JANJOURNAL OF ADVANCED NURSING REVIEW PAPER Music-assisted relaxation to improve sleep quality: meta-analysis Gerrit de Niet, Bea Tiemens, Bert Lendemeijer & Giel Hutschemaekers Accepted for publication 22 January 2009 Correspondence to G. de Niet: e-mail: [email protected]
Gerrit de Niet MSc RN Psychiatric Nurse and Researcher Gelderse Roos Mental Health Care, Institute for Professionalization, Wolfheze, The Netherlands Bea Tiemens PhD Epidemiologist and Senior Researcher Gelderse Roos Mental Health Care, Institute for Professionalization, Wolfheze, The Netherlands Bert Lendemeijer PhD Senior Researcher Faculty of Health, Medicine and Life Sciences, University of Maastricht, The Netherlands Giel Hutschemaekers PhD Professor Department of Social Sciences, University of Nijmegen, and Director, Gelderse Roos Mental Health Care, Institute for Professionalization, Wolfheze, The Netherlands DE NIET G., TIEMENS B., LENDEMEIJER B. & HUTSCHEMAEKERS G. (2009) Music-assisted relaxation to improve sleep quality: meta-analysis. Journal of Advanced Nursing 65(7), 1356–1364 doi: 10.1111/j.1365-2648.2009.04982.x Abstract Title. Music-assisted relaxation to improve sleep quality: meta-analysis. Aim. This paper is a report of a meta-analysis conducted to evaluate the efficacy of music-assisted relaxation for sleep quality in adults and elders with sleep complaints with or without a co-morbid medical condition. Background. Clinical studies have shown that music can influence treatment outcome in a positive and beneficial way. Music holds the promise of counteracting psychological presleep arousal and thus improving the preconditions for sleep. Data sources. We conducted a search in the Embase (1997 – July 2008), Medline (1950 – July 2008), Cochrane (2000 – July 2008), Psychinfo (1987 – July 2008) and Cinahl (1982 – July 2008) databases for randomized controlled trials reported in English, German, French and Dutch. The outcome measure of interest was sleep quality. Methods. Data were extracted from the included studies using predefined data fields. The researchers independently assessed the quality of the trials using the Delphi list. Only studies with a score of 5 points or higher were included. A pooled analysis was performed based on a fixed effect model. Results. Five randomized controlled trials with six treatment conditions and a total of 170 participants in intervention groups and 138 controls met our inclusion criteria. Music-assisted relaxation had a moderate effect on the sleep quality of patients with sleep complaints (standardized mean difference, 0Æ74; 95% CI: 0Æ96, 0Æ46). Subgroup analysis revealed no statistically significant contribution of accompanying measures. Conclusion. Music-assisted relaxation can be used 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. Keywords: insomnia, meta-analysis, music, relaxation, sleep complaints, systematic review 1356 2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd Design A meta-analysis was conducted using data from five randomized controlled trials. Examples include reviews of psychological and behavioural treatment (Morin et al. (2001) found that nurses working in acute inpatient settings reported music as the most often-used independent therapeutic nursing intervention to enhance sleep. French or Dutch. subjective experience of sleep. Although some researchers report statistically significant influences of sedative music on hormonal levels and the immune system. The growing interest for non-pharmacological interventions has led to reviews evaluating the efficacy of such strategies. We chose sleep quality as the primary outcome measure for the intervention. Medline (1950 – July 2008). and number of arousals. the use of music could be beneficial for people with sleep (onset) problems. Because there is evidence that music has the potential to reduce anxiety. readily available. have been proven to be effective and to have resulted in stable therapeutic changes over time (Morin et al. and completely subject controlled’ (Mornhinweg & Voigner 1995. Lazic and Ogilvie (2006) argued that subjective self-report measures could be subject to bias. such as nurses. 2009 The Authors. It comprises quantitative aspects of sleep. such as sleep duration. the precise mechanism by which music may improve human well-being is still unclear. Sleep quality refers to the multi-dimensionally assessed. 2006b). These interventions are ‘relatively inexpensive. The reason for this choice was primarily practical: sleep quality can be assessed without medical competences. However. Psychinfo (1987 – July 2008) and Cinahl (1982 – July 2008) for studies published in English. However. we could not find a review about the efficacy of music as a sleep-promoting intervention. Journal compilation 2009 Blackwell Publishing Ltd 1357 . 1988) also showed that music was the second most important factor in promoting sleep. most non-pharmacological interventions require a relatively large investment in training. This means that professionals without medical training. Morin et al. bright light therapy (Montgomery & Dennis 2002a) and physical exercise (Montgomery & Dennis 2002b). p 252). self-reports reflect the problem from a patient perspective and are therefore highly valued. (2006) in patients undergoing a C-clamp procedure after percutaneous coronary interventions and Almerud and Peterson (2003) in mechanically-ventilated intensive care patients showed positive and statistically significant changes in physiological variables. Subjective measures (assessed by standardized questionnaires) and objective measures (assessed via polysomnografic recording or wrist actigraphy) are not necessarily concordant. Cochrane (2000 – July 2008). However. sleep latency. German. (2006a) found that more then a quarter of a randomly-selected sample of community-dwelling participants used music to promote their sleep. in particular cognitive behavioural treatment. 2006b). as well as more purely subjective aspects. Moreover. The review Aim The aim of this meta-analysis was to evaluate the efficacy of music-assisted relaxation (MAR) for sleep quality in adults and elders with sleep complaints with or without a co-morbid medical condition. A survey among urban people in Finland (Urponen et al. 1989). Non-pharmacological interventions. The systematic application of music interventions does not involve large investments in training or tools. However. are able to assess it. such as depth or restfulness of sleep (Buijsse et al. music could potentially be beneficial. Studies by Chan et al. Music might be a valuable contribution to the range of non-pharmacological nursing interventions to promote sleep. The clinical and systematic use of music as a (complementary) treatment in various medical conditions has been a subject of study in recent decades.JAN: REVIEW PAPER Introduction Music is one of the most-used self-help strategies to promote sleep. Even in patients with chronic sleep problems. Therefore. it holds the promise for counteracting psychological presleep arousal and thus improving the preconditions for sleep. only one report about the actual use of music as a sleep-promoting nursing intervention was found: GagnerTjellesen et al. A meta-analysis of data from previous research findings might provide or enhance the evidence-base of such an intervention. whose frustration about not being able to fall asleep might be a perpetuating factor. Music-assisted relaxation to improve sleep quality portable. Johnson (2003) has suggested that music can decrease the frustration and dread associated with sleep complaints. Clinical studies show that music can influence human emotions and treatment outcome in a positive way. Search methods We conducted searches in Embase (1997 – July 2008). A review by Evans (2002) showed that music decreases the level of anxiety during normal care delivery. However. for instance.5 Did not meet inclusion criteria . oral or written relaxation instructions. Harmat et al. Synthesis Review Manager 5. Initial search: 236 references Excluded references (N = 210) . such as playing instruments. Studies involving active use of music.2 Lack of control condition Papers included in the meta-analyses (N = 5) Figure 1 Flow diagram of the study selection process. five did not meet the inclusion criteria. demographic data and condition properties were extracted from each included study. Of these ten. 2003. Two reviewers (GN and BT) assessed the studies independently. and for the pooled studies using variance analysis. Data abstraction Search outcome After removing duplicates.0. mp3 player. assessing randomization of allocation.g. Many people experience slow rhythm music. no trial). presentation of estimates and intention-to-treat analysis. titles and abstracts were searched. reference lists from identified studies were examined to find additional studies. We divided these interventions into two groups: (1) those offered without additional measures and (2) those offered with additional measures. Use of this distinction makes it possible to determine the contribution of these additional relaxation-improving measures. therapist. To evaluate two studies (Kullich et al. We included published randomized controlled trials performed in an adult (18– 60 years) or elderly (60 years or older) population with primary sleep complaints or sleep complaints co-morbid with a medical condition. The search terms ‘sleep’ or ‘insomnia’ in combination with ‘music’ or ‘music therapy’ were used. Since continuous data from different scales were extracted.Obviously not suitable for aim Potential relevant screened (N = 27) Excluded papers (N = 17) . this list was reduced to 27 potentially-relevant papers. inclusion criteria. Music in the context of this meta-analysis was considered to be recorded music. Consensus was achieved for all data. Finally. the standardized mean difference (SMD) was calculated for effect size based on sample size (Cohen’s d with Hedges adjustment) and 95% confidence intervals for each study. blinding (assessor.2 Unusable outcome Papers retained for detailed evaluation (N = 10) Excluded papers (N = 5) .10 No trial . studies of people suffering neurological or severe cognitive disorders (such as Parkinson or Alzheimer disease) were excluded. Quality appraisal The methodological quality of each selected study was assessed using the Delphi list for quality assessment of RCTs 1358 Pre. 1998). the authors were contacted for additional information. The main reasons for rejection were non-comparability of data and low methodological quality (lack of control).12 (The Cochrane Collaboration 2008) was used to calculate the effect sizes of the individual studies and for calculation of the pooled mean difference. Selection criteria were prespecified. patient). played by CD/DVD player. Seventeen were rejected as obviously unsuitable (e. After carefully reviewing the titles for relevance. that is. The music must have been intentionally applied for the promotion of sleep quality in a passive way.G.3 Incomparable data . (Verhagen et al. group comparison. as relaxing. Ten remaining studies were read in full. the effect is strongly dependent on personal preferences. blinding of allocation. Only studies with a positive score on 5 or more Delphi items (‡55% of the maximum attainable score) were included.and post-test means and standard deviations. without a heavy beat. Music-assisted relaxation in the selected studies was offered with patient preferred or selected music. This is a 9-item list. or with standardized music that had been intentionally composed to relax or promote sleep. 2008). were excluded. listening to music while resting or relaxing. After the searches were completed. Effect sizes of 0Æ2 2009 The Authors. Keywords. Abstracts from all of these were reviewed for usefulness. Journal compilation 2009 Blackwell Publishing Ltd . tape-recorder or video recorder. our initial broad search produced a list of 236 references (see Figure 1). Added measures are. Music-assisted relaxation comprises therapeutic relaxation improving interventions in which music is the key ingredient. de Niet et al. The audio book intervention comprised use of a CD containing 11 hours of short stories.f. all included studies had explicit inclusion criteria and/or exclusion criteria (i. The music condition in the study by Zimmerman et al. Four studies used the Pittsburgh Sleep Quality Index (PSQI) (Buijsse et al. Publication bias was addressed by inspection of the funnel plot (Begg 1994). psychiatric condition. those of 0Æ5 as moderate and from 0Æ8 as large (Cohen 1988). Music-assisted relaxation to improve sleep quality 1989). are not directly comparable. In all included studies the efficacy of the intervention was measured with a subjective. both compared to the same control condition. In high quality RCTs. various medical conditions). In our case. However. Since the studies did not show considerable methodological diversity. These two treatment conditions are presented separately in Table 2. music and an audio book. d. None of the researchers reported adverse effects. Quality of included studies Results Characteristics of included studies The characteristics of the five studies that met the inclusion criteria are presented in Table 1. With the exception of the study by Harmat et al. Five of the six included conditions led to statistically significant improvement of the ‘total score’ for sleep quality. RCSQ scores were converted by subtracting the real score from the maximum score. The studies included a total of 170 participants in intervention groups and 138 controls.e. = 5. the I-square was 36%. a doubleblind process is used: neither participant nor administer should be aware of whether the participant is in the intervention or control group. The duration of the intervention varied between 20 and 45 minutes per session and the follow-up period varied between two days to three weeks. (2008) comprised two treatment conditions. (1996) approached statistical significance (P = 0Æ06). To detect publication 2009 The Authors. also both compared to the same control condition. piano. Potential statistical heterogeneity between the studies was evaluated with a chi-square test. instrumental new age (synthesizer). Since this condition did not involve music. The Delphi list score was mainly compromised by the requirement for blinding. a pooled analysis was conducted (Figure 2).JAN: REVIEW PAPER are usually interpreted as small. The outcomes of the two different used instruments. (2003) used standardized music that was intentionally composed for sleep promotion for every participant. and orchestra) and vocal soothing music. Three studies involved patients in a hospital setting. there is no evidence or theory making a prominent difference in treatment effect between the various populations plausible. sleep apnoea). Mean participant age was 51 years and mean sample size was 69. a high PSQI value means a lower sleep quality. classical and modern instrumental soothing music (harp. Pooled analysis The clinical diversity of the four studies seems rather large (mixed age groups. P = 0Æ17). it was not included in the pooled analysis. one was performed with community-dwelling elders and one was performed with students. The study by Harmat et al. music and music video. as good ethical practice demands. while a high RCSQ value indicates the opposite. The chi-square for statistical heterogeneity was not statistically significant (v2 = 7Æ84. the PSQI and the RCSQ. P < 0Æ0001). With exception of one study (Hernandez-Ruiz 2005). self-rating scale. we chose the fixed effect model. (1996). A funnel plot is a scatter plot of effect sizes against a measure of study size. Kullich et al. An overall SMD of 0Æ74 (95% CI: 0Æ96 to 0Æ52) was found. Randomization was blinded in all included studies. However. use of hypnotics. the nature of the intervention makes blinding of participants virtually impossible. it is impossible to hide the condition to which they are allocated. Table 2 shows the means and calculated effect sizes of the included studies. Because we assumed that the included studies evaluated a common treatment effect. The Z test for overall effect was statistically significant (Z = 6Æ59. (1996) also had two treatment conditions. All included studies suffered from some methodological flaws. Journal compilation 2009 Blackwell Publishing Ltd 1359 . the music in all included studies was offered with an accompanying relaxation technique or instruction. (2008) and one condition in the study by Zimmerman et al. Types of music used in the four included studies were traditional folk-music (Chinese orchestra). Statistically significant heterogeneity was considered present when the P-value was less than 5%. A value greater than 50% may be considered substantial heterogeneity. when patients are informed about the goal and procedure of the trial. The study by Zimmerman et al. The I-square test represents the between-trial difference that cannot be attributed to chance. the fifth study used the Richards-Campbell Sleep Questionnaire (RCSQ) (Richards 1987). To allow calculation of the effect size and standardized mean difference. The other researchers used patient-preferred music that could be selected from a list. Journal compilation 2009 Blackwell Publishing Ltd . 1996* USA USA Taiwan Austria USA Hungary Country Patient selected soothing music. The two treatment conditions are presented separately. 2003 60 28 Hernandez-Ruiz 2005 Lai & Good 2003 94 Harmat et al. daily 20-minute sessions at bedtime Standardized music. daily 45-minute sessions at bedtime Participant selected music. 1996* 65 Kullich et al. Pittsburgh Sleep Quality Index (Buijsse et al. 2008 Study Total (n) Table 1 Characteristics of included studies Statistically significant improvement of total sleep quality score and four of seven PSQI components Statistically significant improvement of total sleep quality score and five of seven PSQI components Almost statistically significant improvement of sleep quality PSQI RCSQ RCSQ PSQI Statistically significant better sleep quality ratings Statistically significant improvement of total sleep quality score and six of seven PSQI components Statistically significant effect on sleep quality PSQI PSQI Result Measure 5 5 6 5 5 5 Delphi list score G. no specified time Standardized classical music. de Niet et al. 96 Zimmerman et al. Richards-Campbell Sleep Questionnaire (Richards 1987). at least once a day. daily 30-minute sessions in the afternoon or early evening Patient selected sedative music. daily 45 minutes at bedtime Treatment 2 days 2 days Scheduled rest Video with relaxing scenes Hospital (postoperative coronary artery bypass graft patients) Hospital (postoperative coronary artery bypass graft patients) Community (elderly) 3 weeks Scheduled rest Care as usual/no intervention None Relaxation instructions Care as usual Booklet with relaxation text Shelter (abused women) Stationary rehabilitation (low back pain patients) 5 days Silence Progressive muscle relaxation University (students with sleep complaints) Dwelling and population 3 weeks 3 weeks No intervention None Intervention duration Control condition Additional relaxation measure *This study comprised two treatment conditions: music and music video. daily 30-minute sessions in the afternoon or early evening Sedative music video.1360 96 Zimmerman et al. 1989). 2009 The Authors. the funnel plot was inspected and found to be roughly symmetrical.1. However. –0·08] –0·29 [–1·03. Mean Difference IV. a subgroup analysis was performed. 95% Cl –0·97 [–1·51. The two treatment conditions of the study Zimmerman et al.2 MAR with added relaxation measures 16·8% Lai and Good 2003 19·0% Zimmerman 1996 . 0Æ44) 1Æ20. = 1. –0·19] –0·58[–1·08. 1996* 4Æ37 (±2Æ43) 32 Subtotal 61 Music-assisted relaxation with added relaxation measure Hernandez-Ruiz 2005 8Æ29 (±4Æ10) 14 Kullich et al. –0·76] –0·47 [–0·97. 0Æ46) 1Æ08. The test for subgroup differences was not statistically significant (v2 = 0Æ56. Fixed. bias.1. l =36% Test for overall effect: Z = 6·59 (P < 0·00001) Test for subgroup differences: Chi2 = 0·56. Music video condition.m. df = 3 (P = 0·50). The data was converted (see statistical analysis). 2003 8Æ13 (±4Æ02) 33 Lai & Good 2003 10Æ07 (±2Æ75) 30 Zimmerman et al. treatment group Control (n) Music-assisted relaxation without added relaxation measure Harmat et al. 0·46] –0·68 [–0·95. Study or Subgroup Weight Std. 0Æ76) 0Æ47 ( 0Æ97. The data was converted (see statistical analysis).music Subtotal (95%) 16·3% 19·6% 35·9% –1·31 [–1·85. –0·40] 2 2 Heterogeneity: Chi = 2·37.f. df = 1 (P = 0·03). 0·02] –0·85 [ –1·22. –0·49] 2 2 Heterogeneity: Chi = 4·91. To determine the possible contribution of the accompanying relaxation measures. Fixed. The second group comprised four conditions in which music was accompanied by an additional relaxation measure. this outcome must be interpreted with some caution because the statistical 2009 The Authors. For the first group we found a SMD of 0Æ85 (95% CI: 1Æ22 to 0Æ49). l = 80% Test for overall effect: Z = 4·55 (P < 0·00001) Total (95% Cl) 100·0% –0·74 [–0·96. The first group – MAR without added relaxation measures – included two conditions in which music was the sole component.3 MAR without added relaxation measures Harmat 2008 Zimmerman 1996 . Journal compilation 2009 Blackwell Publishing Ltd 1361 . d. 1996 4Æ37 (±2Æ43) 32 Subtotal 109 Total 138 Treatment (n) 3Æ27 (±1Æ80) 3Æ20 (±2Æ45) 7Æ00 5Æ81 7Æ13 2Æ80 30 32 62 (±4Æ56) (±3Æ90) (±3Æ19) (±2Æ02) 14 32 30 32 108 170 Standardized mean difference (95% CI) 1Æ31 ( 1Æ85.JAN: REVIEW PAPER Music-assisted relaxation to improve sleep quality Table 2 Effect of music interventions on sleep quality Post-test measure. 2008 5Æ90 (±2Æ19) 29 Zimmerman et al. P = 0Æ45). 0Æ02) 0Æ29 0Æ58 0Æ97 0Æ69 ( ( ( ( 1Æ03. Mean Difference IV. video 19·6% Kullich 2003 8·7% Hernandez 2005 64·1% Subtotal (95% Cl) Std. l 2 = 0% –1 0 1 2 –2 Favours experimental Favours control Note: MAR = Music-assisted relaxation Figure 2 Forest plot. l = 0% Test for overall effect: Z = 4·83 (P < 0·00001) 1. and for the second group a SMD of 0Æ68 (95% CI: 0Æ95 to 0Æ40) was found. (1996) used the same control group. df = 1 (P = 0·45). control group Study Post-test measure. 0Æ08) 1Æ51. –0·52] 2 2 Heterogeneity: Chi = 7·84. 0Æ19) *Music condition. df = 5 (P = 0·17). –0·44] –0·69 [–1·20. 95% Cl 1. What is already known about this topic • • Music is one of the most-used self-help strategies to promote sleep. Since no adverse effects are reported. a regression analysis revealed that follow-up length was not a statistically significant predictor of effect size. by Irwin et al. (2003). this is not a very reliable test. The question might arise whether pooling the data was appropriate. The studies by Kullich et al.G. The clinical diversity of the included studies was large. Music is already one of the most commonly-used self-help strategies to promote sleep. heterogeneity for the first group was statistically significant (v2 = 4Æ91. What this paper adds • • Music-assisted relaxation has a moderate effect on the sleep quality of patients with sleep complaints.f. The most important was the lack of doubleblinding. Regrettably. = 1. included a metaanalysis to evaluate the efficacy of behavioural interventions for insomnia among middle aged and older adults. As poor perceived sleep quality can have different causes (for instance physical. by Nowell et al. the findings are very consistent. The number of included studies and the sample sizes in these studies were 1362 Conclusion The results of this review. they both used randomized controlled trials and sleep quality as outcome measures. followup length might be an important factor.e. To evaluate the clinical relevance. neurological. none of the studies we included gave followup data to evaluate long-term effectiveness. = 1. P = 0Æ15). they found a standardized mean difference of 0Æ62 (95% CI: 0Æ45–0Æ79) for sleep quality. The main limitation of this review was a general limitation of all reviews: it is liable to publication bias.f. based on five relatively small studies. Implications for practice and/or policy • • Music-assisted relaxation can be used without intensive investment in training and materials and is therefore cheap and easily available. Based on five studies. both included studies that enrolled participants with a diagnosis of primary insomnia. However. It also gave an indication that the contribution of added relaxation-improving measures such as oral or written instructions to the improvement of sleep quality is limited. (2006). Weaknesses and strengths The included studies all suffered from some methodological weaknesses. Inspection of the funnel plot showed rough symmetry. The second. This could mean that the effect of the intervention is independent of the patient’s condition and thus that the generalizability of the findings is potentially large. de Niet et al. this is not a conclusive statement. as stated previously. Lai and Good (2003) and Harmat et al. the nature of this intervention makes blinding virtually impossible. d. we compared this result with the results of two other meta-analyses. The first. (2008) showed a cumulative dose effect and reached no ‘plateau’ after three weeks. For the outcome sleep quality. psychological or hormonal) and some sleep problems are unlikely to be influenced by music-assisted relaxation (i. The result was not statistically significant (F = 3Æ13. At first glance our data suggest that studies with a short implementation resulted in lower effect sizes than those with longer implementation periods. Another limitation of the included studies was the lack of a good definition of the sleep problem. However. Journal compilation 2009 Blackwell Publishing Ltd . and as only six conditions were included. However. this is only a rough indication of the absence of publication bias. Like our metaanalysis. We explored the influence of follow-up length on the effect size by performing a regression analysis with effect size as the dependent variable and follow-up length as the independent variable. However. show that music-assisted relaxation is an effective aid for improving sleep quality in patients with various conditions. evaluated the efficacy of benzodiazepines and zolpidem in adult patients (18–65 years). However. d. (1997). Discussion small. P = 0Æ03). restless legs of sleep apnoea). seven studies were included. However. Music-assisted relaxation offers statistically significant benefits for sleep quality without side effects in patients with various conditions. Clinical studies show that music can influence human emotions and treatment outcomes in a positive way. We found scientific support for the effectiveness of the systematic use of music-assisted relaxation to promote sleep quality. Since no adverse effects 2009 The Authors. Since the amount of included studies was small. 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