Running head: MUSIC THERAPY FOR REDUCING CHRONIC PAIN 1

Evidence Based Project: Music Therapy for Reducing Chronic Pain

Melissa R. Roy
University of South Florida

MUSIC THERAPY FOR REDUCING CHRONIC PAIN 2

Abstract
The clinical problem under review is how health care professionals can more adequately
manage and treat hospitalized adult patients who suffer from chronic pain. The purpose of this
paper is to extensively review four evidence based research articles in order to create a project
proposal of how to implement new evidence based practices into an organization. The current
evidence based practice under review is the effects of music therapy in the reduction of chronic
pain in hospitalized adult patients. The search engines utilized to locate the randomized
controlled trial studies were CINAHL, EBSCOhost, and ScienceDirect. The key search words
used were music and chronic pain. Results of the studies indicate that patients who received both
music therapy intervention and standard care (analgesics) had a statistically significant reduction
in chronic pain as opposed to the control groups who only received standard care. In conclusion,
the results of the studies under review confirm that the use of music therapy intervention in the
management of chronic pain is beneficial to the hospitalized adult patient population. Additional
benefits discovered throughout the studies were that music therapy was also effective in
managing anxiety, depression, decrease the consumption of pain medications, and provides a
safe, side effect free alternative to managing pain.







MUSIC THERAPY FOR REDUCING CHRONIC PAIN 3

Evidence Based Project: Music Therapy for Reducing Chronic Pain
In 2011, the Institute of Medicine (IOM) released a report stating that chronic pain affects
nearly 100 million Americans across the nation which results in close to $635 billion in medical
treatment and lost productivity each year (IOM, 2011). Proper pain management is a problem for
many organizations as not only are patients dealing with constant physical discomfort from pain,
but they are more likely to be depressed, have a decreased quality of life, and an increase amount
of hospital stays which ultimately drives up medical expenses for both the patient and hospital
(American Academy of Pain Medicine [AAPM], n.d.). The clinical question being asked is in
hospitalized adult patients who are experiencing chronic pain, how does nurse driven
interventions of music therapy compare to the use of standard care (analgesics) in the reduction
of stated pain level of patients over a six month period? The infrastructure needed to support a
change in the proposed setting involves the Charge Nurse, Director of Nursing, Quality
Improvement Committee and the Board of Directors. The charge nurses are an imperative part of
the infrastructure as they see the need for change first hand and can introduce the proposed
change to the Director of Nursing. The Director of Nursing can then present the evidence based
practice change to the Quality Improvement Committee for review and discussion. The head of
the Quality Improvement Committee may then present the proposal to the Board of Directors at
one of their meetings for final approval and proposed implementation date for the facility.
Literature Search
The primary search engine used to complete the literature search were CINAHL,
EBSCOhost. The key words used to find two articles with significant evidence towards the paper
was music and chronic pain. The third and fourth articles were found through a link to
ScienceDirect which provided two additional studies that were appropriate for the project.
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 4

Literature Review
The study completed by Guetin et al. (2012) was conducted to assess the effects of music
intervention to the management of patients with chronic pain. The study involved 87 participants
with (n= 44) in the intervention group and (n= 43) in the control group. The control group
received standard drug therapy, whereas the intervention group received both standard drug
therapy and music intervention. The music intervention sessions were initiated twice a day for 60
days with each session lasting 20 minutes. The measures of this study included the visual analog
scale (VAS) for determining the patients pain level. The investigators reported that at day 60,
the reduction of pain score was significantly greater in the intervention group as they noted a
relative improvement of 54% as opposed to just 25.8% in the control group (p<0.001).
The study had many strengths including being a randomized controlled trial, participants
had similar demographic and clinical variables, and a blind outcome assessment was performed.
A weakness of the study is that it is single-blinded.
The study conducted by Gutgsell et al. (2013) was performed to determine if a single
music therapy session can reduce pain in palliative care patients. The study had 200 total
participants for the intervention (n= 100) and control (n= 100) groups. A clinical nurse specialist
(CNS) assessed the patients pain level using the Number Rating Scale (NR), Face, Legs,
Activity, Cry, Consolability (FLACC), and functional Pain Scale (FPS) prior to and after the
intervention. The intervention group was given a calm environment, verbal instructions for
autogenic relaxation, and was led into autogenic muscle relaxation by the therapist. The same
harp piece was played for each patient. For the control group, the therapist encouraged relaxation
but gave no specific instructions. After 20 minute sessions for both groups, the CNS reassessed
their pain. In order for the results to be statistically significant, (p<0.05) must be achieved.
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 5

Results indicate a significant difference between the two groups for the NRS scale (p<0.0001),
and the Functional Pain Scale (p<0.0001), but no significant difference for the FLACC Scale
(p>0.05).
The strengths of this study include it being a randomized controlled trial, similar patient
demographics and baseline pain severity, primary and secondary outcomes were clearly stated,
and a blind outcome assessment was completed. Weaknesses of this study include it not being
double-blinded and the music therapy intervention was only performed once.
The randomized controlled clinical study conducted by Onieva-Zafra et al. (2013) was
performed to investigate the effects of music on pain and depression in those diagnosed with
fibromyalgia (FM). The study had 60 participants for the intervention (n= 30) and control (n=
30) groups. The intervention group was given a CD to listen to at least four days per week the
first week and then every day the second week, as well as a visual analog scale (VAS) to
complete on the days they listened to music. The same criteria were followed for the final two
weeks. The scales used to measure pain and depression included the VAS scale, the McGill Pain
Questionnaire Long Form (MPQ-LF), and Beck Depression Scale (BDI). Patient measurements
were taken at baseline and after the fourth week. Results indicate a significant difference
between groups for VAS and MPQ-LF pain scores (p= .041). However, although improved,
there was no significant difference in the VAS and BDI for depression.
Weaknesses of this study include not discussing how the subjects were randomized,
neglecting to define standard care for the control group, and it is unknown if the participants
were blinded to their groups. Strengths of this study include homogenous demographics and
baseline clinical characteristics, valid and reliable instruments, and the study is a randomized
controlled trial.
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 6

The study conducted by Huang, Good, and Zauszniewski (2010) was performed to
examine the effects of relaxing music on cancer pain. The study had a total of 126 participants,
for the intervention (n= 62) and control (n= 64) groups. The patients pain and sensation level
was rated by on 100mm visual analog scale (VAS) prior to and 30 minutes after the intervention.
The intervention group was asked to listen to sedative music of their choice for 30 minutes,
while the control group was instructed to rest in bed for 30 minutes. The initial pain score
assessment indicated that participants in both groups had a moderate pain and sensation level
(49-50mm). At the end of the intervention, post sensation and distress pain in the music
intervention group was now mild (28-31mm) as compared to the control group who remained at
moderate (49-50mm) which indicates that those who listen to relaxing music experience less
cancer pain than those who do not.
Strengths of this study include it being a randomized controlled trial, similar patient
demographics and baseline severity pain, and the participants were blinded to their groups.
Weaknesses of this study include only being single blinded and the music intervention was only
performed for one 30 minute session.
Synthesis
There has been an abundance of statistically significant evidence through each of the
research articles reviewed that support the effectiveness of music therapy in the management of
chronic pain. The music therapy groups were assessed using a visual analog scale (VAS) in three
studies, and a number rating scale (NRS) in the final study to measure the outcome of pain relief
in patients throughout the interventions. Studies utilizing similar evaluation tools proves to be
beneficial in research as it provides consistency throughout the studies, making evidence more
comparable. A notable difference between the studies was the amount of time each music
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 7

intervention was conducted. For example, participants of the music intervention group in one
study was only required to listen to music one time for 30 minutes, and another study listened to
the music one time for 20 minutes. In contrast, the other two studies were completed over a
longer period of time with one study performed over 60 days with two 20 minute therapy
sessions per day, whereas the other study was completed over two weeks with at least four music
therapy sessions per week. The selected articles, although they have many similarities and
differences equally support the proposed practice change with significant evidence in favor of
the use of music therapy in reducing chronic pain.
What is known and unknown in the field is also important to evaluate when determining
the effects of music therapy on the treatment of chronic pain. Across each study music therapy
provided a significant reduction of reported pain. In addition to the decrease in pain, music
therapy has also proven to be effective in managing anxiety, depression, reducing the
consumption of medications, and provides no additional side effects. An unknown of the studies
is if sequential interventions will have the same pain lowering effect over time. Additionally, it is
unknown if giving the patient the option to choose a specific genre of music to listen to makes a
greater difference in the level of pain reported compared to if the patient was required to listen to
a preselected piece. Further research is recommended to determine if the unknowns will make a
significant difference in the reported pain scores of the current studies.
Proposed Practice Change
Given the significant evidence in favor of music therapy in reducing the effects of
chronic pain in hospitalized adult patients, it is recommended that my clinical setting begin to
provide patients with the choice of trying music therapy to help control their pain level as
opposed to only analgesics, while in the hospital. It is also recommended that patients rooms be
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 8

kept as quiet as possible with dimmed lights to promote relaxation and healing. Based on current
research, practice should change to become evidence based by providing patients with a headset
and a recording of relaxing music of their choice to listen to once per day for 30 minutes. Many
studies have shown that listening to music for as little as 20 minutes per day significantly reduces
the symptoms of chronic pain. Nurses will still be required to assess the patients pain scale
before and after therapy with a number rating scale (0-10) just as they would when providing
medication therapy to determine if the intervention has been successful.
Change Strategy
Strategies that can be used to promote staff engagement include involving staff in the
process by determining their priorities and what they believe needs improvement in relation to
managing chronic pain. According to Melnyk and Fineout-Overholt (2011), it may also be
required to provide more education and information regarding evidence based practice and the
process in which changes are implemented in order for all staff to understand the reason for
change. Involving all stakeholders such as the doctors, respiratory therapists, and physical
therapists is also important in order to evaluate how the changes will impact their delivery of
care. Implementation of the new evidence based practice will be most successful when staff
members understand the reason for change, are excited about the new processes and feel
passionately about the improvements. The EBP model that will be used to guide the
implementation of this project is the Model for Evidence Based Practice Change, as each of the
steps in this model are closely associated with the current processes being followed to implement
the proposed practice change.
Roll Out Plan
Step 1: Assess the Need for Change in Practice (May 2014- June 2014)
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 9

Review the state of chronic pain management
o Millions of people live with inappropriately managed chronic pain.
o Long term use of pain medications may lead drug tolerance, drug dependency,
and in some cases, drug addiction.
o Alternative nurse driven interventions such as music therapy to relieve pain may
be a benefit.
Step 2: Locate the Best Evidence (June 2014- July 2014)

Locate evidence to support a nurse driven intervention for pain management, such as
music therapy.
o Utilize search engines: CINAHL, EBSCOhost, and ScienceDirect
Step 3: Critically Analyze the Evidence (July 2014- July 2014)
Identified and analyzed four evidence based articles that support music therapy as a nurse
driven intervention for pain management.
Step 4: Design Practice Change (July 2014- September 2014)
Implement music therapy in conjunction with standard care (analgesics) to the amount of
pain in people who suffer from chronic pain.
o Resources needed include headsets for patients, relaxing music selections, and
training time for the nurses.
Step 5: Implement and Evaluate Change in Practice (October 2014- March 2015)
Implement pilot study to determine if music therapy is beneficial in reducing chronic pain
for our patient population.
o Explore results and seek recommendations from staff on the new practice change
Step 6: Integrate and Maintain Change in Practice (April 2015- July 2015)
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 10

Inform all nurses, providers, and specialists of the new practice change
o Monitor process for new change by running reports and completing random chart
reviews for appropriate documentation for the effectiveness of the intervention.
Project Evaluation
The goal of implementing the new practice change is to reduce the pain score reported by
patients who suffer from chronic pain. The specific data to be collected in order to evaluate the
effectiveness of the change is the numeric pain score rating before music therapy treatment and
after it. Parameters that indicate success would be dependent on each individuals starting pain
score, but the goal is to reduce the patients overall pain score by at least two tenths according to
the number scale. If the patients pain score does not improve or stays the same as it was before
treatment, the change would be considered a failure. The data will be collected by running
specific reports that extract the documented pain scales for each patient both before and after the
intervention, according to their patient record. The success of the intervention can then be
assessed by reviewing the pain scores and determining if pain levels were improved after music
therapy.
Dissemination of EBP
The plan to disseminate the change at my facility includes holding a podium presentation
at the next charge nurse meeting as they are going to be the lead in implementing the change.
There will also be grand rounds that will include an oral presentation from the director of nursing
so that all clinicians from each department in the hospital will have the opportunity to be
involved and ask questions. At the regional level, the plan is to disseminate evidence by writing a
health policy issue brief. As described by Melnyk and Fineout-Overholt (2011), providing a well
written brief that clearly identifies the reason for change, how the change will provide better
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 11

outcomes for the organization and the patients, as well as the supporting evidence in favor of the
change can potentially increase regional participation of managing chronic pain with music
therapy. The dissemination of the practice change will remain the same for all other units,
hospitals, and regions. Since the patient population of hospitalized adult patients who suffer from
chronic pain is so common, each facility could implement the proposed change into their
practices in the same sequence as my facility.
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 12


References
American Academy of Pain Medicine. (n.d.). AAPM facts and figures on pain. Retrieved from
http://www.painmed.org/patientcenter/facts_on_pain.aspx
Guetin, S., Ginies, P., Siou, D. K. A., Picot, M., Pommie, C., Guldner, E., Touchon, J. (2012).
The effects of music intervention in the management of chronic pain: A single blind,
randomized, controlled trial. Clinical Journal of Pain, 28(4), 329-337.
Gutgsell, K. J., Schluchter, M., Margevicius, S., DeGolia, P. A., McLaughlin, B., Harris, M.,
Wiencek, C. (2013). Music therapy reduces pain in palliative care clients: A randomized
controlled trial. Journal of Pain and Symptom Management, 45(5), 822-831.
http://dx.doi.org/10.1016/j.jpainsymman.2012.05.008
Huang, S., Good, M., & Zauszniewski, J. A. (2010). The effectiveness of music in relieving pain
in cancer patients: A randomized controlled trial. International Journal of Nursing
Studies, 47, 1354-1362. http://dx.doi.org/10.1016/j.ijnurstu.2010.03.008
Institute of Medicine. (2011). Relieving pain in america: a blueprint for transforming
prevention, care, education, and research. Retrieved from
http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-
transforming-Prevention-Care-Education-Research/Report-Brief.aspx
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence based practice in nursing &
healthcare: A guide to best practice (2
nd
ed.). Philadelphia, PA: Wolters Kluwer Health
Lippincott Williams & Wilkins.
Onieva-Zafra, M. D., Castro-Sanchez, A. M., Mataran-Penarrocha, G. A., & Moreno-Lorenzo,
C. (2013). Effect of music as nursing intervention for people diagnosed with
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 13

fibromyalgia. Pain Management Nursing, 14(2), e39-346.
http://dx.doi.org/10.1016/j.pmn.2010.09.004










































MUSIC THERAPY FOR REDUCING CHRONIC PAIN 14

Table 1

Literature Review

Reference Aims Design and
Measures
Sample Outcomes /
statistics
Guetin, S.,
Ginies, P., Siou,
D. K. A., Picot,
M., Pommie, C.,
Guldner, E.,
Touchon, J.
(2012). The
effects of music
intervention in
the management
of chronic pain:
A single blind,
randomized,
controlled trial.
Clinical Journal
of Pain, 28(4),
329-337.
To assess the
effects of music
intervention to
the management
of patients with
chronic pain.
Randomized
Controlled
Trial. The
measures
included the
visual analog
scale (VAS)
for
determining
the patients
pain level.
The study
involved 87
participants. 44
in the
intervention
group who
received
standard drug
therapy
(analgesics) and
music therapy,
and 43
participants were
in the control
group and only
received
standard care.

Statistically
significant number
of VAS scores
between groups
who received music
therapy and those
who did not. At day
60 (p<0.001) which
indicates a relative
improvement of
pain of 54% in the
intervention group
compared to 25.8%
in the control
group.
Gutgsell, K. J.,
Schluchter, M.,
Margevicius, S.,
DeGolia, P. A.,
McLaughlin, B.,
Harris, M.,
Wiencek, C.
(2013). Music
therapy reduces
pain in palliative
care clients: A
randomized
controlled trial.
Journal of Pain
and Symptom
Management,
45(5), 822-831.
http://dx.doi.org/
10.1016/j.jpainsy
mman.2012.05.0
08

To determine if a
single music
therapy session
can reduce pain
in palliative care
patients.
Randomized
Controlled
Trial. The
measures
include the
Number
Rating Scale
(NRS), Face,
Legs,
Activity,
Cry,
Consolability
(FLACC),
and
functional
Pain Scale
(FPS) for
determining
the patients
pain level.
The study had
200 total
participants. 100
in the
intervention
group who was
given a calm
environment,
verbal
instructions for
autogenic
relaxation, and
was led into
autogenic muscle
relaxation by the
therapist, and
100 in the
control group
who was only
encouraged to
relax without
instructions.
Significantly
different numbers
for NRS between
the two groups was
observed with
(p<0.001). For the
FLACC scale, both
control and
intervention groups
scores declined, but
with no significant
difference between
the two (p>0.05).
For the FPS scale,
the mean decline
was significantly
greater in the
intervention verses
the control group
(p<0.0001).
MUSIC THERAPY FOR REDUCING CHRONIC PAIN 15


Huang, S., Good,
M., &
Zauszniewski, J.
A. (2010). The
effectiveness of
music in
relieving pain in
cancer patients:
A randomized
controlled trial.
International
Journal of
Nursing Studies,
47, 1354-1362.
http://dx.doi.org/
10.1016/j.ijnurst
u.2010.03.008

To examine the
effects of
relaxing music
on cancer pain.
Randomized
Controlled
Trial. The
patients pain
and sensation
level was
rated by on
100mm
VAS.
The study had a
total of 126
participants. 62
in the
intervention who
listened to music
for 30 minutes,
and 64 in the
control group
who was
instructed to rest
in bed for 30
minutes.
The patients in the
intervention group
had 37% sensation
and 47% less
distress at posttest
than the control
group. In
comparing the
results on a scale of
0-10, the average
improvement for
the intervention
group was a
sensation pain
reduction of 1.5
compared to the
control group.
Onieva-Zafra,
M. D., Castro-
Sanchez, A. M.,
Mataran-
Penarrocha, G.
A., & Moreno-
Lorenzo, C.
(2013). Effect of
music as nursing
intervention for
people
diagnosed with
fibromyalgia.
Pain
Management
Nursing, 14(2),
e39-346.
http://dx.doi.org/
10.1016/j.pmn.2
010.09.004

To investigate
the effects of
music on pain
and depression
in those
diagnosed with
fibromyalgia.
Randomized
Controlled
Trial. The
measures
included the
VAS scale
for pain and
depression,
the McGill
Pain
Questionnair
e Long Form
(MPQ-LF),
and Beck
Depression
Scale (BDI).
The study had 60
participants with
30 in the
intervention
group who
listened to a CD
at least four days
a week, and 30
in the control
group who were
not given a CD.
At week 4, the
intervention group
reported a
significant
difference in pain
on movement
(p=.002) and pain
at rest (p=.001),
compared to the
control group who
had no pain
reduction after 4
weeks. Their pain
on movement was
(p=.42) and pain at
rest (p=.08). The
intervention group
also showed
significant
differences in the
MPQ-LF whereas
the control group
showed no
improvement with
that scale.