.

Burns 2008 (Continued)
Country: USA
1. Music therapy group: participants received music-guided imagery sessions

Music selections provided: classical music and new age music based on patient preference was used
Outcomes Anxiety (STAI-S): 4-weeks postintervention scores
Fatigue (The Functional Assessment of Chronic Illness Therapy—Fatigue scale, FACIT-F): 4-week post-
intervention scores
Positive and negative affect (Affect and Negative Affect Schedule, PANAS): 4 week post-intervention
scores (not used in this review)
Notes Post-test scores were not reported in this study report. Values were obtained from the principal investi-
gator. However, she could only provide us with the 4-week post-intervention scores.
Risk of bias


(selection bias)
mance bias)
All outcomes
Blinding of outcome as- Low risk This study did not address objective outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data High risk Attrition rate is 38.8%. There were 10 withdrawals in the experimental group,
(attrition bias) 9 in the control group for the following reasons: too sick to complete the mea-
All outcomes sures or carry out the intervention (n = 6), voluntary withdrawal (n = 4), trans-
fer to ICU (n = 4), death (n = 3), did not complete follow-up questionnaires (n =
2).
Selective reporting (re- High risk Only feasibility data were reported. No post-test or follow-up scores were re-
porting bias) ported. Follow-up scores (4 weeks post-intervention) were received from the
author.
Informed decisions.

Other bias Low risk Supported by a grant from the National Center for Complementary and Alter-
native Medicine 5F32AT001144-02, and Bardett-Kenkel award from the Walter
Cancer Institute

Burns 2009
Methods RCT
Participants Adolescents and young adults with cancer during stem-cell transplantation (SCT)
Diagnosis: no further diagnosis details reported
Sex: 5 (42%) females, 7 (58%) males (at the onset of the trial)
Ethnicity: 8 (66%) white, other information not provided
Setting: inpatient
Country: USA
1. Music therapy group: music therapy group created therapeutic music video with a board-certified mu-
sic therapist
2. Control group: listened to audiobook with certified child life specialist. Delivered during the acute
phase of SCT
Music selections provided: music videos of 10 songs from 5 music styles including pop, rock, rap, coun-
try, and rhythm and blues
Outcomes Distress (McCorkle Symptom Distress Scale): post-test scores
QoL (Index of Well-Being): post-test scores
Spiritual beliefs (Reed Spiritual Perspective Scale): change scores
Hope (Herth Hope index): not included in this review
Mood (Mental Health Scale of the Child Health Questionnaire), pain (Child Health Questionnaire): can-
not be included because of high attrition
Informed decisions.

Notes —
Risk of bias
Allocation concealment Unclear risk Central randomizations was used, but author is unsure how information was
(selection bias) transferred to field investigators (personal communication with principal in-
vestigator)
Blinding of participants Low risk Music therapist could not be blinded because of the interactive nature of the
and personnel (perfor- music therapy sessions; participants were blinded to the purpose of the study
mance bias) (personal communication with principal investigator)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk 2 participants (16.6%) were dropped from the study when they became very ill
(attrition bias) and were transferred to the intensive care unit; 1 of these 2 participants even-
All outcomes tually died. 1 participant withdrew from the study after learning randomiza-
tions status

porting bias)
Other bias Low risk Supported by American Cancer society IRG-84-002-19

Burrai 2014
Methods RCT
Participants Adults who met the eligibility criteria for diagnosis of cancer receiving chemotherapy treatment
Type of cancer: metastatic cancer (n = 45, 86.6%), non-metastatic cancer (n = 7, 13.4%)
Informed decisions.

Burrai 2014 (Continued)
Ethnicity: not reported
Setting: inpatient
Country: Italy
1. Music group: listening to live saxophone music provided by a nurse

Music selections provided: participant was asked to select 5 or 6 musical pieces from a playlist that in-
cluded music from a wide variety of styles
Outcomes SBP, DBP: change score
HR, oxygen saturation: post-test scores
Mood (VAS): post-test scores
Glycemia: not included in this review
Pain (VAS): not included in this review. Baseline levels indicated that participants were barely experi-
encing pain.
Notes —
Risk of bias
Random sequence genera- Low risk "For the randomisation sequence generation for allocation of the participants,
tion (selection bias) a computer-generated list of random numbers was used. For the randomisa-
tion type, participants were randomly assigned following simple randomisa-
tion procedures (computerized random numbers) to 1 of 2 groups" (p. 304).
Allocation concealment Low risk "As for the allocation concealment mechanism, the allocation sequence was
(selection bias) concealed from the researcher enrolling and assessing participants in se-
quentially numbered, opaque, sealed, and stapled envelopes. Envelopes were
opened only after the enrolled participants completed all baseline assess-
ments, and it was time to allocate the intervention" (p. 304).
Blinding of participants Low risk Live music was used; therefore blinding was not possible
mance bias)
All outcomes
Blinding of outcome as- Unclear risk Not reported

Objective outcomes
Informed decisions.

Burrai 2014 (Continued)
Subjective outcomes
Incomplete outcome data Low risk Flow chart (p. 305) indicates 0% dropouts
(attrition bias)
All outcomes

porting bias)
Other bias Low risk "The authors have disclosed that they have no significant relationships with,
or financial interest in, any commercial companies pertaining to this arti-
cle" (p. 301)

Cai 2001
Methods CCT
Participants Adults with cancer receiving chemotherapy or radiation therapy
Diagnosis: lung cancer (n = 25, 14%), gastric carcinoma (n = 45, 25%), intestinal carcinoma (n = 28,
15%), breast cancer (n = 84, 46%)
N randomized to music group: unclear
N randomized to control group: unclear
N analyzed control group: 54
Mean age: 51 years
Ethnicity: 182 (100%) Chinese
Setting: inpatient
Country: China
1. Music group: listening to pre-recorded music

Music selections provided: Chinese classical music
Outcomes Depression (Zung Self Rating Depression Scale): post-test scores
Informed decisions.

Cai 2001 (Continued)
Anxiety (Zung Self Rating Anxiety Scale): post-test scores
Notes —
Risk of bias
Random sequence genera- Unclear risk Not provided in the translation of the study report
Allocation concealment Unclear risk Not provided in the translation of the study report
(selection bias)
Blinding of participants High risk Participants and personnel were not blinded
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
(attrition bias) participants randomized
All outcomes

porting bias)

Cassileth 2003
Methods RCT
Participants Adults with hematologic malignancy admitted for high dose therapy with autologous stem cell trans-
plantation
Diagnosis: Hodgkin's (n = 8, 12%), non-Hodgkin's lymphoma (n = 31, 45%), myeloma/amyloidosis (n =

30, 43%)
N randomized to control group:33
Informed decisions.

Cassileth 2003 (Continued)
Mean age: 52 years
Setting: inpatient
Country: USA
1. Music therapy group: live bedside music therapy provided by trained music therapist
Music selections provided: each music therapy session was individualized according to the needs of the
participant
Number of sessions: the treatment group received a median of 5 sessions during a median of 10 days
Outcomes Depression (POMS): post-test scores (after 1 session)
Anxiety (POMS): change scores (after 1 session)
Mood (POMS total score): change scores (after 1 session)
Fatigue (POMS): post-test scores (after 1 session)
Notes —
Risk of bias
Random sequence genera- Low risk Quote: "[R]andomized by telephone using the MSKCC clinical research data-
tion (selection bias) base" (p. 2724) and "randomly permuted blocks with the following strata:
whole body/whole lymphatic irradiation (yes/no); diagnosis (lymphoma,
Hodgkin disease, myeloma/amyloidosis); and center (MSKCC/ICC)." (p. 2724).
Allocation concealment Low risk Quote: "[T]he use of telephone registration and randomisation ensured con-
(selection bias) cealment of treatment allocation"
Blinding of participants Low risk Music therapist and participants could not be blinded given the interactive na-
and personnel (perfor- ture of the music therapy session
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Informed decisions.

Cassileth 2003 (Continued)
Incomplete outcome data Low risk Attrition rate = 9 (13%)
(attrition bias)
All outcomes Withdrew before learning allocation (n = 7); discharged before post-test (n = 2)

porting bias)
Other bias Low risk Supported in part, by the Memorial Sloan-Kettering Cancer Center Transla-
tional/Integrative Medicine Research Fund

Chen 2004
Methods RCT
Participants Adults who are ready to receive adjuvant chemotherapy after mastectomy
Diagnosis: breast cancer
Mean age: not provided
Setting: inpatient
Country: China
1. Music group: listening to music and guided imagery

Music selections provided: music selection was based on the patient's psychological status (excited or
inhibited), but no further details are provided
Outcomes CD3, CD4, CD8, CD4/CD8, NK cell activity: post-test scores
Notes —
Risk of bias
Informed decisions.

Chen 2004 (Continued)
Random sequence genera- Low risk Translation sheet: "Table of random numbers"
Allocation concealment High risk No allocation concealment was used

(selection bias)
Blinding of participants High risk Personnel and participants were not blinded
mance bias)
All outcomes
Blinding of outcome as- Unclear risk Information regarding blinding of outcome assessors is not provided in the
sessment (detection bias) translation of the report
Objective outcomes
Blinding of outcome as- Low risk This study did not address subjective outcomes
Subjective outcomes
All outcomes

porting bias)

Chen 2013
Methods CCT
Participants Adult oncology patients
Type of cancer: head and neck (n = 67, 33.5%), gynecological (n = 23, 11.5%), breast (n = 38, 19%), diges-
tive tract (n = 37, 18.5%), lung (n = 12, 6%), prostate (n = 18, 9%) (Numbers do not add up to total N of
200 but are reported as such in the published article)
Informed decisions.

Chen 2013 (Continued)
Setting: outpatient
Country: Taiwan
1. Music condition: music listening via headphones

2. Control condition: sitting quietly
Music selections provided: slow-paced, soft, melodic music at low volume with consistent tempo and
dynamics and an average 60-80 beats per minute. Subjects chose their own music tracks from a selec-
tion of songs in Mandarin, Mandarin pop, traditional Taiwanese songs, Western music (country and
western), and classical music (e.g. chamber music with string instruments).
Outcomes Anxiety (STAI): change scores
HR, RR, SBP, DBP, oxygen saturation: change scores
Notes —
Risk of bias
Random sequence genera- High risk "The 200 patients were randomly assigned by simple random sampling (every
tion (selection bias) other patient) into two groups" (p. 437)

(selection bias)
Blinding of participants High risk Participants were blinded to the study hypothesis. Personnel were not blind-
and personnel (perfor- ed.
mance bias)
All outcomes
Blinding of outcome as- High risk Outcome assessors were not blinded
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk "A total of 209 patients who met the inclusion criteria were enrolled. Nine of
(attrition bias) these patients withdrew at the early stage for reasons of severe clinical condi-
All outcomes tion or personal reasons, and 200 patients were retained for analysis" (p. 437).
Attrition rate: 4.4%.
Selective reporting (re- Unclear risk No evidence of selective reporting

porting bias)
Informed decisions.


Clark 2006
Methods RCT
Participants Adults with cancer undergoing radiation therapy
Diagnosis: prostate (n = 8, 13%), breast (n = 13, 21%), lung (n = 8, 13%), head and neck (n = 14, 22%),
gastrointestinal (n = 9, 14%), gynecological (n = 5, 8%), other (n = 6, 10%).
N analyzed in music group: 18-28 (depending on outcome)
N analyzed in control group: 14-21 (depending on outcome)
Ethnicity: 54 (86%) white, 7 (11%) black, 2 (3%) other
Setting: not stated in study report
Country: USA
1. Music therapy group: music therapist provided instructions on how to use music for relaxation and
distraction
Music selections provided: a personalized tape was created for each patient to use at any time during
the course of therapy.
Number of sessions: 2-4 times per week for approximately 4-5 weeks
Length of sessions: unknown
Outcomes Depression (Hospital Anxiety and Depression Scale, HADS): post-test scores
Fatigue (POMS): post-test scores
Pain (Numeric Rating Scale, NRS): change scores
Distress (NRS): change scores
Notes No standard deviations were reported for post-test scores in the publication. Standard deviations were
obtained from the author.
Risk of bias
Informed decisions.

Clark 2006 (Continued)
Random sequence genera- Low risk Quote: "Patients were randomised using a minimization procedure in which
tion (selection bias) the first subject is assigned to a group with a coin toss. Subsequent subjects
were assigned based upon covariate (tumor site, gender and pain) and assign-
ment of previous subjects using a computer program." (p. 251)
Allocation concealment Low risk Minimization procedure as described above

(selection bias)
Blinding of participants Low risk The music therapist and participants could not be blinded
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk Attrition rate: 8%. Participants did not meet inclusion criteria (n = 4) or did not
(attrition bias) return for radiation therapy treatment (n = 1)
All outcomes

porting bias)

Cook 2013
Methods RCT
Participants Adult oncology patients
Type of cancer: leukemia (n = 7, 41.2%), unspecified or other (n = 10, 58.8%)
Setting: inpatient
Informed decisions.

Cook 2013 (Continued)
Country: USA
1. Music therapy: music therapist played patient-preferred live music

Music selections provided: not reported
Outcomes Spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well Being Scale,
FACIT-Sp.): post-test scores
Notes —
Risk of bias
Random sequence genera- Low risk “...and after they signed the consent form, they were randomly assigned to a
tion (selection bias) controlled condition or an experimental music therapy condition via a com-
puter program” (p. 241).

(selection bias)
Blinding of participants Low risk Music therapist and participants could not be blinded.
mance bias)
All outcomes
Blinding of outcome as- Low risk This study did not address objective outcomes.
Objective outcomes
Blinding of outcome as- High risk Self-report measures were used for subjective outcomes.
Subjective outcomes
Incomplete outcome data High risk Ten participants were lost in music therapy group, seven in the control group.
(attrition bias) Attrition rate: 50%.
All outcomes

porting bias)

Danhauer 2010
Methods RCT
Informed decisions.

Danhauer 2010 (Continued)
Participants Patients with cancer undergoing bone marrow biopsy
Diagnosis: hematological malignancy
Sex: not provided
Setting: outpatient
Country: USA
1. Music group: listening to pre-recorded music for the duration of the procedure
Music selections provided: participants selected from 8 music CDs with various types of relaxing music
(classical, harp, general instrumental, nature sounds, country, gospel and jazz)
Pain (VAS): post-test scores
Notes —
Risk of bias
Allocation concealment Low risk Researcher was blind to randomized blocks (personal communication with
(selection bias) principal investigator)
Blinding of participants Unclear risk Not reported

mance bias)
All outcomes
Informed decisions.

Danhauer 2010 (Continued)
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk Attrition rate: 6.3%. Data for 4 participants were incomplete
(attrition bias)
All outcomes

porting bias)

Duocastella 1999
Methods RCT
Participants Children with neoplasms needing chemotherapy
Diagnosis: acute lymphocytic leukemia (n = 9, 27%), osteosarcoma (n = 5, 15%), Burkitt's lymphoma (n

= 2, 6%), acute myeloid leukemia (n = 2, 6%), synovial sarcoma (n = 2, 6%), Hodgkin's (n = 2, 6%), tumor
in the trunk (n = 2, 6%), Wilm's tumor (n = 2, 6%), Ewings sarcoma (n = 1, 3%), brain tumor (n = 1, 3%),
lymphoblastic lymphoma (n = 1, 3%), primitive neuroectodermal tumor (n = 1, 3%).
N analyzed in music group:15
N analyzed in control group:15
Setting: inpatient
Country: Spain
1. Music therapy group: music therapy interventions were adapted for in-the-moment needs of the child.
Music therapy session included singing, instrument playing, movement to music, and musical games.
2. Control group: activity session led by music therapist but music activities were excluded.
Music selections provided: cultural and ethnic characteristics were considered in selecting songs and
instruments.
Informed decisions.

Duocastella 1999 (Continued)
Outcomes Mood (Patient Opinion Likert Scale, OPEL): post-test scores
Immunoglobulin A (IgA) levels: change scores
Notes —
Risk of bias
Random sequence genera- Low risk Translation sheet: "Computer-generated number list"
Allocation concealment Low risk Translation sheet: "Statistical program Aleator"

(selection bias)
Blinding of participants Low risk The music therapist and the participants could not be blinded
mance bias)
All outcomes
Blinding of outcome as- Low risk Staff responsible for analysing IgA were likely unaware of the participants'
sessment (detection bias) group assignment
Objective outcomes
Blinding of outcome as- High risk Self report measures were used for subjective data
Subjective outcomes
Incomplete outcome data Low risk There were 3 dropouts (9%) (1 in control group)
(attrition bias)
All outcomes

porting bias)

Ferrer 2005
Methods CCT
Participants Adults with cancer receiving chemotherapy
Diagnosis: no details reported
Informed decisions.

Ferrer 2005 (Continued)
Mean age: 55 years
Setting: outpatient
Country: USA
1. Music group: music therapist provided patient-preferred live music

Music selections provided: patient-preferred music with guitar accompaniment
Outcomes Anxiety (VAS): post-test scores
Fatigue (VAS): post-test scores
Systolic blood pressure (SBP): post-test scores
Diastolic blood pressure (DBP): post-test scores
Heart rate: post-test scores
Fear (VAS), worry (VAS), level of comfort (VAS), level of relaxation (VAS): not used in this review
Notes —
Risk of bias


(selection bias)
Blinding of participants Low risk The music therapist and the participants were not blinded
mance bias)
All outcomes

Objective outcomes
Informed decisions.

Ferrer 2005 (Continued)
Subjective outcomes
(attrition bias) participants randomized
All outcomes

porting bias)
Other bias Low risk No funding was received

Fredenburg 2014a
Methods RCT
Participants Adult cancer patients recovering from a blood and marrow transplant
Type of cancer: acute myelogenous leukemia (n = 3, 8.0%), acute lymphoblastic leukemia (n = 2, 5.9%),
chronic lymphocytic leukemia (n = 3, 8.0%), non-Hodgkin's lymphoma (n = 5, 14.7%), myelodysplastic
syndromes (n = 2, 5.9%), multiple myeloma (n = 7, 20.6%), leukemia (not specified) (n = 6, 17.6%), lym-
phoma (not specified) (n = 1, 2.9%), other (n = 3, 8.0%)
Mean age: 53.5
Sex: 17 (55.9%) female, 15 (44.1%) male
Ethnicity: Asian (n = 1, 2.9%), Latino (n = 3, 8%), white (n = 23, 67.6%), other (n = 5, 14.7%)
Setting: inpatient
Country: USA
1. Music therapy group: music therapist provided live music based on patient's stated preferences with
voice and guitar
Music selections provided: patient's preferred music
Informed decisions.

Fredenburg 2014a (Continued)
Outcomes Positive and negative affect (PANAS), pain (NRS): post-test scores
Notes —
Risk of bias
Random sequence genera- Low risk "Participants were randomly assigned via a computer program to either the
tion (selection bias) experimental group (n = 12) or wait-list control group (n = 20)" (p. 176).
Allocation concealment High risk No allocation concealment used (personal communication with chief investi-
(selection bias) gator)
Blinding of participants Low risk Music therapist and participants could not be blinded
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk "2 participants did not complete measures" (p. 177). Attrition rate:6%
(attrition bias)
All outcomes

porting bias)

Fredenburg 2014b
Methods RCT
Participants Adults in bone marrow transplant unit
Type of cancer: acute myelogenous leukemia (n = 2, 18.2%), acute lymphoblastic leukemia (n= 2,
18.2%), chronic lymphocytic leukemia (n = 2, 18.2%), Hodgkin's disease (n = 1, 9.1%),
multiple myeloma (n = 1, 9.1%), non-Hodgkin's lymphoma (n = 2, 18.2%), and lymphoma (n = 1, 9.1%)

Informed decisions.

Fredenburg 2014b (Continued)
Mean age: 49.69
Sex: n = 3 (27.3%) female, n = 8 (72.7%) male
Ethnicity: white: n = 10 (90.9%), other: n = 1 (9.1%)
Setting: inpatient
Country: USA
1. Music therapy group: music therapist played patient-preferred music

Music selections provided: patient-preferred live music
Number of sessions: 3-5
Outcomes Fatigue (Multidimensional Fatigue Inventory, MFI): change scores
Notes Means and standard errors are reported in the journal article. Standard deviations were obtained from
the primary author. Because of large baseline differences between the groups, JB computed change
scores and associated SDs.
Risk of bias
Random sequence genera- Low risk "The participants were randomly assigned via a computer program to either
tion (selection bias) the experimental (n = 7) or wait-list control (n = 4) groups " (p.436).

(selection bias)
mance bias)
All outcomes
Objective outcomes
Blinding of outcome as- High risk Self-report measures were used for subjective outcomes
Subjective outcomes
Incomplete outcome data Low risk Flowchart reported that 13 participants consented and randomized; 11 ana-
(attrition bias) lyzed (p. 435). Attrition rate: 16%.
All outcomes

porting bias)
Informed decisions.

Fredenburg 2014b (Continued)

Gimeno 2008
Methods CCT
cross-over trial
Participants Adult patients with cancer undergoing chemotherapy
Diagnosis: breast cancer (n = 10, 50%), non-small cell lung cancer (n = 5, 25%), lymphoma (n = 2, 10%),
sarcoma (n = 1, 5%), colon cancer (n = 1, 5%), tongue cancer (n = 1, 5%).
Ethnicity: 9 (45%) white, 1 (5%) black, 1 (5%) Latino, 9 (45%) Asian
Setting: outpatient
Country: USA
1. Music therapy condition: adapted Bonny Method of Guided Imagery and Music intervention (BMGIM)
2. Control condition: imagery only
Music selections provided: new age music
Number of sessions: 3 BMGIM sessions and 3 imagery-only sessions
Outcomes Heart rate: post-test scores
Nausea and emesis (no standard deviations (SD) reported): not included in this review
Notes —
Risk of bias

Allocation concealment Low risk Cross-over trial; all patients received both sessions.
(selection bias)
mance bias)
Informed decisions.

Gimeno 2008 (Continued)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data High risk Attrition rate: 50% 1 patient was excluded from the analysis because she only
(attrition bias) completed 4 sessions. Principal investigator mentions other reasons for with-
All outcomes drawal but does not provide specific numbers

porting bias)

Hanser 2006
Methods RCT
Participants Women with metastatic breast cancer
Diagnosis: metastatic breast cancer (stage IV)
Sex: 70 (100%) females, 0 males
Ethnicity: 58 (83%) white, 7 (10%) black, 1 (2%) Latino
Setting: outpatient
Country: USA
1. Music therapy group: music therapy sessions consisted of live music, improvisation, and songwriting
Music provided: live music based on participant's preferences and needs
Informed decisions.

Hanser 2006 (Continued)
Outcomes Depression (HADS): post-test scores
Anxiety (HADS): post-test scores
Physical well-being (the Functional Assessment of Cancer Therapy-General, FACT-G Physical Wellbeing
Subscale): post-test scores
QoL (FACT-G): post-test scores
Spirituality (Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale, FACIT-Sp):

change scores
Notes The 3 music sessions were spread over 15 weeks. Music therapy treatment is usually offered on a week-
ly or biweekly basis with this population. The author reported that it was not feasible to have patients
come to the clinic each week and that because of this spread, the intervention was highly diluted.
Therefore, the data of this study are not included in the meta-analysis of this review.
Risk of bias
Random sequence genera- Low risk Quote: "Computer-generated random numbers determined the assignment of
tion (selection bias) numbered folders to control or experimental conditions" (p. 117).
Allocation concealment Low risk Quote: "the participants opened the sealed envelope to reveal group assign-
(selection bias) ment to either the experimental/music therapy intervention or control/usual
care condition" (p. 117)
Blinding of participants Low risk The music therapist and the participants could not be blinded
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data High risk Attrition rate: n = 28 or 40%. Music therapy group participants cancelled; be-
(attrition bias) fore initiation of the study (too busy, n = 5); from baseline to first follow-up (too
All outcomes busy, n = 2; no interest, n = 2; moved, n = 1; health limits, n = 1; lost, n = 1); and
from first to second follow-up (health limits, n = 1; died, n = 1; lost, n = 1).
Control group participants cancelled before the initiation of the study (too
busy, n = 2; died, n = 2); from baseline to first follow-up (not interested, n = 1;
moved, n = 1; died, n = 2); and from first to second follow-up (died, n = 2; lost, n
= 3)

porting bias)
Other bias High risk The 3 music sessions were spread over 15 weeks. Music therapy treatment is
usually offered on a weekly or biweekly basis with this population. The author
reported that it was not feasible to have patients come to the clinic each week.
Informed decisions.

Hanser 2006 (Continued)
No report of conflict of interest

Harper 2001
Methods RCT
Participants Adults with cancer undergoing chemotherapy
Diagnosis: breast (n = 13, 32.5%), colon (n = 12, 30%), ovarian (n = 7, 17.5%), lung (n = 7, 17.5%),
prostate (n = 1, 2.5%)
N randomized to music-only group: 10
N randomized to problem-focused visualization group: 10 (not included in this review)
N randomized to emotion-focused visualization group: 10 (not included in this review)
N analyzed in problem-focused visualization: 10 (not included in this review)
N analyzed in emotion-focused visualization: 10 (not included in this review)
Mean age: 52 years
Ethnicity: 32 (80%) white, 4 (10%) black, 4 (10%) Latino
Setting: outpatient
Country: USA
1. Music group: music-only intervention, using just the background music from the problem-focused and
emotion-focused tapes.
Music selections provided: new age music, namely Health Journeys: Cancer Image Path
Outcomes Anxiety (STAI-S): change scores
Anxiety (Beck Anxiety Inventory, BAI): not used in this review
Coping (Coping Orientations to Problems Experienced, COPE): not used in this review
Heart rate, SBP, DBP: change scores
Informed decisions.

Harper 2001 (Continued)
White blood cell count (WBC), red blood cell count (RBC), absolute neutrophil count (ANC): not used in
this review; only measured at intake and at 6 weeks follow-up while only 1 music session was used
Notes —
Risk of bias
Random sequence genera- Low risk Quote: "A table of random numbers was used to assign each participant num-
tion (selection bias) ber to a condition" (personal communication with principal investigator)

(selection bias)
mance bias)
All outcomes
Blinding of outcome as- High risk Outcome assessors for WBC, RBC, and ANC were blinded. Outcome assessor
sessment (detection bias) for HR, SBP, and DBP was not blinded (personal communication with principal
Objective outcomes investigator).
Subjective outcomes
Incomplete outcome data Low risk No subject loss in music group or control group
(attrition bias)
All outcomes

porting bias)
Other bias Low risk —

Hilliard 2003
Methods RCT
Participants Adults with terminal cancer
Diagnosis: cancer of lung (n = 27, 33.75%), colon (n = 7, 8.75%), kidney (n = 3, 3.75%), nasopharynx (n
= 1, 1.25%), prostate (n = 1, 1.25%), liver (n = 2, 2.5%), esophogeal (n = 3, 3.75%), breast (n = 5, 6.25%),
pancreas (n = 5, 6.25%), brain (n = 5, 3.75%), oral cavity (n = 1, 1.25%), ovary (n = 2, 2.5%), stomach (n =
2, 2.5%), endometrium (n = 1, 1.25%), sinus (n = 1, 1.25%), larynx (n = 1, 1.25%), leukemia (n = 2, 2.5%),
melanoma (n = 2, 2.5%), multiple myeloma (n = 3, 3.75%), lymphoma (n = 1, 1.25%), head, neck and
face (n = 1, 1.25%) and unspecified cancer (n = 3, 3.75%)
Informed decisions.

Hilliard 2003 (Continued)
Setting: home hospice care
Country: USA
1. Music therapy group: cognitive-behavioural music therapy included singing, lyric analysis, instrument
playing, song parody, planning of funerals, song gifts.
Music provided: music therapy interventions were selected based on the participant's in-the-moment
needs
Number of sessions: 2 to 13. Sessions were offered weekly or bi-weekly until the patient died.
Length of sessions: unknown
Outcomes QoL (Hospice QoL Index-Revised): change scores were computed by JB to allow for computation of
pooled effect size (SMD) with other studies that reported change scores
Physical status (Palliative Performance Scale): post-test scores
Length of life (in days)
Notes —
Risk of bias
Random sequence genera- Low risk Quote: " A computer generated number list was used for randomisation" (per-
tion (selection bias) sonal communication with principal investigator)
Allocation concealment Low risk Quote: "Researcher and assistant did not know what treatment patient was as-
(selection bias) signed to until after consent was completed" (personal communication with
principal investigator)
Blinding of participants Low risk The music therapists and participants could not be blinded
mance bias)
All outcomes
Blinding of outcome as- Low risk Outcome assessors were not blinded, but it is unlikely that the report of length
sessment (detection bias) of life (in days) would have been biased
Objective outcomes
Subjective outcomes
Informed decisions.

Hilliard 2003 (Continued)
Incomplete outcome data Unclear risk Quote: "When participants were lost due to death before they had completed 2
(attrition bias) sessions, additional participants were recruited until a complete data set of 80
All outcomes participants was obtained" (personal communication with principal investiga-
tor)

porting bias)

Huang 2006
Methods RCT
Participants Adult cancer patients with pain
Diagnosis of sample included in final analysis (n = 126): cancer of head or neck (n = 51, 41%), gastroin-
testinal (n = 25, 20%), hematological (n = 16, 13%), genitourinary (n = 15, 12%), lung (n = 7, 6%), bone (n
= 1, 1%), other (n = 11, 9%)
Mean age: 54 years
Ethnicity: 129 (100%) Taiwanese
Setting: inpatient
Country: Taiwan

2. Control group: bedrest
Music provided: music was sedative (60-80 beats) without lyrics, with a sustained melody quality, and
controlled volume and pitch. Participants were asked to select from 4 audiotapes: 2 with Taiwanese
music (Taiwanese folk songs and Buddhist music) and 2 with American music (harp music and piano
music).
Number of sessions:1
Outcomes Pain (VAS): post-test scores
Informed decisions.

Huang 2006 (Continued)
Notes —
Risk of bias
Random sequence genera- Low risk Quote: "A computerized minimization program was used to randomise and
tion (selection bias) conceal the allocation until after assignment and to stratify the groups on hos-
pital unit" (p.2)
Allocation concealment Low risk Quote: "A computerized minimization program was used to randomise and
(selection bias) conceal the allocation until after assignment and to stratify the groups on hos-
pital unit" (p.2

mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk Attrition rate: 2.4%. Inability to focus on the music (n = 1), did not complete
(attrition bias) music protocol because of interruptions (n = 2).
All outcomes

porting bias)

Jin 2011
Methods RCT
Participants Adults with primary liver cancer
Type of cancer: liver (n = 102, 100%)
Mean age: 56.7
Informed decisions.

Jin 2011 (Continued)
Sex: not reported
Ethnicity: 100% Chinese
Setting: inpatient
Country: China
1. Music group: participants listened to taped music-guided relaxation

Music selections provided: This study used the Gaotian-Music relaxation series, which is recorded by
the Center of Music Therapy and published by the people's Liberation Army Health Audio Video Pub-
lishing House. The participants could choose any music they liked from the following 4 CDs: The Sea
Reverie, Mountain Language, The Stream Chant, Grassland Meditation
Length of sessions: for duration of surgery
Outcomes HR, RR, SBP, DBP: post-test scores
Anxiety (STAI): post-test scores
Notes —
Risk of bias
Random sequence genera- Low risk Translation sheet: Table of random numbers
Allocation concealment Unclear risk Translation sheet: not reported

(selection bias)

mance bias)
All outcomes

Objective outcomes
Blinding of outcome as- High risk Self report measures were used for subjective data
Subjective outcomes
Incomplete outcome data Low risk No subject loss

(attrition bias)
All outcomes

porting bias)
Informed decisions.

Jin 2011 (Continued)

Kwekkeboom 2003
Methods RCT
Participants Adults with cancer having noxious medical procedures such as tissue biopsy or port placement or re-
moval
Diagnosis of sample that was included in final analysis (n = 58): breast cancer (n = 17, 29%), lymphoma
(n = 17, 29%), leukemia (n = 9, 16%), colorectal cancer (n = 3, 5%), other (n = 12, 21%).
N randomized to audiobook group: 15
N analyzed in audiobook group: 14 (not included in this review)
Setting: inpatient
Country: USA
1. Music group: listening to pre-recorded music just prior to and during the procedure
Music selections provided: participants selected preferred music from a variety of music styles offered
by the researcher and listened to music through headphones
Length of sessions: duration of procedure
Pain (NRS): post-test scores
Sense of control: not included in this review
Notes Author's comment: "Patients may not want to be distracted or inattentive during the medical proce-
dure as they may have felt the need to monitor what was happening. Some patients specifically com-
mented that the music or book tape made it impossible for them to hear or focus on the surgeon"
Informed decisions.

Kwekkeboom 2003 (Continued)
Risk of bias
Allocation concealment Low risk Opaque sealed envelopes (personal communication with principal investiga-
(selection bias) tor)
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk Attrition rate: n = 2 (3%). 1 participant was excluded because he was random-
(attrition bias) ized to the audiobook group but requested music; 1 from the control group
All outcomes was excluded because the surgeon requested that music be played.

porting bias)
Other bias Low risk This work was funded by a 2001 grant from the Univeristy of Iowa, Central In-
vestment Fund for Research Enhancement

Li 2004
Methods CCT
Participants Adults with gastric cancer awaiting surgery
Diagnosis: stage II and III gastric cancer
Informed decisions.

Li 2004 (Continued)
Setting: inpatient
Country: China

Music selections provided: Chinese classical music (6 different compositions) (no further detailed pro-
vided)
Number of sessions: 2 sessions/day for 4 days pre-operatively, totaling 8 sessions
Outcomes Anxiety (Zung State Anxiety Scale, SAS): post-test scores
Notes —
Risk of bias
Random sequence genera- Unclear risk Not provided in translation of study report
Allocation concealment Unclear risk Not provided in translation of study report

(selection bias)
Blinding of participants Unclear risk Not provided in translation of study report

mance bias)
All outcomes
Objective outcomes
Subjective outcomes
All outcomes

porting bias)

Li 2012
Methods RCT
Informed decisions.

Li 2012 (Continued)
Participants Adult patients with breast cancer after radical mastectomy
N analyzed in music group: 60 at 1st post-test; 54 at 3rd post-test
N analyzed in control group: 60 at 1st post-test; 51 at 3rd post-test
Mean age: 42 years
Sex: 120 (100%) female
Setting: inpatient
Country: China
1. Music listening group: music listening via headphone

2. Control group: routine nursing care
Music selections provided: patients selected their preferred music and controlled the music volume
Number of sessions: twice daily
Outcomes Anxiety (STAI): post-test score
Pain (Short-Form of McGill Pain Questionnaire - Chinese version): post-test score
Depression (Zung Self rating Depression Scale): change score (computed by JB)
Length of hospital stay (days)
Notes —
Risk of bias
Random sequence genera- Low risk "The randomisation procedure was performed with 120 random numbers pro-
tion (selection bias) duced by a computer program and all patients were randomly allocated to
two groups: an experimental group (n = 60) and a control group (n = 60)" (p.
1178).

(selection bias)
Informed decisions.

Li 2012 (Continued)
Blinding of participants High risk Participants and personnel were not blinded. "Because of the specificity of the
and personnel (perfor- study, no blinding was used" (p. 1147)
mance bias)
All outcomes
Blinding of outcome as- High risk "Because of the specificity of the study, no blinding was used" (p. 1147)
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk "None of the participants in the experimental and control groups was lost at
(attrition bias) the first post-test. Fifty-four participants remained in the experimental group
All outcomes (six participants lost) and 51 participants remained in the control group (nine
participants lost) at the second and third post-tests, respectively. A total of 15
patients (12.5%) were lost to follow-up" (p. 1150).
Selective reporting (re- Low risk The reporting of outcomes was divided over three publications but there is no
porting bias) indications that some outcomes may have not been reported

Liao 2013
Methods RCT
Participants Advanced tumor node metastasis cancer patients
Type of cancer: tumor node metastasis
N randomized to Chinese Medicine (CM) 5-element music group: 66
N randomized to Western music group: 63 (not included in this review)
N analyzed in Chinese Medicine (CM) 5-element music group: 57
N analyzed in Western music group: 58 (not included in this review)
Sex: 83 (51.9%) female, 77 (48.1%) male
Ethnicity: not reported although likely that the majority of the participants were Chinese
Setting: inpatient
Country: China
Informed decisions.

Liao 2013 (Continued)
1. CM 5-Element music group: listening to CM 5-element music, a Chinese type of folk music
2. Western music group (not included in this review): listening to Western music
Music selections provided: participants in the CM 5-element music group were offered CM 5-element
music composed by Prof Shi Feng
Number of sessions: 1 session/day for 5 days/week for a total duration of 3 weeks
Outcomes Quality of life (Hospice Quality of Life Index-Revised (HQLI-R)) and physical functioning (KPS): change
scores
Notes Change scores were computed by JB because of significant baseline differences between the groups
Risk of bias
Random sequence genera- Low risk "SAS 9.2 statistical software was used to generate random sequence numbers
tion (selection bias) based on the 2:2:1 ratio" (p. 737)
Allocation concealment Low risk "The random allocation scheme was put into a brown envelope. When a pa-
(selection bias) tient accorded with the inclusion criteria, implementers opened the envelope
to obtain the subject's random allocation" (p. 737). "The randomized scheme
was sealed in an opaque envelope" (p. 737-738).
Blinding of participants High risk "A single-blind design was adopted in the trial, that is, the subject remained
and personnel (perfor- blinded, while the researcher knew the intervention program" (p. 738). Howev-
mance bias) er, participants knew whether they were listening to music or not thus partici-
All outcomes pants in the control group were not blinded.
Blinding of outcome as- Low risk No objective measures were included

Objective outcomes
Blinding of outcome as- High risk "A single-blind design was adopted in the trial, that is, the subject remained
sessment (detection bias) blinded, while the researcher knew the intervention program" (p. 738).Howev-
Subjective outcomes er, participants knew whether they were listening to music or not thus partici-
pants in the control group were not blinded.
Incomplete outcome data Low risk "Fourteen patients dropped out of the study. 7 patients dropped out because
(attrition bias) of aggravation to the disease condition. 7 patients withdrew voluntarily during
All outcomes the study" (p. 738). Attrition rate: 8.75%

porting bias)
Other bias Low risk Study was supported by the project of the Chinese geriatric oncology society
of the "eleventh-5 year: plan of ministry of civil affairs" (no 2008-47-2-45).

Lin 2011
Methods RCT
Informed decisions.

Lin 2011 (Continued)
Participants Adult cancer patients receiving chemotherapy
Type of cancer: lung (n = 14, 14.3%), breast (n = 40, 40.8%), other (n = 44, 44.9%)
N randomized to music group: not reported
N randomized to the verbal relaxation group: not reported
N randomized to control group:not reported
N analyzed in the verbal relaxation group: 30 (not used in this review)
Mean age: 53 years
Sex: 65 (66.3%) female, 33 (33.7%) male
Setting: outpatient
Country: Taiwan
1. Music group: the music intervention followed a 3-step guided imagery process (GIM) (McKinney 2002):
a preparation period (10 min), deep relaxation period (12 min) and music listening period (38 min)
provided by a trained practitioner
2. Verbal relaxation group (not used in this review)
Music selections provided: during the preparation period, participants listened to Songs of the Pacific
('Ambient Moods-Whale Song') including the sound of sea waves, seabirds and whales. During the deep
relaxation period, a meditation-relaxation with taped recorded verbal instructions guides the patient.
In the deep relaxation period, light music,Forest Piano with sounds of nature, such as wind, birds and
piano were played. In the music listening period, Violin Rain and Aroma Lavender were played.
Categorized as music medicine. Although the authors write that the intervention used GIM, a music
therapy intervention, the explanations provided indicate that participants listened through a pre-
recorded tape with verbal instructions rather than the intervention being implemented by a trained
music therapist.
Outcomes Anxiety (C-STAI): post-test scores
Skin temperature and behavioural state: no means and SDs reported, therefore not included in this re-
view
Notes —
Risk of bias
Informed decisions.

Lin 2011 (Continued)
Random sequence genera- Low risk "To maintain good balance, a permuted block randomisation was used to ran-
tion (selection bias) domise patients who met the inclusion criteria into experimental, comparison
or control group. A random number sequence is generated. Each possible per-
muted block is assigned a number. Using each number in the random number
sequence in turn selected the next block, determining the next participant al-
locations. The six block design contained equal proportions in each group with
randomisation to remove sequence bias" (p. 991).

(selection bias)
Blinding of participants Unclear risk "Head phones were then applied for the intervention and comparison group-
and personnel (perfor- s" (p. 992). Appears that personnel may have been blinded but this was not
mance bias) clearly reported
All outcomes

Objective outcomes
Subjective outcomes
Incomplete outcome data High risk "Equipment malfunction occurring in 12 subjects resulted in incomplete da-
(attrition bias) ta. Thirteen subjects withdrew during the study owing to complaints of music
All outcomes preference or personal needs (e.g. toileting). Ninety-eight subjects provided
data for analysis" (pp. 992-993). Attrition rate: 20.3%

porting bias)

Moradian 2015
Methods RCT
Participants Adults diagnosed with breast cancer
N randomized to Nevasic audio group: 34
N analyzed in Nevasic audio group: 34 (not used in this review)

Informed decisions.

Moradian 2015 (Continued)
Sex: n = 99 (100%) females
Setting: inpatient
Country: Iran
1. Nevasic Audio Program: listening to the Nevasic music program, an audio program that uses specially
constructed audio signals postulated to generate an antiemetic reaction (not used in this review)
Music selections provided: pre-selected music via CD player with headphones
Number of sessions: Participant daily self administered music listening
Length of sessions: not reported
Outcomes Mood (EORTC), QoL (EORTC - Global Health Status), fatigue (EORTC), nausea (EORTC), pain (EORTC),
physical functioning (EORTC): post-test scores
Notes —
Risk of bias
Random sequence genera- Low risk "The participants were randomly assigned to one of the three treatment
tion (selection bias) groups using a list (generated by nQuery Advisor program), done by a statisti-
cian who was independent of this study” (p. 283).

(selection bias)
Blinding of participants High risk Participants and personnel were not blinded.
mance bias)
All outcomes
Blinding of outcome as- Low risk No objective measures were included

Objective outcomes
Subjective outcomes
Incomplete outcome data High risk Intention to treat analysis was used. However, by day 5, there was loss to fol-
(attrition bias) low-up for 30 participants representing an attrition rate of 30%.
All outcomes

porting bias)
Informed decisions.

Moradian 2015 (Continued)
Other bias Unclear risk "The authors declare no conflicts of interest." "This work was supported in
part by funding from the Cancer Experiences Collaborative (CECo), a Research
Collaborative funded by the National Cancer Research Institute in the UK; and
Mashhad University of Medical Sciences in Iran. We are grateful to DAVAL Ltd,
UK for providing us with Nevasic CDs and CD players free of charge for the pur-
poses of this study" (p. 290).

Nguyen 2010
Methods RCT
Participants Children with cancer undergoing lumbar puncture (LP)
Diagnosis: leukemia
Mean age: 9.1 years
Ethnicity: 40 (100%) Vietnamese
Setting: inpatient
Country: Vietnam
1. Music group: listening to music via iPod and headphones

2. Control group: put on headphones connected to iPod but did not hear any music
Music selections provided: traditional Vietnamese songs and children's songs
Length of sessions: music started 10 min before LP and continued for the length of the procedure. Du-
ration of the procedure was on average 23 min
Heart rate, respiratory rate, oxygen saturation level, SBP and DBP: post-test scores
Notes Measurements for these outcomes were also obtained during the procedure and are reported in the
study report
Informed decisions.

Nguyen 2010 (Continued)
Risk of bias
Random sequence genera- Low risk Quote: "Randomization was carried out using opaque envelopes, half of which
tion (selection bias) contained a paper that said 'music' and half a paper that said 'no music' (p.
147)
Allocation concealment Low risk Quote: "Randomization was carried out using opaque envelopes, half of which
(selection bias) contained a paper that said "music" and half a paper that said "no music." (p.
147)
Blinding of participants Low risk Personnel were blinded. Quote: "The researcher and the physician did not
and personnel (perfor- know to which group the patient belonged" (p. 148). Participants were not
mance bias) blinded since they knew whether they were listening to music or not. However,
All outcomes it is unlikely that this influenced their physiological responses.
Blinding of outcome as- Low risk Blinding was used for objective outcomes. Quote: "The researcher and the
sessment (detection bias) physician did not know to which group the patient belonged. Heart rate (HR),
Objective outcomes blood pressure (BP), and oxygen saturation (SpO2) were recorded, and the res-
piratory rate (RR) was measured manually by the researcher" (p. 148).
Subjective outcomes
Incomplete outcome data Low risk The flowchart indicates no subject loss
(attrition bias)
All outcomes

porting bias)
Other bias Low risk The authors declared no conflicts of interest with respect to the authorship or
publication of this article.
The authors received no financial support for the research or authorship of

this article.

O'Callaghan 2012
Methods RCT
Participants Adult cancer patients during initial radiotherapy treatment
Type of cancer: prostate (n = 42, 42%), cervix (n = 10, 10%), endometrium (n = 9, 9%), breast (n = 7, 7%),
lung (n = 5, 5%), other (n = 27, 27%)
Informed decisions.

O'Callaghan 2012 (Continued)
Sex: 41 (41%) female, 59 (59%) male
Setting: outpatient
Country: Australia
1. Music group: standard radiotherapy session with listening to pre-recorded music

2. Control group: standard radiotherapy session without music listening
Music selections provided: participants were asked to bring their own preferred music to the first radio-
therapy session
Length of sessions: duration of the radiotherapy treatment
Outcomes Anxiety (STAI): post-test scores
Notes —
Risk of bias
Random sequence genera- Low risk "After obtaining informed consent from participants at radiotherapy planning
tion (selection bias) stage, 100 participants were randomized into control (standard radiothera-
py; no music) or intervention (standard radiotherapy plus self selected mu-
sic) arms balanced by gender using a computer-generated minimisation tech-
nique" (p. 474).
Allocation concealment Low risk Use of computer-generated minimization technique

(selection bias)
Blinding of participants High risk "The triangulation mixed method convergence model design comprised a sin-
and personnel (perfor- gle centre, non-blinded parallel group, randomized controlled trial" (p. 474).
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk "One control group and two music group participants withdrew prior to initial
(attrition bias) radiotherapy" (p. 474). Attrition rate = 3%
All outcomes
Informed decisions.

O'Callaghan 2012 (Continued)
porting bias)
Other bias Low risk "Conflict of interest: The authors have no financial disclosures" (p. 473).

Palmer 2015
Methods RCT
Participants Female cancer patients
N randomized to live music group: 69
N randomized to recorded music group: 70
N analyzed in live music group: 68
N analyzed in recorded music group: 68
Ethnicity: 150 (74.6%) white, 46 (22.9%) black, 3 (1.5%) Asian, 2 (1%) Latino
Setting: inpatient
Country: USA
1. Live music group: music therapist played preferred music pre-operatively; intraoperatively, music
therapist played therapist-selected music
2. Recorded music group: patient listened to self selected preferred music on MP3 player before the
surgery; intraoperatively, the music therapist selected the pre-recorded music
3. Control group: received usual pre-operative care. Control patients wore noise-blocking earmuffs dur-
ing surgery to cancel any possible music played by the surgeon, until the conclusion of surgery
Music selections provided: patient-preferred music
Catogorized as: music therapy
Outcomes Anesthesia requirements: the amount of propofol needed to reach sedation of Bispectral Index (BIS)
score of 70
Anxiety (Global Anxiety-VAS): change scores
Informed decisions.

Palmer 2015 (Continued)
Recovery time: recorded as the interval between surgery end time and the time when the patient had
met discharge criteria according to hospital policy and procedure, determined by the recovery nurse.
Patient satisfaction: measured with a 5-item questionnaire administered to participants orally by a

staff member before discharge, with use of a Likert scale. The questions were constructed from points
on the Consumer Assessment of Health Providers and Systems (CAHPS) Surgical Care Survey.
Notes —
Risk of bias
Random sequence genera- Low risk "Participants were randomly assigned at a 1:1:1 ratio to a control or one of two
tion (selection bias) experimental groups with use of an online randomisation module, which en-
sured adequate concealment" (p. 3163).
Allocation concealment Low risk "Participants were randomly assigned at a 1:1:1 ratio to a control or one of two
(selection bias) experimental groups with use of an online randomisation module, which en-
sured adequate concealment" (p. 3163). "A permuted block randomisation
scheme was used with random block sizes to prevent personnel from guessing
the next assignment" (p. 3163).
mance bias)
All outcomes

Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk Intention-to-treat analysis was used for all analyses. 137 patients were ran-
(attrition bias) domized to the live music or the SC group; 133 completed all measurements.
All outcomes This represents a dropout rate of 3%.

porting bias)
Other bias Low risk "Supported by Grant No. J0251, from The Kulas Foundation. Assistance with
REDCap was provided through Clinical and Translational Science Collaborative
Grant No. UL1TR 000439 at Case Western Reserve University. The Kulas Foun-
dation had no role in the design or conduct of the study; the collection, man-
agement, analysis, or interpretation of the data; the preparation, review, or
approval of the manuscript; or the decision to submit the manuscript for publi-
cation."

Pinto 2012
Methods CCT
Informed decisions.

Pinto 2012 (Continued)
Participants Adult breast cancer patients after surgery
Type of cancer: breast
Mean age: 58 years
Ethnicity: Brazilians (n = 29, 100%)
Setting: inpatient
Country: Brazil
1. Music group: listened to recorded music via headphones

2. Control group: treatment as usual
Music selections provided: recording of The Four Seasons by Vivaldi
Outcomes Anxiety (STAI), temperature, blood pressure, heart rate, respiratory rate: only means are reported. Since
no SDs are reported, we were not able to include this study in the meta-analysis.
Notes —
Risk of bias
Random sequence genera- High risk [translation] Patients whose hospital records ending with even numbers were
tion (selection bias) grouped in the experimental group.
Allocation concealment High risk Allocation concealment was not possible because of systematic method of
(selection bias) group allocation.
Blinding of participants High risk Participants and personnel were not blinded.
mance bias)
All outcomes
Blinding of outcome as- High risk No blinding was used.

Objective outcomes
Informed decisions.

Pinto 2012 (Continued)
Blinding of outcome as- Low risk This study did not include subjective outcomes.
Subjective outcomes
Incomplete outcome data Low risk There were no withdrawals.

(attrition bias)
All outcomes
Selective reporting (re- Low risk No evidence of selective reporting.

porting bias)
Other bias Low risk No conflict of interest reported.

Ratcliff 2014
Methods CCT
Participants Adult cancer patients who have undergone hematopoietic stem cell transplant
Type of cancer: leukemia (n = 57, 63.3%), lymphoma (n = 13, 14.4%), other (n = 20, 22.2%)
N randomized to music therapy group: 29
N randomized to unstructured music group: 30 (not used in this review)
N analyzed in music therapy group: 29
N analyzed in unstructured music group: 30 (not used in this review)
Sex: 47 (52%) female, 43 (48%) male
Ethnicity: 59 (65.5%) white, 7 (7.8%) African-American, 11 (12.2%) Latino, 4 (4.4%) Asian, 9 (10%) other
Setting: outpatient or inpatient in transition to outpatient setting.
Country: USA
1. Music therapy group: participants met with music therapist to select music from a researcher-provid-
ed database and music therapist created 2 CDs. The first CD was designed to transition the patient
from an anxious/tense state to a relaxed state and the second was designed to transition the patient
from a sad/depressed state to an energized state. Participants reviewed and edited CDs with the mu-
sic therapist and in the final session listened to 1 of the 2 CDs.
2. Unstructured music group: patients met with a mental health therapist and created 2 CDs with music
selected from 15 music tracks from the same database as the MT group that made them feel relaxed. In
session 2, patients selected music that made them feel energized. The tracks were organized into two
30 min CDs (1 including relaxing songs and the second including energising songs) based on personal
preference with little input from the therapist.
3. Control condition: standard care
Informed decisions.

Ratcliff 2014 (Continued)
Music selections provided: patient-preferred music selected from a researcher provided database
Categorized as music therapy trial
Outcomes Mood (POMS-Short Form): change score (computed by JB)
Quality of Life (FACIT-G and FACIT-BMT): change scores
Cancer-related symptoms (MD Anderson Symptom Inventory): not included in meta-analysis
Notes —
Risk of bias
Random sequence genera- Unclear risk "Patients were randomly assigned to one of three groups: (1) ISO-principle
tion (selection bias) music therapy (MT) group, (2) unstructured music (UM) group, and (3) usual
care (UC) control group" (p. 2).

(selection bias)
Blinding of participants Low risk Blinding of music therapist and participants was not possible.
mance bias)
All outcomes
Blinding of outcome as- Low risk This study did not include objective outcomes.
Objective outcomes
Subjective outcomes
Incomplete outcome data High risk At the 1 week follow-up, there was 8.4% attrition. At the 4 week follow-up,
(attrition bias) there was 27% attrition (additional data received from Dr. Lorenzo)
All outcomes
Selective reporting (re- High risk "...blood samples were drown but results will be reported in future manuscrip-
porting bias) t." (p. 3).
Other bias Low risk "This research was funded in part by a grant from The Maurice Amado Foun-
dation, by Cancer Center Support Grant CA016672 from the National Institutes
of Health, and by a cancer prevention fellowship for Chelsea Ratcliff support-
ed by the National Cancer Institute Grant R25T CA057730, Shine Chang, Ph.D.,
Principal Investigator" (p. 8).

Robb 2008
Methods CCT
Informed decisions.

Robb 2008 (Continued)
Participants Children with cancer
Diagnosis: no further details provided
N randomized to active music engagement group: 27
N randomized to music listening group: 28 (not included in this review)
N analyzed in active music engagement group: 27
N analyzed in music listening group: 28 (not included in this review)
N analyzed in audiobook control group: 28
Mean age: not reported
Sex: not reported
Setting: inpatient
Country: USA
1. Active Music Engagement group: greeting song (adapted version of the song 'Willoughby Wallaby
Woo', which incorporated the child's name and encouraged manipulation of a stuffed vinyl monkey),
instrument playing (choice of hand-held rhythm instruments played to live music), action songs (fin-
ger puppets, props, and sound effect instruments used with the songs 'Five Little Speckled Frogs' and
'Five Little Monkeys'), illustrated songs in storybook form ('Wheels on the Bus' and 'Down by the Bay'),
and closing song (an original song 'Time to Say Good-Bye', which included choice of sound effects)
2. Audiobook control group: listening to 2 audiobooks with illustrated storybooks
Music selections provided: children's songs
Outcomes Positive affect (behavioral form): post-test scores
Active engagement (behavioral form): post-test scores
Initiation (behavioral form): post-test scores
Notes —
Risk of bias
Random sequence genera- High risk Quote: "[P]articipants were not allocated to the research conditions at ran-
tion (selection bias) dom, but were sequentially assigned to one of three study conditions" (Erra-
tum published online).
Informed decisions.

Allocation concealment High risk Quote: "Participants were sequentially assigned one of three study conditions.
(selection bias) Assignment was done in the same manner at each hospital to maintain an
equal number of participants in each condition across all sites."
Blinding of participants Low risk The music therapist could not be blinded given the interactive nature of the
and personnel (perfor- music therapy session. It is unclear whether the children were blinded to the
mance bias) purpose of the study.
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data High risk No data records were kept on number of subjects approached, consented and
(attrition bias) withdrawn (personal communication with principal investigator)
All outcomes

porting bias)
Other bias Low risk "This research study was sponsored through a National Academy of Recording
Arts and Sciences (NARAS) grant awarded to the American Music Therapy Asso-
ciation (AMTA). This study received additional support through an institutional
post-doctoral fellowship, CA 117865-O1A1.

Robb 2014
Methods RCT
Participants Adolescents and young adults undergoing hematopoietic stem cell transplant
Type of cancer: leukemia ( n = 53, 46.4%), lymphoma ( n = 28, 25.0 %), solid tumor ( n = 32, 28.6%)
Sex: 42.5% female, 57.5% male
Ethnicity: 12 (10.6%) African-American, 66 (58.4%); white, 23 (20.4%); mixed ethnicity, 7 (6.2%); other, 5
(4.4%);
Setting: inpatient
Country: USA
Informed decisions.

1. Music therapy group: participants engaged in a therapeutic music video intervention that involved
writing songs and creating accompanying music videos
2. Control group: participants listened to fiction or non-fiction audiobooks
Music selections provided: participants created their own songs with the music therapist
Length of sessions: not reported
Outcomes Illness-related distress (McCorkle Symptom Distress Scale), coping (Jalowiec Coping Scale-Revised),
spiritual perspective (Reed Spiritual Perspective Scale); social integration (Perceived Social Support),
family environment (Family Adaptability/Cohesion Scale), hope-derived meaning (Herth Hope Index),
self transcendence (Reed Self Transcendence Scale), and resilience (Haase Resilience in Illness Scale):
effect sizes
Notes Effect sizes were reported in the publication. No means or SDs were reported.
Risk of bias
Random sequence genera- Low risk "Participants were randomised to the TMV or low-dose, control group using 24
tion (selection bias) strata (8 sites individually stratified by 3 age groups: 11-14, 15- 18, and 19-24
years)" (p. 911).
Allocation concealment Low risk "We used central randomisation by a third party. So after a participant com-
(selection bias) pleted the baseline measures, the computer triggered randomisation. The
project manager is then notified electronically (e-mail generation) about the
participant's group assignment" (personal communication with investigator).
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data High risk "An intent-to-treat analysis was performed in which all available question-
(attrition bias) naire data at T2 and T3 were used, and participants were analysed according
All outcomes to their assigned group regardless of their degree of adherence to the proto-
cols for the intervention and low-dose control groups" (p. 913-914). Dropout
rate was 28% at T2 and 41% at T3.

porting bias)
Informed decisions.

Other bias Low risk "This work as funded by the National Institute of Nursing Research
(R01NR008583) and the National Cancer Institute (U10CA098543 and
U10CA095861)" (p 916)

Romito 2013
Methods CCT
Participants Adult breast cancer patients receiving chemotherapy
Type of cancer: localized tumor (n = 50, 80.6%), metastatic tumor (n = 12, 19.4%)
Setting: outpatient
Country: Italy
1. Music therapy group: active singing

2. Control group: treatment as usual
Music selections provided: active singing using vocal holding techniques
Outcomes Depression, anxiety, anger, stress, need for help: only means were reported (no standard deviations).
Therefore the results could not be included in the meta-analysis.
Notes —
Risk of bias
Random sequence genera- High risk "The patients gave informed consent to participate and were quasi-randomly
tion (selection bias) assigned to the experimental and control arms of the study" (p. 439).
Informed decisions.

Romito 2013 (Continued)
"On Mondays and Wednesdays of each week, the first consecutive eligible pa-
tients of the day who gave their informed consent to participate in the study
were placed in the same room for chemotherapy infusion and took part in the
experimental group. On Tuesdays and Thursdays the same procedure was
followed and these patients were assigned to the control groups. 31 patients
were allocated to the experimental group and 31 to the control group" (p. 439).

(selection bias)
Blinding of participants Low risk Blinding of music therapist and participants was not possible
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Unclear risk Not reported

(attrition bias)
All outcomes

porting bias)
Other bias Low risk "The authors declare that there is no conflict of interest" (p 443)

Rosenow 2014
Methods RCT
Participants Adult patients recovering from a bone marrow transplant
Type of cancer: leukemia (n = 12, 66.7%), multiple melanoma (n = 5, 27.8%), unknown (n = 1, 5.6%)
N analyzed in control group:10
Sex: 100% female
Ethnicity: 2 (11.1%) African-American, 1 (5.6%) Asian-American, 14 (77.8%) white, 1 (5.6%) Latino
Setting: inpatient
Informed decisions.

Rosenow 2014 (Continued)
Country: USA
1. Music therapy group: patient-preferred music

Music selections provided: music therapist played patient-preferred live music with guitar and voice
Outcomes Fatigue (The Brief Fatigue Inventory): change scores
Notes This manuscript included 2 studies. Only the second study is used in this review as the first study was
not an RCT or CCT
Risk of bias
Random sequence genera- Low risk "After obtaining consent to participate in the study, the researchers consult-
tion (selection bias) ed a randomized list to ascertain each participant’s condition in the study" (p.
68).
Allocation concealment High risk Not reported

(selection bias)
Blinding of participants Low risk Blinding of music therapist and participants was not possible.
mance bias)
All outcomes
Objective outcomes
Subjective outcomes

(attrition bias)
All outcomes
Selective reporting (re- Unclear risk No evidence of selective reporting.

porting bias)
Other bias Low risk No conflict of interests reported

Shaban 2006
Methods CCT
Informed decisions.

Shaban 2006 (Continued)
Participants Adults with cancer with pain
Diagnosis: no further details available in translation of study report
Sex: not reported
Setting: unclear if inpatient or outpatient (treatment provided in hospital)
Country: Iran

2. Control group: progressive muscle relaxation (taught by the investigator)
Music selections provided: 3 types of music (no further detail provided in translation of study report)
Outcomes Pain (VAS): post-test scores
Notes —
Risk of bias
Random sequence genera- High risk Alternate assignment. Quote: "The first patient included in one group and sec-
tion (selection bias) ond person to another group" (personal communication with principal investi-
gator)
Allocation concealment High risk Alternation method

(selection bias)
mance bias)
All outcomes
Objective outcomes
Informed decisions.

Shaban 2006 (Continued)
Subjective outcomes
Incomplete outcome data Unclear risk No dropouts reported. However, it is unlikely that no attrition occurred in a
(attrition bias) study with this sample size.
All outcomes

porting bias)
Other bias Unclear risk Funding information and conflict of interest statement are not provided in the
translation of the study report

Smith 2001
Methods RCT
Participants Adults with cancer receiving radiation therapy
Diagnosis: prostate (n = 24, 55%), lung (n = 6, 14%), head or neck (n = 4, 9%), colorectal (n = 4, 9%),
squamous cell skin (n = 2, 5%), stomach (n = 1, 2%), melanoma (n = 1, 2%)
Sex: 42 (100%) males
Ethnicity: 31 (74%) white, 5 (12%) black, 5 (12%) Latino, and 1 (2%) other
Setting: outpatient
Country: USA
1. Music group: listening to pre-recorded music selected by the participants

Music selections provided: participants were asked to select from rock and roll, big band, country and
western, classical, easy listening, Spanish, or religious music
Number of sessions: daily for duration of treatment
Outcomes Anxiety (STAI-S): post-test scores after 1 week of music interventions
Informed decisions.

Smith 2001 (Continued)
Notes Post-test scores for week 3 and week 5 are also reported
Risk of bias
Random sequence genera- Low risk Quote: "A biostatistician prepared a randomisation list using a computer. On-
tion (selection bias) ly one member of the research team had access to this list of case numbers
and randomisation assignments, which was maintained in a locked filing cabi-
net" (p. 856).
Allocation concealment Low risk Central randomization. Quote: "At the time the patient agreed to participate
(selection bias) in the study and the consent form was signed, the research associate called
the registrar to obtain the patient's assigned case number and randomisation
group."
Blinding of participants Unclear risk Participants were not blinded. It is unclear whether the personnel were blind-
and personnel (perfor- ed.
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk Attrition rate: 5% Quote:"Two patients, one from each group, were excluded
(attrition bias) from final analysis because of incomplete data".
All outcomes

porting bias)
Other bias Low risk This study was supported, in part, by a grant from Sigma Theta Tau, Delta Beta
Chapter, of the
College of Nursing at the University of South Florida.

Stordahl 2009
Methods CCT
Participants Women at the completion of treatment for breast cancer

Informed decisions.

Stordahl 2009 (Continued)
Ethnicity: n = 9 (45%) Latino, n = 6 (30%) white, n = 5 (25%) African-American/Caribbean black
Setting: outpatient
Country: USA
Interventions 2 treatment conditions:
1. Music therapy condition: music-assisted relaxation

2. Relaxation condition: relaxation directive
Music selections provided: contemporary sedative music was paired with standard spoken relaxation
directives
Categorized as music therapy trial
Outcomes Depression [Center for Epidimiologic Diseases - Depression Scale (CES-D)]: post-test scores
Mood (POMS - Short Form): post-test scores
Notes —
Risk of bias


(selection bias)
Blinding of participants Low risk Participants and personnel could not be blinded
mance bias)
All outcomes
Blinding of outcome as- Low risk This study did not include objective measures
Objective outcomes
Subjective outcomes

(attrition bias)
All outcomes
Informed decisions.

Stordahl 2009 (Continued)
Selective reporting (re- Low risk No indication of selective reporting
porting bias)
Other bias Low risk No indication of conflict of interest

Straw 1991
Methods RCT
Diagnosis: no further details provided
Mean age: 49 years
Setting: unclear if inpatient or outpatient
Country: USA

2. Control group: listening to guided imagery and relaxation tape
Music selections provided: a music tape was created by the researcher. If the participants disliked the
music, they could listen to a tape of their own.
Number of sessions: participants listened to tape during chemotherapy treatments and at home. Par-
ticipants were encouraged to listen to the tape each day.
QoL (Functional Living Index): post-test scores
Level of control: not included in this review
Notes —
Risk of bias
Informed decisions.

Straw 1991 (Continued)
Random sequence genera- Low risk Quote: "Random assignment of subjects to condition involved choosing pieces
tion (selection bias) of paper from a box. Half of the pieces had 'one' written on them, and half
a 'two'. In this way, subjects had an equal chance being assigned to either
group".
Allocation concealment Low risk Not reported but we assume that lots were drawn in the presence of the sub-
(selection bias) jects.
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
All outcomes

porting bias)
Other bias Low risk —

Vachiramon 2013
Methods RCT
Participants Adults with skin cancer
Type of cancer: skin (100%)
Sex: 33 (33%) female, 67 (67%) male
Informed decisions.

Vachiramon 2013 (Continued)
Setting: inpatient
Country: USA
1. Music group: music listening via open speaker for duration of procedure
Music selections provided: patients chose a musical genre, artist, or track, which was entered into inter-
net radio (Pandora Media, Inc., Oakland, CA), which creates a mix of music according to the listener's
preferences
Outcomes Anxiety (STAI): post-test scores
Notes —
Risk of bias
Random sequence genera- Low risk "Using a randomisation table (a table of random numbers), eligible subjects
tion (selection bias) were randomly assigned into one of two groups: a control group with no
music or a treatment group that listened to the music of their choice during
surgery" (p. 299).

(selection bias)
Blinding of participants High risk Blinding of participant was not possible. Personnel was not blinded. "This
and personnel (perfor- study was designed as an open-labelled randomized controlled trial" (p. 299).
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk No attrition

(attrition bias)
All outcomes

porting bias)

Informed decisions.

Wan 2009
Methods RCT
Participants Adult cancer patients with pain
Diagnosis: cancer of the lung, liver, gastrointestinal, lymphoma
Ethnicity: 136 (100%) Chinese (Han)
Setting: inpatient
Country: China
1. Music group: music and imagery

Music selections provided: no details on the music reported
Outcomes Depression (Center for Epidemiologic Studies Depression Scale, CES-D): post-test scores
Anxiety (STAI-S): post-test scores
Notes —
Risk of bias
Random sequence genera- Low risk Translation quote: "Simple randomizations"

Allocation concealment High risk Not used

(selection bias)
Informed decisions.

Wan 2009 (Continued)
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
All outcomes

porting bias)

Wang 2015
Methods RCT
Participants Adults after surgery for lung cancer
Type of cancer: lung (n = 60, 100%)
Mean age: 53.65
Setting: inpatient
Country: China
1. Music therapy group: music listening with music imagination

2. Control group: standard pre- and postoperative care
Informed decisions.

Wang 2015 (Continued)
Music selections provided: Western classical music and Chinese music
Number of Sessions: 5 pre-surgery music-assisted relaxation and 4 postsurgery in ICU
Length of Sessions: pre-surgery 15 min, postsurgery 1 h
Outcomes Pain Self Rating Anxiety Scale (SAS) and visual analogue scale (VAS): pre-test, post-SBP, DBP, heart rate
(HR), pulse oxygen saturation (SpO2), respiratory rate, SAS score, VAS score, drug dose, and total con-
sumption of sufentanil at 4, 8, 12, 16, 20, and 24 h were recorded postoperatively
Notes —
Risk of bias
Random sequence genera- Low risk "Consecutive patients were recruited and randomly assigned to the MT group
tion (selection bias) and control (C) group by using a random-numbers table and sealed sequential
envelopes prepared by an independent statistician" (p. 668).
Allocation concealment Low risk "Consecutive patients were recruited and randomly assigned to the MT group
(selection bias) and control (C) group by using a random-numbers table and sealed sequential
envelopes prepared by an independent statistician" (p. 668).
mance bias)
All outcomes
Blinding of outcome as- Low risk For objective outcomes, the following is reported: "All postoperative measure-
sessment (detection bias) ments were evaluated and confirmed by two independent observers. Obser-
Objective outcomes vations were compared between them, and differences were solved by discus-
sion." (p. 669). Therefore rating of low risk for objective outcomes
Subjective outcomes
Incomplete outcome data Low risk There were no withdrawals

(attrition bias)
All outcomes

porting bias)
Other bias Unclear risk "The study was funded by grant no. 2012FJ2004 from the Department of
Science and Technology of Hunan Province, China". "No competing financial
interests exist" (p. 672)

Xie 2001
Methods CCT (randomization method unclear)
Informed decisions.

Xie 2001 (Continued)
Diagnosis: no further details available in the translation of the study report
Sex: not reported
Setting: not reported
Country: China
1. Music group: music and imagery

Music selections provided: no details provided
Number of sessions: 2 times per day for 20 days
Outcomes Physical functioning (Karnofsky Performance Scale): post-test scores
QoL (QoL Questionnaire for Chinese cancer patients): change scores were computed by JB to allow for
computation of pooled effect size (SMD) with other studies that reported change scores
Notes —
Risk of bias


(selection bias)
mance bias)
All outcomes
Informed decisions.

Xie 2001 (Continued)
Objective outcomes
Subjective outcomes
All outcomes

porting bias)

Yates 2015
Methods RCT
Participants Adult
Type of cancer: appendix (n = 1, 3%), bladder (n = 1, 3%), breast (n = 2, 7%), colon/rectal (n = 5, 19%), li-
posarcoma (n = 1, 3%), melanoma (n = 1, 3%), ovarian (n = 2, 7%), pancreatic (n = 1, 3%), papillary (n =
1, 3%), tumor (reported as such in article, no further detail is provided) (n = 2, 7%), uterine (n = 3, 11%),
other (n = 6, 23%)
Mean age: 57.59
Sex: 22 ( 84 % ) females, 4 ( 15 %) males
Ethnicity: 2 (7%) Latino, 21 (80%) white, 3 (11%) other
Setting: inpatient
Country: USA
1. Music therapy group: music therapist played patient-preferred live music as a receptive technique
2. Control group: when a participant was randomized to the control group, she or he had no contact
with the PI for 20-30 min. Music therapist returned after this time administered the post-test and then
provided music therapy
Music selections provided: patient-preferred live music
Number of sessions:1
Informed decisions.

Yates 2015 (Continued)
Outcomes 6 mood states measured by the Quick Mood Scale (QMS), namely wide awake/drowsy, relaxed/anxious,
cheerful/depressed, friendly/aggressive, clearheaded/confused, well-coordinated/clumsy. Only the re-
laxed/anxious and cheerful/depressed states are included in this review: post-test scores
Notes Means and standard errors are reported in the journal article. Standard deviations were obtained from
the primary author.
Risk of bias
Random sequence genera- Low risk “We used a computer program on randomizer.org to create a series of 0 and
tion (selection bias) 1. A 0 meant a participant was in the control group” (personal communication
with chief investigator).
Allocation concealment High risk No allocation concealment used (personal communication with chief investi-
(selection bias) gator).
Blinding of participants Low risk Music therapist and participants could not be blinded.
mance bias)
All outcomes
Blinding of outcome as- Low risk This study did not include objective outcomes.
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk Out of 26 participants, 4 were lost: “Four participants were not included in da-
(attrition bias) ta analyses as two participants fell asleep,one participant had a visit from the
All outcomes doctor, and one participant did not complete the form correctly" (p. 59). Attri-
tion rate: 8.5%.

porting bias)
Other bias Low risk No conflict of interest reported.

Zhao 2008
Methods RCT
Participants Adults with cancer undergoing radiation therapy
Diagnosis: cancer of the lung, esophogus, gastric, liver, breast, ovary, uterine, renal, bladder, ureter
Informed decisions.

Zhao 2008 (Continued)
Ethnicity: 95 (100%) Chinese (Han)
Setting: outpatient
Country: China
1. Music group: listening to pre-recorded music during radiation therapy

Music selections provided: sacred music (Buddhism and Christianity), Chinese classical music, Western
classical music, or yoga music
Outcomes Anxiety (Zung State Anxiety Scale): post-test scores
Anxiety (Hamilton Anxiety Scale, HAMA): not included in this review
HR, RR, SBP, DBP: post-test scores
Notes —
Risk of bias
Random sequence genera- Low risk Drawing of lots

Allocation concealment High risk Not used

(selection bias)
mance bias)
All outcomes
Objective outcomes
Subjective outcomes
Informed decisions.

Zhao 2008 (Continued)
All outcomes

porting bias)

Zhou 2015
Methods RCT
Participants Adults with breast cancer (n = 170, 100%)
Setting: Inpatient
Country: PR China
1. Music group: patients selected their preferred music from list compiled by researchers, patient con-
trolled volume and listened through a headphone connected to the MP3 player.
2. Control group: routine nursing care
Music selections provided: Chinese relaxation music, classical folk music, religious music
Number of sessions: Not reported
Outcomes Depression (Zung Self rating Depression Scale, ZSDS)
Anxiety (State Anxiety Inventory, SAI)
Notes —
Informed decisions.

Zhou 2015 (Continued)
Risk of bias
Random sequence genera- Low risk "The patients were randomly allocated to two groups using 170 random num-
tion (selection bias) bers produced by computer software" (p. 55).

(selection bias)
mance bias)
All outcomes
Blinding of outcome as- Low risk This study did not include objective outcomes
Objective outcomes
Subjective outcomes
Incomplete outcome data Low risk There were no withdrawals

(attrition bias)
All outcomes

porting bias)
Other bias Low risk "We thank the Dreyfus Health Foundation, New York for funding this study" (p
59).
ANC: absolute neutrophil count;BIS: Bispectral Index; BMGIM: Bonny Method of Guided Imagery and Music CCT: controlled clinical trial;
CM: Chinese medicine; DBP: diastolic blood pressure; EORTC: European Organization for Research and Treatment on Cancer; FACIT-
BMT/G/Sp: Functional Assessment of Chronic Illness Therapy-Bone Marrow Transplant/General/Spiritual; GIM: guided imagery and music;
HADS: Hospital Anxiety and Depression Scale; HAMA: Hamilton Anxiety Scale;HR: heart rate;ICU: intensive care unit; KPS: Karnofsky
Performance Scale; LP: lumbar puncture; MAP: mean arterial pressure; MM: music medicine; MT: music therapy; NRS: numeric rating scale;
PI: principal investigator; POMS: Profile of Mood States; QoL: quality of life; RBC: red blood cell; RCT: randomized controlled trial; RR:
respiration rate; SAS: State Anxiety Scale; SBP: systolic blood pressure; SC: standard care;SCT: stem-cell transplantation; SD: standard
deviation; STAI-S: Spielberger State-Trait Anxiety Inventory - State Anxiety form; TMV: therapeutic music video; VAS: visual analogue scale;
WBC: white blood cell.

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion
Akombo 2006 Not RCT/CCT
Allen 2010 Study with cancer survivors - not population of interest
Ardila 2010 Not RCT/CCT
Augé 2015a Not population of interest
Augé 2015b Not RCT/CCT
Informed decisions.

Bailey 1983 Not RCT/CCT
Barrera 2002 Not RCT/CCT
Barry 2010 Standard care control group was allowed to listen to music (authors state that otherwise they
would not have been able to obtain ethics approval), and 4 out of 6 pediatric patients did. If all pa-
tients had opted to listen to music, we could have included this study in the music therapy versus
music medicine comparison.
Boldt 1996 Not RCT or CCT
Bozcuk 2006 Not RCT or CCT
Bunt 1995 Not RCT or CCT
Burke 1997 Sample included participants with malignant as well as benign tumours
Burns 2001b Not RCT/CCT
Canga 2012 Not RCT/CCT
Capitulo 2015 Not RCT/CCT; summary article of the Nguyen 2010 study
Cermak 2005 Severe confounding issues with study design: the music group received 2 sessions whereas the
control group only received 1. In addition, only post-test data were obtained in this small scaled
study; therefore we could not ascertain baseline equivalence between groups.
Chi 2009 No music intervention
Cuenot 1994 Not RCT/CCT
Domingo 2015 Used non-standardized measurement tools. The authors used a standardized scale (HADS) to mea-
sure anxiety and depression but reported a total score for the scale whereas this scale's scoring
guidelines explicitly state that only subscale total scores (one for anxiety and one for depression)
should be used.
Dvorak 2015 Study included cancer patients and their caregivers. Statistics are reported per treatment arm for
patients and caregivers combined. Separate statistics are reported for cancer patients in the exper-
imental group but not for those in the control group.
Ezzone 1998 Insufficient data reporting; attempts to contact authors unsuccessful
Flaugher 2002 Not RCT/CCT
Frank 1985 Not RCT/CCT
Furioso 2002 Not RCT or CCT
Hasenbring 1999 Insufficient data reporting; attempts to contact authors unsuccessful
Hogenmiller 1986 Unacceptable methodological quality: there were important pain-related differences between
the 2 groups at pre-test. For example, there was unequal distribution of different procedures with
the music group, which had significantly more biopsy procedures than the control group. Be-
cause biopsy procedures are more painful than other procedures included in the study, the author
flagged this as a serious confounding variable. In addition, the amount of time that the patient lis-
Informed decisions.


tened to music was not controlled. The author stated that some patients only listened for 30 sec-
onds prior to procedure.
Huang 2000 Not RCT/CCT
Jourt-Pineau 2012 Not RCT/CCT
Jourt-Pineau 2013 Not RCT/CCT
Karagozoglu 2013 Not intervention of interest
Kemper 2008 Not RCT/CCT
Lee 2000 Not RCT/CCT
Lee 2012 Insufficient data reporting; study report includes graphic representation of results but does not in-
clude means and standard deviations
Liu 2014 This is poster abstract. Multiple attempts to contact author to get additional data unsuccessful
Na Cholburi 2004 Article cannot be located. We requested the article through our interlibrary loan departments and
through our Cochrane Review Group. These attempts were unsuccessful. We then googled the in-
vestigator and e-mailed her to request the research report. We sent 3 email requests over a period
of 8 months but received no response.
Nakayama 2009 Not RCT/CCT
Pfaff 1989 Not RCT/CCT
Pienta 1998 Not RCT/CCT
Robinson 2009 Not RCT/CCT
Rose 2008 Not RCT/CCT
Sadat 2009 Not RCT/CCT
Sahler 2003 Not RCT/CCT
Schur 1987 Not RCT/CCT
Sedei 1980 Thesis cannot be located; attempts to contact author unsuccessful
Standley 1992 Not RCT/CCT
Stark 2012 Not population of interest
Tan 2008 Unacceptable methodological quality; control group exposed to background music
Thompson 2011 Not RCT/CCT
Tilch 1999 Not RCT or CCT
Vohra 2011 Not RCT/CCT
Walden 2001 Not RCT/CCT
Informed decisions.

Washington 1990 Not RCT/CCT
Weber 1997 Not RCT/CCT
Whitney 2013 Not RCT/CCT
Wurr 2000 Not RCT/CCT (personal communication with principal investigator)
Yildirim 2007 Not RCT/CCT
Zimmernam 1989 Not RCT/CCT
CCT: controlled clinical trial; HADS: Hospital Anxiety and Depression Scale; RCT: randomized controlled trial.

Characteristics of studies awaiting assessment [ordered by study ID]

Bro 2013
Methods RCT
Participants Adults newly diagnosed with malignant lymphoma and planned first line chemotherapy treatment
Interventions Patient-preferred live music during chemotherapy session compared with patient-preferred taped
music during chemotherapy compared with usual care during chemotherapy only
Outcomes Mental health (anxiety and distress), nausea, serum catecholamines, and QoL
Notes Results are not yet published (personal communication with investigator)

Dileo 2015
Methods RCT
Participants Adult cancer patients with chronic pain
Interventions Music entrainment compared to preferred recorded music
Outcomes Pain, vital signs, medication usage, quality of life and medication side effects
Notes Study has been completed but findings are not yet available

Duong 2013
Methods RCT
Participants Adult patients with multiple myeloma or lymphoma (Hodgkin's or non-Hodgkin's) who are under-
going ASCT
Interventions Music therapy versus standard care
Outcomes Primary outcomes: nausea and pain

Informed decisions.

Duong 2013 (Continued)
Secondary outcomes: mood disturbance, quality of life, use of morphine-equivalent dose of nar-
cotic medications
Notes Study has been completed but findings are not yet available (personal communication with co-in-
vestigator)

NCT00086762
Methods RCT
Participants Patients who are undergoing chemotherapy for newly diagnosed solid tumors
Interventions Mindfulness relaxation compared with relaxing music and standard symptom management educa-
tion
Outcomes Conditioned and nonconditioned nausea and vomiting, mental health (anxiety, depression, and
distress), QoL (cancer-related symptoms, fatigue, sleep, and pain), and immune function
Notes Study has been completed but findings are still not available (personal communication with PI)

NCT02150395
Methods RCT
Participants Newly diagnosed patients with breast cancer, and newly diagnosed patients with head and neck
cancer
Interventions Music therapy compared with no intervention control
Outcomes Mental health (anxiety and distress)
Notes Article is in press. Authors cannot provide results at this time because of embargo (Personal com-
munication with authors)

NCT02639169
Methods RCT
Participants Adult patients undergoing hematopoietic stem cell transplantation
Interventions Apply live music in group format compared with standard treatment
Outcomes Mental health (distress)
Notes We have been unsuccessful in locating the principal investigator to obtain trial results

Informed decisions.

O'Brien 2010
Methods RCT mixed methods
Participants Adult patients with cancer
Interventions Guided Original Lyrics and Music (GOLM) songwriting
Outcomes Mood, distress levels, QoL, and satisfaction with hospital stay
Notes Study has been completed but has not yet been published. We attempted multiple times to obtain
the full text dissertation from the investigator but have not received this from the investigator.
ASCT: autologous stem cell transplant; PI: principal investigator; QoL: quality of life; RCT: randomized controlled trial.

Characteristics of ongoing studies [ordered by study ID]

NCT02261558
Trial name or title Effects of clinical music improvisation on resiliency in adults undergoing infusion therapy
Methods RCT
Participants Adults diagnosed with breast cancer, lung cancer, or gastrointestinal cancer
Interventions Instrumental improvisational music therapy compared with vocal improvisational music therapy
compared with standard care
Outcomes Mental health (resilience, anxiety, stress, and depression), pain
Starting date June 2011
Contact information [email protected]
Notes Anticipated completion date: June 2018

NCT02583126
Trial name or title Guided imagery and music for the reduction of side effects of chemotherapy in teenagers
Methods RCT
Participants Teenagers receiving chemotherapy for cancer treatment
Interventions Guided imagery and music, chemotherapy, and standard care compared with chemotherapy and
standard care
Outcomes Acute nausea, distress regarding nausea, amount of nausea reducing medicine consumed,
chemotherapy side effects, acute vomiting, pain, days to absolute neutrophil count recovery, dura-
tion of fatigue, distress regarding fatigue, food intake, weight, sense of coherence, and satisfaction
with music intervention
Starting date 2014
Informed decisions.

NCT02583126 (Continued)
Notes 2017

NCT02583139
Trial name or title The effect and meaning of designed music narratives on anticipatory, acute, and delayed side ef-
fect of chemotherapy in children (7-12 years) with cancer: a randomized controlled multisite study
Methods RCT
Participants Children (7-12 years old) with cancer who are receiving chemotherapy
Interventions 4 music narratives for children each comprising an introductory relaxation exercise, a resource-ori-
ented narrative including guided imagery suggestions and relaxing nature scenarios plus specially
composed music
Outcomes Duration (min) and intensity of acute nausea, frequency of vomiting, fatigue, pain, food intake,
weight
Starting date 2014
Notes Anticipated completion date: 2018
RCT: randomized controlled trial.

DATA AND ANALYSES

Comparison 1. Music intervention plus standard care versus standard care alone
Outcome or subgroup title No. of No. of Statistical method Effect size

studies partici-
pants
1 Anxiety (STAI) 13 Mean Difference (IV, Random, 95% CI) Subtotals only
1.1 All studies 13 1028 Mean Difference (IV, Random, 95% CI) -8.54 [-12.04, -5.05]
1.2 Sensitivity analysis 11 929 Mean Difference (IV, Random, 95% CI) -8.64 [-12.50, -4.79]
2 Anxiety (non-STAI (full version) 6 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
measures)
2.1 All studies 6 449 Std. Mean Difference (IV, Random, 95% CI) -0.71 [-0.98, -0.43]
2.2 Sensitivity analysis 3 157 Std. Mean Difference (IV, Random, 95% CI) -0.80 [-1.44, -0.16]
3 Anxiety (intervention subgroup) 18 1457 Std. Mean Difference (IV, Random, 95% CI) -0.94 [-1.34, -0.55]
3.1 Music therapy studies 3 111 Std. Mean Difference (IV, Random, 95% CI) -0.62 [-1.01, -0.24]
Informed decisions.


studies partici-
pants
3.2 Music medicine studies 15 1346 Std. Mean Difference (IV, Random, 95% CI) -1.00 [-1.45, -0.55]
4 Anxiety (music preference) 13 1142 Std. Mean Difference (IV, Random, 95% CI) -0.88 [-1.28, -0.47]
4.1 Patient-preferred music 10 860 Std. Mean Difference (IV, Random, 95% CI) -0.86 [-1.38, -0.34]
4.2 Researcher-selected music 3 282 Std. Mean Difference (IV, Random, 95% CI) -0.89 [-1.43, -0.35]
5 Anxiety (music-guided relax- 14 1306 Std. Mean Difference (IV, Random, 95% CI) -0.98 [-1.44, -0.51]
ation)
5.1 Music-guided relaxation stud- 4 476 Std. Mean Difference (IV, Random, 95% CI) -1.61 [-2.56, -0.65]
ies
5.2 Listening to music only 10 830 Std. Mean Difference (IV, Random, 95% CI) -0.71 [-1.16, -0.26]
6 Depression 7 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
6.2 Sensitivity analysis 6 541 Std. Mean Difference (IV, Random, 95% CI) -0.37 [-0.79, 0.05]
7 Depression (intervention sub- 7 723 Std. Mean Difference (IV, Random, 95% CI) -0.40 [-0.74, -0.06]
group)
7.1 Music therapy studies 3 130 Std. Mean Difference (IV, Random, 95% CI) -0.11 [-0.46, 0.24]
7.2 Music medicine studies 4 593 Std. Mean Difference (IV, Random, 95% CI) -0.57 [-1.03, -0.10]
8 Depression (music preference) 4 505 Std. Mean Difference (IV, Random, 95% CI) -0.60 [-1.04, -0.16]
8.2 Researcher-selected music 2 230 Std. Mean Difference (IV, Random, 95% CI) -0.32 [-0.84, 0.19]
9 Mood 5 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
9.1 All studies 5 236 Std. Mean Difference (IV, Random, 95% CI) 0.47 [-0.02, 0.97]
9.2 Sensitivity analysis 4 192 Std. Mean Difference (IV, Random, 95% CI) 0.57 [-0.03, 1.18]
10 Mood (intervention subgroup) 5 236 Std. Mean Difference (IV, Random, 95% CI) 0.47 [-0.02, 0.97]
10.1 Music therapy studies 2 104 Std. Mean Difference (IV, Random, 95% CI) 0.37 [-0.13, 0.87]
10.2 Music medicine studies 3 132 Std. Mean Difference (IV, Random, 95% CI) 0.55 [-0.37, 1.47]
11 Pain 7 528 Std. Mean Difference (IV, Random, 95% CI) -0.91 [-1.46, -0.36]
12 Pain (music preference) 6 496 Std. Mean Difference (IV, Random, 95% CI) -0.92 [-1.53, -0.30]
Informed decisions.


studies partici-
pants
12.2 Researcher-selected music 2 176 Std. Mean Difference (IV, Random, 95% CI) -0.59 [-1.34, 0.15]
13 Fatigue 6 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
13.2 Sensitivity analysis 5 203 Std. Mean Difference (IV, Random, 95% CI) -0.20 [-0.48, 0.08]
14 Physical functioning 4 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
14.2 Sensitivity analysis 3 233 Std. Mean Difference (IV, Random, 95% CI) 0.08 [-0.18, 0.34]
15 Heart rate 8 Mean Difference (IV, Random, 95% CI) Subtotals only
16 Heart rate (music preference) 7 539 Mean Difference (IV, Random, 95% CI) -3.77 [-6.97, -0.58]
16.1 Patient-preferred music 5 479 Mean Difference (IV, Random, 95% CI) -3.13 [-6.54, 0.27]
16.2 Researcher-selected music 2 60 Mean Difference (IV, Random, 95% CI) -7.94 [-15.10, -0.78]
17 Respiratory rate 4 Mean Difference (IV, Random, 95% CI) Subtotals only
17.1 All studies 4 437 Mean Difference (IV, Random, 95% CI) -1.24 [-2.54, 0.06]
18 Systolic blood pressure 7 Mean Difference (IV, Random, 95% CI) Subtotals only
19 Systolic blood pressure (music 6 509 Mean Difference (IV, Random, 95% CI) -6.29 [-8.86, -3.72]
preference)
19.1 Patient-preferred music 4 449 Mean Difference (IV, Random, 95% CI) -6.65 [-10.07, -3.23]
19.2 Researcher-selected music 2 60 Mean Difference (IV, Random, 95% CI) -4.72 [-10.80, 1.37]
20 Diastolic blood pressure 7 Mean Difference (IV, Random, 95% CI) Subtotals only
20.1 All studies 7 559 Mean Difference (IV, Random, 95% CI) -2.35 [-5.88, 1.18]
21 Diastolic blood pressure (mu- 6 509 Mean Difference (IV, Random, 95% CI) -3.74 [-7.53, 0.05]
sic preference)
Informed decisions.


studies partici-
pants
21.1 Patient-preferred music 4 449 Mean Difference (IV, Random, 95% CI) -4.10 [-8.78, 0.59]
21.2 Researcher-selected music 2 60 Mean Difference (IV, Random, 95% CI) -2.01 [-6.26, 2.25]
22 Oxygen Saturation 3 292 Mean Difference (IV, Random, 95% CI) 0.50 [-0.18, 1.18]
23 Quality of Life 6 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
23.2 Sensitivity analysis 4 241 Std. Mean Difference (IV, Random, 95% CI) 0.52 [0.01, 1.02]
24 Quality of life (intervention 5 568 Std. Mean Difference (IV, Random, 95% CI) 0.99 [-0.34, 2.31]
subgroup)
24.1 Music therapy studies 3 132 Std. Mean Difference (IV, Random, 95% CI) 0.42 [0.06, 0.78]
24.2 Music medicine studies 2 436 Std. Mean Difference (IV, Random, 95% CI) 1.33 [-0.96, 3.63]

Analysis 1.1. Comparison 1 Music intervention plus standard
care versus standard care alone, Outcome 1 Anxiety (STAI).
Study or subgroup Music Intervention Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
1.1.1 All studies
Binns-Turner 2008 15 30.7 (12.3) 15 49.7 (18.9) 4.72% -19[-30.41,-7.59]
Bufalini 2009 20 56.7 (14.1) 19 64.2 (18) 5.26% -7.5[-17.68,2.68]
Bulfone 2009 30 36.3 (8.9) 30 44.6 (10.2) 8.04% -8.3[-13.14,-3.46]
Danhauer 2010 29 30.4 (7.6) 30 31.5 (11.2) 8.03% -1.1[-5.97,3.77]
Harper 2001 10 -8.6 (10) 10 11.5 (13.2) 5.22% -20.1[-30.38,-9.82]
Jin 2011 50 42.9 (8.1) 52 51 (6.6) 8.94% -8.14[-11.02,-5.26]
Li 2012 54 30.9 (2.7) 51 40.4 (4.4) 9.37% -9.48[-10.9,-8.06]
Lin 2011 34 29.8 (8.8) 34 35.2 (11) 8.11% -5.39[-10.11,-0.67]
O'Callaghan 2012 48 33 (11.4) 49 31 (9.7) 8.36% 2[-2.22,6.22]
Smith 2001 19 35.7 (11.5) 23 37.3 (12.3) 6.77% -1.6[-8.81,5.61]
Vachiramon 2013 50 28.8 (7.3) 50 35.3 (9.7) 8.74% -6.5[-9.86,-3.14]
Wan 2009 65 33.8 (6.5) 71 55.9 (7.7) 9.11% -22.1[-24.49,-19.71]
Zhou 2015 85 34 (4.7) 85 43.4 (6) 9.33% -9.34[-10.96,-7.72]
Subtotal *** 509 519 100% -8.54[-12.04,-5.05]
Heterogeneity: Tau2=33.4; Chi2=164.94, df=12(P<0.0001); I2=92.72%
Test for overall effect: Z=4.79(P<0.0001)

1.1.2 Sensitivity analysis
Binns-Turner 2008 15 30.7 (12.3) 15 49.7 (18.9) 5.57% -19[-30.41,-7.59]
Danhauer 2010 29 30.4 (7.6) 30 31.5 (11.2) 9.27% -1.1[-5.97,3.77]
Harper 2001 10 -8.6 (10) 10 11.5 (13.2) 6.14% -20.1[-30.38,-9.82]
Jin 2011 50 42.9 (8.1) 52 51 (6.6) 10.26% -8.14[-11.02,-5.26]
Li 2012 54 30.9 (2.7) 51 40.4 (4.4) 10.72% -9.48[-10.9,-8.06]
Favours music -20 -10 0 10 20 Favours control
Informed decisions.

Lin 2011 34 29.8 (8.8) 34 35.2 (11) 9.36% -5.39[-10.11,-0.67]
O'Callaghan 2012 48 33 (11.4) 49 31 (9.7) 9.63% 2[-2.22,6.22]
Smith 2001 19 35.7 (11.5) 23 37.3 (12.3) 7.88% -1.6[-8.81,5.61]
Vachiramon 2013 50 28.8 (7.3) 50 35.3 (9.7) 10.05% -6.5[-9.86,-3.14]
Wan 2009 65 33.8 (6.5) 71 55.9 (7.7) 10.45% -22.1[-24.49,-19.71]
Zhou 2015 85 34 (4.7) 85 43.4 (6) 10.68% -9.34[-10.96,-7.72]
Subtotal *** 459 470 100% -8.64[-12.5,-4.79]

Analysis 1.2. Comparison 1 Music intervention plus standard care versus
standard care alone, Outcome 2 Anxiety (non-STAI (full version) measures).
Study or subgroup Music Intervention Standard care Std. Mean Difference Weight Std. Mean Difference
1.2.1 All studies
Cai 2001 128 46.3 (8.6) 54 50.3 (7.3) 27.06% -0.48[-0.8,-0.16]
Ferrer 2005 25 1.1 (1.7) 25 2.7 (2.5) 14.91% -0.76[-1.34,-0.18]
Li 2004 30 10.7 (5.9) 30 17.9 (8.7) 16.33% -0.96[-1.49,-0.42]
Nguyen 2010 20 8.1 (2.2) 20 13 (4.2) 11.29% -1.44[-2.14,-0.73]
Yates 2015 11 -6.5 (1.2) 11 -5.5 (1.8) 8.26% -0.63[-1.49,0.23]
Zhao 2008 49 40 (5.7) 46 42.3 (5.2) 22.14% -0.43[-0.83,-0.02]
Subtotal *** 263 186 100% -0.71[-0.98,-0.43]
Heterogeneity: Tau2=0.05; Chi2=8.42, df=5(P=0.13); I2=40.61%

Nguyen 2010 20 8.1 (2.2) 20 13 (4.2) 31.46% -1.44[-2.14,-0.73]
Yates 2015 11 -6.5 (1.2) 11 -5.5 (1.8) 26.44% -0.63[-1.49,0.23]
Zhao 2008 49 40 (5.7) 46 42.3 (5.2) 42.1% -0.43[-0.83,-0.02]
Subtotal *** 80 77 100% -0.8[-1.44,-0.16]
Test for overall effect: Z=2.45(P=0.01)

Analysis 1.3. Comparison 1 Music intervention plus standard care
versus standard care alone, Outcome 3 Anxiety (intervention subgroup).
Study or subgroup Music Control Std. Mean Difference Weight Std. Mean Difference
1.3.1 Music therapy studies
Bufalini 2009 20 56.7 (14.1) 19 64.2 (18) 5.34% -0.46[-1.09,0.18]
Ferrer 2005 25 1.1 (1.7) 25 2.7 (2.5) 5.48% -0.76[-1.34,-0.18]
Yates 2015 11 -6.5 (1.2) 11 -5.5 (1.8) 4.79% -0.63[-1.49,0.23]
Subtotal *** 56 55 15.6% -0.62[-1.01,-0.24]
Heterogeneity: Tau2=0; Chi2=0.48, df=2(P=0.79); I2=0%
Informed decisions.

Test for overall effect: Z=3.2(P=0)

1.3.2 Music medicine studies
Binns-Turner 2008 15 30.7 (12.3) 15 49.7 (18.9) 4.99% -1.16[-1.94,-0.38]
Bulfone 2009 30 36.3 (8.9) 30 44.6 (10.2) 5.58% -0.86[-1.39,-0.33]
Cai 2001 128 46.3 (8.6) 54 50.3 (7.3) 5.96% -0.48[-0.8,-0.16]
Danhauer 2010 29 30.4 (7.6) 30 31.5 (11.2) 5.62% -0.11[-0.62,0.4]
Jin 2011 50 42.9 (8.1) 52 51 (6.6) 5.8% -1.09[-1.51,-0.68]
Li 2004 30 10.7 (5.9) 30 17.9 (8.7) 5.57% -0.96[-1.49,-0.42]
Li 2012 54 30.9 (2.7) 51 40.4 (4.4) 5.6% -2.58[-3.1,-2.05]
Lin 2011 34 29.8 (8.8) 34 35.2 (11) 5.67% -0.54[-1.02,-0.05]
Nguyen 2010 20 8.1 (2.2) 20 13 (4.2) 5.18% -1.44[-2.14,-0.73]
O'Callaghan 2012 48 33 (11.4) 49 31 (9.7) 5.84% 0.19[-0.21,0.59]
Smith 2001 19 35.7 (11.5) 23 37.3 (12.3) 5.41% -0.13[-0.74,0.48]
Vachiramon 2013 50 28.8 (7.3) 50 35.3 (9.7) 5.82% -0.75[-1.16,-0.35]
Wan 2009 65 33.8 (6.5) 71 55.9 (7.7) 5.64% -3.07[-3.57,-2.57]
Zhao 2008 49 40 (5.7) 46 42.3 (5.2) 5.82% -0.43[-0.83,-0.02]
Zhou 2015 85 34 (4.7) 85 43.4 (6) 5.91% -1.73[-2.08,-1.38]
Subtotal *** 706 640 84.4% -1[-1.45,-0.55]

Total *** 762 695 100% -0.94[-1.34,-0.55]
Test for subgroup differences: Chi2=1.59, df=1 (P=0.21), I2=37.01%

versus standard care alone, Outcome 4 Anxiety (music preference).
1.4.1 Patient-preferred music
Binns-Turner 2008 15 30.7 (12.3) 15 49.7 (18.9) 6.61% -1.16[-1.94,-0.38]
Bulfone 2009 30 36.3 (8.9) 30 44.6 (10.2) 7.61% -0.86[-1.39,-0.33]
Danhauer 2010 29 30.4 (7.6) 30 31.5 (11.2) 7.68% -0.11[-0.62,0.4]
Jin 2011 50 42.9 (8.1) 52 51 (6.6) 8.01% -1.09[-1.51,-0.68]
Li 2012 54 30.9 (2.7) 51 40.4 (4.4) 7.64% -2.58[-3.1,-2.05]
O'Callaghan 2012 48 33 (11.4) 49 31 (9.7) 8.06% 0.19[-0.21,0.59]
Smith 2001 19 35.7 (11.5) 23 37.3 (12.3) 7.31% -0.13[-0.74,0.48]
Vachiramon 2013 50 28.8 (7.3) 50 35.3 (9.7) 8.04% -0.75[-1.16,-0.35]
Zhao 2008 49 40 (5.7) 46 42.3 (5.2) 8.04% -0.43[-0.83,-0.02]
Zhou 2015 85 34 (4.7) 85 43.4 (6) 8.2% -1.73[-2.08,-1.38]
Subtotal *** 429 431 77.19% -0.86[-1.38,-0.34]

1.4.2 Researcher-selected music
Informed decisions.

Cai 2001 128 46.3 (8.6) 54 50.3 (7.3) 8.29% -0.48[-0.8,-0.16]
Li 2004 30 10.7 (5.9) 30 17.9 (8.7) 7.59% -0.96[-1.49,-0.42]
Nguyen 2010 20 8.1 (2.2) 20 13 (4.2) 6.93% -1.44[-2.14,-0.73]
Subtotal *** 178 104 22.81% -0.89[-1.43,-0.35]

Total *** 607 535 100% -0.88[-1.28,-0.47]
Test for subgroup differences: Chi2=0, df=1 (P=0.95), I2=0%

standard care alone, Outcome 5 Anxiety (music-guided relaxation).
Study or subgroup Experimental Control Std. Mean Difference Weight Std. Mean Difference
1.5.1 Music-guided relaxation studies
Jin 2011 50 42.9 (8.1) 52 51 (6.6) 7.3% -1.09[-1.51,-0.68]
Lin 2011 34 29.8 (8.8) 34 35.2 (11) 7.16% -0.54[-1.02,-0.05]
Wan 2009 65 33.8 (6.5) 71 55.9 (7.7) 7.12% -3.07[-3.57,-2.57]
Zhou 2015 85 34 (4.7) 85 43.4 (6) 7.43% -1.73[-2.08,-1.38]
Subtotal *** 234 242 29.02% -1.61[-2.56,-0.65]

1.5.2 Listening to music only
Binns-Turner 2008 15 30.7 (12.3) 15 49.7 (18.9) 6.38% -1.16[-1.94,-0.38]
Bulfone 2009 30 36.3 (8.9) 30 44.6 (10.2) 7.05% -0.86[-1.39,-0.33]
Cai 2001 128 46.3 (8.6) 54 50.3 (7.3) 7.48% -0.48[-0.8,-0.16]
Danhauer 2010 29 30.4 (7.6) 30 31.5 (11.2) 7.1% -0.11[-0.62,0.4]
Li 2004 30 10.7 (5.9) 30 17.9 (8.7) 7.04% -0.96[-1.49,-0.42]
Li 2012 54 30.9 (2.7) 51 40.4 (4.4) 7.07% -2.58[-3.1,-2.05]
O'Callaghan 2012 48 33 (11.4) 49 31 (9.7) 7.34% 0.19[-0.21,0.59]
Smith 2001 19 35.7 (11.5) 23 37.3 (12.3) 6.86% -0.13[-0.74,0.48]
Vachiramon 2013 50 28.8 (7.3) 50 35.3 (9.7) 7.33% -0.75[-1.16,-0.35]
Zhao 2008 49 40 (5.7) 46 42.3 (5.2) 7.33% -0.43[-0.83,-0.02]
Subtotal *** 452 378 70.98% -0.71[-1.16,-0.26]

Total *** 686 620 100% -0.98[-1.44,-0.51]
Favours music -5 -2.5 0 2.5 5 Favours control

Informed decisions.


care versus standard care alone, Outcome 6 Depression.
Study or subgroup Music Intervention Standard Care Std. Mean Difference Weight Std. Mean Difference
1.6.1 All studies
Cai 2001 128 -5.9 (9.5) 54 -0.7 (10) 16.63% -0.54[-0.86,-0.22]
Cassileth 2003 34 -1.1 (2.3) 26 -0.6 (2.5) 13.53% -0.21[-0.72,0.3]
Clark 2006 27 0 (4.5) 21 0 (3.6) 12.59% -0[-0.57,0.57]
Li 2012 54 -11.3 (3.7) 51 -5.8 (4.7) 15.01% -1.29[-1.72,-0.87]
Wan 2009 65 -0.7 (2.5) 71 -0.7 (2.7) 16.42% 0[-0.34,0.34]
Yates 2015 11 -0.7 (1.1) 11 -0.6 (0.8) 8.92% -0.08[-0.92,0.76]
Zhou 2015 85 -7.3 (4.6) 85 -4.6 (6) 16.9% -0.49[-0.8,-0.19]
Subtotal *** 404 319 100% -0.4[-0.74,-0.06]
Heterogeneity: Tau2=0.15; Chi2=26.52, df=6(P=0); I2=77.38%

Cassileth 2003 34 -1.1 (2.3) 26 -0.6 (2.5) 16.42% -0.21[-0.72,0.3]
Clark 2006 27 0 (4.5) 21 0 (3.6) 15.51% -0[-0.57,0.57]
Li 2012 54 -11.3 (3.7) 51 -5.8 (4.7) 17.82% -1.29[-1.72,-0.87]
Wan 2009 65 -0.7 (2.5) 71 -0.7 (2.7) 19.08% 0[-0.34,0.34]
Yates 2015 11 -0.7 (1.1) 11 -0.6 (0.8) 11.66% -0.08[-0.92,0.76]
Zhou 2015 85 -7.3 (4.6) 85 -4.6 (6) 19.51% -0.49[-0.8,-0.19]
Subtotal *** 276 265 100% -0.37[-0.79,0.05]

standard care alone, Outcome 7 Depression (intervention subgroup).
Cassileth 2003 34 -1.1 (2.3) 26 -0.6 (2.5) 13.53% -0.21[-0.72,0.3]
Clark 2006 27 0 (4.5) 21 0 (3.6) 12.59% -0[-0.57,0.57]
Yates 2015 11 -0.7 (1.1) 11 -0.6 (0.8) 8.92% -0.08[-0.92,0.76]
Subtotal *** 72 58 35.04% -0.11[-0.46,0.24]

Cai 2001 128 -5.9 (9.5) 54 -0.7 (10) 16.63% -0.54[-0.86,-0.22]
Li 2012 54 -11.3 (3.7) 51 -5.8 (4.7) 15.01% -1.29[-1.72,-0.87]
Wan 2009 65 -0.7 (2.5) 71 -0.7 (2.7) 16.42% 0[-0.34,0.34]
Zhou 2015 85 -7.3 (4.6) 85 -4.6 (6) 16.9% -0.49[-0.8,-0.19]
Subtotal *** 332 261 64.96% -0.57[-1.03,-0.1]

Total *** 404 319 100% -0.4[-0.74,-0.06]
Informed decisions.


versus standard care alone, Outcome 8 Depression (music preference).
Li 2012 54 -11.3 (3.7) 51 -5.8 (4.7) 24.57% -1.29[-1.72,-0.87]
Zhou 2015 85 -7.3 (4.6) 85 -4.6 (6) 27.6% -0.49[-0.8,-0.19]
Subtotal *** 139 136 52.17% -0.88[-1.67,-0.09]

Cai 2001 128 -5.9 (9.5) 54 -0.7 (10) 27.16% -0.54[-0.86,-0.22]
Clark 2006 27 0 (4.5) 21 0 (3.6) 20.66% -0[-0.57,0.57]
Subtotal *** 155 75 47.83% -0.32[-0.84,0.19]

Total *** 294 211 100% -0.6[-1.04,-0.16]

Analysis 1.9. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 9 Mood.
1.9.1 All studies
Beck 1989 8 5.4 (17.4) 7 3.5 (16.9) 13.26% 0.1[-0.91,1.12]
Burrai 2014 26 2.8 (2.2) 26 -0.3 (2.2) 20.49% 1.39[0.78,2]
Cassileth 2003 34 9 (12.2) 26 1.7 (11.7) 22.33% 0.6[0.08,1.13]
Moradian 2015 32 16.7 (25.9) 33 14.2 (25) 23.08% 0.1[-0.39,0.58]
Ratcliff 2014 20 9.6 (21.2) 24 7.8 (18) 20.83% 0.09[-0.5,0.69]
Subtotal *** 120 116 100% 0.47[-0.02,0.97]

Beck 1989 8 5.4 (17.4) 7 3.5 (16.9) 17.61% 0.1[-0.91,1.12]
Burrai 2014 26 2.8 (2.2) 26 -0.3 (2.2) 25.88% 1.39[0.78,2]
Favours control -1 -0.5 0 0.5 1 Favours music
Informed decisions.

Cassileth 2003 34 9 (12.2) 26 1.7 (11.7) 27.85% 0.6[0.08,1.13]
Moradian 2015 32 16.7 (25.9) 33 14.2 (25) 28.65% 0.1[-0.39,0.58]
Subtotal *** 100 92 100% 0.57[-0.03,1.18]

versus standard care alone, Outcome 10 Mood (intervention subgroup).
Cassileth 2003 34 9 (12.2) 26 1.7 (11.7) 22.33% 0.6[0.08,1.13]
Ratcliff 2014 20 9.6 (21.2) 24 7.8 (18) 20.83% 0.09[-0.5,0.69]
Subtotal *** 54 50 43.16% 0.37[-0.13,0.87]

Beck 1989 8 5.4 (17.4) 7 3.5 (16.9) 13.26% 0.1[-0.91,1.12]
Burrai 2014 26 2.8 (2.2) 26 -0.3 (2.2) 20.49% 1.39[0.78,2]
Moradian 2015 32 16.7 (25.9) 33 14.2 (25) 23.08% 0.1[-0.39,0.58]
Subtotal *** 66 66 56.84% 0.55[-0.37,1.47]

Total *** 120 116 100% 0.47[-0.02,0.97]
Test for subgroup differences: Chi2=0.12, df=1 (P=0.73), I2=0%
Favours control -4 -2 0 2 4 Favours music

Analysis 1.11. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 11 Pain.
Binns-Turner 2008 15 41.5 (30.2) 15 64.9 (20.9) 12.76% -0.88[-1.63,-0.12]
Danhauer 2010 29 39.9 (23.3) 30 46.6 (27) 14.67% -0.26[-0.77,0.25]
Fredenburg 2014a 12 1.4 (1.2) 20 3.5 (2.7) 12.79% -0.87[-1.62,-0.12]
Huang 2006 62 31 (24) 64 49 (20) 15.67% -0.81[-1.17,-0.45]
Li 2012 54 0.7 (0.7) 51 2.6 (1) 14.79% -2.29[-2.79,-1.79]
Nguyen 2010 20 1.2 (1.4) 20 3 (2) 13.5% -1.03[-1.7,-0.37]
Wan 2009 65 3.5 (0.8) 71 3.7 (0.7) 15.82% -0.27[-0.6,0.07]

Total *** 257 271 100% -0.91[-1.46,-0.36]
Informed decisions.


versus standard care alone, Outcome 12 Pain (music preference).
Study or subgroup Experimental Control Std. Mean Difference Weight Std. Mean Difference
Binns-Turner 2008 15 41.5 (30.2) 15 64.9 (20.9) 14.81% -0.88[-1.63,-0.12]
Danhauer 2010 29 39.9 (23.3) 30 46.6 (27) 16.82% -0.26[-0.77,0.25]
Huang 2006 62 31 (24) 64 49 (20) 17.85% -0.81[-1.17,-0.45]
Li 2012 54 0.7 (0.7) 51 2.6 (1) 16.94% -2.29[-2.79,-1.79]
Subtotal *** 160 160 66.41% -1.06[-1.93,-0.2]

Nguyen 2010 20 1.2 (1.4) 20 3 (2) 15.59% -1.03[-1.7,-0.37]
Wan 2009 65 3.5 (0.8) 71 3.7 (0.7) 18% -0.27[-0.6,0.07]
Subtotal *** 85 91 33.59% -0.59[-1.34,0.15]

Total *** 245 251 100% -0.92[-1.53,-0.3]

Analysis 1.13. Comparison 1 Music intervention plus standard care versus standard care alone, Outcome 13 Fatigue.
1.13.1 All studies
Cassileth 2003 34 4.3 (4) 26 5.2 (4.1) 22.2% -0.22[-0.73,0.29]
Clark 2006 28 7.6 (5.3) 21 8.2 (5.3) 19.93% -0.11[-0.68,0.45]
Ferrer 2005 25 1.9 (1.5) 25 4 (2.4) 18.91% -1.03[-1.62,-0.44]
Fredenburg 2014b 7 -3 (2.6) 4 1.3 (5) 5.48% -1.08[-2.43,0.27]
Moradian 2015 32 -23.1 (26.8) 33 -20.6 (20.1) 23.36% -0.11[-0.59,0.38]
Rosenow 2014 8 -0.6 (2) 10 0.1 (2.4) 10.11% -0.29[-1.22,0.65]
Subtotal *** 134 119 100% -0.38[-0.72,-0.04]

Cassileth 2003 34 4.3 (4) 26 5.2 (4.1) 29.68% -0.22[-0.73,0.29]
Informed decisions.

Clark 2006 28 7.6 (5.3) 21 8.2 (5.3) 24.28% -0.11[-0.68,0.45]
Fredenburg 2014b 7 -3 (2.6) 4 1.3 (5) 4.26% -1.08[-2.43,0.27]
Moradian 2015 32 -23.1 (26.8) 33 -20.6 (20.1) 32.88% -0.11[-0.59,0.38]
Rosenow 2014 8 -0.6 (2) 10 0.1 (2.4) 8.89% -0.29[-1.22,0.65]
Subtotal *** 109 94 100% -0.2[-0.48,0.08]

care versus standard care alone, Outcome 14 Physical functioning.
1.14.1 All studies
Hilliard 2003 40 -10.8 (13) 40 -12.5 (16.6) 24.98% 0.11[-0.33,0.55]
Liao 2013 57 2.1 (9) 31 3.1 (8.6) 24.98% -0.11[-0.55,0.32]
Moradian 2015 32 12 (13.7) 33 7.9 (14) 24.86% 0.29[-0.2,0.78]
Xie 2001 124 -5.2 (5.6) 136 -20.8 (5.5) 25.18% 2.83[2.48,3.17]
Subtotal *** 253 240 100% 0.78[-0.74,2.31]

Hilliard 2003 40 -10.8 (13) 40 -12.5 (16.6) 35.6% 0.11[-0.33,0.55]
Liao 2013 57 2.1 (9) 31 3.1 (8.6) 35.75% -0.11[-0.55,0.32]
Moradian 2015 32 12 (13.7) 33 7.9 (14) 28.65% 0.29[-0.2,0.78]
Subtotal *** 129 104 100% 0.08[-0.18,0.34]

care versus standard care alone, Outcome 15 Heart rate.
Study or subgroup Music Intervention Standard Care Mean Difference Weight Mean Difference
1.15.1 All studies
Binns-Turner 2008 15 2 (11.4) 15 6.8 (10.9) 8.28% -4.8[-12.78,3.18]
Burrai 2014 26 75.8 (9.1) 26 73.6 (11.6) 12.1% 2.2[-3.47,7.87]
Chen 2013 100 -4.4 (0.8) 100 -3.3 (1.1) 22.71% -1.12[-1.38,-0.86]
Ferrer 2005 25 79.2 (12.3) 25 79 (11) 10.59% 0.2[-6.27,6.67]
Harper 2001 10 0 (15.9) 10 4 (10.2) 4.79% -4[-15.7,7.7]
Jin 2011 50 71.8 (7.5) 52 79.8 (8.9) 17.82% -7.97[-11.15,-4.79]
Nguyen 2010 20 100.8 (11.4) 20 111.1 (17.2) 7.01% -10.3[-19.35,-1.25]
Zhao 2008 49 76.3 (8.5) 46 80.1 (9.5) 16.71% -3.75[-7.38,-0.12]
Subtotal *** 295 294 100% -3.32[-6.21,-0.44]
Informed decisions.


Binns-Turner 2008 15 2 (11.4) 15 6.8 (10.9) 12.47% -4.8[-12.78,3.18]
Burrai 2014 26 75.8 (9.1) 26 73.6 (11.6) 18.16% 2.2[-3.47,7.87]
Harper 2001 10 0 (15.9) 10 4 (10.2) 7.22% -4[-15.7,7.7]
Jin 2011 50 71.8 (7.5) 52 79.8 (8.9) 26.62% -7.97[-11.15,-4.79]
Nguyen 2010 20 100.8 (11.4) 20 111.1 (17.2) 10.56% -10.3[-19.35,-1.25]
Zhao 2008 49 76.3 (8.5) 46 80.1 (9.5) 24.98% -3.75[-7.38,-0.12]
Subtotal *** 170 169 100% -4.63[-8.18,-1.09]

versus standard care alone, Outcome 16 Heart rate (music preference).
Study or subgroup Music Control Mean Difference Weight Mean Difference
Binns-Turner 2008 15 2 (11.4) 15 6.8 (10.9) 9.67% -4.8[-12.78,3.18]
Burrai 2014 26 75.8 (9.1) 26 73.6 (11.6) 13.8% 2.2[-3.47,7.87]
Chen 2013 100 -4.4 (0.8) 100 -3.3 (1.1) 24.37% -1.12[-1.38,-0.86]
Jin 2011 50 71.8 (7.5) 52 79.8 (8.9) 19.66% -7.97[-11.15,-4.79]
Zhao 2008 49 76.3 (8.5) 46 80.1 (9.5) 18.55% -3.75[-7.38,-0.12]
Subtotal *** 240 239 86.05% -3.13[-6.54,0.27]

Harper 2001 10 0 (15.9) 10 4 (10.2) 5.71% -4[-15.7,7.7]
Nguyen 2010 20 100.8 (11.4) 20 111.1 (17.2) 8.24% -10.3[-19.35,-1.25]
Subtotal *** 30 30 13.95% -7.94[-15.1,-0.78]

Total *** 270 269 100% -3.77[-6.97,-0.58]

Informed decisions.


care versus standard care alone, Outcome 17 Respiratory rate.
1.17.1 All studies
Chen 2013 100 -0.6 (0.1) 100 -0.5 (0.1) 36.53% -0.19[-0.23,-0.15]
Jin 2011 50 20.6 (8.6) 52 21.2 (1.8) 16.05% -0.55[-2.98,1.88]
Nguyen 2010 20 24.5 (3.5) 20 28.2 (3.7) 17.57% -3.7[-5.94,-1.46]
Zhao 2008 49 16.2 (2.7) 46 17.7 (2.3) 29.85% -1.44[-2.46,-0.42]
Subtotal *** 219 218 100% -1.24[-2.54,0.06]

Jin 2011 50 20.6 (8.6) 52 21.2 (1.8) 24.23% -0.55[-2.98,1.88]
Nguyen 2010 20 24.5 (3.5) 20 28.2 (3.7) 26.76% -3.7[-5.94,-1.46]
Zhao 2008 49 16.2 (2.7) 46 17.7 (2.3) 49.01% -1.44[-2.46,-0.42]
Subtotal *** 119 118 100% -1.83[-3.36,-0.3]

versus standard care alone, Outcome 18 Systolic blood pressure.
1.18.1 All studies
Burrai 2014 26 1 (16) 26 3.7 (13.8) 9.35% -2.7[-10.82,5.42]
Chen 2013 100 -5.7 (0.4) 100 -0.7 (1.3) 34.03% -5.02[-5.29,-4.75]
Ferrer 2005 25 124.2 (15.6) 25 120.6 (13) 9.59% 3.6[-4.38,11.58]
Harper 2001 10 -2 (21.6) 10 7 (11.5) 3.32% -9[-24.19,6.19]
Jin 2011 50 122.7 (10.8) 52 132.9 (8.2) 21.9% -10.22[-13.95,-6.49]
Nguyen 2010 20 98.5 (10.1) 20 102.4 (11.3) 12.32% -3.9[-10.54,2.74]
Zhao 2008 49 112.9 (18.2) 46 121 (21.5) 9.49% -8.1[-16.14,-0.06]
Subtotal *** 280 279 100% -5.4[-8.32,-2.49]

Burrai 2014 26 1 (16) 26 3.7 (13.8) 13.51% -2.7[-10.82,5.42]
Harper 2001 10 -2 (21.6) 10 7 (11.5) 4.1% -9[-24.19,6.19]
Jin 2011 50 122.7 (10.8) 52 132.9 (8.2) 49.17% -10.22[-13.95,-6.49]
Nguyen 2010 20 98.5 (10.1) 20 102.4 (11.3) 19.45% -3.9[-10.54,2.74]
Zhao 2008 49 112.9 (18.2) 46 121 (21.5) 13.78% -8.1[-16.14,-0.06]
Subtotal *** 155 154 100% -7.63[-10.75,-4.52]

Informed decisions.


standard care alone, Outcome 19 Systolic blood pressure (music preference).
Burrai 2014 26 1 (16) 26 3.7 (13.8) 8.22% -2.7[-10.82,5.42]
Chen 2013 100 -5.7 (0.4) 100 -0.7 (1.3) 45.97% -5.02[-5.29,-4.75]
Jin 2011 50 122.7 (10.8) 52 132.9 (8.2) 23.42% -10.22[-13.95,-6.49]
Zhao 2008 49 112.9 (18.2) 46 121 (21.5) 8.37% -8.1[-16.14,-0.06]
Subtotal *** 225 224 85.99% -6.65[-10.07,-3.23]

Harper 2001 10 -2 (21.6) 10 7 (11.5) 2.7% -9[-24.19,6.19]
Nguyen 2010 20 98.5 (10.1) 20 102.4 (11.3) 11.32% -3.9[-10.54,2.74]
Subtotal *** 30 30 14.01% -4.72[-10.8,1.37]

Total *** 255 254 100% -6.29[-8.86,-3.72]

versus standard care alone, Outcome 20 Diastolic blood pressure.
1.20.1 All studies
Burrai 2014 26 -0.4 (9.4) 26 1.9 (6.7) 14.19% -2.3[-6.72,2.12]
Chen 2013 100 -1.7 (0.9) 100 -1.4 (0.9) 18.24% -0.3[-0.54,-0.06]
Ferrer 2005 25 77.4 (8.7) 25 71.2 (7.7) 13.99% 6.16[1.6,10.72]
Harper 2001 10 -2 (12.5) 10 3 (12) 6.79% -5[-15.74,5.74]
Jin 2011 50 72.5 (6.1) 52 80.6 (5.3) 17.02% -8.1[-10.32,-5.88]
Nguyen 2010 20 62.8 (4.8) 20 64.2 (9.4) 13.89% -1.45[-6.08,3.18]
Zhao 2008 49 65.9 (7) 46 71.6 (8.7) 15.88% -5.75[-8.95,-2.55]
Subtotal *** 280 279 100% -2.35[-5.88,1.18]

Burrai 2014 26 -0.4 (9.4) 26 1.9 (6.7) 19.61% -2.3[-6.72,2.12]
Harper 2001 10 -2 (12.5) 10 3 (12) 5.91% -5[-15.74,5.74]
Jin 2011 50 72.5 (6.1) 52 80.6 (5.3) 30.37% -8.1[-10.32,-5.88]
Nguyen 2010 20 62.8 (4.8) 20 64.2 (9.4) 18.77% -1.45[-6.08,3.18]
Zhao 2008 49 65.9 (7) 46 71.6 (8.7) 25.34% -5.75[-8.95,-2.55]
Subtotal *** 155 154 100% -4.94[-7.78,-2.09]
Informed decisions.


standard care alone, Outcome 21 Diastolic blood pressure (music preference).
Burrai 2014 26 -0.4 (9.4) 26 1.9 (6.7) 16.49% -2.3[-6.72,2.12]
Chen 2013 100 -1.7 (0.9) 100 -1.4 (0.9) 21.25% -0.3[-0.54,-0.06]
Jin 2011 50 72.5 (6.1) 52 80.6 (5.3) 19.82% -8.1[-10.32,-5.88]
Zhao 2008 49 65.9 (7) 46 71.6 (8.7) 18.46% -5.75[-8.95,-2.55]
Subtotal *** 225 224 76.01% -4.1[-8.78,0.59]

Harper 2001 10 -2 (12.5) 10 3 (12) 7.85% -5[-15.74,5.74]
Nguyen 2010 20 62.8 (4.8) 20 64.2 (9.4) 16.14% -1.45[-6.08,3.18]
Subtotal *** 30 30 23.99% -2.01[-6.26,2.25]

Total *** 255 254 100% -3.74[-7.53,0.05]

care versus standard care alone, Outcome 22 Oxygen Saturation.
Burrai 2014 26 98.2 (1.5) 26 96.9 (1.8) 24.94% 1.3[0.4,2.2]
Chen 2013 100 -0 (0.1) 100 -0.1 (0.1) 44.32% 0.05[0.01,0.09]
Nguyen 2010 20 99.7 (0.5) 20 99.2 (1.5) 30.75% 0.5[-0.18,1.18]

Total *** 146 146 100% 0.5[-0.18,1.18]
Favours control -10 -5 0 5 10 Favours music

Informed decisions.


care versus standard care alone, Outcome 23 Quality of Life.
1.23.1 All studies
Burns 2001a 4 16.4 (10.9) 4 1.8 (7.9) 13.88% 1.33[-0.33,2.99]
Hilliard 2003 40 7.8 (37.4) 40 -10.6 (34.9) 17.27% 0.5[0.06,0.95]
Liao 2013 57 4.5 (8.4) 31 2.7 (10) 17.28% 0.2[-0.24,0.63]
Moradian 2015 32 11.9 (18) 33 8.7 (20.5) 17.21% 0.16[-0.32,0.65]
Ratcliff 2014 20 6.1 (14.1) 24 3.9 (15.1) 17.02% 0.15[-0.44,0.74]
Xie 2001 124 -2 (3.7) 136 -15.4 (3.7) 17.34% 3.61[3.21,4]
Subtotal *** 277 268 100% 0.98[-0.36,2.33]

Burns 2001a 4 91.8 (12.3) 4 77.9 (6.9) 7.82% 1.22[-0.4,2.84]
Hilliard 2003 40 214.6 (35.3) 40 177.9 (36.8) 30.64% 1.01[0.54,1.47]
Liao 2013 57 4.5 (8.4) 31 2.7 (10) 31.62% 0.2[-0.24,0.63]
Moradian 2015 32 11.9 (18) 33 8.7 (20.5) 29.93% 0.16[-0.32,0.65]
Subtotal *** 133 108 100% 0.52[0.01,1.02]

standard care alone, Outcome 24 Quality of life (intervention subgroup).
Burns 2001a 4 16.4 (10.9) 4 1.8 (7.9) 13.8% 1.33[-0.33,2.99]
Hilliard 2003 40 7.8 (37.4) 40 -10.6 (34.9) 17.27% 0.5[0.06,0.95]
Ratcliff 2014 20 6.1 (14.1) 24 3.9 (15.1) 17.01% 0.15[-0.44,0.74]
Subtotal *** 64 68 48.09% 0.42[0.06,0.78]
Heterogeneity: Tau2=0; Chi2=2.08, df=2(P=0.35); I2=3.71%

Liao 2013 57 4.5 (8.4) 31 2.7 (10) 17.28% 0.2[-0.24,0.63]
Liao 2013 57 4.5 (8.4) 31 2.7 (10) 17.28% 0.2[-0.24,0.63]
Xie 2001 124 -2 (3.7) 136 -15.4 (3.7) 17.34% 3.61[3.21,4]
Subtotal *** 238 198 51.91% 1.33[-0.96,3.63]

Total *** 302 266 100% 0.99[-0.34,2.31]
Favours music -5 -2.5 0 2.5 5 Favours control
Informed decisions.


Comparison 2. Music therapy plus standard care versus music medicine plus standard care
Outcome or subgroup ti- No. of No. of partici- Statistical method Effect size
tle studies pants
1 Anxiety 2 166 Mean Difference (IV, Fixed, 95% CI) -3.67 [-11.68, 4.35]

Analysis 2.1. Comparison 2 Music therapy plus standard care
versus music medicine plus standard care, Outcome 1 Anxiety.
Study or subgroup Music therapy Music medicine Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) Fixed, 95% CI Fixed, 95% CI
Bradt 2015 16 15 (16.5) 15 18.2 (16.3) 48.18% -3.2[-14.75,8.35]
Palmer 2015 67 -30.9 (36.3) 68 -26.8 (29.3) 51.82% -4.1[-15.24,7.04]

Total *** 83 83 100% -3.67[-11.68,4.35]
Favours music therapy -50 -25 0 25 50 Favours music medicine

Comparison 3. Music interventions plus standard care versus standard care plus placebo control

studies partici-
pants
1 Distress 2 Mean Difference (Random, 95% CI) -0.07 [-0.39, 0.26]
2 Spiritual well-being 2 Std. Mean Difference (Fixed, 95% CI) 0.31 [-0.11, 0.73]

Analysis 3.1. Comparison 3 Music interventions plus standard care
versus standard care plus placebo control, Outcome 1 Distress.
Study or subgroup Music Control Mean Dif- Mean Difference Weight Mean Difference
ference
N N (SE) IV, Random, 95% CI IV, Random, 95% CI
Burns 2009 0 0 0.3 (0.48) 11.73% 0.34[-0.6,1.28]
Robb 2014 0 0 -0.1 (0.175) 88.27% -0.12[-0.46,0.22]

Total (95% CI) 100% -0.07[-0.39,0.26]
Favours music -5 -2.5 0 2.5 5 Favours audiobook

Informed decisions.

Analysis 3.2. Comparison 3 Music interventions plus standard care versus

standard care plus placebo control, Outcome 2 Spiritual well-being.
Study or subgroup Experi- Control Std. Mean Std. Mean Difference Weight Std. Mean Difference
mental Difference
N N (SE) IV, Fixed, 95% CI IV, Fixed, 95% CI
Burns 2009 0 0 0.5 (0.706) 9.28% 0.52[-0.86,1.9]
Robb 2014 0 0 0.3 (0.226) 90.72% 0.29[-0.15,0.73]

Total (95% CI) 100% 0.31[-0.11,0.73]
Favours audiobook -2 -1 0 1 2 Favours music therapy

APPENDICES
Appendix 1. CENTRAL search strategy

#1 MeSH descriptor Neoplasms explode all trees
#2 malignan* or neoplasm* or cancer or carcinoma* or tumo*
#3 (#1 OR #2)
#4 MeSH descriptor Music explode all trees
#5 MeSH descriptor Music Therapy explode all trees
#6 music* or melod*
#7 sing or sings or singing or song* or compose or composing or improvis*
#8 (#4 OR #5 OR #6 OR #7)
#9 (#3 AND #8)
Appendix 2. MEDLINE search strategy (OvidSp)

1 exp neoplasms/
2 (malignan* or neoplas* or cancer* or carcinoma* or tumo*).mp.
3 1 or 2
4 music/ or music therapy/
5 (sing or sings or singing or song* or improvis*).mp.
6 (music* or melod*).mp.
7 4 or 5 or 6
8 3 and 7
9 randomized controlled trial.pt.
10 controlled clinical trial.pt.
11 randomized.ab.
12 placebo.ab.
13 clinical trials as topic.sh.
14 randomly.ab.
15 trial.ti.
16 9 or 10 or 11 or 12 or 13 or 14 or 15
17 8 and 16
key: mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary
concept, rare disease supplementary concept, unique identifier; pt=publication type; ab=abstract; ti=title
Appendix 3. Embase search strategy (OvidSp)

1 exp neoplasm/
2 (malignan* or neoplasm* or cancer* or carcinom* or tumo*).mp.
3 1 or 2
4 music therapy/ or music/
5 (sing or sings or singing or song* or improvis*).mp.
6 (music* or melod*).mp.
Informed decisions.

7 4 or 5 or 6
8 3 and 7
9 crossover procedure/
10 double-blind procedure/
11 randomized controlled trial/
12 single-blind procedure/
13 random*.mp.
14 factorial*.mp.
15 (crossover* or cross over* or cross-over*).mp.
16 placebo*.mp.
17 (double* adj blind*).mp.
18 (singl* adj blind*).mp.
19 assign*.mp.
20 allocat*.mp.
21 volunteer*.mp.
22 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21
23 8 and 22
key: [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device
trade name, keyword]
Appendix 4. CINAHL search strategy (EbscoHost)

S22 S21 and S7 and S4
S21 S20 or S19 or S18 or S17 or S16 or S15 or S14 or S13 or S12 or S11 or S10 or S9 or S8
S20 TI ( (singl* or doubl* or treb* or tripl*) ) and TI ( (blind* or mask*) )
S19 AB ( (singl* or doubl* or treb* or tripl*) ) and AB ( (blind* or mask*) )
S18 Randomized controlled trials/
S17 evaluation studies/
S16 comparative study/
S15 prospective studies/
S14 clinical trial/
S13 study design/
S12 AB ( (control$ or prospectiv$ or volunteer$) ) or TI ( (control$ or prospectiv$ or volunteer$) )
S11 AB random$ or TI random$
S10 AB placebo$ or TI placebo$
S9 placebos/
S8 AB (clin$ N25 trial$) or TI (clin$ N25 trial$)
S7 S5 OR S6
S6 TX (malignan$ or neoplasm$ or cancer or carcinoma$ or tumo$)
S5 neoplasms/
S4 S3 OR S2 OR S1
S3 TX (music$ OR melod$ OR sing OR singing OR sings OR song$ OR improvis$)
S2 music therapy/
S1 music/
Appendix 5. PsycInfo search strategy (OvidSp)

1 exp Neoplasms/
2 (malignan$ or neoplasm$ or cancer or carcinoma$ or tumo$).tw.
3 1 or 2
5 (music$ or melod$).tw.
6 (sing or sings or singing or song$ or improvis$).tw.
7 or/4-6
8 3 and 7
9 empirical study.md.
10 followup study.md.
11 longitudinal study.md.
12 prospective study.md.
13 quantitative study.md.
14 "2000".md.
15 treatment effectiveness evaluation/
Informed decisions.

16 exp hypothesis testing/

17 repeated measures/
18 exp experimental design/
19 placebo$.ti,ab.
20 random$.ti,ab.
21 (clin$ adj25 trial$).ti,ab.
22 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$ or mask$)).ti,ab.
23 or/9-22
24 8 and 23
25 limit 24 to human
Appendix 6. LILACS search strategy (Virtual Health Library)

((music$)) and ((((malignan$ or neoplasm$ or cancer or carcinoma$ or tumo$)) or (("cancer"))))
Appendix 7. Social Science Citation Index search strategy (ISI)

#1 Topic=(music*)
#2 TopiC= (music therapy)
#3 Topic=(singing or sings or song* or improvis* or melod*)
#4 #1 OR #2 OR #3
#5 Topic=(neoplasm*)
#6 Topic=(malignan* or neoplasm* or cancer or carcinoma* or tumo*)
#7 #5 OR #6
#8 Topic=(random allocation)
#9 Topic=(controlled clinical trial*)
#10 Topic=(randomized controlled trial*)
#11Topic=(double blind method*)
#12 Topic=(single blind method*)
#13 Topic=(clinical trial*)
#14 Topic=(placebo*)
#15 Topic=(random*)
#16 #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15
#17 #4 AND #7 AND # 16
Appendix 8. CancerLit search strategy

music OR (music therapy)
Appendix 9. CAIRSS search strategy

Cancer OR neoplasm OR neoplasms
Malignant OR carcinoma OR carcinomas
Tumor OR tumour
Appendix 10. Proquest Digital Dissertations search strategy (Proquest)

Music and (cancer or tumor or malignant or neoplasm)
Appendix 11. clinicaltrials.gov search strategy

music OR "music therapy"
Appendix 12. Current Controlled Trials search strategy

music OR "music therapy"
Appendix 13. National Research Register search strategy

music
Appendix 14. RILM Abstracts of Music Literature search strategy (EbscoHost)

Cancer or tumor or malignant or neoplasm
Informed decisions.

Appendix 15. Study Selection, Quality Assessment & Data Extraction Form
Review: Music interventions for improving psychological and physical outcomes in cancer patients
Name Coder:
Date:
Paper Code:

First author Title Journal/Conference Proceedings etc Year Language

Other references to trial
If there are further references to this trial, link the papers now & list below. All references to a trial should be linked under one Study ID in
RevMan (main paper should be [number]A; other publications related to the same trial should be [same number]B)

Code each paper Author(s) Journal/Conference Proceedings etc Year Language

Study eligibility

1. Level of Randomization 2. Cancer Pa- 3. Intervention: 4. Outcome:
tients?
Music vs standard care alone Psychological/physical/or social
outcomes?
Music vs. standard care + other treatment
RCT Sys- Unclear Yes/ No / Un- Yes / No / Unclear Yes / No / Unclear

tematic clear
method

Do not proceed if the answers to 2), 3), or 4) are No. If study to be included in Excluded studies section of the review, record below
the information to be inserted into Table of excluded studies (give specific reason for exclusion).
EXCLUDED BECAUSE (circle)
1. Not RCT (list study design:____________________________________________)
Informed decisions.

(Continued)
2. Not population of interest
3. Not music/music therapy intervention vs standard care or vs standard care + other treatment
4. Not outcome of interest
5. Other:_____________________________________________________
AWAIT FURTHER ASSESSMENT TO MAKE DECISION
Study Design (circle): 2-arm parallel group 3-arm parallel group cross-over trial
Describe experimental and control group/condition interventions:
Experimental group:
Control group:

Participants and trial characteristics

Participant characteristics
Age (mean, median, range) Experimental: Control: Total: Range:
Sex of participants (numbers / %) Experimental: F M Control: F M Total: F M
Ethnicity (%)
Diagnosis/Disease status (if available)
Setting (please circle) Inpatient
Outpatient
Other:
Methodological quality

Method of randomization
Was the trial reported as randomized? Yes
No
Random sequence generation Low risk
Informed decisions.

(Continued)
Unclear risk
High risk
State here randomization method used and reasons for grading (circle):
1. Computer-generated number list
2. Table of random numbers
3. Draw of lots
4. Flip coin
5. Systematic, please specify:
6. Other:

Concealment of allocation
Concealment of allocation Low risk
Unclear risk
High risk
State here the method used to conceal allocation and reasons for grading
1. Opaque sealed envelopes
2. Central randomization
3. Alteration method
4. Other___________________________________________

Low risk: (1) central randomization, (2) serially numbered opaque envelopes, (3) other descriptions with convincing concealment
High risk: (1) alternation methods, (2) other manners in which allocation was not adequately concealed
Unclear risk: authors did not adequately report on method of concealment used

Blinding
Blinding of study participants and music therapist/music provider Low risk
Unclear risk
High risk
Blinding of outcome assessor(s) for objective outcomes Low risk
Informed decisions.

(Continued)
Unclear risk
High risk
Blinding of outcome assessor(s) for subjective outcomes Low risk
Unclear risk
High risk
Intention-to-treat
• Low risk: if fewer than 20% of patients were lost to follow-up and reasons for loss to follow-up Low risk
were similar in both treatment arms
• Unclear risk: if loss to follow-up was not reported Unclear risk
• High risk: if more than 20% of patients were lost to follow-up or reasons for loss to follow-up dif- High risk
fered between treatment arms
Number of withdrawals:
Were withdrawals described? Yes No ? Not clear ?
Please add reasons for withdrawal + N or % here:
Selective reporting
• Low risk: reports of the study were free of suggestion of selective outcome reporting Low risk
• High risk: reports of the study suggest selective outcome reporting
Unclear risk
High risk
Other sources of bias
Are studies free of other problems that could have put them at high risk of bias (e.g. financial con- Low risk
flict of interest)?
Unclear risk
Please list other sources of bias:
High risk
Data reporting
Is data reporting sufficient for inclusion in review (are means and SD for each outcome variable re- Yes / No
ported for experimental group/condition and for control group/condition)?
If no, please detail what type of data is available:

Data extraction

Outcomes relevant to your review
Reported in paper (circle) Reported in pa-

per (circle)
Psychological outcomes (depression, anxiety, etc) Yes / No Communication Yes / No
Informed decisions.

(Continued)
Physical outcomes (pain, nausea) Yes / No Disease-free survival Yes / No
Physiological outcomes (HR, RR, AP, SBP, DBP) Yes / No Social/Spiritual out- Yes / No
comes
Quality of life Yes / No

For continuous data
Library
Cochrane
Intervention group Control group If mean (SD) are not
reported, report ei-
Code Unit of N Mean N Mean (SD) ther:
of pa- mea- (SD)
per Outcomes sure- - t-value and/or P
ment value associated

or with t-test
Better health.
Informed decisions.
Trusted evidence.
scale
used - SE of means cal-
culated from within
group
- confidence interval
of means from within
group
- description of re-
sults in text
Depression
Anxiety
Anger
Hopelessness
Helplessness
Other psychological:

Other psychological:
Quality of life
Fatigue
Nausea
146

(Continued)
Pain
Library
Cochrane
Heart rate
Respiratory rate
Arterial pressure
Better health.
Informed decisions.
Trusted evidence.
Systolic blood pressure
Diastolic blood pressure
Cortisol levels
IgA levels
Other hormone levels: _________
Other hormone levels:
_________
Social support. Specify:
Communication. Specify:
Disease free survival

147

Informed decisions.


Other information which you feel is relevant to the results
Indicate if: any data were obtained from the primary author; if results were estimated from graphs etc; or calculated by you using a
formula (this should be stated and the formula given). In general if results not reported in paper(s) are obtained this should be made
clear here to be cited in review.

Music Intervention

Music Medicine Yes / No Patient-Preferred? Yes / No
Type:

Music Therapy Yes / No Intervention used (mark):
Music Listening
Music used:

Patient-Preferred? Yes / No / Unknown
Active Music Making
Type: ________________________________
Music-guided Imagery
Music used:

Patient-Preferred? Yes / No / Unknown
Intensity Number of sessions:

Duration of each session:
Time period (State weeks / months, etc, if

cross-over trial give length of time in each
arm):
Informed decisions.

(Continued)

Appendix 1

Trial characteristics
Further details
Single centre / multicentre
Country / countries
How was participant eligibility defined?
How many people were randomizedrandomized?
Number of participants in each intervention group (circle groups that are used for this review if 3- Exp.group 1: Exp group 2:
arm parallel group) Control:
Number of participants who received intended treatment Exp.group 1: Exp group 2: Con-
trol:
Number of participants who were analyzed Exp.group 1: Exp group 2:

Control:
Time-points when measurements were taken during the study
Time-points reported in the study
Time-points you are using in RevMan
Other
Appendix 16. Original search strategies

MEDLINE search strategy (OvidSp)
1 exp Neoplasms/
2 (malignan$ or neoplasm$ or cancer or carcinoma$ or tumo$).tw.
3 1 or 2
5 (sing or sings or singing or song$ or improvis$).tw.
6 (music$ or melod$).tw.
Informed decisions.

7 or/4-6
8 Randomized Controlled Trials/
9 random allocation/
10 Controlled Clinical Trials/
11 control groups/
12 clinical trials/
13 double-blind method/
14 single-blind method/
15 Placebos/
16 placebo effect/
17 cross-over studies/
18 Multicenter Studies/
19 Therapies, Investigational/
20 Research Design/
21 Program Evaluation/
22 evaluation studies/
23 randomized controlled trial.pt.
24 controlled clinical trial.pt.
25 clinical trial.pt.
26 multicenter study.pt.
27 evaluation studies.pt.
28 random$.tw.
29 (controlled adj5 (trial$ or stud$)).tw.
30 (clinical$ adj5 trial$).tw.
31 ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
32 (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
33 ((multicenter or multicentre or therapeutic) adj5 (trial$ or stud$)).tw.
34 ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
35 ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
36 (coin adj5 (flip or flipped or toss$)).tw.
37 latin square.tw.
38 (cross-over or cross over or crossover).tw.
39 placebo$.tw.
40 sham.tw.
41 (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
42 controls.tw.
43 (treatment$ adj6 order).tw.
44 or/8-43
45 3 and 7 and 44
46 limit 45 to humans
Embase search strategy (OvidSp)
1 exp Neoplasm/
2 (malignan* or neoplasm* or cancer or carcinom* or tumo*).mp. [mp = title, abstract, subject headings, heading word, drug trade name,
original title, device manufacturer, drug manufacturer name]
3 1 or 2
4 exp music therapy/ or exp music/
5 (music* or melod*).mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug
manufacturer name]
6 (sing or sings or singing or song* or compose or composing or improvis*).mp. [mp = title, abstract, subject headings, heading word, drug
trade name, original title, device manufacturer, drug manufacturer name]
7 6 or 4 or 5
8 Randomized Controlled Trial/
9 Randomization/
10 exp Controlled Clinical Trial/
11 Control Group/
12 Clinical Trial/
13 Double Blind Procedure/
14 Single Blind Procedure/
15 Placebo/
16 Crossover Procedure/
Informed decisions.

17 Multicenter Study/
18 Experimental Therapy/
19 Methodology/
20 exp Health Care Quality/
21 exp Evaluation/
22 random*.mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug
manufacturer name]
23 (controlled adj5 (trial* or stud*)).mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device
manufacturer, drug manufacturer name]
24 (clinical* adj5 trial*).mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer,
drug manufacturer name]
25 ((control or treatment or experiment* or intervention) adj5 (group* or subject* or patient*)).mp. [mp = title, abstract, subject headings,
heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
26 (quasi-random* or quasi random* or pseudo-random* or pseudo random*).mp. [mp = title, abstract, subject headings, heading word,
drug trade name, original title, device manufacturer, drug manufacturer name]
27 ((multicenter or multicentre or therapeutic) adj5 (trial* or stud*)).mp. [mp = title, abstract, subject headings, heading word, drug trade
name, original title, device manufacturer, drug manufacturer name]
28 ((control or experiment* or conservative) adj5 (treatment or therapy or procedure or manage*)).mp. [mp = title, abstract, subject
headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
29 ((single* or double* or tripl* or trebl*) adj5 (blind* or mask*)).mp. [mp = title, abstract, subject headings, heading word, drug trade
name, original title, device manufacturer, drug manufacturer name]
30 (coin adj5 (flip or flipped or toss*)).mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device
31 latin square.mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug
manufacturer name]
32 (cross-over or cross over or crossover).mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device
33 placebo*.mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug
manufacturer name]
34 sham.mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer
name]
35 (assign* or alternate or allocat* or counterbalance* or multiple baseline).mp. [mp = title, abstract, subject headings, heading word,
drug trade name, original title, device manufacturer, drug manufacturer name]
36 controls.mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug
manufacturer name]
37 (treatment* adj6 order).mp. [mp = title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer,
drug manufacturer name]
38 35 or 33 or 32 or 11 or 21 or 26 or 17 or 22 or 18 or 30 or 23 or 16 or 13 or 29 or 27 or 25 or 28 or 36 or 9 or 12 or 14 or 15 or 20 or 8 or
34 or 37 or 24 or 10 or 19 or 31
39 38 and 3 and 7
40 39
CancerLit Search Strategy (CancerLit was searched in the original review but is no longer available)
music OR (music therapy)
Musictherapyworld.de (was searched in the original review but is no longer functional)
The site's research register, dissertation archive, and bibliography were searched in 2008 for the following terms:
cancer or tumor or tumour or malignant or neoplasm or neoplasms or carcinoma or carcinomas
WHAT'S NEW

Date Event Description
29 April 2016 New search has been performed In the previous version of this review, we searched the databas-
es until September 2010 (Bradt 2011). In this updated version
we reran the searches until January 2016. We also extended our
handsearching to include two additional journals, namely Mu-
sic Medicine and Approaches. In this updated review we have re-
Informed decisions.


vised the 'Risk of bias' tables for all studies according to the new
Cochrane 'Risk of bias' tool.
29 April 2016 New citation required and conclusions This review is an update of the previous Cochrane review that in-
have changed cluded 30 studies (Bradt 2011). This updated review includes 22
new trials.
One of the previous authors, Dr Denise Grocke, decided not to

participate in the update of this review, and we added a new co-
author, Aaron Teague.
Our conclusions about the impact of music interventions on

state anxiety in people with cancer remain similar to those in
Bradt 2011. Although the pooled effect of the studies that used
the Spielberger State Anxiety Inventory (STAI) was slightly lower
than in the previous review, the addition of trials examining this
outcome resulted in a more precise estimate. The pooled effect
of studies that used measurement tools other than the STAI was
higher than in the previous review.
The conclusions for the effect of music interventions on depres-

sion changed. Whereas the previous review did not find support
for an effect, this review update found a moderate effect for de-
pression. We also found a similar effect size (moderate) as the
previous review for mood, but the pooled effect was no longer
statistically significant in this update.
The conclusions for the effect of music interventions on pain

changed. Whereas the previous review reported a moderate ef-
fect, this review update found a large effect for pain.
The conclusions for the effect of music interventions on fatigue

also changed. Whereas the previous review did not find evidence
of an effect, this review update found a small to moderate effect
for music interventions on fatigue. The conclusions for physical
functioning remained the same.
The conclusion for the effect of music interventions on quality

of life remained similar, that is, there was a large pooled effect
size that was not statistically significant. However, a subgroup
analysis revealed that music therapy interventions resulted in a
moderate and statistically significant effect that was consistent
across trials, whereas music medicine studies resulted in a large
but heterogeneous effect size that was not statistically signifi-
cant.
The conclusions for the effects of music interventions on vital

signs remained similar to those of the previous review.
This review update included additional outcomes such as re-

silience, coping, and anesthetic and analgesic intake, but no
meta-analysis was possible because we only identified one study
per outcome.
Because of the addition of many trials in this update, we were

able to conduct a priori determined sub-analyses comparing
music therapy with music medicine studies and comparing pa-
tient-preferred music with researcher-selected music for several
of the outcomes.
Informed decisions.


HISTORY
Protocol first published: Issue 1, 2008
Review first published: Issue 8, 2011

15 July 2011 Amended Label revision in forest plot of 'distress' outcome.
24 June 2008 Amended Converted to new review format.

CONTRIBUTIONS OF AUTHORS
Background, objectives, criteria for considering studies: Bradt, Dileo, Grocke and Magill
Search strategies, methods: Bradt (reviewed and approved by Dileo, Grocke and Magill)
Database searches and handsearches: Bradt, Dileo, Grocke, Magill and Teague
Screening search results: Bradt, Teague and graduate assistants
Organising retrieval of papers: Bradt
Screening retrieved papers against inclusion criteria: Bradt and Teague
Appraising quality of papers: Bradt, Dileo and Magill
Abstracting data from papers: Bradt,Teague and graduate assistants
Writing to authors of papers for additional information: Bradt, Teague and graduate assistant
Providing additional data about papers: Bradt
Obtaining and screening data on unpublished studies: Bradt
Data management for the review: Bradt
Entering data into Review Manager (Review Manager 2014): Bradt, Teague and research assistant
RevMan statistical data: Bradt
Other statistical analysis not using RevMan: Bradt
Interpretation of data: Bradt, Dileo, Grocke and Magill
Statistical inferences: Bradt
Writing the review: Bradt (reviewed and approved by Dileo, Grocke and Magill)
Securing funding for the review: Dileo (for original review)
Guarantor for the review (one author): Bradt
Person responsible for reading and checking review before submission: Bradt
DECLARATIONS OF INTEREST
All authors are music therapists.
SOURCES OF SUPPORT
Internal sources
• Drexel University, USA.
Drexel University provided financial support for a research assistant to assist with the update of this review
External sources
• State of Pennsylvania Formula Fund, USA.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
Disease free survival was listed in the protocol as a secondary outcome but was excluded in the review as per recommendation of the
peer review.
We slightly altered the MEDLINE search strategy, removing the words 'compose' and 'composing' as text words because they resulted in
hundreds of irrelevant returns.
We added the RILM Abstracts of Music Literature database to the search strategy as per recommendation of the peer review.
Informed decisions.

INDEX TERMS
Medical Subject Headings (MeSH)

Affect; Anxiety [*therapy]; Body Image; Depression [therapy]; Fatigue [therapy]; Music [psychology]; Music Therapy [*methods];
Neoplasms [physiopathology] [*psychology]; Pain Management; Quality of Life; Standard of Care; Stress, Psychological [therapy];
Treatment Outcome
MeSH check words

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Bradt J, Dileo C, Magill L, Teague A

Bradt J, Dileo C, Magill L, Teague A.

Music interventions for improving psychological and physical outcomes

Joke Bradt1, Cheryl Dileo2, Lucanne Magill3,4, Aaron Teague1

Editorial group: Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group.

Data collection and analysis

Can music interventions benefit cancer patients?

The aim of the review

What are the main findings?

No adverse effects of music interventions were reported.

Quality of the evidence

What are the conclusions?

Patient or population: cancer patients

Out- Relative effect (95% CI) No of par- Quality of Comments

GRADE Working Group grades of evidence

a The majority of the trials were at high risk of bias.

BACKGROUND • combining music with other therapeutic modalities (e.g.

OBJECTIVES 2. MEDLINE (OvidSp) (1950 to January, week 2, 2016) (Appendix 2);

We also handsearched the website of the Deutsches Zentrum • Setting

Blinding of outcome assessors Unit of analysis issues

Subgroup analysis and investigation of heterogeneity RESULTS

Figure 1. Study flow diagram.

We found a pooled estimate of −5.40 mmHg (95% CI −8.32 to −2.49,

We conducted a subgroup analysis based on music preference

Depression Secondary outcomes

NCT02150395 {unpublished data only} Bradt 2014

Rossetti A, Chadha M, Lucido D, Hylton D, Loewy J, Harrison, Burns 1999

NCT02583126 {unpublished data only} Dileo 1999

2011].. The Cochrane Collaboration, 2011. Available from NCI 2010

Characteristics of included studies [ordered by study ID]

Participants Adults with documented cancer-related pain

Mean age: 55.6 years

Sex: 12 (80%) females, 3 (20%) males

Ethnicity: 15 (100%) white

Setting: patients' home

Interventions 2 study groups

1. Music condition: listening to music via headphones

Length of sessions: 45 min

Categorized as music medicine trial

Blinding of participants Unclear risk It is unclear whether personnel were blinded

Selective reporting (re- Low risk No evidence of selective reporting

Other bias Low risk No conflict of interest reported

2-arm parallel group design

Participants Women undergoing mastectomy

Type of cancer: breast cancer

N randomized to music group: 15

N randomized to control group: 15

N analyzed in music group: 15

N analyzed in control group: 15

Mean age: 56.63 years

Sex: 30 (100%) females, 0 (0%) males

Ethnicity: 24 (80%) white, 6 (20%) black

Interventions 2 study groups

Categorized as music medicine

Heart rate (HR), mean arterial pressure (MAP): change scores

Bias Authors' judgement Support for judgement

Incomplete outcome data Low risk No dropouts

Selective reporting (re- Low risk No evidence of selective reporting

Participants Adults receiving cancer treatment