Abstract
Objective:
This study aimed to investigate the effects of five-element music therapy combined with Traditional Chinese Medicine (TCM) comprehensive rehabilitation on liver function, nutritional status, sleep quality and psychological state in hospitalised patients with decompensated liver cirrhosis.
Methods:
A retrospective analysis was conducted on 156 patients hospitalised for decompensated liver cirrhosis from June 2022 to March 2024. The patients were divided into two groups as follows: TCM comprehensive rehabilitation (76 cases) and five-element music therapy combined with TCM comprehensive rehabilitation (80 cases). Changes in psychological state (Self-rating Anxiety Scale [SAS] and Self-rating Depression Scale [SDS], liver function (alanine aminotransferase [ALT], aspartate aminotransferase [AST], total bilirubin [TBIL], direct bilirubin [DBIL] and albumin [ALB], nutritional status (haemoglobin, prealbumin [PA], total protein, Nutritional Risk Screening 2002 and Simplified Nutritional Appetite Questionnaire [SNAQ] and sleep quality (Pittsburgh Sleep Quality Index [PSQI] were compared before and after the nursing approach was implemented.
Results:
Both groups showed significant improvements post-nursing approach in SAS, SDS, liver function, nutritional status and sleep quality (P < 0.05). The five-element music therapy group exhibited significant reductions in SAS, SDS and PSQI scores and better improvements in PA and SNAQ scores than the TCM comprehensive rehabilitation group (P < 0.05). Although the liver function indicators (ALT, AST, TBIL, DBIL and ALB) improved in both groups, no statistically significant differences were observed between groups (P > 0.05).
Conclusion:
Five-element music therapy combined with TCM comprehensive rehabilitation significantly improves psychological state, nutritional status and sleep quality in hospitalised patients with decompensated liver cirrhosis. This integrative care model is worth promoting in clinical practice.
Keywords: anxiety, depression, liver cirrhosis, music therapy, sleep, traditional chinese medicine
LiLi Jiang and LiHua Zhang are co-first authors. These authors contributed equally to this work.
KEY MESSAGES
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(1)
Five-element music therapy with Traditional Chinese Medicine (TCM) rehab improved psychological state, nutrition and sleep in patients with liver cirrhosis.
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(2)
The music therapy group showed better improvements in anxiety, depression and sleep.
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(3)
This integrative model combines traditional and modern therapies effectively.
INTRODUCTION
This study demonstrates that five-element music therapy combined with Traditional Chinese Medicine (TCM) comprehensive rehabilitation provides superior outcomes compared with TCM rehabilitation alone in patients with decompensated liver cirrhosis. These symptoms not only seriously affect patients’ physiological health but also adversely impact their psychological state, which negatively impacts prognosis. Given the complex and multidimensional burden faced by patients with decompensated cirrhosis, a comprehensive assessment of their psychological status, sleep quality, nutritional condition and liver function parameters is instrumental in evaluating overall treatment efficacy. Therefore, developing and evaluating effective integrative nursing cares to address these multidimensional challenges have become an important area of focus in clinical practice.
Traditional medical care models mainly focus on the treatment of the disease itself, whilst neglecting patients’ psychological needs and overall comfort. TCM comprehensive rehabilitation represents a holistic nursing approach rooted in TCM theory, emphasising the integration of physical, psychological and lifestyle interventions.[1] This approach encompasses multiple therapeutic modalities, including acupoint massage, herbal therapies, dietary guidance based on TCM principles and lifestyle modifications aligned with circadian rhythms and meridian flow theory. Accumulating evidence suggests that TCM offers distinct advantages in treating liver diseases, including protecting hepatocytes, inhibiting hepatic inflammation and demonstrating antifibrotic effects.[2] Five-element music therapy is a music therapeutic approach that is based on TCM’s five-element theory, utilising specific pentatonic scales (Gong, Shang, Jue, Zhi and Yu).[3] According to TCM five-element theory, each musical mode corresponds to a specific element and organ system: Gong mode corresponds to earth and spleen, Shang mode to metal and lung, Jue mode to wood and liver, Zhi mode to fire and heart and Yu mode to water and kidney. The therapeutic effects are believed to operate through resonance between specific musical frequencies and corresponding organ systems.[4] Research has shown that five-element music therapy can alleviate anxiety and depression, improve sleep quality and possess certain auxiliary effects on liver function through the regulation of the nervous system.[5] In patients with liver cirrhosis, the application of five-element music therapy can improve mood and reduce patients’ stress response, thereby potentially indirectly promoting liver self-repair.[6] Additionally, five-element music has been shown to regulate amino-acid neurotransmitters (e.g., Glu/GABA balance) in a modality-specific manner,[7] providing a neurochemical mechanism that underlies its anxiolytic and sleep-promoting effects and further supports its potential to benefit liver function.
In recent years, the concept of integrative medicine has been widely applied in clinical nursing.[8] Combining five-element music therapy with TCM nursing may provide more comprehensive and personalised nursing services for patients with decompensated liver cirrhosis. However, studies on the comprehensive effects of five-element music therapy combined with TCM comprehensive rehabilitation on patients with decompensated liver cirrhosis remain limited. This study aimed to explore the effects of five-element music therapy combined with TCM comprehensive rehabilitation on liver function, nutritional status and sleep quality in hospitalised patients with decompensated liver cirrhosis, providing scientific evidence for clinical nursing practice.
MATERIALS AND METHODS
Study Design
A retrospective analysis was conducted on the clinical data of 156 patients with decompensated liver cirrhosis who were hospitalised in the Department of Gastroenterology of our hospital from June 2022 to March 2024. During this period, the department implemented a phased protocol change. From June 2022 to March 2023, patients received TCM comprehensive rehabilitation as standard care (forming the TCM comprehensive rehabilitation group). From April 2023 to March 2024, the department adopted five-element music therapy combined with TCM comprehensive rehabilitation as the new standard protocol (forming the five-element music therapy group). Patients were allocated to groups on the basis of their admission date relative to this protocol implementation timeline. All patients who met the inclusion criteria and completed the full 14-day nursing care were included in the analysis.
This study was approved by Nantong Third People’s Hospital (Ethics Approval Number: EK2024150). All patients in this study provided informed consent. The study was conducted in accordance with the Declaration of Helsinki and institutional guidelines for retrospective research.[9]
Sample Selection and Grouping
A total of 185 patients were initially assessed for eligibility between June 2022 and March 2024. Amongst them, 29 were excluded: 12 due to terminal stage liver disease with expected survival <3 months, eight due to severe cardiovascular comorbidities, five due to cognitive dysfunction preventing questionnaire completion, three due to transfer to other hospitals and one due to self-discharge. Ultimately, 156 patients were enrolled in the final analysis (76 in the TCM comprehensive rehabilitation group and 80 in the five-element music therapy group).
Inclusion and Exclusion Criteria
Inclusion criteria were as follows: (1) confirmed diagnosis of decompensated liver cirrhosis, hospitalised for complications such as ascites, hepatopulmonary syndrome, variceal bleeding or jaundice requiring medical management[9]; (2) age ≥18 years; (3) hospitalisation time ≥14 days; (4)stable vital signs; and (5)complete clinical data.
Exclusion criteria were as follows: (1) terminal stage liver disease with expected survival <3 months; (2) combined with severe cardiovascular and cerebrovascular diseases; (3) history of mental illness, cognitive dysfunction or hepatic encephalopathy that could impair questionnaire completion; (4) pregnancy or lactation period; and (5) transfer to another hospital or self-discharge during treatment.
Nursing Methods
TCM Comprehensive Rehabilitation
On the basis of routine nursing, the TCM comprehensive rehabilitation group received a comprehensive nursing method protocol in accordance with TCM theory and practice as follows:
(1) Acupoint massage: Acupoint massage was applied to soothe the liver, strengthen the spleen and harmonise qi and blood circulation through targeting specific acupoints. Main acupoints included Taichong (LR3), Sanyinjiao (SP6), Zusanli (ST36), Ganshu (BL18), Pishu (BL20), Weishu (BL21), Shenmen (HE7), Yintang (EX-HN3), Zhongwan (CV12) and Tianshu (ST25) for loss of appetite. Massage was performed twice daily at 8:00–9:00 AM and 3:00–4:00 PM, with each acupoint massaged for 3–5 minutes until patients felt soreness and distension. The massage technique emphasised gentle manipulation to avoid excessive stimulation to these vulnerable patients.
(2) Herbal foot bath: Herbal foot bath was performed 1 hour after dinner daily. The herbal formula consisted of Danshen 30 g, Honghua 15 g, Chuanxiong 20 g, Aiye 15 g, Danggui 20 g and Jixueteng 30 g. These herbs were boiled in 2000 mL of water for 30 minutes, filtered to obtain the juice and poured into a foot bath basin, with water temperature controlled at 38–42 °C, water level at 3–5 cm above the ankle joint and soaking time of 20–30 minutes. Hot water was added regularly during the process to maintain optimal temperature until patients’ feet showed mild redness and slight sweating, indicating improved peripheral circulation. Treatment was stopped immediately if discomfort occurred.
(3) Emotional regulation: Emotional regulation was performed by trained TCM nursing staff. (I) Diversion therapy: Attention was diverted through appropriate recreational activities and reading. (II) Emotion control: In accordance with five-element mutual restraint theory, appropriate emotional regulation methods were used, such as using appropriate joyful emotions to regulate patients with excessive worry. (III) Verbal guidance: Guided by TCM emotional theory, patients were helped to regulate their emotional state through verbal counselling and psychological suggestion. Each session lasted 20–30 minutes, once daily.
(4) Dietary care: Dietary care involved following the TCM principles of strengthening the spleen and nourishing the liver; emphasising easily digestible, low-fat and moderate protein foods; and developing personalised dietary plans. (I) Regular timing: Patients ate three meals at regular times and quantities and avoided overeating. (II) Food selection: Foods were mainly easily digestible and light foods. Protein intake was appropriately increased by eating fish, lean meat and soy products. (III) Medicine-food homology: Ingredients with liver-nourishing and spleen-strengthening effects, such as Chinese yam, lotus seeds and red dates, were appropriately added.
(5) Lifestyle regulation combined with TCM meridian flow theory: Patients were guided to fall asleep during the gallbladder meridian time (11:00 PM–1:00 AM) and maintain deep sleep during the liver meridian time (1:00–3:00 AM) in accordance with the circulation pattern of meridian qi and blood. Individualised sleep schedules were established for patients to promote liver function recovery.
Five-Element Music Therapy
The five-element music therapy group received five-element music therapy combined with TCM comprehensive rehabilitation on the basis of the TCM comprehensive rehabilitation group. The principles of Jue-mode music therapy are the following: all patients received Jue-mode music therapy on the basis of TCM theory that ‘liver governs free coursing and stores blood’ and considering that liver cirrhosis primarily involves liver system dysfunction. Jue mode, corresponding to the wood element and liver system in five-element theory, uses the tonal sequence (3-5-6-1-2), which produces ascending and flowing musical patterns that specifically promote liver qi circulation and emotional regulation.
(1) Music selection and compilation: A specialised Jue-mode music repertoire of 24 pieces (average duration of 6.23 ± 1.87 minute) was developed in accordance with the ‘Traditional Chinese Five-Element Music (Orthodox Mode)’ compiled by the Chinese Medical Association. The repertoire included verified Jue-mode compositions such as ‘Gu Su Xing’ (Journey to Gusu), ‘Zhe Gu Fei’ (Partridges Flying), ‘Chun Feng De Yi’ (Spring Breeze Brings Joy), ‘Hu Jia Shi Ba Pai’ (Eighteen Songs of a Nomad Flute), ‘Jiang Nan Si Zhu Yue’ (Jiangnan Silk and Bamboo Music), ‘Jiang Nan Hao’ (Beautiful Jiangnan) and other officially recognised Jue-mode pieces from the standardised TCM music therapy collection. All pieces strictly adhered to the authentic Jue-mode tonal sequence (3-5-6-1-2), corresponding to the wood element and liver system in five-element theory and ensuring consistent therapeutic effects on liver qi circulation and emotional regulation. (2) Implementation method: Five-element music therapy was conducted once each at 9:30–10:00 AM and 4:30–5:00 PM daily, 30 minutes each time. Patients assumed comfortable positions. They could choose semi-recumbent or lateral positions, relaxing whole-body muscles. High-quality headphones (JBL E55BT, USA) were used to play music, with volume controlled at 40–60 decibels, based on patient comfort. They could be appropriately adjusted in accordance with personal preference. During treatment, ward doors and windows were closed, and curtains were drawn to create a quiet, dim environment. Before treatment, patients were instructed to close their eyes and listen, coordinate with abdominal breathing, try emptying their thoughts and focus on the music itself. Attention was paid to inquiring about patients’ physical condition before treatment, and treatment was suspended if discomfort occurred.
Both groups received continuous nursing methods for 14 days.
Observation Indicators
(1) Baseline characteristics: Patients’ gender, age, disease duration and aetiology composition were collected, with electronic medical records reviewed by two independent researchers to ensure data consistency. Alcoholic aetiology was established when the patient sustained harmful alcohol consumption (>3 standard drinks/day in men or >3 in women, approximately 12 g of ethanol each) for ≥12 months, substantiated by confirmation from at least one first-degree relative and after exclusion of viral, autoimmune and inherited liver disorders.[10]
(2) Psychological state assessment: Before and after nursing care was implemented in both groups, the Self-rating Anxiety Scale (SAS, Cronbach α = 0.82) was used to assess anxiety symptoms. The scale contains 20 items, each scored from 1 to 4, with the total score multiplied by 1.25 to obtain the standard score. The total score’s range is 25–100 points. The scales mainly assess individual subjective anxiety symptoms, such as tension, fear and palpitations, with scores greater than 50 indicating an anxious state, and higher scores indicating more severe anxiety level.[11,12] The Self-rating Depression Scale (SDS, Cronbach α = 0.78) was used to assess depression status. The scale contains 20 items, including two items for psychic affective symptoms, eight items for somatic disorders, two items for psychomotor disorders and eight items for depressive psychological disorders, with each item scored on a 4-point Likert scale (1–4). Standard scores greater than 53 indicate a depressive state, with higher scores indicating more severe depression levels.[13,14]
(3) Liver function indicators: Fasting venous blood was collected from patients before and after nursing care. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), direct bilirubin (DBIL) and albumin (ALB) levels were detected using an automatic biochemical analyser (Hitachi 7600).
(4) Nutritional status indicators: Before and after the nursing methods were applied, haemoglobin (Hb) was detected using an automatic blood cell analyser; prealbumin (PA) and serum total protein (TP) were detected using an automatic biochemical analyser; height and weight were measured, and body mass index (BMI) = weight(kg)/height2(m2) was calculated. The Nutritional Risk Screening (NRS) tool 2002 was used to assess nutritional status. This scale consists of initial and final screenings. Initial screening involves BMI, weight loss, food intake and disease severity. Final screening includes nutritional impairment, disease severity and age, with a maximum total score of 7 points. A total score ≥3 indicates that the patient has a high nutritional risk.[15] The Simplified Nutritional Appetite Questionnaire (SNAQ) was used to assess patients’ appetite status. This scale includes four questions about appetite, satiety, food taste and daily meal frequency, with each question scored as 1–5 points, the total score range being 4–20 points and ≤14 points indicating a risk of weight loss exceeding 5–10% in the next 6 months.[16,17]
(5) Sleep quality assessment: Before and after nursing care was implemented, the Pittsburgh Sleep Quality Index (PSQI, Cronbach α = 89) was used to assess patients’ sleep quality. This scale includes seven dimensions, with a total score of 0–21 points: sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication and daytime dysfunction. Higher scores indicate poorer sleep quality, with scores >7 indicating poor sleep quality.[18,19]
Statistical Methods
Statistical analyses were performed using SPSS (version 26.0, IBM Corp., Armonk, NY, USA). Continuous variables were tested for normality using the Shapiro–Wilk test. Normally distributed data were expressed as mean ± standard deviation (x̄±s). Independent sample t-test was used for between-group comparisons, and paired t-test was used for within-group pre- and post-nursing care comparisons. For non-normally distributed data, Mann–Whitney U test was used for between-group comparisons, and these data were expressed as median (interquartile range). Count data were expressed as frequency and percentage by using χ2 test. The model for end-stage liver disease (MELD) score was calculated using the following formula: MELD = 3.78 × ln (serum bilirubin [mg/dL] + 11.2 × ln (INR) + 9.57 × ln (serum creatinine [mg/dL] + 6.43.[20] P < 0.05 was considered statistically significant.
RESULTS
Comparison of General Data
No statistically significant differences were found between the two groups in terms of baseline characteristics such as gender, age, disease duration and aetiology composition (P > 0.05), indicating comparability [Table 1].
Table 1.
Comparison of general data between two groups
| Items | TCM comprehensive rehabilitation group (n = 76) | Five-element music therapy group (n = 80) | t/χ 2/U | P |
|---|---|---|---|---|
| Gender [n (%)] | 0.124 | 0.725 | ||
| Male | 45 (59.21) | 49 (61.25) | ||
| Female | 31 (40.79) | 31 (38.75) | ||
| Age (years) | 58.43 ± 12.27 | 57.82 ± 11.94 | 0.315 | 0.753 |
| BMI (kg/m2) | 21.76 ± 3.28 | 22.14 ± 3.45 | 0.704 | 0.482 |
| Disease duration (years)* | 3.84 (2.27–5.63) | 4.12 (2.58–6.21) | 2847 | 0.598 |
| Aetiology [n (%)] | 0.327 | 0.849 | ||
| Hepatitis B | 38 (50.00) | 43 (53.75) | ||
| Hepatitis C | 24 (31.58) | 22 (27.50) | ||
| Alcoholic | 14 (18.42) | 15 (18.75) | ||
| Child-Pugh class [n (%)] | 0.312 | 0.559 | ||
| Class B | 52 (68.42) | 58 (72.50) | ||
| Class C | 24 (31.58) | 22 (27.50) | ||
| Primary complications [n (%)] | 0.336 | 0.953 | ||
| Ascites | 42 (55.26) | 47 (58.75) | ||
| Hepatopulmonary Syndrome | 18 (23.68) | 16 (20.00) | ||
| Variceal bleeding | 12 (15.79) | 13 (16.25) | ||
| Jaundice | 4 (5.26) | 4 (5.00) | ||
| MELD score | 16.83 ± 4.27 | 17.36 ± 4.65 | 0.740 | 0.460 |
Note: Data are presented as mean ± standard deviation (x̄±s) for normally distributed continuous variables. BMI, body mass index; MELD, model for end-stage liver disease, calculated as 3.78 × ln [bilirubin (mg/dL)] + 11.2 × ln [INR] + 9.57 × ln [creatinine (mg/dL)] + 6.43; *Mann–Whitney U test was used for non-normally distributed data.
Comparison of Psychological State
As shown in Table 2, before nursing care was implemented, no statistically significant differences were found in SAS and SDS scores between the two groups (P > 0.05). After nursing care was applied, the SAS scores decreased from 58.42 ± 8.17 to 48.63 ± 6.74 in the TCM comprehensive rehabilitation group and from 57.93 ± 8.56 to 43.21 ± 5.92 in the five-element music therapy group, with both groups showing significant improvements (P < 0.05). Similarly, the SDS scores decreased from 61.34 ± 9.08 to 52.76 ± 7.43 in the TCM comprehensive rehabilitation group and from 60.87 ± 8.75 to 46.89 ± 6.81 in the five-element music therapy group (P < 0.05). Between-group comparison showed that the five-element music therapy group achieved significantly greater reductions in SAS (48.63 ± 6.74 vs. 43.21 ± 5.92, P < 0.001) and SDS scores (52.76 ± 7.43 vs. 46.89 ± 6.81, P < 0.001) than the TCM comprehensive rehabilitation group.
Table 2.
Comparison of psychological state between two groups
| Items | TCM comprehensive rehabilitation group (n = 76) | Five-element music therapy Group (n = 80) | t | P |
|---|---|---|---|---|
| SAS score | ||||
| Before nursing care | 58.42 ± 8.17 | 57.93 ± 8.56 | 0.374 | 0.709 |
| After nursing care | 48.63 ± 6.74* | 43.21 ± 5.92* | 5.296 | <0.001 |
| SDS score | ||||
| Before nursing care | 61.34 ± 9.08 | 60.87 ± 8.75 | 0.345 | 0.731 |
| After nursing care | 52.76 ± 7.43* | 46.89 ± 6.81* | 5.012 | <0.001 |
Note: Data are presented as mean ± standard deviation (x̄±s) for normally distributed continuous variables (Shapiro–Wilk test, P > 0.05). SAS, Self-rating Anxiety Scale; SDS, Self-rating Depression Scale; *Compared with the same group before nursing care, P < 0.05.
Comparison of Liver Function Indicators
Before nursing care was applied, no statistically significant differences were observed in liver function indicators between the two groups (P > 0.05). After nursing care was implemented, the ALT levels decreased from 89.47 ± 31.25 to 52.73 ± 18.67 U/L in the TCM comprehensive rehabilitation group and from 91.28 ± 33.16 to 48.25 ± 16.94 U/L in the five-element music therapy group (P < 0.05). The AST levels decreased from 105.62 ± 38.74 to 69.47 ±2 0.83 U/L in the TCM comprehensive rehabilitation group and from 107.39 ± 39.95 to 62.65 ± 18.72 U/L in the five-element music therapy group (P < 0.05). TBIL decreased from 42.73 ± 18.94 to 28.96 ± 10.28 µmol/L and from 43.84 ± 19.67 to 26.74 ± 8.63 µmol/L in the TCM comprehensive rehabilitation group and five-element music therapy group, respectively (P < 0.05); DBIL decreased from 22.84 ± 8.35 to 12.73 ± 6.59 µmol/L and from 23.59 ± 8.87 to 11.54 ± 5.83 µmol/L, respectively (P < 0.05). ALB increased from 28.74 ± 4.23 to 31.83 ± 4.18 g/L in the TCM comprehensive rehabilitation group and from 29.15 ± 4.46 to 32.26 ± 4.02 g/L in the five-element music therapy group (P < 0.05). Although the five-element music therapy group showed numerically better improvements in all liver function parameters, between-group comparisons revealed no statistically significant differences (ALT: P = 0.118; AST: P = 0.112; TBIL: P = 0.145; DBIL: P = 0.183; ALB: P = 0.513; Table 3).
Table 3.
Comparison of liver function indicators between two groups (x̄±s)
| Items | TCM comprehensive rehabilitation group (n = 76) | Five-element music therapy group (n = 80) | t | P |
|---|---|---|---|---|
| ALT (U/L) | ||||
| Before nursing care | 89.47 ± 31.25 | 91.28 ± 33.16 | 0.350 | 0.727 |
| After nursing care | 52.73 ± 18.67* | 48.25 ± 16.94* | 1.571 | 0.118 |
| AST (U/L) | ||||
| Before nursing care | 105.62 ± 38.74 | 107.39 ± 39.95 | 0.281 | 0.779 |
| After nursing care | 69.47 ± 20.83* | 62.65 ± 18.72* | 1.598 | 0.112 |
| TBIL (µmol/L) | ||||
| Before nursing care | 42.73 ± 18.94 | 43.84 ± 19.67 | 0.359 | 0.720 |
| After nursing care | 28.96 ± 10.28* | 26.74 ± 8.63* | 1.464 | 0.145 |
| DBIL (µmol/L) | ||||
| Before nursing care | 22.84 ± 8.35 | 23.59 ± 8.87 | 0.543 | 0.588 |
| After nursing care | 12.73 ± 6.59* | 11.54 ± 5.83* | 1.337 | 0.183 |
| ALB (g/L) | ||||
| Before nursing care | 28.74 ± 4.23 | 29.15 ± 4.46 | 0.589 | 0.557 |
| After nursing care | 31.83 ± 4.18* | 32.26 ± 4.02* | 0.655 | 0.513 |
Note: Data are presented as mean ± standard deviation (x̄±s) for normally distributed continuous variables (Shapiro–Wilk test, P > 0.05). ALB, albumin; ALT, alanine aminotransferase; AST, aspartate aminotransferase; DBIL, direct bilirubin; TBIL, total bilirubin; *Compared with the same group before nursing care, P < 0.05.
Comparison of Nutritional Status Indicators
Before nursing care was applied, no statistically significant differences were noted in nutritional status indicators between the two groups (P > 0.05). After nursing care was implemented, the Hb levels increased from 96.73 ± 17.26 to 117.85 ± 16.48 g/L in the TCM comprehensive rehabilitation group and from 95.94 ± 18.15 to 121.34 ± 14.97 g/L in the five-element music therapy group (P < 0.05), with no significant between-group difference (P = 0.168). The PA levels increased from 157.32 ± 38.64 to 206.84 ± 34.17 mg/L in the TCM comprehensive rehabilitation group and from 159.73 ± 41.25 to 217.65 ± 33.04 mg/L in the five-element music therapy group (P < 0.05), with the latter group showing significantly greater improvement (P = 0.046). The TP levels increased from 58.47 ± 6.82 to 62.74 ± 6.39 g/L in the TCM comprehensive rehabilitation group and from 58.93 ± 7.15 to 64.12 ± 5.98 g/L in the five-element music therapy group (P < 0.05), with no significant between-group difference (P = 0.165). BMI showed minimal changes in both groups (from 21.76 ± 3.28 to 22.09 ± 3.16 kg/m2 and from 22.14 ± 3.45 to 22.37 ± 3.29 kg/m2, respectively, P > 0.05). The NRS 2002 scores decreased from 4.27 ± 1.38 to 3.84 ± 1.06 points in the TCM comprehensive rehabilitation group and from 4.41 ± 1.47 to 3.71 ± 0.98 points in the five-element music therapy group (P < 0.05), with no significant between-group difference (P = 0.427). The SNAQ scores increased from 11.47 ± 2.38 to 13.74 ± 2.18 points in the TCM comprehensive rehabilitation group, and from 11.59 ± 2.43 to 14.46 ± 2.04 points in the five-element music therapy group (P < 0.05), with the latter group showing significantly greater improvement (P = 0.035, Table 4).
Table 4.
Comparison of nutritional status indicators between two groups (x̄±s)
| Item | TCM comprehensive rehabilitation group (n = 76) | Five-element music therapy group (n = 80) | t | P |
|---|---|---|---|---|
| Hb (g/L) | ||||
| Before nursing care | 96.73 ± 17.26 | 95.94 ± 18.15 | 0.278 | 0.781 |
| After nursing care | 117.85 ± 16.48* | 121.34 ± 14.97* | 1.386 | 0.168 |
| PA (mg/L) | ||||
| Before nursing care | 157.32 ± 38.64 | 159.73 ± 41.25 | 0.376 | 0.707 |
| After nursing care | 206.84 ± 34.17* | 217.65 ± 33.04* | 2.009 | 0.046 |
| TP (g/L) | ||||
| Before nursing care | 58.47 ± 6.82 | 58.93 ± 7.15 | 0.411 | 0.682 |
| After nursing care | 62.74 ± 6.39* | 64.12 ± 5.98* | 1.393 | 0.165 |
| BMI (kg/m2) | ||||
| Before nursing care | 21.76 ± 3.28 | 22.14 ± 3.45 | 0.704 | 0.482 |
| After nursing care | 22.09 ± 3.16 | 22.37 ± 3.29 | 0.542 | 0.589 |
| NRS 2002 (points) | ||||
| Before nursing care | 4.27 ± 1.38 | 4.41 ± 1.47 | 0.613 | 0.541 |
| After nursing care | 3.84 ± 1.06* | 3.71 ± 0.98* | 0.796 | 0.427 |
| SNAQ (points) | ||||
| Before nursing care | 11.47 ± 2.38 | 11.59 ± 2.43 | 0.311 | 0.756 |
| After nursing care | 13.74 ± 2.18* | 14.46 ± 2.04* | 2.131 | 0.035 |
Note: Data are presented as mean ± standard deviation (x̄±s) for normally distributed continuous variables (Shapiro–Wilk test, P > 0.05). BMI, body mass index; Hb, haemoglobin; PA, prealbumin; TP, total protein; NRS 2002, Nutritional Risk Screening 2002; SNAQ, Simplified Nutritional Appetite Questionnaire. *Compared with the same group before nursing care, P < 0.05.
Comparison of Sleep Quality
Before nursing care was implemented, no statistically significant differences were observed in PSQI scores between the two groups (12.43 ± 3.26 vs. 12.78 ± 3.47, P = 0.518). After nursing care was applied, the PSQI scores decreased significantly in both groups, from 12.43 ± 3.26 to 8.97 ± 2.64 points in the TCM comprehensive rehabilitation group and from 12.78 ± 3.47 to 6.73 ± 2.18 points in the five-element music therapy group (P < 0.05). The five-element music therapy group achieved significantly greater improvement in sleep quality than the TCM comprehensive rehabilitation group (8.97 ± 2.64 vs. 6.73 ± 2.18, P < 0.001; Table 5).
Table 5.
Comparison of sleep quality between two groups (x̄±s, points)
| Group | TCM comprehensive rehabilitation group (n = 76) | Five-element music therapy group (n = 80) | t | P |
|---|---|---|---|---|
| Before nursing care | 12.43 ± 3.26 | 12.78 ± 3.47 | 0.648 | 0.518 |
| After nursing care | 8.97 ± 2.64* | 6.73 ± 2.18* | 5.791 | <0.001 |
Note: Data are presented as mean ± standard deviation (x̄±s, points) for normally distributed continuous variables (Shapiro–Wilk test, P > 0.05). PSQI, Pittsburgh Sleep Quality Index. Higher scores indicate poorer sleep quality. *Compared with the same group before nursing care, P < 0.05.
DISCUSSION
Liver cirrhosis, as the end stage of chronic liver disease, has shown increasing global incidence and become a major threat to human health.[21] Patients with decompensated cirrhosis commonly experience liver dysfunction, malnutrition and sleep disorders,[22] significantly affecting their physical health, psychological state and quality of life. Traditional medical care models focus primarily on pharmacological treatment whilst insufficiently addressing patients’ psychological needs and overall comfort.[23] With the development of integrative medicine concepts, non-pharmacological therapeutic approaches in clinical nursing have gained increasing attention. This study analysed the effects of five-element music therapy combined with TCM comprehensive rehabilitation on patients with decompensated liver cirrhosis to provide evidence-based guidance for clinical nursing practice.
The results showed that five-element music therapy combined with TCM comprehensive rehabilitation could significantly improve the psychological state of patients with decompensated liver cirrhosis. After nursing care was implemented, the SAS and SDS scores of the five-element music therapy group were significantly reduced, which is consistent with previous research findings.[24] Therapeutic mechanisms operate through multiple pathways as music modulates autonomic nervous system activity, reduces sympathetic arousal, enhances parasympathetic tone and influences the release of neurotransmitters such as dopamine, serotonin and endorphins.[25,26] According to TCM theory, the liver governs emotional regulation (shu xie function), and liver cirrhosis is associated with liver qi stagnation syndrome.[27] Music therapy helps patients relax physically and mentally through soothing music, alleviating negative emotions, and its mechanism aligns with the TCM principle of soothing the liver and resolving depression (shu gan jie yu). This therapy can not only regulate patients’ emotional states but also complement the emotional regulation care in TCM comprehensive rehabilitation, jointly improving patients’ emotional and physical conditions.[28]
Chronic psychological stress activates the hypothalamic-pituitary-adrenal axis and increases cortisol levels, which may exacerbate hepatic inflammation and impair liver regeneration.[29] Research evidence demonstrates that music nursing care significantly reduces cortisol levels and physiological stress markers, potentially creating a more favourable environment for hepatic repair.[30,31] The TCM theory that ‘the liver stores blood and governs free coursing’ supports this finding because emotional tranquillity facilitates liver qi flow and blood circulation, thereby promoting liver function recovery.[32] Beyond stress reduction, improved psychological state may enhance treatment adherence and patient engagement in rehabilitation activities, contributing to enhanced overall clinical outcomes.[33]
Both nursing approach groups demonstrated significant within-group improvements in liver function parameters (ALT, AST, TBIL, DBIL and ALB). However, the between-group differences did not reach statistical significance. Several factors may explain this finding. Firstly, the nursing care duration of 14 days may be insufficient for liver function biomarkers to demonstrate significant between-group differences, with Wang et al. observing significant improvements only after 8 weeks of nursing care.[6] Secondly, the relatively small sample size in this study may have resulted in insufficient statistical power, making it difficult to detect significant differences in liver function indicators between the two groups. Thirdly, the TCM comprehensive rehabilitation group may have received multiple comprehensive rehabilitation measures, which could have some beneficial effects on liver function, thereby weakening the differences between the five-element music therapy and TCM comprehensive rehabilitation group. Despite the lack of statistical significance, the five-element music therapy group showed numerically favourable trends in all liver function parameters, suggesting potential benefits that may become evident with longer nursing care periods and larger sample sizes.
Nutritional status improvement represents a clinically significant outcome because malnutrition is prevalent in patients with cirrhosis due to impaired hepatic synthetic function; altered nutrient metabolism; and gastrointestinal dysfunction, including portal hypertensive gastropathy, early satiety and malabsorption.[34,35] The five-element music therapy group demonstrated significantly greater improvements in PA levels and appetite scores (SNAQ) than the TCM comprehensive rehabilitation group, whereas the other nutritional markers (Hb, TP, BMI and NRS 2002) showed no significant between-group differences. PA, with its short half-life (2 or 3 days), serves as a sensitive early marker of nutritional status changes and hepatic protein synthetic function, explaining its responsiveness to the nursing care.[36] The improvement in appetite scores likely reflects the anxiolytic effects of music therapy because anxiety and depression are well-established contributors to anorexia in chronic illness. Enhanced appetite and food intake may have contributed to the improvements in PA synthesis.[25] Other nutritional parameters, such as BMI, Hb and TP, typically require long periods of sustained nutritional intake to demonstrate measurable changes, which may explain the absence of significant between-group differences after only 14 days of nursing care.[37]
Sleep disturbances are highly prevalent in patients with cirrhosis and bidirectionally associated with disease progression, hepatic encephalopathy risk and impaired quality of life, making sleep quality an important therapeutic target.[38] Research shows that music can improve sleep quality through multiple mechanisms, including activating the parasympathetic nervous system, regulating emotions, alleviating anxiety, influencing brainwave activity, promoting endorphin release and improving sleep structure.[39] In the present study, the improvement in the PSQI scores of the five-element music therapy group was significantly better than that of the TCM comprehensive rehabilitation group, indicating that five-element music therapy has unique advantages in improving sleep quality. The therapeutic music employed in this study, characterised by pentatonic melodies and moderate tempo, may have facilitated relaxation and sleep onset through entrainment of physiological rhythms.[40] Additionally, the TCM component emphasising alignment of sleep timing with meridian flow theory (particularly maintaining sleep during the liver meridian time of 1:00–3:00 AM) may have synergistically contributed to improved sleep and hepatic regeneration.[41]
A notable detail that the organic combination of five-element music therapy and TCM comprehensive rehabilitation in this study reflects the development trend of mutual integration between modern medicine and traditional medicine, providing new ideas and methods for the comprehensive management of chronic diseases. However, this study has several important limitations that should be acknowledged. Firstly, as a retrospective study, selection and information biases may be present because the treatment allocation was based on clinical protocols rather than randomisation. Secondly, the observation period was relatively short (14 days), which may be insufficient to capture the full effects of the nursing care on slow-responding outcomes, such as liver function parameters and certain nutritional indicators. Thirdly, the sample size (n = 156) may have provided insufficient statistical power to detect modest but clinically relevant differences in liver function markers, and the single-centre design limits generalisability to other healthcare settings and patient populations. Fourthly, long-term outcomes beyond the nursing care period were not assessed, thereby limiting the understanding of the durability of treatment effects. Fifthly, the study lacked assessment of potential confounding factors such as medication adherence, concurrent medical treatments and baseline disease severity variations beyond Child-Pugh classification.
Future studies should consider conducting multicentre, adequately powered prospective randomised controlled trials with extended observation periods to comprehensively explore the long-term effects and optimal nursing care protocols of five-element music therapy combined with TCM comprehensive rehabilitation. Importantly, mediation analysis should be employed to investigate whether improvements in psychological state, sleep quality and nutritional status serve as mediating pathways influencing liver function parameters, which could elucidate the underlying mechanisms of this integrative nursing care. Additionally, future research should investigate dose–response relationships (optimal frequency, duration and timing of music therapy sessions), identify patient subgroups most likely to benefit from this nursing care and conduct economic evaluations to assess cost-effectiveness compared to standard care.
CONCLUSION
Five-element music therapy combined with TCM comprehensive rehabilitation significantly improves the psychological state, nutritional status and sleep quality of hospitalised patients with decompensated liver cirrhosis, showing clear advantages compared with TCM comprehensive rehabilitation alone in these domains. This integrative nursing model represents a meaningful integration of TCM principles with contemporary nursing care, offering valuable supportive care options particularly for psychological well-being, appetite improvement and sleep quality enhancement for patients with decompensated liver cirrhosis. It also warrants further investigation in clinical settings.
Availability of Data and Materials
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
Author Contributions
LiLi Jiang (First Author): Conceptualized the study design, coordinated data collection, performed data analysis, and drafted the initial manuscript.
LiHua Zhang (Co-first Author): Contributed to the study design, supervised data analysis, and provided critical revisions to the manuscript.
Su Chen (Corresponding Author): Provided overall supervision, secured research resources, reviewed the manuscript for intellectual content, and ensured the study’s scientific integrity.
YuanYuan Wang (Corresponding Author): Assisted with study planning and implementation, reviewed the manuscript for intellectual content, and provided oversight during patient recruitment and clinical interventions.
Ethical Approval and Consent to Participate
This study was approved by Nantong Third People’s Hospital (Ethics Approval Number: EK2024150). All patients in this study provided informed consent. The study was conducted in accordance with the Declaration of Helsinki and institutional guidelines for retrospective research.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgement
The authors thank the patients and their families for participating in this research.
Funding Statement
Nantong Health Commission Research Topic: Contribution to the analysis of the impact of Traditional Chinese Medicine comfort care on liver function, nutritional status, and quality of life in liver cirrhosis patients (Project Number: MSZ2023050). Nantong Science and Technology Bureau Research Topic: Development of core competency evaluation indicators for infectious disease nursing specialists (Project Number: MSZ2022053).
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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 datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
