1066484 JFM Journal of Feline Medicine and SurgeryPaz et al

Original Article

Journal of Feline Medicine and Surgery

Evaluation of music therapy to 1­–7

© The Author(s) 2021
Article reuse guidelines:
reduce stress in hospitalized cats sagepub.com/journals-permissions
DOI: 10.1177/1098612X211066484
https://doi.org/10.1177/1098612X211066484
journals.sagepub.com/home/jfm
This paper was handled and processed
by the American Editorial Office (AAFP)
for publication in JFMS
Juliane EG Paz1, Fernanda VA da Costa2 ,
Luciana N Nunes3, Eduardo R Monteiro2
and Jenifer Jung4

Abstract
Objectives  This study aimed to evaluate the use of two different types of music – cat-specific music and classical
music – compared with no music, to reduce stress in cats during hospitalization.
Methods  Thirty-five hospitalized cats were randomly divided into three groups and each group received a different
stimulus – cat-specific music, classical music or no music (control) – throughout their hospitalization. Respiratory
rate, salivary cortisol and social interaction were documented. A blinded researcher performed the Cat Stress
Score (CSS) during the video analysis of recordings at five specific times over 31 h of hospitalization.
Results  There was no difference in the mean CSS between cats listening to cat-specific music, classical music and
control throughout the five evaluations. Cat-specific music had a higher percentage of positive social interactions
than the other groups on the first evaluation (P <0.05). The average respiratory rate was significantly lower in the
classical music group vs control on the fourth evaluation (P <0.05). Although statistically insignificant, the average
respiratory rate decreased only in the classical music group during the five evaluations. Cortisol quantification did
not seem to follow the CSS results. However, owing to the low and unrepresentative number of samples, it was not
possible to perform statistical analysis on these results or a group sample comparison.
Conclusions and relevance  Both cat-specific music and classical music seem to have some benefit to hospitalized
cats. The salivary cortisol analysis was not adequate nor useful to measure stress in hospitalized cats in our study.

Keywords: Species-specific music; hospitalization; well-being; salivary cortisol; Cat Stress Score

Accepted: 22 November 2021

Introduction in elephants;11 reduction in chimpanzee aggressiveness

The positive psychological and physiological effects of and an increase in their rest time;12 increase in the milk
music have been well reported in humans.1–7 Changes in production of dairy cows and an easier approach to the
brain physiology, cognition, chemistry and morphology milking parlor when music was playing;13,14 and reduc-
induced by music have been studied in animal models tion in the barking frequency of sheltered dogs and, when
and have provided evidence that music can affect ani-
mals the same way it affects humans. The potential ben- 1Veterinary Science Post Graduation Program, Universidade
efits of music in animal wellbeing include environmental Federal do Rio Grande do Sul, Porto Alegre, Brazil
enrichment, stress reduction and behavioral modulation.8 2Department of Animal Medicine, Faculty of Veterinary Sciences,

Likewise, music can be beneficial in masking potentially Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
3Department of Statistics, Institute of Mathematics and Statistics,
sudden artificial and stressful noises, as well as breaking
Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
the silence in a monotonous environment.9 The goal of 4Veterinary Clinics Hospital, Universidade Federal do Rio Grande
environmental enrichment is to help confined animals do Sul, Porto Alegre, Brazil
deal with their daily environmental challenges, such as
the feeling of lack of control or unpredictability, encour- Corresponding author:
aging normal behaviors for the species, and reducing Fernanda VA da Costa MV, MSc, PhD, Department of Animal
Medicine, Faculty of Veterinary Sciences, Universidade Federal
abnormal or stereotyped behaviors.10 do Rio Grande do Sul, Av Bento Gonçalves 9090, Porto Alegre,
Music’s beneficial effects have been reported in other Rio Grande do Sul, 91540-000, Brazil
animals, including: reduction in stereotyped behaviors Email: [email protected]
2 Journal of Feline Medicine and Surgery 

classical music was playing, more time resting and less best of our knowledge, this is the first study to evaluate
time standing.15 Bowman et al also studied dogs, and they the effect of music in a hospital environment with non-
found no significant reduction in barking; however, bark- experimental cats.
ing increased after ceasing the sound stimulus.16
Several environmental aspects can affect the well- Materials and methods
being of cats when confined in a hospital environment.17 Animals
Chronic stress is undesirable not only for humanitar- The present study was approved by the Animal Ethics
ian reasons, but also because it can negatively affect the Committee (CEUA/UFRGS, approval 35922). The own-
immune system,18,19 which may develop or reactivate ers of each animal signed an informed consent form to
infection.20 Besides, cats under stress may reduce their participate in this study.
grooming and eating, and increase their vigilance, which Inclusion criteria were cats with a minimum hospi-
may compromise their recovery and discharge.21,22 talization of 31 h (cats arrived at least 1 h before the first
Increased noise levels, such as staff conversation, heat- evaluation at 11:30 am and stayed until the last evalua-
ing and cooling systems, alarms and animal noise, com- tion on the following day at 5:30 pm), no severe/decom-
bined with novel environments, restraint for treatments pensated respiratory dysfunction, the absence of motor
and medical procedures, may culminate in harmful stress injury that would prevent them from assuming natural
levels and increased morbidity in hospitalized veterinary positions for the species, normal state of consciousness
patients.18–24 and no evidence of therapy with corticosteroids.
The use of music should be carried out with the aware-
ness of the perception of the species-specific range of Study design
sound sensitivity and how it may vary between species.9 This was a prospective, randomized and partially blinded
Snowdon et al suggested that music would be more effec- study. Each cat underwent one of the three different audi-
tive if it were appropriate for the sensory and communi- tory tests (cat-specific music, classical music or control).
cation systems of the species under study.25 Based on this, We generated a random distribution plan using an open-
the authors composed songs for cats and reported that access website (http://www.randomization.com). The
cats showed greater interest in this music, compared with methods are summarized in Figure 1. The website chose
human classical music. These songs contain frequencies auditory tests to start from 7:30 am until 11:30 am and
similar to cat vocal ranges and are composed to create an from 1:30 pm until 5:30 pm in the hospitalization room at
affiliative effect on cats using pulses related to purring the Feline Medicine Service in the Universidade Federal
(1380 bpm) and suckling (250 bpm).25 Recently, another do Rio Grande do Sul’s Veterinary Teaching Hospital.
study demonstrated the advantage of cat-specific music The time intervals were chosen because they contained
over classical music or silence in a veterinary consulta- the greatest flow of people in the day, which concentrates
tion.26 A study in dogs compared classical music to music the handling time of the cats. The average number of peo-
composed for dogs, and found that classical music was ple present in the hospitalization room during the study
more effective in mitigating stress.27 period was five (minimum one and maximum 10 peo-
Our study aimed to evaluate whether music with dif- ple). The Feline Medicine Service (MedFel) is certified
ferent auditory stimuli – classical music and cat-specific with a gold standard status by the American Association
music – compared with no music – can reduce stress of Feline Practitioners’ (AAFP) Cat Friendly Practice
signs in cats in the hospital environment. Stress indica- Program. The cat’s area is physically separated from
tors include the Cat Stress Score (CSS),28 social interaction the dog’s area and contains nine cages arranged in three
(SIC), respiratory rate (RR) and salivary cortisol. To the vertical rows and three horizontal rows. Each cage is

Figure 1  Summarized methods of the five assessments (A1–A5). CSS = Cat Stress Score; RR = respiratory rate
Paz et al 3

walking away, crouching, showing body tension, facial

expression of fear and/or ears flattened or turned back,
hissing, dilated pupils and other signs (Table 1). SIC was
neutral when the cat did not react when approached or
touched. All SIC evaluations were performed by the same
observer and in the same way. There were three times
in which the SIC scores were carried out: observation in
front of the cat’s cage; a slow approximation to open the
cage; and hand approximation to try to touch the cat.
The researcher tried not to make eye contact with cat, to
avoid appearing confrontational and did not speak dur-
ing the test.

Music
For classical music, we selected a playlist generated on
Spotify, with pieces of music from previous studies.25,29,30
Figure 2  Cages used in the study, located in the cat The classical music included only instrumental pieces,
hospitalization room in the Feline Medicine Service of the
and were based on the piano. For cat-specific music, we
Veterinary Teaching Hospital, UFRGS
selected the playlist performed and produced by David
Teie, available on Spotify. Musci was played via wireless
90 cm width × 60 cm height × 60 cm depth, with a shelf Bluetooth speakers (JBL) from 7:30 am to 11:30 am and
and a hiding place (Figure 2). from 1:30 pm to 5:30 pm. Speaker volume was set manu-
Cats that met the inclusion criteria were followed for ally each day to around 60 dB and was kept the same
at least 31 h. As auditory stimuli were placed in the entire throughout the study.
environment, all owners who had their cats hospitalized
during this time had to agree with the presence of music, Salivary cortisol
even if their cats did not participate in the study. We We collected saliva with a specific swab (Salivette;
assessed the cats at five times (A1–A5). A1 was meas- Sarstedt) placing the swab inside the cats’ oral cavity, on
ured 1 h after the cat arrived, after the cat was medicated the labial commissure region, and leaving it there until
if needed and manipulated. Each assessment was video- the cotton was visibly moist. The analysis required a min-
recorded and had the audio removed, allowing a blinded imum volume of 25 µl. We immediately froze samples at
observer to score each cat’s behavioral responses using –20°C and, on the day of analysis, thawed the samples to
the CSS. The CSS describes seven possible stress levels of room temperature and centrifuged at 1500 × g for 15 mins.
a cat based upon posture and behavioral elements. The Then we analyzed cortisol using a commercial immuno-
scores ranges from ‘fully relaxed’ (score 1) to ‘extremely assay kit (Salivary Cortisol ELISA Kit; Salimetrics) at the
stressed’ (score 7) (see the supplementary material). 28 laboratory.
We collected saliva during the second and fourth assess-
ments, and evaluated RR and SIC during all assessments. Statistical analysis
SIC was positive when the cat showed positive emo- We performed descriptive analyses of all variables.
tions, like rubbing when the researcher approached and Regarding categorical variables, we used simple fre-
touched the cat’s chin, and negative when the cat had quency tables, with absolute and relative frequency, as
negative emotions when approached or touched, such as well as cross tables, when convenient. For quantitative

Table 1  Social interaction score created by the authors to evaluate cats’ responses during the study

Score Behavior description

Positive When the researcher approaches, the cat’s behavior or facial expression does not change
The cat walks towards the researcher in a friendly manner or stays still
When the researcher’s hand touches the cat, it responds to petting, pushing the petted area closer
The cat may be shy and motionless, but when the researcher’s hand touches the cat, it responds in a
positive manner by pushing the petted area closer
Neutral When the researcher approaches, the cat’s behavior or facial expression does not change
When the researcher’s hand touches the cat, the cat’s behavior or facial expression does not change
Negative When the researcher approaches, the cat looks scared and attempts to escape or it freezes. If the
researcher’s hand approaches the cat, agonistic behaviors worsen
4 Journal of Feline Medicine and Surgery 

variables, we calculated minimum, maximum, mean Table 3  Respiratory rate of cats during the five
and SD. As for the scores, we calculated the means of the assessments (A1–A5), according to music group
evaluations. The tests performed were a Wilcoxon non-
Assessments Cat-specific Classical Control
parametric test, to verify whether there was a difference
(n= 11) (n = 12) (n = 12)
between the first and the last score; a one-way ANOVA
test, to assess the difference in mean CSS and mean RR A1 28 ± 10.5 34.6 ± 18.2 31.6 ± 9.8
between the groups; Tukey’s test, to verify which groups A2 28 ± 7.4 29.3 ± 10 31.4 ± 14.1
differed in resonance frequency; Student’s t-test, to com- A3 28.8 ± 6.7 27.2 ± 5.8 28.4 ± 10.6
pare females and males with the average score; and a χ2 A4 28.8 ± 4.8 24.7 ± 4.3* 32.7 ± 9.4*
test, to analyze the association of SIC with each group. A5 28 ± 7.6 24.4 ± 3.7 31 ± 9
The level of significance adopted was 5%.
Data are mean ± SD
*Significant difference between groups (P = 0.02)
Results
Thirty-eight cats were initially included in the study, but
was no difference between the mean CSS in the groups
three were excluded because their clinical signs worsened,
(P = 0.44). No significant differences were found in CSS
meeting the exclusion criteria. Thirty-five cats completed
between males and females (P = 0.5) and between cats
at least four of the assessments required. Assessments
older and younger than 8 years of age (P = 0.4).
conducted during the postanesthetic period or sedation
In the first assessment, a significant association was
were excluded. The average room temperature during the
found in SIC evaluation: the χ2 test showed that the cat-
study was 24.1 ± 1.9°C.
specific music group had more positive interactions than
There were 22 (63%) males and 13 (37%) females, with
the other groups (P = 0.002). However, this association
a mean age of 5.8 ± 4.1 years. Other demographic data are
did not repeat in the following assessments. Most cats
shown in Table 2. There were no significant differences in
(62.8%) kept the same interaction score over assessments.
age (P = 0.6) or sex (P = 0.4) among groups.
However, among the cats that did change their scores,
The mean CSS of the five assessments in the cat-
77% (n = 10/13) changed to a positive result. There was
specific music group was 2.5 ± 0.1, 2.4 ± 0.2 in the classi-
no difference between males and females in SIC (P = 0.27).
cal music group and 2.7 ± 0.1 in the control group. There
The mean RRs in each of the assessments are shown in
Table 3. The mean RR in the cat-specific music group had
Table 2  Demographic data of cats divided according to minimal changes during the assessments. In the classical
music group music group, apparently the mean RR gradually reduced;
and in the control group, the mean RR increased on A4.
Variables Cat-specific Classical Control However, only in the A4 group was there a statistical dif-
(n = 11) (n = 12) (n = 12)
ference in the RR mean between the classical music group
Sex   and the control group (P = 0.02).
 Male 7 9 6 There was no difference regarding voluntary food
 Female 4 3 6 consumption between groups. Most cats (62.2%) showed
Reason for hospitalization   appropriate feeding behavior only about 20 h after being
 FLUTD 2 8 4 hospitalized.
 CKD 2 0 1 During the analysis of the salivary cortisol, it was
  Liver disease 0 1 2 noted that only six cats had enough volume of saliva for
  Skin wound 0 1 1 the two analyses. Enough saliva volume for an individual
  Bone fracture 2 0 0 analysis was collected in 16/35 cats on the first day and in
  Small bowel biopsy 0 1 1 10/35 cats on the second day. Several samples had blood
 Pyometra 0 1 1 and food contamination. Most cats rejected swab perma-
 SCC 2 0 0
nence in the oral cavity to achieve an adequate collection.
 FeLV 1 0 1
Some cats bit the swab and, to prevent the risk of inges-
  Diaphragmatic hernia* 1 0 0
tion, the collection had to be discontinued in these cats.
 Aggression 1 0 0
investigation
 Lameness 0 0 1 Discussion
Mean ± SD age (years) 6.1 ± 4.6 4.5 ± 2.2 6.7 ± 5.0 Many stressful noises can be present in the hospital envi-
ronment,23,24 and music may help some animals to cope
*Stable and with a respiratory rate within the reference interval with stress.10 However, to avoid adverse effects, the music
FLUTD = feline lower urinary tract disease; CKD = chronic kidney
disease; SCC = squamous cell carcinoma; FeLV = feline leukemia
volume should be below a conversational level and only
virus during the animals’ active periods.9 In our study, the
Paz et al 5

music was played only during periods when the hospital at temperatures <15°C because cats cannot assume a
environment had increased activity (ie, the noisiest times). relaxed position at this environmental temperature.28 In
Acute stress responses in cats subjected to short- our study, the average temperature in the cat cages was
term cage environments are not well known, compared 24.1°C, with a minimum of 19.1°C.
with chronic stress responses in long-term cage envi- The mean RR in the classical music group on the fourth
ronments.31 Cats’ behavioral and physiological coping assessment showed a significant difference compared
responses must be better understood to ensure the well- with the control group (Table 2). Although not statisti-
being of cats kept in cages.32 Stress evaluations involving cally significant, the mean RR apparently decreased in the
interaction with cats may be more useful than the CSSs, classical music group over the course of all assessments,
as the score can underestimate stress, as has already been compared with the control group, while the mean RR in
reported in sheltered cats.33 As the first reaction of a cat the cat-specific music group remained the same. A study
under stress is to stop interactions,34 using a tool to rec- with anesthetized cats showed that animals submitted
ognize this reaction beforehand may be useful, mainly to classical music demonstrated a lower RR vs silence or
because some shy cats may be more relaxed after a posi- other musical genres.30
tive interaction with a person. For this reason, we tested Owing to the small number of viable saliva samples
a SIC score using described behaviors, in a similar way and difficulties during sampling, a statistical analysis
to Zeiler et al.31 We found a significant difference among with salivary cortisol was not possible. Salivation is regu-
groups at the first assessments. The cat-specific music lated by the autonomic nervous system and it decreases
group had a higher percentage of positive interactions in response to activation of the sympathetic nervous sys-
with the researcher than the other groups. Our results tem; thus, hospitalized cats are expected to produce less
agree with the observations of Hampton et al,26 who con- saliva when stressed, and this may impair sample collec-
cluded that handling cats when listening to cat-specific tion.41 Another study reported difficulties in saliva collec-
music is easier than in cats listening to classical music tion and sample contamination with food and/or blood.41
or silence.26 However, in our study, the difference found Another limitation in salivary cortisol measurement is
in social interactions was not replicated in the following the difficulty in achieving a positive correlation between
assessments. It is hard to imagine whether SIC can be plasma cortisol and cat behavior.41,42 A study showed a
used as an acute stress measuring tool or if it is only a relationship between salivary cortisol with behavioral
reflex of cats’ temperaments.31 In our study, most cats reactions in dogs, associating stress-related behaviors
kept the same interaction score over the assessments. with increased salivary cortisol.43 Another study corre-
Among the cats that changed their scores, 77% changed lated salivary and urinary cortisol with plasma cortisol
to a positive result. The emotional stability in most cats in dogs, showing a connection between them.44 A study
during SIC in our study might be a sign of wellbeing, as failed to show a correlation between CSS for behavior
there was no negative anticipation, even when cats were measuring and physiological measuring in cats, such as
handled many times for normal procedures during their cortisol levels.33
period of hospitalization. Some of the limitations of this study included lack of
There was no difference between sex and age in the an adequate stress score tool for hospitalized cats. There
CSSs, which differed from a study that showed higher is currently not an effective non-invasive accurate method
scores in male and older cats.35 However, Hampton et al to assess stress in cats.39 Future research may create a
also did not find a difference between sex and age in wellbeing score for hospitalized cats that includes a pain
the CSSs.26 The mean CSS of the five assessments in the scale. Another limitation was the difficulty in comparing
groups was between 2 and 3 (ie, between ‘weakly relaxed’ cats with different diseases, which may affect the way cats
and ‘weakly tense’). These results were similar to findings react to stress. Also, the number of times cats were being
in another study.28 Although widely used, there is a lack manipulated for medical assessments, treatments and
of studies about the application of the CSS in unhealthy sample collections could affect their stress levels.
cats, as all studies we analyzed described the use of the The music had good acceptance by most veterinarians
score on healthy owned or healthy sheltered cats.26,28,33,36– and technicians, although some sounds present in the cat-
38 It is unknown how pain or disease can influence the specific music were not pleasing to some people. Music
CSS measuring system, or how demeanor affects feline therapy may have a relaxing effect on technicians, which
pain-assessment scales.39 can lead to lower levels of stress in animals during their
Although widely used as a stress-assessment method, care.9 This phenomenon may have been a confounding
there is discussion about the effectiveness of the CSS, as factor in our study.
in reality it measures fear, which is different from stress.39
Furthermore, when using scales based on a cat’s behav- Conclusions
ior, we must remember that cats’ instincts include hiding There was no difference in the mean CSS between groups.
signs of illness, pain or stress,40 so the scale may have Classical music vs control had a lower mean of RR in one
limitations. In addition, the CSS should not be applied of the assessments. Also, cat-specific music presented a
6 Journal of Feline Medicine and Surgery 

higher number of positive interactions between cats and 5 Gómez Gallego M and Gómez García J. Musicoterapia
researchers, but only in one of the assessments. As for en la enfermedad de Alzheimer: efectos cognitivos, psi-
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Cat Stress Score, based on Kessler and Turner 1997.28 mal physiology, behavior and welfare. Lab Anim (NY)
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Conflict of interest The authors declared no potential 9 Patterson-Kane EG and Farnworth MJ. Noise exposure,
conflicts of interest with respect to the research, authorship, music, and animals in the laboratory: a commentary based
and/or publication of this article. on laboratory animal refinement and enrichment forum
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Funding  This study was supported by research grants from 10 Wells DL. Sensory stimulation as environmental enrich-
the National Council for Scientific and Technological Develop- ment for captive animals: a review. Appl Anim Behav Sci
ment (CNPq) (grant number 131701/2018-5). 2009; 118: 1–11.
11 Wells DL and Irwin RM. Auditory stimulation as enrich-
Ethical approval This work involved non-experimental ment for zoo-housed Asian elephants (Elephas maximus).
animals (owned or unowned) and procedures that differed Anim Welf 2008; 17: 335–340.
from internationally established and recognized high stand- 12 Howell S, Schwandt M, Fritz J, et al. A stereo music system
ards (‘best practice’) of veterinary clinical care for the indi- as environmental enrichment for captive chimpanzees.
vidual patient. The study therefore had prior ethical approval Lab Anim (NY) 2003; 32: 31–36.
from an established (or ad hoc) committee as stated in the 13 Uetake K, Hurnik JF and Johnson L. Effect of music on vol-
manuscript. untary approach of dairy cows to an automatic milking
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Informed consent Informed consent (verbal or written) 14 Moregaonkar SD, Bharkad GP, Patil AD and Markandeya
was obtained from the owner or legal custodian of all animal(s) NM. Effect of Indian instrumental music on milk produc-
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(prospective or retrospective studies). No animals or people are auditory stimulation on the behaviour of dogs housed in
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Physiol Behav 2017; 171: 207–215.
ORCID iD  Fernanda VA da Costa https://orcid.org/0000-
17 Stella J, Croney C and Buffington T. Environmental factors
0002-1031-7728 
that affect the behavior and welfare of domestic cats (Felis
Eduardo R Monteiro https://orcid.org/0000-0001-8672-7830  silvestris catus) housed in cages. Appl Anim Behav Sci 2014;
Jenifer Jung https://orcid.org/0000-0003-4765-1575 160: 94–105.
18 Connor TJ and Leonard BE. Depression, stress and immu-
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