Mobilizing ICU survivors with music

UM News, 06-13-2019

Nursing researchers and music therapists test a simple and cost-effective way of motivating critical care patients to exercise their weakened muscles.
Music therapy for ICU survivors
From left are music therapist Kimberly Sena Moore, from the Frost School of Music, SONHS assistant professor Zhan Liang, and SONHS Dean Cindy L. Munro. Photo: RM Lamazares-Romero/University of Miami  


As a critical care nurse, Zhan Liang knew her patient had a rough and uncertain road to recovery ahead of him. As he was being discharged home from the intensive care unit (ICU), still bedridden and on a mechanical ventilator, she thought about all the patients who leave the hospital severely disabled after enduring a critical care experience.

“A lot of patients who survive the ICU can take years to recover,” said Liang, an assistant professor at the University of Miami School of Nursing and Health Studies. “I thought, ‘there must be an alternative way to help these patients get better.’”

Her novel answer was something that already inspires countless people to move their muscles: music. Funded by a nursing research award Liang received from the American Thoracic Society (ATS) Foundation, she and her research team are wrapping up a small pilot study at UHealth Tower to determine whether ICU survivors can begin to reverse muscle loss by listening to specially designed instrumental playlists while performing simple exercise routines targeting their shoulders, elbows, wrists, knees, and feet.

They hope music-enhanced therapy will prove to be a simple and cost-effective solution to the many challenges that nurses face in helping ICU survivors regain strength and mobility, and the ability to breathe on their own. One significant challenge is muscle atrophy, or wasting, that many ICU patients suffer after being confined to bed for days or weeks.

As Liang noted, a 2013 study in JAMA, “Acute skeletal muscle wasting in critical illness,” found that 30 percent of muscle loss occurs in the first 10 days of an ICU stay. Various factors can speed up muscle atrophy, including being on a ventilator or on sedation drugs.

As nurses know, early mobility is key to preventing and treating muscle atrophy. However, mobilizing ICU patients, especially those on ventilators, is a complex endeavor.

“It requires a resource-intensive clinician team, including nurses, physicians, physical therapists, and respiratory therapists,” Liang said. “Most of the time, these health care providers are very busy, so patients do not get enough attention and their muscle loss worsens.” 

This staffing issue becomes more problematic when ICU patients are transferred to non-critical care units. “The nurse-to-patient ratio can be one-to-eight or one-to-nine on these units,” Liang said. “Nurses are already very busy giving meds and taking care of other things, so patients may lie in bed without doing anything.”

Because of these challenges, Liang recognized that any new solution for reversing muscle wasting had to be easy to implement and stimulating enough to motivate very weak and often-depressed or anxious patients to move and strengthen their muscles.

Given current pressures on hospitals to rein in health care expenses, Liang also knew the intervention had to be low cost.

After considering all these requirements, Liang thought the often-inspirational sounds of music could provide an inexpensive way of motivating recovering ICU patients to exercise.

One of Liang's co-investigators, Tanira Ferreira, a pulmonologist, intensivist, and the chief medical officer at UHealth Tower, and her senior mentor, Cindy L. Munro, dean of the School of Nursing and Health Studies, were both committed to testing the feasibility and effectiveness of music-enhanced physical therapy. Munro, whose two decades of research has improved outcomes for mechanically ventilated patients in adult ICUs, called the idea “a novel approach to better understanding a significant but understudied issue for this vulnerable population.”

Liang had already explored the benefit of patient-preferred music intervention for very sick ICU patients for her Ph.D. dissertation. While at the University of Pittsburgh, she worked with music therapists who created playlists designed to help ventilated patients manage their anxiety and learn to breathe on their own again.

When the patients listened to these playlists during daily ventilator-weaning trials, their heart rates and respiratory rates significantly decreased, compared to days they did not listen to music. Their reported levels of anxiety and shortness of breath also improved on music days. Most important, the patients were able to stay off the ventilator for longer periods when listening to music.

Sharon M. Graham, one of the music therapists collaborating with Liang, explained that music engages every major region of the brain and is a powerful tool for neuroplasticity and rehabilitation.

“When a patient is faced with a seemingly insurmountable goal of walking again after significant injury, hearing one’s favorite song can revive strong memories and feelings of love and happiness, releasing neurotransmitters like oxytocin into the body, which can elevate mood and decrease perception of pain,” said Graham, the founder and director of the Tampa Bay Institute for Music Therapy.

Under Liang’s guidance, Graham and music therapists from the Frost School of Music, assistant professor Kimberly Sena Moore, and recent master’s graduate Hilary Yip, wrote the musical pieces for the pilot study, which used rhythmic cues to remind patients when to, for example, lift or put down their arm. The playlist was individualized for each patient, taking into account the patient’s instrumental music preference (i.e., piano, guitar, or wind instrument) and the pace with which the patient could perform the 15- to 20-minute exercise routine.

With her ATS award, Liang and her team purchased the technology and resources needed for the research, including music software to create playlists, MP3 players and speakers for patients to listen to the music, and translation capabilities to help the research team communicate with Spanish-speaking patients.

To date, they have enrolled 18 of their goal of 20 adult ICU survivors who have transferred from the ICU to a non-critical care unit at the hospital. Having survived ICU stays of five or more days, all the subjects were weak at the time of enrollment, but differed in age, disease history, and use of mechanical ventilation.

For the study, all the patients are asked to perform the same exercise routine on their own at least twice daily for five days. But only half of them receive the MP3 players loaded with individualized playlists and are taught to coordinate their exercises to the music.

The researchers are determining the feasibility of the intervention by how often and how long each patient exercises. They are establishing the effectiveness by comparing assessments of hand and foot strength, as well as patients’ emotional health at baseline, during, and at the end of the study.

Liang believes the pilot study will demonstrate that music-guided exercise helps improve muscle strength and mood in ICU survivors, and she hopes to conduct a randomized control study involving a larger population of ICU survivors.

“The ultimate goal is to improve the health outcomes for this very vulnerable patient population,” Liang said. “In the future, this low-cost intervention could be applied in multiple ways, whether for nursing home patients or as an app that can be used for home care patients.”

She’s also excited about music therapy’s potential for engaging the families and caregivers of ICU patients or ICU survivors. “Caregivers can be more involved in the care of their loved ones by encouraging them to listen to the playlist and do their exercises.”

An earlier version of this article appeared in Heartbeat.