Clinical Reviews

By Lynn Keegan, RN, PhD, HNC, FAAN

Music Therapy for Respiratory Patients

Source: McBride S, et al. The therapeutic use of music for dyspnea and anxiety in patients with COPD who live at home. J Holistic Nurs 1999;17:229-250.

Context: The use of music as an alternative and/or complementary therapy is increasing and in many instances has been validated as being helpful in calming anxiety and inducing sleep.

Objective: To examine the feasibility of using music as a therapeutic intervention and identify music’s effects on the perception of anxiety and dyspnea in COPD patients who live in their own homes.

Design: A mixed quantitative and qualitative design was used. The quantitative aspect consisted of a repeated measure. Twenty-four participants who experienced dyspnea at least once a week were studied over a 5-week period. Baseline data were collected at week 1. Measures of anxiety and dyspnea were taken at week 2, prior to, and immediately following the use of music. Their measures were repeated at week 5.

Setting: Patients in a large metropolitan area in southern Ontario, Canada.

Instruments: Visual Analogue Dyspnea Scale, Speilberger State Anxiety Scale, Music Use and Preference Questionnaire, measures to monitor use and effect of music, music diary, and music effectiveness questionnaire.

Results: There was a significant decrease in dyspnea following the use of music as reported in the music diary (P < 0.001). There was a significant decline in anxiety (P < 0.05) and dyspnea (P < 0.01) following the use of music at week 2. There was no significant change in anxiety or dyspnea over the five-week period. The results of this study suggest that people with COPD will use music in conjunction with dyspnea in their own homes. There was a significant decline in dyspnea and anxiety at time 2 as well as a significant decline of dyspnea reported in the diary. This finding is consistent with other studies’ findings showing that music is effective in relieving anxiety in cardiac patients and in relieving pain in patients with rheumatoid arthritis.

Limitation: The fact that by the end of the study period there was a decline in the number of participants reporting the use of music in the diary suggests a difficulty in monitoring the use of music in an uncontrolled setting, and thus, a difficulty in examining effect over time. Also because the use of music was need-based, there was no control over how frequently participants used it.

Comment: This well-done study suffered the unfortunate effect of lack of participant controls due to inconsistent contact between the investigators and the subjects. It would be good to replicate this study with a larger sample of hospital inpatients or patients in a long-term setting facility that would ensure following the study guidelines. Music can be used as an effective noninvasive adjunct therapy for a variety of chronic and acute care conditions. Clinicians would be wise to develop a music library for both inpatients and long-term home care.

Acupuncture for Pain in HIV Neuropathy

Source: Shlay J, et al. Acupuncture and amitriptyline for pain due to HIV-related peripheral neuropathy. JAMA 1998;280: 1590-1595.

Context: Peripheral neuropathy is common in persons infected with the human immunodeficiency virus (HIV) but few data on symptomatic treatment are available.

Objective: To evaluate the efficacy of a standardized acupuncture regimen (SAR) and amitriptyline hydrochloride for the relief of pain caused by HIV-related peripheral neuropathy in HIV-infected patients.

Design: Randomized, placebo-controlled, multicenter clinical trial. Each site enrolled patients into one of the following: (1) a modified double-blind 2 x 2 factorial design of SAR, amitriptyline, or the combination compared with placebo, (2) a modified double-blind design of an SAR vs. control points, or (3) a double-blind design of amitriptyline vs. placebo.

Setting: Terry Berin Community Programs for Clinical Research on AIDS (HIV primary care providers) in 10 U.S. cities.

Patients: Patients with HIV-associated, symptomatic, lower-extremity peripheral neuropathy. Of 250 patients enrolled, 239 were in the acupuncture comparison (125 in the factorial option and 114 in the SAR option vs. control points option), and 136 patients were in the amitriptyline comparison (125 in the factorial option and 11 in amitriptyline option vs. placebo option).

Interventions: Standardized acupuncture regimen vs. control points, amitriptyline (75 mg/d) vs. placebo, or both for 14 weeks.

Main Outcome Measure: Changes in mean pain scores at 6 and 14 weeks, using a pain scale ranging from 0.0 (no pain) to 1.55 (extremely intense), recorded daily.

Results: Patients in all four groups showed reduction in mean pain scores at 6 and 14 weeks compared with baseline values. For both the acupuncture and amitriptyline comparisons, changes in pain score were not significantly different between the two groups. At six weeks, the estimated difference in pain reduction for patients in the SAR group compared with those in the control points group (a negative value indicates a greater reduction for the "active" treatment) was 0.01 (95% CI, P = 0.88) and for patients in the amitriptyline group vs. those in the placebo group was -0.07 (95% CI, P = 0.38). At 14 weeks, the difference for those in the SAR group compared with those in the control points group was -0.08 (95% CI, P = 0.26) and for amitriptyline compared with placebo was 0.00 (95% CI, P = 0.99).

Conclusions: In this study, neither acupuncture nor amitriptyline was more effective than placebo in relieving pain caused by HIV-related peripheral neuropathy.

Comment: This funded study is the largest reported randomized, placebo-controlled clinical trial of symptomatic treatment for HIV-related peripheral neuropathy. The results were a blow to the acupuncture community who hoped to be able to use this modality for treatment of this condition. It is important to note, however, that other studies do support acupuncture for treatment of other conditions, such as headache, fibro-myalgia, and Raynaud’s syndrome. Obviously more clinical trials are needed.

Castor Oil and Onset of Labor

Source: Garry D, et al. Use of castor oil in pregnancies at term. Altern Ther Health Med 2000;6:77-79.

Context: Derived from the Ricinus communis bean, castor oil has been used historically to stimulate the labor process.

Objective: To evaluate the relationship between castor oil and the onset of labor.

Design and Setting: Prospective evaluation at a community hospital.

Subjects: One hundred three singleton pregnancies with intact membranes at 40-42 weeks referred for antepartum testing. Patients underwent cervical examination, had Bishop score of 4 or less, and showed no evidence of uterine contractions on tocometry. In the no-treatment group, two patients were lost to follow-up and one patient inadvertently received castor oil.

Treatment/Dose/Route/Duration: Patients were alternately assigned to either treatment or no-treatment groups. Those in the treatment group received a single oral dose of 60 ml castor oil diluted in orange or apple juice.

Outcome Measures: Treatment and no-treatment groups were compared for onset of labor within 24 hours, delivery method, presence of meconium-stained amniotic fluid, Apgar score, and birth weight. Castor oil was deemed successful if labor began within 24 hours. Labor was defined as one or more contractions every five minutes with cervical dilatation of ³ 4 cm.

Results: Thirty of 52 women (57.7%) receiving castor oil began active labor within 24 hours compared to two of 48 women (4.2%) receiving no treatment (P < 0.001). Twenty-five of 30 women (83.3%) receiving castor oil delivered vaginally. All women in the treatment group were nauseated after ingesting the castor oil. Patients receiving castor oil had a 36-fold increase in the likelihood of labor within 24 hours (odds ratio = 36.3; 95% confidence interval [CI], 7.6-172.1; P < 0.001).

Comment: This is an excellent preliminary study of the use of castor oil to initiate labor. A follow-up investigation of this underreported technique with a larger sample using randomized groups could provide definitive information about the efficacy of the use of this natural substance to stimulate uterine contractions for full-term induction.