J William M Tweedie
Well-Known Member
Introduction
For centuries, the harmonious melodies of music have made people spring to their feet and dance along to its tune,[1] but could music be used to make even those with aching joints and bones move along to its beat too? This article takes us through the journey of available evidence for how music could be beneficial to rheumatology patients and how it can be utilized daily.
In the past, the concept of using music as a form of treatment in rheumatology was somewhat controversial. During antiquity, music was thought to be a tool that could balance the 4 humors of the body, equating to good health; however, the use of this philosophy for rheumatologic conditions found little acceptance.[2] In the Middle Ages, music therapy gained some support, but this was short-lived.[2] Recently, music therapy within rheumatology has started to receive an increasing number of advocates. Researchers, equipped with more knowledge of the subject and more advanced technology, have turned their attention toward this, and the evidence found toward music as a valid form of adjunct therapy for rheumatologic conditions is surprising.
Objective
The objective of this study was to review all published studies relating to music therapy in specific rheumatologic conditions, notably osteoarthritis, fibromyalgia, rheumatoid arthritis, and systemic lupus erythematous.
Methods
To identify relevant studies that were structured around the PICO process (patient/intervention/comparison/outcome),[3] a free-text search on PubMed and Ovid databases using the terms ("music") AND ("name of pathology") was undertaken. The pathologies included osteoarthritis, fibromyalgia, lupus, and rheumatoid arthritis. To identify articles that were more focused on our topic, we searched for articles that contained the subheadings or "tags" of ("music") AND ("name of pathology"). We included only articles with full text in English language and published in peer-reviewed journals prior to April 17, 2015. All records and their references were reviewed by 2 independent investigators. Importantly, we considered only articles where the experimental intervention consisted predominately of music and the outcome affected pain or perception of pain, mood, or mobility relating to 1 of the rheumatologic pathologies stated earlier. A total of 72 records resulted from the search, and 6 met the inclusion criteria. The selected studies related to osteoarthritis (3/6) and fibromyalgia (3/6). In most of the articles, trained music therapists carried out the experimental interventions, and a summary of all the studies is provided in the Table 1. The methodological quality of the studies was also assessed using a Jadad Oxford Quality scoring system;[4] however, given the low number of studies identified, this was used only for information, and we did not exclude a study on the basis of the score. This scoring is usually based on 7 criteria that evaluate the random allocation, double blinding of interventions, and flow of participants. However, because of the nature of music therapy, it is impossible to double-blind an experiment using music as its intervention. Subsequently, it is not possible for any studies involving music therapy to achieve all points on the traditional Jadad scoring system, and therefore, we used a modified Jadad score with a maximum scoring point of 3 accounting for with the results shown in the
Table 1. Demonstrating the Characteristics of Identified Studies Involving Music With Osteoarthritis and Fibromyalgia (Uploaded file)
Results and Discussion
Osteoarthritis is the most prevalent chronic joint disease with the aging population and obesity epidemic contributing to its rapidly rising incidence.[5] The disease is often diagnosed too late to expect much help from disease-modifying osteoarthritis drugs; therefore, any nonpharmacological approaches such as music therapy would be of particular clinical interest.[5] The predominant symptom of osteoarthritis is chronic pain and is usually the reason behind patients seeking medical help.[6] A well-designed study investigating the effect of music on pain randomly assigned 66 patients with osteoarthritis to an experimental or control group.[7] Participants in the experimental group listened to classical music by Mozart for 20 minutes daily for 16 days, whereas the control group listened to 20 minutes of silence. Any change in pain perception was recorded using the McGill Pain Questionnaire, which has been validated by Graham et al[8] to have a high reliability and consistency. This study illustrated that patients who listened to 20 minutes of relaxing music a day perceived a 52% decrease in pain on the pain rating index compared with the control group in pain perception, which could lead onto increased mobility and quality of life.[7] A possible explanation for the beneficial effect of music was postulated in that it induced a state of relaxation and distracted the patient from focusing on the pain, leading to a reduction of muscle tension surrounding the injured area. The positive aspects of the study's methodology were that the patient's age, sex, and particularly the duration of time that patients had been experiencing osteoarthritic pain were taken into account. In addition, it was appropriately randomized with sufficient patient numbers from both sexes both in the treatment and control arms. However, the study failed to record the patients' use of pain relief including regular and as-required nonsteroidal anti-inflammatory drugs, which could drastically impact their perception of pain and mask the results.[9]
Interestingly, not only listening to music but also playing an instrument has been found to be beneficial. In a separate feasibility study, 4 patients diagnosed with hand osteoarthritis met with an investigator 4 times a week for 30 minutes during a 4-week period. During this time, keyboard playing was used to motivate patients to exercise their affected joints for 20 minutes without interruption, and their arthritic discomfort and finger velocity were measured afterward using a pinch meter and goniometer.[10] This confirmed that on average the patients had a mild increase in finger strength and dexterity (~2.5% improvement) after playing the keyboards,[10] and furthermore, as reported by a psychologist, Gaston, certain rhythmic phrases found in music could also energize patients,[11] with potentially beneficial effects seen over and above arthritic discomfort and finger velocity. The study accounted well for the patient's previous musical experience, and any differences in baseline arthritic pain were considered. However, the study aimed to show feasibility and had a limited number of patients, did not consider the fact that patients may play instruments outside the study, and finally the patients played different musical pieces during the 20-minute sessions, which could have skewed the results.
For patients with osteoarthritis, once less invasive medical management techniques fail to bring the pain to a controllable level, surgery can be an option. Regarding patients undergoing surgical procedures, a study analyzed the effect of music on perioperative pain and anxiety in patients undergoing joint lavage of the knee.[12] Sixty-two patients were randomly assigned to 2 groups: the interventional group listening to music before and during their procedure, whereas the control did not listen to any music. The patients' anxiety and pain levels were "measured" using blood pressure and heart rate as surrogates as well as with a 100-mm visual analog scale (VAS). The positive aspects of the study were that it used an objective measurement of anxiety and pain. However, even though the same piece of music was used for the interventional group, headphones were not used; therefore, other noises in their surroundings could have impacted on their anxiety levels. This study found that patients who listened to music reported significantly lower levels of pain (27 vs 51 mm, P = 0.0005) and anxiety (40 vs 58mm, P = 0.046) compared with the control group, as well as lower heart rate (69 vs 77 beats/min, P = 0.043) but similar diastolic and systolic blood pressure. This suggests that music can be used to reduce the need for analgesic/anxiolytic drugs, limiting any of their possible adverse effects as well as improving the tolerability of the procedure.[12]
Reviewing the available evidence, it would appear that music seems to be a simple yet potentially effective tool that can be incorporated into clinical settings easily to boost the quality of life of patients with osteoarthritis, but do these findings also have implications on other illnesses?
Fibromyalgia is a disorder that was defined relatively recently and is still not fully understood.[13] It is characterized by chronic widespread pain and is frequently associated with other conditions including anxiety and depression.[14] As with other medically unexplained syndromes, there is no accepted cure; therefore, any treatment that alleviates symptoms would be of particular interest. A recent study involving 21 fibromyalgia patients was used to assess the effect of music on such patients.[15] The patients were presented with 2 auditory backgrounds: control ("pink" noise) and a musical piece. The musical piece was self-chosen by the patients, but needed to be pleasant in nature and less than 120 beats/min. After each group finished listening to their auditory background, their pain perception and motility were measured. Pain was measured with a verbal rating scale. Motility was measured with the "Timed Up and Go Task," which is validated test and used successfully in other studies.[16] This study illustrated that music helped patients with fibromyalgia tolerate pain better and increase functional mobility. The music group demonstrated significant decrease in pain perception (5.0 to 3.9, P < 0.05), whereas the control group showed similar values before and after (5.3 vs 5.1), and at the same time, the music group demonstrated significantly better functional mobility following the intervention (11.3 to 10.5, P < 0.006), whereas no significant difference was seen in the control group (11.3 vs 11.0).[15] An area that could potentially merit improvement in this study is that 20 of 21 patients were females. Even though there are more female who have fibromyalgia, the sex ratio is not this extreme, and therefore, the experiment is not completely representative of fibromyalgia patients, but limited to the female patient population. This study further noted that self-selected music was more effective at inducing analgesic effect when compared with music selected by the experimenter.[15] Although there is no concrete scientific explanation for music-induced analgesia, it is known that music is a powerful inducer of emotions and mood, which can reduce pain.[15] Furthermore, even though it is culturally believed that classical music is better at reducing the perception of pain than other genres, possibly due to the well-known "Mozart effect," this study proved that a variety of music had the same ability to induce analgesic effects from pop to folk to simple nature sounds.[15]
In addition, another study using salsa and classical pieces has shown that music can also be used to tackle the high levels of depression shown by patients with fibromyalgia.[17] In this study, 60 fibromyalgia patients listened to 1-hour music for more than 4 times in the first week and daily in the following 3 weeks. Depression was measured using the Beck Depression Inventory,[18] and pain was assessed using a VAS. The mean depression scores measured by the Beck Depression Inventory from baseline to week 4 improved for the music group (4.0 to 3.3, P = 0.016), while remaining unchanged in the control group (3.6 to 3.7). Furthermore, there was significant improvement in the VAS in the music group both at rest and with movement at week 4 (rest: 5.5 to 4.4, P = 0.002; movement: 7.5 to 5.8, P = 0.001) with mild nonsignificant worsening in the control group (rest: 5.6 to 5.8; movement: 7.2 to 7.8). A possible explanation for this beneficial effect seen is that the sound of music can release catecholamines, which elevate mood.[7] Although this was a well-conducted randomized study, it is interesting to note that the type of music that the patients listened to is not reported and that again more than 90% of the participants were females. Moreover, the patients listened to the soundtrack at their homes; therefore, there is no way of assessing adherence.
Finally, a study has shown that music can be used alongside other complementary therapies to alleviate some of the symptoms of fibromyalgia. One hundred twenty patients were divided in 4 equal groups, and 1 group listened to Bach's classical music, another group was subjected to vibratory stimuli on a combination of acupuncture points on the skin, a third group listened to Bach music as well as having vibratory stimuli as per the second group, and a fourth group received no stimulation.[19] The influence of vibration, music, and the combination of the 2 was assessed using the Fibromyalgia Impact Questionnaire score and the Health Assessment Questionnaire,[20] which is proven to be reliable form of measurement in rheumatoid conditions.[21] The Fibromyalgia Impact Questionnaire showed improvement across all 4 groups, suggesting that the placebo effect can be high in this cohort; however, the effect was most notable in the group receiving both vibratory and musical stimuli (control: 76.9 to 67.0, P = 0.035; vibration: 69.0 to 62.0, P = 0.001; music: 74.2 to 60.7, P = 0.024; and finally the music/vibration combination: 78.2 to 55.8, P < 0.001). The results seen with the Health Assessment Questionnaire assessment were similar, indicating improvement in all groups but more so in the combination music/vibration group (control: 1.8 to 1.6, P = 0.016; vibration: 1.9 to 1.8, P = 0.015; music: 1.8 to 1.5, P = 0.008; and music/vibration combination: 2.0 to 1.6, P < 0.001). This was a well-designed randomized study including a control group. All patients within a group were subjected to the same stimuli (same music and vibratory stimuli) and was a relatively big study. However, all the patients were female, again limiting the results to the female patients with fibromyalgia.
In fibromyalgia therefore too, music appears to be a simple and inexpensive method of possibly improving the quality of life for patients, and evidence for the physiological mechanisms behind its effects is only now beginning to emerge.
Conclusions
Even though current research provides promising evidence toward the beneficial effect of music therapy for osteoarthritis and fibromyalgia, at present, there is a lack of studies that explore the effect of music on other rheumatologic conditions including rheumatoid arthritis and systemic lupus erythematosus. Therefore, there is little research that supports the use of this complementary therapy for these conditions. However, a trial of music therapy can be considered especially in patients with resistant symptoms, as it is likely to help alleviate similar symptoms in different rheumatologic conditions, whereas in parallel research studies can be conducted to research further the effect of music on these.
But let us make no mistake—music therapy does not claim to alleviate pain completely or prevent the need for pharmacotherapy or surgery; its aim is to be used alongside conventional rheumatologic interventions to help manage symptoms and improve quality of life. As opposed to modern-day medicine, music therapy has no known adverse effects, and therefore, any benefit derived from its use is advantageous. Even though research into this area of medicine is still in its early stages, it is apparent that music can have a vast array of beneficial effects on patients with rheumatologic conditions. Perhaps in the future, this can help patients with rheumatologic conditions pirouette away to the sound of music. Until then, encouraging our patients to enjoy music both inside and outside the hospital seems to be a stable, solid, enjoyable, cheap, and safe first step.
For centuries, the harmonious melodies of music have made people spring to their feet and dance along to its tune,[1] but could music be used to make even those with aching joints and bones move along to its beat too? This article takes us through the journey of available evidence for how music could be beneficial to rheumatology patients and how it can be utilized daily.
In the past, the concept of using music as a form of treatment in rheumatology was somewhat controversial. During antiquity, music was thought to be a tool that could balance the 4 humors of the body, equating to good health; however, the use of this philosophy for rheumatologic conditions found little acceptance.[2] In the Middle Ages, music therapy gained some support, but this was short-lived.[2] Recently, music therapy within rheumatology has started to receive an increasing number of advocates. Researchers, equipped with more knowledge of the subject and more advanced technology, have turned their attention toward this, and the evidence found toward music as a valid form of adjunct therapy for rheumatologic conditions is surprising.
Objective
The objective of this study was to review all published studies relating to music therapy in specific rheumatologic conditions, notably osteoarthritis, fibromyalgia, rheumatoid arthritis, and systemic lupus erythematous.
Methods
To identify relevant studies that were structured around the PICO process (patient/intervention/comparison/outcome),[3] a free-text search on PubMed and Ovid databases using the terms ("music") AND ("name of pathology") was undertaken. The pathologies included osteoarthritis, fibromyalgia, lupus, and rheumatoid arthritis. To identify articles that were more focused on our topic, we searched for articles that contained the subheadings or "tags" of ("music") AND ("name of pathology"). We included only articles with full text in English language and published in peer-reviewed journals prior to April 17, 2015. All records and their references were reviewed by 2 independent investigators. Importantly, we considered only articles where the experimental intervention consisted predominately of music and the outcome affected pain or perception of pain, mood, or mobility relating to 1 of the rheumatologic pathologies stated earlier. A total of 72 records resulted from the search, and 6 met the inclusion criteria. The selected studies related to osteoarthritis (3/6) and fibromyalgia (3/6). In most of the articles, trained music therapists carried out the experimental interventions, and a summary of all the studies is provided in the Table 1. The methodological quality of the studies was also assessed using a Jadad Oxford Quality scoring system;[4] however, given the low number of studies identified, this was used only for information, and we did not exclude a study on the basis of the score. This scoring is usually based on 7 criteria that evaluate the random allocation, double blinding of interventions, and flow of participants. However, because of the nature of music therapy, it is impossible to double-blind an experiment using music as its intervention. Subsequently, it is not possible for any studies involving music therapy to achieve all points on the traditional Jadad scoring system, and therefore, we used a modified Jadad score with a maximum scoring point of 3 accounting for with the results shown in the
Table 1. Demonstrating the Characteristics of Identified Studies Involving Music With Osteoarthritis and Fibromyalgia (Uploaded file)
Results and Discussion
Osteoarthritis is the most prevalent chronic joint disease with the aging population and obesity epidemic contributing to its rapidly rising incidence.[5] The disease is often diagnosed too late to expect much help from disease-modifying osteoarthritis drugs; therefore, any nonpharmacological approaches such as music therapy would be of particular clinical interest.[5] The predominant symptom of osteoarthritis is chronic pain and is usually the reason behind patients seeking medical help.[6] A well-designed study investigating the effect of music on pain randomly assigned 66 patients with osteoarthritis to an experimental or control group.[7] Participants in the experimental group listened to classical music by Mozart for 20 minutes daily for 16 days, whereas the control group listened to 20 minutes of silence. Any change in pain perception was recorded using the McGill Pain Questionnaire, which has been validated by Graham et al[8] to have a high reliability and consistency. This study illustrated that patients who listened to 20 minutes of relaxing music a day perceived a 52% decrease in pain on the pain rating index compared with the control group in pain perception, which could lead onto increased mobility and quality of life.[7] A possible explanation for the beneficial effect of music was postulated in that it induced a state of relaxation and distracted the patient from focusing on the pain, leading to a reduction of muscle tension surrounding the injured area. The positive aspects of the study's methodology were that the patient's age, sex, and particularly the duration of time that patients had been experiencing osteoarthritic pain were taken into account. In addition, it was appropriately randomized with sufficient patient numbers from both sexes both in the treatment and control arms. However, the study failed to record the patients' use of pain relief including regular and as-required nonsteroidal anti-inflammatory drugs, which could drastically impact their perception of pain and mask the results.[9]
Interestingly, not only listening to music but also playing an instrument has been found to be beneficial. In a separate feasibility study, 4 patients diagnosed with hand osteoarthritis met with an investigator 4 times a week for 30 minutes during a 4-week period. During this time, keyboard playing was used to motivate patients to exercise their affected joints for 20 minutes without interruption, and their arthritic discomfort and finger velocity were measured afterward using a pinch meter and goniometer.[10] This confirmed that on average the patients had a mild increase in finger strength and dexterity (~2.5% improvement) after playing the keyboards,[10] and furthermore, as reported by a psychologist, Gaston, certain rhythmic phrases found in music could also energize patients,[11] with potentially beneficial effects seen over and above arthritic discomfort and finger velocity. The study accounted well for the patient's previous musical experience, and any differences in baseline arthritic pain were considered. However, the study aimed to show feasibility and had a limited number of patients, did not consider the fact that patients may play instruments outside the study, and finally the patients played different musical pieces during the 20-minute sessions, which could have skewed the results.
For patients with osteoarthritis, once less invasive medical management techniques fail to bring the pain to a controllable level, surgery can be an option. Regarding patients undergoing surgical procedures, a study analyzed the effect of music on perioperative pain and anxiety in patients undergoing joint lavage of the knee.[12] Sixty-two patients were randomly assigned to 2 groups: the interventional group listening to music before and during their procedure, whereas the control did not listen to any music. The patients' anxiety and pain levels were "measured" using blood pressure and heart rate as surrogates as well as with a 100-mm visual analog scale (VAS). The positive aspects of the study were that it used an objective measurement of anxiety and pain. However, even though the same piece of music was used for the interventional group, headphones were not used; therefore, other noises in their surroundings could have impacted on their anxiety levels. This study found that patients who listened to music reported significantly lower levels of pain (27 vs 51 mm, P = 0.0005) and anxiety (40 vs 58mm, P = 0.046) compared with the control group, as well as lower heart rate (69 vs 77 beats/min, P = 0.043) but similar diastolic and systolic blood pressure. This suggests that music can be used to reduce the need for analgesic/anxiolytic drugs, limiting any of their possible adverse effects as well as improving the tolerability of the procedure.[12]
Reviewing the available evidence, it would appear that music seems to be a simple yet potentially effective tool that can be incorporated into clinical settings easily to boost the quality of life of patients with osteoarthritis, but do these findings also have implications on other illnesses?
Fibromyalgia is a disorder that was defined relatively recently and is still not fully understood.[13] It is characterized by chronic widespread pain and is frequently associated with other conditions including anxiety and depression.[14] As with other medically unexplained syndromes, there is no accepted cure; therefore, any treatment that alleviates symptoms would be of particular interest. A recent study involving 21 fibromyalgia patients was used to assess the effect of music on such patients.[15] The patients were presented with 2 auditory backgrounds: control ("pink" noise) and a musical piece. The musical piece was self-chosen by the patients, but needed to be pleasant in nature and less than 120 beats/min. After each group finished listening to their auditory background, their pain perception and motility were measured. Pain was measured with a verbal rating scale. Motility was measured with the "Timed Up and Go Task," which is validated test and used successfully in other studies.[16] This study illustrated that music helped patients with fibromyalgia tolerate pain better and increase functional mobility. The music group demonstrated significant decrease in pain perception (5.0 to 3.9, P < 0.05), whereas the control group showed similar values before and after (5.3 vs 5.1), and at the same time, the music group demonstrated significantly better functional mobility following the intervention (11.3 to 10.5, P < 0.006), whereas no significant difference was seen in the control group (11.3 vs 11.0).[15] An area that could potentially merit improvement in this study is that 20 of 21 patients were females. Even though there are more female who have fibromyalgia, the sex ratio is not this extreme, and therefore, the experiment is not completely representative of fibromyalgia patients, but limited to the female patient population. This study further noted that self-selected music was more effective at inducing analgesic effect when compared with music selected by the experimenter.[15] Although there is no concrete scientific explanation for music-induced analgesia, it is known that music is a powerful inducer of emotions and mood, which can reduce pain.[15] Furthermore, even though it is culturally believed that classical music is better at reducing the perception of pain than other genres, possibly due to the well-known "Mozart effect," this study proved that a variety of music had the same ability to induce analgesic effects from pop to folk to simple nature sounds.[15]
In addition, another study using salsa and classical pieces has shown that music can also be used to tackle the high levels of depression shown by patients with fibromyalgia.[17] In this study, 60 fibromyalgia patients listened to 1-hour music for more than 4 times in the first week and daily in the following 3 weeks. Depression was measured using the Beck Depression Inventory,[18] and pain was assessed using a VAS. The mean depression scores measured by the Beck Depression Inventory from baseline to week 4 improved for the music group (4.0 to 3.3, P = 0.016), while remaining unchanged in the control group (3.6 to 3.7). Furthermore, there was significant improvement in the VAS in the music group both at rest and with movement at week 4 (rest: 5.5 to 4.4, P = 0.002; movement: 7.5 to 5.8, P = 0.001) with mild nonsignificant worsening in the control group (rest: 5.6 to 5.8; movement: 7.2 to 7.8). A possible explanation for this beneficial effect seen is that the sound of music can release catecholamines, which elevate mood.[7] Although this was a well-conducted randomized study, it is interesting to note that the type of music that the patients listened to is not reported and that again more than 90% of the participants were females. Moreover, the patients listened to the soundtrack at their homes; therefore, there is no way of assessing adherence.
Finally, a study has shown that music can be used alongside other complementary therapies to alleviate some of the symptoms of fibromyalgia. One hundred twenty patients were divided in 4 equal groups, and 1 group listened to Bach's classical music, another group was subjected to vibratory stimuli on a combination of acupuncture points on the skin, a third group listened to Bach music as well as having vibratory stimuli as per the second group, and a fourth group received no stimulation.[19] The influence of vibration, music, and the combination of the 2 was assessed using the Fibromyalgia Impact Questionnaire score and the Health Assessment Questionnaire,[20] which is proven to be reliable form of measurement in rheumatoid conditions.[21] The Fibromyalgia Impact Questionnaire showed improvement across all 4 groups, suggesting that the placebo effect can be high in this cohort; however, the effect was most notable in the group receiving both vibratory and musical stimuli (control: 76.9 to 67.0, P = 0.035; vibration: 69.0 to 62.0, P = 0.001; music: 74.2 to 60.7, P = 0.024; and finally the music/vibration combination: 78.2 to 55.8, P < 0.001). The results seen with the Health Assessment Questionnaire assessment were similar, indicating improvement in all groups but more so in the combination music/vibration group (control: 1.8 to 1.6, P = 0.016; vibration: 1.9 to 1.8, P = 0.015; music: 1.8 to 1.5, P = 0.008; and music/vibration combination: 2.0 to 1.6, P < 0.001). This was a well-designed randomized study including a control group. All patients within a group were subjected to the same stimuli (same music and vibratory stimuli) and was a relatively big study. However, all the patients were female, again limiting the results to the female patients with fibromyalgia.
In fibromyalgia therefore too, music appears to be a simple and inexpensive method of possibly improving the quality of life for patients, and evidence for the physiological mechanisms behind its effects is only now beginning to emerge.
Conclusions
Even though current research provides promising evidence toward the beneficial effect of music therapy for osteoarthritis and fibromyalgia, at present, there is a lack of studies that explore the effect of music on other rheumatologic conditions including rheumatoid arthritis and systemic lupus erythematosus. Therefore, there is little research that supports the use of this complementary therapy for these conditions. However, a trial of music therapy can be considered especially in patients with resistant symptoms, as it is likely to help alleviate similar symptoms in different rheumatologic conditions, whereas in parallel research studies can be conducted to research further the effect of music on these.
But let us make no mistake—music therapy does not claim to alleviate pain completely or prevent the need for pharmacotherapy or surgery; its aim is to be used alongside conventional rheumatologic interventions to help manage symptoms and improve quality of life. As opposed to modern-day medicine, music therapy has no known adverse effects, and therefore, any benefit derived from its use is advantageous. Even though research into this area of medicine is still in its early stages, it is apparent that music can have a vast array of beneficial effects on patients with rheumatologic conditions. Perhaps in the future, this can help patients with rheumatologic conditions pirouette away to the sound of music. Until then, encouraging our patients to enjoy music both inside and outside the hospital seems to be a stable, solid, enjoyable, cheap, and safe first step.
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