music therapy research and evidence based practice

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Effectiveness of music therapy: a summary of systematic reviews based on randomized controlled trials of music interventions

Hiroharu kamioka.

1 Faculty of Regional Environment Science, Tokyo University of Agriculture, Tokyo, Japan

Kiichiro Tsutani

2 Department of Drug Policy and Management, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan

Minoru Yamada

3 Kyoto University Graduate School Research, Kyoto, Japan

Hyuntae Park

4 Department of Functioning Activation, National Center for Geriatrics and Gerontology, Aichi, Japan

Hiroyasu Okuizumi

5 Mimaki Onsen (Spa) Clinic, Tomi, Nagano, Japan

Koki Tsuruoka

6 Graduate School of Social Services, Japan College of Social Work, Tokyo, Japan

Takuya Honda

7 Japanese Society for the Promotion of Science, Tokyo, Japan

Shinpei Okada

8 Physical Education and Medicine Research Foundation, Tomi, Nagano, Japan

Sang-Jun Park

Jun kitayuguchi.

9 Physical Education and Medicine Research Center Unnan, Shimane, Japan

Takafumi Abe

Shuichi handa, takuya oshio.

10 Social Welfare Service Corporation CARE-PORT MIMAKI, Tomi, Nagano, Japan

Yoshiteru Mutoh

11 The Research Institute of Nippon Sport Science University, Tokyo, Japan

Associated Data

References to studies excluded in this review

Abbreviations: NICU, neonatal intensive care unit; RCT, randomized controlled trial; SR, systematic review.

The objective of this review was to summarize evidence for the effectiveness of music therapy (MT) and to assess the quality of systematic reviews (SRs) based on randomized controlled trials (RCTs).

Study design

An SR of SRs based on RCTs.

Studies were eligible if they were RCTs. Studies included were those with at least one treatment group in which MT was applied. We searched the following databases from 1995 to October 1, 2012: MEDLINE via PubMed, CINAHL (Cumulative Index of Nursing and Allied Health Literature), Web of Science, Global Health Library, and Ichushi-Web. We also searched all Cochrane Database and Campbell Systematic Reviews up to October 1, 2012. Based on the International Classification of Diseases , 10th revision, we identified a disease targeted for each article.

Twenty-one studies met all inclusion criteria. This study included 16 Cochrane reviews. As a whole, the quality of the articles was very good. Eight studies were about “Mental and behavioural disorders (F00-99)”; there were two studies on “Diseases of the nervous system (G00-99)” and “Diseases of the respiratory system (J00-99)”; and there was one study each for “Endocrine, nutritional and metabolic diseases (E00-90)”, “Diseases of the circulatory system (I00-99)”, and “Pregnancy, childbirth and the puerperium (O60)”. MT treatment improved the following: global and social functioning in schizophrenia and/or serious mental disorders, gait and related activities in Parkinson’s disease, depressive symptoms, and sleep quality.

This comprehensive summary of SRs demonstrated that MT treatment improved the following: global and social functioning in schizophrenia and/or serious mental disorders, gait and related activities in Parkinson’s disease, depressive symptoms, and sleep quality. MT may have the potential for improving other diseases, but there is not enough evidence at present. Most importantly, no specific adverse effect or harmful phenomenon occurred in any of the studies, and MT was well tolerated by almost all patients.

Article focus

Although many studies have reported the effects of music therapy (MT), there is no review of systematic reviews (SRs) based on randomized controlled trials (RCTs).

Key messages

The key messages of this paper are as follows.

• This is the first SR of SRs of the effectiveness of cure based on music interventions in studies with RCT designs.
• Our study is unique because it summarizes the evidence for each target disease according to the International Classification of Diseases , revision 10 (ICD-10).
• We propose the future research agenda for studies on the treatment effect of MT.

Strength and limitation of this study

The strengths of this study are as follows: 1) the methods and implementation registered high on the PROSPERO database; 2) it was a comprehensive search strategy across multiple databases with no data restrictions; and 3) there were high agreement levels for quality assessment of articles.

This study has three limitations. Firstly, some selection criteria were common across studies; however, the bias remained due to differences in eligibility for participation in each original RCT. Secondly, publication bias was a limitation. Lastly, since this review focused on summarizing the effects of MT for each disease, we did not describe all details on quality and quantity, such as type of MT, frequency of MT, and time on MT.

Introduction

MT is widely utilized for treatment of and assistance in various diseases. In one literature review, the authors found seven case reports/series and seven studies on MT for multiple sclerosis patients. The results of these studies as well as the case reports demonstrated patients’ improvements in the domains of self-acceptance, anxiety, and depression. 1 Another review examined the overall efficacy of MT in children and adolescents with psychopathology, and examined how the size of the effect of MT is influenced by the type of pathology, the subject’s age, the MT approach, and the type of outcome. 2 The analysis revealed that MT had a medium to large positive effect (effect size =0.61) on clinically relevant outcomes that was statistically highly significant ( P <0.001) and statistically homogeneous. A more recent SR assessed the effects of musical elements in the treatment of individuals with acquired neurological disorder. 3 The results showed that mechanisms of recovery remained unclear: two of the three studies that examined mechanisms of recovery via neuro-imaging techniques supported the role of the right hemisphere, but reports were contradictory, and exact mechanisms of recovery remained indefinable. An interesting meta-analysis described results that justified strong consideration for the inclusion of neonatal intensive care unit (NICU) MT protocols in best practice standards for NICU treatment of preterm infants: examples of these therapies were listening to music for pacification, music reinforcement of sucking/feeding ability, and music as a basis for pacification during multilayered, multimodal stimulation. 4

Examining the curative effects of MT has unique challenges. A review article by Nilsson 5 described how nurses face many challenges as they care for the needs of hospitalized patients, and that they often have to prioritize physical care over the patient’s emotional, spiritual, and psychological needs. In clinical practice, music intervention can be a tool to support these needs by creating an environment that stimulates and maintains relaxation, wellbeing, and comfort. Furthermore, the Nilsson article 5 presented a concrete recommendation for music interventions in clinical practice, such as “slow and flowing music, approximately 60 to 80 beats per minute”, “nonlyrical”, “maximum volume level at 60 dB”, “patient’s own choice, with guidance”, “suitable equipment chosen for the specific situation”, “a minimum duration of 30 minutes in length”, and “measurement, follow up, and documentation of the effects”. In addition, MT has been variably applied as both a primary and accessory treatment for persons with addictions to alcohol, tobacco, and other drugs of abuse. However, an SR 6 described that no consensus exists regarding the efficacy of MT as treatment for patients with addictions.

On the other hand, music may be considered an adjunctive therapy in clinical situations. Music is effective in reducing anxiety and pain in children undergoing medical and dental procedures. 7 A meta-analysis confirmed that patients listening to music during colonoscopy, which is now the recommended method for screening colon cancer, was an effective method for reducing procedure time, anxiety, and the amount of sedation. More importantly, no harmful effects were observed for all the target studies. 8 The usual practice following a cervical cancer abnormal cervical smear is to perform a colposcopy. However, women experience high levels of anxiety and negative emotional responses at all stages of cervical screening. An SR of RCTs evaluated interventions designed to reduce anxiety levels during colposcopic examination. Psychosexual dysfunction (ie, anxiety) was reduced by playing music during colposcopy. 9

The definition of musical intervention is complex, but the literature describes two broad categories of music interventions: music medicine and MT. 10 Music medicine is the use of passive listening (usually involving prerecorded music) as implemented by medical personnel. In music medicine studies, the subject’s preference for the music used may be considered by having him or her select from a variety of tapes. Alternately, some studies use predefined music stimuli that do not take the subject’s preferences into account. Furthermore, there is generally no attempt by the researcher to form a therapeutic relationship with the subject, and there is no process involved in the music treatment. In essence, music medicine studies usually allow one to assess the effects of music alone as a therapeutic intervention. In contrast, MT interventions most often involve a relationship between the therapist and the subject, the use of live music (performed or created by the therapist and/or patient), and a process that includes assessment, treatment, and evaluation. Patient preference for the music is usually a consideration in MT studies.

We were interested in evaluating the curative effect of MT according to diseases because many of the primary studies and review articles of much MT have reported results in this way. In particular, we wanted to focus on all cure and rehabilitation effects using the ICD-10. It is well known in research design that evidence grading is highest for an SR with meta-analysis of RCTs. Although many studies have reported the effects of MT, there is no review of SRs based on RCTs. The objective of this review was to summarize evidence for the effectiveness of MT and to assess the quality of SRs based on RCTs of these therapies.

Criteria for considering studies included in this review

Types of studies.

Studies were eligible if they were SRs (with or without a meta-analysis) based on RCTs.

Types of participants

There was no restriction on patients.

Types of intervention and language

Studies included were those with at least one treatment group in which MT was applied. The definition of MT is complex, but in this study, any kind of MT (not only music appreciation but also musical instrument performance and singing, for example) was permitted and defined as an intervention. Studies had to include information on the use of medication, alternative therapies, and lifestyle changes, and these had to be comparable among groups. There was no restriction on the basis of language.

Types of outcome measures

We focused on all cure and rehabilitation effects using the ICD-10.

Search methods for studies identification

Bibliographic database.

We searched the following databases from 1995 to October 1, 2012: MEDLINE via PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science, Ichushi Web (in Japanese), the Global Health Library (GHL), and the Western Pacific Region Index Medicus (WPRIM). The International Committee of Medical Journal Editors (ICMJE) recommended uniform requirements for manuscripts submitted to biomedical journals in 1993. We selected articles published (that included a protocol) since 1995, because it appeared that the ICMJE recommendation had been adopted by the relevant researchers and had strengthened the quality of the reports.

We also searched the Cochrane Database of Systematic Reviews (Cochrane Reviews), the Database of Abstracts of Reviews of Effects (Other Reviews), the Cochrane Central Register of Controlled Trials (Clinical Trials or CENTRAL), the Cochrane Methodology Register (Methods Studies), the Health Technology Assessment Database (Technology Assessments), the NHS Economic Evaluation Database (Economic Evaluations), About The Cochrane Collaboration databases (Cochrane Groups), the Campbell Systematic Reviews (the Campbell Collaboration), and the All Cochrane, up to October 1, 2012.

All searches were performed by two specific searchers (hospital librarians) who were qualified in medical information handling, and who were experienced in searches of clinical trials.

Search strategies

The special search strategies contained the elements and terms for MEDLINE, CINAHL, Web of Science, Ichushi Web, GHL, WPRIM, and All Cochrane databases ( Figure 1 and Table 1 ). Only keywords about intervention were used for the searches. First, titles and abstracts of identified published articles were reviewed in order to determine the relevance of the articles. Next, references in relevant studies and identified SRs were screened.

Flowchart of trial process.

Note: *Reduplication.

Abbreviations: CINAHL, Cumulative Index of Nursing and Allied Health Literature; CENTRAL, Cochrane Central Register of Controlled Trials; RCT, randomized controlled trial; SR, systematic review.

The special search strategies

Registry checking

We searched the International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov , and the University Hospital Medical Information Network – Clinical Trials Registry (UMIN-CTR), up to October 1, 2012.

ICTRP in the WHO Registry Network meet specific criteria for content, quality and validity, accessibility, unique identification, technical capacity, and administration. Primary registries meet the requirements of the ICMJE. Clinical ClinicalTrials.gov is a registry of federally and privately supported clinical trials conducted in the US and around the world. UMIN-CTR is a registry of clinical trials conducted in Japan and around the world.

Handsearching and reference checking

We handsearched abstracts published on MT in relevant journals in Japan. We checked the references of included studies for further relevant literature.

Review methods

Selection of trials.

To make the final selection of studies for the review, all criteria were applied independently by four authors (ie, TH, JK, SJP, and TA) to the full text of articles that had passed the first eligibility screening ( Figure 1 ). Disagreements and uncertainties were resolved by discussion with other authors (ie, HK, KT, and YM).

Studies were selected when 1) the design was an SR based on RCTs and 2) one of the interventions was a form of MT. Protocols without results were excluded, and we included only completed studies. Cure and rehabilitation effects were used as a primary outcome measure. Trials that were excluded are presented with reasons for exclusion ( Table S1 ).

Quality assessment of included studies

To ensure that variation was not caused by systematic errors in the study design or execution, eleven review authors (HP, MY, HO, SO, SJP, TO, KT, TH, SH, JK, and HK) independently assessed the quality of the articles. A full quality appraisal of these papers was made using the combined tool based on the AMSTAR checklist 11 developed to assess the methodological quality of SRs.

Each item was scored as “present” (Yes), “absent” (No), “unclear or inadequately described” (Can not answer), or “not applicable” (n/a). Depending on the study design, some items were not applicable. The “n/a” was excluded from calculation for quality assessment. We displayed the percentage of descriptions that were present on all items for the quality assessment of articles. Then, based on the percentage of risk of poor methodology and/or bias, each item was assigned to one of the following categories: good description (80%–100%), poor description (50%–79%), or very poor description (0%–49%).

Disagreements and uncertainties were resolved by discussion with other authors (ie, KT and HK). Inter-rater reliability was calculated on a dichotomous scale using percentage agreement and Cohen’s kappa coefficient (κ).

Summary of studies and data extraction

Eleven review authors (HP, MY, HO, SO, SJP, TH, TO, SH, JK, KT, and HK) described the summary from each article based on the structured abstracts. 12 , 13

Benefit and harm

The GRADE Working Group 14 reported that the balance between benefit and harm, quality of evidence, applicability, and the certainty of the baseline risk were all considered in judgments about the strength of recommendations. Adverse events for intervention were especially important information for researchers and users of clinical practice guidelines, and we presented this information with the description of each article.

Research protocol registration

We submitted and registered our research protocol to the PROSPERO (no 42012002950). PROSPERO is an international database of prospectively registered SRs in health and social care. 15 Key features from the review protocol are recorded and maintained as a permanent record in PROSPERO. This provides a comprehensive listing of SRs registered at inception, and enables comparison of reported review findings with what was planned in the protocol. PROSPERO is managed by UK Centre for Reviews and Dissemination (CRD) and funded by the UK National Institute for Health Research. Registration was recommended because it encourage full publication of the review’s findings and transparency in changes to methods that could bias findings. 16

Study selection

The literature searches included potentially relevant articles ( Figure 1 ). Abstracts from those articles were assessed, and 63 papers were retrieved for further evaluation (checks for relevant literature). Forty-two publications were excluded because they did not meet the eligibility criteria ( Table S1 ). A total of 21 studies 17 – 37 met all inclusion criteria ( Table 1 ). The language of all eligible publications was English.

Study characteristics

The contents of all articles were summarized as structured abstracts ( Table 2 ). Sinha et al 17 reported that there was no evidence that auditory integration therapy or other sound therapies are effective as treatments for autism spectrum disorders. Mossler et al 18 concluded that MT as an addition to standard care helps people with schizophrenia to improve their global state, mental state (including negative symptoms), and social functioning if a sufficient number of MT sessions are provided by qualified music therapists. Bradt et al 19 indicated that music interventions may have beneficial effects on anxiety, pain, mood, and quality of life (QoL) in people with cancer. Bradt and Dileo 20 reported that there may be a benefit of MT on QoL of people in end-of-life care. Vink et al 21 reported that the methodological quality and the reporting of the included studies on dementia were too poor to draw any useful conclusions. Bradt et al 22 indicated that listening to music may have a beneficial effect on heart rate, respiratory rate, and anxiety in mechanically ventilated patients. Cepeda et al 23 reported that listening to music reduces pain intensity levels and opioid requirements on patients with chronic, acute, neuropathic, and cancer pain or experimental pain, but the magnitude of these benefits is small and therefore its clinical importance unclear. Bradt et al 24 reported that rhythmic auditory stimulation might be beneficial for gait improvement in people with stroke. Gold et al 25 indicated that MT may help children with autistic spectrum disorder to improve their communicative skills. Laopaiboon et al 26 indicated that music during planned cesarean section under regional anesthesia may improve pulse rate and birth satisfaction score. Bradt and Dileo 27 reported that listening to music may have a beneficial effect on blood pressure, heart rate, respiratory rate, anxiety, and pain in persons with coronary heart disease. Maratos et al 28 suggested that MT is accepted by people with depression and is associated with improvements in mood, but the small number and low methodological quality of studies meant that it is not possible to be confident about its effectiveness. de Dreu et al 29 reported that music-based movement therapy appeared promising for the improvement of gait and gait-related activities in Parkinson’s disease. Cogo-Moreira et al 30 concluded that there is no evidence available on which to base a judgment about the effectiveness of music education for the improvement of reading skills in children and adolescents with dyslexia. Drahota et al 31 reported that music may improve patient-reported outcomes in certain circumstances such as anxiety for hospital patients. Chan et al 32 concluded that listening to music over a period of time helps to reduce depressive symptoms in the adult population. Naylor et al 33 reported that there is limited qualitative evidence to support the effectiveness of music on health-related outcomes for children and adolescents with clinical diagnoses. Irons et al 34 concluded that because no studies that met the criteria were found, their review was unable to support or refute the benefits of singing as a therapy for people with cystic fibrosis. Irons et al 35 reported that they could not draw any conclusion to support or refute the adoption of singing as an intervention for people with bronchiectasis because of the absence of data. de Niet et al 36 concluded that music-assisted relaxation could be without intensive investment in training and materials and is therefore cheap, easily available and can be used by nurses to promote music-assisted relaxation to improve sleep quality. Gold et al 37 reported that MT is an effective treatment which helps people with psychotic and nonpsychotic severe mental disorders to improve global state, symptoms, and functioning.

A structured abstract of 21 systematic reviews

Abbreviations: ASSIA, Applied Social Sciences Index and Abstracts; BPRS, Brief Psychiatric Rating Scale; CAG, Cochrane Airways Group; CAIRSS, Computer-Assisted Information Retrieval System; CCDANCTR, Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register; CDCIG, Cochrane Dementia and Cognitive Improvement Group; CENTRAL, Cochrane Central Register of Controlled Trials; CHD, coronary heart disease; CI, confidence interval; CINAHL, Cumulative Index of Nursing and Allied Health Literature; ERIC, Education Resource Information Centre; Ham-D, Hamilton Depression Scale; ICTRP, International Clinical Trials Registry Platform; LILACS, Latin American and Caribbean Health Sciences Literature; MbM, music-based movement; MD, mean difference; MeSH, Medical Subject Headings; NIH, National Institutes of Health; NNT, number needed to treat; PANSS, Positive and Negative Symptoms Scale; PD, Parkinson’s disease; PEDro, Physiotherapy Evidence Database; QoL, quality of life; RAS, rhythmic auditory stimulation; RCT, randomized controlled trial; RR, risk ratio; SANS, Scale for the Assessment of Negative Symptoms; SDS, Self-rating Depression Scale; SDSI, Social Disability Schedule for Inpatients; SES, summary effect size; SMD, standardized mean difference; STAI-S, State-Trait Anxiety Inventory – State; UPDRS, Unifed Parkinson’s Disease Rating Scale; WHO, World Health Organization.

Based on ICD-10, we identified a disease targeted in each article ( Table 3 ). Among 21 studies, eight studies were about “Mental and behavioural disorders (F00-99)”. There were two studies in “Diseases of the nervous system (G00-99)” and “Diseases of the respiratory system (J00-99)”, and one study in “Endocrine, nutritional and metabolic diseases (E00-90)”, “Diseases of the circulatory system (I00-99)”, and “Pregnancy, childbirth and the puerperium (O60)”. Because there were a variety of target diseases, there were six articles in which we could not identify a single disease.

International classification of target diseases in each article

Abbreviation: ICD, International Classification of Diseases.

Evidence of effectiveness

Table 4 presents a brief summary of 21 SRs. Five studies (ie, schizophrenia for global and mental state and social functioning, 18 Parkinson’s disease for gait and related activities, 29 depressive symptoms, 32 sleep quality, 36 and serious mental disorders for global and social functioning 37 ) concluded that there are effects of the intervention.

Brief summary of 21 systematic reviews

Abbreviation: QoL, quality of life

Ten studies with a meta-analysis (ie, cancer for anxiety, pain, mood, and QoL, 19 advanced life-limiting illness for QoL, 20 mechanically ventilated patients for heart rate, respiratory rate, and anxiety, 22 multiple pain for intensity level and opioid requirement, 23 acquired brain injury for gait parameters, 24 autistic spectrum disorders for communicative skills, 25 cesarean section for heart rate and birth satisfaction, 26 coronary heart disease for blood pressure, heart rate, respiratory rate, anxiety, and pain, 27 hospital patients for self-reported outcomes such as anxiety, 31 and various clinical conditions for health outcomes in children with learning and developmental disorder 33 ) concluded that there might be an effect of the intervention. An SR without a meta-analysis of depression reported that there might be an effect of the intervention. 28

Two studies (ie, autism spectrum 17 and dementia 21 ) described that the effect of intervention is unclear. There was no evidence for three studies (ie, dyslexia, 30 cystic fibrosis, 34 and bronchiectasis 35 ) because they were not RCTs.

Adverse events

There were no specific adverse events in any of the studies.

Quality assessment

We evaluated eleven items from the AMSTAR checklist in more detail ( Table 5 ). Inter-rater reliability metrics for the quality assessment indicated substantial agreement for all 231 items (percentage agreement 95.3% and κ =0.825). As a whole, the quality of the articles was very good.

AMSTAR is a measurement tool created to assess the methodological quality of systematic reviews

Abbreviations: CENTRAL, Cochrane Central Register of Controlled Trials; MeSH, Medical Subject Headings; Can’t, can not.

This is the first SR of SRs of the effectiveness of cure based on music interventions in studies with RCT designs. Our study is unique because it summarized the evidence for each target disease according to ICD-10 classification. We assume that this study will be helpful to researchers who want to grasp an effect of MT comprehensively and could provide information that is indispensable for the organization that is going to make the guidelines according to each disease.

Twenty-one SRs based on RCTs were identified, and music intervention was clearly effective for five diseases (ie, schizophrenia for global and mental state and social functioning, Parkinson’s disease for gait and related activities, depressive symptoms, sleep quality, and serious mental disorders for global and social functioning).

A review of all SRs showed that there was no special adverse effect or harm associated with MT.

Tendency of target disease and outcome

The most commonly reported target diseases were “Mental and behavioural disorders (F00-99)”, 17 , 18 , 21 , 25 , 28 , 30 , 32 , 36 and the effect of MT on these diseases was improved mental health (eg, anxiety and mood), pain, QoL, and communication skills. The main reason given in these articles for improved mental health was that the beauty and rhythm of the music tone allowed the patient to be comfortable. In studies about the effects of MT on anxiety, discomfort, fear, and pain, MT has been variably applied as an accessory treatment for persons with addictions, 6 and as evasion of direct discomfort for undergoing medical device procedures such as colonoscopy, 8 colposcopy 9 and dental procedures. 7

The second most frequently reported target diseases were “Diseases of the nervous system (G00-99)”, 24 , 29 and the effects of MT on these diseases showed commonly gait parameters. MT is expected to improve gait and related activities such as rehabilitation in diseases of the central nervous system. There were also several studies that identified “Diseases of the respiratory system (J00-99).” 22 , 35 Improvements seen in these studies were mainly due to effects of singing on breathing function, such as respiratory rate, and on the circulation function, such as heart rate.

Validity of overall evidence based on quality assessment

We performed an evaluation of all SRs by the AMSTAR checklist developed to assess the methodological quality of SRs. There were no serious problems with the conduct and reporting of all target studies. This study included 16 Cochrane Reviews. 17 – 28 , 30 , 31 , 34 , 35 In the Cochrane Reviews, the eligibility criteria for a meta-analysis are strict, and for each article, heterogeneity and low quality of reporting are to first be excluded. Therefore, we assumed that the conclusion of each SR had enough validity.

Overall evidence

Most importantly, a specific adverse effect or harmful phenomenon did not occur in any study, and MT was well tolerated by almost all patients. MT treatment has positive effects for the following: schizophrenia and/or serious mental disorders for global and social functioning, Parkinson’s disease for gait and related activities, depressive symptoms, and sleep quality. We assume that the direct effects of MT are generally improvement of mental health and sense of rhythm, and reduction of pain. In addition, we assume that communication with other people improves through music, the sense of isolation disappears, and QoL rises.

Although further accumulation of RCT data is necessary, MT may be effective treatment for the following diseases and symptoms: cancer and/or advanced life-limiting illnesses affecting mental state and QoL, mechanically ventilated patients with impaired respiratory function and mental state, chronic pain requiring opioid treatment, acquired brain injury affecting gait parameters, autistic spectrum disorders involving communicative skills, cesarean section effects on heart rate and birth satisfaction, coronary heart disease effects on circulatory, respiratory function, and mental state, and self-reported outcomes for hospitalized patients and other patients with various clinical conditions. These SRs describe the need for additional high quality RCTs to assess the effect of MT.

Future research agenda to build evidence

Table 6 shows the future research agenda for studies on the treatment effect of MT. Because only SRs of RCTs were included in this study, their characteristic study designs limited our results to the assessment of short-term effects. Even if a study is not an RCT design, it is necessary to evaluate the long-term effects.

Future research agenda to build evidence of music therapy

Because studies of intervention using music vary in design, a consensus of the framework is necessary. 10 In this study, examination according to a detailed intervention method was not possible, but it would be important for future studies to define MT. Furthermore, studies to assess dose–response relationships according to each disease are clearly necessary. 18

Bowen et al 38 suggested that public health is moving toward the goal of implementing evidence-based intervention. However, the feasibility of possible interventions and whether comprehensive and multilevel evaluations are needed to justify them must be determined. It is at least necessary to show the cost of such interventions. We must introduce an interventional method based on its cost-benefit, cost-effectiveness, and cost-utility.

In addition, MT as an intervention is unique and completely different than pharmacological or traditional rehabilitation methods. Therefore, it may be necessary to add some original items like herbal intervention, 39 aquatic exercise, 40 and balneotherapy 41 to the CONSORT 2010 checklist as alternative or complementary medicines.

Strength and limitations

This review has several strengths: 1) the methods and implementation registered high on the PROSPERO database; 2) it was a comprehensive search strategy across multiple databases with no data restrictions; 3) there were high agreement levels for quality assessment of articles; and 4) it involved detailed data extraction to allow for collecting all articles’ content into a recommended structured abstract.

This review also had several limitations that should be acknowledged. Firstly, some selection criteria were common across studies, as described above; however, bias remained due to differences in eligibility for participation in each original RCT. Secondly, publication bias was a limitation. Although there was no linguistic restriction in the eligibility criteria, we searched studies with only English and Japanese keywords. Thirdly, in order to be specific to SRs based on RCTs, it ignores some excellent results of primary research by other research designs. Fourthly, as a point of terminology for MT, because we applied a broad definition to the use of music in medicine, it may be more confusing or a bit misleading in the cultural context of Western health care.

In addition, since this review focused on summaries of effects of MT for each disease, we did not describe all details on quality and quantity such as type of MT, frequency of MT, and time on MT. Moreover, we could not follow standard procedures as estimates of the effects of moderating variables. Finally, because we broadly defined MT as music appreciation, musical instrument performance, and singing, we could not assess a specific intervention.

This comprehensive summary of SRs demonstrates that MT treatment improved the following: global and social functioning in schizophrenia and/or serious mental disorders, gait and related activities in Parkinson’s disease, depressive symptoms, and sleep quality. MT may have the potential for improving other diseases, but there is not enough evidence at present. Most importantly, a specific adverse effect or harmful phenomenon did not occur in any of the studies, and MT was well tolerated by almost all patients.

To most effectively assess the potential benefits of MT, it will be important for future research to explore 1) long-term effects, 2) a consensus of the framework of music intervention, 3) dose–response relationships, 4) the cost of the intervention, and 5) development of the original check item in MT.

Music therapy : research and evidence-based practice

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• Contributors

Description

Creators/contributors, contents/summary.

• Forword / Jayne M. Standley
• Author's preface / Olivia Swedberg Yinger
• Overview of the music therapy profession / Olivia Swedberg Yinger
• Neurologic foundations of music-based interventions / Kimberly Sena Moore
• Music therapy in educational settings / Michael R. Detmer
• Music therapy in mental health treatment / Lori F. Gooding
• Music therapy in medical treatment and rehabilitation / Darcy DeLoach
• Music therapy in hospice and palliative care / Meganne K. Masko
• Music therapy in gerontology / Olivia Swedberg Yinger
• Music therapy and wellness / Lorna E. Segall
• Current trends and future directions in music therapy / Alejandra J. Ferrer.

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Evidence-based music therapy practice: an integral understanding

Affiliation.

• 1 Montclair State University, USA.
• PMID: 21488603
• DOI: 10.1093/jmt/47.4.351

The American Music Therapy Association has recently put into action a plan called its Research Strategic Priority, with one of its central purposes to advance the music therapy field through research promoting Evidence-Based Practice of music therapy. The extant literature on music therapy practice, theory, and research conveys a range of very different perspectives on what may count as the "evidence" upon which practice is based. There is therefore a need to conceptualize evidence-based music therapy practice in a multifaceted, yet coherent and balanced way. The purpose of this paper is to illustrate a framework based upon four distinct epistemological perspectives on evidence-based music therapy practice that together represent an integral understanding.

• Evidence-Based Practice / organization & administration*
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• Music Therapy / methods
• Music Therapy / organization & administration*
• Practice Guidelines as Topic*
• Practice Patterns, Physicians' / organization & administration*
• Professional Competence
• Research Design
• Societies, Medical
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39 Music Therapy Research: An Overview

Professor Barbara Wheeler, Professor Emerita, Montclair State University, USA

• Published: 05 May 2015
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Music therapy is a diverse field and music therapy research increasingly reflects that diversity. Many methods and approaches are used to examine the various facets of music therapy practice and theory. This chapter provides an overview of music therapy research, and provides basic information about how research is conducted in this field. Research methods in music therapy research are similar to those used in other healthcare disciplines. A range of methods are reviewed and presented including; experimental research and Randomized Controlled Trials, Participatory Action Research, Grounded Theory, and Phenomenological methods.

Music therapy is a diverse field and music therapy research increasingly reflects that diversity. Many methods and approaches are used to examine the various facets of music therapy practice and theory. This chapter provides an overview of music therapy research, and provides basic information about how research is conducted in this field.

Music therapy research is similar to research in other disciplines, but it has some unique aspects. It has the same definition and purposes, as described below, and most of the research methods that are employed are similar to those in other fields of health research. The focus on music is distinctive from most other types of health research. When the music, the therapist, and the client are included in the research process and outcomes a unique perspective is gained.

Definition of research

Bruscia (1995b) has defined research as “a systematic, self-monitored inquiry which leads to a discovery or new insight which, when documented and disseminated, contributes to or modifies existing knowledge or practice” (p. 21). Gfeller (1995) described research as “a disciplined or systematic inquiry” (p. 29). She has also pointed to the importance of the definition proposed by Phelps et al. (2005) that research is “a carefully organized procedure that can result in the discovery of new knowledge, the substantiation of previously held concepts, the rejection of false tenets, and the formal presentation of data collected” (p. 3).

Questions and types of research

Research comes from the questions of the researcher or research team. Once the question is developed and refined a research method or approach is chosen because of its suitability to answer the question. While some people begin their research with a particular research method in mind, it is more usual to begin with the question and to let the question determine the method. Some basic examples of questions that lead to research designs are presented here.

Quantitative research

Descriptive.

We might ask, “How does X influence our client during the process of therapy?” where X could be variations in the tempo, volume, tonality, or another aspect of an improvisation; type of instrument used; or things that are happening in the client’s life outside of music therapy. Examples of descriptive research in music therapy could include studies that are based on surveys and questionnaires, single subject designs that rely on numerical data to determine the results, and studies of groups of people that use quantitative measures of outcomes but do not include a control group for comparison.

Experimental Research

We might ask, “Does X treatment work better than Y treatment?” X and Y could be music therapy and movement therapy or music therapy in combination with physical therapy versus music therapy alone. In experimental research, two or more treatment conditions are compared and participants are randomly assigned to conditions so that no variables outside of those that are being tested vary among conditions. Although it is not possible to achieve strict control outside of a laboratory, these designs do as much as possible to control all factors. These are standard experimental designs that answer questions about the effectiveness of music therapy and are often requested by those who determine what therapy should be supported or paid for.

Qualitative research

In qualitative research, we might ask, “What do clients experience in music therapy?” Qualitative research examines how phenomena are experienced and constructed through description, analysis, and interpretation. It relies upon words, music, sounds, or pictures to report the results and can help us learn more about aspects of the therapeutic setting. Qualitative research encompasses a wide range of methods, some of which grew out of phenomenology, existentialism, and hermeneutics in the social sciences. It looks for meaning and understanding and allows phenomena to unfold over time.

Examples of music therapy research

The following sections provide an overview of music therapy research with reference to a variety of methods. Examples have been selected to represent good research using each design, and encompassing a variety of topics. Although most studies are selected to represent a single method, studies can frequently employ several methods.

Experimental research, including randomized control trials; exploratory trials; meta-analysis; survey research; quantitative single-case designs, including applied behavior analysis; and longitudinal research are examples of quantitative research and will be discussed here.

Experimental research/randomized control trials

A number of randomized control trials are currently available on various aspects of music therapy. The Journal of Music Therapy and the Nordic Journal of Music Therapy require authors to follow the CONSORT (Consolidated Standards of Reporting Trials) Statement ( Schulz et al. 2010 ), which provides guidelines for reporting randomized control trials (RCTs) and insures that the reported information is transparent. In a RCT, participants are randomly assigned to conditions, with random assignment meaning that each person has an equal opportunity of being assigned to each condition. This controls for confounding variables by insuring that the conditions or groups are equivalent.

Examples of RCTs include two studies by Ghetti. In one ( Ghetti 2011 ), of active music engagement with emotional-approach coping to improve well-being in liver and kidney transplant recipients, she evaluated the impact of music therapy under two conditions to which the patients were randomly assigned. One group received music therapy with an emphasis on emotional-approach coping, which uses emotional expression, awareness, and understanding to facilitate coping with significant life stressors, and the other group received music therapy without the emphasis on emotional-approach coping. In another RCT, Ghetti (2013) evaluated the use of music therapy emphasizing emotional-approach coping on preprocedural anxiety in adults receiving cardiac catheterization. Another RCT by Gattino et al. (2011) examined the effects of relational music therapy plus routine clinical activities compared with routine clinical activities alone on communication of children with autism.

Exploratory trials or studies

Exploratory trials ( Medical Research Council 2000 ) or exploratory studies allow the researcher to gather information on how an intervention works but without including random assignment to conditions. Some of these, sometimes called quasi-experimental designs ( Shadish et al. 2002 ), are similar to experimental designs such as the RCT but participants are not randomly assigned to groups.

One example is a study by Bensimon and Gilboa (2010) , who studied Musical Presentation (MP), a therapeutic tool in which members of a group present themselves through musical pieces of their choice in and receive feedback from their peers, with the aim of increasing their sense of purpose in life and self-consciousness. Rather than randomly assigning participants to experimental and control groups, the researchers assigned them to the groups based on the times at which they were available.

Nayak et al. (2000) investigated the use of music therapy as an aid in improving mood and social interaction among people who have had traumatic brain injuries or strokes. Although the original intention was to randomly assign participants to the different groups that included an experimental group who received music therapy, a control group who received art therapy, and a control group receiving standard care, this goal was not achieved due to problems finding enough participants who met the criteria and were willing to participate. The completed study compared music therapy to standard treatment, but the condition to which participants were assigned was based on their availability rather than random assignment. Without randomization of participants the study design is considered to be much weaker because of the risk of bias.

In another type of exploratory study, data are collected but there is no control condition. The information gathered can help to determine whether the intervention can be carried out as planned. Studies of this type are often shared in professional journals. It is important that those writing them make it clear that, because they do not include any type of control, it is impossible to say what caused the effects that are seen. These studies are similar if not identical to what many clinicians do when they collect data on their work about how their clients respond or change during and after therapy. It is important for those involved with these designs to be aware of the limitations of such designs, and also to consider the similarities with data collected in regular clinical work.

Two studies of the Sing and Grow program for young children and their parents in Australia used pre-experimental designs. Nicholson et al. (2008) assessed the impact of a 10-week program for marginalized parents and their children in promoting positive parenting and child development. Williams et al. (2012) explored the impact on parental well-being, parenting behaviors, and child development for parents of children with disabilities and their children. Another example is of a music therapy program for women coping with breast cancer ( Wheeler et al. 2010 ), while a fourth is the evaluation of a music therapy protocol to enhance swallowing training for people who have had strokes and have dysphagia ( Kim 2010 ). In all four studies, data were gathered on targeted responses at several points and an evaluation of changes was made, but none of them included a control group. The findings of such studies can be used to develop more robust experimental procedures for future studies.

Meta-analysis

In a meta-analysis the researcher calculates a standard effect size 1 for each study, giving an indication of the size and variability of the phenomenon under investigation and allowing the studies to then be compared among themselves across all measures and variables. Meta-analyses have provided important information on the efficacy of music and music therapy in medicine. Standley (2000) conducted the first of these in 1986 and subsequently updated it several times. Standley (2002) later performed meta-analyses on the effectiveness of music therapy with premature infants in neonatal intensive care units and of music versus no music conditions during medical treatment of pediatric patients ( Standley and Whipple 2003 ).

Dileo and Bradt (2005) completed a meta-analysis of 184 studies involving music in medical treatment. They included all studies that had been conducted with a control group that did not receive music. They included 47 dependent variables. The effects of music and music therapy were reported for each dependent variable, grouped according to 11 medical specialty areas: premature infants, fetal responses to music, pediatrics, obstetrics/gynecology, cardiology/intensive care, oncology and terminal illness, general hospital, surgery, rehabilitation, dementia, and dentistry.

Additional meta-analyses that have been conducted include an analysis of music education and music therapy objectives ( Standley 1996 ), dementia ( Koger et al. 1999 ), symptoms of psychosis ( Silverman 2003 ), children and adolescents with autism ( Whipple 2004 ), children and adolescents with psychopathology ( Gold et al. 2004 ), stress reduction ( Pelletier 2004 ), neurologic rehabilitation of upper and lower limbs ( Chandra 2005 ), endoscopy procedures ( Rudin et al. 2007 ), and several aspects of the treatment of people with Parkinson’s disease ( de Dreu et al. 2012 ). Meta-analyses are also part of some Cochrane reviews, discussed elsewhere in this chapter.

Survey research

Survey research refers to:

the selection of a relatively large sample of people from a pre-determined population (the “population of interest”; this is the wider group of people in whom the researcher is interested in a particular study), followed by the collection of a relatively small amount of date from those individuals. The researcher therefore uses information from a sample of individuals to make some inference about the wider population. Kelley et al. 2003

Wigram (2005) divided music therapy survey research into three categories: (a) surveys of journals, (b) clinical surveys, and (c) surveys of training methods.

Surveys of journals, books, and other printed of web-based texts categorize the research and other articles according to the purpose of the survey. They can alert the profession to strengths and weaknesses, provide insight into where the research is happening, and determine how research is divided among clinical fields. Recent examples of this type of survey research include an analysis of music therapy journal articles by Brooks (2003) and analyses by Aigen of journals and books (2008a) and dissertations (2008b) . Roberts and McFerran (2008) utilized both quantitative and qualitative methods for a content analysis of how music therapy was reported in Australian print media over a 10-year period.

Clinical surveys consider aspects of clinical practice, attitudes from both professionals and clients, and information about where people work. Examples include such diverse topics as: a survey of the use of aided augmentative and alternative communication during music therapy sessions with persons with autism spectrum disorders ( Gadberry 2011 ); a survey of repertoire and music therapy approaches employed by Australian music therapists in working with older adults from culturally and linguistically diverse groups ( Baker and Grocke 2009 ); and a survey of the expectations of cancer and cardiac hospitalized cancer and cardiac patients regarding the medical and psychotherapeutic benefits of music therapy ( Bruscia et al. 2009 ). In an extension of traditional survey methods, Vega (2010) surveyed music therapists and also gave them a personality test and a test of burnout to examine possible relationships between personality, burnout level, longevity, and demographic variables among professional music therapists.

Surveys of training methods seek to learn more about music therapy practice, the experiences and attitudes of music therapy students, to assess the effectiveness of clinical training, and to explore competency requirements for music therapists. Researchers have sought information on a variety of topics. Stewart (2000) surveyed music therapists from the United Kingdom to assess personal qualities of music therapists, working models, support networks, and job satisfaction. Young (2009) surveyed music therapy internship directors to examine the extent to which multicultural issues were being addressed in internships in the United States and Canada; Gardstrom and Jackson (2011) surveyed music therapy program coordinators for information on personal therapy for undergraduate students; and Hahna and Schwantes (2011) surveyed music therapy educators regarding their views and use of feminist pedagogy and feminist music therapy.

Quantitative single-case designs and applied behavior analysis

Yin (2009) defines a case study as “an empirical inquiry that investigates a contemporary phenomenon in depth and within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident” (p. 18). Smeijsters (2005) developed music therapy applications of case studies as single-case designs. Examples of quantitative single-case designs include a study of a preschooler with vision impairment in which the authors looked at the child’s participation through several different playground adaptations that include musical stations and staff interactions ( Kern and Wolery 2001 ); an examination of how girls with Rett syndrome make song choices ( Elefant 2002 , 2005 ); and a study of the emotional development of a client as reflected in improvisations ( Smeijsters 2005 ; Wosch and Frommer 2002 ). Each of these studies used evaluation measurements and either a single case or a series of single cases to gather information.

Applied behavior analysis ( Hanser 2005 ) can be considered a type of single-case design that includes specific designs and techniques, including reversal and multiple baseline designs. These designs are applied in behavioral research to test a hypothesis about the behavior of a single individual or group, examine the effect of a particular strategy, or examine intra-subject changes over time under different conditions. Wlodarczyk (2007) used a reversal design to examine the effect of music therapy on the spirituality of people in an in-patient hospice unit. Using a multiple baseline design, de Mers et al. (2009) looked at the effects of music therapy on challenging behaviors of young children in a special education setting. These designs have been used frequently in music therapy, as evidenced by Gregory’s (2002) finding of 96 examples of this design in an analysis of four decades of the Journal of Music Therapy .

Longitudinal research

Longitudinal research provides information over a period of time ( Ledger and Baker, 2005 ). According to Menard (2002) , longitudinal research is when: (a) data are collected for each individual unit for two or more distinct time periods; (b) the units are the same from one time period to the next; and (c) the analysis of collected data involves some comparison of data between or among time periods. The most commonly used longitudinal designs are: (a) repeated cross-sectional studies what are carried out regularly, each time using a different sample (or primarily different sample); (b) prospective (panel) studies that collect information from the same people repeatedly over a period of time (the preferred type); and (c) retrospective studies in which people are asked to remember and reconstruct events and aspects of their lives ( Ruspini 2002 ). Several methods may be combined.

An example of a longitudinal study in music therapy is Ledger and Baker’s (2007) investigation of the long-term effects of group music therapy on agitation levels of nursing home residents with Alzheimer’s disease. They tested residents at five time points over a year. Although they found short-term reductions in agitation for those who received weekly music therapy sessions, these positive effects did not continue over the year. Another example is Dingle et al.’s (2013) exploration of the personal experiences of choir members with various mental, physical, and intellectual disabilities in relation to their wellbeing using the interpretative phenomenological analysis method developed by Smith (2004) . Interviews with participants occurred at the inception of the choir, after six months, and after 12 months. This study is an example of a longitudinal study employing a qualitative research method.

Mixed methods research

Mixed methods research uses a range of research methods. This allows diverse perspectives, methods, and data to generate the information that is desired ( Bradt et al. 2013b ; Creswell and Clark 2011 ). These methods are relatively new and in their very early stages of development and expertise in music therapy research. Issues in combining methods occur on pragmatic and philosophical/paradigmatic levels and are the subject of numerous discussions and debates (K. Bruscia, personal communication, June 26, 2012; Johnson and Onwuegbuzie 2004 ; Teddlie and Tashakkori 2003 ).

Examples of mixed methods research in music therapy include a study by Grocke et al. (2009) in which they studied the effect of group music therapy on quality of life and social anxiety for people who had a severe and enduring mental illness. Quantitative data were gathered through several scales that measured the dependent variables, and qualitative data were gathered through focus group interviews and an analysis of lyric themes. Barry et al. (2010) studied the effects of creating a music CD on pediatric oncology patients’ distress and coping during their initial radiation therapy treatment. They collected numeric and textual data for quantitative and qualitative analyses. Ridder (2005 ; Ridder and Aldridge 2005 ) combined quantitative (including physiological measurements) and qualitative approaches, using therapeutic singing, in case studies of individuals with frontotemporal dementia.

Qualitative research is a broad term used to describe:

the varieties of social inquiry that have their intellectual roots in hermeneutics, phenomenological sociology, and the Verstehen tradition. Many scholars use the phrase qualitative inquiry as a blanket designation for all forms of social inquiry that rely primarily on qualitative data (i.e. data in the form of words)… To call a research activity qualitative inquiry may broadly mean that it aims at understanding the meaning of human action Schwandt 2007 , pp. 247–248.

Tesch (1990) listed 46 terms used to describe different types of research that is broadly considered as qualitative research in the social sciences. The terms include: action research, case study, clinical research, collaborative inquiry, content analysis, dialogical research, conversation analysis, Delphi study, descriptive research, discourse analysis, ecological psychology, ethnography, ethnomethodology, experiential psychology, field study, focus group research, grounded theory, hermeneutics, heuristic research, holistic ethnography, imaginal psychology, interpretive interactionism, life history study, naturalistic inquiry, oral history, participant observation, phenomenography, phenomenology, qualitative evaluation, symbolic interactionism, and transcendental realism (p. 58).

Interest in qualitative research in music therapy began in the mid-1980s, when some music therapists started to consider the limitations of quantitative research in capturing important aspects of the music therapy experience ( Wheeler and Kenny, 2005 ). All around the world music therapists started to explore the use of qualitative methods in their research. In the US, Aigen (1991) set the stage for the consideration of qualitative inquiry by music therapists in his doctoral dissertation, The Roots of Music Therapy: Towards an Indigenous Research Paradigm , as he considered historical influences on music therapy research from the philosophy and theory of science and critiqued what he called the received view from a position of process, clinical realities, creativity, and research methodologies ( Wheeler and Kenny 2005 ). In Australia in the early 1990s, O’Callaghan was researching the experience of palliative care patients using grounded theory method and content analysis by examining the text of their songs created in music therapy ( O’Callaghan 1996 ). Earlier in the US, Forinash (1992) used phenomenology to consider the experience of improvisation in Nordoff-Robbins music therapy sessions. In Germany at the same time Langenberg ( Langenberg et al. 1992 ) and her colleagues used hermeneutic inquiry to understand which aspects of the therapeutic process were helpful for the client. The First International Symposium for Qualitative Research in Music Therapy was held in 1994, offering music therapists who were using qualitative methods in their research an opportunity to share and collaborate ( Langenberg et al. 1996 ). This symposium was followed by similar gatherings, continuing until 2007.

Since the mid-1990s the number of qualitative studies has increased (see Aigen 2008a , b ). This chapter will focus on some of the qualitative research methods that have been used by music therapists.

Many qualitative studies use naturalistic inquiry ( Aigen 2005 ; Ely et al. 1991 ; Lincoln and Guba 1985 ), with the research being carried out in the settings that researchers want to understand, with the researcher’s self experience and observation as the primary vehicle for data-gathering and analysis. Although naturalistic inquiry is sometimes considered to be a type of qualitative research ( Aigen 2005 ), it is regarded in this chapter as a way of approaching the research and gathering information/data.

Phenomenological inquiry

Phenomenology is defined as: “A philosophy or method of inquiry based on the premise that reality consists of objects and events as they are perceived or understood in human consciousness and not of anything independent of human consciousness” ( American Heritage Dictionary 2000/2009 ). Forinash and Grocke (2005) stated that “phenomenologists examine what is called the lived experience. This refers to experiences that we, as humans, have in relation to any event that we experience” (p. 321). Phenomenological inquiry is a frequently used method for music therapy researchers, probably because many of the questions of interest to music therapists are about people’s experiences. Reflexive phenomenology is a term used by Colaizzi ( Tesch 1990 ) for a form of phenomenology where the researcher uses his or her own experience as data. This is contrasted with empirical phenomenology, where data are gathered from others.

Examples of phenomenological inquiry in music therapy include Comeau’s (2004) examination of how music therapists experienced times of being effective and ineffective in their work; Cooper’s (2010) study of clinical-musical responses of Nordoff-Robbins music therapists during the process of clinical improvisation, which had a similar topic and some similar methods to an earlier phenomenological study of the lived experience of clinical improvisation by Nordoff-Robbins music therapists ( Forinash 1992 ); and Gardstrom’s (2004) study using descriptive phenomenology, as well as hermeneutic inquiry, to explore the experience of clinical improvisation with troubled adolescents.

Hermeneutic inquiry

Hermeneutics refers to the “art, theory, and philosophy of interpreting the meaning of an object” ( Schwandt 2001 , p. 115). The hermeneutic circle involves a constant analytic movement between the phenomena of interest and the structures (theories) developed in order to better understand the phenomenon. Theories are therefore tentative and evaluated against the data, further refined, and then reapplied to the data. The goal of hermeneutic research is to engage deeply in the circle of understanding in order to develop insightful and plausible interpretations of events.

Langenberg and her colleagues ( Langenberg 1988 ; Langenberg et al. 1992 , 1993 ) developed a psycho-analytically based method using what is called the resonator function to help observers gain access to the hidden meaning of an improvisation through a series of steps in which they listen to and respond to an improvisation by a client. Their system involves having a number of observers listen to a recording of a music therapy session and write down descriptions of the improvisation. They then follow a number of steps to compare and interpret the information and, finally, analyze the results in a process of hermeneutic circling in relation to clinical data from the client’s case history.

Rolvsjord (2007 , 2010 ) applied hermeneutic research to her study of a resource-oriented approach to music therapy, which intends to amplify the client’s strengths rather than to focus on reparation of symptoms or difficulties. Rolvsjord states:

According to the hermeneutic research tradition, understanding is arrived at through a process of dialogue between the researchers horizon and the texts that are studied. In my study, understanding and knowledge were generated through a similar reflexive and dialogical process between the empirical data and theory. This strategy for discovery has been labeled [by Alvesson and Sköldberg 2000] abduction. Rolvsjord 2007 , p. 50

Others who have used hermeneutic inquiry in music therapy research include Bonde (2005) , who employed a hermeneutic framework for understanding Bonny Method of Guided Imagery and Music (BMGIM) sessions; Gardstrom (2004) , who used phenomenological and hermeneutic inquiry to investigate meaning in clinical music improvisation with troubled adolescents; Luce (2008) , who studied music therapy students’ epistemological development and how that influences their education and clinical training; and Jackson (2010) , who explored responses to client anger in music therapy by examining cases, as units of data, through a process of hermeneutic phenomenological reflection.

Grounded theory

Grounded theory is defined as:

a general approach of comparative analysis linked with data collection that uses a systematically applied set of methods to generate an inductive theory about a substantive area with the purpose of discovering theory from data. The researcher focuses on one area of study, gathers data from a variety of sources, and analyzes the data using coding and theoretical sampling procedure. Amir 2005

O’Callaghan (2012) presents a number of considerations and applications of grounded theory in music therapy.

Examples of grounded theory studies in music therapy include numerous studies by O’Callaghan, including one of the perceptions of a Chinese music therapy educator and students’ perceptions of their music project’s relevance for Sichuan earthquake survivors ( Gao et al. 2013 ); another on the effect of music therapy on oncologic staff bystanders ( O’Callaghan and Magill 2009 ); and one of the relevance of music for pediatric cancer patients ( O’Callaghan et al. 2011 ). Amir (1996 ; see also Amir 1992 ) studied how music therapists and music therapy clients experienced meaningful moments in the music therapy process; while a study by Bonde (2007) in which he used a grounded theory procedure to investigate how cancer survivors described the experience and perceived outcome of therapy using BMGIM.

First-person research

First-person research is defined by Bruscia (2005b) as “any method in which researchers or participants gather data from themselves, using processes such as introspection, retrospection, self-perception, self-observation, self-reflection, self-inquiry, and so forth” (p. 379). One of the most well known types of first-person research is heuristic research ( Moustakas 1990 ), in which a person studies his or her own responses as a way of understanding a phenomena. Bruscia suggests that the following situations may occur in first-person research: the researcher studies self, the researcher studies self and participants, participants study themselves, and co-researchers study themselves.

Examples of first-person research include a study by Bruscia (1995a) of his shifts in awareness/consciousness as he guided a Guided Imagery with Music (GIM) session and a study by Wheeler (1999) of the various sources of pleasure experienced in working with children with severe disabilities. The study of flute improvising by Schenstead (2012) , described as a heuristic arts-based self-study (under arts-based research , below), is also an example of first-person research.

Participatory action research

Participatory action research is defined by Stige (2005b) as “… situated research advocating the primacy of the voices and goals of the participants themselves.” Stige lists four of the dimensions central to this tradition: (a) active lay participation in the research process; (b) empowerment of participants and sociocultural change as part of the research agenda; (c) linkage of theory, practice, and research; and (d) application of a broad conception of knowledge when evaluating research processes and outcomes.

Baines (2000) reported on a pilot study for a program to “develop a cost effective group music therapy program that prioritized the requests of the consumers as the process for development, thereby readily incorporating consumer concerns and hopefully meeting consumer needs” (p. 54). A survey to assess the program was jointly developed by staff and consumers (clients), thus incorporating elements of participatory action research. A later report ( Baines and Danko 2010 ) provided follow-up survey data supplemented by information from interviews with consumers.

Elefant’s (2010) research suggests the importance of considering empowerment and social change when designing research so as not to risk ignoring critical voices among participants and thus contributing to preserving the status quo. The participatory action research project, with individuals who were part of a choir for people with severe physical disabilities, was a way of helping them to make their voices heard.

There are varied examples of action or participatory action research in the music therapy literature. One is Stige’s (2002 , Chapter 4) research with Upbeat, a group of people with mental challenges who were involved in a collaborative process to develop a more inclusive life in the community. Another is by Baker (2007) , who used action research to evaluate a problem-based learning activity with students who were doing their first year of clinical training, emphasizing developing clinical reasoning skills. McFerran and Hunt (2008) used an action research process in a program to help adolescents cope with grief and loss in several situations. Rickson (2009) worked collaboratively with team members to facilitate their use of music with children who have special education needs and included action research in her consulting.

Ethnography and ethnographically informed research

Stige (2005a) stated: “Ethnography may be understood as a scholarly approach to the study of culture as lived, experienced, and expressed by a person or a group of people” (p. 392). There is an increasing amount of ethnographically informed research in music therapy.

Ledger (2010a) conducted an ethnographic study of service development in a health care organization. The ethnographic work revealed the inherent complexity of the researcher roles as she shifted between the identities of researcher, therapist, friend, and student while doing this research ( Ledger 2010b ).

Most of the case studies in the book about Community Music Therapy, Where Music Helps ( Stige et al. 2010 ), are ethnographically informed music therapy research exploring how the effects of music and musicking are linked to human interaction in context. Ansdell (2010) , explored what happens with a group of people in West London who get together to create and perform music. Pavlicevic (2010) documented the rich ethnographic context in and around a children’s choir in South Africa. Stige (2010) studied participation in a festival that was started by music therapists several decades ago. In each of these cases, the researcher employed ethnographic research methods to study the people, the events, and the process of collaborative music making.

Arts-based research

Austin and Forinash (2005) have defined arts-based inquiry as “a research method in which the arts play a primary role in any or all of the steps of the research method. Art forms such as poetry, music, visual art, drama, and dance are essential to the research process itself and central in formulating the research question, generating data, analyzing data, and presenting the research results” (p. 458). Only a small number of arts-based research studies have been done in music therapy. Ledger and Edwards (2011) reviewed the arts based research conducted in music therapy and queried why music therapists have not engaged more enthusiastically in arts-based research. They suggested that music therapy researchers may be reluctant to adopt arts-based research practices due to a desire to insure that music therapy research is accepted as scientific and scholarly among other health care research. They also wondered whether music therapists may have used arts creation within their research approaches but have not highlighted this for various reasons, some of which might be related to the quest for recognition as a scientific and scholarly discipline.

Schenstead (2012) conducted a heuristic arts-based self-study through which she took an in-depth look at the intricacies of the personal improvisational process using her primary instrument, the flute. She improvised on stories and poetry that she had written and wrote about her experiences in a journal that became the main source of data. The journal was analyzed using an arts-based method and the findings took on the form of a performance piece in which she perform the stages of my process using a synthesis of poetry, artwork, music, and personal reflections. A final meta-reflection of the entire project presents a philosophy explaining the dynamics of the intrapersonal relationship.

Vaillancourt (2009 , 2011 ) used arts-based research to create an apprenticeship music therapy model. In the first phase of the research, a research group met for five sessions, using “discussions, instrumental and vocal improvizations, adapted group sessions of the Bonny Method of Guided Imagery and Music (BMGIM), mandala drawing, collective and individual writing, and poetry” to deepen their reflections on their mentoring needs. In the second phase, Vaillancourt used a phenomenological approach to investigate the lifeworlds of the participants regarding their work together, using the artistic data from the previous work together to structure the interview questions. The results of the study, the emerging themes and essences of the participants’ experiences, were reported through narratives and music, art, and poetry.

Evidence-based practice and music therapy

Evidence-based practice (EBP) is defined as “conscientious, explicit, and judicious use of current best evidence in making decisions about care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” ( Sackett et al. 1996 , p. 71). EBP represents the combined use of (a) systematic reviews of the scientific literature, (b) practitioner experience and opinion, and (c) patient/client preferences and values for making clinical decisions and treatment/intervention planning.

EBP has received increased attention in music therapy as it has become apparent that by meeting the standards of EBP music therapy increases the opportunity to be accepted and funded. This is not without controversy and the issues surrounding the implementation of the evidence-based approach to music therapy have been elaborated ( Abrams 2010 ; Edwards 2005b ) The Cochrane Library and Cochrane reviews are an important source of information on EBP, and a number of Cochrane reviews have been done in music therapy, with the largest number in recent years.

The Cochrane Database of Systematic Reviews (< www.cochrane.org >) includes numerous reviews of various health care interventions. Cochrane reviews have been undertaken on music therapy for people with acquired brain injury ( Bradt et al. 2010b ), autistism spectrum disorder ( Geretsegger et al. 2014 ), dementia ( Vink et al. 2013 ), depression ( Maratos et al. 2008 ), end-of-life care ( Bradt and Dileo 2010 ), and for schizophrenia and schizophrenia-like disorders ( Mössler et al. 2011 ); music during Caeserian section ( Laopaiboon et al. 2009 ), for mechanically ventilated patients ( Bradt et al. 2010a ), improving psychological and physical outcomes in cancer patients ( Bradt et al. 2011 ), preoperative anxiety ( Bradt et al. 2013a ), and stress and anxiety reduction in coronary heart disease ( Bradt and Dileo 2009 ); and for singing for children and adults with cystic fibrosis ( Irons et al. 2010 ).

Other types of research

Research on music.

Bonde (2005) suggests that researching music includes “any method within music therapy in which researchers gather data concerning the relationship between music—improvised or composed, recorded or performed live—and client experiences and behavior” (p. 489) and that “the focus may be on material properties of music (stimulus or effect); on intentional properties of music (description, analysis, and interpretation of meaning); or on musical processes (interactions and relationships)” (p. 489). These may include studies of nonmusical or musical responses.

Studies that focuses on nonmusical responses include one by Elefant (2002 , 2005 ), who used a single case multiple baseline, time series, within-subjects design to investigate whether songs in music therapy intervention could enhance the communication skills of seven girls with Rett syndrome. Ridder’s research (2005 ; Ridder and Aldridge 2005 ) studied the use of therapeutic singing with individuals with frontotemporal dementia. This is presented under mixed methods research . They also viewed nonmusical responses, as do the examples of RCTs by Ghetti (2011 ; 2013 ) and Gattino et al. (2011) ; the exploratory studies by Bensimon and Gilboa (2010) ; Nayak et al. (2000) ; Williams et al. (2012) ; Wheeler et al. (2010) ; and Kim (2010) among others. The fact that so many examples of research on nonmusical responses have been presented in this chapter highlights that a great deal of music therapy research has focused on nonmusical responses or outcomes by music therapists.

There are also numerous examples of research on musical responses. The work on the resonator function , described under hermeneutic inquiry ( Langenberg 1988 ; Langenberg et al. 1992 , 1993 ), helped observers gain access to the hidden meaning of an improvisation. Bergstrøm-Nielsen (1993 , 1999 , 2010 ) developed a graphic notation as a tool for music therapists in notating and analyzing improvisations. Turry (2010) analyzed the relationship between words and music in clinically improvised songs with a woman with whom he had music therapy sessions for a number of years. Additional studies of musical responses that have been cited earlier in this chapter are by Cooper (2010) , Forinash (1992) , and Gardstrom (2004) .

Historical research

Historical research is defined as “the systematic study of the past practices, materials, institutions, and people involved in therapeutic applications of music” ( Solomon and Heller 1982 ). Historical research is a way of preserving the history of music therapy that people in the future will know of what led to that point. Historical research topics cover a wide range.

Several studies of music therapy pioneers, including Ira Maximillian Altshuler ( Davis 2003 ), Willem van de Wall ( Clair and Heller 1989 ), and James Leonard Corning ( Davis 2012 ), have been published. Historical uses of music in hospitals, and the development of the profession of music therapy for hospital patients has been researched (e.g. Edwards 2007 , 2008 ; Taylor 1981 ). Reschke-Hernández (2011) examined the history of music therapy treatment interventions for children with autism.

Kim (2009) conducted an “Historical Investigation Regarding the Perception of Music Therapy Among Korean Medical Professionals as Seen in Medical Journal Articles,” which combines historical research with survey methods. In a narrative inquiry, Hadley (2001) explored connections between historical information and other aspects of Mary Priestley’s life and work. She conducted a similar study of the life of Clive Robbins ( Hadley 2003 ).

Philosophical inquiry and theory development

Bruscia (2005a) has said that a “theory is way of thinking about what we do or what we know” (p. 540) and that philosophy and theory “have the same aim: understanding.” Bruscia also suggested that “they relate to practice and research in the same way” and that “both involve thinking activities, such as reflection, reasoning, criticism, speculation, and intuition” (p. 541).

Theory development has always been a part of the research work in music therapy. Sears (1968) suggested three processes in music therapy: experience within structure, experience in self-organization, and experience in relating to others, still provides a basis for the thinking of many about what music therapy does. Kenny (1989 , 2006 ) organized her ideas into a formal theory and found a language to reflect her understanding of the music therapy process in what she termed The Field of Play .

Music therapy theory has continued to develop. Working to develop theory for the music therapy as procedural support for invasive medical procedures, Ghetti (2012) used qualitative document analysis to examine the literature in this field. She integrated findings from 19 primary sources to formulate a theoretically grounded working model. Robb (2012) suggests that music therapy research is moving from being outcomes-based to theory-based and that the attention that is now being paid to theory “offers one way to advance our understanding of the complex interactions between music, clients, and the education or health care environment” (p. 5).

In adaptations of theoretical research, Hadley (1999) compared philosophical premises underlying two approaches to music therapy, Creative Music Therapy, developed by Nordoff and Robbins (2007) , and Analytical Music Therapy, developed by Priestley (1994) . Mössler (2011) combined the development of theory and historical research as she examined the influence of theory construction on the formation of professional identity as it occurs in the Viennese School of Music Therapy.

Abrams (2011) has proposed that music is a temporal-aesthetic way of being. He proposed that music can be conceptualized as a phenomenon that transcends the concrete, physical medium of sound. In Abrams’s theory, while music may be expressed through sound, its essence is located in the ways that human thought, feeling, and action unfold aesthetically in time, allowing the music in music therapy to be not merely a means for promoting non-musical health but also a particular dimension of human health itself, manifesting as the temporal-aesthetic component of each health domain typically targeted within music therapy work.

Research publications

Eight music therapy journals are published regularly in English, many by music therapy associations of their countries, and include varying amounts of research. In order of the dates on which they commenced publication (and which are listed), they are: Journal of Music Therapy 1964 (US); Canadian Journal of Music Therapy 1973; Music Therapy Perspectives 1982 (US); British Journal of Music Therapy 1987; Australian Journal of Music Therapy 1990; Nordic Journal of Music Therapy 1992 (representing all of the Nordic countries and now an international journal); New Zealand Journal of Music Therapy 1994; and Voices: A Worldwide Forum for Music Therapy 2001 (on-line: < www.voices.no >).

In addition to these journals published in English, the German journal, Musiktherapeutische Umshcau, has been published since 1980 and plays an important role in the development of German music therapy and thus music therapy internationally. Music Therapy: Journal of the American Association for Music Therapy was published from 1981–1996. The Arts in Psychotherapy, an international journal that covers all of the arts therapies, has been in publication since 1973, and includes a substantial amount of music therapy research. The Journal of the Association of Music and Imagery (AMI) , published since 1992, focuses on the Bonny Method of Guided Imagery and Music (BMGIM), which is closely related to music therapy. Music and Medicine: An Interdisciplinary Journal , published since 2009, includes current practices of music and medicine, including music therapy. Finally, many music therapy studies are published in journals of related disciplines.

Several people have reviewed music therapy research in the past decade, primarily through analyses of journal articles. Brooks (2003) examined 1521 articles from nine music therapy journals over a 37-year period, looking for trends and types of article and comparing them across journals. She tallied the numbers of research articles classified in the categories of quantitative, qualitative, clinical, historical, philosophical/theoretical, and professional. 2 The number of articles published in each of these journals is, of course, related to the length of time that the journal has been published and the number of issues a year. Brooks found quantitative research articles to be the predominant category across all journals, with 542 articles. She found 55 historical articles and 136 philosophical/theoretical articles.

Edwards (2005a) reviewed eight journals for content and trends, and also examined the number of articles from one journal that were referenced in other journals. This was in order to reveal the extent to which music therapists showed awareness of each others work across the international community. To examine how many articles from one journal were cited by authors writing in other journals, she reviewed papers from the Journal of Music Therapy (JMT) from 1964–2003 and the British Journal of Music Therapy (BJMT) from 1995–2003. She found no papers from either the New Zealand Journal of Music Therapy or the Canadian Journal of Music Therapy to have been cited in JMT during the publication period reviewed. Citations from the BJMT appeared in eight papers in JMT, five of which were authored by music therapists from countries outside the United States. The lack of awareness and citation of authors from other countries is a concern for the internationalization of the discipline of music therapy.

Aigen examined qualitative articles and chapters (2008a) and qualitative dissertations (2008b) published from 1987–2006. He found 92 articles and book chapters, 55 doctoral studies, and six books to have been published during that period. In the period from 1987–1990, two articles and chapters and two dissertations (or doctoral theses) were published; from 1991–1994, five articles and chapters and seven dissertations; from 1995–1998, 20 articles and chapters and seven dissertations; from 1999–2002, 31 articles and chapters and 13 dissertations; and from 2003–2006, 34 articles and chapters and 23 dissertations. This clearly represents a large increase in qualitative research in music therapy, beginning in the mid-1990s.

Issues and problems

As music therapists work to meet the demands of evidence-based practice, making it clear that RCTs need to be conducted to determine the efficacy of music therapy, there is much discussion about several areas. One of these is whether too much emphasis is being placed on RCTs. Many music therapists feel that the work that they do cannot be adequately investigated using RCTs and other quantitative approaches. Edwards (2005b) indicated some of these concerns and the ways they can be addresses in medical music therapy, and her suggestions can apply beyond medical areas. Bradt (2012) has emphasized that RCTs are not the only type of investigation that should be done about music therapy processes and outcomes. She wrote, “It is of great importance to the field of music therapy that multiple types of evidence contribute to its knowledge base and that the dialogue of clinical effectiveness is not dominated by the biomedical hierarchical model of evidence-based practice (EBP) in which meta-analytic reviews and randomized controlled trials reign” (p. 121).

Another discussion is about how well the requirements for rigorous control in conducting RCTs can match with what actually occurs in a music therapy session. As Bradt (2012) says, “One of the major concerns expressed by music therapists about the use of RCTs is the claim that the treatments used in RCTs suffer so severely from the required standardization that they become irrelevant to clinical practice” (p. 136). One way to address this concern is to use a treatment manual, which contains guidelines for the treatment approach being investigated but does not provide a rigid set of procedures to use. Rolvsjord et al. (2005) , who developed a manual for an RCT investigating resource oriented music therapy, say:

Our pragmatic solution… has been to produce a manual with open descriptions of principles that emphasize contextual and collaborative aspects. The manual thus focuses upon underlying assumptions and values informing a contextual approach to resource-oriented music therapy, rather than describing specific actions, techniques, or procedures. In this way we hope to have avoided that the manualization should limit the possibilities for each therapeutic process to be tailored to match the individual client. We also think that the principles, if practiced with competence and not only adherence, have left enough space for the collaborative therapeutic process to develop relatively freely. (p. 28)

Another issue is the quality of music therapy research. As research has been reviewed for Cochrane Reviews and the quality evaluated on a number of criteria, it has become apparent that many music therapy studies are not of high enough quality to be included. Bradt (2012) said, “Reviews of the music therapy research literature indicate a need for increased scientific rigor in the design and conduct of RCTs” (p. 146). “It is important that music therapists contributing to our evidence base through RCT research are prepared to design trials that meet current methodological standards and, equally important, are able to respond appropriately to those design aspects (e.g. blinding of the participants) that are not feasible in music therapy research” (p. 121).

The positive side of this is that it providing guidance for music therapy researchers in raising the quality of the studies, leading to more studies that meet criteria for inclusion. This applies primarily to RCTs, and it seems that the number of RCTs about music therapy research is increasing.

Another problem in experimental research in music therapy is enrolling enough participants for the research study, which generally requires a certain number of participants who meet the inclusion criteria for the study. Since many music therapy procedures require multiple sessions, the number of available participants can be further limited. One of the solutions for this problem is for researchers from several facilities to collaborate so that the research includes participants from several institutions. This was done, for example, in two hospitals with a study of the effects of music therapy for mood disturbance during hospitalization for autologous stem cell transplantation ( Cassileth et al. 2003 ), a multi-site study of the effects of parent-preferred melodies and entrained live rhythm and breath sounds on babies in neonatal intensive care units ( Loewy et al. 2013 ), and a multi-site study of the effects of active music engagement on children with cancer ( Robb et al. 2008 ) as well as a more recent study further investigating a therapeutic music video intervention ( Robb et al. 2014 ). Increasing international cooperation is making international multi-site studies possible, as exemplified by a study of improvisational music therapy ’ s effectiveness for children with autism spectrum disorders that aims to enroll 300 participants recruited from nine different countries ( Geretsegger et al. 2012 ; International Standard Randomized Controlled Trial Number Register 2013 ) and one of individual music therapy for mental health care clients with low therapy motivation that enrolled 144 adults from three countries ( Gold et al. 2013 ).

Challenges to music therapy research that are not specific to RCTs have to do with whether music therapy clinicians and others use the research that has been done. This has been an ongoing challenge for music therapy research (see Wheeler 2005 , p. 6). Waldon (2015) surveyed US music therapists for information on the extent to which they engage in research-related activities or whether they perceive barriers to integrating research into clinical. He found differences in how research is utilized as well as perceived barriers between music therapist whose primary job role is research and those in clinical positions. He says that “this suggests a divide between those generating knowledge about the profession (researchers and academicians) and those responsible for delivering treatment (clincians). Furthermore, reported utilization varies as a function of work setting (e.g. between rehabilitation/medical settings and others)” (p. 1). There are also questions about how qualitative research, an important portion of current music therapy research, is related to the demands of evidence-based practice. One way that this is being addressed is through synthesis of qualitative research, which combines and integrates qualitative research that addresses a similar topic, question or population ( Hannes and Lockwood 2012 ; Sandelowski and Barroso 2007 ).

Along with the challenges confronting music therapy research and researchers, there is a great deal of development and extension work that builds the profession and increases our knowledge within the profession as well as our visibility to others. Music therapy research draws from various traditions of inquiry, selecting the method as relevant to the questions being asked, and doing it with increasingly high quality. All of this brings music therapy closer to achieving an integral connection between theory, clinical practice, and research that Gaston (1968) suggested should form a tripod, each necessary in order for the other to stand.

An effect size is the difference between means in standardized units, or the number of standard deviations by which the means differ.

Since the focus of this chapter is music therapy research, clinical and professional articles are not included in this summary, although they were part of Brooks’ (2003) analysis.

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Oxford University Press's Academic Insights for the Thinking World

Music therapy research and evidence-based practice

Journal of music therapy.

• November 23 rd 2013

With the American Music Therapy Association’s Annual Conference this weekend, we asked Andrea Farbman, Executive Director of the American Music Therapy Association; Dr. Sheri Robb, editor of Journal of Music Therapy ; and Dr. Anthony Meadows, editor of Music Therapy Perspectives , to tell us about the profession of music therapy in a three-part series.

By Dr. Sheri Robb

There is a saying in American English when a home is attractive to view from the sidewalk or edge of the road. That is, we say it has “curb appeal”. As an integral part of everyday life, music has great curb appeal. People value it and intuitively recognize the beneficial role music plays in daily life and well-being. But, when talking about music therapy, the conversation shifts beyond mere curb appeal — and becomes even more intriguing because the practice of music therapy requires the integration and application of theory, research, and clinical practice knowledge to meet the needs of the patients and families we serve.

As a profession dedicated to research and evidence-base practice, we continue to build foundational knowledge to advance the science and practice of music therapy. The elements of music — rhythm, timbre, melody, harmony, dynamics, and form — are the building blocks for music used in a therapeutic process. In the hands of trained, board-certified music therapists the building blocks of music are manipulated as part of specific interventions designed to address a variety of clinical needs and outcomes. The American Music Therapy Association (AMTA) defines music therapy as “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional” (AMTA, 2013).

As a music therapist of 24 years, it has been an honor to work in a profession that values ethical standards of care within a defined scope of practice. Credentialed music therapists, including Board Certified Music Therapists, engage in lifelong learning through continuing education and participation in scholarship and research. I am also privileged to serve as Editor-in-Chief of the Journal of Music Therapy (JMT), which is owned by the AMTA.

Journal of Music Therapy is a forum for authoritative articles of current music therapy research and theory. Our mission is to advance research, theory, and practice in music therapy through the dissemination of scholarly work. We publish all types of research and strives to present a variety of research approaches and topics, to promote critical inquiry, and to serve as a resource and forum for researchers, educators, and clinicians in music therapy and related professions. Ultimately, JMT contributes to evidence-based practice, which according to the American Music Therapy Association, “integrates the best available research, the music therapists’ expertise, and the needs, values, and preferences of the individual(s) served” (AMTA, 2013). 

I am proud to be a part of AMTA and the rich history of our journals, and I look forward to exciting opportunities that will come as a result of AMTA’s partnership with Oxford University Press.

Dr. Robb is Associate Professor, School of Nursing, Indiana University. She is Coordinator for the Undergraduate Honors Program and is core faculty for the university’s Research in Palliative and End-of-Life Communication and Training (RESPECT) Center. Dr. Robb is Editor-in-Chief of the Journal of Music Therapy and a Board Certified Music Therapist with degrees in music therapy and early childhood special education. In 2009, she completed a post-doctoral fellowship awarded by the U.S. National Institutes of Health (NIH) in behavioral oncology and cancer control. In 2011, she was awarded a NIH career development award. Dr. Robb’s program of research focuses on the development and testing of music-based interventions to manage distress, improve positive health outcomes, and prevent secondary psychosocial morbidity in children/adolescents with cancer and their families.

A forum for authoritative articles of current music therapy research and theory, Journal of Music Therapy , seeks to advance research, theory, and practice in music therapy through the dissemination of scholarly work. The journal publishes all types of research, including quantitative, qualitative, historical, philosophical, theoretical, and musical concerning the psychology of music, applied music therapy techniques, perception of music, and effects of music on human behavior. Journal of Music Therapy is an official publication of the American Music Therapy Association.

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Music and Health: What the Science Says

Clinical Guidelines, Scientific Literature, Info for Patients:  Music and Health

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There is some evidence that music-based interventions may help to relieve pain associated with specific health conditions.

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• A 2016 meta-analysis of 97 randomized controlled trials involving a total of 9,184 participants examined music-based interventions for acute or chronic pain associated with a variety of health problems and medical procedures. The overall evidence suggested that music-based interventions may have beneficial effects on both pain intensity and emotional distress from pain and may lead to decreased use of pain-relieving medicines.  
• A 2017 systematic review and meta-analysis of 14 randomized trials (1,178 participants) examined music-based interventions for various types of chronic pain and found that the interventions reduced self-reported chronic pain and associated depressive symptoms, with a greater effect when the music was chosen by the participant rather than the researcher. The study participants had a variety of conditions that can cause chronic pain, including cancer, fibromyalgia, multiple sclerosis, or osteoarthritis, and most of the interventions involved listening to recorded music.   Overall, the data suggested that as an adjuvant therapy, music reduces self-reported pain and common comorbidities associated with chronic pain.
• In recent studies, music-based interventions were helpful for pain associated with childbirth, platinum-based chemotherapy, shock wave lithotripsy, oocyte retrieval for in vitro fertilization, treatment of nose fractures, and sickle cell disease.   However, music didn’t seem to be helpful for pain associated with loop electrosurgical excision, and the results of studies on pain during cystoscopy and pain during colonoscopy were inconsistent.

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Music-based interventions have been evaluated for their effects on anxiety in a variety of disease conditions and health care settings. Most studies have had promising results.

• A 2013 Cochrane systematic review of 26 studies involving a total of 2,051 participants found that listening to recorded music significantly reduced anxiety in people who were waiting to have surgery. However, there was potential for bias in most of the studies because the investigators who performed the studies knew which participants had listened to music. 
• A 2016 Cochrane systematic review of 17 studies involving a total of 1,381 participants evaluated the effect of music-based interventions on anxiety in adults with cancer. The findings from the review suggested that music-based interventions may have a large anxiety-reducing effect as well as beneficial effects on pain, fatigue, and quality of life in people with cancer. However, there was a high risk of bias in the studies. 
• A 2015 systematic review and meta-analysis of 5 studies (290 participants) in people who were receiving incenter maintenance hemodialysis suggested that listening to music reduced anxiety. However, the studies included in the review have limitations because of their small size and high risk of bias.

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It’s uncertain whether music-based interventions are helpful for people with ASD.

• A 2021 systematic review of 22 studies (850 participants) on music therapy for children with ASD was unable to reach any definite conclusions on whether adding music therapy to their care was beneficial, although some studies had promising results. For example, some studies of educational music therapy (involving techniques such as musical games) showed possible benefits on the children’s speech, and some studies of improvisational music therapy (in which children produce music) showed possible benefits on social functioning.
• A 2017 randomized controlled trial of improvisational music therapy for children with ASD (which was included in the review described above) was a multinational trial involving 364 children from 9 countries. It is the largest study completed so far, and its design was especially rigorous. In this study, the severity of symptoms related to difficulties in social communication did not differ between children who received improvisational music therapy along with standard care and those who received standard care alone.  

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There is some limited evidence that music-based interventions may be helpful for shortness of breath, anxiety, and sleep quality in adults with COPD.

• A 2021 systematic review of 12 studies (812 participants) showed that music-based interventions (i.e., listening to music or a combination of listening and singing) were helpful for shortness of breath, anxiety, and sleep quality in adults with COPD but were not helpful for depression. Because the studies were brief (several days to 12 months) and because researchers measured effects in different ways in different studies, there is some uncertainty about the conclusions.

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Much research is being done on the potential benefits of music-based interventions for people with cognitive impairment or various types of dementia, such as Alzheimer’s disease. Limited evidence suggests that music-based interventions may improve emotional well-being, behavioral challenges, and quality of life in people with these conditions. Whether the interventions have benefits for cognitive functioning is unclear; effects might depend on the population studied or the type of intervention used.

• A 2018 Cochrane systematic review evaluated 22 studies (1,097 participants) of music-based interventions for people with dementia who were living in institutions. Some of the interventions were receptive (listening to music), some were active (singing, playing instruments, moving to music, etc.), and some were a combination of the two. The evidence from these studies indicated that music-based interventions probably reduce depressive symptoms and improve overall behavioral problems, but effects differ for different behavior problems. They may also improve emotional well-being and quality of life and reduce anxiety. However, the interventions may have little or no effect on agitation, aggression, or cognitive function. 
• A 2021 systematic review and meta-analysis analyzed 21 studies involving 1,472 participants with either mild cognitive impairment or mild or moderate dementia for potential effect sizes and intervention activities. Nine of the studies (495 participants) were included in a quantitative analysis of effects on cognitive functioning This analysis indicated that the music-based interventions had a small beneficial effect on cognitive functioning for older adults with probable mild cognitive impairment or dementia. There was also some evidence for beneficial effects on mood and quality of life.

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There is some evidence that adding music-based interventions to usual treatment may improve depressive symptoms when compared with usual treatment alone. There is also some evidence that music-based interventions may help decrease anxiety levels and improve functioning in people with depression.

• A 2017 Cochrane systematic review looked at 9 studies (421 participants) of music-based interventions in adults or adolescents with depression. There was moderate-quality evidence that adding music-based interventions to usual treatment saw improvement based on clinician‐rated and patient‐reported measures of depression when compared with usual treatment alone. Music-based interventions also helped decrease anxiety levels and improve functioning of people with depression (for example, their ability to maintain involvement in work, activities, and relationships).

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Findings from several studies suggest that music-based interventions may be beneficial for coordination, balance, some aspects of gait and walking, emotional status, and pain in people with MS.

• A 2021 systematic review of music-based interventions for people with multiple sclerosis (10 trials, 429 participants) found consistent evidence overall that the music-based therapies were better than conventional care or no intervention for fatigue level, fatigability, coordination, balance, some aspects of gait and walking, emotional status, and pain, but no effect was observed for mental fatigability or memory.  The music-based therapy came from one of four different modalities: (1) Rhythmic auditory; (2) Playing musical instruments; (3) Dance strategy; and (4) Neurological music therapy.   

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There is some limited evidence that rhythmic auditory stimulation may significantly improve gait speed and stride length in people with PD. There is some evidence that music-based movement therapy may improve motor function, balance, freezing of gait, walking speed, and mental health. In addition, a few studies have found some evidence that singing may have a beneficial effect on speech in people with PD.

• Rhythmic auditory stimulation. A 2021 systematic review and meta-analysis of 5 studies (209 total participants) showed significant improvements in gait speed and stride length in people with PD who participated in rhythmic auditory stimulation. However, the quality of evidence was low, and the number of studies and participants was small.
• Music-based movement therapy.  A 2021 systematic review and meta-analysis of 17 studies (598 participants) of music-based movement therapy showed evidence of improvements in motor function, balance, freezing of gait, walking speed, and mental health but not gait cadence, stride length, or quality of life in people with PD.
• Singing. The potential benefits of singing for people with PD have been studied primarily in terms of effects on speech. In a 2016 systematic review of 7 studies (102 participants), 5 studies found some evidence of a beneficial effect on speech.

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Results of studies have been mixed as to whether music-based interventions can be helpful for sleep problems.

• A 2021 systematic review of 16 studies involving 812 older adults with sleep problems found mixed results; some studies suggested that the music interventions were helpful, while others did not.
• 2015 Cochrane systematic review of 6 studies involving a total of 314 participants with insomnia found that music-based interventions may be effective for improving subjective sleep quality in adults with insomnia.

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Music-based interventions, particularly music therapy, may be helpful for improving physical and psychological markers associated with stress, according to two related reviews.

• A 2020 systematic review and two meta-analyses of 104 studies (9,617 participants), analyzed the effects of a variety of music-based interventions on measures associated with stress, including both physiological measures (heart rate, blood pressure, and levels of stress-related hormones) and psychological measures (anxiety, nervousness, restlessness, and feelings of worry). The music-based interventions had a small-to-medium sized beneficial effect on the physiological measures and a medium-to-large beneficial effect on the psychological measures. 
• A 2022 systematic review and meta-analysis of 47 studies (2,747 participants) of music therapy (excluding other music-based interventions) found an overall medium-to-large beneficial effect on stress-related outcomes. The effects were greater than those seen in the larger review. The investigators who performed the review suggested that the opportunity for music therapists to tailor interventions to the needs of individual patients might account for the difference.

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There is evidence that music-based interventions may be helpful in the rehabilitation of people who have had a stroke.

• A 2019 systematic review of 27 studies (730 participants) found positive effects on physical status (upper-limb activity, various aspects of walking, balance), cognition (paying attention, communication), and mood in people who had a stroke. In particular, rhythmic auditory stimulation had beneficial effects on gait and balance, and receptive music therapy was helpful for mood and some aspects of cognitive function (i.e., verbal memory, focused attention).

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• In general, research studies of music-based interventions do not show any negative effects. However, listening to music at too high a volume can contribute to noise-induced hearing loss. You can find out about this type of hearing loss on the National Institute on Deafness and Other Communication Disorders website . 
• Because music can be associated with strong memories or emotional reactions, some people may be distressed by exposure to specific pieces or types of music. 
• Music-based interventions that involve exercise or other types of movement could lead to injury if appropriate safety precautions are not taken.

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• Aalbers   S, Fusar-Poli L, Freeman RE, et al. Music therapy for depression .  Cochrane Database of Systematic Reviews.  2017;(11):CD004517. 
• Barnish   J, Atkinson RA, Barran SM, Barnish MS. Potential benefit of singing for people with Parkinson’s disease: a systematic review .  Journal of Parkinson’s Disease.  2016;6(3):473-484. 
• Bradt   J, Dileo C, Magill L, et al . Music interventions for improving psychological and physical outcomes in cancer patients .  Cochrane Database of Systematic Reviews.  2016;(8):CD006911. Accessed at  https://www.cochranelibrary.com  on October 29, 2021.
• Bradt   J, Dileo C, Shim M. Music interventions for preoperative anxiety .  Cochrane Database of Systematic Reviews.  2013;(6):CD006908. Accessed at  https://www.cochranelibrary.com  on October 29, 2021. 
• Buglione A, Saccone G, Mas M, et al. Effect of music on labor and delivery in nulliparous singleton pregnancies a randomized clinical trial . Archives of Gynecology and Obstetrics . 2020;310(3):693-698.
• Burrai   F, Apuzzo L, Zanotti R. Effectiveness of rhythmic auditory stimulation on gait in Parkinson disease. A systematic review and meta-analysis .  Holistic Nursing Practice.  June 11, 2021. [Epub ahead of print]. 
• Burrai   F, Magavern EF, Micheluzzi V, et al. Effectiveness of music to improve anxiety in hemodialysis patients. A systematic review and meta-analysis .  Holistic Nursing Practice.  2020;34(6):324-333. 
• Cakmak O, Cimen S, Tarhan H, et al. Listening to music during shock wave lithotripsy decreases anxiety, pain, and dissatisfaction. A randomized controlled study .  Wiener Klinische Wochenscrift.  2017;129:687-691.
• Çelebi D, Yılmaz E, Şahin ST, et al. The effect of music therapy during colonoscopy on pain, anxiety and patient comfort: a randomized controlled trial .  Complementary Therapies in Clinical Practice.  2020;38:101084.
• Chantawong N, Charoenkwan K. Effects of music listening during loop electrosurgical excision procedure on pain and anxiety: a randomized trial .  Journal of Lower Genital Tract Disease.  207;21(4):307-310.
• Cheung CWC, Yee AWW, Chan PS, et al. The impact of music therapy on pain and stress reduction during oocyte retrieval – a randomized controlled trial .  Reproductive Biomedicine Online.  2018;37(2):145-152.
• Çift   A, Benlioğlu C. Effect of different musical types of patient’s relaxation, anxiety and pain perception during shock wave lithotripsy: a randomized controlled study .  Urology Journal.  2020;17(1):19-23.
• de Witte   M, da Silva Pinho A, Stams G-J, et al. Music therapy for stress reduction: a systematic review and meta-analysis .  Health Psychology Review.  November 27, 2020. [Epub ahead of print]. 
• de Witte M, Spruit A, Van Hooren S, et al. Effects of music interventions on stress-related outcomes: a systematic review and two meta-analyses .  Health Psychology Review.  2020;14(2):294-324. 
• Dorris   JE, Neely S, Terhorst L, et al. Effects of music participation for mild cognitive impairment and dementia: a systematic review and meta-analysis .  Journal of the American Geriatrics Society.  2021;69(9):2659-2667. 
• Garza-Villareal   EA, Pando V, Vuust P, et al. Music-induced analgesia in chronic pain conditions: a systematic review and meta-analysis .  Pain Physician.  2017;20(7):597-610.
• Huang   J, Yuan X, Zhang N, et al. Music therapy in adults with COPD .  Respiratory Care.  2021;66(3):501-509. 
• Jespersen   KV, Koenig J, Jennum P, et al. Music for insomnia in adults .  Cochrane Database of Systematic Reviews.  2015;(8):CD010459. Accessed at  https://www.cochranelibrary.com  on October 29, 2021
• Ko SY, Leung DYP, Wong EML. Effects of easy listening music intervention on satisfaction, anxiety, and pain in patients undergoing colonoscopy: a pilot randomized controlled trial . Clinical Interventions in Aging . 2019;14:977-986.
• Le Perf   G, Donguy A-L, Thebault G. Nuanced effects of music interventions on rehabilitation outcomes after stroke: a systematic review .  Topics in Stroke Rehabilitation.  2019;26(6):473-484. 
• Lee   JH. The effects of music on pain: a meta-analysis .  Journal of Music Therapy.  2016;53(4):430-477.
• Lopes   J, Keppers II. Music-based therapy in rehabilitation of people with multiple sclerosis: a systematic review of clinical trials .  Arquivos de Neuro-psiquiatria.  2021;79(6):527-535. 
• Mayer-Benarous H, Benarous X, Vonthron F, et al. Music therapy for children with autistic spectrum disorder and/or other neurodevelopmental disorders: a systematic review .  Frontiers in Psychiatry.  2021;12:643234. 
• McClintock G, Wong E, Mancuso P, et al. Music during flexible cystoscopy for pain and anxiety – a patient-blinded randomized control trial .  BJU International.  2021;128 Suppl 1:27-32.
• Mumm J-N, Eismann L, Rodler S, et al. Listening to music during outpatient cystoscopy reduces pain and anxiety and increases satisfaction: results from a prospective randomized study .  Urologia Internationalis . 2021;105(9-10):792-798.
• Ortega   A, Gauna F, Munoz D, et al. Music therapy for pain and anxiety management in nasal bone fracture reduction: randomized controlled clinical trial .  Otolaryngology—Head and Neck Surgery.  2019;161(4):613-619.
• Perković   R, Dević K, Hrkać A, et al. Relationship between education of pregnant women and listening to classical music with the experience of pain in childbirth and the occurrence of psychological symptoms in puerperium . Psychiatria Danubina . 2021;33(Suppl 13):260-270.
• Petrovsky DV, Ramesh P, McPhillips MV, et al. Effects of music interventions on sleep in older adults: a systematic review .  Geriatric Nursing.  2021;42(4):869-879. 
• Rodgers-Melnick SN, Matthie N, Jenerette C, et al. The effects of a single electronic music improvisation session on the pain of adults with sickle cell disease: a mixed methods pilot study . Journal of Music Therapy . 2018;55(2):156-185.
• Tang   H, Chen L, Wang Y, et al. The efficacy of music therapy to relieve pain, anxiety, and promote sleep quality, in patients with small cell lung cancer receiving platinum-based chemotherapy .  Supportive Care in Cancer.  2021;29(12):7299-7306.
• van der Steen   JT, Smaling HJA, van der Wouden JC, et al. Music-based therapeutic interventions for people with dementia .  Cochrane Database of Systematic Reviews.  2018;(7):CD003447. Accessed at cochranelibrary.com on October 29, 2021.
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Information for Your Patients

• Music and the Brain: Report on an NIH/Kennedy Center Workshop  

NCCIH Clinical Digest is a service of the National Center for Complementary and Integrative Health, NIH, DHHS. NCCIH Clinical Digest, a monthly e-newsletter, offers evidence-based information on complementary health approaches, including scientific literature searches, summaries of NCCIH-funded research, fact sheets for patients, and more.

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Music Therapy: Evidence-Based Practice

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• Berklee Music and Health Institute Research Collection Scientific papers 2000-present, divided into collections on music and dementia, music and pain, music and mental health, music and substance use/abuse, and more.
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The evidence on music therapy

A new study published in the Journal of the American Medical Association found that children admitted to the emergency department who listened to music during routine procedures showed less distress and reported lower pain scores than those who didn’t listen to music.

The study included a total of 42 children aged 3 to 11 years who had an IV line placed. Half of them were randomly selected to listen to music selected by a music therapist during the procedure. Health care providers reported that it was easier to insert the IV line in children who were listening to the music;  health providers also reported more satisfaction with the placement compared to those who did not listen to music.

Those are some convincing results, but still only a single study. So we went looking for systematic reviews on the impact of music in medical settings. It turns out, there is plenty more evidence showing the positive effects of music on health.  Among them:

• A 2011 review published in the Cochrane libraries found music therapy and music medicine interventions can help cancer patients. The review found some positive effects of music on anxiety, pain, mood, quality of life, heart rate, respiratory rate, and blood pressure.
• Another Cochrane review published in 2009 looked for studies measuring whether music therapy is useful in treating depression. The reviewers only found five studies appropriate for the review. Four of them concluded that patients exposed to music therapy had a greater reduction in symptoms compared to those who didn’t listen to music.
• And a third review published in the Journal of Advanced Nursing in 2002 looked at the impact of music therapy on patients admitted to the hospital. Researchers reviewed 19 studies, and found music therapy improved patients anxiety levels in the hospital. Researchers didn’t find any impact on vital signs or anxiety during a procedure, but still recommended music therapy as an effective way to calm patients.

The bottom line: There is plenty of evidence to show that music therapy used in health care settings can help calm patients. And given there are no side effects associated to music listening, it’s certainly a treatment worth trying.

I agree, music therapy works. A lot of experiments have been done on how the different waves affect the human organism. Really interesting topic that should be researched even more.

Music expresses what cannot be put in words and it is very healthy to express one self. Although I find it most enjoyable when listening to electronic music

I know music can change the mood and shift your concentration. Thus pain can be lessen though. Music can help the patients to heal faster due to the relaxation on the body.

Music also affact the human thinking and emotion . When you will hear joy or happiness and good music you will think positive and also your health will be good. On the other hand when you will hear sad music your will feel sad and it will affact your body. This is simple example . Thanks for your article.

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May 17, 2024

This article has been reviewed according to Science X's editorial process and policies . Editors have highlighted the following attributes while ensuring the content's credibility:

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New guideline: Barrett's esophagus precedes esophageal cancer, but not all patients need abnormal cell removal

by American Gastroenterological Association

The American Gastroenterological Association's (AGA) new evidence-based Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia, published today in Gastroenterology , establishes updated guidance for Barrett's esophagus patients.

A precursor to esophageal cancer , Barrett's esophagus is a condition in which the cells in the esophagus have been replaced with non-cancerous abnormal cells. These cells can progress to a condition called dysplasia , which may in turn become cancer. Dysplasia is considered low-grade or high-grade, depending on the degree of cellular change.

"While the benefit is clear for patients with high-grade dysplasia, we suggest considering endoscopic eradication therapy for patients with low-grade dysplasia after clearly discussing the risks and benefits of endoscopic therapy," said guideline author Dr. Tarek Sawas, assistant professor in the department of internal medicine at UT Southwestern.

"A patient-centered approach ensures that treatment decision is made collaboratively, taking into account both the medical evidence and the patient's preferences and values. Surveillance is a reasonable option for patients who place a higher value on harms and a lower value on the uncertain benefits regarding reduction of esophageal cancer mortality"

Endoscopic eradication therapy consists of minimally invasive procedures such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), followed by ablation (burning or freezing) techniques.

Key guideline takeaways:

• For patients with low-grade dysplasia, it may be appropriate to either remove or monitor the cells. This is a decision doctors and patients should make together after discussing the risks and benefits of treatment.
• For patients with high-grade dysplasia, AGA recommends endoscopic therapy to remove the abnormal pre-cancerous cells.
• Most patients undergoing endoscopic eradication can be safely treated with EMR, which has a lower risk of adverse events. Patients who undergo ESD can face an increased risk of strictures and perforation. AGA recommends reserving ESD primarily for lesions suspected of harboring cancers invading more deeply into the wall of the esophagus or those who have failed EMR.
• Patients with Barrett's esophagus (dysplasia or early cancer) should be treated and monitored by expert endoscopists and pathologists who have experience in Barrett's neoplasia.

"We need to have a conversation with patients in clinic prior to when they show up in the endoscopy unit on a gurney. Patients need to be fully aware of the risks and benefits, both in the short term but also in the long run, to decide which treatment approach is best for them. This decision often comes down to personal factors and values," added guideline author Dr. Joel Rubenstein, who is the director of the Barrett's Esophagus Program at the University of Michigan.

The guideline provides the following general implementation considerations:

• Tobacco use and obesity are risk factors for esophageal adenocarcinoma, so counseling patients to abstain from tobacco use and to lose weight can help improve outcomes.
• In patients with Barrett's esophagus, reflux control should be optimized with both medication and lifestyle modifications.

Guideline: https://www.gastrojournal.org/article/S0016-5085(24)00302-0/fulltext

Clinical decision support tool: https://www.gastrojournal.org/article/S0016-5085(24)00432-3/fulltext

Spotlight (infographic): https://www.gastrojournal.org/article/S0016-5085(24)00433-5/fulltext

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