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نقش مداخلات موسیقایی در بهبود پیامدهای روان‌شناختی و فیزیکی در افراد مبتلا به سرطان

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پیشینه

این یک نسخه به‌روز شده از مروری است که در کتابخانه کاکرین، سال 2016، شماره 8 منتشر شد. ابتلا به سرطان ممکن است موجب رنج عاطفی، فیزیکی و اجتماعی زیادی شود. از مداخلات موسیقایی برای تسکین نشانه‌ها و عوارض جانبی درمان در افراد مبتلا به سرطان استفاده شده است. این مرور شامل مداخلات موسیقی است که به صورت موسیقی‌‐درمانی ارائه شده توسط درمان‌گران موسیقی آموزش‌دیده تعریف شد، هم‌چنین شامل موسیقی پزشکی است، که به صورت گوش دادن به موسیقی از پیش ضبط شده و ارائه شده توسط کادر پزشکی تعریف شد.

اهداف

ارزیابی و مقایسه تاثیرات مداخلات موسیقی‐درمانی و موسیقی پزشکی بر پیامدهای روان‌شناختی و فیزیکی در افراد مبتلا به سرطان.

روش‌های جست‌وجو

پایگاه مرکزی ثبت کارآزمایی‌های کنترل شده کاکرین (CENTRAL؛ شماره 3؛ 2020) در کتابخانه کاکرین؛ MEDLINE از طریق Ovid؛ Embase از طریق Ovid؛ CINAHL؛ PsycINFO؛ LILACS؛ Science Citation Index؛ CancerLit؛ CAIRSS؛ Proquest Digital Dissertations؛ ClinicalTrials.gov؛ Current Controlled Trials؛ RILM Abstracts of Music Literature؛ /http://www.wfmt.info/Musictherapyworld، و پایگاه ثبت ملی پژوهش‌ها (National Research Register) را جست‌وجو کردیم. تمام بانک‌های اطلاعاتی را، به جز دو مورد آخر، از زمان آغاز به کار تا اپریل 2020 جست‌وجو کردیم؛ دو مورد بعدی دیگر فعالیت ندارند، بنابراین آنها را تا زمان پایان کارشان جست‌وجو کردیم. مجلات موسیقی‌‐درمانی را به صورت دستی جست‌وجو کرده، فهرست منابع را مرور کرده و با کارشناسان تماس گرفتیم. هیچ گونه محدودیت زبانی اعمال نشد.

معیارهای انتخاب

کلیه کارآزمایی‌های تصادفی‌سازی و شبه‐تصادفی‌سازی و کنترل شده را در مورد مداخلات موسیقایی برای بهبود پیامدهای روان‌شناختی و فیزیکی در بزرگسالان و کودکان بیمار مبتلا به سرطان در این مرور گنجاندیم. بیمارانی را که تحت بیوپسی و آسپیراسیون برای مقاصد تشخیصی قرار گرفتند، حذف کردیم.

گردآوری و تجزیه‌وتحلیل داده‌ها

دو نویسنده مرور به‌طور مستقل از هم داده‌ها را استخراج و خطر سوگیری (bias) را ارزیابی کردند. در مواردی که امکان‌پذیر بود، نتایج را در متاآنالیز (meta‐analysis) با استفاده از تفاوت‌های میانگین (MD) و تفاوت‌های میانگین استاندارد شده (SMD) ارائه دادیم. از نمرات پس از تست (post‐test) استفاده کردیم. در مواردی که تفاوت در ابتدای مطالعه معنادار بود، از نمرات تغییر (change scores) استفاده کردیم. متاآنالیزهای جداگانه‌ای را برای مطالعات با شرکت‌کنندگان بزرگسال و مطالعاتی که شرکت‌کنندگان کودک داشتند، انجام دادیم. پیامدهای اولیه مورد نظر شامل پیامدهای روان‌شناختی و نشانه‌های فیزیکی و پیامدهای ثانویه شامل پاسخ‌های فیزیولوژیکی، عملکرد فیزیکی، مصرف داروی بی‌هوشی و آنالژزیک، طول مدت بستری در بیمارستان، حمایت اجتماعی و معنوی، برقراری ارتباط، و کیفیت زندگی (quality of life; QoL) بودند. از سیستم درجه‌‏بندی توصیه‏، ارزیابی، توسعه و ارزشیابی (GRADE) برای ارزیابی قطعیت شواهد بهره بردیم.

نتایج اصلی

تعداد 29 کارآزمایی جدید را برای گنجاندن در این نسخه به‌روز شده شناسایی کردیم. در مجموع، شواهد این مرور بر اساس 81 کارآزمایی با مجموع 5576 شرکت‌کننده بنا می‌شود. از 81 کارآزمایی، 74 مورد شامل بیماران بزرگسالان (N = 5306) و هفت مورد شامل بیماران کودک (N = 270) بستری در بخش انکولوژی بودند. تعداد 38 کارآزمایی را به عنوان کارآزمایی موسیقی‌‐درمانی و 43 مورد دیگر را به عنوان کارآزمایی‌های موسیقی پزشکی طبقه‌بندی کردیم. این مداخلات با مراقبت استاندارد مقایسه شدند.

پیامدهای روان‌شناختی

نتایج نشان می‎‌دهند که مداخلات موسیقی ممکن است تاثیر زیادی در کاهش اضطراب در بزرگسالان مبتلا به سرطان داشته باشند، میانگین کاهش اضطراب گزارش شده 7.73 واحد (17 مطالعه، 1381 شرکت‌کننده؛ 95% فاصله اطمینان (CI): 10.02‐ تا 5.44‐؛ شواهد با قطعیت بسیار پائین) در مقیاس پرسش‌نامه اضطراب ایالت اسپیلبرگر (Spielberger State Anxiety Inventory scale) (بین 20 و 80؛ مقادیر پائین‌تر نشان‌دهنده اضطراب کمتر) بود. نتایج هم‌چنین تاثیر مثبت و نسبتا قوی مداخلات موسیقی را بر افسردگی در بزرگسالان نشان داد (12 مطالعه، 1021 شرکت‌کننده؛ تفاوت میانگین استاندارد شده (SMD): 0.41‐؛ 95% CI؛ 0.67‐ تا 0.15‐؛ شواهد با قطعیت بسیار پائین). هیچ حمایتی را از تاثیر مداخلات موسیقی بر خلق‌وخو (mood) پیدا نکردیم (SMD: 0.47؛ 95% CI؛ 0.02‐ تا 0.97؛ 5 مطالعه، 236 شرکت‌کننده؛ شواهد با قطعیت بسیار پائین). مداخلات موسیقی ممکن است امید را در بزرگسالان مبتلا به سرطان افزایش دهند، میانگین افزایش گزارش‌شده 3.19 واحد (95% CI؛ 0.12 تا 6.25) در شاخص امید هرث (Herth Hope Index) بود (بین 12 و 48؛ نمرات بالاتر نشان دهنده امید بیشتر)، اما این یافته بر اساس نتایج فقط دو مطالعه بود (53 شرکت‌کننده؛ شواهد با قطعیت بسیار پائین).

پیامدهای فیزیکی

تاثیر متوسطی را از مداخلات موسیقی بر کاهش درد پیدا کردیم (SMD: ‐0.67؛ 95% CI؛ 1.07‐ تا 0.26‐؛ 12 مطالعه، 632 شرکت‌کننده بزرگسال؛ شواهد با قطعیت بسیار پائین). علاوه بر این، مداخلات موسیقی تاثیر درمانی کمی بر خستگی داشتند (SMD: ‐0.28؛ 95% CI؛ 0.46‐ تا 0.10‐؛ 10 مطالعه، 498 شرکت‌کننده بزرگسال؛ شواهد با قطعیت پائین).

نتایج نشانگر تاثیرات عمیق مداخلات موسیقایی بر QoL شرکت‏‌کنندگان بزرگسال بود، اما نتایج میان مطالعات مختلف بسیار متنوع بوده، و اندازه تاثیرگذاری تجمعی همراه با فاصله اطمینان گسترده بود (SMD: 0.88؛ 95% CI؛ 0.31‐ تا 2.08؛ 7 مطالعه، 573 شرکت‌کننده؛ شواهد بسیار نامطمئن است). حذف مطالعاتی که از روش‌های تصادفی‌سازی نامناسب استفاده کردند، منجر به اندازه تاثیرگذاری متوسطی شد که ناهمگونی کمتری داشت (SMD: 0.47؛ 95% CI؛ 0.06 تا 0.88؛ P = 0.02؛ I2 = 56%).

تعداد کمی از کارآزمایی‌ها شامل شرکت‏‌کنندگان بستری در بخش انکولوژی کودکان بودند. یافته‌ها نشان می‌دهند که مداخلات موسیقی ممکن است اضطراب را کاهش دهند اما این یافته فقط بر اساس دو مطالعه بود (SMD: ‐0.94؛ 95% CI؛ 1.9‐ تا 0.03؛ شواهد با قطعیت بسیار پائین). به دلیل کم بودن تعداد مطالعات، نتوانستیم در مورد تاثیرات مداخلات موسیقی بر خلق‌وخو، افسردگی، QoL، خستگی یا درد در شرکت‌کنندگان کودک مبتلا به سرطان نتیجه‌گیری کنیم.

اکثریت مطالعات گنجانده‌شده در این نسخه به‌روز شده با خطر بالای سوگیری همراه بودند، بنابراین قطعیت کلی شواهد در سطح پائین قرار داشت. برای چندین پیامد (یعنی اضطراب، افسردگی، درد، خستگی، و QoL) تاثیرات درمانی سودمند در سراسر مطالعات برای مداخلات موسیقی‌‐درمانی ارائه‌شده توسط درمان‌گران، هم‌سو و سازگار بودند. در مقابل، مداخلات موسیقی پزشکی منجر به تاثیرات درمانی متناقض بین مطالعات برای این پیامدها شدند.

نتیجه‌گیری‌های نویسندگان

این مرور سیستماتیک نشان می‌دهد که مداخلات موسیقی در مقایسه با مراقبت‌های استاندارد ممکن است تاثیرات مفیدی بر اضطراب، افسردگی، امید، درد و خستگی در بزرگسالان مبتلا به سرطان داشته باشند. نتایج دو کارآزمایی نشان می‌دهند که مداخلات موسیقی ممکن است تاثیر مفیدی بر اضطراب کودکان مبتلا به سرطان داشته باشند. کارآزمایی‌های بسیار کمی با شرکت‌کنندگان کودک برای نتیجه‌گیری در مورد مزایای درمانی موسیقی برای دیگر پیامدها گنجانده شد. برای چندین پیامد، مداخلات موسیقی‌‐درمانی ارائه‌شده توسط یک موسیقی‐درمان‌گر آموزش‌دیده منجر به نتایج هم‌سو و سازگار در سراسر مطالعات شد و این مورد برای مداخلات موسیقی پزشکی صدق نمی‌کرد. علاوه بر این، شواهدی از تاثیر مداخلات موسیقی‌‐درمانی برای QoL و خستگی یافت شد، اما نه برای مداخلات موسیقی پزشکی. بیشتر کارآزمایی‌ها در معرض خطر بالای سوگیری و شواهد با قطعیت پائین یا بسیار پائین بودند؛ بنابراین، این نتایج باید با احتیاط تفسیر شوند.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

آیا مداخلات موسیقایی برای افراد مبتلا به سرطان مزیتی به همراه دارند؟

موضوع
سرطان ممکن است باعث ایجاد رنج عاطفی، فیزیکی و اجتماعی زیادی شود. مداخلات موسیقی‌‐درمانی و موسیقی پزشکی برای کاهش نشانه‌ها و درمان عوارض جانبی و رسیدگی به نیازهای روانی‌اجتماعی در افراد مبتلا به سرطان استفاده شده‌اند. در مداخلات موسیقی پزشکی، بیماران به سادگی به موسیقی از پیش ضبط شده که توسط یک متخصص پزشکی ارائه می‌شود، گوش می‌دهند. موسیقی‌‐درمانی اما نیاز به اجرای یک مداخله موسیقی توسط یک درمان‌گر موسیقی آموزش‌دیده، یک روند درمانی و استفاده از تجارب موسیقی متناسب با شخص، دارد.

هدف مرور
این مرور یک نسخه به‌روز شده از مرور قبلی کاکرین در سال 2016 است که شامل 52 مطالعه بود. برای این به‌روزرسانی، به دنبال یافتن کارآزمایی‌های بیشتری بودیم که تاثیر مداخلات موسیقایی را بر پیامدهای روان‌شناختی و فیزیکی در افراد مبتلا به سرطان مطالعه کردند. برای یافتن مطالعات تا اپریل 2020 به جست‌وجو پرداختیم.

یافته‌های اصلی چه هستند؟
تعداد 29 مطالعه جدید را شناسایی کردیم، بنابراین شواهد این نسخه به‌روز شده از مرور، در حال حاضر بر 81 مطالعه با 5576 شرکت‌کننده استوار است. از 81 مطالعه، 74 کارآزمایی شامل بزرگسالان و 7 کارآزمایی شامل کودکان بودند. این یافته‌ها نشان می‌دهند که مداخلات موسیقی‌‐درمانی و موسیقی پزشکی ممکن است تاثیرات مفیدی بر اضطراب، افسردگی، امید، درد، خستگی، تعداد ضربان قلب، و فشار خون در افراد مبتلا به سرطان داشته باشند. مداخلات موسیقی‌‐درمانی، نه موسیقی پزشکی، ممکن است کیفیت زندگی بیماران بزرگسال و سطح خستگی را بهبود بخشند. شواهدی را نیافتیم که مداخلات موسیقی باعث بهبود خلق‌وخو، دیسترس یا عملکرد فیزیکی می‌شوند، اما فقط چند کارآزمایی این پیامدها را مطالعه کردند. ما نمی‌توانیم هیچ نتیجه‌گیری را در مورد تاثیر مداخلات موسیقایی بر عملکرد ایمونولوژیک، انعطاف‌پذیری، بهزیستی (well‐being) معنوی یا پیامدهای ارتباطی در بزرگسالان داشته باشیم چرا که کارآزمایی‌هایی که به این جنبه‌ها بپردازند، به اندازه کافی وجود ندارند. به دلیل تعداد کم کارآزمایی‌ها، نتوانستیم در مورد کودکان نتیجه‌گیری کنیم. بنابراین، انجام پژوهش‌های بیشتری مورد نیاز است.

به‌طور کلی، مزایای درمانی مداخلات موسیقی‌‐درمانی در طول کارآزمایی‌ها نسبت به مداخلات موسیقی پزشکی هم‌سو و سازگارتر بود، که منجر به اطمینان بیشتر به تاثیر درمانی مداخلات موسیقی‌‐درمانی ارائه‌شده توسط یک موسیقی‌‐درمان‌گر آموزش‌دیده شد.

هیچ موردی از عوارض جانبی ناشی از مداخلات موسیقایی گزارش نشد.

کیفیت شواهد
اغلب کارآزمایی‌ها در معرض خطر بالای سوگیری (bias) بودند، بنابراین این نتایج باید با احتیاط تفسیر شوند. تضاد منافع را در مطالعات وارد شده شناسایی نکردیم.

نتیجه‌گیری‌ها چه هستند؟
ما نتیجه می‌گیریم که مداخلات موسیقایی ممکن است تاثیرات مفیدی بر اضطراب، افسردگی، امید، درد، و خستگی در بزرگسالان مبتلا به سرطان داشته باشند. علاوه بر این، موسیقی می‌تواند تاثیر مثبت اندکی بر ضربان قلب و فشار خون بر جای بگذارد. کاهش اضطراب، افسردگی، خستگی و درد پیامدهای مهمی برای افراد مبتلا به سرطان هستند، چرا که بر سلامت و کیفیت کلی زندگی تاثیر می‌گذارند.

Authors' conclusions

Implications for practice

This systematic review indicates that music interventions may have beneficial effects on anxiety, depression, hope, pain, and fatigue in adults with cancer. Music therapy interventions had a moderate effect on QoL in adults, whereas we found no support for an effect for music medicine studies. Furthermore, the results suggest that music may reduce heart rate and blood pressure, though this reduction is rather small and therefore may not be clinically significant. Results from single trials suggest that music listening in cancer patients undergoing surgery may reduce anesthetic and analgesic consumption and reduce the length of hospital stay, but more research is needed before drawing solid conclusions. Results from a single study furthermore suggest that post‐surgery recovery time may be shortened when a music therapist offers live, individualized music before and during surgery. Overall, evidence of the trials included in this review suggest that music interventions may be offered as a complementary treatment to adults with cancer and that music therapy interventions delivered by a trained music therapist may lead to more consistent results.

No evidence of effect was found for distress, mood, physical functioning, or oxygen saturation. However, only a small number of trials investigated the effects of music on these outcomes. More research is needed. We cannot draw any conclusions at this time regarding the effects of music interventions on resilience, spiritual well‐being, mean arterial pressure, immunologic functioning or communication behaviours in adults because the results of the studies that included these outcomes could not be pooled or because we could only identify one trial.

A small number of trials included pediatric oncology participants. Not all trials included the same outcomes, therefore, we could only compute pooled effect sizes for a small number of outcomes. Those findings suggest that music interventions may reduce anxiety, but no evidence of an effect was found for distress or spiritual well‐being. However, there were only two trials included for each of these outcomes, thus more research is needed. At this time, we cannot draw conclusions regarding the effects of music interventions on mood, resilience, coping, QoL, communication behaviors, pain, or physiological responses in pediatric patients with cancer, because the results of the studies that included these outcomes could not be pooled or because we could only identify one trial.

Because participants cannot be blinded to music interventions and subjective outcomes are measured by self‐report measures, there was a high risk of bias for most studies. Therefore, the findings of this review need to be interpreted with caution.

Implications for research

This systematic review provides evidence that music interventions may have beneficial effects on anxiety, depression, hope, pain, fatigue, heart rate and blood pressure in adults with cancer. Only a few trials with pediatric participants were included and therefore no conclusions can be drawn at this time regarding the impact of music interventions on pediatric oncology patients. Comparative analyses between music therapy and music medicine interventions indicate that music therapy is more effective in improving QoL and fatigue than music medicine interventions. Moreover, the treatment effects of music therapy interventions show greater consistency across studies than music medicine interventions for anxiety, depression, and pain. At this time, more RCTs are needed to determine the effectiveness of music medicine versus music therapy for other outcomes in this review. This can be achieved by including more music medicine as well as music therapy RCTs in future reviews, when these become available or, alternatively, future trials could directly compare the effects of these two types of interventions. It is important to note that Bradt 2015 undertook such a comparative study based on the recommendation of the original systematic review, concluding that both music therapy and music medicine interventions were similarly effective for symptom management. However, the results of their mixed methods research study clearly indicated that even listening to pre‐recorded music can evoke strong emotions and existential issues in people with cancer and that the participants in this study were grateful for the presence of a music therapist to process these emotions and fears. Participants furthermore emphasized the importance of interactive music‐making, as it allowed them to access their creativity; this is considered an important resource for the facilitation of resilience in the face of life's challenges.

Future research should explore patient characteristics as moderators of treatment benefits of music therapy interventions versus listening to pre‐recorded music. For example, Bradt 2015 suggested that listening to music may cause distress in patients who have a negative outlook on life. It is possible that these patients are at greater risk for music's powerful capacity to access sad and traumatic memories, and such patients may be better served by listening to music in the presence of a music therapist who can help them process their emotions. On the other hand, Bradt and colleagues emphasized that some patients have a great need for stability and emotional security during this challenging time in their life and may therefore prefer the familiarity of their own music. Self‐selected music presents predictable musical and emotional content and may, therefore, provide a much needed holding environment for the patient.

We recommend that future research efforts aim to enhance understanding of how music therapy and music medicine interventions can be optimized for symptom management, how music interventions can best serve patients along the cancer treatment trajectory, and what unique aspects of music therapy and music medicine interventions contribute to the care of patients (Bradt 2015).

As stated in other reviews, it is important that investigators consider qualitative and mixed methods research, as these enhance understanding of the qualitative aspects of a patient's experience and identify factors that may contribute to or limit the effectiveness of music therapy or music medicine interventions (Bradt 2010; Bradt 2013a; Bradt 2014).

Future trials that use listening to pre‐recorded music should report more details related to the music selections made available to participants and exercise greater care in selecting music that reflects the patient's true preference (rather than just giving the patient the option to select from four or five general genres). It is recommended that reporting guidelines for music‐based interventions as outlined by Robb 2010 are used in clinical trial reports. In addition, researchers need to carefully consider the potential negative impact of the use of headphones during procedures because of hampered communication between the patient and medical personnel.

More research is needed that examines the relationship between frequency and duration of music interventions and treatment effects.

Many trials used small sample sizes and did not indicate the use of power calculations. Future trials need to include power calculations in order to use adequate sample sizes.

More studies are needed on the use of music interventions in pediatric patients with cancer. Of the 81 trials in this review, only seven studies focused on outcomes in children and adolescents.

Many studies examined the effects of music interventions on anxiety. Given that the findings regarding anxiety‐reducing effects of music are quite robust, it is important that future studies focus on other outcomes included in this review.

Formal cost‐benefit evaluations of music medicine and music therapy are needed.

Summary of findings

Open in table viewer
Summary of findings 1. Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in adult cancer patients

Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in adult cancer patients

Patient or population: adult cancer patients (≥ 18 years)
Setting: inpatient and outpatient cancer care
Intervention: music intervention (music therapy or music medicine) plus standard care
Comparison: standard care alone (i.e. usual cancer treatment as per the site's standard care protocol)

Outcomes*

Illustrative Comparative Risk
(95% CI)

__________________

Corresponding Risk

__________________

Music intervention

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Anxiety assessed with: Spielberger State Anxiety Index Scale (STAI)

Score range: 20 to 80. A lower score represents less anxiety.

Follow‐up: immediately post‐intervention

The mean anxiety in the music intervention group was 7.73 units less (10.02 less to 5.44 less) than in the standard care group.

1381
(17 RCTs)

⊕⊝⊝⊝
VERY LOW 1 2

Music intervention may result in a large reduction in anxiety. However, the evidence is very uncertain.

Depression

Follow‐up: immediately post‐intervention

The mean depression in the music intervention group was 0.41 standard deviations less (0.67 worse to 0.15 worse) than in the standard care group

1021
(12 RCTs)

⊕⊝⊝⊝
VERY LOW 1 3

Music intervention may result in a small to moderate reduction of depression. However, the evidence is very uncertain.

Mood

Follow‐up: immediately post‐intervention

The mean mood in the music intervention group was 0.53 standard deviations better (0.03 worse to 1.11 better) than in the standard care group

221
(4 RCTs)

⊕⊝⊝⊝
VERY LOW 1 4

Music interventions may result in a moderate improvement in mood. However, the evidence is very uncertain.

Hope

Score range: 12 to 48. A higher score represents greater hope.

Follow‐up: immediately post‐intervention

The mean hope in the music intervention group was 3.19 units more (0.12 more to 6.25 more) than in the standard care group

53

(2 RCTS

⊕ ⊝ ⊝⊝

VERY LOW 1 7

Music intervention may result in a large increase in hope. However, the evidence is very uncertain.

Pain

Follow‐up: immediately post‐intervention

The mean pain in the intervention group was 0.67 standard deviations less (1.07 less to 0.26 less) than in the standard care group

632
(12 RCTs)

⊕⊝⊝⊝
VERY LOW 1 5

Music interventions may result in a moderate to large improvement in pain. However, the evidence is very uncertain.

Fatigue

Follow‐up: immediately post‐intervention

The mean fatigue in the music intervention group was 0.28 standard deviations less (0.46 less to 0.01 less) than in the standard care group

498
(10 RCTs)

⊕⊕⊝⊝
LOW 1

Music intervention may result in a slight reduction in fatigue.

Quality of Life

Follow‐up: immediately post‐intervention

The mean quality of life in the music intervention group was 0.88 standard deviations more (0.31 less to 2.08 more) than in the standard care group

573
(7 RCTs)

⊕⊝⊝⊝
VERY LOW 1 6

Music interventions may result in a large improvement in quality of life. However, the evidence is very uncertain.

*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

GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded two levels for high risk of bias. The majority of the trials were at high risk of bias because participants could not be blinded to the music intervention and outcome was measured using self‐report.

2 Downgraded two levels for very serious inconsistency across studies as evidenced by I2 = 93%.

3 Downgraded one level for serious inconsistency across studies as evidenced by I2 = 72%.

4 Downgraded one level for serious inconsistency across trials as evidenced by I2 = 70%.

5 Downgraded two levels for very serious inconsistency across trials as evidenced by I2 = 81%.

6 Downgraded two levels for very serious inconsistency across trials as evidenced by I2 = 97%.

7 Downgraded two level s for imprecision due to a small number of participants.

Open in table viewer
Summary of findings 2. Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in paediatric cancer patients

Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in pediatriccancer patients

Patient or population: pediatric cancer patients (< 18 years)
Setting: inpatient and outpatient cancer care
Intervention: music interventions (music therapy or music medicine) plus standard care
Comparison: standard care alone (i.e. usual cancer treatment as per the site's standard care protocol)

Outcomes

Illustrative comparative risk (95% CI)

____________________

Corresponding risk

____________________

Music intervention

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Anxiety (STAI)

The score: 20 to 80. A lower score represents less anxiety.

Follow‐up: immediately post‐intervention

The mean anxiety in the music intervention group was 0.94 standard lower (1.9 lower to 0.03 higher)

79
(2 RCTs)

⊕⊝⊝⊝
VERY LOW 1 2 3

Music intervention may result in a large reduction in anxiety.

Depression

not estimable

(0 studies)

Mood

not estimable

(0 studies)

Pain
assessed with: 0 to 10 NRS. A higher score represents more pain

Listening to pre‐recorded music resulted in less pain during and after lumbar puncture (during mean: 2.35, SD 1.9; after mean: 1.2, SD 1.36) than standard care (during mean: 5.65, SD 2.5; after mean: 3.0, SD 2.0 ).

40
(1 RCT)

⊕ ⊝ ⊝ ⊝

LOW 1 3

Fatigue

not estimable

(0 studies)

Quality of Life

not estimable

(0 studies)

Hope

not estimable

(0 studies)

*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; RR: Risk ratio; OR: Odds ratio;

GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded two levels for high risk of bias. These trials were at high risk of bias because participants could not be blinded to the music intervention and outcome was measured using self‐report.

2 Downgraded one level for serious inconsistency across studies as evidenced by I2 = 76%.

3 Downgraded two levels for imprecision due to a small number of participants.

Background

Description of the condition

The lifetime risk of developing any type of cancer is 40% for men and 38% for women (Howlader 2019), and a diagnosis of cancer may result in extensive emotional, physical and social suffering. Many symptoms and treatment side effects have an impact on cancer patients' physical well‐being and quality of life (QoL), including appetite disturbance, difficulty swallowing, nausea, vomiting, constipation, diarrhea, dyspnea or difficulty breathing, fatigue, insomnia, muscle weakness and numbness (King 2003). In addition, study findings clearly indicate that people with cancer experience elevated levels of psychological distress and depression in response to diagnosis and treatment (Massie 2004; Norton 2004; Parle 1996; Raison 2003; Sellick 1999; Van't Spijker 1997). The actual experience of chemotherapy‐induced side effects, such as nausea and vomiting, and their influence on psychological well‐being varies widely in patients receiving the same cytotoxic agents. This suggests that non‐pharmacological factors possibly play an important role in how patients experience or interpret physical symptoms during the treatment phase (Montgomery 2000; Thune‐Boyle 2006). It is therefore important that cancer care incorporates services that help meet patients' psychological, social and spiritual needs.

Description of the intervention

The use of music in cancer care can be situated along a continuum of care, namely from music listening initiated by patients, to pre‐recorded music offered by medical personnel, to music psychotherapy interventions offered by a trained music therapist. Therefore, when examining the efficacy of music interventions in people with cancer, it is important to make a clear distinction between music interventions administered by medical or healthcare professionals (music medicine) and those implemented by trained music therapists (music therapy). A substantive body of evidence suggests that music therapy interventions provided by music therapists are more effective than music medicine interventions for a wide variety of outcomes (Dileo 2005). This difference might be attributed to the fact that music therapists individualize their interventions to meet patients' specific needs, more actively engage the patients in music‐making, and employ a systematic therapeutic process including assessment, treatment and evaluation. Dileo 1999 categorizes interventions as music medicine when medical personnel offer pre‐recorded music for passive listening. For example, they may offer people a compact disc (CD) for relaxation or distraction; however, no systematic therapeutic process is present, nor is there a systematic assessment of the elements and suitability of the music stimulus. In contrast, 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.

These tailored music experiences include:

  • listening to live, improvised or pre‐recorded music;

  • performing music on an instrument;

  • improvising music spontaneously using voice, instruments or both;

  • composing music;

  • combining music with other therapeutic modalities (e.g. movement, imagery, art) (Dileo 2007).

How the intervention might work

Music interventions have been used in different medical fields to meet patients' psychological, physical, social and spiritual needs. Research on the effects of music and music therapy for medical patients has burgeoned over the past 20 years, examining a variety of outcome measures in a wide range of specialty areas (Dileo 2005). For both adult and pediatric cancer patients, music has been used to decrease anxiety prior to or during surgical procedures (Alam 2016; Burns 1999; Haun 2001), to decrease stress during chemotherapy or radiation therapy (Bradt 2015; Bro 2019; Clark 2006), to lessen treatment side effects (Bozcuk 2006; Ezzone 1998; Frank 1985), to improve mood (Barrera 2002; Burns 2001a; Cassileth 2003), to enhance pain management (Akombo 2006; Arruda 2016; Beck 1989; Verstegen 2018), to improve immune system functioning (Burns 2001a), and to improve quality of life (QoL) (Burns 2001a; Hilliard 2003; Porter 2018).

There are inherent elements of music — such as rhythm and tempo, mode, pitch, timbre, melody and harmony — that are known to influence physiological and psycho‐emotional responses in humans. For example, music has been found to arouse memory and association, stimulate imagery, evoke emotions, facilitate social interaction, and promote relaxation and distraction (Dileo 2006). In cancer settings, music therapists conduct ongoing assessments and utilize various individualized interventions in people with cancer and their families, including pertinent elements of music within the context of therapeutic relationships, to address prevailing biopsychosocial and spiritual issues, symptoms and needs (Magill 2009; McClean 2012). The following music therapy interventions are common: use of songs (singing, song writing, and lyric analysis); music improvisation (instrumental and vocal), music and imagery, music‐based reminiscence and life review, chanting and toning, music‐based relaxation, and instrumental participation (O'Callaghan 2015). Based on patient preferences and assessment outcomes, music therapists adapt and modify music interventions to address symptoms and areas of difficulty; they utilize music and verbal strategies to provide opportunities for expression and communication, reminiscence, the processing of thoughts and emotions and improvement of symptom management (Magill 2011). Therapist‐supported music therapy environments often provide the space and time through which patients and families may experience social connection, improve self fulfilment and acquire effective coping strategies (Magill 2015).

Why it is important to do this review

Several research studies on the use of music with cancer patients have reported positive results (Beck 1989; Bradt 2015; Cassileth 2003; Harper 2001; Hilliard 2003; Robb 2008). The majority of these studies, however, are compromised by small sample size and lack of statistical power. In addition, differences in factors such as methods of interventions and type and intensity of treatment have led to varying results. A systematic review is needed to more accurately gauge the efficacy of music interventions in cancer patients as well as to identify variables that may moderate its effects.

Objectives

To assess and compare the effects of music therapy and music medicine interventions for psychological and physical outcomes in people with cancer.

Methods

Criteria for considering studies for this review

Types of studies

All randomized controlled trials (RCTs) and studies with quasi‐randomized methods of treatment allocation (e.g. alternate allocation of treatments) were eligible for inclusion.

Types of participants

This review included participants diagnosed with any type of cancer. We included studies that included a few participants (< 10% of total sample size) with non‐cancer diagnoses (e.g. aplastic anemia). There were no restrictions as to age, sex, ethnicity or type of setting. We did exclude participants undergoing biopsy, bone marrow biopsy and aspiration for diagnostic purposes. This review did not include studies with cancer survivors.

Types of interventions

The review included all trials comparing standard treatment plus music therapy or music medicine interventions (as defined in the Background; Description of the intervention) with:

  1. standard care alone;

  2. standard care plus alternative intervention (e.g. music therapy versus music medicine);

  3. standard care plus placebo.

Placebo treatment can involve the use of headphones for the participant without provision of music stimuli or with another type of auditory stimulus (e.g. audiobooks, white noise (hiss), pink noise (sound of ocean waves) or nature sounds).

Music therapy and music medicine interventions were pooled in the same analysis but, where possible, subgroup analyses were conducted to compare the effects of music therapy and music medicine interventions as outlined in the Subgroup analysis and investigation of heterogeneity section.

Types of outcome measures

Primary outcomes

  • Psychological outcomes (e.g. state anxiety, depression, distress, mood, hope, resilience)

  • Physical symptoms (e.g. fatigue, pain)

Secondary outcomes

  • Physiological outcomes (e.g. heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, oxygen saturation, immune system functioning)

  • Physical functioning

  • Anesthetic and analgesic intake

  • Length of hospitalization and recovery time

  • Social and spiritual support (e.g. spiritual well‐being, social support)

  • Communication (e.g. verbalization, facial affect, gestures)

  • Quality of life (QoL)

We presented a 'summary of findings Table 1 and summary of findings Table 2 reporting the following outcomes: anxiety, depression, mood, hope, pain, fatigue, and QoL.

Search methods for identification of studies

There were no language restrictions for either searching or trial inclusion.

Electronic searches

We searched the following electronic databases and trials registers for the updated review:

Searching other resources

We handsearched the following journals from first available date to December 2020:

  • Australian Journal of Music Therapy.

  • Australian Music Therapy Association Bulletin.

  • Canadian Journal of Music Therapy.

  • International Journal of the Arts in Medicine.

  • Journal of Music Therapy.

  • Musik‐,Tanz‐, und Kunsttherapie (Journal for Art Therapies in Education, Welfare and Health Care).

  • Musiktherapeutische Umschau.

  • Music Therapy.

  • Music Therapy Perspectives.

  • Nordic Journal of Music Therapy;

  • Music Therapy Today (online journal of music therapy).

  • Voices (online international journal of music therapy).

  • New Zealand Journal of Music Therapy.

  • Arts in Psychotherapy.

  • British Journal of Music Therapy.

  • Music and Medicine.

  • Approaches.

In an effort to identify further published, unpublished and ongoing trials, we searched the bibliographies of relevant trials and reviews, contacted experts in the field, and searched available proceedings of music therapy conferences. We consulted music therapy association websites to help identify music therapy practitioners and conference information (e.g. the American Music Therapy Association at www.musictherapy.org and the British Association for Music Therapy at http://www.bamt.org). We also handsearched the website of the Deutsches Zentrum fur Musiktherapieforschung (www.dzm-heidelberg.de/forschung/publikationen/) and the research pages of the PhD programs that are listed on the website of the European Music Therapy Confederation (emtc-eu.com/music-therapy-research/).

Data collection and analysis

Selection of studies

We divided the responsibility of the searches, as outlined in the search strategy, amongst JBr, JBi and KMC. JBr, JBi, and KMC scanned titles and abstracts of each record retrieved from the search and deleted obviously irrelevant references. When we could not reject a title or abstract with certainty, we consulted the other review author. We used an inclusion criteria form to assess the trial's eligibility for inclusion (Appendix 15). We kept a record of all excluded trials that initially appeared eligible and the reason for exclusion.

Data extraction and management

JBi and KMC independently extracted data from the selected trials using a standardized coding form. We discussed differences in data extraction until reaching a consensus. We extracted the following data.

General information

  • Author

  • Year of publication

  • Title

  • Journal (title, volume, pages)

  • If unpublished, source

  • Duplicate publications

  • Country

  • Language of publication

Intervention information

  • Type of intervention (e.g. singing, song‐writing, music listening, music improvisation)

  • Music selection (detailed information on music selection in case of music listening)

  • Music preference (patient‐preferred versus researcher‐selected in case of music listening)

  • Level of intervention (music therapy versus music medicine, as defined by the authors in the Background ; Description of the intervention)

  • Length of intervention

  • Frequency of intervention

  • Comparison intervention

Participant information

  • Total sample size

  • Number in experimental group

  • Number in control group

  • Sex

  • Age

  • Ethnicity

  • Diagnosis

  • Illness stage

  • Setting

  • Inclusion criteria

Outcomes

We extracted pre‐test means, post‐test means, standard deviations and sample sizes for the treatment group and the control group for the following outcomes (if applicable). For some trials, only change scores, instead of post‐test scores, were available.

  • Psychological outcomes (e.g. depression, anxiety, anger, hopelessness, helplessness)

  • Physical symptoms (e.g. fatigue, nausea, pain)

  • Physiological outcomes (e.g. heart rate, respiratory rate, immunoglobulin A (IgA) levels)

  • Social and spiritual support (e.g. family support, spirituality, social activity, isolation)

  • Communication (e.g. verbalization, facial affect, gestures)

  • Quality of life

Assessment of risk of bias in included studies

Two review authors (JBr and CD) assessed all included trials for risk of bias for the original review. New studies included in this update were assessed for risk of bias by CD, JBi and KMC (two reviewers per study). All authors were blinded to each other's assessments. JBr reviewed the reviewer authors' decisions. When there was no consensus between the two reviewer authors, JBr provided input to reach consensus. We resolved any disagreements by discussion. The authors used the following criteria for quality assessment.

Random sequence generation

  • Low risk

  • Unclear risk

  • High risk

We rated trials to be at low risk for random sequence generation if every participant had an equal chance to be selected for either condition, and the investigator was unable to predict which treatment the participant would be assigned to. Use of date of birth, date of admission or alternation resulted in a judgement of high risk of bias.

Allocation concealment

  • Low risk methods to conceal allocation include:

    • central randomization;

    • serially numbered, opaque, sealed envelopes;

    • other descriptions with convincing concealment.

  • Unclear risk ‐ authors did not adequately report on method of concealment

  • High risk (e.g. trials used alternation methods)

Blinding of participants and personnel

  • Low risk

  • Unclear risk

  • High risk

Since participants cannot be blinded in a music intervention trial, we did not downgrade studies for not blinding the participants. As for personnel, in music therapy studies, music therapists cannot be blinded because they are actively making music with the participants. In contrast, in music medicine studies, blinding of personnel is possible by providing control group participants with headphones but no music (e.g. blank CD). Therefore, downgrading for not blinding personnel was only applied in studies that used listening to pre‐recorded music.

Blinding of outcome assessors

  • Low risk

  • Unclear risk

  • High risk

When the study included no objective outcomes, we noted this in the Characteristics of included studies table, and we rated the trial as being at low risk of bias for outcome assessment of objective outcomes. The majority of the studies used self‐report measures for subjective outcomes. We rated these studies as being at high risk of bias for subjective outcomes, unless study participants were blinded to the study hypothesis (for comparative studies).

Incomplete outcome data

We recorded the proportion of participants whose outcomes were analyzed. We coded loss to follow‐up for each outcome as:

  • low risk: if fewer than 20% of participants were lost to follow‐up and reasons for loss to follow‐up were similar in both treatment arms;

  • unclear risk: if loss to follow‐up was not reported;

  • high risk: if more than 20% of participants were lost to follow‐up or reasons for loss to follow‐up differed between treatment arms.

Selective reporting

  • Low risk: reports of the study were free from suggestions of selective outcome reporting

  • Unclear risk

  • High risk: reports of the study suggested selective outcome reporting

Other sources of bias

  • Low risk

  • Unclear risk

  • High risk

We considered information on potential financial conflicts of interest to be a possible source of additional bias.

The above criteria were used to give each article an overall quality rating (based on section 8 of the Cochrane Handbook for Systematic Reviews of Interventions;Higgins 2021).

  • Low risk of bias ‐ all criteria met.

  • Moderate risk of bias ‐ one or more of the criteria only partly met.

  • High risk of bias ‐ one or more criteria not met.

Studies were not excluded based on a low quality score. We planned to use the overall quality assessment rating for sensitivity analysis. However, since most trials were at high risk of bias, we could not carry out this analysis.

Measures of treatment effect

We presented all outcomes in this review as continuous variables. We calculated standardized mean differences with 95% confidence intervals (CI) for outcome measures using results from different scales. When there were sufficient data available from various studies using the same measurement instrument, we computed a mean difference (MD) with 95% CI.

For cross‐over studies, if no carry‐over effects or period effects were apparent, we used data from the paired analyses in the meta‐analysis using a generic inverse‐variance approach. If paired analyses were not reported, we approximated the mean difference or standardized mean difference using methods outlined in Elbourne 2002. If carry‐over or period effects were present, the cross‐over trial were excluded from the meta‐analysis.

Unit of analysis issues

In all studies included in this review, participants were individually randomized to the intervention or the standard care control group. Post‐test values or change values on a single measurement for each outcome from each participant were collected and analyzed.

Dealing with missing data

We did not impute missing outcome data. We analyzed data on an endpoint basis, including only participants for whom final data point measurement was available (available case analysis). We did not assume that participants who dropped out after randomization had a negative outcome.

Assessment of heterogeneity

We investigated heterogeneity using visual inspection of the forest plots as well as the I2 statistic (Higgins 2002).

Assessment of reporting biases

We tested for publication bias visually in the form of funnel plots (Higgins 2021).

Data synthesis

We presented all outcomes in this review as continuous variables. We calculated standardized mean differences (SMD) for outcome measures using results from different scales. We used mean differences (MD) for results using the same scales. We anticipated that some individual trials would have used final scores and others change scores and even analysis of covariance (ANCOVA) in their statistical analyses of the results. We combined these different types of analyses as MDs. We calculated pooled estimates using the more conservative random‐effects model. We calculated 95% confidence intervals (CI) for each effect size estimate. We interpreted the magnitude of the SMDs using the interpretation guidelines put forth by Cohen 1988. Cohen 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 made the following treatment comparisons in meta‐analyses:

  • Music interventions plus standard care versus standard care alone in adults.

  • Music interventions plus standard care versus standard care alone in children.

  • Music interventions plus standard care versus standard care plus placebo control in children.

  • Music therapy plus standard care versus music medicine plus standard care in adults.

In the update of this review, we separated pediatric studies (participants < 18 years of age) from adult clinical trials for data synthesis. In prior versions of this review, these studies were combined in meta‐analyses.

Subgroup analysis and investigation of heterogeneity

We conducted the following subgroup analyses within the music interventions plus standard care versus standard care alone comparison for outcomes with a sufficient number of available studies.

  1. Music medicine versus music therapy.

  2. Type of intervention (e.g. music listening alone versus music‐guided relaxation).

  3. Music preference (patient‐preferred music versus researcher‐selected music).

We planned the following subgroup analyses a priori, but we could not carry these out because of insufficient numbers of trials per outcome for age subgroup analysis and because no separate data were available according to stage of illness.

  1. Different age groups.

  2. Stages of illness.

We conducted subgroup analyses as described by Deeks 2001 and recommended in section 10.10 of Higgins 2021.

Sensitivity analysis

We examined the impact of sequence generation by comparing the results of including and excluding trials that used inadequate or unclear randomization methods. We also examined whether the inclusion of studies with non‐cancer participants (< 10%) had an impact on the pooled effect size.

Summary of findings and assessment of the certainty of the evidence

We presented the overall certainty of the evidence for each outcome (see Types of outcome measures) according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which takes into account issues not only related to internal validity (risk of bias, inconsistency, imprecision, publication bias) but also to external validity such as directness of results (Langendam 2013; Schünemann 2011). We presented a summary of findings table (see summary of findings Table 1) based on the methods described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2021) and using GRADEpro 2020. We used the GRADE checklist and GRADE Working Group certainty of evidence definitions (Meader 2014). We downgraded the evidence from 'high' certainty by one level for serious (or by two for very serious) concerns study for limitations for each outcome:

  • High‐certainty: We are very confident that the true effect lies close to that of the estimate of the effect.

  • Moderate‐certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

  • Low‐certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.

  • Very low‐certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Results

Description of studies

Results of the search

For the original review, the database searches and handsearching of conference proceedings, journals and reference lists resulted in 773 unique citations. One review author (JBr) and a research assistant examined the titles and abstracts and identified 101 reports as potentially relevant, which we retrieved for further assessment. One review author (JBr) and a research assistant then independently screened them. We included 30 trials, reported in 36 records, in the original review. Where necessary, we contacted principal investigators to obtain additional details on trials and data.

The 2016 update of the search resulted in 1187 unique citations. Two review authors (JBr and AT) and one research assistant examined the titles and abstracts, retrieving full‐text articles, where necessary. This resulted in the addition of 25 references reporting on 22 trials (Figure 1) and three new ongoing trials (Mondanaro 2020; NCT02583139; NCT0258312).


Study flow diagram.

Study flow diagram.

The 2020 update of the search resulted in 1314 unique citations. Two review authors (JBi and KMC) examined the titles and abstracts, retrieving full‐text articles, where necessary. A research assistant helped with article retrieval. This resulted in the addition of 31 references reporting on 29 trials (Figure 1). In addition, we identified 19 ongoing trials (see Characteristics of ongoing studies) and 15 trials awaiting assessment (see Characteristics of ongoing studies) including Mondanaro 2020, which was an ongoing study in the 2016 update and has since been published.

Included studies

We included a total of 81 trials (74 trials with 5306 adult participants and seven trials focused on 270 pediatric oncology participants). Twenty‐six trials included participants who underwent chemotherapy or radiation therapy (Alcantara‐Silva 2018; Bradt 2015; Bro 2019; Bulfone 2009; Burns 2018; Burrai 2014; Cai 2001; Chen 2013; Chen 2020; Clark 2006; Ferrer 2005; Firmeza 2017; Gimeno 2008; Hunter 2020; Jin 2011; Karadag 2019; Lin 2011; Moradian 2015; O'Callaghan 2012; Romito 2013; Rossetti 2017; Smith 2001; Straw 1991; Tuinmann 2017; Xie 2001; Zhao 2008), 23 trials examined the effects of music during procedures or surgery (Alam 2016; Bates 2017; Binns‐Turner 2008; Burns 2009; Cassileth 2003; Danhauer 2010; Doro 2017; Fredenburg 2014a; Fredenburg 2014b; Kwekkeboom 2003; Li 2004; Li 2012; Mou 2020; Pedersen 2020; Palmer 2015; Pinto 2012; Ratcliff 2014; Rosenow 2014; Vachiramon 2013; Wang 2015; Wren 2019; Yates 2015; Zhou 2015), and 25 trials included general cancer participants (Arruda 2016; Beck 1989; Bieligmeyer 2018; Burns 2001a; Burns 2008; Chen 2004; Chen 2018; Cook 2013; Hanser 2006; Harper 2001; Hilliard 2003; Horne‐Thompson 2008; Huang 2006; Jasemi 2016; Keenan 2017; Letwin 2017; Liao 2013; Porter 2018; Ramirez 2018; Reimnitz 2018; Shaban 2006; Verstegen 2016; Verstegen 2018; Wan 2009; Warth 2015). Seven trials (N = 270) examined music interventions in pediatric participants (Bufalini 2009; Burns 2009; Duocastella 1999; Nguyen 2010; Robb 2008; Robb 2014; Robb 2017). Four trials included a few participants (< 10% of total sample size) who had a hematological disease but did not have a cancer diagnosis (e.g. aplastic anemia) (Horne‐Thompson 2008; Porter 2018; Reimnitz 2018; Verstegen 2018).

This review included 3238 adult females and 1809 adult males. The pediatric trials included 103 females and 144 males. Five trials did not provide information on the distribution between sexes (Danhauer 2010; Jin 2011; Robb 2008; Shaban 2006; Xie 2001). The average age of the participants was 54.72 years for adult trials and 11.12 years for pediatric trials.

Thirty‐one studies did not report on the ethnicity of the participants (Alam 2016; Arruda 2016; Bieligmeyer 2018; Bro 2019; Burns 2001a; Burns 2008; Burrai 2014; Cassileth 2003; Chen 2013; Chen 2018; Chen 2020; Cook 2013; Doro 2017; Duocastella 1999; Ferrer 2005; Firmeza 2017; Horne‐Thompson 2008; Jasemi 2016; Karadag 2019; Letwin 2017; Lin 2011; Moradian 2015; Mou 2020; O'Callaghan 2012; Pedersen 2020; Robb 2008; Romito 2013; Straw 1991; Vachiramon 2013; Wang 2015; Zhou 2015). For trials that did provide information on ethnicity, the distribution was as follows: 56% white, 25% Asian, 10% black, 6% Latino, and 3% other.

The trials took place in 13 different countries: the United States (Alam 2016; Bates 2017; Bradt 2015; Burns 2018; Beck 1989; Binns‐Turner 2008; Burns 2001a; Burns 2008; Burns 2009; Cassileth 2003; Clark 2006; Cook 2013; Danhauer 2010; Ferrer 2005; Fredenburg 2014a; Fredenburg 2014b; Hanser 2006; Harper 2001; Hilliard 2003; Hunter 2020; Keenan 2017; Kwekkeboom 2003; Letwin 2017; Gimeno 2008; Palmer 2015; Ratcliff 2014; Reimnitz 2018; Robb 2008; Robb 2014; Robb 2017; Rosenow 2014; Rossetti 2017; Smith 2001; Straw 1991; Vachiramon 2013; Verstegen 2016; Verstegen 2018; Wren 2019; Yates 2015), China (Cai 2001; Chen 2004; Chen 2020; Jin 2011; Li 2004; Li 2012; Liao 2013; Mou 2020; Wan 2009; Xie 2001; Zhao 2008), Denmark (Bro 2019; Pedersen 2020), Germany (Bieligmeyer 2018; Tuinmann 2017; Warth 2015), Italy (Bufalini 2009; Bulfone 2009), Iran (Jasemi 2016; Moradian 2015; Shaban 2006), Ireland (Porter 2018), Spain (Duocastella 1999; Ramirez 2018), Taiwan (Chen 2013; Chen 2018; Huang 2006; Lin 2011; Wang 2015; Zhou 2015), Brazil (Alcantara‐Silva 2018; Arruda 2016; Doro 2017; Firmeza 2017; Pinto 2012), Australia (Horne‐Thompson 2008; O'Callaghan 2012), Turkey (Karadag 2019), and Vietnam (Nguyen 2010). Trial sample size ranged from 8 to 260 participants.

We classified 39 trials as music therapy studies (Alcantara‐Silva 2018; Bates 2017; Bieligmeyer 2018; Bradt 2015; Bufalini 2009; Burns 2001a; Burns 2008; Burns 2009; Burns 2018; Cassileth 2003; Clark 2006; Cook 2013; Doro 2017; Duocastella 1999; Ferrer 2005; Fredenburg 2014a; Fredenburg 2014b; Hanser 2006; Hilliard 2003; Horne‐Thompson 2008; Letwin 2017; Gimeno 2008; Palmer 2015; Porter 2018; Ramirez 2018; Ratcliff 2014; Reimnitz 2018; Robb 2008; Robb 2014; Robb 2017; Romito 2013; Rosenow 2014; Rossetti 2017; Stordahl 2009; Tuinmann 2017; Verstegen 2016 ; Verstegen 2018; Warth 2015; Yates 2015). Of these trials, ten used interactive music‐making with the participants, five used music‐guided imagery, three used music‐guided relaxation, 10 used live patient‐selected music performed by the music therapist, two used music listening accompanied by processing of emotions evoked by the music, five studies used a combination of interactive music making and listening to live music, one study used vibro‐acoustic therapy, and two used music video‐making. We classified 43 trials as music medicine studies (Alam 2016; Arruda 2016; Beck 1989; Binns‐Turner 2008; Bro 2019; Bulfone 2009; Burrai 2014; Cai 2001; Chen 2004; Chen 2013; Chen 2018; Chen 2020; Danhauer 2010; Firmeza 2017; Harper 2001; Huang 2006; Hunter 2020; Jasemi 2016; Jin 2011; Karadag 2019; Keenan 2017; Kwekkeboom 2003; Li 2004; Li 2012; Liao 2013; Lin 2011; Moradian 2015; Mou 2020; Nguyen 2010; O'Callaghan 2012; Pedersen 2020; Pinto 2012; Shaban 2006; Smith 2001; Straw 1991; Vachiramon 2013; Wan 2009; Wang 2015; Wren 2019; Xie 2001; Zhao 2008; Zhou 2015), as defined by the authors in the background section, and used listening to pre‐recorded music as the intervention.

Frequency and duration of treatment sessions greatly varied among the trials. The total number of sessions ranged from 1 to 40 (e.g. multiple music listening sessions per day for length of hospital stay). Most sessions lasted 30 to 45 minutes. We reported details on the frequency and duration of sessions for each trial in the Characteristics of included studies table.

Seventy‐eight trials used parallel‐group designs, whereas three trials used a cross‐over design (Bradt 2015; Beck 1989; Gimeno 2008). Not all trials measured all outcomes identified for this review.

We provided details of the included trials in the review in the Characteristics of included studies table.

Excluded studies

In the original review, 27 of the 101 reports that we retrieved for further assessment were assessed not to be outcome research studies. We identified 38 experimental research studies that appeared eligible for inclusion. However, we excluded these after closer examination or after receiving additional information from the principal investigators. Reasons for exclusions were: not a randomized or quasi‐randomized controlled trial (29 studies); insufficient data reporting (2 studies); unacceptable methodological quality (3 studies); not a music intervention (1 study); not exclusively cancer participants (1 study); and article could not be located (2 studies).

For the 2016 update, we retrieved 94 reports for further assessment. We excluded 60 studies for the following reasons: not a randomized or quasi‐randomized controlled trial (36 studies), insufficient data reporting (2 studies), not a music intervention (12 studies), not population of interest (8 studies), use of healthy controls (1 study), and use of non‐standardized measurement tools (1 study).

For the current update, we retrieved 83 reports for further assessment. We excluded 37 studies for the following reasons: not a randomized or quasi‐randomized controlled trial (14 studies), not a music intervention (9 studies), and not population of interest (14 studies).

For studies with insufficient data reporting or those that could not be located, we attempted to contact the authors on multiple occasions.

Details about reasons for exclusion are provided in the Characteristics of excluded studies table.

Risk of bias in included studies

We detailed the risk of bias for each trial in the risk of bias tables included in the Characteristics of included studies table and the risk of bias summary (Figure 2). In addition, readers can consult an overall assessment of risk of bias in Figure 3.


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

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


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

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

Allocation

We included 61 trials that used appropriate methods of randomization (e.g. computer‐generated table of random numbers, drawing of lots, coin flip), nine trials that used systematic methods of treatment allocation (e.g. alternate group assignment, date of birth), and 11 trials that reported using randomization but failed to state the randomization method.

Thirty‐three trials concealed allocation, whereas 16 trials did not. For the remainder of the trials, authors did not mention allocation concealment.

Blinding

Twenty‐five trials included objective outcomes, but only seven of them reported blinding of the outcome assessors. For 11 trials, the use of blinding was unclear (Bro 2019; Burrai 2014; Chen 2004; Chen 2020; Ferrer 2005; Firmeza 2017; Jin 2011; Palmer 2015; Ramirez 2018; Tuinmann 2017; Wren 2019). The other trials did not use blinding. The majority of the trials included subjective outcomes only. It is important to point out that blinding of outcome assessors is not possible in the case of self‐report measurement tools for subjective outcomes (e.g. STAI; Spielberger 1983) unless the participants are blinded to the intervention. Blinding of the participants is often not feasible in music therapy and music medicine studies. This may introduce possible bias.

Incomplete outcome data

The dropout rate was small for most trials, falling between 0% and 17%. Fifteen trials reported dropout rates of more than 20%. For 21 trials, it was unclear whether there were any participant withdrawals. Most trials reported reasons for dropout. Detailed information on dropout rate and reasons is included in the Characteristics of included studies table.

Selective reporting

We found evidence of selective reporting in three trials (Burns 2008; Hunter 2020; Ratcliff 2014).

We examined publication bias visually in the form of funnel plots for several of the included outcomes. Visual inspection suggested that there was no publication bias for anxiety (Figure 4), depression (Figure 5), pain (Figure 6),


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

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


Funnel plot of comparison: 1 Music intervention plus standard care versus standard care alone with adults, outcome: 1.6 Depression.

Funnel plot of comparison: 1 Music intervention plus standard care versus standard care alone with adults, outcome: 1.6 Depression.


Funnel plot of comparison: 1 Music intervention plus standard care versus standard care alone with adults, outcome: 1.13 Pain.

Funnel plot of comparison: 1 Music intervention plus standard care versus standard care alone with adults, outcome: 1.13 Pain.

Other potential sources of bias

For ten trials, it was unclear if there were other potential sources of bias because no explicit declaration of interest statement was included in the publication..

Overall risk of bias

As a result, only one trial was at overall low risk of bias (Bradt 2015). Three additional trials were at low risk of bias for objective outcomes, as they satisfied all criteria used to assess risk of bias (Alam 2016; Duocastella 1999; Nguyen 2010). Five trials were at moderate risk of bias for objective outcomes (Binns‐Turner 2008; Bro 2019; Burrai 2014; Hilliard 2003; Palmer 2015). Seventy‐two trials were at high risk of bias. The main reason for receiving a high risk of bias rating was the lack of blinding. As pointed out above, blinding is often impossible in music therapy and music medicine studies that use subjective outcomes, unless the studies compare the music intervention with another active treatment intervention (e.g. progressive muscle relaxation). This is especially true for music therapy studies that use active music‐making. Therefore, it appears impossible for these types of studies to receive a low or even moderate risk of bias even if they have adequately addressed all other risk factors (e.g. randomization, allocation concealment, etc.).

Effects of interventions

See: Summary of findings 1 Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in adult cancer patients; Summary of findings 2 Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in paediatric cancer patients

Comparison 1: Music intervention plus standard care versus standard care alone in adults

Primary outcomes
Psychological outcomes

State anxiety

Thirty‐three trials examined the effects of music interventions plus standard care compared to standard care alone for anxiety in adult participants with cancer. Nineteen trials measured anxiety by means of the Spielberger State‐Trait Anxiety Inventory ‐ State Anxiety form (STAI‐S) (Alam 2016; Binns‐Turner 2008; Bro 2019; Bulfone 2009; Chen 2013; Danhauer 2010; Firmeza 2017; Harper 2001; Jin 2011; Kwekkeboom 2003; Li 2012; Lin 2011; O'Callaghan 2012; Rossetti 2017; Smith 2001; Vachiramon 2013; Wan 2009; Wren 2019; Zhou 2015); and fourteen trials reported mean anxiety measured by other scales, such as a numeric rating scale (NRS) or a visual analogue scale (VAS) (Cai 2001; Chen 2020; Cassileth 2003; Doro 2017; Ferrer 2005; Hanser 2006; Karadag 2019; Li 2004; Mou 2020; Palmer 2015; Tuinmann 2017; Verstegen 2018; Yates 2015; Zhao 2008). We could not include the data from Burns 2008 because it did not report post‐test or follow‐up scores. The author did provide follow‐up scores (four weeks post‐intervention), but we could not combine these with the post‐test scores of the other trials. Moreover, Burns 2008 reported a large moderating effect of pre‐intervention affect state scores on post‐test scores and follow‐up scores. We also did not include the data from Kwekkeboom 2003 in the meta‐analysis because this study was affected by a serious flaw in the implementation of the intervention. Participants in this trial listened to music while undergoing painful medical procedures. However, they reported that the use of headphones prevented them from hearing the surgeon, increasing their anxiety. Finally, we reported the data from Hanser 2006 narratively and did not include them in the meta‐analysis because of the high attrition rate (40%). In addition, the researchers experienced serious issues with intervention implementation within the predetermined implementation timeframe (three sessions were implemented over a 15‐week period), and the authors concluded that the intervention was significantly diluted because of this.

A meta‐analysis of 17 trials (N = 1381) that used the full STAI‐S (score range: 20 to 80) to examine state anxiety in 1381 participants indicated a lower state of anxiety in participants who received standard care combined with music interventions than those who received standard care alone (MD −7.73, 95% CI −10.02 to −5.44, P < 0.00001; very low‐certainty evidence; Analysis 1.1). Statistical heterogeneity was high across the trials (I2 = 93%). Removal of outliers (Binns‐Turner 2008; Harper 2001; Wan 2009) did not reduce heterogeneity much (I2 = 80%) . In Kwekkeboom 2003, participants in the music listening group reported higher levels of anxiety at post‐test (mean: 33.45, standard deviation (SD) 1.77) than those in the standard care group (mean: 30.59, SD 1.93). A sensitivity analysis excluding the trials that used inadequate methods of randomization (Bulfone 2009; Chen 2013) had minimal impact on the pooled effect size (MD −7.83, 95% CI −10.91 to −4.76, P < 0.00001, I2 = 92%; Analysis 1.1).

The standardized mean difference (SMD) of trials that reported post‐test anxiety scores on measures other than the full‐form STAI‐S (N = 882) also suggested a moderate to large anxiety‐reducing effect of music (SMD −0.76, 95% CI −1.28 to −0.25, P = 0.004; Analysis 1.2; 9 trials (Cai 2001; Chen 2020; Ferrer 2005; Karadag 2019; Li 2004; Mou 2020; Verstegen 2018; Zhao 2008; Yates 2015)). The results were not consistent across the trials (I2 = 91%) with one trial reporting a much larger effect size than other trials (Mou 2020) and one trial favoring the standard care control condition (Chen 2020). We did not include the data of four trials in the meta‐analysis because change scores and final scores should not be combined for the computation of a SMD (Alam 2016; Cassileth 2003; Doro 2017; Palmer 2015) or because only effect sizes were reported (Tuinmann 2017). However, the data by Cassileth 2003 were consistent with the results of the meta‐analysis, reporting a greater effect of music therapy on anxiety (mean change score: −2.6, SD 2.5) than standard care alone (mean change score: −0.9, SD 3.0) on the POMS‐anxiety subscale (score range: 0 to 36). Likewise, the data from Palmer 2015 indicated a beneficial effect of music therapy (mean change score: −30.9, SD 36.3) versus standard care (mean change score: 0, SD 22.7) on the Global Anxiety‐VAS (score range: 0 to 100 mm). The findings from Tuinmann 2017 also supported a greater treatment benefit of music therapy than standard care control (MD = −0.3, 95% CI −1.8 to −1.2). Finally, Alam 2016 reported similar change scores for the music intervention treatment arm (mean change score: −9.94, SD 2.42) and the control treatment arm (mean change score: −9.35, SD = 2.71), whereas Doro 2017 reported negligible change in anxiety for both treatment arms. A sensitivity analysis to examine the impact of randomization method, excluding the data of Cai 2001, Ferrer 2005 and Li 2004, had a minimal impact on the pooled effect size (SMD −0.72; 95% CI −1.67 to 0.23, P = 0.14; Analysis 1.2 ). A sensitivity analysis removing studies that included some participants without a cancer diagnosis (Verstegen 2018) did not impact the effect size estimate (SMD −0.75, 95% CI −1.3 to −0.21, P = 0.007, I2 = 92%; Analysis 1.2).

Based on these findings, we can conclude that music interventions may have a large anxiety‐reducing effect. However, because participants could not be blinded to the music intervention and anxiety was measured using self‐report, there is a potential for biased reporting by the participants. Due to this potential bias combined with the high heterogeneity associated with the pooled effect, the finding is low‐certainty evidence (summary of findings Table 1).

We conducted several a priori‐determined subgroup analyses, as outlined in the Methods.

Firstly, we compared the treatment benefits of music therapy versus music medicine studies for anxiety. We only included studies that reported post‐test scores in this analysis to allow for computation of a standardized mean difference across studies. The pooled effect of four music therapy studies (SMD −0.81, 95% CI −1.16 to −0.46, P < 0.00001, I2 = 0%; Ferrer 2005; Rossetti 2017; Verstegen 2018; Yates 2015) was similar to that of the music medicine studies (SMD −0.87, 95% CI −1.28 to −0.47, P < 0.0001, I2 = 94%; Binns‐Turner 2008; Bro 2019; Bulfone 2009; Cai 2001; Chen 2020; Danhauer 2010; Jin 2011; Karadag 2019; Li 2004; Li 2012; Lin 2011; Mou 2020; O'Callaghan 2012; Smith 2001; Vachiramon 2013; Wan 2009; Wren 2019; Zhao 2008; Zhou 2015). Although there was no evidence of a difference in effect between the music therapy studies and the music medicine studies (P = 0.83), it is worth noting that the results of the music therapy studies were consistent across studies, whereas the results of the music medicine studies were highly heterogeneous (Analysis 1.3). Because the results of the music therapy studies were consistent across studies, we can have greater confidence that music therapy interventions offered by a trained music therapist will result in large reductions in anxiety in adults with cancer.

Secondly, we compared studies that used patient‐preferred music with studies that used researcher‐selected music. For this comparison, we only included studies that used listening to pre‐recorded music as the intervention. Music preference did not appear to impact the treatment benefits for anxiety. The use of patient‐preferred music resulted in a SMD of −0.81 (95% CI −1.3 to −0.32, P = 0.001, I2 = 94%), whereas researcher‐selected music resulted in a SMD of −0.79 (95% CI −1.19 to −0.39, P = 0.0001, I2 = 56%) (Analysis 1.4).

Finally, we compared the music medicine studies by type of intervention (e.g. music‐guided relaxation, music listening alone, etc.). We could not conduct this subgroup analysis for music therapy studies because of an insufficient number of trials. The majority of the music medicine studies used listening to pre‐recorded music. Four studies, however, embedded relaxation or imagery instructions within the pre‐recorded music (Jin 2011; Lin 2011; Wan 2009; Zhou 2015). The pooled effect of these four studies (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% CI −1.16 to −0.26, P = 0.002, I2 = 89%), but because of the large heterogeneity, there was no evidence of a difference in effect between these two types of interventions (P = 0.10) (Analysis 1.5).

Depression

Twelve trials (N = 1021) examined the effects of music plus standard care compared to standard care alone on depression in 1021 participants (Arruda 2016; Bates 2017; Cai 2001; Cassileth 2003; Chen 2020; Clark 2006; Karadag 2019; Li 2012; Verstegen 2018; Wan 2009; Yates 2015; Zhou 2015). Their pooled estimate indicated a moderate treatment effect of music (SMD −0.41, 95% CI −0.67 to −0.15, P = 0.002; very low‐certainty evidence; Analysis 1.6), but the results were inconsistent across trials (I2 = 72%). When we removed two outliers (Karadag 2019; Li 2012), heterogeneity was greatly reduced (I2 = 13%), but there was no identifiable reason why these studies acted like an outlier. At first sight, it appeared that the outlier values might be explained by the fact that both of these studies used a large number of sessions (i.e. up to 25‐60 sessions compared to 1‐5 sessions in other studies). However, Cai 2001 used 30 sessions and this study did not act as an outlier.

A sensitivity analysis examining the impact of randomization method resulted in a smaller pooled effect size (SMD −0.32, 95% CI −0.59 to −0.04, P = 0.03, I2 = 70%; Analysis 1.6). A sensitivity analysis excluding one study that included some participants who did not have a cancer diagnosis (Verstegen 2018) did not impact the pooled effect size (SMD −0.41, 95% CI −0.68 to −0.15, P = 0.002, I2 = 75%; Analysis 1.6). Because participants could not be blinded to the music intervention and self‐report was used to measure depression, there is a potential for bias. This, as well as the fact that results were inconsistent across trials, makes this very‐low certainty evidence (summary of findings Table 1).

Subgroup analyses revealed that there was no evidence of a difference in effect between music therapy and music medicine studies for the outcome of depression (P = 0.14) (Analysis 1.7) or between patient‐preferred versus researcher‐selected music (Analysis 1.8).

Distress

Two trials (N = 127) examined the effects of music interventions on distress during radiation therapy (Clark 2006; Rossetti 2017). Their pooled estimate did not find support for an effect of music (SMD −0.38, 95% CI −1.43 to 0.66, I2 = 88%, P = 0.47).

Mood

The pooled estimate of five trials (N = 221) resulted in little effect of music interventions for mood in participants with cancer (SMD 0.53, 95% CI −0.03 to 1.11, P = 0.07; very low‐certainty evidence) Analysis 1.10; Burrai 2014; Cassileth 2003; Moradian 2015; Ratcliff 2014). The results were inconsistent across studies (I2 = 76%), with Burrai 2014 reporting much larger treatment benefits than the other studies. Removal of this outlier greatly reduced the heterogeneity (I2 = 0%). Although Burrai 2014 was the only study that used live saxophone music played by a nursing staff member, other studies included in this analysis used live music offered by music therapists. Therefore, it is unclear if the use of live music may have accounted for the large treatment benefit in the Burrai 2014 study. The potential bias stemming from participants not being blinded to the music intervention and the high heterogeneity associated with the pooled effect makes this very low‐certainty evidence (summary of findings Table 1).

A sensitivity analysis based on randomization method slightly increased the pooled effect (SMD 0.68, 95% CI −0.04 to 1.39, P = 0.06, I2 = 81%; Analysis 1.10) but the evidence concerning the impact of music interventions on mood is very uncertain.. We could not include the data from Burns 2001a in the meta‐analysis because the authors did not use a constant in the computation of their scores, as recommended in the Profile of Mood States (POMS) scoring guide (McNair 1971). The results of the meta‐analysis were robust compared to Burns 2001a, which reported a mean post‐test score of −48.25 (SD 32.96) for the music therapy group and a mean post‐test score of 20.75 (SD 30.87) for the control group. Due to a large baseline difference between the music and control treatment arms in Doro 2017, the post‐test values of this trial could not be included in the meta‐analysis. The results by Bieligmeyer 2018 are reported separately because this study used vibro‐acoustic therapy as the intervention. The authors reported larger mood‐enhancing effects in the vibro‐acoustic treatment arm (pretest scores: 71.8 SD 19.67; post‐test scores: 81, SD 16.26) than the control group (pre‐test scores: 73.52, SD 20.62; post‐test scores: 72.75, SD 20.63).

A subgroup analysis comparing music therapy (SMD 0.37, 95% CI −0.13 to 0.87, P = 0.15) with music medicine (SMD 0.73, 95% CI −0.54 to 1.99, P = 0.26) found no evidence of a difference in effect between the two types of studies (SMD 0.53, 95% CI ‐0.03 to 1.10, P = 0.6), but the results of the music therapy studies were consistent across studies (I2 = 37%), whereas the music medicine studies were inconsistent across studies (I2 = 90%) (Analysis 1.11).

Hope

Two studies examined the treatment benefits of music interventions for hope (Arruda 2016; Verstegen 2018) (Analysis 1.12). The pooled effect size indicated an increase of 3.19 on the Herth Hope Index with music interventions compared to control (MD, 95% CI 0.12 to 6.25, I2 = 48%, P = 0.04; very low‐certainty evidence).

Resilience

One music therapy trial with adult cancer participants (N = 15) (Letwin 2017) reported greater improvements in resilience in the music therapy treatment arm (pre‐test scores: 74.13, SD 11.29; post‐test scores: 81.88, SD 7.55) than in the control arm (pre‐test scores: 75.29, SD 13.29; post‐test scores: 78.57, SD 9.14) as measured on the The Response to Stressful Events Scale (RSES) (range: 0 to 88) (Johnson 2011).

Physical symptoms

Pain

Twenty trials compared the effects of music versus standard care on pain (Alam 2016; Arruda 2016; Bieligmeyer 2018; Binns‐Turner 2008; Clark 2006; Danhauer 2010; Doro 2017; Fredenburg 2014a; Huang 2006; Kwekkeboom 2003; Letwin 2017; Li 2012; Moradian 2015; Reimnitz 2018; Tuinmann 2017; Verstegen 2016; Verstegen 2018; Wan 2009; Wren 2019).

We could not include the data from Alam 2016, Clark 2006 or Moradian 2015 in the meta‐analysis because of the use of change scores. We could not include the post‐test scores from Doro 2017 due to large baseline differences between the treatment arms. Tuinmann 2017 only reported effect sizes which could not be included in this meta‐analysis. Kwekkeboom 2003 compared the effects of music listening, audiotape and standard care on procedural pain and anxiety, finding that participants did not like wearing the headsets as it prevented them from hearing the surgeon, causing greater anxiety. The literature suggests that increased anxiety leads to increased pain perception (McCracken 2009); therefore, we excluded these data from the meta‐analysis. We did not include the data from Bieligmeyer 2018 in the meta‐analysis because this study examined the effects of vibro‐acoustic therapy which combines music with vibrations to affect the body.

The pooled effect of the remaining twelve studies with 632 participants resulted in a moderate effect for music on pain perception (SMD −0.67, 95% CI −1.07 to −0.26, P = 0.001; very low‐certainty evidence; Analysis 1.13). There was disagreement between the trials on the size of the effect (I2 = 81%), but this was due to Li 2012 reporting much larger treatment benefits than the other trials. Removal of this outlier reduced the heterogeneity to 23%. As this was the only study with a large number of sessions (up to 60 sessions), frequency of sessions may be a potential explanation for this outlier. As with other outcomes in this review, there is a potential for bias because the participants could not be blinded and self‐report outcome measures were used. In addition, the large heterogeneity lowered the certainty of the evidence for this outcome. A sensitivity analysis excluding those studies that included some participants who did not have a cancer diagnosis (Reimnitz 2018; Verstegen 2016; Verstegen 2018) resulted in a larger effect size (SMD −0.77, 95% CI −1.25 to −0.29, P = 0.002, I2 = 85%; Analysis 1.13).

Using a 0 to 10 numeric rating scale, Clark 2006 found that music therapy resulted in greater pain reduction (mean change score: −0.44, SD 2.55) than standard care (mean change score: 0.45, SD 1.87). In contrast, Moradian 2015 reported similar improvements in pain for the treatment (mean change score: −12.96, SD 24.16) and the control group (mean change score: −13.58, SD 28.51). Tuinmann 2017 reported a greater treatment benefit for music compared to standard care for pain (MD = ‐10, 95% CI ‐18.9 to ‐1.2) on the pain subscale of the European Organization for Research and Treatment on Cancer scale (EORTC). In contrast, Alam 2016 reported minimal pain reduction in participants who listened to pre‐recorded music (mean change score: ‐0.41, SD = 1.69) versus those who did not (mean change score: ‐0.23, SD = 1.57) during cutaneous surgery. Finally, Bieligmeyer 2018 reported greater pain‐reducing effects in participants who underwent vibro‐acoustic therapy (pre‐test scores: 12.88, SD 19.59; post‐test scores: 10, SD 16.3) than those in the control group (pre‐test scores: 12.75, SD 18.62; post‐test scores: 15.36, SD 21.56).

For this outcome, we were able to compare the treatment benefits of music therapy versus music medicine studies (Analysis 1.14). The pooled effect of five music therapy trials suggested a moderate pain‐reducing effect of music therapy. This effect was consistent across trials and therefore enhanced our confidence in this evidence (SMD −0.47, 95% CI −0.86 to −0.07, P = 0.02, I2 = 0%; Fredenburg 2014a; Letwin 2017; Reimnitz 2018; Verstegen 2016; Verstegen 2018). The pooled effect of music medicine studies was larger but was highly inconsistent across studies (SMD −0.81, 95% CI −1.38 to −0.24, P = 0.005, I2 = 89%; (Arruda 2016; Binns‐Turner 2008; Danhauer 2010; Huang 2006; Li 2012; Wan 2009; Xie 2001).

We were also able to examine the impact of music preference on treatment effect (SMD −0.84, 95% CI −1.34 to −0.33, P = 0.001, I2 = 87%; Analysis 1.15). Although there was no evidence of a difference in effect between the use of patient‐preferred music and researcher‐selected music (P = 0.78), the use of patient‐preferred music led to a larger pooled effect (SMD −0.87, 95% CI −1.65 to −0.1, P = 0.03, I2 = 90%) than the use of researcher‐selected music (SMD −0.74, 95% CI −1.33 to 0.14, P = 0.02, I2 = 73%). The large heterogeneity was due to some studies reporting a much larger beneficial effect than others.

Fatigue

Ten trials examined the effects of music interventions on fatigue in 498 participants (Bates 2017; Cassileth 2003; Chen 2020; Clark 2006; Ferrer 2005; Fredenburg 2014b; Moradian 2015; Reimnitz 2018; Rosenow 2014; Wren 2019). The pooled estimate of their change scores indicated a small effect for music interventions (SMD −0.28, 95% CI −0.46 to −0.10, P = 0.002; low‐certainty evidence, Analysis 1.16), with consistent results across studies (I2 = 0%). Burns 2008 also collected data on fatigue; however, investigators did not report post‐intervention data; the study provided us with four‐week post‐intervention follow‐up scores, but could not provide the immediate post‐test scores. This prevented us from pooling their data with data from the other three studies. A sensitivity analysis excluding one study due to inadequate randomization methods (Ferrer 2005) had minimal impact on the pooled effect (SMD −0.26, 95% CI −0.45 to ‐0.07, P = 0.007, I2 = 0%; Analysis 1.16). A sensitivity analysis excluding one study that included some participants who did not have a cancer diagnosis (Reimnitz 2018) also had minimal impact on the pooled effect (SMD −0.26, 95% −0.44 to −.0.07, P = 0.007, I2 = 0%; Analysis 1.16).

A comparison between music therapy and music medicine trials suggested a small to moderate effect for music therapy trials that was consistent across trials (SMD −0.36, 95% CI −0.61 to −0.12, P = 0.004, I2 = 0%; Bates 2017; Cassileth 2003; Ferrer 2005; Fredenburg 2014b; Reimnitz 2018; Rosenow 2014), whereas there was no evidence of an effect for music medicine trials (SMD −0.15, 95% CI −0.43 to 0.14, P = 0.31, I2 = 0%; Chen 2020; Moradian 2015; Wren 2019) (Analysis 1.17).

Secondary outcomes
Physiological outcomes

Heart rate

Twelve trials examined the effects of music on heart rate in 1165 participants (Alam 2016; Binns‐Turner 2008; Bro 2019; Burrai 2014; Chen 2013; Ferrer 2005; Firmeza 2017; Harper 2001; Jin 2011; Mou 2020; Wren 2019; Zhao 2008). All of the studies except for Ferrer 2005 were music medicine studies. Since Bro 2019 only reported effect sizes, the findings of that study were not included in this meta‐analysis. The pooled estimate of the remaining 11 studies (N = 1022) showed a decrease in heart rate, favoring music interventions over standard care (MD −3.4, 95% CI −5.58 to −1.23, P = 0.002; Analysis 1.19). However, the results were inconsistent across studies (I2 = 82%). A sensitivity analysis excluding Ferrer 2005 and Chen 2013 because of an unknown randomization method and a lack of proper randomization, respectively, resulted in a larger effect with less heterogeneity (MD −4.37, 95% CI −6.29 to −2.44, P < 0.00001, I2 = 51%; Analysis 1.19).

Bro 2019 reported a greater decrease in heart rate for participants who listened to live music during chemotherapy versus those in the control group (MD ‐1.8, 95% CI ‐3.9 to 0.2, P = 0.08).

A subgroup analysis for music preference indicated that there was no evidence of a difference in effect (P = 0.62) for heart rate between researcher‐selected music (MD −4.47, 95% CI −8.02 to −0.91, P = 0.01, I2 = 61%) and patient‐preferred music (MD −3.34, 95% CI −6.06 to −0.62, P = 0.02, I2 = 80%; Analysis 1.20).

One cross‐over trial compared the effect of music and imagery with imagery alone (Gimeno 2008). Both interventions resulted in similar decreases in heart rate from pre‐test to post‐test (P = 0.9): the music and imagery group's mean heart rate dropped from 89.58 beats per minute (bpm) (SD 17.32) at pre‐test to 78.84 bpm (SD 13.46) at post‐test; the imagery only group's mean heart rate dropped from 93.31 bpm (SD 15.76) to 81.05 bpm (SD 13.96).

Respiratory rate

The pooled estimate of five trials (N = 437) suggested a very small, beneficial effect for music interventions on respiratory rate (MD −0.71, 95% CI −1.18 to −0.23, P = 0.004; Analysis 1.21; Chen 2013; Firmeza 2017; Jin 2011; Mou 2020; Zhao 2008), and the studies did not agree on the size of effect (I2 = 86%). A sensitivity analysis excluding Chen 2013 because of failure to use a proper method of randomization resulted in a larger pooled effect (MD −1.18, 95% CI −2.46 to 0.11, P = 0.07, I2 = 88%; Analysis 1.21).

We could not conduct a subgroup analysis based on music preference for this outcome due to an insufficient number of trials differentiating music type.

Systolic blood pressure

We found a pooled estimate of −4.18 mmHg (95% CI −6.7 to −1.66, P = 0.001; N = 992; Analysis 1.22) for systolic blood pressure (SBP), favoring music interventions (Alam 2016; Burrai 2014; Chen 2013; Ferrer 2005; Firmeza 2017; Harper 2001; Jin 2011; ; Mou 2020; Wren 2019; Zhao 2008). The results were inconsistent across studies (I2 = 70%). Excluding Chen 2013 and Ferrer 2005 because of lack of proper randomization had minimal impact on the pooled effect size (MD −4.5 mmHg, 95% CI −8.36 to −0.64, P = 0.02, I2 = 73%; Analysis 1.22). All of the studies except for Ferrer 2005 were music medicine studies. Bro 2019 reported a minimal effect on SBP of listening to live music compared to standard care (MD −0.7, 95% CI −4.3 to 2.9, P = 0.7)).

We conducted a subgroup analysis based on music preference (Analysis 1.23), but no significant difference was found between the effect of patient‐preferred music (MD −4.82, 95% CI −7.9 to −1.75, P = 0.002, I2 = 70%) compared to researcher‐selected music (MD −4.71, 95% CI −12.04 to 2.63, P = 0.21, I2 = 78%) (P = 0.98).

Diastolic blood pressure

We found a pooled estimate of −2.34 mmHg (95% CI −4.7 to 0.01; Analysis 1.24) for diastolic blood pressure (DBP) in 992 participants (Alam 2016; Burrai 2014; Chen 2013; Ferrer 2005; Firmeza 2017; Harper 2001; Jin 2011; Mou 2020; Wren 2019; Zhao 2008).The results were inconsistent across studies (I2 = 88%). Excluding Chen 2013 and Ferrer 2005 in a sensitivity analysis resulted in a larger MD of −3.86 mmHg (95% CI −6.01 to −1.71, P = 0.0004) that was less heterogeneous (I2 = 65%; Analysis 1.24). All of the studies except for Ferrer 2005 were music medicine studies.

Bro 2019 reported a minimal effect of listening to live music on DBP (MD = 0.7, 95% CI ‐2.2 to 3.5, P = 0.63).

Patient‐preferred music resulted in somewhat greater reductions in DBP (MD −3.36, 95% CI −6.46 to −0.27, P = 0.03, I2 = 92%; Analysis 1.25) than researcher‐selected music (MD −2.51, 95% CI −5.03 to 0.02, P = 0.05, I2 = 0%) (P = 0.67).

Mean arterial pressure

Binns‐Turner 2008 reported on the effects of music on mean arterial pressure (MAP) in 30 participants and found a large decrease in MAP for the music group (mean change score: −15.1 mmHg, SD 17.1, 95% CI −23.76 to −6.44). In contrast, participants in the standard care group experienced an increase in MAP (mean change score: 4.5 mmHg, SD 15.3, 95% CI −3.25 to 12.25).

Oxygen saturation level

Two trials with 252 participants reported no effect for music listening on oxygen saturation levels (MD 0.59, 95% CI −0.62 to 1.8, P = 0.34, I2 = 86%; Analysis 1.26; Burrai 2014; Chen 2013; ).

Immune system functioning

Two trials examined the effects of music on immune system functioning. Chen 2004 compared music listening to standard care in 46 participants and found post‐test differences for the following indicators of immune system functioning: CD3 (music: mean 44, SD 12.62; control: mean 36.73, SD 11.01), CD4/CD8 (music: mean 1.67, SD 0.76; control: mean 1.32, SD 1.01), and natural killer (NK) cell activity (music: mean 25.23, SD 15.20; control: mean 21.36, SD 12.86), indicating a positive effect of music listening on the immune system in women with breast cancer. CD3 and CD4/CD8 are proteins that play a role in immune system functioning. Tuinmann 2017 investigated the effects of music listening in addition to standard care in patients undergoing high‐dose chemotherapy after autologous stem cell transplantation. No evidence of treatment effect was found for IgA (MD = −0.5, 95% CI −1.3 to 0.2), IgG (MD = −0.4, 95% CI −2.9 to 2.1), T4 (MD = 0.1, 95% CI −1.6 to 1.7), T8 (MD = −0.2, 95% CI −1.5 to 1.1), and NK (MD = −0.5, 95% CI −1.3 to 0.3) cell activity.

Physical functioning

Six trials examined the effects of music on participants' physical functioning (Hanser 2006; Hilliard 2003; Liao 2013; Moradian 2015; Tuinmann 2017; Xie 2001). We could not include the results of Hanser 2006 in the pooled estimate because of the use of change scores and the high attrition rate. The results of Tuinmann 2017 are reported separately because the authors only reported an effect size. The pooled estimate of the remaining studies indicated no evidence for an effect of music on physical status in 493 participants with cancer (SMD 0.78, 95% CI −0.74 to 2.31, P = 0.31; Analysis 1.18). The results were highly inconsistent (I2 = 98%), with Xie 2001 reporting a much larger beneficial effect. In Hanser 2006, music therapy led to a greater improvement in physical well‐being (FACT‐G Physical Well‐Being Subscale, score range: 0 to 28) (mean change score: 2.0, SD 4.6) than standard care (mean change score: −0.4, SD 3.7). In the study by Tuinmann 2017 with cancer patients during high‐dose chemotherapy and stem cell support, physical functioning as measured by the Karnofsky Performance Scale deteriorated in both the music listening and the control group. A smaller decline was found in the music listening group (MD = 0.8, 95% CI ‐2.2 to 3.9). Removing Xie 2001 because of an improper randomization method resulted in a small effect that was consistent across studies (SMD 0.08, 95% CI −0.18 to 0.34, P = 0.54, I2 = 0%; Analysis 1.18).

Anesthetic and analgesic intake

Two studies included use of anesthesia and analgesics as an outcome. Palmer 2015 examined the amount of propofol needed to reach a sedation score of 70 on the Bispectral Index (BIS) in women undergoing breast surgery. A BIS reading of 70 represents moderate sedation. The average propofol needed in the live music group (N = 67) was 67.2 mg (SD 53.7), 61.9 mg (SD 34.1) in the recorded music group (N = 65), and 70.5 mg (SD 35.2) in the usual care group (N = 62). Wang 2015 examined the impact of music‐guided relaxation compared to standard care on postoperative consumption of the sufentanil, a narcotic medicine, and use of a patient‐controlled analgesia (PCA) pump. Participants in the music treatment arm consumed a smaller amount of sufentanil (52.68 µg, SD 7.07) than the standard care treatment arm (82.65 µg, SD 6.19). PCA use was also lower in the music treatment arm (19.06, SD 3.49) than in the control group (30.96, SD 4.0).

Length of hospital stay and recovery time

Palmer 2015 also examined the effect of music on recovery time following breast surgery. Recovery time was defined as the interval between surgery end time and the time when the participant had met all discharge criteria determined by the recovery nurse. The results indicated that there was no difference in recovery time between the two types of music interventions (live music by a music therapist and listening to pre‐recorded music) and the usual care group, suggesting that the addition of a music intervention did not increase participant time commitment. A difference was found between the live music group (52.4 minutes, SD 21.6) and the recorded music group (64.8 minutes, SD 35.3), with the live music group getting discharged approximately 12 minutes faster than the recorded music group. However, the authors suggest a careful interpretation of these results as other factors could have contributed to this difference.

Li 2012 tracked the length of women's hospital stay after radical mastectomy. Women in the music listening treatment arm stayed an average of 13.62 days (SD 2.04), whereas women in the usual care control arm stayed an average of 15.53 days (SD 2.75) (P < 0.001).

Social and spiritual support

Spiritual well‐being

Two trials under this comparison assessed spiritual well‐being (Cook 2013; Hanser 2006). One trial compared music therapy to usual care using the Functional Assessment of Chronic Illness Therapy‐Spiritual Well‐Being subscale (FACIT‐Sp, score range: 0 to 48) (Hanser 2006). Results indicated that participants in the music therapy treatment arm reported a slightly greater increase in spiritual well‐being (mean change score: 2.5, SD 8.56) than those in the control group (mean change score: 0.7, SD 6.95). Cook 2013 compared music therapy with standard care and reported a greater improvement in the music therapy treatment arm (mean change score: 4.4, SD 4.84) than the control arm (mean change score: 2.0, SD 6.08) on the FACIT‐Sp.

Quality of life

Eleven trials compared the impact of music interventions to standard care on QoL (Bieligmeyer 2018; Bro 2019; Burns 2001a; Hanser 2006; Hilliard 2003; Liao 2013; Moradian 2015; Porter 2018; Ratcliff 2014; Tuinmann 2017; Xie 2001). We did not include Bieligmeyer 2018; Bro 2019; Hanser 2006; Tuinmann 2017 in the meta‐analysis for reasons discussed above. Meta‐analysis of the remaining seven trials (N = 573) resulted in a heterogeneous SMD of 0.88 (95% CI −0.31 to 2.08, P = 0.15, I2 = 97%; Analysis 1.27; Burns 2001a; Hilliard 2003; Liao 2013; Moradian 2015; Porter 2018; Ratcliff 2014; Xie 2001), with Xie 2001 reporting a much larger beneficial effect than the other trials. Removal of this outlier resulted in a small effect size that was homogeneous (SMD 0.29, 95% CI 0.07 to 0.52, P = 0.01, I2 = 0%).

We conducted a sensitivity analysis removing all studies that used improper methods of randomization. This resulted in a moderate effect size (SMD 0.47, 95% CI 0.06 to 0.88, P = 0.02, I2 = 56%; Analysis 1.27). Overall, the lack of blinding of participants to the music intervention and the use of self‐report measures, makes this very low‐certainty evidence.

A subgroup analysis per intervention type resulted in a homogenous, moderate effect of music therapy on QoL (SMD 0.40, 95% CI 0.08 to 0.71, P = 0.01, I2 = 0%; Analysis 1.28) that was consistent across studies. In Hanser 2006, music therapy resulted in a greater improvement in QoL (FACT‐G, 0‐108) (mean change score: 3.5, SD 13.75) than standard care (mean change score: 0.9, SD 15.8). For the music medicine studies, there was no evidence of an effect and the pooled effect was very heterogeneous (SMD 1.32, 95% CI −1.02 to 3.67, P = 0.21, I2 = 99%). The large heterogeneity was due to the outlying values of Xie 2001; removing it from the analysis resulted a pooled effect that was consistent across studies but the conclusion of no evidence of effect remained (SMD 0.18, 95% CI −0.14 to 0.51, P = 0.27, I2 = 0%). There was no evidence of a difference in treatment effect between the music therapy studies and the music medicine studies (P = 0.44). Because there was only evidence of an effect for music therapy interventions and the results were consistent across trials, we can be more certain that music therapy interventions delivered by a trained music therapist will result in improvements in quality of life of adults with cancer.

Comparison 2: Music intervention plus standard care versus standard care alone in children

Seven trials included pediatric participants (N = 270). Two trials compared music interventions with standard care (Bufalini 2009; Nguyen 2010), one trial compared music therapy with an activities session (Duocastella 1999), three trials compared music therapy with an audiobook control (Burns 2009; Robb 2008; Robb 2014), and one trial compared a parent‐delivered music intervention with an audiobook control condition (Robb 2017). In this comparison, we reported on the two trials that compared a music intervention with standard care. In comparison 3, we reported on the remainder of the pediatric trials.

Primary outcomes
Psychological outcomes

State anxiety

Two trials (Bufalini 2009; Nguyen 2010) examined the effects of music on state anxiety. Whereas Bufalini 2009 used the full STAI form, Nguyen 2010 used the STAI‐short form. Therefore a standardized mean difference was computed. The pooled effect size suggested a large treatment effect for music (SMD −0.94, 95% CI −1.9 to 0.03, P = 0.06, I2 =76%; Analysis 2.1; very low‐certainty evidence ).

Depression

We identified no studies for this outcome.

Distress

We identified no studies for this outcome.

Mood

We identified no studies for this outcome.

Hope

We identified no studies for this outcome.

Resilience

We identified no studies for this outcome.

Physical symptoms

Pain

Nguyen 2010 examined the effects of listening of pre‐recorded music on children's pain during and after lumbar puncture (LP). Children who listened to music reported significantly less pain during LP (mean: 2.35, SD 1.9) than children in the standard care condition (mean: 5.65, SD 2.5). Children in the music condition continued to report less pain after the LP (mean: 1.2, SD 1.36) compared to children in the control condition (mean: 3.0, SD 2.0).

Fatigue

We identified no studies for this outcome.

Secondary outcomes
Physiological outcomes

Nguyen 2010 also found beneficial effects of listening to pre‐recorded music on physiological responses during and after LP. Children in the music group exhibited an average heart rate of 102.7 (SD 9.24) during and 100.8 (SD 11.4) after LP compared to children in the control group (during: 117.7, SD 19.49; after: 111.1, SD 17.23); an average respiratory rate of 25.1 (SD 3.6) during and 24.5 (SD 3.49) after LP compared to 28.5 (SD 3.86) during and 28.2 (3.72) after LP in the control group; an average oxygen saturation level of 99.2 (SD 1.14) during and 99.7 (SD 0.49) after LP compared to 98 (SD 2.77) during and 99.2 (1.47) after LP in the control group; an average SBP of 97.1 (SD 8.57) during and 98.5 (SD 10.13) after LP compared to 105.6 (SD 15.97) during and 102.4 (SD 11.26) after LP in the control group; and an average DBP of 65.2 (SD 6.83) during and 62.75 (4.82) after compared to 69.8 (11.67) during and 64.2 (SD 9.4) after LP in the control group.

Comparison 3: Music interventions plus standard care versus standard care plus placebo control in children

Primary outcomes
Psychological outcomes

State Anxiety

We identified no studies for this outcome.

Depression

We identified no studies for this outcome.

Distress

Two trials examined the effects of music therapy on reduction of distress, comparing a music video intervention with an audiobook control condition in adolescents and young adults during stem cell transplantation (Burns 2009; Robb 2014). In the music video, participants wrote songs and created accompanying music videos in collaboration with a music therapist. The pooled effect of the two trials did not provide support for an effect of music therapy (SMD −0.07, 95% CI −0.39 to 0.26, P = 0.69, I2 = 0%; Analysis 3.1). In Burns 2009, both groups reported an increase in distress post‐intervention scores, which were used in the meta‐analysis. However, follow‐up measures at 100 days after the stem‐cell transplantation indicated a lower mean distress score for the music therapy group (mean: 1.67, SD 0.55) than the audiobook group (mean: 2.00, SD 0.64).

Robb 2017 examined the feasibility and acceptability of a parent‐delivered music intervention in the care of young children. Even though emotional distress was lower for children who received the parent‐delivered intervention compared to children with the audiobook control condition, parents found the parent delivery format not acceptable.

Mood

Duocastella 1999 compared the effects of music therapy with an activities session on mood in children but did not find significant differences between the two treatment arms. Children in the music therapy treatment arm reported post‐intervention scores of 4.67 (SD 0.62) versus 4.47 (SD 0.51) reported by children in the activities treatment arm.

Hope

We identified no studies for this outcome.

Resilience

One music therapy study in 80 adolescents and young adults undergoing hematopoietic stem cell transplant (HSCT) included resilience as an outcome and and found no evidence of an effect (SMD 0.21, P = 0.35) (Robb 2014). The authors reported that the study was underpowered to detect medium and small effect sizes.

Coping

Robb 2014 examined the effect of music therapy on coping. They reported a moderate effect size for courageous coping immediately post‐transplant. At the same time, they found no change in the use of defensive coping strategies, suggesting that adolescents and youth in the music therapy treatment arm increased their use of positive coping strategies.

Physical outcomes

Pain

We identified no studies for this outcome.

Fatigue

We identified no studies for this outcome.

Secondary outcomes
Physiological outcomes

Immune system functioning

In one trial with 30 children, Duocastella 1999 found no evidence of an effect on Immunoglobin A (IgA) levels of live music‐making (mean change score: 7.07 mg/L, SD 34.52) compared to engaging children in activities that did not involve music (mean change score: 4.13 mg/L, SD 41.02).

Social and spiritual support

Spiritual well‐being

Burns 2009 and Robb 2014 also examined the effect of a music video intervention versus audiobook control condition on spiritual well‐being in adolescents and young adults. Their pooled estimate did 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).

Social support

Robb 2014 examined the effect of music therapy on perceived social support in adolescents and young adults during stem cell transplant. At 100 days post‐transplant, participants in the music therapy treatment arm reported greater improvements in perceived social support (SMD 0.54, P = 0.028) and family environment (i.e. family cohesion, family adaptation, family communication, and family strength) (SMD 0.66, P = 0.008) than participants in the audiobook control group. Qualitative analysis of the music videos that accompanied the songs written by the participants revealed that study participants were "identifying peers (i.e. social integration), family members (i.e. family environment), and faith/spirituality (i.e. spiritual perspective) as important sources of support" (p. 916).

Communication

One trial in children with cancer compared the effects of one session of active music‐making to music listening and audio storybooks on levels of active engagement and initiation in 55 children (Robb 2008). Active music therapy sessions led to higher active engagement (post‐test mean: 26.03, SD 4.1) than music listening (post‐test mean: 15.65, SD 6.2, P < 0.0001) or audio storybooks (post‐test mean: 15.17, SD 4.9, P < 0.0001). Active music‐making (post‐test mean: 14.19, SD 8.3) and music listening (post‐test mean: 15.89, SD 11.2) also increased the child's initiation behaviour compared to the audio storybooks (post‐test mean: 7.43, SD 6.6) (P = 0.04 and P = 0.002, respectively).

Quality of life

Burns 2009 compared music therapy to an audiobook control, finding a small increase in QoL in the music therapy group (Index of Well‐Being, score range 9 ‐ 63) (mean change score: 0.31, SD 1.73, N = 7) and a small decrease in the control group (mean change score: −0.22, SD 1.24, N = 3). However, the sample size was too small to draw any meaningful conclusions.

Comparison 4: Music therapy plus standard care versus music medicine plus standard care in adults

Only two studies reported on the direct comparison between music therapy and music medicine interventions. Both studies were with adult participants.

Primary outcomes
Psychological outcomes

State Anxiety

Two trials directly compared the effects of music therapy with music medicine on cancer participants' anxiety using a 100 mm visual analogue scale (Bradt 2015; Palmer 2015). Music therapy resulted in greater anxiety reduction than music medicine (MD −3.55, 95% CI −7.13 to 0.02, P = 0.05, I2 = 0%; Analysis 4.1). A total of 77.4% of the participants in the cross‐over trial by Bradt 2015 expressed a preference for receiving music therapy sessions for the remainder of their cancer treatment or future treatments. The main reasons cited by participants for this preferences were that they felt cared for by the music therapist, enjoyed the interactive and creative music‐making, and valued the opportunity for emotional expression and processing.

Depression

We identified no studies for this outcome.

Distress

We identified no studies for this outcome.

Mood

We identified no studies for this outcome.

Hope

We identified no studies for this outcome.

Resilience

We identified no studies for this outcome.

Physical outcomes

Pain

We identified no studies for this outcome.

Fatigue

We identified no studies for this outcome.

Comparison 5: Music interventions plus standard care versus standard care plus alternative relaxation interventions in adults

Several studies compared music interventions with other relaxation interventions such as progressive muscle relaxation, guided imagery and relaxation, and verbal relaxation instructions. At this time, only single studies were identified per outcome. This precluded meta‐analysis of the results.

Primary outcomes
Psychological outcomes

State Anxiety

Straw 1991 compared music listening to guided imagery and relaxation training and found that both interventions reduced state anxiety as measured by the STAI‐S (score range 20 to 80) (guided imagery post‐test mean: 38.6, SD 10.01; music listening post‐test mean: 34.22, SD 10.12).

Depression

Stordahl 2009 compared music‐assisted relaxation with verbal relaxation instructions in 20 women with breast cancer and reported a lower level of depression on the Center for Epidimiologic Diseases ‐ Depression Scale (CES‐D, score range 0 to 60) following treatment in the music‐assisted relaxation treatment arm (N = 10; post‐test mean: 6.6, SD 5.02) than in the verbal relaxation treatment arm (N = 10; post‐test mean: 9.20, SD 10.96).

Mood

Stordahl 2009 also compared the impact of music‐assisted relaxation with verbal relaxation instructions on mood in women with breast cancer and found that music‐assisted relaxation resulted in lower scores (i.e. better mood) on the POMS‐SF (score range 14 to 70 as reported in this thesis) (post‐test mean: 6.5, SD 5.19) than verbal relaxation instructions (post‐test mean = 8.64, SD 6.42).

Distress

We identified no studies for this outcome.

Mood

We identified no studies for this outcome.

Hope

We identified no studies for this outcome.

Resilience

We identified no studies for this outcome.

Physical symptoms

Pain

Shaban 2006 compared the effects of progressive muscle relaxation (PMR) to music listening and found that PMR was more effective in reducing pain (100 mm VAS) (mean post‐test score: 6.22, SD 2.45) than listening to pre‐recorded music (mean post‐test score: 4.96, SD 2.76) in 100 participants.

Warth 2015 compared live‐music based relaxation provided by a trained music therapist with listening to a pre‐recorded mindfulness‐based stress reduction (MBSR) programme. Both resulted in similar pain reductions, namely from 2.95 (SD 2.3) at pretest to 2.45 (SD 2.1) at post‐test for music and from 2.89 (SD 2.17) to 2.57 (SD 2.16) for MBSR.

Fatigue

We identified no studies for this outcome.

Secondary outcomes
Quality of life

Straw 1991 compared a guided imagery and relaxation intervention to music listening and found that music listening led to a greater increase in QoL (Functional Living Index, score range 22 to 154) (mean change score: 16.33, SD 20.73) than the guided imagery and relaxation group (mean change score: 4.6, SD 20.49).

Warth 2015 reported a greater increase in QoL (EORTC‐QLQ‐C15) in the live‐music based relaxation treatment arm (mean change score: 10.6, SD 19.6) than in the MBSR treatment arm (mean change score: 7.54, SD 23.0).

Discussion

Summary of main results

The results of 26 trials (Table 1) suggest that music therapy and music medicine interventions may have a beneficial effect on anxiety in adults with cancer, with a reported anxiety reduction of 7.73 units, on average, on the STAI‐S (score range: 20 to 80) scale and −0.76 standardized units on other anxiety scales (which is considered a moderate to large effect). Although the magnitude of the effect differed across the studies, all but two trials (Chen 2020; O'Callaghan 2012) agreed on the direction of the point estimates. These anxiety‐reducing results are consistent with the findings of three other Cochrane systematic reviews on the use of music with coronary heart disease patients (Bradt 2013a), with mechanically ventilated patients (Bradt 2014), and for preoperative anxiety (Bradt 2013b). A comparison of music therapy with music medicine trials for anxiety reduction in people with cancer suggest a large treatment effect for music therapy studies (SMD −0.81) that was consistent across studies. Music medicine trials resulted in a similar treatment effect (SMD −0.87) but results were highly inconsistent across studies. Cohen 1988 suggested that an effect size of 0.20 could be considered a small effect, an effect size of 0.50 medium, and an effect size of 0.80 large. A direct comparison of music therapy with music medicine interventions for anxiety reduction in two studies indicated greater anxiety reduction of music therapy interventions. It is noteworthy that a large majority of the participants in one of the comparative studies expressed a preference for the music therapy intervention. The results of two trials suggest that music interventions may have a beneficial effect on anxiety in children with cancer with a reported reduction of ‐0.94 standardized units.

The results of 12 studies (Table 1) suggest that music interventions may reduce depression in adults with cancer. The results of a single study (Robb 2014) suggest that music therapy may help adolescents and young adults employ positive coping strategies during stem cell transplant, a high‐risk and high‐intensity treatment. We found no evidence of effect for distress or mood.

The results of two studies (Table 1) suggest that music interventions may increase hope in adult cancer patients by an average of 3.19 units on the Herth Hope Index (score range: 12 to 48).

As for the effect of music on physical symptoms in adults, the results of 12 trials (Table 1) suggest that music has a moderate pain‐reducing effect of −0.67 standardized units. Music interventions also had a small effect on fatigue (−0.28 standardized units). We found no evidence for an effect of music on physical status. The results of a single study with pediatric oncology participants also found pain‐reducing effects of music. Reduction of anxiety, depression, fatigue and pain are important outcomes for people with cancer, as they have an impact on health and overall QoL.

It is important that careful consideration is given to the implementation of music listening interventions. The results of Kwekkeboom 2003 indicate that listening to music through headphones may be contraindicated during painful procedures because it prevents the patient from hearing the surgeon's instructions and comments. This may greatly increase patients' anxiety and, consequently, their perceived pain. In this case, it is better to listen to music without headphones.

Furthermore, results suggest that music interventions may have a beneficial effect on several physiological responses in adult patients with cancer. Listening to music may reduce heart rate by an average of three to four beats per minute. These results are consistent with the findings of a Cochrane systematic review on the use of music with coronary heart disease patients (Bradt 2013a), which reported a heart rate reduction of 3.4 bpm. Similar results were reported in a Cochrane review on music interventions for mechanically ventilated patients (Bradt 2014), namely a mean heart rate reduction of 3.95 bpm. In the case of a resting heart rate within normal range, a reduction of 4 bpm may not be clinically significant. However, it might be in the case of a tachycardiac rate. In a study examining the quantitative relationship between resting heart rate reduction and clinical benefit, Cucherat 2007 found that each 10 bpm reduction in heart rate was estimated to reduce the relative risk of cardiac death by 30%. The findings of this review suggest that music listening may have minimal impact on respiratory rate (less than 1 breath per minute), yet the findings of other systematic reviews suggest that listening to music may help reduce respiratory rate by 2 to 3 breaths per minute (Bradt 2013a; Bradt 2014). The results of this review also indicate that listening to music may have a beneficial effect on SBP and DBP. Trials on music listening with cardiac patients and mechanically ventilated patients have also reported reductions in systolic blood pressure (Bradt 2013a; Bradt 2014). The reduction of heart rate and blood pressure corresponds with the anxiety‐reducing effects found by subjective outcome measures in this review.

Only one study in this review examined the effects of music on physiological responses in children and reported beneficial treatment effects of music for heart rate, respiratory rate, oxygen saturation level and blood pressure during lumbar puncture (Nguyen 2010).

No evidence of support was found for an effect of music interventions on oxygen saturation level in adult patients. Single trials included in this review found support for a beneficial effect of music on mean arterial pressure .

Music therapy interventions had a moderate effect of 0.4 standardized units on quality of life in adults, whereas we found no support for an effect for music medicine studies. Two studies that compared music therapy with audiobook control in adolescents and young adults did not find support for spiritual well‐being (Burns 2009; Robb 2014). Two music therapy studies with adults reported conflicting results for this outcome. Finally, a single study with adolescents and young adults during stem cell transplant reported beneficial effects of music therapy on perceived social support and the family environment.

Subgroup analyses of treatment effects between music therapy and music medicine studies was possible for six outcomes, namely anxiety, depression, mood, pain, fatigue and quality of life. There was a difference for quality of life and fatigue, with music therapy studies contributing to a larger pooled treatment effect, whereas no evidence of effect was found for music medicine studies; we found no difference between music therapy and music medicine studies for the other outcomes. However, it is worth noting that, for all outcomes, music therapy interventions resulted in consistent findings across studies whereas the results of music medicine studies were highly heterogeneous for these outcomes. As a result, there is greater confidence in the treatment effects of music therapy interventions delivered by a trained music therapist than in the treatment effects of music medicine interventions.

We could examine the impact of music preference for anxiety, depression, pain, heart rate, systolic and diastolic blood pressure. Music preference did not impact on the treatment effect of music.

For all outcomes, the sensitivity analyses were robust to the original conclusions.

The summary of findings Table 1 and summary of findings Table 2 provide a summary of the main results of this review with associated risks. Because participants could not be blinded to music interventions and subjective outcomes are measured by self‐report measures, there was a high risk of bias for most studies. As a result, the evidence ranged from uncertain to very uncertain for most outcomes.

It is important to note that the included studies compared music interventions with standard care (except for Analysis 3.1 and Analysis 3.2). Therefore, it is unclear how much of the treatment effect is attributable to the specific effect of music‐based interventions versus how much is due to contextual effects (e.g. participant‐therapist relationship) (Rossettini 2018).

Overall completeness and applicability of evidence

This review included 81 randomized controlled trials and quasi‐randomized trials. Seventy‐four trials enrolled adult oncology participants whereas seven trials enrolled pediatric participants with cancer.

Forty‐three trials used listening to pre‐recorded music, and 38 trials used music therapy interventions that actively engaged the participants (Characteristics of included studies). We were able to compare the treatment effects of music therapy studies with music medicine studies for six outcomes. For the other outcomes, this was not possible due to an insufficient number of music therapy and music medicine studies per outcome.

This review included both music therapy and music medicine studies, as defined in the Background. Music therapists who work with cancer patients do not limit their interventions to offering music listening for relaxation purposes. Music therapists are specially trained clinically and academically to carefully select music interventions to offer emotional and spiritual support, support communication with loved ones, enhance a sense of control, and improve physical well‐being in patients with cancer. Comparative analyses suggest that music therapy interventions are more effective than music medicine interventions in improving quality of life and fatigue. We found no differences between music therapy and music medicine interventions for other outcomes, but it is worth noting that the results of music therapy studies were consistent across trials whereas the results of music medicine studies were highly inconsistent across studies. This is likely due to the fact that music therapists are trained to meet the individual needs of patients through music interventions (e.g. meeting the patient's in‐the‐moment needs when offering live music) rather than offering a limited selection of pre‐recorded music, which may not be suitable for all patients. Participants in a cross‐over trial who experienced both music therapy and music medicine interventions overwhelmingly preferred the music therapy sessions because of the personal attention and care, the creativity of the interactive music‐making, and the opportunity for emotional expression through singing and playing instruments.

In general, the trials that used listening to pre‐recorded music provided little information about the music selections used, except for mentioning general music styles (e.g. new age, classical music, easy listening, etc). Music within each of these styles can vary widely, and more detailed information would help clinicians make well‐informed decisions regarding music selections.

The frequency and duration of the interventions varied widely across the trials. Twenty‐four trials offered a single music session. We would like to suggest that offering multiple music listening sessions allows for the participant to give feedback about the music, select different music if needed, and become more skilled in using music for relaxation purposes. In the case of music therapy interventions, multiple sessions allow for the development of a therapeutic relationship and deepening of the therapeutic process through the music. This may lead to greater health benefits. At this time, however, the relationship between the frequency and duration of treatment and treatment effect remains unclear. Further investigation into the optimal frequency and duration of music interventions for specific outcomes in people with cancer is needed.

Presently, we cannot provide data regarding cost or cost‐effectiveness of music therapy or music medicine applications in the care of cancer patients, as the reviewed trials did not provide these data.

Quality of the evidence

Because of the large number of trials at high risk of bias, readers should interpret the findings of this review with caution. Often blinding of participants is not possible in music medicine or music therapy studies unless a comparative design is used (e.g. Bradt 2015). Many of the trials in this review included subjective outcomes, such as anxiety, pain, mood and quality of life. When participants cannot be blinded to the intervention, there is definitely an opportunity for bias when they are asked to report on these subjective outcomes.

For many trials, the principal investigators needed to be contacted to provide additional methodological and statistical information, which improved the quality of evidence in the review.

For anxiety and quality of life, there were large effects across studies. The trials did not agree on the size of effect, with some reporting much larger beneficial effects than others, resulting in large confidence intervals. For both outcomes, the certainty of the evidence was low and very low, respectively . For pain and mood, the pooled effect sizes were moderate to large but the evidence was very uncertain. For depression, the pooled effect was small to moderate but here too, there was very low‐certainty evidence. Finally, the pooled effect for fatigue was small and the evidence was of low certainty (summary of findings Table 1; summary of findings Table 2).

Potential biases in the review process

The strength of our review is that we searched all available databases and a large number of music therapy journals (English, German, and French language), checked reference lists of all relevant trials, contacted relevant experts for identification of unpublished trials, and included publications without restricting language. We requested additional data, where necessary, for all trials we considered for inclusion. This allowed us to get accurate information on the trial quality and data for most trials and helped us make well‐informed trial selection decisions. The database searches were completed more than one year ago. Due to the COVID 19 pandemic, we experienced delays in data extraction and analyses. We decided not to update the searches closer to the time of publication as to not further delay the publication of this updated review.

Although we cannot completely rule out the possibility that we missed some published and unpublished trials, we are confident that our detailed search strategy combined with extensive handsearching identified all relevant trials. It is possible that we did not identify some grey literature; however, it is doubtful that this would have had a significant impact on our results. Grey literature tends to include trials with relatively small numbers of participants and inconclusive results (McAuley 2000).

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, the risk of bias was independently assessed by JBi, CD, and KMC. Data extraction was completed independently by JBr, JBi, and KMC.

Agreements and disagreements with other studies or reviews

The findings of this review are consistent with the results of a review (32 RCTs and controlled clinical trials) assessing the effect of music interventions on psychological and physical outcomes in cancer patients (Zhang 2012). Zhang and colleagues reported a mean difference of −12.3 for anxiety (STAI‐S, score range 20 to 80), −6.23 for depression (Self‐Rating Depression Scale, score range 20 to 80), −0.52 for pain (0 to 10 numeric rating scale) and 13.32 for quality of life (Quality of Life ‐ Cancer, score range 0‐100). The authors also reported that the effects of music on vital signs, especially blood pressure, were small. In contrast, Nightingale 2013 (a review of four RCT studies) evaluated the effects of music on anxiety in adult cancer patients, reporting no evidence of an effect for music on anxiety. This was likely due to the small number of studies included in this review. In addition, reviewers included Kwekkeboom 2003 in the meta‐analysis, which was a quite problematic trial in terms of the implementation of the music listening interventions, as discussed in the Results section of our review. Study participants reported that the use of headphones while undergoing painful medical procedures was anxiety‐provoking because it prevented them from hearing the surgeon. In addition, Nightingale 2013 included Hanser 2006 in the meta‐analysis, whereas we included this study in the narrative only. Our decision was based on a very high attrition rate (40%) and the inability to implement the music therapy intervention within the a priori set time frame, thereby highly diluting the intervention, as reported by the authors.

Kohler 2020 conducted a systematic review of music therapy studies with adult oncology patients. The authors reported a pooled effect size for psychological well‐being (mood, anxiety, depression), physical symptom distress (pain, fatigue, physical symptom scales) and quality of life. The reported pooled effect size for quality of life (d = 0.36, 95% 0.07 to 0.65, P = 0.023, I2 = 0%) was similar to the findings in our review for music therapy studies (Analysis 1.28).

Study flow diagram.

Figures and Tables -
Figure 1

Study flow diagram.

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

Figures and Tables -
Figure 2

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

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

Figures and Tables -
Figure 3

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

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

Figures and Tables -
Figure 4

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

Funnel plot of comparison: 1 Music intervention plus standard care versus standard care alone with adults, outcome: 1.6 Depression.

Figures and Tables -
Figure 5

Funnel plot of comparison: 1 Music intervention plus standard care versus standard care alone with adults, outcome: 1.6 Depression.

Funnel plot of comparison: 1 Music intervention plus standard care versus standard care alone with adults, outcome: 1.13 Pain.

Figures and Tables -
Figure 6

Funnel plot of comparison: 1 Music intervention plus standard care versus standard care alone with adults, outcome: 1.13 Pain.

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 1: Anxiety (STAI)

Figures and Tables -
Analysis 1.1

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 1: Anxiety (STAI)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 2: Anxiety (non‐STAI (full version) measures)

Figures and Tables -
Analysis 1.2

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 2: Anxiety (non‐STAI (full version) measures)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 3: Anxiety (intervention subgroup)

Figures and Tables -
Analysis 1.3

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 3: Anxiety (intervention subgroup)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 4: Anxiety (music preference)

Figures and Tables -
Analysis 1.4

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 4: Anxiety (music preference)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 5: Anxiety (music‐guided relaxation)

Figures and Tables -
Analysis 1.5

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 5: Anxiety (music‐guided relaxation)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 6: Depression

Figures and Tables -
Analysis 1.6

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 6: Depression

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 7: Depression (intervention subgroup)

Figures and Tables -
Analysis 1.7

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 7: Depression (intervention subgroup)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 8: Depression (music preference)

Figures and Tables -
Analysis 1.8

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 8: Depression (music preference)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 9: Distress

Figures and Tables -
Analysis 1.9

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 9: Distress

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 10: Mood

Figures and Tables -
Analysis 1.10

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 10: Mood

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 11: Mood (intervention subgroup)

Figures and Tables -
Analysis 1.11

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 11: Mood (intervention subgroup)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 12: Hope

Figures and Tables -
Analysis 1.12

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 12: Hope

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 13: Pain

Figures and Tables -
Analysis 1.13

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 13: Pain

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 14: Pain (intervention subgroup)

Figures and Tables -
Analysis 1.14

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 14: Pain (intervention subgroup)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 15: Pain (music preference)

Figures and Tables -
Analysis 1.15

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 15: Pain (music preference)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 16: Fatigue

Figures and Tables -
Analysis 1.16

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 16: Fatigue

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 17: Fatigue (intervention subgroup)

Figures and Tables -
Analysis 1.17

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 17: Fatigue (intervention subgroup)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 18: Physical functioning

Figures and Tables -
Analysis 1.18

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 18: Physical functioning

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 19: Heart rate

Figures and Tables -
Analysis 1.19

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 19: Heart rate

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 20: Heart rate (music preference)

Figures and Tables -
Analysis 1.20

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 20: Heart rate (music preference)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 21: Respiratory rate

Figures and Tables -
Analysis 1.21

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 21: Respiratory rate

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 22: Systolic blood pressure

Figures and Tables -
Analysis 1.22

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 22: Systolic blood pressure

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 23: Systolic blood pressure (music preference)

Figures and Tables -
Analysis 1.23

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 23: Systolic blood pressure (music preference)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 24: Diastolic blood pressure

Figures and Tables -
Analysis 1.24

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 24: Diastolic blood pressure

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 25: Diastolic blood pressure (music preference)

Figures and Tables -
Analysis 1.25

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 25: Diastolic blood pressure (music preference)

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 26: Oxygen saturation

Figures and Tables -
Analysis 1.26

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 26: Oxygen saturation

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 27: Quality of life

Figures and Tables -
Analysis 1.27

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 27: Quality of life

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 28: Quality of life (intervention subgroup)

Figures and Tables -
Analysis 1.28

Comparison 1: Music intervention plus standard care versus standard care alone in adults, Outcome 28: Quality of life (intervention subgroup)

Comparison 2: Music interventions plus standard care versus standard care alone in children, Outcome 1: Anxiety (STAI)

Figures and Tables -
Analysis 2.1

Comparison 2: Music interventions plus standard care versus standard care alone in children, Outcome 1: Anxiety (STAI)

Comparison 3: Music interventions plus standard care versus standard care plus placebo control in children, Outcome 1: Distress

Figures and Tables -
Analysis 3.1

Comparison 3: Music interventions plus standard care versus standard care plus placebo control in children, Outcome 1: Distress

Comparison 3: Music interventions plus standard care versus standard care plus placebo control in children, Outcome 2: Spiritual well‐being

Figures and Tables -
Analysis 3.2

Comparison 3: Music interventions plus standard care versus standard care plus placebo control in children, Outcome 2: Spiritual well‐being

Comparison 4: Music therapy plus standard care versus music medicine plus standard care in adults, Outcome 1: Anxiety

Figures and Tables -
Analysis 4.1

Comparison 4: Music therapy plus standard care versus music medicine plus standard care in adults, Outcome 1: Anxiety

Summary of findings 1. Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in adult cancer patients

Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in adult cancer patients

Patient or population: adult cancer patients (≥ 18 years)
Setting: inpatient and outpatient cancer care
Intervention: music intervention (music therapy or music medicine) plus standard care
Comparison: standard care alone (i.e. usual cancer treatment as per the site's standard care protocol)

Outcomes*

Illustrative Comparative Risk
(95% CI)

__________________

Corresponding Risk

__________________

Music intervention

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Anxiety assessed with: Spielberger State Anxiety Index Scale (STAI)

Score range: 20 to 80. A lower score represents less anxiety.

Follow‐up: immediately post‐intervention

The mean anxiety in the music intervention group was 7.73 units less (10.02 less to 5.44 less) than in the standard care group.

1381
(17 RCTs)

⊕⊝⊝⊝
VERY LOW 1 2

Music intervention may result in a large reduction in anxiety. However, the evidence is very uncertain.

Depression

Follow‐up: immediately post‐intervention

The mean depression in the music intervention group was 0.41 standard deviations less (0.67 worse to 0.15 worse) than in the standard care group

1021
(12 RCTs)

⊕⊝⊝⊝
VERY LOW 1 3

Music intervention may result in a small to moderate reduction of depression. However, the evidence is very uncertain.

Mood

Follow‐up: immediately post‐intervention

The mean mood in the music intervention group was 0.53 standard deviations better (0.03 worse to 1.11 better) than in the standard care group

221
(4 RCTs)

⊕⊝⊝⊝
VERY LOW 1 4

Music interventions may result in a moderate improvement in mood. However, the evidence is very uncertain.

Hope

Score range: 12 to 48. A higher score represents greater hope.

Follow‐up: immediately post‐intervention

The mean hope in the music intervention group was 3.19 units more (0.12 more to 6.25 more) than in the standard care group

53

(2 RCTS

⊕ ⊝ ⊝⊝

VERY LOW 1 7

Music intervention may result in a large increase in hope. However, the evidence is very uncertain.

Pain

Follow‐up: immediately post‐intervention

The mean pain in the intervention group was 0.67 standard deviations less (1.07 less to 0.26 less) than in the standard care group

632
(12 RCTs)

⊕⊝⊝⊝
VERY LOW 1 5

Music interventions may result in a moderate to large improvement in pain. However, the evidence is very uncertain.

Fatigue

Follow‐up: immediately post‐intervention

The mean fatigue in the music intervention group was 0.28 standard deviations less (0.46 less to 0.01 less) than in the standard care group

498
(10 RCTs)

⊕⊕⊝⊝
LOW 1

Music intervention may result in a slight reduction in fatigue.

Quality of Life

Follow‐up: immediately post‐intervention

The mean quality of life in the music intervention group was 0.88 standard deviations more (0.31 less to 2.08 more) than in the standard care group

573
(7 RCTs)

⊕⊝⊝⊝
VERY LOW 1 6

Music interventions may result in a large improvement in quality of life. However, the evidence is very uncertain.

*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

GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded two levels for high risk of bias. The majority of the trials were at high risk of bias because participants could not be blinded to the music intervention and outcome was measured using self‐report.

2 Downgraded two levels for very serious inconsistency across studies as evidenced by I2 = 93%.

3 Downgraded one level for serious inconsistency across studies as evidenced by I2 = 72%.

4 Downgraded one level for serious inconsistency across trials as evidenced by I2 = 70%.

5 Downgraded two levels for very serious inconsistency across trials as evidenced by I2 = 81%.

6 Downgraded two levels for very serious inconsistency across trials as evidenced by I2 = 97%.

7 Downgraded two level s for imprecision due to a small number of participants.

Figures and Tables -
Summary of findings 1. Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in adult cancer patients
Summary of findings 2. Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in paediatric cancer patients

Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in pediatriccancer patients

Patient or population: pediatric cancer patients (< 18 years)
Setting: inpatient and outpatient cancer care
Intervention: music interventions (music therapy or music medicine) plus standard care
Comparison: standard care alone (i.e. usual cancer treatment as per the site's standard care protocol)

Outcomes

Illustrative comparative risk (95% CI)

____________________

Corresponding risk

____________________

Music intervention

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Anxiety (STAI)

The score: 20 to 80. A lower score represents less anxiety.

Follow‐up: immediately post‐intervention

The mean anxiety in the music intervention group was 0.94 standard lower (1.9 lower to 0.03 higher)

79
(2 RCTs)

⊕⊝⊝⊝
VERY LOW 1 2 3

Music intervention may result in a large reduction in anxiety.

Depression

not estimable

(0 studies)

Mood

not estimable

(0 studies)

Pain
assessed with: 0 to 10 NRS. A higher score represents more pain

Listening to pre‐recorded music resulted in less pain during and after lumbar puncture (during mean: 2.35, SD 1.9; after mean: 1.2, SD 1.36) than standard care (during mean: 5.65, SD 2.5; after mean: 3.0, SD 2.0 ).

40
(1 RCT)

⊕ ⊝ ⊝ ⊝

LOW 1 3

Fatigue

not estimable

(0 studies)

Quality of Life

not estimable

(0 studies)

Hope

not estimable

(0 studies)

*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; RR: Risk ratio; OR: Odds ratio;

GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded two levels for high risk of bias. These trials were at high risk of bias because participants could not be blinded to the music intervention and outcome was measured using self‐report.

2 Downgraded one level for serious inconsistency across studies as evidenced by I2 = 76%.

3 Downgraded two levels for imprecision due to a small number of participants.

Figures and Tables -
Summary of findings 2. Music intervention plus standard care compared to standard care alone for improving psychological and physical outcomes in paediatric cancer patients
Comparison 1. Music intervention plus standard care versus standard care alone in adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Anxiety (STAI) Show forest plot

17

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1.1 All studies

17

1381

Mean Difference (IV, Random, 95% CI)

‐7.73 [‐10.02, ‐5.44]

1.1.2 Sensitivity analysis (randomization method)

15

1121

Mean Difference (IV, Random, 95% CI)

‐7.83 [‐10.91, ‐4.76]

1.2 Anxiety (non‐STAI (full version) measures) Show forest plot

9

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

1.2.1 All studies

9

882

Std. Mean Difference (IV, Random, 95% CI)

‐0.76 [‐1.28, ‐0.25]

1.2.2 Sensitivity analysis (randomization method)

5

530

Std. Mean Difference (IV, Random, 95% CI)

‐0.72 [‐1.67, 0.23]

1.2.3 Sensitivity analysis (< 10% non‐cancer excluded)

8

869

Std. Mean Difference (IV, Random, 95% CI)

‐0.75 [‐1.30, ‐0.21]

1.3 Anxiety (intervention subgroup) Show forest plot

23

2003

Std. Mean Difference (IV, Random, 95% CI)

‐0.86 [‐1.22, ‐0.50]

1.3.1 Music therapy studies

4

144

Std. Mean Difference (IV, Random, 95% CI)

‐0.81 [‐1.16, ‐0.46]

1.3.2 Music medicine studies

19

1859

Std. Mean Difference (IV, Random, 95% CI)

‐0.87 [‐1.28, ‐0.47]

1.4 Anxiety (music preference) Show forest plot

16

1590

Std. Mean Difference (IV, Random, 95% CI)

‐0.82 [‐1.22, ‐0.41]

1.4.1 Patient‐preferred music

13

1288

Std. Mean Difference (IV, Random, 95% CI)

‐0.81 [‐1.30, ‐0.32]

1.4.2 Researcher‐selected music

3

302

Std. Mean Difference (IV, Random, 95% CI)

‐0.79 [‐1.19, ‐0.39]

1.5 Anxiety (music‐guided relaxation) Show forest plot

15

1334

Std. Mean Difference (IV, Random, 95% CI)

‐0.93 [‐1.38, ‐0.47]

1.5.1 Music‐guided relaxation studies

4

476

Std. Mean Difference (IV, Random, 95% CI)

‐1.61 [‐2.56, ‐0.65]

1.5.2 Listening to music only

11

858

Std. Mean Difference (IV, Random, 95% CI)

‐0.67 [‐1.09, ‐0.24]

1.6 Depression Show forest plot

12

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

1.6.1 All studies

12

1021

Std. Mean Difference (IV, Random, 95% CI)

‐0.41 [‐0.67, ‐0.15]

1.6.2 Sensitivity analysis (randomization method)

10

779

Std. Mean Difference (IV, Random, 95% CI)

‐0.32 [‐0.59, ‐0.04]

1.6.3 Sensitivity analysis (< 10% non‐cancer studies excluded)

11

1008

Std. Mean Difference (IV, Random, 95% CI)

‐0.41 [‐0.68, ‐0.15]

1.6.4 Sensitivity analysis (outliers removed)

9

674

Std. Mean Difference (IV, Random, 95% CI)

‐0.20 [‐0.36, ‐0.05]

1.7 Depression (intervention subgroup) Show forest plot

12

1021

Std. Mean Difference (IV, Random, 95% CI)

‐0.41 [‐0.67, ‐0.15]

1.7.1 Music therapy studies

5

225

Std. Mean Difference (IV, Random, 95% CI)

‐0.19 [‐0.46, 0.07]

1.7.2 Music medicine studies

7

796

Std. Mean Difference (IV, Random, 95% CI)

‐0.53 [‐0.90, ‐0.17]

1.8 Depression (music preference) Show forest plot

7

708

Std. Mean Difference (IV, Random, 95% CI)

‐0.55 [‐0.91, ‐0.19]

1.8.1 Patient‐preferred music

3

375

Std. Mean Difference (IV, Random, 95% CI)

‐0.59 [‐1.26, 0.09]

1.8.2 Researcher‐selected music

4

333

Std. Mean Difference (IV, Random, 95% CI)

‐0.53 [‐0.98, ‐0.07]

1.9 Distress Show forest plot

2

127

Std. Mean Difference (IV, Random, 95% CI)

‐0.38 [‐1.43, 0.66]

1.10 Mood Show forest plot

4

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

1.10.1 All studies

4

221

Std. Mean Difference (IV, Random, 95% CI)

0.53 [‐0.03, 1.10]

1.10.2 Sensitivity analysis (randomization method)

3

177

Std. Mean Difference (IV, Random, 95% CI)

0.68 [‐0.04, 1.39]

1.11 Mood (intervention subgroup) Show forest plot

4

221

Std. Mean Difference (IV, Random, 95% CI)

0.53 [‐0.03, 1.10]

1.11.1 Music therapy studies

2

104

Std. Mean Difference (IV, Random, 95% CI)

0.37 [‐0.13, 0.87]

1.11.2 Music medicine studies

2

117

Std. Mean Difference (IV, Random, 95% CI)

0.73 [‐0.54, 1.99]

1.12 Hope Show forest plot

2

53

Mean Difference (IV, Random, 95% CI)

3.19 [0.12, 6.25]

1.13 Pain Show forest plot

12

1206

Std. Mean Difference (IV, Random, 95% CI)

‐0.72 [‐1.01, ‐0.42]

1.13.1 All studies

12

632

Std. Mean Difference (IV, Random, 95% CI)

‐0.67 [‐1.07, ‐0.26]

1.13.2 Sensitivity analysis (< 10% non‐cancer studies excluded)

9

574

Std. Mean Difference (IV, Random, 95% CI)

‐0.77 [‐1.25, ‐0.29]

1.14 Pain (intervention subgroup) Show forest plot

12

632

Std. Mean Difference (IV, Random, 95% CI)

‐0.67 [‐1.07, ‐0.26]

1.14.1 Music therapy studies

5

105

Std. Mean Difference (IV, Random, 95% CI)

‐0.47 [‐0.86, ‐0.07]

1.14.2 Music medicine studies

7

527

Std. Mean Difference (IV, Random, 95% CI)

‐0.81 [‐1.38, ‐0.24]

1.15 Pain (music preference) Show forest plot

8

567

Std. Mean Difference (IV, Random, 95% CI)

‐0.84 [‐1.34, ‐0.33]

1.15.1 Patient‐preferred music

5

348

Std. Mean Difference (IV, Random, 95% CI)

‐0.87 [‐1.65, ‐0.10]

1.15.2 Researcher‐selected music

3

219

Std. Mean Difference (IV, Random, 95% CI)

‐0.74 [‐1.33, ‐0.14]

1.16 Fatigue Show forest plot

10

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

1.16.1 All studies

10

498

Std. Mean Difference (IV, Random, 95% CI)

‐0.28 [‐0.46, ‐0.10]

1.16.2 Sensitivity analysis (randomization method)

9

448

Std. Mean Difference (IV, Random, 95% CI)

‐0.26 [‐0.45, ‐0.07]

1.16.3 Sensitivity analysis (< 10% non‐cancer studies excluded)

9

463

Std. Mean Difference (IV, Random, 95% CI)

‐0.26 [‐0.44, ‐0.07]

1.17 Fatigue (intervention subgroup) Show forest plot

9

449

Std. Mean Difference (IV, Random, 95% CI)

‐0.27 [‐0.46, ‐0.08]

1.17.1 Music therapy studies

6

256

Std. Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.61, ‐0.12]

1.17.2 Music medicine studies

3

193

Std. Mean Difference (IV, Random, 95% CI)

‐0.15 [‐0.43, 0.14]

1.18 Physical functioning Show forest plot

4

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

1.18.1 All studies

4

493

Std. Mean Difference (IV, Random, 95% CI)

0.78 [‐0.74, 2.31]

1.18.2 Sensitivity analysis (randomization method)

3

233

Std. Mean Difference (IV, Random, 95% CI)

0.08 [‐0.18, 0.34]

1.19 Heart rate Show forest plot

11

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.19.1 All studies

11

1022

Mean Difference (IV, Random, 95% CI)

‐3.40 [‐5.58, ‐1.23]

1.19.2 Sensitivity analysis (randomization method)

9

772

Mean Difference (IV, Random, 95% CI)

‐4.37 [‐6.29, ‐2.44]

1.20 Heart rate (music preference) Show forest plot

10

972

Mean Difference (IV, Random, 95% CI)

‐3.65 [‐5.94, ‐1.35]

1.20.1 Patient‐preferred music

7

807

Mean Difference (IV, Random, 95% CI)

‐3.34 [‐6.06, ‐0.62]

1.20.2 Researcher‐selected music

3

165

Mean Difference (IV, Random, 95% CI)

‐4.47 [‐8.02, ‐0.91]

1.21 Respiratory rate Show forest plot

5

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.21.1 All studies

5

737

Mean Difference (IV, Random, 95% CI)

‐0.71 [‐1.18, ‐0.23]

1.21.2 Sensitivity analysis (randomization method)

4

537

Mean Difference (IV, Random, 95% CI)

‐1.18 [‐2.46, 0.11]

1.22 Systolic blood pressure Show forest plot

10

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.22.1 All studies

10

992

Mean Difference (IV, Random, 95% CI)

‐4.18 [‐6.70, ‐1.66]

1.22.2 Sensitivity analysis (randomization method)

8

742

Mean Difference (IV, Random, 95% CI)

‐4.50 [‐8.36, ‐0.64]

1.23 Systolic blood pressure (music preference) Show forest plot

9

942

Mean Difference (IV, Random, 95% CI)

‐4.76 [‐7.25, ‐2.26]

1.23.1 Patient‐preferred music

6

777

Mean Difference (IV, Random, 95% CI)

‐4.82 [‐7.90, ‐1.75]

1.23.2 Researcher‐selected music

3

165

Mean Difference (IV, Random, 95% CI)

‐4.71 [‐12.04, 2.63]

1.24 Diastolic blood pressure Show forest plot

10

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.24.1 All studies

10

992

Mean Difference (IV, Random, 95% CI)

‐2.34 [‐4.70, 0.01]

1.24.2 Sensitivity analysis (randomization method)

8

742

Mean Difference (IV, Random, 95% CI)

‐3.86 [‐6.01, ‐1.71]

1.25 Diastolic blood pressure (music preference) Show forest plot

9

942

Mean Difference (IV, Random, 95% CI)

‐3.21 [‐5.63, ‐0.80]

1.25.1 Patient‐preferred music

6

777

Mean Difference (IV, Random, 95% CI)

‐3.36 [‐6.46, ‐0.27]

1.25.2 Researcher‐selected music

3

165

Mean Difference (IV, Random, 95% CI)

‐2.51 [‐5.03, 0.02]

1.26 Oxygen saturation Show forest plot

2

252

Mean Difference (IV, Random, 95% CI)

0.59 [‐0.62, 1.80]

1.27 Quality of life Show forest plot

7

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

1.27.1 All studies

7

573

Std. Mean Difference (IV, Random, 95% CI)

0.88 [‐0.31, 2.08]

1.27.2 Sensitivity analysis (randomization method)

5

269

Std. Mean Difference (IV, Random, 95% CI)

0.47 [0.06, 0.88]

1.28 Quality of life (intervention subgroup) Show forest plot

7

573

Std. Mean Difference (IV, Random, 95% CI)

0.88 [‐0.31, 2.08]

1.28.1 Music therapy studies

4

160

Std. Mean Difference (IV, Random, 95% CI)

0.40 [0.08, 0.71]

1.28.2 Music medicine studies

3

413

Std. Mean Difference (IV, Random, 95% CI)

1.32 [‐1.02, 3.67]

Figures and Tables -
Comparison 1. Music intervention plus standard care versus standard care alone in adults
Comparison 2. Music interventions plus standard care versus standard care alone in children

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

2.1 Anxiety (STAI) Show forest plot

2

79

Std. Mean Difference (IV, Random, 95% CI)

‐0.94 [‐1.90, 0.03]

Figures and Tables -
Comparison 2. Music interventions plus standard care versus standard care alone in children
Comparison 3. Music interventions plus standard care versus standard care plus placebo control in children

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

3.1 Distress Show forest plot

2

Mean Difference (IV, Random, 95% CI)

‐0.07 [‐0.39, 0.26]

3.2 Spiritual well‐being Show forest plot

2

Std. Mean Difference (IV, Fixed, 95% CI)

0.31 [‐0.11, 0.73]

Figures and Tables -
Comparison 3. Music interventions plus standard care versus standard care plus placebo control in children
Comparison 4. Music therapy plus standard care versus music medicine plus standard care in adults

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

4.1 Anxiety Show forest plot

2

194

Mean Difference (IV, Fixed, 95% CI)

‐3.55 [‐7.13, 0.02]

Figures and Tables -
Comparison 4. Music therapy plus standard care versus music medicine plus standard care in adults