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The Effects of Music as Therapy on the Overall Well-Being of Elderly Patients on Maintenance Hemodialysis
Yen-Ju Lin, Kuo-Cheng Lu, Ching-Min Chen and Chia-Chi Chang Biol Res Nurs 2012 14: 277 originally published online 27 June 2011 DOI: 10.1177/1099800411413259 The online version of this article can be found at: http://brn.sagepub.com/content/14/3/277

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The Effects of Music as Therapy on the Overall Well-Being of Elderly Patients on Maintenance Hemodialysis
Yen-Ju Lin, RN1, Kuo-Cheng Lu, MD2,3, Ching-Min Chen, RN, DNS4, and Chia-Chi Chang, RN, PhD5

Biological Research for Nursing 14(3) 277-285 The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1099800411413259 http://brn.sagepub.com

Abstract In this study, the authors explored the use of music during hemodialysis (HD) as a complementary therapy to improve overall well-being in elderly patients. The authors recruited a convenience sample of 88 patients on maintenance HD from a teaching hospital in northern Taiwan and randomly assigned them to either an experimental group (n 44) or a control group (n 44). In the first week, participants in the experimental group created their own music playlists. During the second week, these participants listened to music from their own playlists during each HD session (three times/week). The authors evaluated the effects of music as therapy by assessing its impact on perceived stressors and adverse reactions during HD (HD Adverse Reactions Self-Assessment Scale and HD Stressor Scale [HSS]) and measuring changes in physiological indices during the course of the music listening. After 1 week of the use of music as therapy during HD, the authors noted significant reductions in the frequency and severity of adverse reactions during dialysis and in scores on the HSS, p < .001. The authors also observed significantly decreased respiratory rate and significantly increased finger temperature and oxygen saturation, p < .001, during the same period. In conclusion, listening to music during HD may promote overall patient well-being. It may thus serve as a complementary form of therapy that facilitates care and delivery of adequate dialysis and thus improves overall patient well-being in the long run. Keywords music, hemodialysis, adverse reactions, end-stage renal disease (ESRD) Taiwan currently holds the dubious honor of having the highest incidence and prevalence of chronic kidney disease requiring long-term hemodialysis (HD) worldwide (United States Renal Data System, 2010). Of these end-stage renal disease (ESRD) patients on HD, 44.65% are over 65 years of age (Taiwan Bureau of National Health Insurance, 2011). Older patients often have multiple comorbidities and are more likely to experience greater degrees of physical and psychological functional decline. Elderly patients are also more likely to develop adverse reactions during HD, such as hypotension, muscle cramping, nausea, vomiting, headache, and chest pain (Tan & Yang, 2005). HD treatment is thus often a source of stress and anxiety for these patients; they are more inclined than younger patients to ask for earlier termination of treatment or to skip scheduled HD treatments altogether, frequently compromising the adequacy of dialysis therapy. Management of adverse reactions during HD usually only provides symptomatic relief and cannot fully prevent patients from having recurrent reactions during subsequent HD sessions. Current recommended strategies to manage and prevent these adverse reactions may have unintended consequences as well. Thus, alleviating the physical discomfort and emotional distress, these patients experience remains a major concern in clinical practice. Previous studies have shown that unique characteristics in the melody and rhythm of certain types of music can relieve stress and help receptive patients relax, with investigators observing lower levels of blood pressure (BP) as well as decreased respiratory and basal metabolic rates in these patients (Glynn, 1986; Kemper & Danhauer, 2005). Researchers and clinicians have used music therapy for the treatment of stress and depression, as well as for sleep induction, pain alleviation, muscle relaxation, and attempts to enhance immune function against infection (Burns, Harbuz, Hucklebridge, &

Dialysis Center, Department of Nursing, Cardinal Tien Hospital, New Taipei City, Taiwan, Republic of China 2 School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan, Republic of China 3 Division of Nephrology, Cardinal Tien Hospital, New Taipei City, Taiwan, Republic of China 4 Department of Nursing, College of Medicine, National Cheng-Kung University, Tainan, Taiwan, Republic of China 5 School of Geriatric Nursing and Care Management, College of Nursing, Taipei Medical University, Taipei, Taiwan, Republic of China Corresponding Author: Chia-Chi Chang, No. 250, Wu-Xing St. Taipei 110, Taiwan, Republic of China Email: cchang@tmu.edu.tw

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278 Bunt, 2001; Chang & Sung, 2005). Music therapy may also serve as a distraction for patients and decrease awareness of the passage of time during HD sessions, which may improve treatment outcomes. We hypothesized that listening to music during HD would decrease the level of anxiety and stress that many older patients experience during these sessions, thus facilitating patient adjustment to and acceptance of HD treatment. In the present study, we explored the effects of music therapy on the incidence and severity of adverse reactions during HD treatment and measured changes in biophysical parameters during treatment.

Biological Research for Nursing 14(3) waves, which is associated with improvements in memory and creativity during conscious meditation (Wang, 2002). In addition, investigators have reported that music therapy makes receptive individuals feel a sense of peace and comfort, eliminating negative, hostile, and anxious thoughts and increasing motivation (Beck, 1991; Brown, Martinez, & Parsons, 2004; Prinsley, 1986). Menon and Levitin (2005) demonstrated that listening to music regularly increases dopamine release, producing positive thoughts, and a sense of wellbeing. Other researchers have shown that music therapy promotes social interactions, reducing avoidance behavior and increasing the chance of participation in social organizations (Prinsley, 1986; Wang, Yeh, & Chang, 2003).

Background Factors Associated With Adverse Reactions During HD Sessions

The adverse reactions patients most commonly experience during HD are hypotension (2550%), muscle spasm (520%), nausea and vomiting (515%), headache (5%), chest pain (25%), back pain (25%), pruritus (5%), fever and chills (1%; M. S. Wu, 2007). Though there are current recommended guidelines for the prevention and management of these adverse reactions, elderly patients with ESRD often have comorbidities such as cardiovascular disease and autonomic dysfunction which limit their ability to cope with physiological stressors and maintain hemodynamic stability during the HD procedure (Li, Jiang, & Xu, 2008). Elderly diabetic patients with ESRD, who comprise the largest group of patients on long-term HD, are particularly at risk and have significantly higher morbidity and mortality rates (Wang, 2007). Thus, effective prevention and management of these potentially life-threatening adverse reactions are needed to improve patient safety and well-being (Sulowicz & Radziszewski, 2007), as well as to improve adherence to therapy.

Principles of Implementation of Music Therapy

Gerdner (2000) and Lai (2004) found that, prior to the implementation of music therapy, researchers or clinicians must adequately assess patients personal background and information regarding their preferences in music to maximize the potential effects of treatment. The characteristics of relaxing music appropriate for music therapy include a slow tempo (60*80 crotchet beats per minute), low-to-medium pitch, low volume, and melodious rhythms comprised mostly of wind instruments (OSullivan, 1991). Staum and Brotons (2000) reported that keeping the volume at 6070 dB maximizes relaxation and reduces psychological stress. During the course of music therapy, which is best conducted individually in a quiet room, the clinicians or researchers encourage the patient to assume a relaxed and comfortable position and listen to the music for 2045 min (Wang et al., 2003). They might also provide patients with headphones to reduce ambient and background noise and set playlists on automatic replay to minimize interruptions during sessions and maximize treatment effects (Beck, 1991; S. Lee, Lieu, & Chen, 1999).

The Physiological, Psychological, Social, and Spiritual Aspects of Music Therapy

Music is perceived by the cochlear nerve, which subsequently transmits neural signals to the cortex, activating the limbic system. The limbic system then relays signals to the pituitary gland, which releases endorphins that possess analgesic properties, thus causing decreased perception of pain signals (Beck, 1991). Music also has the ability to decrease pressuredependent adrenocorticotropic hormone (ACTH) stimulation and cortisol release, resulting in decreased catecholamine secretion from the adrenal medulla. The consequent changes in BP, heart rate, respiratory rate, temperature, and serum free fatty acids have beneficial effects on the cardiovascular, respiratory, musculoskeletal, and nervous systems as well as the bodys metabolism, such as the alleviation of migraine headache and hypertension and easing of muscle tension, and may lower the risks associated with coronary heart disease and stroke (Cook, 1986; Mo ckel et al., 1994). Research has also shown that music increases the rhythmicity of alpha brain

Effects of Music Therapy in the Clinical Setting

Researchers have studied music therapy as a complementary treatment in a variety of medical fields. Midwives have used music therapy to reduce stress and anxiety during labor, increase concentration, and facilitate positive experiences for the mother and her relatives (Chang & Chen, 2005). Richardson, Babiak-Vazquez, and Frenkel (2008) likewise reported that music therapy effectively reduced pain, discomfort, and anxiety in the palliative care of cancer patients. Hilliard (2005) showed that music therapy facilitates the building of patient relationships with caregivers and other patients and improves patients quality of life. Among patients with chronic psychosis, Wang et al. (2003) demonstrated that music therapy reduces negative symptoms associated with these chronic conditions and improves social interaction and levels of interest in patients surroundings. In pediatrics, L. Lee, Chan, Ho, Cheng, and Su (2005) found that music therapy improves learning motivation in autistic children, increasing cognitive and conversational abilities.

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Lin et al.

279

A subject is deemed eligible for enrollment and qualified based on sample criteria

Subjects are randomly assigned to experimental or control group by coin flip

Informed consent is secured for enrollment in study

Experimental group

Control group

Pretest data collection: First HD session, Week 1: Demographics Sheet and HSS. Last HD session, Week 1: - During HD: physiological monitoring - After HD: HD Adverse Reactions SelfAssessment Scale and music selection.

Pretest data collection: First HD session, Week 1: Demographics Sheet and HSS. Last HD session, Week 1: - During dialysis: physiological monitoring - After HD: HD Adverse Reactions SelfAssessment Scale

Regular clinical care with music therapy

Regular clinical care only

Posttest data collection: Last HD session, end of week 2: - During dialysis: physiological monitoring - After HD: HD Adverse Reactions SelfAssessment Scale and HSS

Posttest data collection: Last HD session, end of week 2: - During dialysis: physiological monitoring - After HD: HD Adverse Reactions SelfAssessment Scale and HSS

Data processing and analysis

Figure 1. Data-collection process. Note. HD hemodialysis; HSS HD Stressor Scale. Coin flip results: subjects on Mon-Wed-Fri HD schedule were assigned to the experimental group; subjects on Tue-Thu-Sat HD schedule were assigned to the control group.

Patients on HD often present with acute complaints that need immediate attention. In maintenance HD patients, music therapy has had beneficial effects on stress, anxiety, and depression. Investigators have also noted increased blood oxygen saturation in these patients (Kim, Lee, & Sok, 2006; Lin, Chen, Kuo, Wang, & Huang, 2007). To date, however, there is little evidence in the literature regarding the effects of music therapy on the well-being of patients on HD, especially the elderly.

Method Design and Setting

The Ethics Committee on Human Studies at Cardinal Tien Hospital, Taipei, Taiwan, approved the study protocol. We obtained written informed consent from each patient who participated. We recruited a convenience sample of 88 HD patients and randomly assigned them to the experimental (n 44) or control group (n 44) by flipping a coin. Patients deemed eligible for enrollment in the study were aged 60 years and over, known to have ESRD for at least 3 months, on maintenance HD three times every week (4 hr/per session) and able to

communicate effectively in Mandarin or Taiwanese. Patients with severe cognitive or hearing impairments and those with pacemakers were excluded from this study. In the first week, patients in the experimental group selected and created their own music playlists. During the second week, the experimental group listened to music from their own playlist during each HD session (three times/week). We evaluated the effects of the music therapy by assessing its impact on stressors and adverse reactions during HD (HD Adverse Reactions Self-Assessment Scale and HD Stressor Scale [HSS]) and measuring changes in physiological indices during the course of the treatment (Figure 1). We checked the physiological indices every 30 min for the entire HD treatment and averaged data from eight time points (30, 60, 90, 120, 150, 180, 210, and 240 min after HD initiation) to obtain the postintervention measures for each patient.

Instruments
Demographic data. To account for possible confounding factors during analysis, we recorded and controlled for the

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280 following demographic data: age, sex, education level, marital status, time on HD, comorbidities, and musical preferences. Hemodialysis Adverse Reactions Self-Assessment Scale. Adapted from relevant literature and clinical nursing management experience, the self-assessment scale contained 17 common adverse reactions that may occur during HD (Tan & Yang, 2005; Tanimu et al., 2000; M. S. Wu, 2007). We used 4-point Likert-type scales to quantify symptom frequency (0 none, 1 once or twice, 2 35 times, and 3 more than 5 times) and severity (1 only mildly ill, 2 moderately ill, 3 seriously ill, and 4 extremely ill). Frequency scores ranged between 0 and 51, with higher scores indicating a higher frequency. Severity scores ranged between 17 and 68, with higher scores likewise representing a greater severity. Cronbachs a of the scale was .662 and coefficient of variation (CVI) was .91. Hemodialysis Stressor Scale. The HSS (Chou, 2002) is a 32item scale used to rate the incidence and severity of stressors associated with HD. Subjects rated the extent of being troubled by each of the 32 stressors using a 4-point scale (0 not at all, 1 slightly, 2 moderately, and 3 a great deal). We obtained a subtotal score for each construct by summing the ratings for each; the higher the score, the greater the stress. We used the HSS for both longer-term recall (i.e., 12 months prior to study) and more immediate recall (during the Week 2 of the study period). Cronbachs a of this scale was .905 in the current study. Physiological indicators. We used a biological monitoring system (GE Medical Systems Information Technologies, Inc., Milwaukee, WI) to monitor and record data regarding BP, heart rate, respiratory rate, and oxygen saturation. The Department of Health, Executive Yuan and the Bureau of Standards (2010), Metrology and Inspection approved this system. A certified engineer made any necessary adjustments. When individuals are in a state of relaxation, parasympathetic effects are enhanced, leading to capillary expansion and an increase in the surface temperature of the fingers. Investigators can measure this physiological change and use it as an indicator of emotional state (P. H. Chen, 2003; Kistler, Mariauzouls, & von Berlepsch, 1998). For the current study, we measured finger surface temperature using the TEMPview Temperature Feedback Monitor, with an accuracy within 0.1  C (TM-903A, Ronmac Int. Corp, Taipei, Taiwan, manufactured in 2009).

Biological Research for Nursing 14(3) participant. All available selections were melodic instrumental music with a tempo of 6080 beats per min. During the second week, participants in the experimental group received music as therapy during every HD session. They wore earphones to eliminate background noise and selected music from their own playlists. Participants could listen to music for the first 20 min of every hour for the first 3 hr of HD. For the fourth hour, we asked participants to listen to music during the last 20 min of HD treatment. We did not provide the control group with any music at all during HD.

Statistical Analysis
We express continuous variables as means + SD and categorical values as percentages. We tested normal distribution of samples using the KolmogorovSmirnov test and performed comparisons between groups using Students t test or Mann Whitney U test (according to data characteristics). We used Fishers exact test or chi-square analysis to analyze categorical data, Wilcoxons signed ranks test to analyze the differences between pretest and posttest in the experimental group, and Spearman rank correlation coefficient test to examine the correlations between age, the habit of listening to music, and other indices. We consider a p value < .05 to be statistically significant. We used the Statistical Package for the Social Sciences (SPSS/PC, SPSS, Inc., Chicago, IL) for our statistical analyses.

Results Baseline Data and Physiological Parameters

We cross-referenced patient demographic data with currently available nationwide research data (Chang, 2005; L. H. Lee, 2003; Sung, Chang, & Abbey, 2006). We found no statistically significant differences between the experimental and control groups with regard to sex, level of education, marital status, religion, annual income, living arrangement, length of time on HD and duration of each session, average frequency and severity of adverse reactions, HSS scores during HD, or physiological indices (Table 1). The experimental group had a lower mean age (69.11 + 7.88 versus 75.55 + 9.16, p .001) and its members were more likely to have a habit of listening to music (w2 19.17, p < .001) compared to the control group. Since we noted significant differences between the two groups with respect to age and the habit of listening to music, we used the Spearmans rank correlation coefficient to analyze the relationships between these two demographic variables and the physiological parameters in all the patients (Table 2). We found a negative correlation between age and diastolic BP (r .332, p .002), which might be due to the decreased elasticity and compliance of arteries that occurs with age (M. F. Chen, 2009). We found no statistically significant correlation between the habit of listening to music and any of the physiological parameters or with respect to sources of stress and the frequency and severity of adverse reactions during HD.

Intervention
In the first week, we encouraged participants in the experimental group to choose their favorite musical styles by listening to the first 30 s of each of the songs on the complete playlist with 5 s intervals between songs. There were three songs to choose from in each music category and participants had free rein to select and eliminate songs and music categories to create their own personal playlists, which we then recorded for each

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Lin et al.
Table 1. Demographic and Baseline Variables of the Two Groups (N 88) Variable Age SexFemale Educational level Uneducated (illiterate) Elementary school Junior high school High school College, university, and above Marital status Single Married Divorced Separated Widowed Religion None Chinese traditional religion Christianity Catholicism Annual income Insufficient Enough Good Very good Lives with familyNo Length of time on hemodialysis (years) Duration of hemodialysis sessions < 4 hr 4 hr > 4 hr Number of other chronic diseases 0 1 2 3 Habit of listening to musicNo Frequency of adverse reactions score Severity of adverse reactions score Hemodialysis Stressor Scale score SBP (mmHg) DBP (mmHg) % of SBP < 100 mmHg Heart rate (beats/min) Respiratory rate (breaths/min) Finger temperature ( C) Oxygen saturation (%) Experimental (n 44) 69.11 + 7.881 22 (50) 7 19 6 6 6 (15.9) (43.2) (13.6) (13.6) (13.6) Control (n 44) 75.55 + 9.156 29 (65.9) 13 18 7 4 2 2 18 1 1 22 4 37 2 1 (29.5) (40.9) (15.9) (9.1) (4.5)

281

p .001a** .131b .389c

.113c 3 (6.8) 28 (63.6) 0 0 13 (29.5) 2 (4.5) 38 (86.4) 4 (9.1) 0 5 23 12 4 5 6.80 (11.4) (52.3) (27.3) (9.1) (11.4) + 5.290 (4.5) (40.9) (2.3) (2.3) (50.0) .588c (9.1) (84.1) (4.5) (2.3) .300c 10 (22.7) 24 (54.5) 6 (13.6) 4 (9.1) 7 (15.9) 4.42 + 3.584 4 (9.1) 40 (90.9) 0 .461c 6 7 21 10 17 2.36 2.45 27.00 134.60 70.05 5.52 71.59 18.52 31.85 98.43 (13.6) (16.0) (47.7) (22.7) (38.6) + 2.934 + 3.605 + 17.032 + 18.992 + 9.665 + 11.2 + 15.345 + 1.944 + 1.912 + 1.022 1 (2.3) 13 (29.5) 21 (47.7) 9 (20.5) 37 (84.1) 1.93 + 2.491 1.77 + 2.144 28.18 + 15.919 133.66 + 18.570 66.26 + 9.492 7.79 + 17.82 71.50 + 10.582 18.87 + 1.903 31.31 + 1.988 98.16 + 0.938

.379b .054a .183c

2 (4.5) 39 (88.6) 3 (6.8)

.000b*** .415a .505a .573a .815a .081a .952a .611a .537a .163a .125a

Note. Continuous variables are expressed as mean + SD; categorical variables are expressed as n (%). DBP diastolic blood pressure; SBP systolic blood pressure. a Chi-square test. b Fishers exact test. c MannWhitney U test. ** p < .01. *** p < .001.

Analysis of Variables Before and After Music Therapy

The frequency and severity of adverse reactions as well as scores on the HSS decreased significantly after three sessions (1 week) of music as therapy (see Table 3). Respiratory rate and finger

temperature also significantly decreased, and oxygen saturation significantly increased. We found no significant differences with respect to heart rate, systolic and diastolic BP (DBP), including the percentage of systolic BP (SBP) below 100 mmHg.

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282
Table 2. Correlations Between Age and the Habit of Listening to Music and Physiological and Hemodialysis-Related Variables (n 88) Variable Frequency of adverse reactions Score Severity of adverse reactions Score Hemodialysis Stressor Scale Score Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Heart rate (beats/min) Respiratory rate (breaths/min) Finger temperature ( C) Oxygen saturation (%) Age .055 .001 .167 .150 .332** .020 .208 .047 .121 Habit of Listening to Music .155 .136 .034 .104 .154 .087 .069 .077 .178

Biological Research for Nursing 14(3)

Listening to Music and Sources of Stress

Our results also show that music therapy can mitigate the effects of stress in HD patients. These results are consistent with the results of Giedts (1999) study, which evaluated the psychoneuroimmunological effects of guided imagery, and Lin et al.s (2007) observations regarding the effects of music therapy on anxiety and stress. We compared participants scores on the HSS measuring the level of stress related to HD in the 12 months prior to the study to their scores after the 2-week study period and noted a significant attenuation of stress. In particular, we observed significant improvement in 9 items on the scale, as described in Results, above, which implies that some stressors may be amenable to treatment with short-term music therapy, while other sources of stress may require a longer period of intervention. Music therapy may create a sense of comfort by gradually eliciting hormonal and physiological changes and indirectly influencing emotional states. Music may also eliminate negative emotions, stimulate motivation, and decrease levels of anxiety and hostility (Beck, 1991; Brown et al., 2004; Cook, 1986; Menon & Levitin, 2005). Since stress may be due to a chronic accumulation of negative feelings, music therapy may help mitigate stress by allowing patients to focus less on their problems or physical discomforts and decreasing their awareness of time; thus helping patients to relax and facilitate effective delivery of treatment during HD.

Note. Spearmans rank correlation coefficient analysis was used to determine correlations. ** p < .01.

Comparison of Change in Variables After Music Therapy Between the Two Groups
The incidence and severity of adverse reactions as well as scores on the HSS significantly decreased after 1 week of music therapy compared to the control group (see Table 4). Subsequent analysis of the 32 items in the HSS showed significant alleviation of stress after music therapy with regard to nine stressors: poor/inadequate A-V fistula function, itching, hypotension, loss of bodily function, limitation of activity, sleep disturbances, coping with family responsibilities, vacation limitations, and frequency of hospitalizations. Respiratory rate decreased significantly and oxygen saturation increased significantly in the experimental group compared to the control group after 1 week of music therapy.

Effects of Music Therapy on Physiological Indicators

Several studies have observed reduced respiratory rates in patients receiving music therapy (Chan, Chan, Mok, & Kwan Tse, 2009; Glynn, 1986; Lai, 2004). Chlan (1998) observed that heart rate, in patients receptive to music, slowed down and synchronized with the tempo of the music. These patients reported a reduced sense of anxiety. Thus, patients listening to music during HD treatment may be more able to relax and, thus, help to reduce rapid respiratory and heart rates. Our results showed significantly increased oxygen saturation in the experimental group. As the sympathetic nervous system becomes less active with relaxation, respiratory and basal metabolic rates decrease and oxygen saturation levels increase (Kemper & Danhauer, 2005; C. C. Wu, 1994). We also observed a significant increase in finger temperature in patients after music therapy (Table 3), which is consistent with results from previous studies (Hwang, Chang, Lee, Ko, & Chu, 1996; Lai, 2004; D. F. Lee & Hwang, 1997). In a state of calm and relaxation, a change in finger temperature is mediated by a reduction in autonomic nervous system activity and reduced muscle tension, which leads to expansion of superficial capillaries and greater blood flow (P. H. Chen, 2003). In a study of the effects of music therapy on 60 patients on HD, Lin et al. (2007) also observed a slight increase in the subjects body temperature. However, the sample size was quite small (effect size 0.68, power < 0.9) and their results were not statistically significant.

Discussion The Effects of Music as Therapy in Reducing the Frequency and Severity of Adverse Reactions During HD
Our results show significantly reduced frequency and severity of adverse reactions after music therapy in the experimental group compared to the control group. Pothoulaki et al. (2008) found that music therapy attenuated the perception of pain in patients undergoing HD. Investigators have also observed improved BP control, reduced respiratory rate, muscle relaxation, and alleviation of nausea and vomiting after music therapy (Beck, 1991; Brown et al., 2004; Cook, 1986; Menon & Levitin, 2005). Thus, music therapy may help improve patient compliance with HD treatment and promote adequacy of dialysis, especially among elderly patients, who are more likely to both experience adverse reactions during HD and to ask to discontinue treatment because of them (Inrig, 2010).

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Lin et al.
Table 3. Mean + SD for Variables Before and After Music Therapy in the Experimental Group (n 44) Variable Frequency of adverse reactions score Severity of adverse reactions score Hemodialysis Stressor Scale Score SBP (mmHg) DBP (mmHg) % SBP < 100mmHg Heart rate (beats/min) Respiratory rate (breaths/min) Finger temperature ( C) Oxygen saturation (%)
Note. Wilcoxons signed ranks test was used for analysis. DBP diastolic blood pressure; SBP systolic blood pressure. ** p < .01. *** p < .001.

283

Before Therapy 2.36 2.45 27.00 134.60 70.05 5.52 71.59 18.52 31.85 98.43 + 2.934 + 3.605 + 17.032 + 18.992 + 9.665 + 11.2 + 15.345 + 1.944 + 1.912 + 1.022

After Therapy 0.59 + 0.55 + 21.11 + 131.83 + 68.78 + 3.25 + 71.51 + 16.08 + 32.38 + 99.27 + 1.263 1.247 15.680 18.229 8.810 8.072 13.458 1.552 1.485 0.685

p .000*** .000*** .000*** .137 .178 .106 .566 .000*** .008** .000***

Table 4. Comparison of Changes in Variables From Premusic to Postmusic Therapy Between the Two Groups (n 88) Variable Frequency of adverse reactions score Severity of adverse reactions score Hemodialysis Stressor Scale Score SBP DBP % SBP < 100 mmHg Heart rate (beats/min) Respiratory rate (breaths/min) Finger temperature ( C) Oxygen saturation (%) Experimental Group (n 44) 1.77 + 1.91 + 5.89 + 2.77 + 1.26 + 2.27 + 0.08 + 2.44 + 0.53 + 0.83 + 2.281 2.675 4.785 12.865 6.212 9.214 7.514 1.435 1.573 0.802 Control Group (n 44) 0.14 + 0.32 + 1.59 + 0.38 + 0.28 + 0.65 + 1.18 + 0.08 + 0.31 + 0.08 + 3.739 2.924 7.212 14.391 5.18 13.413 5.668 1.579 1.32 0.843 p .000*** .000*** .000*** .282 .234 .362 .187 .000*** .280 .000***

Note. Data are described as mean + SD. The MannWhitney U test was used for this analysis. DBP diastolic blood pressure; SBP systolic blood pressure. *** p < .001.

The HD procedure constitutes an extracorporeal circulation, which can often lead to hemodynamic instability in elderly patients. The most common reaction is an activation of the autonomic nervous system, which increases the heart rate and causes peripheral vasoconstriction (M. S. Wu, 2007). During HD, a patient who experiences a 25% decline in BP or greater from previous readings needs immediate intervention to prevent the development of excessive hypotension and more serious complications (Prakash, Garg, Heidenheim, & House, 2004). Thus, though we observed no significant differences in heart rate, SBP, DBP, or the percentage of SBP less than 100 mmHg, we cannot exclude the possibility of effects of music therapy on autonomic nervous system activity.

frequent problem in HD patients (Schubert, Palazzolo, Brum, Ribeiro, & Tan, 1997). Thus, measurement of HRV, which involves a relatively simple and noninvasive method, could be used to monitor physiological changes during music therapy in future studies.

Conclusions
Providing music during HD may be an effective complementary therapy to improve overall patient well-being. Since music therapy alleviates the frequency and severity of adverse reactions associated with HD, improves physiological parameters, and reduces patient stress and anxiety, it may increase patient adherence to therapy and promote adequacy of dialysis. The use of music as therapy during HD may also facilitate patient care by allowing patients to participate in their own health care and help create a more harmonious relationship between patient and caregivers. Though it is not in widespread use among nurses at this time, the provision of music therapy as a clinical treatment tool could provide further avenues for nursing care in the future.

Limitations
We did not assess plasma hormone levels in the present study. Measurement of levels of cortisol or other hormones in blood or saliva as an additional indicator of stress may be a future research goal. Monitoring of heart rate variability (HRV) may also be a reliable method of detecting autonomic dysfunction, which is a

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284 Findings from the current and prior research indicate that HD patients could likely benefit from the clinical use of music therapy. Further research into the benefits of music therapy will likely reveal additional applications and provide an increased understanding of the mechanisms at work. Authors Note
The authors Yen-Ju Lin and Kuo-Cheng Lu contributed equally to this work.

Biological Research for Nursing 14(3)

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Acknowledgments
The authors would like to thank all participants for their assistance in conducting this research. The authors are also grateful for grants from the National Science Council, Taiwan R.O.C. and Cardinal Tien Hospital.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was partly supported by grants from the National Science Council (NSC 97-2314-B-038-017-MY2) and Cardinal Tien Hospital (CTH99-1-2A02).

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