Effects of live sax music on various physiological parameters, pain level, and mood level in cancer patients: a randomized controlled trial.

F E AT U R E S

Effects of Live Sax Music on Various Physiological Parameters, Pain Level, and Mood Level in Cancer Patients A Randomized Controlled Trial ■

Francesco Burrai, PhD, RN ■ Valentina Micheluzzi, MSN, RN ■ Valentina Bugani, MSN, RN Background: Few randomized controlled trial studies have focused on the effect of music in cancer patients, and there are no randomized controlled trials on the effects of live music with saxophone in cancer patients. Objectives: To determine the effects of live saxophone music on various physiological parameters, pain level, and mood level. Design: A randomized controlled trial study. Participants: 52 cancer patients were randomized to a control group (n = 26), an experimental group (n = 26) whose members received 30 minutes of live music therapy with saxophone. Measurements: Systolic and diastolic blood pressure, pulse rate, glycemia, oxygen saturation, pain level, and mood level were measured before and after the live music performance. Results: There was a statistical difference between the groups for oxygen saturation (0.003) and mood level (0.001). Conclusions: Live music performed with a saxophone could be introduced in oncology care to improve the oxygen saturation and mood in cancer patients. KEY WORDS: cancer patients, music therapy, nursing, research Holist Nurs Pract 2014;28(5):301–311

For centuries, man has understood the therapeutic and psychosomatic effects of music.1 Music therapy uses music and musical activity as a therapeutic instrument to improve the patient’s physical, mental, and spiritual well-being,2 contributing to the treatment of somatic and mental diseases.3 Music therapy, in the category of “mind-body medicine,”4 can therefore be described as an allied health profession and one of the expressive therapies, focusing on an interpersonal process in which a trained music therapist uses music in all its aspects—physical, emotional, mental, social, aesthetic, and spiritual—to help clients improve or maintain their health.5 Music answers the holistic needs of patients,6 and music is linked to human inner dimension, maybe especially significant for 1 person, and most pieces of music may speak directly to Author Affiliations: School of Medicine and Surgery, University of Bologna (Dr Burrai); and Villa Della Salute Hospital (Mss Micheluzzi and Bugani), Bologna, Italy. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Francesco Burrai, PhD, RN. AOSP S’Orsola MalpighiSchool of Medicine and Surgery, University of Bologna, Viale G.B. Ercolani 6, 40138 Bologna ([email protected]). DOI: 10.1097/HNP.0000000000000041

another person.7 Music may provide resources for the recovery of self-identity8 and may contribute to the quality of life through the awareness of feelings. It may provide vitality and develop agency and empowerment, as a resource in building social networks, and as a way of providing meaning and coherence in life.9 In cancer patients, music therapy has been used mainly during procedures in adult and pediatric care,10,11 in the treatment of cancer symptoms and adverse effects of chemotherapy,12 and in different oncology nursing settings.13-17 Randomized controlled trials have been used to study the effects of the music interventions mainly on physiological outcomes, such as systolic blood pressure, diastolic blood pressure, pulse rate, glycemia level, oxygen saturation level and pain level, and on psychological outcomes especially mood level. Randomized controlled trials have showed a reduction in systolic blood pressure and in diastolic blood pressure,18-21 in pulse rate,22-25 in glycemia level,26-28 in pain level,5,15,29-31 and in increments in oxygen saturation level.32,33 Several trials have shown that music interventions improve the state of mood level during chemotherapy,23 during hospitalization in 301

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cancer patients undergoing stem cell transplantation,34 in people diagnosed with terminal cancer,11 in women undergoing mastectomies,35 in children,36 and in adults.19,37,38 The choice of saxophone for this study is because this musical instrument has very interesting psychoacoustic, music psychological, and music therapeutic characteristics. In fact, from a musical point of view, the saxophone shows a very wide range, which can be up to 5 octaves, can makes over acute, has wide timbre and texture, which can vary from dark to bright enough to be very brilliant in the higher octaves,39 and can be played very gently at extremely low volume.40 The saxophone can play any piece of music with a greater range of interpretation compared to the vast majority of other music instruments, with extremely different emotional colors.41 From the psychoacoustic and psychological point of view, the saxophone produces frequencies, amplitudes, and harmonics and envelopes sound that can easily and efficiently influence the brain physiology with psychological effects.42-44 There are several music therapy schools and music therapist associations that teach the use of the saxophone for therapeutic uses and its application in hospitals, for example, American Music Therapy Association, Music Therapy Association, Infinity Music Therapy Services, and North American Saxophone Alliance. There are interesting live music therapy applications with saxophones in hospitals,45-47 but there are no randomized controlled trials on the effects of live music with saxophones in cancer patients, and this study seeks to answer this research question.

THEORETICAL FRAMEWORK The conceptual framework that will guide this study and the choice of the primary outcome and secondary outcomes is based on neurophysiologic perspective. In the neurophysiologic perspective, the music acoustic projection has 2 centers of elaboration: the primary auditory projection center on the temporal lobes, in areas 41 and 42, and the secondary auditory projection center, always on the temporal lobes, in area 22.48,49 However, these distinctions are not so clear and cannot be generalizable. According to the neurophysiologic model, music can influence the pulse rate, systolic blood pressure, diastolic blood pressure, and

respiration, activating the noradrenergic neurons in the brainstem and midbrain,50 which activate the cholinergic system.51 Cardiovascular parameters such as pulse rate, systolic blood pressure, and diastolic blood pressure are controlled by cholinergic mechanisms in the central nervous system and dopaminergic neurotransmission, and the sensory and motor function can also be activated through epinephrine, norepinephrine, and serotonin.52 Some authors indicated that music exerts its effect through the entrainment of body rhythms,53,54 defining entrainment as the tendency of 2 oscillating bodies to lock into phase and thus vibrate in harmony,32 similar to individual pulsing heart muscle cells that begin pulsing in synchrony when they are brought close together. When a person is experiencing discomfort, stress or anger, their body rhythms (breathing, heartbeat, and blood flow) will change55 and adrenaline is released from the adrenal medulla,56 which affects heart rate and breathing, leading to a change in blood pressure, heart rate, respiratory rate, and oxygen saturation.57 Music influences the levels of morphine-6-glucuronide and interleukin-6,52 raises endorphin and serotonin levels, reduces catecholamine levels,53 increases activity of alpha brain waves, and creates a cheerful atmosphere; it also induces a state of psychological relaxation by activating beneficial cognitive, emotional, and imagination-related processes54,58 that improve mood.32,55,56 According to the neurophysiologic model, the relaxing effects in a patient’s mood is interconnected to pleasant music and unpleasant music.57-60 Neuroimaging technology gives us the answer about the neuroanatomical basis for musical emotion and neural correlates of musical pleasure. Under positron emission tomography and functional magnetic resonance imaging, chill-inducing music was associated with a significant increase in regional cerebral blood flow in the ventral striatum and midbrain61 and in the nucleus accumbens, insula, and hippocampus62,63 and an increase in dopamine in the nucleus accumbens and in the caudate.64 Pleasant music shows a significant increase of the regional cerebral blood flow in the ventral striatum, and decrease in amygdala, hippocampus, parahippocampal gyrus, and temporal poles.65 These findings are very important, because the deactivations in the amygdala, hippocampus, parahippocampal gyrus, and the temporal poles in response to pleasant music are linked at the response to stress, and this deactivation may be related to modulation of the stress hormone cortisol in response to pleasant music, influencing


Effects of Live Sax Music in Cancer Patients

pulse rate, systolic blood pressure, diastolic blood pressure, glycemia, pain, and mood level.66 Another important variable is familiar pleasant music. Familiar pleasant music shows an increase of the regional cerebral blood flow in insula, in ventral striatum (caudate nucleus), and the medial prefrontal cortex.67 When patients listen to pleasant music, there is a nucleus accumbens and ventral tegmental area activation. During musical pleasure, the emotional and cognitive dimension are linked to orbitofrontal cortex with the mesocorticolimbic dopaminergic circuitry of the nucleus accumbens and ventral tegmental area.63 There is an association between sensation of chills by musical pleasure and dopamine release in the nucleus accumbens with pain reduction level and mood improvement.64 The pleasant music choices made by the patients have effects on stress hormones levels along the hypothalamic-pituitary-adrenal axis, with pain reduction level, and mood improvement, an increase in oxytocin level and oxygen saturation,68-70 in the epinephrine level,71 in the beta-endorphin level,72 and in the interleukin 6.73 Listening to pleasant music choices by patients can increase the growth hormone level,71 immunoglobulin A,74 and 5-Hydroxyindolacetic acid to cortisol ratio75 and can decrease cytokine interleukin-10 and interferon-G level.76 About cancer pain is often categorized by determining whether the symptoms are neuropathic, caused by a lesion or dysfunction in the nervous system, or nociceptive, occurring when the nociceptors activate because of an actual or threatened damage to nonneural tissue.77,78 There are many different mechanisms that may be involved in music’s ability to reduce pain. Gate control theory79 suggests that music activates type II sensory fiber (group Aβ), which trigger the inhibitory interneurons that block the transmission of pain signals to the brain; thus the gate is considered closed, and patients undergo a reduction or neutralization of their pain perception.80 Another possible explanation is that music requires powerful mental processes involved in concentration that modify the transmission of pain impulses in the spinal cord, as well providing stimuli that compete with other peripheral nerve impulses, which arrive from peripheral nervous system (PNS) to the central nervous system (CNS) transferring the brain’s focus from the nociceptor to the sound signal.81 Music interventions can mask environmental hospital stimuli that activate or increase the perception of pain, increase endorphin levels, and encourage imagination and

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other similar processes distracting from pain-related thoughts,82 and encourage music enjoyment.83

OBJECTIVES In the current study, we will test the null hypothesis that there would be no differences in various physiological parameters, in pain-level and mood-level outcomes between patients who experienced music therapy and patients who experienced only standard care. Three hypotheses were generated from the conceptual framework: 1. It is hypothesized that patients who listen to live saxophone music will show a reduction in systolic and diastolic blood pressure, a reduction in pulse rate, a reduction in glycemia level, than those who don’t; 2. It is hypothesized that patients who listen to live saxophone music will show a reduction in pain level than the those who don’t; 3. It is hypothesized that patients who listen to live saxophone music will show a reduction in mood level than the those who don’t.

METHODS Trial design This pilot study is a monocenter, longitudinal, nonstratified random controlled trial, with equal randomization for the parallel group (1:1 for 2 groups).

Patients Eligible participants were all adults aged 18 or older who met the eligibility criteria for diagnosis of cancer on chemo treatment. Exclusion criteria were hearing impairment, cognitive deficits, and life expectancy less than 1 month.

Study settings The study took place at the Medical Oncology ward at Policlinico Sant’Orsola Malpighi in Bologna, Italy.

Outcomes The primary endpoint is the mood level measured by visual analog scale (VAS) for mood, which measures mood level on a scale from 0 to 10, where 0 would


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describe “a great mood” and 10 would describe “the worst mood possible.” The VAS scales provide reliable, valid, tangible, and automatic measures of subjective variables such as pain level and mood.84-86 The secondary endpoints are as follows: pain level, measured by VAS for pain, which measures the intensity of pain on a scale from 0 to 10, where 0 would describe “absence of pain” and 10 would describe “the worst pain possible”; systolic blood pressure, diastolic blood pressure, and pulse rate measured by Omron HEM-705CP Automatic Digital Blood Pressure Monitor (OMRON Healthcare Europe B.V., Hoofddorp,The Netherlands); glycemia measured by Precision Xceed Pro Blood Glucose (Abbott Diabetes Care Inc., Alameda, CA) and oxygen saturation measured by Nonin 9550 Onyx II 9550 fingertip pulse oximeter (Nonin Medical, Inc., Plymouth, MN). R

R

R

Sample size On the basis of an expected incidence of the primary endpoint of quality of life, we calculated that we would need a sample size of 52 patients to give 80% power to detect a significant difference between music and control, with a 2-sided type 1 error level of 5%. In this study, we used a nonparametric Mann-Whitney test. The power of this nonparametric test is around 95.5% of the parametric test, so we estimated that a sample size of patients (n1 = n2 = 52) was necessary to achieve the desired statistical power.

Randomization For the randomization sequence generation for allocation of the participants, a computer-generated list of random numbers was used. For the randomization type, participants were randomly assigned following simple randomization procedures (computerized random numbers) to 1 of 2 groups. As for the allocation concealment mechanism, the allocation sequence was concealed from the researcher enrolling and assessing participants in sequentially numbered, opaque, sealed, and stapled envelopes. Envelopes were opened only after the enrolled participants completed all baseline assessments, and it was time to allocate the intervention. Seventy patients recovering in oncology ward were chosen to participate in the study. Out of the 58 who were eligible, 6 patients did not meet the inclusion criteria, 1 declined to participate, and 1 was excluded for other

reasons. Fifty-two patients were randomly assigned to either the music group (n = 26) or the control group (n = 26). The patients were allocated randomly in the 2 groups by random numbers method. The flowchart of this study is shown in Figure 1.

Data collected The study instrument consisted of 3 parts: Part 1: Demographic and Clinical data: age, gender, marital status, level of education, religious beliefs, musical preferences, pathology, and analgesic therapy; Part 2: Physiological parameters: systolic blood pressure, diastolic blood pressure, pulse rate, glycemia, and oxygen saturation; Part 3: Pain level, using the VAS for pain, which measures the intensity of pain on a scale from 0 to 10, where 0 would describe “absence of pain” and 10 would describe “the worst pain possible.” Mood level, using the visual analog scale for mood, which measures mood level on a scale from 0 to 10, where 0 would describe “a great mood” and 10 would describe “the worst mood possible.”

Procedure This study is in accordance with the Declaration of Helsinki statement. The research project has obtained the ethical approval of the hospital. Participants signed the informed consent form. The eligible patients were informed about the type of study as well as its aim and about the procedures regarding data collection. Patients were assured about privacy and anonymity by identifying them only by case numbers. All parts of the study instrument were administered by blinded outcome assessors. Part 1 of the study instrument was administered in the first week during baseline data collection for all patients. Music group A holistic nurse, with holistic nursing education and music skills, played the saxophone to the patient of the music group. All the saxophone music interventions were performed in a specified patient room, called “the music room,” with only 1 bed, with the patient lying in bed, and the door closed. The location of this hospital room, inside the oncology ward, prevented the sound of the saxophone to be heard in other rooms, avoiding problems such as intrusive sounds, and protecting people who did not consent to participate in



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Assessed for eligibility (n= 58 )

Excluded (n= 6 ) Not meeting inclusion criteria (n= 6 ) Declined to participate (n= 1 ) Other reasons (n= 1 )

Randomized (n=52 )

At week 1 Allocated to music intervention (n= 26) Received allocated intervention (n= 26) Did not receive allocated intervention (n= 0 ) Baseline demographic and Clinical data, psychological data, pain and mood data were collected

At week 1 Allocated to non-music intervention (n= 26) Received allocated intervention (n= 26) Did not receive allocated intervention (n= 0 ) Baseline demographic and Clinical data, psychological data, pain and mood data were collected

At week 2 Lost to follow-up (give reasons) (n= 0) Discontinued intervention (n= 0 ) Psychological, pain and mood data were collected






Analyzed (n= 26) Excluded from analysis (give reasons) (n= 0 )

Analyzed (n= 26) Excluded from analysis (give reasons) (n= 0 )

FIGURE 1. Flowchart of the trial.

the study or were enrolled in the control group. In this room, the patients of the music group were allowed to choose 5 or 6 musical pieces of very different styles (including relaxing, cheerful, and lively pieces) and genres (pop, classical, film scores, folk, and jazz) among a playlist made up of hundreds of the most famous national and international pieces. After choosing, the patient listened to 5 or 6 pieces played with the saxophone for about 30 minutes. At the end of the 30-minute live music performance, the patient

returned to his room in hospital. Part 2 and part 3 of the instrument were administered as baseline before the 30-minute music intervention in week 1. For week 2 to week 4, part 2 and part 3 of the instrument were administered after the music intervention.

Control group For the control group, part 2 and part 3 of the instrument were administered in weeks 1 to 4 after a


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30-minute rest period. The patient’s data was collected after the 30-minute rest period.

Statistical analysis Descriptive statistics were used to describe the demographic and clinical data using averages of the central tendency indexes, standard deviation and range for the dispersion index, and frequencies and percentages for distribution indexes. The t test, chi-squared test, and Fisher exact test were used to test the homogeneity between groups for demographic and clinical data. Shapiro-Wilk test was used to examine the normality of the continuous data. The results suggested that nonparametric tests were appropriate. To demonstrate the effect in patients, the changes in the variables from baseline to after intervention and nonintervention were measured after 30 minutes, calculating the delta. Mann-Whitney U test was used to examine whether or not statistically significant

differences existed in the measured variables between the groups, from baseline to posttest measurements. The Wilcoxon test was used to examine whether or not statistically significant differences existed within each group, from baseline to posttest measurements. Differences were considered statistically significant with values of P < .05, with a 2-tailed test. The statistical analysis was completed using Version 18.0 of SPSS for Windows (IBM Corporation, Armonk, NY).

RESULTS Demographic and clinical data The average age of the sample participants was 64.5 (σ = 12.7), with 82.7% women (n = 43), and 76.9% (n = 40) were married. Most participants had attained an average level of education (n = 23, 46.1%), and

TABLE 1. Demographic and Clinical Data Between Groups Groups, n (%) Variables

Age, average ± SD, y Gender Male Female Marital status Married Single Separated Widow/Widower Level of education None Elementary school Middle school High school University Religious belief Catholic Others Music listening Yes No Pathology Metastatic cancer Nonmetastatic cancer Analgesic therapy Yes No a b c

Total (n = 52), n (%)

Controlled (n = 26)

Experimental (n = 26)

P

64.5 ± 12.7

64.6 ± 12.8

64.3 ± 12.9

.940a

9 (17.3) 43 (82.7)

8 (30.7) 18 (62.3)

1 (3.8) 25 (96.2)

.024b

40 (76.9) 5 (9.6) 2 (3.9) 5 (9.6)

20 (76.9) 3 (11.6) 1 (3.8) 2 (7.7)

20 (76.9) 2 (7.7) 1 (3.8) 3 (11.6)

.940c

1 (1.9) 12 (23.0) 24 (46.1) 9 (17.4) 6 (11.6)

0 (0.0) 7 (26.9) 11 (42.4) 6 (23.1) 2 (7.6)

1 (3.5) 5 (19.3) 13 (50.0) 3 (11.6) 4 (15.4)

.530c

51 (98.1) 1 (1.9)

26 (100.0) 0 (0.0)

25 (96.2) 1 (3.8)

1.000b

51 (98.0) 1 (2.0)

25 (96.1) 1 (3.9)

26 (100.0) 0 (0.0)

1.000b

45 (86.6) 7 (13.4)

24 (92.3) 2 (7.7)

21 (80.7) 5 (19.3)

.419b

32 (61.5) 20 (38.4)

13 13

19 7

153b

T test. Fisher exact test. Chi-squared test.


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nearly all participants were Catholic (n = 51, 98.1%). Of them, 98% participants (n = 51) listen to music regularly, and most patients had metastasis (n = 45, 86.6%). More than half of the participants took part in analgesic therapy (n = 32, 61.5%). There were no statistically significant differences between the groups with regard to the demographic and clinical variables as demonstrated in Table 1.

Physiological parameters As shown in Table 2, there were no statistically significant differences in the physiological variables between groups, except for oxygen saturation, where statistical differences were found between the groups (P = .003) with a significant reduction of 1.2% (P = .003) as shown in Figure 2.

Pain and mood level As shown in Table 2, there were statistical differences between the groups for mood level (P = .001), with a significant reduction of 70% (P = .001), as shown in Figure 2. There were no statistically significant differences between groups for pain level (P = .136). Only within music group, the pain level showed a statistically significant difference at posttest for VASP (P = .001).

DISCUSSION This study shows a statistically significant increase in oxygen saturation. The most recent version of the Cochrane systematic review,87 which included 30

TABLE 2. Outcomes Comparisons Between Groups Groups Controlled (n = 26) Outcomes

Average (SD)

Systolic blood pressure Baseline 100.9 (13.4) Posttest 104.6 (14.2) Wilcoxon test Z = −1.480 Diastolic blood pressure Baseline 66.5 (6.7) Posttest 68.4 (6.7) Wilcoxon test Z = −1.553 Pulse rate Baseline 75.7 (13.4) Posttest 73.6 (11.6) Wilcoxon test Z = −2.357 Glycemia Baseline 133.15 (56.2) Posttest 125.8 (46.4) Wilcoxon test Z = −0.996 Oxygen saturation Baseline 97.3 (1.3) Posttest 96.9 (1.8) Wilcoxon test Z = −1.446 VASP Baseline 1.3 (0.5) Posttest 1.4 (0.5) Wilcoxon test Z = −1.000 VASM Baseline 3.8 (2.2) Posttest 4.1 (2.2) Wilcoxon test Z = −2.333

Experimental (n = 26)

Mann-Whitney

Median [Range]

Average (SD)

Median [Range]

U Test

Pa

100.0 [70.0-130.0] 100.0 [80.0-130.0] P = .139

107.0 (19.2) 108.0 (12.0) Z = −0.463

100.0 [80.0-160.0] 110.0 [80.0-130.0] P = .644

286.50 277.00

.334 .253

70.0 [50.0-80.0] 70.0 [60.0-80.0] P = .120

71.1 (11.7) 70.7 (6.2) Z = −0.166

70.0 [50.0-110.0] 70.0 [60.0-90.0] P = .868

265.00 281.00

.146 .223

74.5 [50.0-104.0] 74.0 [55.0-98.0] P = .018

75.0 (9.2) 75.8 (9.1) Z = −0.423

75.0 [54.0-97.0] 74.0 [56.0-84.0] P = .672

331.50 300.00

.905 .486

125.0 [46.0-293.0] 114.0 [75.0-274.0] P = .319

117.1 (34.3) 109.0 (24.8) Z = −1.306

108.0 [65.0-201.0] 104.0 [74.0-157.0] P = .192

288.00 273.50

.360 .238

97.0 [94.0-100.0] 97.0 [91.0-100.0] P = 0.148

97.2 (1.7) 98.2 (1.5) Z = −3.335

98.0 [94.0-100.0] 99.0 [94.0-100.0] P = 0.001

335.50 178.00

.963 .003

1.6 [0.0-5.0] 1.6 [0.0-5.0] P = 0.317

1.8 (1.9) 0.7 (1.1) Z = −3.461

2.0 [0.0-5.0] 0.0 [0.0-4.0] P = 0.001

292.50 265.00

.378 .136

3.5 [1.0-10.0] 4.0 [1.0-10.0] P = 0.020

5.0 (2.1) 2.2 (2.3) Z = −4.220

5.4 [2.0-10.0] 2.0 [0.0-10.0] P = 0.000

194.50 161.50

.008 .001

a

Significant at P < .005 two-sided test. Abbreviations: VASM, visual analog scale for mood; VASP, visual analog scale for pain.


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FIGURE 2. Mean differences between groups.

trials and 1891 patients, suggests that definitive conclusions can still not be drawn regarding the effects of music on the level of oxygen saturation in adults with cancer. Even so, higher levels of oxygen saturation have been observed in patients of some studies after listening to music. A systematic review, which included 13 randomized controlled studies and 2 meta-analyses, have shown a positive effect of some nonpharmacological interventions, including listening to music, on physiologic parameters, such as oxygen saturation in preterm and term newborns in a neonatal intensive care unit.88 One high-quality pilot study regarding neonates showed benefits of music on oxygen saturation at the end of the surgical procedure.89 In elderly patients on maintenance hemodialysis, music interventions showed a significantly increased oxygen saturation (P < .001),90 and a statistically significant increase in oxygen saturation (P = .001) was shown in patients after open-heart surgery.91 In Nguyen’s trial,20 40 participants reported no effects for music listening on oxygen saturation levels in children with cancer undergoing lumbar puncture compared to standard care. This study shows also a statistically significant improvement in state of mood. Our data are in accordance with 6 trials. In Cassileth’s trial patients in the music therapy group scored 37% lower (P = .01) on the total mood disturbance score compared with controls. Gallagher’s trial92 showed that among the 123 palliative care patients with mood disturbance in the single arm a mean self-reported mood disturbance scores improved

from 1.8 to 0.7 on a 5-point VAS after a single music therapy session (P < .001). Other studies showed improvements in mood level in adults with cancer-related pain18 and in children with neoplasms needing chemotherapy.36 Burns’ trial,10 with a quantitative pre-post test study and psychological/physiological measures, showed a link between listening to music and an improved state of mood. Ratcliff’s trial93 showed that music listening improves mood acutely. Kempler’s trial94 showed an improved relaxation in music group than rest (P < .01). Li’s trial95 showed a significant reduction in the state of anxiety score in the music group than control group that only received routine nursing care. Chuang’s trial22 showed a significantly increased relaxation sensation and significantly decreased fatigue sensation in the music group.

CONCLUSIONS The results suggest that the use of live saxophone music increases the oxygen saturation and improves the state of mood in cancer patients recovering in an oncology ward. Cancer patients, who have a better oxygen saturation, show a reduction of fatigue, and drowsiness, an increase of muscle strength and better coordinated movements. Cancer patients with a better state of mood show a reduction in anxiety, depression, and pain level, better coping, better communication of their difficulties, and a different perception of their own body.



There are important differences between recorded music and live music in nursing cancer care. In a live music intervention during the musical performance, the relationship between player and patient is dynamic and continuous with verbal and nonverbal communication. Music becomes the communication channel of the emotional world between player and patient. The patient observes the movements and the body expressions of the player during the live music performance, and the player changes and modulates the live music performance based on verbal and nonverbal patient communication. This type of relationship is not present during the listening of recorded music. Finally, to avoid the possibility that playing live music might cause adverse effects in cancer patients, it is necessary that the musician have expert skills. The player should be a bachelor in a musical instrument and should have music therapy skills and experience. In this study, all music interventions are performed by holistic nurse with a bachelor’s degree in saxophone and with an important experience in music therapy.

IMPLICATIONS FOR FURTHER RESEARCH This was a pilot study, and these limitations should be addressed in further research. Patients were limited to a single Italian medical oncology ward, and the results should be generalized with caution in other countries due to potential cultural differences. This study was conducted only in a medical oncology setting, so the results cannot be generalized to other oncology fields, such as hematology. Only 1 player has performed the saxophone music intervention in the study, thus it was not possible to determine whether significant improvement in the measured parameters was due at least in part to the relationship between that specific player and the patient.

IMPLICATIONS FOR NURSING PRACTICE This article presents an evidence-based pilot study about the integration of live saxophone music as a holistic, noninvasive, nonpharmacological intervention in oncology nursing care. Live music performed by an expert in music therapy with saxophone could be an oncology care tool, which can help patients to reconnect with themselves through personal musical experience, improving their state of

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mood, improving better coping with hospitalization and chemotherapy, promoting patient well-being, and improving the quality of their interactions with other patients and the nursing team.

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Effects of live saxophone music on physiological parameters, pain, mood and itching levels in patients undergoing haemodialysis.

Well-loved music robustly relieves pain: a randomized, controlled trial.

Acute effects of single and multiple level thoracic manipulations on chronic mechanical neck pain: a randomized controlled trial.

The Effects of Music Intervention on Background Pain and Anxiety in Burn Patients: Randomized Controlled Clinical Trial.

Recurrent aphthous stomatitis and pain management with low-level laser therapy: a randomized controlled trial.

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Topical Mannitol Reduces Capsaicin-Induced Pain: Results of a Pilot-Level, Double-Blind, Randomized Controlled Trial.

EFFECT OF THERAPEUTIC TOUCH ON PAIN RELATED PARAMETERS IN PATIENTS WITH CANCER: A RANDOMIZED CLINICAL TRIAL.

Randomized controlled trial of a health plan-level mood disorders psychosocial intervention for solo or small practices.

Effects of Gentle Human Touch and Field Massage on Urine Cortisol Level in Premature Infants: A Randomized, Controlled Clinical Trial.

Effects of Walnut Consumption on Mood in Young Adults-A Randomized Controlled Trial.

The effect of low-level laser on postoperative pain after tibial fracture surgery: a double-blind controlled randomized clinical trial.

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Short-Term Effects of a Combined Nutraceutical on Lipid Level, Fatty Liver Biomarkers, Hemodynamic Parameters, and Estimated Cardiovascular Disease Risk: A Double-Blind, Placebo-Controlled Randomized Clinical Trial.

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The effect of music on the level of cortisol, blood glucose and physiological variables in patients undergoing spinal anesthesia.

Electroacupuncture treatment for pancreatic cancer pain: a randomized controlled trial.

Effects of cinnamon on perineal pain and healing of episiotomy: a randomized placebo-controlled trial.

Effects of neuromuscular electrical stimulation and low-level laser therapy on the muscle architecture and functional capacity in elderly patients with knee osteoarthritis: a randomized controlled trial.

Music preferences of mechanically ventilated patients participating in a randomized controlled trial.

Effects of music videos on sleep quality in middle-aged and older adults with chronic insomnia: a randomized controlled trial.