INTRODUCTION
Cancer patients with advanced disease may experience debilitating physical symptoms as well as profound emotional and spiritual struggles (Egan & Labyak, Reference Egan, Labyak, Ferrell and Coyle2006). Some of these symptoms include pain, dyspnea, nausea, fatigue, delirium, and anxiety. In addition, there are multiple losses, such as loss of independence and self-care, loss of role in the family and society, and losses related to changes in body image and feelings of self-esteem (Glass et al., Reference Glass, Cluxton, Rancour, Ferrell and Coyle2006). As a result, patients sometimes challenge and question their sense of personal identity and life meaning (Breitbart, Reference Breitbart2002; Puchalski, Reference Puchalski, Berger, Portenoy and Weissman2002; Coyle, Reference Coyle, Ferrell and Coyle2006). The process of dying can be accompanied by feelings of loneliness, fear, and disheartenment. Physical, psychological, and spiritual distress can cause suffering (Cassell, Reference Cassell1991) and reduce quality of life in advanced stage cancer patients (Akechi et al., Reference Akechi, Okuyama and Sugawara2004), and their families (Zabora & Loscalzo, Reference Zabora, Loscalzo, Berger, Portenoy and Weissman2002). End-of-life care emphasizes symptom control and relief of suffering (National Comprehensive Cancer Network, 2003). A holistic approach is considered essential for the patient's quality of life (Rousseau, Reference Rousseau, Berger, Portenoy and Weissman2002; Coyle, Reference Coyle, Ferrell and Coyle2006). Complementary therapies, such as music therapy and reflexology, can facilitate improvement in quality of life for the patient and family (Cassileth, Reference Cassileth1998).
Complementary therapies have been increasingly utilized by cancer patients to reduce the multifaceted complications associated with advanced disease (Deng et al., Reference Deng, Vickers and Cassileth2005). Literature supports the benefits of massage, reflexology, music therapy, acupuncture, and meditation for patients in the advanced stages of cancer (Deng & Cassileth, Reference Deng and Cassileth2005; Berenson, Reference Berenson2007). These interventions can help reduce adverse symptoms, such as pain, nausea, anxiety, and depression, and can help assuage feelings of helplessness and hopelessness (Deng & Cassileth, Reference Deng and Cassileth2005; Berenson, Reference Berenson, Ferrell and Coyle2006). Literature regarding the conjoint use of complementary therapies in cancer care is limited. This article addresses the benefits of the combined use of music therapy and foot reflexology for reduction of physical/psychosocial/spiritual distress in hospitalized end-of-life cancer patients and their families. Two case studies are presented to illustrate the application and benefits of this approach for help with family issues, anxiety, and cognitive impairment.
INTEGRATIVE MEDICINE
Integrative medicine incorporates the use of evidence-based complementary therapies along with mainstream medical care (Deng et al., Reference Deng, Vickers and Cassileth2005; Sagar, Reference Sagar2006, Mansky & Wallerstedt, Reference Mansky and Wallerstedt2006). The Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center offers a range of these therapies to cancer patients and caregivers. The evidence-based modalities offered in this program emphasize integration of body, mind, and spirit and have been found to improve symptoms (Cassileth & Vickers, Reference Cassileth and Vickers2004). When used in conjunction with mainstream care, these therapies are found to bring relief from distress and improve quality of life (Deng et al., Reference Deng, Cassileth and Yeung2004).
MUSIC THERAPY
Music therapy is the use of music, with the guidance of a professionally trained music therapist, to reduce symptoms of suffering and effect meaningful changes in physical, psycho-emotional, social, and spiritual processes (Magill & Luzzato, Reference Magill, Luzzato, Berger, Portenoy and Weissman2002). Over recent years, there has been a growing interest and demand for its use in oncology and palliative care programs, and it is now one of the commonly used complementary modalities in settings such as Memorial Sloan-Kettering Cancer Center (Berenson, Reference Berenson, Ferrell and Coyle2006). Music is a multidimensional medium, capable of transcending time, space, and boundaries. Thus, when used in the context of illness, pain, and loss, music therapy can address a broad array of disease-related issues and challenges.
Music therapy has been found to help manage exigent symptoms presented in cancer and palliative care (Magill & Luzzato, Reference Magill, Luzzato, Berger, Portenoy and Weissman2002; Hilliard, Reference Hilliard2003; Aldridge, Reference Aldridge2004; Hanser, Reference Hanser, Dileo and Loewy2005; O'Callaghan, Reference O'Callaghan2006). Carefully selected music therapy techniques can help reduce pain (Curtis, Reference Curtis1986; Dileo & Bradt, Reference Dileo, Bradt and Dileo1999; Magill-Levreault, Reference Magill-Levreault1993; O'Callaghan, Reference O'Callaghan1996; Rider, Reference Rider and Loewy1997; Krout, Reference Krout2001; Dileo & Bradt, Reference Dileo and Bradt2005), improve mood (Bailey, Reference Bailey1983; Hanser, Reference Hanser1985; Lane, Reference Lane and Martin1989; Edwards, Reference Edwards and Dileo1999; Cassileth et al., Reference Cassileth, Vickers and Magill2003), enhance communication (O'Callaghan, Reference O'Callaghan1993), and ease spiritual distress (Aldridge, Reference Aldridge1995; Magill, Reference Magill2001; Lipe, Reference Lipe2002; Magill, Reference Magill2006; Wlodarczyk, Reference Wlodarczyk2007) in patients and caregivers. Techniques include the use of songs, melodic and instrumental improvisation, lyric improvisation, and song writing, chanting, and mindful music listening (Dileo, Reference Dileo and Dileo1999; Aldridge, Reference Aldridge2004; Magill, Reference Magill, Dileo and Loewy2005).
Music therapists have elaborated extensively on the essence of the music-therapeutic relationship that resides in the human contact and the supportive, caring presence of the therapist (Dileo & Zanders, Reference Dileo, Zanders, Dileo and Loewy2005; Magill, Reference Magill, Dileo and Loewy2005). Because this human element contributes to the efficacy of music therapy and other complementary therapies, music therapists regard the significance of their roles in fostering a compassionate, attentive, and creative milieu within which patients and families can express, explore, and regain a sense of dignity and existential meaning.
REFLEXOLOGY
Reflexology is a form of touch therapy that is historically based on the belief in reflex points on the hands and feet that, when stimulated by the therapists' fingers and hands, can relax the whole body to allow tension and pain to subside (Cassileth, Reference Cassileth1998). It is noninvasive and easily administered to the patient in any comfortable position, with no movement required (Cassileth, Reference Cassileth1998). It is effective in helping diminish a variety of adverse symptoms, such as stress, fatigue, pain, and tension (Berenson, Reference Berenson, Ferrell and Coyle2006). Because human touch can decrease isolation and loneliness (Zabora & Loscalzo, Reference Zabora, Loscalzo, Berger, Portenoy and Weissman2002), reflexology is one of the complementary therapies that can bring comfort and can communicate compassion and empathy for advanced stage cancer patients and their families (Berenson, Reference Berenson, Ferrell and Coyle2006).
Research reports the effectiveness of reflexology with advanced cancer and it has been found to impact quality of life by improving symptoms (Hodgson, Reference Hodgson2000; Vickers & Cassileth, Reference Vickers and Cassileth2001). It has also been found to reduce anxiety, depression, pain, nausea, and agitation (Grealish et al., Reference Grealish, Lomasney and Whiteman2000; Stephenson et al., Reference Stephenson, Weinrich and Tavakoli2000; Quattrin et al., Reference Quattrin, Zanini and Buchini2006), as well as improve relaxation, the ability to cope, and the ability to sleep (Gambles et al., Reference Gambles, Crooke and Wilkinson2002). The combined use of aromatherapy, foot massage, and reflexology was found to reduce fatigue in cancer patients (Kohara et al., Reference Kohara, Miyauchi and Suehiro2004). Involving caregivers in hand massage treatments of their loved ones was found to reduce anxiety and pain and to improve communication (Kolcaba et al., Reference Kolcaba, Schirm and Steiner2006).
METHOD
Patients identified with symptoms of distress are referred to receive these therapies. It is common for health care specialists to be the primary source of referral; however, many patients and family members also self-request these treatments. Therapists work throughout the hospital setting in collaboration with multidisciplinary teams to best treat the multiple needs presented in cases.
In selecting appropriate approaches to use with patients and families, individual therapists generally meet the patient, family, and staff and identify the prevailing issues and options that could benefit them the most. In cases where there are multifaceted needs and complex dynamics present, a collaborative approach is considered. Following their own individual contact(s) with the patient and family and when it seems appropriate to consider this conjoint approach, the two therapists discuss the case together before proposing a collaborative approach to patient and family. Once it is agreed upon by those involved, the therapists begin their team approach.
Within sessions, there are several procedures followed by the therapists. Each therapist assesses the patients and families on a moment-by-moment basis to determine the choice, flow, and direction of the specific techniques. Patients' wishes are the central focus, and each therapist strives to help the patient feel improved comfort and sense of control. The music therapist carefully observes emotions, nonverbal language, and physiological responses and also listens to all the words conveyed, persistently adjusting the dynamics and lyrics of the live music to meet the needs. In addition, the music therapist observes the level of pain, degree of comfort with feelings, and the abilities to cope with sensory, cognitive, emotional, and social stimulation. Words within songs are potent mediums that can facilitate expression and help convey the images, feelings, and thoughts a patient may wish to express; however the words are monitored carefully so as to ensure comfort and contentment. Soft improvised instrumental music, sometimes accompanied by the use of patient-preferred imagery, is also used as a way to support the need to relax. The reflexologist also carefully monitors facial expressions, physiological responses, and words shared by patient and family members as a way to guide the reflexology treatment. She asks the patient regarding the level and degree of touch and encourages the patient to convey any need for change. She also offers support through her words and attentive presence.
In addition to these individual skills, the therapists work together on determining other directions within sessions. If children are present, the music therapist generally works with them, using her guitar and small instruments, alongside the patient. The reflexologist situates herself near the patient and invites a close family member to assist her when appropriate. The rhythm and dynamics of the music in sessions is used to help the patient and family members feel enhanced comfort in the hospital room as well as to support the reflexologist's treatment aims.
CLINICAL CASE STUDIES
The conjoint use of music therapy and reflexology brought meaningful results in the following two cases. These particular examples typify the ways that two therapists, offering unique sensory mediums, can work together to collaboratively address an array of symptoms and issues. The cases demonstrate ways that specific areas of distress, such as family distress and cognitive impairment, can be effectively approached.
Family Distress
Patients who are in the end stages of cancer need relief of symptoms, whereas their caregivers often need extra emotional support (Cherny et al., Reference Cherny, Coyle and Foley1994; Egan & Labyak, Reference Egan, Labyak, Ferrell and Coyle2006). Families often report feelings of helplessness as they witness the suffering in their loved one (Zabora & Loscalzo, Reference Zabora, Loscalzo, Berger, Portenoy and Weissman2002). The patient's condition and way of coping with his/her illness tend to influence the family's feelings and feelings of ability to cope. Families may have symptoms that are as pronounced as the patient's symptoms, such as anxiety, depression, irritability, and fatigue (Zabora & Loscalzo, Reference Zabora, Loscalzo, Berger, Portenoy and Weissman2002; Egan & Labyak, Reference Egan, Labyak, Ferrell and Coyle2006). Interventions such as music therapy and reflexology provide additional support and assistance to help ease the process of dying for the patient and the family.
The following case study demonstrates a 6-month period of time during which the combined use of music therapy and reflexology was used to treat the symptoms of advanced disease and to address the needs of the family, including children. Felicity was a 40-year-old female with Aplastic Anemia. She was Scottish, born in India, and was a world traveler who immigrated to the United States. She was married and the mother of three boys, ages 11, 9, and 7. She received an allogeneic bone marrow transplant that was complicated by Graph versus Host Disease, dialysis dependency, pleural effusions, and hepatic failure. Felicity was hospitalized throughout the entire course of her illness and died 8 months after the time of her diagnosis. Her stated concerns were separation from her children and its effect on them, long hospitalization in isolation, her declining physical condition, and uncertainty of the future. The husband was overwhelmed with addressing the severity of his wife's illness, attempting to keep routines for his young sons, holding down his job, and keeping hope afloat with all concerned.
Reflexology and music therapy were introduced 6 months before Felicity's death. She was referred by the social worker and nurse to Integrative Medicine for relief of multifaceted symptoms of suffering. Initially, she was seen individually by each therapist. Due to the positive effects of music and reflexology for the patient and due to the need for the family to participate, it was decided with the patient that conjoint sessions would be held. The treatments would take place in the afternoons after school when the children and the father were present.
During their first two sessions, the therapists worked in different locations of the patient's room, the music therapist near the family and the reflexologist near the patient. The children sat on the couch in Felicity's room, appearing timid, sullen, and anxious. While the touch therapist provided foot and hand reflexology, Felicity smiled and said, “Please keep coming to seeing me and us.” The husband was pleased to see his wife in a more relaxed state and was shown how to massage her feet so he could provide her with comfort on his own. The music therapist engaged the children in gentle music through guitar and songs that they and their mother selected and the father sat near Felicity. They spoke about the woods and mountains of Scotland and their children's love for music. The children touched the guitar and interacted with the music therapist in the familiar songs they wanted to hear. The mood, tempo, and volume of the music were played with gentleness to suit Felicity's needs and support the treatment. At different times during the sessions, both therapists explained to the children the potential ways that music and reflexology were helping their mother. The father expressed feelings of pleasure in seeing his wife relax and his children enjoying participating in the music.
During the next several sessions, Felicity's symptoms escalated. She had difficulty breathing and reported generalized pain. Upon arrival, the children were quiet and anxious, but became relaxed and engaged as they partook in the songs and small instruments that the therapist brought with her. As the touch therapist provided reflexology to Felicity, the father began to sit next to the children and the music therapist in order to sing with them. The children began to use the songs to create and improvise stories about family experiences. For example, a favorite song was “She'll be Comin' Round the Mountain,” the lyrics of which progressed from mountain settings to school stories and then home scenes, eventually including words referring to their desires to be at home together as a family again. The father's presence during the songs inspired the children to communicate with him more in the room, as they hugged and playfully interacted with him, smiling, singing, and listening. The patient, who in the beginning displayed restlessness and feelings of discomfort, appeared relaxed and calm during these sessions, observably in improved states of comfort during and after treatment. The music therapist continued to observe Felicity closely, including her name in songs and assuring that the dynamics of the music were soothing and gentle. Occasionally, the father came to Felicity's side and spoke reassuringly to her. During one of these sessions, the father was noticeably fatigued and distressed and reported that he was not sleeping at night. He was given foot reflexology and promptly fell asleep. At the end of sessions, the touch therapist interacted in the songs, and together with the music therapist, spoke with the family about the benefits of touch, music, and soft singing, encouraging them to help their mother in these ways.
During the last session, this combined approach seemed to benefit them in numerous ways. Felicity had declined and had deteriorated in her ability to respond. She opened her eyes briefly when her husband spoke to her. The children were sitting on the couch and were agitated and restless; the father was tense and teary eyed. While the touch therapist provided Felicity with reflexology, the music therapist sat near the children. They quickly selected instruments and the father began to sing. The children joined in immediately and selected many songs, during which they spontaneously entered words of their own. Their songs were replete with energy and intensity, using active and edgy images. The music therapist altered the dynamics of the music to support Felicity's needs and focused on helping the children express themselves through their symbolic sounds and images. They then selected specific songs to sing, wanting to sing for their mother and help play the guitar. The music therapist encouraged them to include their own words and they told their mother about school, home, and their love for her. During the music, both therapists encouraged the husband and children to sing to Felicity. By the end of the session, the children were relaxed and sat closer to their mother, talking to her with their father. She died a day after the last session.
The combined approach in this case served to improve the expression and involvement of the distressed family members while helping mitigate adverse symptoms. The nurturing presence of human touch that the reflexologist brought to the sessions eased the patient, the husband, and the children as they witnessed the patient being cared for and finding a way to relax into a more comfortable state. Music therapy also served to promote relaxation of patient and family and had pronounced effects on their moods. The music therapy techniques provided the children with a safe, and sometimes symbolic, outlet for their anxieties and fear. The presence of music and the therapeutic techniques eased the family's communication with her, assisted them in finding a sense of comfort in the hospital environment and with her deteriorating condition, and, overall, played a memorable role in helping them prepare for her dying.
Cognitive Impairment
Patients sometimes experience impaired cognitive functioning, especially during the final stages of illness (Ingham & Kachiuk, Reference Ingham, Kachiuk, Berger, Portenoy and Weissman2002). This symptom is particularly stressful for patients and family members when ability to effectively communicate is diminished. This case example presents a patient with disease-related cognitive impairment and his wife and demonstrates the use of a combined music therapy and reflexology approach to ameliorate anxiety and improve ability to communicate.
Joseph was a 63-year-old patient who had been an active volunteer in his community following retirement from his career. His wife was an elementary school teacher in a distant urban neighborhood. According to her, Joseph was well loved in his school-based volunteer work, often observed telling improvised stories to eager children in classrooms. He was diagnosed with a brain tumor a few months before their marriage. As soon as he was diagnosed, they were married immediately, a day before surgery. Joseph was referred to music therapy due to postsurgical communication impairment and spousal distress. In addition, because Joseph loved music and had played the guitar for years, his wife was eager to bring music to his side. He was also referred to reflexology for assistance with pain, relaxation, and tension.
Joseph was diagnosed with a progressive brain tumor. Following surgery, he had symptoms of aphasia. While these symptoms were exacerbated by surgery, it was determined that the expressive impairment would persist due to his prognosis. Initially, each of the therapists individually visited Joseph and his wife as a way to become acquainted with their needs and offer additional support. The music therapist learned that Joseph loved Irish music and collected many of his favorite songs for him. The touch therapist introduced her therapy to the patient and wife and provided him care immediately following surgery. The music therapist also offered soothing music postsurgery. The therapists then suggested a combined approach to treat multiple senses simultaneously and to provide his wife with additional support. The rationale was that this patient could benefit from sensory stimulation and could potentially integrate the benefits of both modalities more comprehensively. The wife eagerly welcomed the concept of this approach. Over a period of 6 months prior to his death at home, Joseph and his wife were seen by both therapists simultaneously for four sessions during two hospitalizations. In addition, the patient and wife received individual treatments by both therapists.
The first two sessions occurred in the days following surgery. Each therapist was situated near Joseph and provided care, assuring that his wife was next to him. Joseph responded instantly to the music and held his hands as if he was playing the guitar. The music therapist held the guitar so that he could strum it and he sporadically attempted to sing fragments of the favorite songs she was singing. He made eye contact with his wife and his restless movements diminished. The therapists encouraged the wife to place herself in his view. During both of these sessions, it was evident that his responses were bringing joy and relief to his wife as she saw him participating in “Danny Boy” and “When Irish Eyes Are Smiling.” The touch therapist demonstrated simple ways she could calm him through touch of hands and feet during times of agitation, and the music therapist encouraged her to use her voice as a way to convey her presence and provide audio stimulation.
Both therapists continued to work with them when he was transferred to his hospital room from the Intensive Care Unit. His levels of awareness improved over the next several weeks; however, he lacked coordination and ability to speak in sentences. His wife talked at length about their relationship and their impromptu hospital wedding ceremony. The music therapist learned their favorite love song and, when he was participating in walking exercises, invited them to dance their “first dance” as a couple, as this had not occurred yet. Joseph seemed uplifted and pleased that he was able to participate meaningfully with his wife, dancing and singing segments of songs for her. His wife was elated during these sessions and, when he was sleeping, would often talk to each therapist about her coping, seeming to benefit from the time to focus on her feelings and receive support.
A few months later, he was readmitted due to progression of disease and need for further testing and treatment. The therapists again worked together with Joseph and his wife, as a way to offer a combined approach for his multiple needs. During these sessions, Joseph was lethargic and weak. As the touch therapist treated Joseph, the music therapist sat near them. When the music began, he opened his eyes and sang brief fragments of “Danny Boy.” As his wife saw glimpses of her husband's personality emerge, she wept and smiled, encouraging and reassuring him. The touch therapist offered her support and continued working on his feet while the music therapist sang their favorite songs. His responsiveness continued throughout the sessions. Joseph appeared calm and relaxed and his wife, while grieving, expressed her joy in being able to interact with him in these ways again. The reflexologist again demonstrated gentle ways of touch that the wife could use during this time of stress.
Before he was discharged to a hospice near their home, the music therapist audio recorded Joseph singing during the sessions. He had wanted to offer this to his wife. The recording was given to his wife as memoir. He died in a hospital near their home.
In this case, the combination of live music and touch served to promote access to levels of awareness and was found to help increase responsiveness and reduce distress. The familiar melodies being sung at his side reached him and helped him become more engaged in his surroundings. This seemed to improve his alertness in ways that could help him become even more cognizant of the nurturing he was receiving through reflexology. Likewise, the soothing touch enhanced relaxation, further assisting him in redeveloping awareness of and communication with those around him. In addition, his wife, while also benefiting from the support offered, witnessed ways to use these complementary sensory mediums in conjunction with one another to reduce his agitation and distress.
DISCUSSION
The combined use of music therapy and reflexology offer physiological, psychosocial, and spiritual benefits to cancer patients and their family members. The use of touch in reflexology reduces pain, tension, and anxiety, while promoting relaxation, and comfort. Touch, whether by the reflexologist or the family member, communicates to the patient, “I am here” and “I care about you,” messages that can reassure and reaffirm a patient's feelings of self worth and purposefulness. Likewise, music therapy offers the medium of acoustic sound in the form of rhythms, melodies, and harmonies. This form of sensory input has been found to stabilize physiological responses, such as breath rate and pulse (Dileo & Bradt, Reference Dileo, Bradt and Dileo1999). Both therapies can influence mood and offer hope. The physical comfort and pleasure commonly experienced during reflexology can instill feelings of calm and peace, helping diffuse fear and anger. Likewise, music has an immediate effect on mood and enhances cognitive functioning, personal expression, and social interactions. The music in music therapy sessions also stirs memories and associations with special times, places, and people in one's life, an effect that often influences one's sense of meaning in life during times when patients are facing multiple losses and changes in body image, self-esteem, and functioning abilities.
Feelings of comfort and sense of control are kept the primary focus. Because music commonly stirs emotions and facilitates reminiscence, the music therapist's ongoing assessment is vital. There are times when the dynamics of favorite music need to be altered in such a way as to provide for control of feelings when emotional strength is needed to cope effectively. The music therapist applies therapeutic skill in the timing, adjustment, and duration of the lyrics and musical dynamics of patient-selected songs, carefully adapting them to promote a sense of peace or to increase physical activity and emotional enlightenment. The use of live music is beneficial due to the multiple benefits of caring presence and the therapist's abilities to respond instantly to needs and issues as they arise.
Both therapies bring human presence. It is well known that nurturance, acceptance, and compassion can reassure and sometimes help foster personal implementation of inner resources in patients and caregivers. The caring presence of the therapists plays important roles in sessions.
Referral to this combined approach is based on need assessment. Patients and families with multifaceted symptoms who are identified as suffering can sometimes benefit from a multisensory approach that can facilitate assimilation of the benefits of each individual therapy, such as in the case of Joseph and his wife. Likewise, when there are multiple family issues and the patient is dying, a multimodal approach may be a way for the family to be together in the same room and have specific needs met simultaneously. This was observed in Felicity's case, as she needed relief from pain and tension and the children needed direct attention and support in expressing their feelings of fear and tension. Ongoing collaborative assessment is vital to appropriately pace each session and avoid overstimulation and sensory depletion. This combined approach was found effective during different stages of disease; however, it was found to be especially meaningful in advanced stages of disease.
CONCLUSION
Music therapy and reflexology provide compassionate comfort and support to cancer patients and families. The combined use of these therapies brings the presence of touch and live music into times of stress. These mediums can penetrate suffering and restore calm, tranquility, and contentment on a deeper level. Ongoing assessment and clinical skill are vital to the timing and pacing of therapies, so as to provide beneficial care and enhance overall well-being. The combined use of these therapies can help foster relief from numerous symptoms of distress, especially in those cases where multiple needs would benefit from a simultaneous treatment of physical and psychosocial issues. The compassion, empathy, and acceptance that are conveyed in the caring presence of professionals can potentially provide for long-to-be-recalled moments of communication, sharing, and peace.
