Abstract
Objective:
This study aimed to explore the effect of music-assisted progressive muscle relaxation on patients with locally advanced gastric cancer (LAGC) undergoing concurrent chemoradiotherapy (CCRT).
Methods:
A retrospective study was conducted on the medical records of 124 patients with LAGC who received CCRT in Jiaozhou Central Hospital from December 2021 to November 2023. These patients were divided into the conventional care group (n = 65) and the music relaxation group (n = 59) on the basis of different nursing methods. Negative emotions (Hospital Anxiety and Depression Scale [HADS], sleep quality (Self-Rating Scale of Sleep [SRSS], and quality of life (Quality-of-Life Questionnaire-Chinese Cancer Chemotherapy Patients) were compared between the two groups before and after treatment.
Results:
After treatment, the HADS and SRSS scores of the music relaxation group were significantly lower than those of the conventional care group (P < 0.001), and the Quality-of-Life Questionnaire-Chinese Cancer Chemotherapy Patients scores of the music relaxation group were significantly higher than those of the conventional care group (P < 0.001).
Conclusion:
Music-assisted progressive muscle relaxation can improve the psychological state of patients with LAGC undergoing concurrent radiotherapy, promote sleep quality and help improve quality of life.
Keywords: chemoradiotherapy, gastric cancer, music, quality of life, rehabilitation
KEY MESSAGES
-
(1)
Music-assisted progressive muscle relaxation helps alleviate anxiety and depression in patients with locally advanced gastric cancer undergoing concurrent chemoradiotherapy.
-
(2)
Music-assisted progressive muscle relaxation can effectively improve patients’ sleep quality.
-
(3)
Music-assisted progressive muscle relaxation is conducive to improving patients’ quality of life and promoting physical recovery.
INTRODUCTION
Despite the decline in its global incidence and mortality over the past few decades, gastric cancer remains one of the most common cancers globally, causing more than 1 million new cases and nearly 800,000 deaths annually.[1] Gastric cancer in China ranks third amongst all malignant tumours in terms of incidence and mortality rates. The data of 2022 showed that China accounted for about 44.0% of the global new cases of gastric cancer and 48.6% of the global deaths.[2] Gastric cancer remains a threat in China due to the country’s massive population and its poor survival rate.[3] About 70% of patients with gastric cancer in China have already progressed to advanced stages when diagnosed due to the lack of typical symptoms and screening programmes at an early stage, missing the best time for radical surgery.[4] Patients with locally advanced gastric cancer (LAGC) often receive neoadjuvant chemotherapy and postoperative chemotherapy to improve surgical efficacy.[5] A study showed that concurrent chemoradiotherapy (CCRT) is superior to chemotherapy alone, not only in reducing the overall risk of recurrence but also in improving 5-year overall survival rate, especially in patients with lymphatic, vascular and perineural infiltration.[6] Guan et al.[7] confirmed that CCRT after chemo-immunotherapy is safe and effective in patients with stage III non-small cell lung cancer. Although CCRT can benefit patients, its complications, such as radiation dermatitis and insomnia, can negatively affect patients’ physical and mental functioning, quality of life and overall health and may even influence cancer progression.[8,9] The National Comprehensive Cancer Network guidelines recommend multimodal treatment for LAGC, and music therapy as an adjunct can be integrated into this framework.[10] Studies found that music combined with progressive muscle relaxation may be effective in alleviating perioperative anxiety, depression and stress in patients with breast or gynaecologic malignancies and beneficial in improving patients’ quality of life.[11,12] However, few literature reports on music therapy for patients with LAGC.
A retrospective study was conducted to confirm the effect of music-assisted progressive muscle relaxation on patients with LAGC undergoing CCRT and provide information for the development of subsequent treatment protocols.
MATERIALS AND METHODS
Study design
This study used a retrospective design. Patients with LAGC who received CCRT in Jiaozhou Central Hospital from December 2021 to November 2023 were selected as the study subjects. Ethical principles were strictly adhered to protect the privacy and rights of the participants.[13] Approval was obtained from the Ethics Committee of Jiaozhou Central Hospital (approval number: 202409032). All participants provided informed consent.
Sample selection and grouping
Sample size was calculated using G*Power 3.1 software (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany). In accordance with a previous study,[14] a medium effect size (Cohen’s d) of 0.5 with a significance level of α = 0.05, power = 0.80 and a two-tailed test were used. The minimum required sample size was calculated to be 130 participants (65 for each group). The initial sample size was 130, and 6 patients were excluded (1 had severe hearing impairment, 2 received other psychotherapy, 2 had comorbid epilepsy and 1 had a specific musical preference), yielding a final sample size of 124. The final sample size was slightly lower than the theoretical value of 130, so there was a risk of insufficient statistical power. Therefore, the results should be interpreted with caution.
On the basis of different treatment methods, the patients were divided into the music relaxation group (n = 59) and the conventional care group (n = 65).
Inclusion and exclusion criteria
Inclusion criteria were as follows: (1) meeting the diagnostic criteria for LAGC,[15] (2) patients’ physical condition and laboratory test indicators meeting the requirement of CCRT, (3) normal speech and cognitive function, (4) hospital stay of more than 10 days and (5) complete clinical data.
Exclusion criteria were as follows: (1) severe hearing impairment, (2) serious complications requiring immediate treatment, (3) combined with epilepsy, (4) undergoing other psychological treatment and (5) with specific musical preferences
Treatment method
CCRT program
(1) Conventional radiotherapy: The total dose was 45 Gy for 25 sessions, 1.8 Gy/session, 5 sessions/week, for a total course of 5 weeks. A 6 MV linear gas pedal radiotherapy (Infinity Medical Technology Co., Ltd., Shanghai, China) was used. The target areas included primary foci and high-risk lymph nodes.
(2) Chemotherapy: DCF (docetaxel, cisplatin and 5-fluorouracil) regimen was used with 75 mg/m2 of docetaxel (Tianjin Hualida Bioengineering Co., Ltd., Tianjin, China), Day 1; 25 mg/m2 of cisplatin (Jiangsu Hansoh Pharmaceutical Group Co., Ltd., Lianyungang, China) infused intravenously for 4 h, Days 1–3; and 750 mg/m2 of 5-fluorouracil (Harbin Pharmaceutical Group Sanjing Pharmaceutical Co., Ltd., Harbin, China) was continuously infused, Days 1–5. The chemotherapy cycle lasted for 21 days.
(3) Concurrency mode: Chemotherapy and radiation therapy started on the same day. Cycle 1 of chemotherapy overlapped with Weeks 1–3 of radiotherapy, and Cycle 2 overlapped with Weeks 4 and 5 of radiotherapy.
(4) Adverse reaction monitoring: The patients’ blood counts, renal function and prophylactic use of antiemetics were monitored weekly.
Routine nursing care method
The conventional group received routine nursing care for CCRT. During the hospitalisation period, the patients were provided with supportive psychological care. Nurses monitored the vital signs, actively prevented adverse reactions and strengthened oral and skin care during radiotherapy. They also took the initiative to care for the patients, communicated with them, provided encouragement and comfort and explained details regarding CCRT. The patients were informed of the progress of the disease treatment, and a good nurse–patient relationship was established. Families were guided to communicate with patients, observe patients’ emotional changes and provide comfort and encouragement at an appropriate time to relieve their bad mood.
Music-assisted progressive muscle relaxation
The music relaxation group received music-assisted progressive muscle relaxation, with the following arrangement:
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(1)
Reasonable arrangement of resource allocation: Resources needed for music-assisted progressive muscle relaxation were provided, including equipment (such as audio equipment and music playback software), location (quiet treatment rooms or ward corners) and time (arranging special time slots for training).
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(2)
Personnel training: Professional training was provided for staff about the skills of music-assisted progressive muscle relaxation, including music selection, patient communication and how to deal with problems that may be encountered.
-
(3)
Prior to music therapy, patients were asked to take a lying position and choose a piece of soothing music as background music, such as ‘High Mountains and Flowing Water’, ‘Colorful Clouds Chasing the Moon’ or ‘Piano Concerto No. 2’. Then, they were instructed to adjust their breath and enter the training state as follows:
-
(1)
Music-assisted progressive muscle relaxation: When patients were in a musical environment, they were verbally guided to conduct contraction–relaxation of muscles in the order of hands, forearms, upper arms, shoulders and neck, thorax and back, abdomen and thighs, calves and foot muscle groups. The patients first tensed their muscles for 5–10 seconds and then slowly relaxed for 10–20 seconds, fully experiencing the sensation of tension and relaxation. (2) Music association training: Relevant musical elements were provided in accordance with the patient’s situation. Personalised verbal guidance for association training was developed (e.g., ‘imagine being in a natural environment and in harmony with nature’ and ‘what shape does this music bring to your mind?’) to eliminate anxiety and horror and enable relaxation. The patients were asked to do breathing exercises in the following order: exhale for 5–10 seconds, pause for 2 seconds, inhale for 3–5 seconds and keep the respiratory rate as low as possible. During the training process, professionals need to pay real-time attention to the patient’s response and status and adjust the training program in time to ensure that the patient can successfully complete the training. Music relaxation was conducted every day at 9:00 a.m. before medication, 20–30 minutes each time, once a day for 10 days.
Observation indicators
Baseline information
Baseline data, including gender, age, tumour location, T-staging, N-staging, degree of tumour differentiation, pathological type, surgical history and hospital stay, were collected from the hospital’s electronic medical records.
Anxiety and depression
The Hospital Anxiety and Depression Scale (HADS) was used to evaluate the anxiety and depression status of the patients before and after treatment (before treatment is defined as the day before music therapy and after treatment is defined as the day after music therapy was completed). This scale consists of 14 items, including a depression subscale (HADS-D) and an anxiety subscale (HADS-A), each with seven items. Each item is rated on a 4-point scale from 0 points to 3 points. The two subscales are scored as follows: 0–7 points for no symptoms, 8–10 points for suspected symptoms of anxiety or depression and 11–21 points for definite symptoms of anxiety or depression. This scale has a Cronbach’s α of 0.879.[16]
Sleep quality
The Self-Rating Scale of Sleep (SRSS) was used to evaluate sleep quality before and after treatment. This scale consists of 10 items. Each item is divided into five grades, with scores ranging from 10 points to 50 points. A score of ≥23 is defined as insomnia, with high scores indicating poor sleep quality. This scale has a reliability of 0.6468 and a validity of 0.5625.[17]
Quality of life
The Quality-of-Life Questionnaire-Chinese Cancer Chemotherapy Patients (QLQ-CCC) was used to evaluate patients’ quality of life before and after treatment. It covers the following four dimensions: physical functioning (16 items), psychological functioning (5 items), social functioning (5 items) and general feeling (9 items), with a total of 35 items. Each item adopts a 1–4-point scale, with scores ranging from 35 to 140. A high score is indicative of a high quality of life. QLQ-CCC has a Cronbach’s α of 0.700–0.900.[18]
Statistical analyses
SPSS (version 26.0, IBM Corporation, Armonk, New York, USA) was used to process the collected data. Microsoft Office Word 2019 (Microsoft Corporation) was used to plot tables. Continuous variables were tested for normality by using the Shapiro-Wilk method, whereas non-normally distributed variables were analysed using Wilcoxon rank-sum tests and denoted as M (P25, P75). Categorical variables were denoted as (n [%] and assessed using chi-square test (when n ≥ 40 and theoretical frequency (T) ≥ 5, Pearson’s chi-square test is used; when n ≥ 40 and 1 ≤ T ≤ 5, the corrected chi-square test is used) or Fisher’s exact test (when n < 40 or T < 1 occurs in any cell). Differences were considered statistically significant when P < 0.05.
RESULTS
Baseline information
No significant difference was found between the two groups in terms of gender, age, tumour location, degree of differentiation, T-staging, N-staging, pathological type, surgical history and duration of hospital stay (P > 0.05). The detailed data are presented in Table 1.
Table 1.
Comparison of baseline information between the two groups
| Baseline data | Conventional care group (n = 65) | Music relaxation group (n = 59) | χ2/Z | P |
|---|---|---|---|---|
| Gender (n [%] | 0.046 | 0.830 | ||
| Male | 34 (52.31) | 32 (54.24) | ||
| Female | 31 (47.69) | 27 (45.76) | ||
| Age (years) | 54.00 (45.00, 62.50) | 54.00 (45.00, 62.00) | −0.038 | 0.970 |
| Tumour location (n [%] | 1.035 | 0.596 | ||
| Cardia | 39 (60.00) | 40 (67.80) | ||
| Gastric body | 16 (24.62) | 13 (22.03) | ||
| Gastric sinus | 10 (15.38) | 6 (10.17) | ||
| T staging (n [%] | 0.068 | 0.794 | ||
| T3 | 46 (70.77) | 43 (72.88) | ||
| T4 | 19 (29.23) | 16 (27.12) | ||
| N-staging (n [%] | 0.999 | 0.607 | ||
| N1 | 6 (9.23) | 4 (6.78) | ||
| N2 | 46 (70.77) | 39 (66.10) | ||
| N3 | 13 (20.00) | 16 (27.12) | ||
| Degree of tumour differentiation (n [%] | 0.045 | 0.978 | ||
| Poorly differentiated | 40 (61.54) | 36 (61.02) | ||
| Moderately differentiated | 17 (26.15) | 15 (25.42) | ||
| Well differentiated | 8 (12.31) | 8 (13.56) | ||
| Pathological type (n [%] | 0.342 | 0.987 | ||
| Tubular adenocarcinoma | 28 (43.08) | 24 (40.68) | ||
| Papillary adenocarcinoma | 5 (7.69) | 5 (8.47) | ||
| Mucinous adenocarcinoma | 7 (10.77) | 8 (13.56) | ||
| Poorly cohesive | 6 (9.23) | 6 (10.17) | ||
| Mixed adenocarcinoma | 19 (29.23) | 16 (27.12) | ||
| Received radical surgery (n [%] | 0.012 | 0.912 | ||
| Yes | 37 (56.92) | 33 (55.93) | ||
| No | 28 (43.08) | 26 (44.07) | ||
| Hospital stay (day) | 13.00 (11.00, 15.00) | 13.00 (11.00, 14.00) | −0.216 | 0.829 |
HADS scores
The HADS scores of the two groups before and after treatment are demonstrated in Table 2. No significant difference was found in the HADS scores between the two groups before treatment (P > 0.05). The HADS scores after treatment were significantly lower than before treatment in both groups (P < 0.05). However, the music relaxation group had significantly lower HADS-A and HADS-D scores than the conventional care group after treatment (P < 0.05).
Table 2.
Comparison of HADS scores between the two groups (point, M [P25,P75]
| HADS subscale | Conventional care group (n = 65) | Music relaxation group (n = 59) | Z | P | |
|---|---|---|---|---|---|
| HADS-A | Before treatment | 11.00 (9.00, 13.00) | 12.00 (10.00, 13.00) | 1.250 | 0.211 |
| After treatment | 10.00 (9.00, 12.00) | 9.00 (8.00, 11.00) | −3.652 | <0.001 | |
| Z | −1.385 | −5.949 | |||
| P | 0.166 | < 0.001 | |||
| HADS-D | Before treatment | 13.00 (11.00, 14.00) | 13.00 (11.00, 14.00) | −0.282 | 0.778 |
| After treatment | 11.00 (10.00, 13.00) | 11.00 (9.00, 12.00) | −2.203 | 0.028 | |
| Z | −4.409 | −5.338 | |||
| P | < 0.001 | < 0.001 | |||
SRSS scores
No significant differences were found in the SRSS scores of the two groups before treatment (P > 0.05). After treatment, the SRSS scores of the conventional care group did not improve significantly (P > 0.05), and those of the music relaxation group decreased significantly (P < 0.001). The SRSS scores of the music relaxation group after treatment were significantly lower than those of the conventional care group (P < 0.001), as illustrated in detail in Table 3.
Table 3.
Comparison of SRSS scores of the two groups (point, M[P25,P75]
| Group | Before treatment | After treatment | Z | P |
|---|---|---|---|---|
| Conventional care group (n = 65) | 36.00 (32.00, 39.00) | 35.00 (31.00, 38.00) | 0.000 | 1.000 |
| Music relaxation group (n = 59) | 36.00 (32.00, 39.00) | 29.00 (25.00, 32.00) | −41.350 | <0.001 |
| Z | −1.700 | −38.968 | ||
| P | 0.089 | < 0.001 |
QLQ-CCC scores
No significant difference was found between the QLQ-CCC scores of the two groups before treatment (P > 0.05). After treatment, the QLQ-CCC scores of the conventional care group did not significantly improve (P > 0.05), whereas those of the music relaxation group significantly improved after treatment compared with before treatment (P < 0.001). Moreover, the QLQ-CCC scores after treatment were significantly higher in the music relaxation group than in the conventional care group (P < 0.001, Table 4).
Table 4.
QLQ-CCC scores at different time points of the two groups (point, M[P25,P75]
| Group | Before treatment | After treatment | Z | P |
|---|---|---|---|---|
| Conventional care group (n = 65) | 64.00 (55.00, 70.50) | 64.00 (54.00, 72.50) | 0.179 | 0.858 |
| Music relaxation group (n = 59) | 64.00 (58.00, 68.00) | 78.00 (73.00, 84.00) | 8.323 | <0.001 |
| Z | 0.170 | 7.186 | ||
| P | 0.865 | <0.001 |
DISCUSSION
Oncological treatments lead to physical and emotional difficulties with notable consequences in everyday life.[19] These factors can affect the social life and ability to work of patients. The sequelae of gastrectomy and toxicity of chemotherapy and radiotherapy can lead to a considerable reduction in health-related quality of life.[20] Over the past few decades, the field of oncology has seen a growing acceptance of complementary therapy (e.g., nutritional support and psychological interventions). Progressive muscle relaxation is a promising intervention widely used to reduce mental health problems, and it has been shown in a systematic evaluation to reduce stress, anxiety and depression in adults.[21]
Music therapy has been used to alleviate symptoms and address psychosocial needs in patients with cancer as an adjunctive treatment, thus providing patients with a source of aesthetic support. For example, an in-depth personally selected music playlist may assist in cognitive recovery and improve mood in patients undergoing treatment or rehabilitation.[22] A meta-analysis has concluded that music interventions can reduce fatigue in patients with cancer.[23] Providing pre-recorded music and attending live music shows were found to reduce cancer-related fatigue. Another study found that music therapy is easy to implement in hospitals and that the rhythm and melody of music distract patients from clinical treatments, most of which are potentially invasive and painful, such as biopsy, surgery, chemotherapy and radiotherapy.[24] A prospective study found that music intervention combined with progressive muscle relaxation could reduce depression and anxiety levels in troop recruits.[25]
The HADS scores obtained in this study clearly demonstrate that music-assisted progressive muscle relaxation improved patients’ depression and anxiety, similar to the results of the study of Dalli et al.[26] The reasons for this finding are hypothesised to be as follows: firstly, music can stimulate emotional resonance through its melody, rhythm and harmony, helping patients with advanced cancer and release their inner stress and anxiety. Secondly, progressive muscle relaxation can reduce stress and anxiety responses and promote physical and mental relaxation by inhibiting the overactivity of the sympathetic nervous system, regulating the functional balance between the anterior thalamus and the hypothalamic nucleus and reducing the secretion of norepinephrine.[27] Music activates the limbic system (e.g., amygdala and hippocampus) through auditory stimulation, which promotes the release of pleasure-related neurotransmitters, such as dopamine and 5-hydroxytryptamine, and at the same time reduces the level of cortisol. Music therapy combined with progressive muscle relaxation forms a two-way regulatory loop, namely, the central regulation and peripheral feedback, to achieve enhanced mood improvement effects.[28] Improvement in anxiety and depression may enhance patient adherence to treatment, thus improving overall treatment outcomes and survival rates.
Whilst CCRT can improve survival rates, it also leads to adverse reactions, such as insomnia, which substantially affects survivors’ sleep quality.[28] The current study revealed that music-assisted progressive muscle relaxation improved the sleep quality of the patients. The possible reasons are as follows: music enhances the sensitivity of γ-aminobutyric acid (GABA) receptor through the auditory pathway and progressive muscle relaxation further promotes the release of GABA through muscle feedback. These two together inhibit the overexcitability of the central nervous system and prolong the duration of deep sleep, resulting in improved sleep quality. This result was confirmed in the study of Içel and Başoğul.[29]
The present study confirmed that music-assisted progressive muscle relaxation is helpful for improving the quality of life, which may be because it can divert patients’ attention from pain and improve sleep quality, so it can break the vicious cycle of ‘pain–anxiety–insomnia’ and improve quality of life, consistent with the findings of Nguyen et al.[30]
LIMITATIONS
Firstly, this study is retrospective, the data were obtained from past records, and the results may be affected by incomplete or inaccurate information. Secondly, the final sample size was lower than the theoretical sample size, which may pose a risk of false-negative results, mainly limited by factors such as the study period and single centre. Thirdly, long-term reliance on music for relaxation training may cause psychological dependence on music, which may prevent patients from achieving a state of relaxation without music. Furthermore, hospital noise may interfere with patients’ attention and relaxation. Fourthly, the continuity of music therapy may be interrupted by various events, such as treatment arrangements, nursing operations and family visits; thus reducing the training effect. Finally, the training effect may be affected by the patient’s daily life experience, religious beliefs or level of education, amongst other factors.
Prospective studies should be conducted as much as possible in subsequent studies, and more objective data collection methods should be used to control and reduce the influence of information bias. The scope and sample size of the study should be expanded as much as possible to enhance the stability and generalizability of the results. The training environment could be further optimised, and the interference of external noise could be reduced. Future studies could adopt the ‘acute + maintenance’ segmentation model and use remote technologies (e.g., online instruction and wearable devices) to break through the limitations of hospitalisation scenarios.
CONCLUSION
Music-assisted progressive muscle relaxation can reduce depression and anxiety, improve sleep quality and enhance quality of life in patients with LAGC undergoing concurrent radiotherapy. It has a remarkable potential for comprehensive clinical application.
Availability of Data and Materials
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Author Contributions
ZJW designed the study. ZFY analysed the data. Both authors contributed to editorial changes of the manuscript, read and approved the final manuscript. Both authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.
Ethics Approval and Consent to Participate
Approval was obtained from the Ethics Committee of Jiaozhou Central Hospital, Qingdao, China (approval number: 202409032). Given that this study was a retrospective analysis, patients’ identifying information was concealed and all participants were given informed consent.
Conflicts of Interest
The authors declare no conflict of interest.
Acknowledgment
Not Applicable.
Funding Statement
This research received no external funding.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
