Assessment of quality of scientific evidence on musical interventions in caring for cancer patients

Abstracts

This integrative review aimed to assess the quality of scientific evidence on musical interventions in caring for cancer patients. The search strategy was conducted in July 2013, using descriptors indexed in the Bireme, Cochrane Library, Medline, Embase, Web of Science, CINAHL and Scopus databases. We selected four randomized clinical trials (two of high and two of low methodological quality) and two systematic reviews (both of high methodological quality). The greatest limitations of the clinical trials were in the descriptions of the resources and musical structures used; and of the systematic reviews, in their focus on the methodological designs. Most of the studies had high methodological quality, but the resources and musical structures used were neither described nor discussed, thereby trivializing the therapeutic potential of music and limiting replication of the studies and incorporation of evidence into clinical practice.

Medical oncology; Oncologic nursing; Neoplasms; Music; Music therapy

Esta revisão integrativa pretendeu avaliar a qualidade de evidências científicas sobre intervenções musicais na assistência a pacientes com câncer, utilizando descritores indexados nas bases de dados: Bireme, The Cochrane Library, Medline, Embase, Web of Science, CINAHL e Scopus. Foram selecionados quatro ensaios clínicos randomizados (dois de alta e dois de baixa qualidade metodológica) e duas revisões sistemáticas (ambas de alta qualidade metodológica). As maiores limitações dos ensaios clínicos estão na descrição dos recursos e estruturas musicais utilizadas e das revisões sistemáticas, no foco nos delineamentos metodológicos, em detrimento da qualidade dos relatórios das intervenções musicais. Na maioria dos estudos foi apresentada alta qualidade metodológica, mas não foram descritos e tampouco discutidos os recursos e as estruturas musicais utilizados, banalizando o potencial terapêutico da música e limitando sua replicação e incorporação das evidências na prática clínica.

Oncologia; Enfermagem oncológica; Neoplasias; Música; Musicoterapia

Revisión de integración cuyo objetivo fue evaluar la cantidad de evidencias científicas sobre intervenciones musicales en la asistencia a pacientes con cáncer y que fue realizada en julio de 2013, con descriptores indexados en las bases de datos: Bireme, The Cochrane Library, Medline, Embase, Web of Science, CINAHL y Scopus. Se seleccionaron cuatro ensayos clínicos randomizados (dos de alta y dos de baja calidad metodológica). Las mayores limitaciones de los ensayos clínicos están en la descripción de los recursos y estructuras musicales utilizadas y de las revisiones sistemáticas, en el enfoque de las delineaciones metodológicas, en perjuicio de la calidad de los informes de las intervenciones musicales. En la mayoría de los estudios se presentó alta calidad metodológica, pero no se describió, tampoco se discutieron los recursos y estructuras musicales utilizados, trivializando el potencial terapéutico de la música y limitando su replicación e incorporación de las evidencias en la práctica clínica.

Oncología; Enfermería oncológica; Neoplasias; Música; Musicoterapia

Introduction

Given the multidimensional complexity that permeates cancer diagnosis, treatment and prognosis, many initiatives structured around a variety of theoretical-philosophical reference points such as complementary holistic therapies, palliative care, anthroposophy and music therapy have used music as a care resource for cancer patients.

The constant contribution of nursing towards comprehension of the mechanisms that music uses when it triggers physiological reactions in human beings, along with its indications and limitations, can be emphasized¹. Within this perspective, musical interventions “presuppose an intricate network of sensations, emotions, feelings and symbolic and cultural meanings”, which are intrinsic to each human being and capable of resonating and producing various therapeutic effects² such as pain, stress and anxiety reduction, promotion of comfort, muscle relaxation and dignity among hospitalized people, and retrieval of institutionalized elderly individuals’ reminiscences and identity, among other effects¹.

Regarding emotions, six psychological mechanisms for decoding information that induce emotions through listening to music are proposed: brain reflexes (interpretation of auditory perceptions through consonant and dissonant frequencies that determine sensations of pleasure or displeasure and excitement or relaxation); evaluative conditioning (repetitive pairing of music with other stimuli); emotional contagion (influenced by the emotional expressivity of the composition); visual imagination (interaction between music and mental images evoked while listening to music); episodic memory (evocation of affective memories linked to important moments of life); musical expectation (violation – unexpected or expected – of an essential specific characteristic of the music, linked to past experiences with the musical genre in question)³.

The importance of musical experiences for oncological or palliative care patients, or for those who experienced significant existential anguish and suffering, can be highlighted². Regarding palliative care, which is an interdisciplinary care philosophy that aims towards quality of life and prevention and relief of suffering among patients and their families who live with life-threatening diseases, a bibliographic review study concluded that, when used competently and sensitively, music converges with its philosophical assumptions, given that it acts therapeutically on all human dimensions, especially through promoting an atmosphere which supports emotional and affective expression⁴.

In this context, encounters mediated by music constitute a resource within nursing care that inspires life during patients’ days, imprinting in them the sensation of care and giving new meaning to their existence in the world with cancer. Music can support the sharing of experiences, expectations and coping strategies, i.e. being with other people in their existential fatefulness⁵.

Despite this, experimental studies that have built the “state of the art” regarding musical interventions seem to have ignored the complexity of the musical stimuli that exist, as well as the mechanisms through which they induce therapeutic effects in human beings, when describing their interventions. In this light, the present study had the objective of evaluating the quality of the scientific evidence on musical interventions for caring for cancer patients as well as the quality of reports regarding resources and musical structures used.

Methods

The present work was an integrative review of the literature conducted in July 2013, structured into six stages: 1) identification of the topic and elaboration of the research question; 2) definition of the inclusion and exclusion criteria; 3) categorization of the selected studies; 4) evaluation of the studies included in the review; 5) interpretation of the results; and 6) summarized presentation of the knowledge⁶. The research question was: what are the therapeutic effects of music on the human dimensions in caring for cancer patients?

The inclusion criteria were that the studies should be randomized clinical trials and systematic reviews on musical interventions in caring for adult cancer patients, without restrictions on language or time of publication. The exclusion criteria were: musical interventions among children, adolescents or caregivers; interventions performed during clinical treatments (chemotherapy, radiotherapy or brachytherapy) or surgical, invasive and/or diagnostic procedures (biopsy, mammography or colonoscopy), since these would involving psycho-emotional issues (fear or anxiety) relating to the treatments and procedures and not to the disease itself.

The search strategy ("oncology" [MeSH Terms] OR "oncologic nursing" [MeSH Terms] OR "medical oncology" [MeSH Terms] OR "neoplasm" [MeSH Terms] OR "neoplasms" [MeSH Terms] OR "cancer" [MeSH Terms] AND "music" [MeSH Terms] OR "music therapy" [MeSH Terms]) resulted in  228 studies  in the following databases: Bireme (1), The Cochrane Library (3), Medline (35), Embase (21), Web of Science (57), CINAHL (6) and Scopus (105).

However, only six studies were selected through reading their titles and abstracts and, subsequently, complete reading guided by the inclusion criteria. The following were excluded: 89 duplicated studies, 63 studies that encompassed  other topics (geriatrics, palliative care and alternative and complementary practices), 20 studies on children, adolescents or caregivers, 12 studies performed during clinical treatments, 10 studies performed during surgical treatments, 10 studies performed during invasive and/or diagnostic procedures, 11 studies that used other methodologies, six studies without abstracts available and one study that was not found to be complete.

In addition to the data commonly gathered in review studies (reference point for the study, country, language, methodological design and outcome), the researchers used the guidelines for musical intervention reports proposed by Robb et al.⁷. The randomized clinical trials underwent the methodological quality analysis proposed by Jadad et al.⁸. This scale consists of five criteria and ranges from 0 to 5 points, in which scores lower than 3 indicate that the study has low methodological quality and that it would be difficult to extrapolate its results to other scenarios⁹.

The systematic reviews underwent the AMSTAR¹⁰ quality assessment and were classified in accordance with the classification system used by the Canadian Agency for Drugs and Technologies in Health (CADTH). The scores in this system, which range from 0 to 11, correspond to high (9-11), medium (5-8) or low (0-4) quality¹¹. The descriptions of the musical interventions were evaluated based on the abovementioned guidelines.

Results

Out of the six studies selected, four (S1, S3, S5 and S6) were randomized clinical trials (RCTs) and two (S2 and S4) were systematic reviews. Regarding the musical intervention, three RCTs (S1, S5 and S6) were conducted in the United States by music therapists  and one (S3) was performed in Taiwan, by nurses. The systematic reviews encompassed interventions performed both by music therapists and by healthcare professionals and were developed by American researchers, one (S2) in a partnership with Chinese researchers. The methodological designs of the studies are presented in Box 1.

Box 1
Characteristics of the studies according to country, year of publication, methodological design and outcome. Brazil, 2013.

According to the methodological quality analysis proposed by Jadad et al.8, although two RCTs (S1 and S3) were not described as double-blind studies, they presented high quality. On the other hand, the others (S5 and S6) were considered to be low-quality studies because they did not describe the randomization sequence properly, as observed in Table 1.

Table 1
Evaluation of the quality of reports on randomized clinical trials, according to Jadad et al.⁸. Brazil, 2013.

Items	Studies selected
	S1	S3	S5	S6
Was the study described as randomized?	Yes	Yes	Yes	Yes
Was the study described as double-blind?	No	No	No	No
Was there a description of exclusions and losses?	Yes	Yes	No	No
Was the method to generate the randomization sequence described and appropriate?	Yes	Yes	No	No
Was the double-blind method described and appropriate?	No	No	No	No
Points	3	3	1	1

Based on the AMSTAR¹⁰ quality evaluation and in conformity with the classification system used by CADTH¹¹, studies S2 and S4 obtained scores of 10 and 11 respectively and therefore presented high quality, although S2 did not provide a list of studies excluded (Table 2).

Table 2
Evaluation of the methodological quality of systematic reviews, according to Shea et al.10. Brazil, 2013.

Items	Studies selected
	S2	S4
1. Was a project provided “a priori”?	Yes	Yes
2. Was there duplication in the selection of studies and data extraction?	Yes	Yes
3. Was a comprehensive bibliographic investigation/search performed?	Yes	Yes
4. Was the publication status (in other words, gray literature) used as an inclusion criterion?	Yes	Yes
5. Was a list of studies (included and excluded) provided?	No	Yes
6. Were the characteristics of the included studies provided?	Yes	Yes
7. Was the scientific quality of the included studies evaluated and documented?	Yes	Yes
8. Was the scientific quality of the included studies used properly in formulating the conclusions?	Yes	Yes
9. Were the methods used to match the results from the studies appropriate?	Yes	Yes
10. Was the likelihood of publication bias evaluated?	Yes	Yes
11. Were conflicts of interest informed?	Yes	Yes
Quality	10	11

Regarding the evaluation of the quality of the musical intervention reports of the RCTs, conducted using the checklist proposed by Robb et al.⁷ (Box 2), deficient description of the musical resources and structures used can be seen. Apart from the song Amazing Grace, which was superficially mentioned, the study S1 neither described the other songs used nor their overall structure. The study S3 only referred to the musical styles used, and did not describe the sound resources and structures used. Although the study S5 reported the album used in the intervention, it mentions that other complementary classical selections were used, but does not describe them. In the study E6, the researcher does not describe the songs and material used, or the duration of the music therapy sessions.

Box 2
Methodological description of musical interventions relating to the RCTs, in accordance with the checklist proposed by Robb et al.7. Brazil, 2013.

Regarding the systematic reviews, it was seen that the researchers focused their evaluations on the methodological quality of the studies. However, the descriptions of the musical interventions were limited, insufficient, diversified and inconclusive, thus hampering comparative analysis. The studies S2 and S4 indicated that there is a need to develop new investigations with detailed descriptions of the musical stimuli used. The study S4 suggested that the relationship between frequency and duration of the sessions and the effects of the treatment should be evaluated.

Discussion

The first point that drew our attention was the small number of clinical trials and systematic reviews relating to human dimensions of oncological patients, thus showing that the reasoning of procedures and management of complications from the disease is still the tonic in our environment.

We recognize the emphasis given to the hierarchical model, which assigns levels of evidence according to the methodology used in various studies. Exactly because they are so valued, it is crucial that when healthcare professionals read a clinical trial, they should be able to evaluate its quality and understand its limitations. The idea induced is that if, when caring for patients, a professional does not behave in accordance with what was “demonstrated” in one clinical trial or another, or in systematic reviews and meta-analyses, he will be out-of-date regarding his knowledge and will be instituting care “without scientific evidence”. Clinical trials are a useful tool for clinical practice, but cannot be used simplistically and en-masse. They should be regarded as a source of evidence for guiding decision-making, but cannot be used as if they were unquestionable dogma¹⁸.

On the other hand, although good clinical studies conducted by researchers have led to advances in science, methodological rigor is still needed even when more integrative healthcare resources are used. In this regard, essential aspects of musical interventions have been neglected.

There is no doubt that musical interventions within the field of healthcare field have shown the therapeutic effects of music, irrespective of which professionals have implemented them. However, the great challenge of reflecting on why this happens and how music acts to produce these effects on human beings² has been little questioned, investigated or discussed. 

This task becomes particularly hard in the light of the way in which the methodological description of musical interventions has been presented. Because of the complexity of musical stimuli and other intervening factors such as the choice of music, means of delivery or combination of music with other intervention strategies, the methodological descriptions of various musical interventions have been insufficient to allow generalizations, comparisons, replications and execution⁷. Like in the systematic reviews (S2 and S4) evaluated here, the present study also showed that the descriptions of the musical interventions of the clinical trials evaluated present limitations.

This reflection relates to the four basic principles that govern the use of music in nursing care, which are consequent to its universal characteristics. The ontological principle refers to experiences of sound and music and to the essence of human beings as musical beings. The physical principle translates the way that human beings perceive and are affected by music, i.e. how sound and musical stimuli that are conducted through the auditory nerve to the cortex produce physiological, mental and emotional sensory responses¹. 

The musical principle is shown through the musical elements inherent to the intervention. Some of these are coupled to the physical dimension, such as the rhythm, while others are coupled to emotions, such as the melody. The social dimension is taken into account through the historical-cultural context in which the music originated, which enables the sensation of belonging to a group, a place, a history and a time. In the spiritual dimension, which has been little understood and investigated, the musical elements converge to articulate all human dimensions, thus enabling profound contact with human beings’ own essence, the universe, God, or any other conception of spirituality¹.

The relational principle translates the interpersonal relationship mediated by music: a phenomenon created by human beings. As a care resource, music emerges from the intentionality of care, through facilitating the encounter between the caregiver and the care receiver, and providing support for expressions of affection, compassion and solidarity, through the gestures, looks, smiles and smooth touches inherent to producing music¹.

However, the instrument that evaluated the quality of the reports on musical interventions⁷ showed how deficient the description of the resources used is, especially with regard to those of the musical structures involved (i.e. musical principles): tone, mode (major or minor), rhythm (two, three or four beats to the bar, and so on), tempo (bpm), genre (European classical, popular, religious, etc) and timbre (instrumental and/or vocal grouping). The use of various music therapy techniques, in different contexts, can also hamper control over the underlying variables and consequently interfere in the evaluation of the therapeutic effects of the music.

The systematic reviews also focused on evaluating the methodological designs, to the detriment of evaluating the quality of the reports regarding the sound resources and musical structures used. Taking evidence-based practice into consideration, the following question arises: regarding the properties of the music, what was shown? Thus, its limitations are displayed and the validity/reliability of the evidence and inferences published can be questioned, along with its replication and incorporation in the clinical practice.

On the other hand, there are many reports that have highlighted the therapeutic effects of music, such as:

Music managed to make three gigantic contributions to my rescue: the first was as a powerful anesthetic. A buffer for pain and suffering. Going from my mother’s lullaby songs and the games of improvised singing, to ‘the challenge’ of my father, the hit parades of portable transistor radios and a permanent companion in hospitals. Music represented the beginning of a train of thought for hope.¹⁹ (p.7)

These effects relate to people’s experiences of long treatments and long hospital stays, through their recognition of music as a natural “anesthetic” that held their hopes during hard times, with a physical principle. Every case study or experience is unique and has unquestionable value. These reports describe individual strategies in which the elements proposed for analyzing musical interventions may even be described, but are not usually the focus of the description and have a very limited "n". In this regard, musicians with links to teaching and the use of music within the field of healthcare recognize the difficulty of indicating a specific song because both the instrument and the musician interfere with the result.

Singing therapy is an intervention with an anthroposophical approach and, although it is structured from the patient’s musical history, it is attentive to musical structures, i.e. melodies that alternate between major and minor modes; songs constructed on pentatonic scales; or liturgical modes such as the Gregorian singing or canons. Regarding children, it is adapted to their stages of affective/cognitive development. It also retrieves the professional/patient relationship – the relational principle – as the most important aspect to be considered²⁰. The unity of each relationship comprises an extra “ingredient” in the analysis of the final results.

It is important to highlight a study on music therapy interventions that was conducted with the aim of contributing towards the reception in the waiting room of a primary healthcare unit, where users can interact by suggesting songs, singing, composing or playing a musical instrument, as well as through body movements and emotional expressiveness. The results showed the appreciation and integration of professionals and users, expression of feelings, harmonization of the soundscape, users’ autonomy, protagonist role and self-assurance, and also discovery of new potentials and overcoming of limits, thereby bringing the benefits established through hospital humanization to primary care²¹. Although the distinction and articulation of the abovementioned four basic principles aforementioned can be seen, the importance of qualified listening and the feeling of belonging inherent to the intervention is paramount, i.e. meeting with other people, through the relational principle.

Despite this, the feelings and emotions expressed through music, through the ontological principle, constitute an enigma that, by itself, is susceptible to risks and ambiguities. The secret of success or failure of the musical project may be hidden in knowing how to deal with equivocation of the component structures. This vulnerability may be presented at several levels. According to the musicologist Carl Dahlhaus, the expression of feelings is genuinely more related to musical interpretation than to composition²².In discussing sound language, the responsibility that healthcare professionals should have when proposing to use a sound resource or “compound sound” with therapeutic purposes should be emphasized, because inadequate use of music can lead to undesired effects²³.

The polysemic nature of music is responsible for the difficulty that we found in explaining it and using it in a desirable manner for different clinical situations or when we thought about the human dimensions that we wanted to address.

Although the musical experience is individual, which often favors using an individualized musical set list, neuroscience studies have indicated that the brain’s processing of music is more physiological than what is determined by individual preferences.

The elements that comprise the music, whatever the pitch (different intonation of notes from bass to treble), the duration (time interval over which the sound lasts), the intensity (the same as volume) and the timbre (characteristic that qualifies and differs the sounds), are processed by the human brain. This means that musical preference can determine specific behavior (individual or even collective, and it is learned), but it does not necessarily have an intrinsic relationship with the psychological-physiological effects that are observed and reported in the literature. Before the current idea that music can be a therapeutic resource, evolutive issues originally existed (which therefore had nothing to do with preferences).

 The perceptual basis of music derives from auditory mechanisms. Their syntactic components may have been co-opted from the language and its effects on our emotions might have been triggered by acoustic similarity with other sounds of greater biological relevance, such as vocalizations or animal sounds. Thus, it would be an evolutionary history of the language, directed towards social cohesion (as in group activities relating to war or religion) or even through its pacifying effect on babies²⁴. On the other hand, the harmonic structures and tone scales depend on learning, which leads to the existence of cultural differences in the musical universes of different populations. However, when related to emotions, as the main path of human response to music, they are not enough to block its effects.

Studies increasingly indicate that the human response is intrinsically connected to the sound material offered. A study conducted on a native African population that did not know the western music system, presented similar results regarding the recognition of basic emotions (happiness or sadness, for example), in comparison with the ability of Western listeners who were familiar with this tonal system, in this same task²⁵. This, once again, emphasizes that mastery of music and its constituents is needed by professionals who aim to make it a therapeutic resource, as well as the need for detailed descriptions of the musical interventions used in scientific studies.

Musical experience is therefore founded on a trio: the listener, the sound material and the context. Thus, it is important for therapists who conduct such interventions to create the context needed for using sound material that best applies to the therapeutic objectives, which are determined jointly with their patients².

Conclusion

Because of the complexity and multi-dimensionality inherent to caring for cancer patients, many studies on musical interventions have been developed. However, these have often focused on the adverse effects of anti-neoplastic treatments and diagnostic procedures and have not addressed the human dimensions of those who experience diseases (in this case, oncological conditions). This explains the small sample of the present study. The absence of randomized clinical trials and systematic reviews within this context, conducted in Brazil, can be highlighted.

According to the evaluation instruments used, four studies presented high methodological quality and, although the majority of the items of the checklist for intervention reports were referenced, the resources and musical structures (which place value on the therapeutic potential) were not described, nor were they analyzed and discussed. This shows the complexity of the “music” strategy as a therapeutic resource.

A tendency not to describe the resources and musical structures used in musical interventions was observed, even after the publication of the guidelines that were used for analyses in this study. Without mastery of pharmacokinetics and pharmacodynamics, healthcare professionals would not prescribe or administer a drug. However, this kind of care has not been implemented regarding musical interventions. Within this perspective, in order to systematize the use of music as a care resource, through evidence-based practice, and to avoid its trivialization, it is essential to draw up projects and reports for future research on musical interventions using these guidelines.

Referências

• ¹
  Leão ER, Puggina AC, Gatti MFZ, Almeida AP, Silva MJP. Música e Enfermagem: um recurso integrativo. In: Salles LF, Silva MJP, organizadores. Enfermagem e as práticas complementares em saúde. São Caetano do Sul: Yendis; 2011. p. 155-74.
• ²
  Leão ER, organizador. Cuidar de pessoas e música: uma visão multiprofissional. São Paulo: Yendis; 2009. p. 347-68.
• ³
  Juslin PN, Västfjall D. Emotional responses to music: the need to consider underlying mechanisms. Behav Brain Sci. 2008; 31(5):559-621.
• ⁴
  Seki NH, Galheigo SM. O uso da música nos cuidados paliativos: humanizando o cuidado e facilitando o adeus. Interface (Botucatu). [Internet] 2010 [acesso 2014 Mai 8]; 14(33):273-84. Disponível em: http://www.scielo.br/pdf/icse/v14n33/a04v14n33.pdf
  » http://www.scielo.br/pdf/icse/v14n33/a04v14n33.pdf
• ⁵
  Silva VA, Sales CA. Musical meetings as a resource in oncologic palliative care for users of a support homes. Rev Esc Enferm USP. [Internet] 2013 [acesso 2014 Abr 17]; 47(3):626-33. Disponível em: http://www.scielo.br/pdf/reeusp/v47n3/en_0080-6234-reeusp-47-3-00626.pdf
  » http://www.scielo.br/pdf/reeusp/v47n3/en_0080-6234-reeusp-47-3-00626.pdf
• ⁶
  Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. [Internet] 2008 [acesso 2014 Abr 17]; 17(4):758-64. Disponível em: http://www.scielo.br/pdf/tce/v17n4/18.pdf
  » http://www.scielo.br/pdf/tce/v17n4/18.pdf
• ⁷
  Robb SL, Burns DS, Carpenter JS. Reporting guidelines for music-based interventions. Health Psychol. 2001; 16(2):342-52.
• ⁸
  Jadad AR, Moore RA, Carrol D, Jenkinson C, Reynolds DJM, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996; 17(1):1-12.
• ⁹
  Carvalho FD, Artuzo FSC, Chrysostomo TN, Andrade RC. Influência do seguimento farmacoterapêutico sobre o tratamento medicamentoso de diabetes mellitus tipo 2 no Brasil: revisão sistemática. Rev Bras Farm Hosp Serv Saude. 2011; 2(2):5-10.
• ¹⁰
  Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007; 7:10.
• ¹¹
  Canadian Agency for Drugs and Technologies in Health – CADTH [Internet]. Canadian Agency for Drugs and Technologies and Health, 2011. [updated 2014; cited 2014 Mai 8]. Available from: http://www.cadth.ca/en
  » http://www.cadth.ca/en
• ¹²
  Cook EL, Silverman MJ. Effects of music therapy on spirituality with patients on a medical oncology/hematology unit: a mixed-methods approach. Arts Psychother. 2013; 40(2):239-44.
• ¹³
  Zhang JM, Wang P, Yao J, Zhao L, Davis MP, Walsh D, et al. Music interventions for psychological and physical outcomes in cancer: a systematic review and meta-analysis. Support Care Cancer. 2012; 20(12):3043-53.
• ¹⁴
  Huang ST, Good M, Zauszniewski JA. The effectiveness of music in relieving pain in cancer patients: a randomized controlled trial. Int J Nurs Stud. 2010; 47(11):1354-62.
• ¹⁵
  Bradt J, Dileo C, Grocke D, Magill L. Music interventions for improving psychological and physical outcomes in cancer patients. Cochrane Database Syst Rev. 2011; (8):CD006911.
• ¹⁶
  Burns DS. The effect of the Bonny Method of guided imagery and music on the mood and life quality of cancer patients. J Music Ther. 2001; 38(1):51-65.
• ¹⁷
  Hilliard RE. The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer. J Music Ther. 2003; 40(2):113-37.
• ¹⁸
  Tura BR, Silva NAS, Pereira BB. Avaliação crítica e limitação dos ensaios clínicos. Rev SOCERJ [Internet] 2003 [acesso 2014 Abr 17]; 16(2):110-23. Disponível em: http://sociedades.cardiol.br/socerj/revista/2003_02/a2003_v16_n02_art03.pdf
  » http://sociedades.cardiol.br/socerj/revista/2003_02/a2003_v16_n02_art03.pdf
• ¹⁹
  Tejon JL. Música, a esperança sem dor. In: Leão ER, organizador. Cuidar de pessoas e música: uma visão multiprofissional. São Paulo: Yendis; 2009. p. 1-9.
• ²⁰
  Rennó A. Cantoterapia. In: Leão ER, organizador. Cuidar de pessoas e música: uma visão multiprofissional. São Paulo: Yendis; 2009. p. 209-21.
• ²¹
  Pimentel AF, Barbosa RM, Chagas M. A musicoterapia na sala de espera de uma unidade básica de saúde: assistência, autonomia e protagonismo. Interface (Botucatu). [Internet] 2011 [acesso 2014 Mai 8]; 15(38):741-54. Disponível em: http://www.scielo.br/pdf/icse/v15n38/10.pdf
  » http://www.scielo.br/pdf/icse/v15n38/10.pdf
• ²²
  Molina S. Música e emoção estética. In: Leão ER, organizador. Cuidar de pessoas e música: uma visão multiprofissional. São Paulo: Yendis; 2009. p. 51-65.
• ²³
  Luz MC, Davino GE. Música, sedução e comunicação. In: Leão ER, organizador. Cuidar de pessoas e música: uma visão multiprofissional. São Paulo: Yendis; 2009. p. 67-93.
• ²⁴
  McDermott J. The evolution of music. Nature. 2008; 453(7193):287-8.
• ²⁵
  Fritz T, Jentscheke S, Gosselin N, Sammler D, Peretz I, Turner R, et al. Universal recognition of three basic emotions in music. Curr Biol. 2009; 19(7):573-6.

Publication Dates

• Publication in this collection
  01 Aug 2014
• Date of issue
  Jul-Sep 2014

History

• Received
  30 Oct 2013
• Accepted
  23 Feb 2014