Effects of music therapy on mood, pain, and satisfaction in the neurologic inpatient setting

Abstract Purpose Music therapy (MT) has been used in health care settings for a wide variety of treatment goals. Many inpatients with neurologic impairments struggle with low mood and pain for which MT may be a novel adjunct treatment. The aims of this study were to: (1) evaluate change in mood and pain following a single MT session; (2) explore the impact of an MT program on mood, pain and satisfaction from the perspective of the patient, family and staff. Materials and methods A mixed-methods study was conducted. Forty participants completed pre/post MT surveys evaluating mood, pain and satisfaction. Individual semi-structured interviews and focus groups were conducted with 14 MT program participants (inpatients), 5 family members of participants and 16 staff. Results There was significant improvement in mood (p < 0.001) and decrease in pain (p < 0.05) from pre-to-post MT with 74% reporting being “very satisfied” with the session. “Benefits of MT” was the overarching theme of the qualitative data. Subthemes were emotional regulation, pain management, effects on self-concept, enjoyment, and social connectedness. Conclusions Improvements in mood and pain were reported from pre-to-post MT session and in interviews. Further evaluation of MT effectiveness against standard of care rehabilitation and cost implications is required. Implications for Rehabilitation Music therapy (MT) is delivered by accredited music therapists (MTAs) in health care settings, including rehabilitation units, as an individual, group or co-treatment therapy. MT can be used for a range of health outcomes, including the treatment of mood and pain, in addition to improving inpatient satisfaction. Early evidence using pre/post MT surveys suggests an improvement in mood and pain following a single therapy session. Qualitative data suggest overall benefit of offering MT services in addition to standard neurorehabilitation therapy, including improvements to emotional regulation, pain management, self-concept, enjoyment, and social connectedness.


Introduction
In Canada, the prevalence of acute neurologic disorders requiring inpatient neurorehabilitation is increasing [1,2]. This includes, but is not limited to, diagnoses of spinal cord injury (SCI), traumatic and non-traumatic brain injury, central nervous system tumors, neurovascular conditions including stroke, and select neurodegenerative disorders [3]. The incidence of pain and mood-related disorders in hospitalized neurorehabilitation patients ranges from 14% to 80% and 20% to 50%, respectively [4]. For many acute neurorehabilitation patients, it is felt that it is the combination of physical, functional, and psychosocial impairments which contribute to the increased rates of depression and anxiety, and the number of co-morbid conditions that adversely affect quality of life [4,5].
Traditionally, high-intensity neurorehabilitation is performed in hospital and involves a combination of physical, occupational, speech, and/or recreational therapy [6]. The goals of any rehabilitation program are to improve functional independence, reduce activity limitations, and to facilitate participation in important life roles [7,8]. In the acute neurorehabilitation setting, pain and low mood have the greatest potential to negatively impact rehabilitation participation [9,10]. While pharmacologic management is often appropriate for managing these symptoms, especially when severe, non-invasive and non-pharmacologic strategies should not be underestimated. Music therapy (MT) is a potentially novel approach shown to improve mental state and functioning for a variety of disorders including depression, generalized anxiety, and dementia as well as reduce anxiety in patients with asthma, osteoarthritis, and those undergoing medical procedures [10][11][12][13][14][15]. Recent reviews have also demonstrated reductions in postoperative pain and anxiety, decreased consumption of sedatives and analgesics, and increased patient satisfaction in hospitalized patients receiving MT [12][13][14]16]. Therefore, MT may offer a unique adjunct strategy to manage pain and low mood in neurorehabilitation patients [17].
This mixed-methods study evaluated the impact of participation in an MT program in the short term (following a single MT session) using quantitative methods and over time using qualitative methods. The aims of this study were to: (1) evaluate change in mood and pain following a single MT session; (2) explore the impact of an MT program on mood, pain, and satisfaction of inpatients from the perspective of the patient, health care professional, and family.

Material and methods
This study was approved by the University of Calgary Conjoint Health Research Ethics Board (REB18-1145) and registered with clinicaltrials. gov (NCT03829813).
This mixed-methods study included patients, health care professionals, and family members of patients in contact with or directly participating in the MT program at a tertiary academic center in Calgary, Canada between November 2018 and February 2020. The MT program included individual, group, and co-treatment therapy sessions (see Table 1) provided by certified music therapists (MTAs). Both quantitative and qualitative methods were used with concurrent data collection for both components. The quantitative component involved pre and post MT session reporting of mood, pain, and satisfaction via standardized surveys. A subset of participants, whether having received individual, group or co-treatment therapy, were invited to participate in a semistructured interview to explore the benefits and barriers of participating in MT. Semi-structured interviews were also conducted with family members and health care professionals of patients receiving MT.

Participants
Participants receiving MT on acute neurologic units (i.e., neurologic step-down, general neurologic, or acute spine and stroke) or a tertiary neurorehabilitation unit were approached to participate in the study. Eligible unit patients had attended at least one MT session and were fluent in English. Participants with variable time on the unit were included. Individuals with aphasia were excluded from study participation, but could participate in the MT program. There was no further exclusion criteria for individuals with cognitive difficulties. Upon starting the qualitative portion of the study, all participants having attended at least one MT session were eligible and provided the opportunity to participate in an individual interview or focus group. Focus groups followed group MT sessions on pre-determined days. If participants having attended the group session did not feel comfortable participating in the focus group, but still wanted to provide feedback, the option of an individual interview was offered.
Immediate family members of patients participating in the MT program were eligible to participate in an interview if they had attended at least one MT session with the patient.
Health care professionals eligible to participate in an interview included nurses, unit clerks, physiotherapists, occupational therapists, recreational therapists, speech-language pathologists, program volunteers, porters, and MTAs. Staff were eligible if they had been present at an MT session, if they conducted co-treatments or if they cared for patients receiving MT. A broad inclusion criteria was used for recruitment of health care professionals with the aim of representing the perceived impacts of the MT program on staff (workload, morale, social connectedness, satisfaction, etc.).
We enrolled a sample of 40 participants for the quantitative portion of the study. Recruitment was ended prior to the anticipated end-date due to the COVID-19 pandemic. Individual interviews and focus groups included a total of 35 participants before reaching data saturation.

Intervention
The MT program is a donor-funded initiative introduced in April 2018 for select inpatient units. MTAs provided MT services on each of the acute neurologic units and a tertiary neurorehabilitation unit one or two times per week. Patients could be referred to the MT program by any member of their care team (nurse, speech language pathologist, physiotherapist, occupational therapist) or self-refer to the program through the completion of a standardized intake form. Patients may be referred for a variety of care needs such as help with expressive speech, mood, pain, relaxation, socialization, creative expression, respiratory function, or motor coordination (including gait). Upon referral review by the MTA, additional information on the patient, diagnosis, or care needs was provided by the unit clerk if needed. Participation in individual versus group or co-treatment therapy was based on unit, patient needs, and staffing. The number of therapy sessions received by each patient in the program varied depending on other patient therapies, MTA availability, and length of hospital stay. Several patients received MT sessions on both an acute and tertiary neurorehabilitation unit over the course of their hospital stay. MT goals and techniques varied depending on therapy modality (individual versus group versus co-treatment), the patient's needs and their physical abilities. MTAs are trained to use a broad scope of techniques depending on therapy goals (see Table 2).

Procedure
Upon referral to the MT program an MTA approached the patient to offer therapy. Program MTAs also worked with physiotherapists, occupational therapists, recreation therapists, and speechlanguage pathologists in co-treatment sessions. Patients receiving MT were approached to participate in either the quantitative and/ or qualitative part(s) of the study. All participants signed informed consent prior to completing pre/post surveys and/or a qualitative interview or focus group. For participants who were unable to provide written consent due to upper extremity motor impairment or limited cognitive/expressive communication, verbal consent was obtained with surrogate signatures by a neutral third party.

Pre/post music therapy surveys
Participants completed a series of questions prior to and directly following either individual or group MT sessions. Surveys were administered verbally by a trained program volunteer (who did not have a role in administering the MT) to ensure all participants (including those with cognitive difficulties) understood the rating scales and other measures.
Measures. Primary outcomes of pain and mood were rated using a numeric and faces visual analogue scale (VAS) prior to and immediately following a single MT session. Mood was assessed verbally by asking "How are you feeling". Participants were presented with a VAS: 0 ¼ sad, down, depressed; 10 ¼ happy, great, awesome. Similarly, pain was assessed ("How much pain do you feel?") with a VAS: 0 ¼ no pain; 10 ¼ most severe pain. Numeric and faces VAS have been validated in the literature and used in prior MT intervention studies for measuring pain and mood [10,[17][18][19][20][21][22].
Participant health goals ("How did the music therapy session impact your health goals related to … ?") including mood/anxiety/ emotional wellbeing and pain management were self-reported following MT sessions as either: 1 ¼ much worse; 2 ¼ worse; 3 ¼ same/no change; 4 ¼ better; 5 ¼ much better. Participants were also asked to rate their "satisfaction with the music therapy session today" as follows:

Semi-structured interviews
This study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [23]. Written and verbal consent were obtained prior to interviews. Authors D. M. L., a medical doctor and trained qualitative researcher, and two graduate students, conducted all interviews in person or over the phone. Focus groups were conducted in person and did not exceed five participants. Interviewers had no prior relationship with participants and the research question and goals of the interview were shared with all participants prior to the start of the interview. Interviews were semi-structured, with open-ended questions designed to explore the benefits and barriers of MT, program implementation factors and the impact of MT on relationships (see Supplementary  Figure 1 for Interview Guide). Interviews were designed in line with the theoretical framework of grounded theory. Initially an inductive approach to questioning was undertaken with deductive questioning to test assertions performed later.
Neurologic patients participated in either individual interviews or focus groups depending on participant availability, conflicts with other therapies and patient preference. Family members of patients were interviewed either with or without the patient present. All health care professionals were interviewed individually.

Analysis
Quantitative data -pre/post music therapy surveys Pre and post mood and pain VAS scores were not normally distributed. Therefore, a Wilcoxon test for paired samples was performed to assess change in mood and pain VAS scores from participants' MT session. Given the high frequency of no difference (from pre-to-post session), the test was repeated with only participants whose score (either pain or mood) had changed. A linear mixed-effects model was also utilized since pre and post VAS scores were clustered per participant. The model allowed us to confirm if our conclusion from the Wilcoxon test was robust and investigate which risk factors were associated with mood and pain changes. Current participant unit (acute neuro versus subacute neurorehabilitation), session type (individual versus group), and age (<60 versus �60) were examined as risk factors.

Qualitative data
Interviews and focus groups were audio recorded, de-identified, then transcribed verbatim. Interviews ranged from 15 to 70 mins. Focus groups were approximately 45 mins in length. Follow up questions were asked to expand on prompts in the interview guide (see Supplementary Figure 1) to further explore the concepts of mood, pain, and satisfaction and ensure observations were attributed to participation in the MT program. Data were independently coded line-by-line in duplicate (by co-authors D. M. L., a medical doctor, and L. J. M., a graduate student) using QSR International's NVivo 10 Software [24]. Coders first familiarized themselves with the data and created a "living" codebook with hierarchical categories, which was updated as new themes emerged from the data during coding. Coders met throughout the coding process to compare coded themes, review terminology, hierarchy of themes/sub-themes and collapse categories. The process of updating the codebook was iterative and continued until all data were coded and authors reached a consensus. Authors agreed there was consistency among categorization of themes/subthemes.

Results
Forty-four participants aged 59 ± 12 years were included. Five eligible individuals approached to participate declined. Participant characteristics and MT session type (i.e., individual versus group) are presented in Table 3.

Pre/post music therapy mood & pain
Mood VAS ratings before and after MT sessions were a mean of 5.8 ± 2.5 and 7.4 ± 2.5, respectively. Change scores (pre-to-post) are presented in Figure 1(A); this change was significant. The same conclusion was drawn when including only participants with a change in mood VAS score (beta1 ¼ 1.52, p < 0.001, from the data including no changes; beta1 ¼ 2. 16, p < 0.001, from the data excluding no changes). In the linear-effects model, none of the investigated risk factors (hospital unit, MT session type, age) were significantly associated with mood VAS change.
Pain VAS ratings before and after MT sessions were a mean of 3.4 ± 3.0 and 2.8 ± 2.8, respectively. There was a significant pre-topost decrease in pain in the linear mixed-effect model (b1 ¼ À 0.6, p < 0.05, from the data including no changes; b1 ¼ À 1.31, p < 0.05, from the data excluding no changes). However, none of the participant characteristics were significantly associated with score change (Figure 2).
Participant health goal data related to impact of the MT session on "mood/anxiety/emotional wellbeing" and "pain management" is reported in Figure 3. Participant satisfaction with their first MT session is also reported in Figure 3.

Interviews & focus groups
A total of 35 participants (n ¼ 14 patients; n ¼ 5 family members; n ¼ 16 health care professionals) participated in individual interviews (n ¼ 20) or focus groups (n ¼ 5). The overarching theme of the study was "benefits of MT." Subthemes represent the various perceived benefits of MT as an adjunct to patients' standard of care neurorehabilitation therapies. These included: (1) emotional regulation, (2) pain management; (3) effects on self-concept; (4) enjoyment; and (5) social connectedness.

Subtheme 1: Emotional regulation
Music is known for its ability to influence mood and provoke emotion. MTAs use music in a purposeful manner for specific treatment goals, which may include improvement of mood and relaxation. MT can also facilitate patients' expression of emotions, due in part to the safe environment it creates, the emotions and memories that songs trigger, or through verbal counselling.
Improved mood. During their long hospital stay, neurorehabilitation patients may experience mental health struggles, including low mood. A variety of factors contribute to low mood in these individuals including coping with a new disability, changes to self-concept, being an inpatient for a prolonged duration and separation from family. Many patients expressed the benefits MT sessions had on their mood. In many cases, they contrasted the benefits of MT in this regard compared to other standard of care rehabilitation therapies (i.e. physical therapy, occupational therapy).
During about five or sometimes six sessions a day of physiotherapy in different forms, I might be just beyond exhausted. But then when I come here [MT group] it lifts me up and makes me feel really good and I guess it brightens my day and then just kind of gives me the motivation, oh, yes, I can do another day of physiotherapy. So it really brightens my mood and lifts me up. (P09, focus group, patient, female) I've seen everything from being very upset and depressed and in a lot of pain, and they [patients] come here [MT group] and you're smiling. You don't see that throughout the day really, when they're in other therapies, when they're doing that work. But they can come here and they're just almost different people. Happy, smiling with each other, joking with each other. (P03, focus group, hospital porter, male) Given the chronic conditions being treated on the neurorehabilitation unit (from which 71% of participants were recruited) and intensity of daily therapies, patient mood can affect the liveliness of the unit. Improvements in mood were not only reported during/immediately after MT sessions, but were also reported to persist following therapy, thus positively impacting the atmosphere on the unit. Both patients and staff reported a positive, lightened mood on the unit from: (a) music being played on the unit (individual MT sessions in patients' rooms); and (b) improved mood of patients following group sessions.    Mood and pain were rated on a 5-point scale (much worse to much better). Satisfaction was rated on a 5-point scale (very dissatisfied to very satisfied) (A) Answer to "How did the music therapy session impact your health goals related to mood/anxiety/emotional wellbeing?" (B) Answer to "How did the music therapy session impact your health goals related to pain management?" (C) Answer to "How satisfied were you with the music therapy session today?" It's nice to see that the excitement isn't just the patients. The other thing is I think, it's powerful when music therapy is happening, and the staff are enjoying and benefitting at the same time. Particularly in acute care, there's a lot of sad stories and the staff really benefit from hearing music and have really commented on how it has really helped their day when it has been a particularly rough day. Maybe they had a code and the tension is high. They are benefitting as well. (P03, focus group, MT program volunteer, female) I would say it's probably one of the best programs I've seen in my years of nursing here that makes the largest benefit to patients and staff as far as attitude and mood and decreasing patients' depression and anxiety. (P16, interview, nurse, female)

Calm & relaxation.
MT has been used in other patient populations for treatment of agitation [25]. Staff members reported situations where MT was used to manage patient agitation or provide general calming and relaxing effects. In some cases, this helped the nursing staff to complete their tasks in a calmer, safer environment.
[It was] Overall, quite a difficult situation for staff and for the family and patient. And then it was pretty amazing. We had music therapy come in one day, and for the first time ever he [patient] was calm. And then a few songs in, he was so engaged with the music and he started tearing up. And you could just tell there is a connection there that we hadn't seen before. And just a piece of, I guess, humanity, that we saw in him. that was a really amazing thing for us. (P11, interview, nurse, female) The calming effect of participating in the MT group was echoed by patients and their family members. Either individual or group MT sessions provide a unique time during the day for patients to relax, reflect, and have a reprieve from their tiring rehabilitation therapy schedules.
Music gives me relaxation, and it gives you time to breathe and sometimes to think about and relax and be yourself, right? So, I think it helps a lot of us to cope with different, let's say, whatever we are feeling it gives us a bit of breathing, that we are here, especially this music group. Actually, it gives us comfort (P23, focus group, patient, female)

Expression of emotions.
Patients reported that MT sessions provided a time to process and express the range of complex emotions that accompany a (for many) life-changing injury. Whether it was during verbal counselling (within the scope of MTA practice) or a particularly touching song, patients described the importance of expressing their emotions and that apart for their MT sessions they did not have many other outlets for this.
It's a really nice release. And I find that I walk away or I leave the group feeling really happy or sometimes very sad. It provokes a lot of different emotions for me, but I think all of it is very cleansing and purifying, actually. So being happy or sad, I welcome all. And with this group it allows me to have that experience. (P09, focus group, patient, male) Subtheme 2: Pain management Distraction from pain. Participants commented on the impact of MT in terms of pain management. While this is a heterogeneous population, not all of whom suffer with pain, those who do commented on the ability of MT sessions to serve as a distraction from their pain.
From day one that I heard about it, I just though this is just one of the best things that could happen in health care, period, especially as far as pain management. It's amazing. (P03, focus group, hospital porter, male) Even after people [ … ] they've done therapies all day. You can tell they're spent, they're in pain, but they come here [MT group], and they just forget it. They forget all about it and they're just so focused and they're so happy. (P03, focus group, hospital porter, male)

Reduced medication requirement.
There is a high rate of polypharmacy in the patients on the neurorehabilitation unit, with many individuals continuing to be treated for pain following an accident or surgery. Music has previously been investigated in other patient populations for reducing postoperative analgesic use [13]. Here, staff commented anecdotally of cases in which patients declined pain medication or delayed doses following MT sessions. I find that they don't need as much pain medication when they participate in the music therapy because I believe music therapy provokes a physiologic response. Like we've already discussed it releases endorphins.
[ … ] And I think if we were to delve into it a bit further I think it decreases their hospital stays, shortens it. (P17, interview, nurse, female)

Subtheme 3: Effects on self-concept
Self-concept can be defined as an individual's answer to the question, "Who am I?". Following a traumatic and/or debilitating injury such as a traumatic brain injury or SCI (as experienced by neurologic inpatients in this study), the "disabled self" may dominate the way individuals perceive themselves. The use of songwriting for reconstruction of self-concept post-injury has previously been evaluated for individuals with SCI [26]. However, other MT techniques can also be used to foster self-confidence, trigger memories of the pre-morbid self and foster hope for the future. These themes were commonly reported by patients who participated in the MT program.
Self-confidence. MT, especially individual sessions, are goal focused and follow individualized treatment plans. MTAs are trained healthcare professionals that can assist with a range of functional rehabilitation goals in co-treatments with other allied health staff. Health care staff reported on the benefits of co-treatments with MTAs on patients' self-esteem.
[ … ] at least for the half an hour [of MT] he could demonstrate that he had all those skills of being loud and being um using good breath support and improved speech intelligibility. With that half an hour doing music therapy and that was even good for his own self-esteem because he was able to hear himself sound clear and sound good and close to normal. He loved it … those were probably his favourite sessions of the week. (P02, interview, speech language pathologist, female) You know, because some people think ok I am not worthy to have these [MT] one-on-one sessions, 'look at me', and people after injury a lot of times you know with spinal cord injury and brain injury they don't see themselves as the same. They don't have a self-concept. Their self-concept has also been injured by the injury so I think that music therapy really helps to bring out that positive self-concept. (P17, interview, nurse, female)

Memory of pre-morbid self.
MT is a powerful therapy for triggering memories associated with music, especially in neurologic populations with memory impairment and can also serve to reconnect individuals with their passion for music. Music may also trigger memories of happy times prior to their injury, serving as an escape from their present reality.
We had this patient and I guess he used to be an opera singer way back in the day and nobody knew that about him because we just have our kind of limited kind of information. And then um, he had heard that music was playing in another room and he was like, 'What is that?', oh 'That is our music therapist, did you want her to come in and see you next?', and he was like 'Oh yes!' and then so we like filled out the form with him and then [the MTA] went in to see him in like a couple patients. [ … ] Like it was so good just cuz he really opened up. And then we couldn't stop him from singing after that day. (P20, interview, nurse, female) Hope for the future. MT uniquely serves those who were previously very musical and may have lost that part of their identity following their injury. This may be due to aphasia or impaired motor control hindering ability to play an instrument. For these patients, providing a specialized therapy (MT) with a targeted treatment goal of returning these individuals to playing an instrument they love can have a great impact on quality of life and provide hope for the future. Instrument playing can be facilitated through co-treatments between MTAs and physiotherapy or occupational therapy. For certain individuals, the ability to return to playing an instrument (in some capacity) can be an important benchmark in their recovery and provide hope and motivation to continue in their rehabilitation. I think different people are in different spaces emotionally, and we just have to honour that, and go with the flow. But I think overall, most of our participants have always felt better after. Sometimes it [MT] does touch a nerve, so to speak. But I think that that's also beneficial. It helps people with healing and growth and to learn that they can play music in different ways, that may not be the way they played before. I think that's important (P03, focus group, volunteer, female)

Subtheme 4: Enjoyment
Life as an inpatient brings with it unique challenges, including the drastic change in one's daily schedule largely centered around the individual's illness and their rehabilitation. Patients described MT as an enjoyable respite from their taxing rehabilitation schedule, with the group MT sessions serving as a form of entertainment for some patients.
Well, of course when you're sick, you're undergoing a lot of different emotions. Your emotions are erratic, so sometimes you're happy, sometimes you're sad, you're crying and everything because you're trying to cope, right? [ … ] And when you sing or when we are in the group, as I mentioned earlier, it gives us a breather, right? I mean like a chance to at least enjoy, and not think about the sickness, but just be with each other and just try to enjoy the music, which we all love [ … ] (P23, focus group, patient, female)

Enjoyment of MT in contrast to other therapies.
Rehabilitation therapies, such as physiotherapy, occupational therapy, and speech therapy, are generally oriented to treatment goals and patient outcomes. While MTAs also develop goal-oriented treatment plans, patients describe this type of therapy as uniquely enjoyable, serving as a balance to other therapies that may be more physically or mentally arduous. Participants who attended the MT group with a family member reported that the group setting not only brought them joy but was also a time where family members could relax and de-stress.

Subtheme 5: Social connectedness
Social connectedness can be defined as the relationships you have with the people around you whether close or distant. In addition to significant therapy and adapting to new physical and/ or cognitive impairments, one's time as an inpatient (specifically, in the neurorehabilitation context) may also be marked with loneliness and difficulty expressing oneself. During interviews, patients highlighted that MT allowed for personal expression, connection to family members and connection with peers (fellow inpatients).

Personal expression.
In some cases, MTAs may propose the creation of a song or "legacy track" for patients. Legacy tracks are pieces of music written and recorded by the patient with the help of an MTA. Legacy tracks may either serve to tell a patient's life story or articulate a message to loved ones. This lasting piece of music can help convey powerful emotion and deeply touch family members. Patients spoke of the deep impact this exercise had on them and their loved ones. Patients endorsed that the MT sessions allowed a safe space for them and their peers to express their feelings. For some, this was an emotional release, such as crying, and for other this included sharing memories or stories of a particular song with the group.
So we talked about how certain songs make us relax, or be happy, or even sad. [ … ] So, that was very interesting to me. It just points out how emotional music can be. Different times, different people have tears, but there's a lot of mutual support in the [MT] group. (P03, focus group, patient, male) Connection to family members. For some patients, the MT sessions offered an opportunity to spend time with loved ones apart from the day-to-day routine of being an inpatient. This provided an unexpected chance for family members, in some cases who had previously not been close, to re-connect.
[patient] and I haven't lived together for 20 years or more, and because of the medical problems now we're constantly together. But I'm learning so much about her and the music class is part of that. Knowing her moods and how much the music means to her, it's just a way to get closer, that we haven't been through [ Connection to peers. During interviews and focus groups, participants expressed that there is a lack of camaraderie on the neurorehabilitation unit and it is difficult to get to know fellow inpatients. This may lead to an increased sense of loneliness, especially for those with few visitors or external supports. Patients reported spending time with peers in the MT group translated to increased engagement once back on the unit; this was also endorsed by staff. Feedback in this regard was related to the group (not individual) MT sessions.
Probably the best thing I've seen is that the music therapy group that they have, where it really becomes like a social gathering for people, where their mood is lifted and they leave that group so happy and have made new friends and it's really the most positive feedback I've gotten from patients is how much they love going to that group that's really well run by the music therapist there. (P02, interview, speech language pathologist, female) Likewise, patients reported on the impact that the camaraderie provided by the MT group had on their experience as an inpatient. There was also recognition that many patients are experiencing the same challenges, emotions and fears and that MT group sessions provide a forum to connect. The group sessions allowed patients to share their feelings with others and debrief following long days of (other) therapy.
That's something we hear time and time again, is the camaraderie from the group. Getting to know the others and feeling that it is a safe environment to express yourself, share what's on your mind. What were the struggles of that day, what were the successes? Just as we heard today with someone being able to stand up for the first time and share that with the group, I think that leads to further motivation for the recovery. (P03, focus group, patient, male) And then also I was able to connect with my fellow patients. I think that's the important thing. I got to know them, because when you go upstairs [to the unit], you just only see their faces, but you don't really know them. And all of us in a very, you know, in a situation we're in, we are really in a unique situation right now in our lives, and we need support. (P23, focus group, patient, female)

Appreciation for program
Throughout the interviews and focus groups, patients, family members, and staff reported a variety of positive impacts of the program, generally advocating for increased adoption of music in the neurorehabilitation setting. Further, 74% of patients reported being "very satisfied" with their first MT session (see Figure 3). I think overall, it's a really great initiative. I've seen really positive, I've heard really positive feedback from the patients. I've seen personally patients respond really well to music therapy and I am really excited to have the program continue to grow and develop. (P02, interview, speech language pathologist, female) So, I'm very thankful. And every hospital should have music therapy in it, seven days a week, honestly. (P23, focus group, patient, male) Um I don't know what to say other than I love music therapy (P22, interview, patient, male)

Discussion
MT is emerging as a potentially useful complimentary neurorehabilitation therapy modality for a variety of outcomes, including mood and pain [27][28][29]. While many studies have evaluated music listening and rhythmic auditory stimulation interventions in neurologic populations [27], relatively few have evaluated music interventions delivered by accredited music therapists (MTAs). MTAs have specialized training to deliver therapy addressing a broad scope of patient goals with a variety of techniques (see Table 2). This study presents pain and mood outcomes in the short term (following a single MT session) using quantitative methods and in MT program participants over time using qualitative methods. Interviews and focus groups including patients, family members and health care professionals provided a comprehensive report of the benefits of the described MT program with five subthemes emerging: (a) emotional regulation; (b) pain management; (c) effects on self-concept; (d) enjoyment; and (e) social connectedness. To our knowledge, no studies have previously reported on the benefits of MT for neurologic inpatients including the perspectives of both family members of patients and health care professionals, despite these perspectives being vital in gaining a comprehensive understanding of the impact of such therapy. Our findings suggest there is improvement in mood and pain VAS scores following a single MT session, though results did not reach clinical significance (defined as a 3-point change (for mood) or 1.3-point change (for pain) on an 11-point VAS scale) [30]. Further, 95% of participants reported being "somewhat satisfied" or "very satisfied" with their first MT session. Our study suggests that patients experience benefits to mood and pain from even a single MT session, but that (qualitatively) there is even greater improvement in these outcomes with repeated exposure over time.

Impact of music therapy on mood outcomes
Improvement in mood was reported both pre-to-post MT sessions and "Improved mood" emerged as a sub-subtheme (under "Emotional regulation" subtheme) in the qualitative data. There was a mean improvement in mood VAS scores of 1.6-points, which did not meet clinical significance. Assessments were made following participants' first MT session and greater improvement in mood scores would likely be seen with an increased dose over time (i.e., 3�/week for 30-60 mins) [14]. Improvement in mood across the intervention (qualitative data) was not only described by MT program participants but also by family members of participants and health care professionals. The unit staff specifically commented on liveliness of the unit following group and individual sessions, which had a significant positive impact on both patients and staff. The MT program accepted referrals for all patients interested in participating in MT; however, not all individuals may benefit equally from MT interventions, which may be in part mediated by an individual's ability to experience pleasure from musical activities. A positive correlation between improvement in motor outcomes and participants' capacity to experience pleasure from engaging in musical activities has previously been reported in a stroke cohort [31]. It is likely some participants intrinsically experienced more pleasure from the music, thus reporting greater improvement in mood post-session. A measure of musical activity enjoyment should be considered in future work. Further, mood data were collected following both individual and group MT sessions. Although session type (individual versus group) did not emerge as a factor significantly associated with mood VAS change, it is important to consider how session type may influence mood outcomes. Individual MT sessions contain a greater amount of patient-preferred live music (PPLM) compared to group sessions, which aim to broadly appeal to group participants. PPLM can be defined as "a receptive MT experience involving music selected and preferred by the patient" [32]. Improvement on a mood VAS following listening to (patientselected) preferred pleasant music for 1 min (compared to unpleasant music or white noise) has previously been reported in patients following stroke [33].
Multiple other studies in cohorts following stroke have evaluated changes in mood following a wide variety of active music interventions, including music-supported therapy [34], music-movement therapy [35], group MT [36], individual MT [37,38], improvisational MT [39], relational active MT [40], and neurologic music therapy [41]. Comparison is limited by heterogeneity of intervention (type, duration, individual versus group) and variety of outcome measures. However, several studies have also reported positive mood outcomes [36,38,40,42]. Using an intervention similar to the group MT sessions described in this study, Kim et al. [36] evaluated mood following 4-weeks of MT (2 � 40 mins per week) versus standard of care. The MT sessions consisted of a hello song, planned musical activities, sharing of feelings and a goodbye song [36], closely mirroring the group sessions delivered as part of the MT program at our institution. Following the 4-week intervention Kim et al. found a significant decrease in Beck Depression Inventory scores in the intervention (MT) group [36]. Similar to our findings, short term improvements in mood following a single MT session were also reported by Rushing et al. following a 30 min MT session [38]. The reported mean score change was 0.84-points, compared to a change of 1.6-points reported in our study [38]. However, they used a 7point scale compared to the 11-point scale employed in this study and their cohort was recruited within 2 weeks of stroke, whereas the majority of our study participants were weeks-months post-hospital admission [38]. Notably, their intervention (Rushing et al.) was also delivered by board-certified music therapists [38]. Similarly, a study by Street et al. evaluating pre/post VAS scores following a single Neurologic Music Therapy session reported a significant increase in "Happy" scores and a significant decrease in "Sad" scores [41]. Taken together, these studies suggest that one session of MT in either the acute or sub-acute phase of stroke recovery/rehabilitation has a positive effect on participant mood. Only one other qualitative study in a stroke cohort reported on mood following a music-based intervention [43,44]. Forsblom et al. evaluated daily preferred music (�1 h per day for 8 weeks) vs. audiobook listening [43,44]. Meaning units (from interviews) falling under the "positive mood change" response category were reported significantly more in the musiclistening group (versus the audiobook listening group) [43,44].
In the context of music-interventions for SCI rehabilitation, the majority of studies including mood outcomes have evaluated a 12-week songwriting intervention for self-concept [26,45,46]. However, the only RCT to evaluate this intervention versus standard of care did not find a significant improvement in mood outcomes compared to the control group; mood was not the primary outcome [45]. However, there are qualitative data to support improvements in mood following the 12-week songwriting intervention [47]. While some of the participants in the MT program at our institution did work with MTAs to write songs/legacy tracks, participants reported positive benefits to social connectedness/ self-expression, rather than improved mood with songwriting. Similarly, following a 12-week intervention of group singing versus music appreciation/relaxation, mood outcomes did not significantly differ between groups [48]; however, qualitative data did report improved mood and less depressed thoughts [49]. This intervention had a primary aim of improving respiratory function [48,49].

Impact of music therapy on pain outcomes
There was a significant decrease in pain VAS scores from pre-topost MT session, although score change did not reach clinical significance. This may be due to several factors. First, pre-session pain scores were relatively low (mean of 3.4 on an 11-point scale); to reach clinical significance the mean post-session pain score would have had to be 2.1-points [30]. Further, the majority of our cohort was in the sub-acute/chronic stage of recovery and their pain was being treated pharmacologically, or rather pain was no longer a chief complaint. Unfortunately, pain medication data and dosing schedules (relative to MT session administration) were not collected. A subtheme of "Pain management" emerged from the qualitative data. Patients reported on the ability of MT sessions to distract from pain, serving as a form of entertainment so as to take focus away from the pain. Staff anecdotally reported on delayed administration of pain medications following MT sessions, which again may be due in part to the ability of MT to distract from pain, which may persist even once the session has ended. A small number of studies in stroke and SCI cohorts have previously reported on pain following music-based interventions. Scholz et al. found that musical sonification therapy reduced joint pain following a 10-day upper-extremity motor training protocol for individuals following stroke [50]. Wood et al. evaluated pre/postsession pain (using an 11-point VAS scale) following two musicassisted relaxation (MAR) sessions for individuals acutely post-SCI [51]. A greater mean difference in pain scores (1.6-points) was reported by Wood et al. [51] compared to our study (0.8-points); however, this may be explained by a relatively higher pain rating pre-session, cohorts being in different stages of recovery (acute versus sub-acute/chronic) and difference in MT interventions being evaluated (MAR versus individual/group MT sessions). Further, in a patient satisfaction survey following the MAR intervention, 80% reported "decreased perception of pain" [51]. There is also qualitative data to support the ability of a variety of music interventions to distract from pain or improve pain control in individuals with SCI [47,52,53]. There is great need for larger trials of music-based interventions evaluating pain outcomes and medication use in neurologic populations, specifically in the acute period following injury.

Impact of music therapy on patient satisfaction
Positive effects of music-based interventions on patient satisfaction have been reported in several patient cohorts, including inpatients discharged from medical/surgical units [54], individuals in the emergency department [55], during endoscopy/colonoscopy [56], and during childbirth/cesarean section [57,58]. Following a single session of individual or group MT, 74% of our cohort reported being "very satisfied" and 21% reported being "somewhat satisfied" with the therapy. Satisfaction with a group MT program was also reported by Kim et al. with 67% of patients endorsing that "MT inspired motivation and actually helped rehabilitation treatment, and that they would actively recommend MT to others" following a 4-week intervention [36]. Group MT sessions described by Kim et al. [36] closely mirrored those delivered at our institution. Wood et al. reported on patient satisfaction following two individual MT sessions delivered acutely post-SCI, where 80% of participants reported being "very satisfied" with the MT services received (20% no response) [51].

Limitations
There were several limitations to this study. Quantitative mood/ pain scores were only collected at a single timepoint (first MT session). Greater improvement may have been seen with adequate dosing (i.e., 3�/week for 30-60 mins). Individuals having participated in either individual and/or group MT sessions were included, therefore there was considerable variability across sessions in terms of MT techniques employed. Individual sessions are tailored to patient-specific treatment goals, whereas group MT is not. However, session type (individual versus group) was not significantly associated with mood or pain VAS score change. Group sizes were also variable, which could impact the subjective experience of participants across different sessions. Music type was also variable with individual sessions having a greater component of PPLM. It is likely that many participants in the cohort were being treated pharmacologically for their pain and therefore it was no longer a chief complaint; this was reflected by the relatively low pre-session VAS scores. Alternatively, not all neurorehabilitation patients (and thus MT program participants) have pain and may be attending MT for other reasons (mood, enjoyment, etc.). Medication data and diagnoses of depression or other psychiatric conditions were not collected. All participants were receiving standard of care treatment/therapies at an academic tertiary care center; however, as data on daily therapies and medications were not collected, we cannot directly comment on the impact of additional therapy load on response to MT. However, hospital unit (acute versus sub-acute) was not significantly associated with mood or pain score change, suggesting that other interventions (standard of care) did not significantly influence the variables of interest. Finally, this study did not include a control group.

Music therapy delivery in the COVID-19 context
The COVID-19 pandemic has introduced new challenges to the delivery of adjunct rehabilitation programs (such as MT) in hospitals and continuing care. Work has been done by other groups to promote music listening programs [59] and employ MT telerehabilitation to combat loneliness and reduce feelings of anxiety on a neurosciences unit during the pandemic [60]. Bonakdarpour et al. reported that following 30-40 mins telemusic sessions, participants indicated improved mental and emotional state (9.2 on 10-point Likert scale) and endorsed it to be a pleasurable experience (9.2 on 10-point Likert scale) [60]. Since the end of study data collection, we too have successfully implemented virtual MT sessions [61]; however, benefits of virtual versus in persons sessions on the presented outcomes (mood, pain, satisfaction) have yet to be explored.

Conclusions
This mixed-methods study demonstrates improvement in mood and pain outcomes following a single MT session in addition to characterizing the benefits of participating in an MT program from the perspective of the patient, family members, and health care professionals. This study suggests that neurologic inpatients with a variety of diagnoses may benefit from either group or individual MT sessions delivered by an MTA. The subtheme of social connectedness emerged in interviews/focus groups, which has not previously been discussed in the literature as a benefit of MT for neurologic inpatients. An MT program, such as that in the presented study, has the potential to create an enriched hospital environment and complement current standard of care neurorehabilitation as highlighted in the qualitative data.