Evaluating the Effects of Music on Dyspnea During Exercise in Individuals with Chronic Obstructive Pulmonary Disease: A Pilot Study

Dina Brooks, PhD Souraya Sidani, PhD Jane Graydon, PhD Sandra McBride, EdD Leslie Hall, PhD Krisztina Weinacht, Dip PT CAE

Key words anxiety, chronic obstructive pulmonary disease,

dyspnea, exercise, music

In this study, we examined the effects of rnusic on the dyspnea and anxiety experienced by people with chronic obstructive pul- monary disease (COPD) when they are walking. A crossover design was used. Patients walked for I0 niiniites without music and for 10 minutes while listertiiig to inusic. The order of the interventions was detemiined by chance. The levels of perceived dyspnea (modijed Borg scale) and anxiety (State-Trait Anxiety Inventory-State) were measured at baseline (before a 6-minute walk), at pretest (afrer that walk and before the I0-minute walks), and afier the walks. Thirty subjects with a mean age of 70 k 7 years participated in the study. There were no direr- ences in dyspnea or anxiety levels between the walks with rnusic and with no music (p > 0.05). Despite some positive trends, this study did not provide conclusive evidence to support the eficacy of listening to music during exercise; fclrther research is needed to support this intervention.

Diria Brooks is an assistant professor at the University of Toronto Department of Physical Therapy. Souraya Sidani is an associate professor at the University of Toronto. Jane Graydori is a Professor Emerita at the University of Toronto Department of Physical Therapy. Sandra McBride is a Pro- fessor Enierita at Ryersoii University School of Nursing. Leslie Hall is an assistant professor at Ryerson University Department of Philosophy and Music. Krisztina Weinacht is a physiotherapist at Toronto East General Hospital Reha- bilitation Department. Address correspondence to Dina Brooks, Department of Physical Therapy, University of Toronto, Room 848, 500 University Avenue, Toronto, On- tario M5G I V7, or e-mail dina.brooks@utoronota.ca.

Chronic obstructive pulmonary disease (COPD) is charac- terized by airflow obstruction resulting from chronic bronchi- tis or emphysema (American Thoracic Society, 1995). In Cana- da, it is the fourth leading cause of death in men and the seventh leading cause of death in women (Lacasse, Brooks, & Gold- stein, 1999). Among the five most common diseases, COPD is the only one in which morbidity and mortality continue to in- crease (Lacasse et al., 1999). Its prevalence in Canada is esti- mated to be 5.7% in the overall population and ranges from 3.2% of people over 34 years of age to 6.9% of those older than 75 (Lacasse et al., 1999). These numbers are similar to those re- ported in the United States and Europe (National Center for Health Statistics, 1993; Gulsvik, 1999). It is estimated that 1 in 20 deaths in Canada are caused by COPD (Halpin, 2002).

Dyspnea, the sensation of having difficulty in breathing, or of having to make an increased effort to breathe, or both, is a debili- tating symptom that is frequently reported by people with COPD (McCarley, 1999; Wanner & Sackner, 1983). While the exact

mechanisms that cause dyspnea are not well known, various phys- iological and psychological factors are postulated as precipitating it (Canieri, Janson-Bjerklie, &Jacobs, 1984; McCord & Cronin- Stubbs, 1992; Campbell, 1996). Physical activity increases energy demands and ventilation, resulting in increased work breathing that is perceived as dificulty breathing by individuals with COPD (Mahler, 1990). Experiencing dyspnea interferes with a person’s physical and psychological functioning and may cause anxiety (Clark, Salkovski, & Chalkley, 1985). Anxiety, in turn, influences the perception of dyspnea and impairs the ability to cope with the experience (Gift, Moore, & Soeken, 1992). Dyspnea and anxiety lim- it a person’s ability to engage in usual activities and reduce physi- cal functioning (Kaplan & Atkins, 1988; Gift et al., 1992).

Interventions aimed at managing dyspnea and anxiety are needed to help patients improve their physical functioning. Mu- sic can potentially affect shortness of breath, anxiety, and toler- ance in several ways when a person is exercising; it may have a relaxing effect on patients, it may give them focus and thereby

192 Rehabilitation Nursing Volume 28, Number 6 NovemberDecember 2003

distract them from feeling short of breath, or it may motivate them to entrain so as to perform at a higher level. Music is enjoyed by most people and serves as an adjunct to medical care.

Soothing music has helped to promote relaxation in various patient populations (Elliot, 1994; Augustin & Hains, 1996; Bi- ley, 2000; Evans, 2002), including people with COPD (McBride, Graydon, Sidani, & Hall, 1999). The effects of soothing music on respiratory rates have been inconsistent, with some studies showing a decrease in the rate (White, 1992; Augustin & Hains, 1996), and others showing no change (Davis-Rollans & Cun- ningham, 1987; Wong, Lopez-Nahas, & Molassiotis, 2001). A decrease in respiratory rate may translate to improvement in per- ceived dyspnea. Only one study (Thomby, Haas, & Axen, 1995) has examined the effects of music during exercise in people with COPD; it found lower levels of perceived dyspnea and greater dis- tance walked while the subjects were listening to music.

Given the limited information on the use of music with COPD patients, we performed this pilot study to expand knowledge about the effects that music has on the dyspnea, anxiety, and tolerance for physical activity that COPD patients experience while walk- ing. Ethical approval for the study was obtained from the Human Subjects Review Committees at the participating facilities.

Setting and sample Thirty patients with COPD were recruited from three reha-

bilitation programs in an urban setting. Patients were included if they had a confirmed medical diagnosis of COPD (i.e., chron- ic bronchitis, emphysema, or both), could speak and read En- glish, could ambulate independently, reported experiencing dys- pnea at least once a week, and showed an increase in the level of perceived dyspnea of at least two points on the Borg scale after a 6-minute walk. The last two criteria were used since they were valid indicators of the impact of perceived dyspnea on physical functioning in patients with moderate severity of COPD (Bemstein et al., 1994). All subjects provided written informed consent.

Design All patients who met the study selection criteria walked for

10 minutes without music (control condition), or walked for 10 minutes while listening to music (experimental condition). The order of exposure to the two interventions was determined by chance. Thus, participants served as their own control since they were exposed to both experimental and control conditions.

This design controlled for individual characteristics, such as music background, that may influence a person’s response to music, while permitting meaningful comparison between the two conditions.

Participants took a 6-minute walk to induce dyspnea before being tested under each condition. The 6-minute test was con- sidered a physiological stressor that predisposed one to the sen- sation of dyspnea (Bernstein et al., 1994; Guyatt et al., 1984). Participants walked for 6 minutes at their own pace, with no en- couragement from the researcher. Dyspnea and anxiety were measured at baseline (before the 6-minute walk) and before and after the 10-minute test walks (Figure 1).

The two walks were conducted on the same day, under iden- tical conditions, and by the same researcher. The same stan- dardized approach was used for walking under both conditions, which are described below:

1. Walking only (no music): Participants were asked to walk for 10 minutes at their own pace. The researcher accompanied the subject in order to measure the dis- tance walked, and did not initiate conversation or pro- vide encouragement.

2. Walking while listening to music: Participants were given the same instructions for walking, except that they were asked to listen to a music tape (selected by the investigators) during the walk. Moderate tempo music was used to promote physical activity. This music had a regular beat in 214 or 4/4 time. This music included selections from baroque works such as Bach’s “Brandenburg Concerto No. 3” and Vivaldi’s “Four Seasons,” both of which have sections in moderate tempo, major keys, and regular rhythm. Participants clipped the audiocassette player onto their clothes while walking.

The study was conducted primarily in the participants’ homes to minimize any additional physical effort associated with trav- eling to a particular research site and thereby avoid undue fa- tigue. The home environment was also a familiar one in which potential anxiety associated with an unfamiliar environment was reduced. The same, longest available, straightway was used for the walk under both conditions. Seven of the 30 participants preferred to do the walks at the facility where they attended their rehabilitation programs. In this situation, they walked in a hallway in the facility.

Control run baseline -6-minute pretest 10-minute posttest measurement walk measurement test walk no music measurement

posttest measurement music * measurement walk measurement test walk

Experimental baseline 6-minute pretest 10-minute run cc Subject”

*order of intervention was determined by chance

Rehabilitation Nursing Volume 28, Number 6 NovemberlDecember 2003 193

Music in COPD

Measures Dyspnea

The intensity of perceived dyspnea was measured with the modified Borg scale, which is an interval scale ranging from 0 to 10 and supplemented with simple verbal expressions. It has been used to quantify perceived dyspnea resulting from a specific stim- ulus such as exercise (Brown, 1985; Bernstein et al., 1994). The Borg scale is valid and sensitive to change (Killian, 1985).

Anxiety The level of anxiety was measured with the State-Trait Anx-

iety Inventory-State form (STAI-S) developed by Spielberger, Gorsuch, and Lushene (1970). The STAI-S has 20 items scored on a four-point Likert-type scale. Higher scores indicate in- creased anxiety. The STAI-S has been widely used in various patient populations, including people with COPD (Gift et al., 1992). It has internal consistency (Cronbach alpha ranging from 0.8 to 0.9), as well as construct validity and sensitivity to changes in the perceived level of stress (Spielberger & Sydeman, 1994). In the repeated measurement of state anxiety, scales consisting of 4 to 5 items randomly selected from its 20 items can be used to minimize the effect of testing bias (Spielberger et al., 1970). The short scales provide valid measures of state anxiety (Spiel- berger et al., 1970). In this study, six short scales were formed by randomly selecting four of the STAI-S items, with each of the six scales being used once in each group, preceding or follow- ing the experimental and control walks. Tolerance for physical activity

Tolerance for physical activity was operationalized as the dis- tance walked during each of the 10-minute walks, as measured by a pedometer. Descriptive variables

The following information was obtained from the partici- pants: age, gender, marital status, living condition, working sta- tus, other comorbid conditions, length of time they had had COPD, and inhaler use. Subjects were asked if they listened to music on a regular basis and what type of music they preferred.

Data analysis Descriptive statistics were used to characterize the sample

on each variable and to examine the distribution of scores on the dependent variables. A repeated-measures analysis of variance (RM-ANOVA) was used to examine differences in the mean scores on each dependent variable (i.e., dyspnea and anxiety) over the baseline, pretest, and posttest measurements associat- ed with the control and experimental conditions. Post hoc com- parisons (paired f-tests) were made if the RM-ANOVA results indicated statistically significant differences. In addition, a change in each outcome from pretest to posttest was examined between the control and experimental conditions. A p value of less than 0.05 was considered significant.

Results Characteristics of the sample

Table 1 presents the frequency distribution on the sample de- scriptive variables. The 30 subjects were medically diagnosed as having COPD for an average of 10 & 8 years (mean age = 70

Descriptive variable Age (years) <50 50-69 270

Gender Female Male

’ Married Marital status

Not married

Alone With spouse With others

Working status Not workinghetired Working

Yes No

Yes No

Yes No

Living condition

Comorbidity

Use of inhaler

Listen to music

Frequency

0 16 14

15 15

19 1 1

10 18 2

27 3

22 8

29 1

16 14

Percentage

0 53 47

50 50

63 37

33 60

7

90 10

73 27

97 3

53 47

years & 7 SO). Most reported having other diseases, including cardiac conditions (n = 5) , arthritis (n = 7), osteoarthritis/osteo- porosis (n = 6), cancer (n = 2), high blood pressure (n = 1). ini- table bowel (n = l), and epilepsy (n = 1). They had been involved in arehabilitation program an average of 3.3 years. Most (67%) experienced dyspnea every day, with the level of severity aver- aging 4.4 (+ 1.5) on the 10-point Borg scale. Sixteen (53%) in- dicated that they listened to music every day as “background” during activities of daily living (ADL). They listen to various types of music, including classical, country and western, and “oldies.” Effect of music while walking

In the control walking condition, the level of dyspnea changed over the three points of measurement (F(2,58) = 7 5 . 5 , ~ < 0.01; Figure 2). It increased from baseline (1.1) to pretest (4.3), and from pretest to posttest (5.2) (all p < 0.01). In contrast, the lev- el of anxiety did not change significantly over time (1.4, 1.4, and 1.6 respectively, Figure 3). The levels of dyspnea and anxiety differed over time when subjects walked while listening to mu- sic (Figures 2 and 3). Although they increased significantly from baseline to pretest (p < O.Ol), they did not change from pretest to posttest (dyspnea = 1.4,4.3 and 5.0; anxiety = 1.3, 1.8, and 1.9, respectively). Although the anxiety mean score was bor- derline significantly higher after the experimental condition com- pared with the control condition (p = 0.04), the difference was not clinically important.

194 Rehabilitation Nursing Volume 28, Number 6 November/December 2003

-f- No Music --@ With Music

l o 8 c Y

152

T

O C 1 I I

Baseline Pretest Posttest ~~

Vore: Values are provided as means and standard deviations for baseline, iretest (after the 6-minute walk), and posttest (after the 10-minute walk with or without music). There were significant differences over time @< 01). but no differences between the two test walks.

Posttest mean scores in the control and experimental runs were not significantly different in dyspnea scores (p > 0.05). However, the percentage of participants who showed either no change or positive change (i.e., decrease) in the level of dysp- nea was much lower after walking with no music (32%) than after walking while listening to music (55%). The percentage of participants who demonstrated a positive change (ie., de- crease) in anxiety was the same (23%) in both conditions.

Tolerance for physical activity did not differ significantly be- tween the control and experimental runs; the average distances walked were 506 and 500 meters, respectively (p > 0.05).

Discussion This pilot study sought to determine how music affects dys-

pnea, anxiety, and tolerance for physical activity when patients with COPD are walking. In general, the results show some pos- itive trends in the number of participants who showed no change or a decrease in the symptoms when walking with music com- pared with walking without music. However, this study did not provide conclusive evidence to support the efficacy of listening to music during exercise, and further research is needed.

As expected, walking for 10 minutes increased the subjects’ perceived level of dyspnea. However, this perception did not change significantly after walking for 10 minutes while listen- ing to music with a moderate tempo. Several participants had no change, or experienced a decrease in dyspnea after walking with music. These results imply that in some patients, moderate tem- po music was successful in preventing the level of dyspnea from

+ No Music U With Music

3.5

3.0 1 2.5 .-

2 2 2.0 ? 0 I

1.5

1 .o

0.5

0.0 ‘ I I I I I

Baseline Pretest Posttest

Vore: Values are provided as means and standard deviations for baseline, iretest (after the 6-minute walk), and posttest (after the IO-minute walk with or without music). There were significant differences over time @< 01). but no differences between the two test walks.

getting worse after the walk. Listening to moderate tempo music did not affect anxiety or tolerance for physical activity. The find- ings differ from those of Thorby et al. (1995), which indicated that patients reported lower levels of perceived dyspnea, walked 22% longer, and performed 53% more work when listening to music than when listening to grey noise (i.e., hum) or hearing only silence during the exercise test. The inconsistency in results could be explained by differences in the sample size and char- acteristics, in the music selected, and in the setting in which the studies were conducted (patients’ homes versus laboratory).

Respiratory rehabilitation is a therapeutic approach provided by an interdisciplinary team of healthcare professionals and directed to people with pulmonary disease and their families (Fishman, 1994). Respiratory rehabilitation aims at minimizing impairment, disability, and handicap in such patients. The goal is for the patient to achieve and maintain the maximum level of independence and functioning in the community (Fishman, 1994). Walking is an important com- ponent of respiratory rehabilitation. For patients with severe lung disease, rehabilitation professionals are invQlved in teaching strate- gies for managing dyspnea, such as positioning, relaxation exer- cises, and breathing techniques. Patients can use the strategies while resting, performing ADLs, or exercising. Listening to music could be an approach that decreases the perception of breathlessness dur- ing exercise. If future studies find support for the effectiveness of music, rehabilitation nurses could consider incorporating it into their management approach by educating patients about the posi- tive effects of listening to music at home and during exercise sessions in pulmonary rehabilitation.

Rehabilitation Nursing Volume 28, Number 6 NovemberlDecember 2003 195

Music in COPD

A limitation of this study was its small sample size. It is pos- sible that the study was underpowered to detect the effect of mu- sic. Furthermore, with the limited sample, we could not explore music’s effectiveness in subgroups. One’s musical background, as well as one’s gender and ethnicity, are some of the variables that may influence response to music while walking. Further- more, different types of music (soothing versus up-tempo) and music preference may also affect dyspnea and anxiety; this needs to be investigated. In this study, we arbitrarily chose the music, and this may have influenced the results. We selected classical music because it is not familiar to many people and would not evoke memories that could affect their responses. Furthermore, our participants had attended a rehabilitation program and were aware of different dyspnea management strategies. The effect of music on people with different musical backgrounds and on those who have not attended rehabilitation or support groups needs to be addressed in future research. Despite the limitations of this pilot study, we detected some positive trends in the num- ber of those who showed either no change or a decrease in dys- pnea while walking and listening to music.

Given that this was a pilot study, these trends are reported to stimulate other researchers to further examine this issue. How- ever, data from trends should be interpreted cautiously when a statistically significant difference is not found for the mean change. Future studies need to investigate the effects of music in a larger sample of patients with different backgrounds and on various clinical outcomes.

Acknowledgment We would like to acknowledge the assistance of May Ghul-

miyyah and Pamela Wilton in recruiting participants and in col- lecting data. Financial support was received from Ontario Res- piratory Care Society, Ontario Lung Association, Toronto.

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(SUPPI), 84s-90s.

NO. 190, USDHHS (PHS) 95-1518).

Continuing education articles discuss

tion offering (code number RNC-221) will A bilitation nursing. This continuing educa-

this article and complete the application form on page 214. This independent study offering is appropriate for all rehabilitation nurses. By read- ing this article, the learner will achieve the following ob- jectives: 1. Discuss how music could potentially affect shortness

2. Describe how the results of this study could be used

3. Identify variables that may influence response to

current trends and issues affecting reha-

provide 1 contact hour to those who read

of breath in individuals with COPD.

clinically in a pulmonary rehabilitation program.

music in individuals with COPD.

196 Rehabilitation Nursing Volume 28, Number 6 NovemberDecember 2003