Music as a Nursing Intervention for Postoperative Pain: A Systematic Review

Margaretha Engwall, MSc, RN, Gill Sorensen Duppils, PhD, RN

The purpose of this systematic review was to examine the effect of music on postoperative pain. A search for scientic articles was conducted using online databases. Included were quantitative studies published from 1998 through 2007 that considered the effect of music interventions on postoperative pain in adult patients. After the search and appraisal of quality, 18 studies were included in the review. The results in 15 of the studies included indicated a signicant positive effect of music on postoperative pain. Four studies found that the use of analgesics was lower for the intervention groups. The patients in the studies were scheduled for different kinds of surgery and assessments and the interventions were performed at different times. Various types of music were used, mostly chosen by the researchers. The conclusion is that music can be used as an adjuvant for the relief of postoperative pain. Keywords: music, intervention, postoperative, pain. 2009 by American Society of PeriAnesthesia Nurses

THE FEAR OF PAIN is ranked second only after the fear of death.1,2 Pain is a symptom and a warning that something is wrong in the organism. Acute pain is dened as pain of recent onset and probable limited duration. It usually has an identiable temporal and causal relationship to injury or disease.3 Music is a nonpharmacological/nonchemical method used as an adjunct to traditional care and medical treatment in the management of postoperative pain.4,5 From a nursing perspective, music interventions have been used to promote patients health and well-being.6 The purpose of this systematic review was to examine the effect of music on postoperative pain, the methods used to measure the effect, and how the interventions were carried out.

Postoperative Pain
Postoperative pain, a form of acute pain, is an expected but undesirable consequence after all surgical
Margaretha Engwall, MSc, RN, is a Lecturer, University College in Dalarna, Department of Health and Social Sciences, Falun, Sweden; Gill Sorensen Duppils, PhD, RN, is an Assistant Professor, University College in Dalarna, Department of Health and Social Sciences, and Surgical Department, Falu Lasarett, Falun, Sweden. Address correspondence to Margaretha Engwall, Hogskolan Dalarna/HVO, S-791 88 Falun, Sweden; e-mail address: men@du.se. 2009 by American Society of PeriAnesthesia Nurses 1089-9472/09/2406-0006$36.00/0 doi:10.1016/j.jopan.2009.10.013
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procedures.7 Important goals for postoperative pain management are to eliminate discomfort, to make recovery easier, and to avoid complications associated with the therapy.3 Many patients experience unrelieved postoperative pain, despite increased knowledge regarding pain and pain management.3,8,9 If the relief of postoperative pain is inadequate, it has a negative inuence on patient satisfaction.5 Furthermore, recovery can be prolonged and the length of hospital stay and the health care costs can be increased.5 It is accepted that all patients are entitled to good quality care,9,10 and it is unethical if a patient who suffers from pain does not receive help for relief.11 The experience of pain can also be inuenced by psychological factors such as fear, anxiety, and the extent to which the patient can sense a feeling of control. Nonpharmacological methods have been used as adjuncts in the treatment of postoperative pain with the goal of increasing the patients experience of well-being.3

Music and Nursing

Music is a source of pleasure for many people12 and has been used throughout history to alleviate sickness and suffering.13 Florence Nightingale noticed the power of music in the early 1800s. She thought that music with a continued harmony, performed by the human voice, on wind instruments and on string instruments, had a benecial effect.14
Journal of PeriAnesthesia Nursing, Vol 24, No 6 (December), 2009: pp 370-383

MUSIC AS A NURSING INTERVENTION FOR POSTOP PAIN

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Different types of music can inuence the frequency and depth of breathing, the heart rate, blood pressure, and the cardiac muscles need for oxygen.15 Studies have investigated the effect of music on anxiety,16,17 distraction,18 and for different kinds of pain conditions.19,20 Nursing is one of many disciplines that have conducted such studies.6,21 Music is a unique experience for the individual. The individuals musical preferences and response to music are inuenced by earlier experiences of music and by gender, age, culture, mood, and attitude.22 Consideration for the individuals musical preferences and accuracy in the choice of music are crucial and contribute to the therapeutic effect.6,22 Nurses have a central role in the care of patients with pain, and because they spend much time close to the patients, they have the opportunity to help.9,11 By carrying out measures for pain relief, identifying needs for additional measures, and intervening and assessing the effect on patients, nurses can provide optimal pain control.23 Reilly4 notes that music is well suited to the operative environment. Considering that nurses have a key role in pain management for postoperative patients, it is important to explore complementary strategies such as music to combat pain. The purpose of this systematic literature review was to examine the effect of music on postoperative pain, the methods used to measure the effect, and how the interventions were carried out. Research questions concerned:  The effect of music intervention on postoperative pain.  The methods used to measure that effect.  How interventions were carried out with regards to type of surgery, group design, music and music selection, instructions, and manipulation of the environment and the time of the intervention.

Table 1. Keyword Combinations

music AND postoperative AND pain music AND postoperative pain music AND analgesia music AND postoperative pain AND analgesia music AND surgery music AND postoperative pain AND surgery music AND surgery AND pain music AND therapy AND postoperative pain music therapy AND postoperative pain music AND surgery AND postoperative music AND pain Note: Two-word terms in quotes were used in search engines to ensure results would appear with those words together.

pain as an outcome measure. Studies evaluating interventions that combined music with other nonpharmacological methods were also included. Exclusion criteria included review articles, studies with qualitative design, studies that did not include music in the interventions, and studies that used sounds instead of music. The rst author evaluated the abstracts and articles for appropriateness, and a total of 43 articles met the inclusion criteria. These articles were reviewed several times for the research aim, research questions, and method. On further evaluation, 19 studies were excluded in accordance with the exclusion criteria. The 24 remaining studies were appraised according to their quality by using a set of modied and adapted questions concerning research methods, characteristics of the subjects, inclusion and exclusion criteria, selection methods, process of randomizing, statistical analyses, ethics, reliability, validity, and the generalization of the results. Six studies were excluded after this appraisal, leaving 18 studies in the nal review (Table 2). During the critique and analysis, data considered relevant to the research questions were collected. These data were author, year, design, sample/population, type of surgery, description of the intervention, music and music selection, outcome measure(s), instruments, method of measurement, results/effect, and statistical signicance (P value).

Method
A search for studies evaluating the effect of music on postoperative pain between 1998 and 2007 was conducted. The online databases Blackwell Synergy, Cinahl, PubMed, and Elsevier/Science Direct were used and all of the included articles were published in the English language. The keywords used during the search were music, music therapy, postoperative, pain, analgesia, and surgery. These keywords were mixed in different combinations, all of which included the word music (Table 1). A total of 1,631 articles were found. Inclusion criteria were quantitative studies with randomized controlled trials (RCTs) or a quasi-experimental design. Further inclusion criteria were studies limited to adult patients that included music interventions and used postoperative

Results
Eighteen studies were included in this systematic review. The studies were performed in the United States, Sweden, Japan, Hong Kong, China, and Taiwan; altogether, the studies included 1,604 patients. Fourteen of the studies were RCTs and 4 were quasi-experimental. Their design, methods, type of intervention, methods of measurement, and sample are presented in Table 2.

Table 2. Included Studies

Ref 24 Author, Year, Nationality Good et al, 2005, USA Sample n 5 167 age 20-70 yr 1 music group 1 jaw relaxation group 1 music/jaw relaxation group 1 control group Design RCT Secondary analysis to Good et al 1999 Surgery Intestinal Intervention Instructions preoperatively. Intervention tapes during ambulation and during rest on postoperative days 1 and 2. The control group received usual care. Data collector stayed in the room during the intervention. Instructions preoperatively. Intervention tapes during ambulation and during rest on postoperative days 1 and 2. The control group received usual care. Data collector stayed in the room during the intervention. Teaching tape before the surgery. Music listening during 15 min post-op day 1 and 2. The control group rested in bed for 15 minutes. Instructions preoperatively. Intervention tapes during ambulation and during rest on postoperative days 1 and 2. The control group received usual care. Data collector stayed in the room during the intervention. Instructions preoperatively. Intervention tapes during ambulation and during rest on postoperative days 1 and 2. The control group received usual care. Data collector stayed in the room during the intervention. Method and Time for Measurement The measurement was made before and after the preparation for ambulation, after ambulation, and after recovery from ambulation. Before and after the 15 mins of rest. The measurement was made before and after the preparation for ambulation, after ambulation, and after recovery from ambulation. Before and after the 15 mins of rest. Outcome measures were assessed before and after the music intervention and before and after the rest in bed. The measurement was made before and after the preparation for ambulation, after ambulation, and after recovery from ambulation. Before and after the 15 mins of rest. The measurement was made before and after the preparation for ambulation, after ambulation, and after recovery from ambulation. Before and after the 15 mins of rest.

372

25

Good et al, 2002, USA

n 5 199 age 20-70 yr 1 music group 1 jaw relaxation group 1 music/jaw relaxation group 1 control group

RCT Secondary analysis to Good et al 1999

Gynecological

26

Good et al, 1998, Taiwan, USA

n 5 38 Age 26-56 yr 1 music group 1 control group n 5 500 age 18-70 yr 1 music group 1 jaw relaxation group 1 music and jaw relaxation group 1 control group

RCT

General and gynecological

27

Good et al, 1999, USA

RCT Multicenter

Major abdominal: gynecological gastrointestinal exploratory urinary

28

Good et al, 2001, USA

n 5 468 age z 45 yr 1music group 1 jaw relaxation group 1 music/jaw relaxation group 1 control group

RCT Secondary analysis to Good et al 1999

Abdominal Gynecological Gastrointestinal Urinary

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29

Nilsson et al, 2003, Sweden

n 5 183 age z 50 yr ASA* I-II 1 music group 1 music and therapeutic suggestion group 1 control group n 5 90 age z 50 yr 1 music group 1 music and therapeutic suggestion group 1 control group n 5 151 age 21-85 yr ASA I-II 1 intraoperative music group 1 postoperative music group 1 control group

RCT

Varicose vein and open inguinal hernia Day care surgery

Each intervention tape was played from the arrival at the PACU until the patient wanted to stop. The control group listened to a blank tape with no sound. The intervention tapes were played from the time of the skin incision until the wound was closed. The control group listened to a tape with OR sounds. One group listened to music during surgery and to a blank CD postoperative. One group listened to a blank CD during surgery and to music at PACU, 1 hour from the arrival. The control group had blank CDs at both times. One group listened to music during the surgery from the end of anesthesia to the end of surgery. Postoperatively they had a sham CD. One group had a sham CD during surgery and listened to music for 1 hour from the arrival in PACU. The control group had a sham CD both times. Intervention during 30 min, starting 15 min after arrival in the PACU. The control group had a blank CD. Preoperative preparation for the intervention groups. The intervention took place throughout surgery and during the whole post-op period.

Pain intensity was assessed postoperatively every half hour until the patient reported #3 on the VAS.

30

Nilsson et al, 2001, Sweden

RCT double-blind

Gynecological hysterectomy

Pain intensity was assessed every hour, during the rst 24 hours, and then every 3 hours until the patient felt no pain.

31

Nilsson et al, 2003, Sweden

RCT

Varicose vein and inguinal hernia Day care surgery

Pain was assessed every half hour for 2 hours in the PACU.

32

Nilsson et al, 2005, Sweden

n 5 75 age mean 55 yr ASA I-II 1 intraoperative music group 1 postoperative music group 1 control group

RCT

Inguinal hernia Day care surgery

Pain was assessed 30 min before anesthesia and 1 hour after arrival in the PACU.

33

Ikonomidou et al, 2004, Sweden

n 5 60 age 25-45 yr ASA I-II 1 music group 1 control group n 5 84 age 20-55 yr 1 music group 1 guided imagery group 1 control group

RCT

Gynecological laparoscopy

The assessment took place before and after the intervention.

34

Laurion et al, 2003, USA

RCT

Gynecological laparoscopy Ambulatory surgery

The measurements were made 3 times: rst upon arrival in the PACU, after 1 hour, and at discharge from the PACU. (Continued on following page )
373

374

Table 2. Included Studies (Contd)

Ref 35 Author, Year, Nationality Taylor et al, 1998, USA Sample n 5 61 age 24-62 yr 1 music group 1 headphone group 1 control group n 5 44 age 60-89 yr 1 music group 1 control group Design Quasiexperimental Surgery Abdominal hysterectomy Intervention The intervention took place during the whole stay in the PACU. No music for the headphone group. The control group received usual care. The intervention took place on day 3 after surgery. The music group listened to music for 20 min. The control group received usual care. The music group listened to music 20 min 2 times/day on postoperative days 1-3. The control group rested in bed for 20 mins 2 times/day. The environment was manipulated. The music group listened to music for 30 min during chair rest. The scheduled rest group rested with their eyes closed for 30 min. The control group received usual care. Instructions were given and the environment was manipulated. The intervention began 30 min after return from surgery and lasted 30 min. It was repeated 3 times during the rst 24 hours. The control group received usual care. Method and Time for Measurement The outcome measures were assessed every 15 min during the stay in the PACU. The last assessment was just before discharge and with the graphic numeric pain intensity scale. The outcome measures were assessed before the intervention started and 10 and 20 min after the intervention. Pain was assessed before and after each 20 min of intervention.

36

Masuda et al, 2005, Japan

RCT

Orthopedic

37

Sendelbach et al, 2006, USA

n 5 86 age mean 63.3 yr 1 music group 1 control group

RCT Multicenter

Coronary artery bypass and valve replacement

38

Voss et al, 2004, USA

n 5 61 age mean 63 yr 1 music group 1 scheduled rest group 1 control group

RCT Pretest Posttest

Open heart

Outcome measures were assessed twice: rst when patients were settled in the chair and 30 min after the interventions.

39

Tse et al, 2005, Hong Kong

n 5 57 age 15-69 1 music group 1 control group

Quasiexperimental

Nasal surgery

Pain intensity was assessed upon arrival in the PACU, then immediately after each intervention. Pain was assessed at the same times in the control group.

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Pain intensity was assessed 3 times: upon admission to the PACU, 30 min after, and at discharge.

Pain levels were assessed 5 min before session, directly after the session, and for 10 min after.

Half of the 18 studies included were performed by two research teams: ve by Good et al24-28 and four by Nilsson et al.29-32 Three of the ve studies by Good et al24,25,28 were secondary analyses of a main study, performed in 1999.27 The four studies by Nilsson et al were all independent studies.29-32
*ASA, American Society of Anesthesiologists rating, preoperative judgement; RCT, randomized controlled trial; CD, compact disc; VAS, visual analog scale.

Music Intervention SURGERY. The samples in the studies were patients scheduled for different surgical procedures with varying degrees of complexity (Table 2). In some of the studies, the intervention and control groups consisted of subjects undergoing one type of surgery, which included gynecological,25,30,33-35 hernia repair,32 intestinal,24 orthopedic,36 open-heart,37,38 and nasal surgery.39 In other studies, subjects who underwent different surgical procedures were mixed in the intervention and control groups, eg, gynecological and abdominal and intestinal26; gynecological, gastrointestinal, exploratory, and urinary27; gynecological, gastrointestinal, and urinary28; varicose vein and inguinal hernia29,31; all surgical procedures except open heart40; and vascular and thoracic surgery.41 In four of the studies, the patients underwent ambulatory surgery (Table 2).29,31,34,40 DESIGN. A summary of the research designs and interventions is presented in Table 2. Six studies were designed to consist of an intervention group and a control group,26,33,36,37,39,40 and seven studies were based on three groups: two intervention groups and one control group.29-32,34,35,38 The main study by Good et al27 and its secondary analyses24,25,28 were designed to include four intervention groups and one control group. The study by Aragon et al was a single case study and the subjects were their own controls.41 Additional interventions used in addition to music included nonpharmacological interventions such as therapeutic suggestions,29,30 guided imagery,34 scheduled rest,38 jaw relaxation24,25,27,28 and decreased noise levels (Table 2).40 MUSIC AND MUSIC SELECTION. The music used in the studies is presented in Table 3. The research team selected the music in seven studies.29-34,40 In nine studies,24-28,34,36-38 the participants could choose various types of music from tapes or compact discs made by the investigators. In the study by Taylor et al,35 however, the subjects brought their own music and in the study by Tse et al,39 the participants had the choice to either bring their own music or choose from a selection made by the investigator. All studies but one41 used CD players or cassette players, and all but one of those40 included the use of headphones. Aragon et al41 used live music performed bedside by a harpist. The same harpist played at all sessions and she selected the music.

The music/low-noise group listened to tapes with music for 1 hour, upon admission to the PACU. The control group received usual post-op care. Elective surgery Day care surgery Quasiexperimental n 5 97 age 26-86 yr 1 music/low-noise group 1 control group Shertzer et al, 2001, USA 40

41

Aragon et al, 2002, USA

n 5 17 age 35-70 yr 1 music group No control group

Quasiexperimental

Vascular and thoracic

Patients listened to live harp music for 20 min post-op. The room was prepared to avoid interruption and to reduce extraneous noise. The same harpist played at all sessions.

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Table 3. Type of Music and Music Selection

Ref 24-28 29 30 31, 32 33 34 35 36 37 38 39 40 41 Type of Music Piano, harp, synthesizer, orchestral, slow jazz without lyrics Soft classical music Relaxing and calming accompanied by sound of sea waves Soft instrumental, new-age synthesizer Peaceful pan ute music Piano music Classical, jazz, light rock, country, rock and roll, easy listening, gospel, country and rock and roll Western classical music Gagaku,* Noh songs,* Enkay Easy listening, classical, and jazz Synthesizer, harp, piano, orchestra, slow jazz, and ute Chinese and Western music Mozart and ocean music Slow, soft melodies; played on a harp Person Who Selected the Music The subjects, from a selection of ve types The investigator The investigator The investigator The investigator The investigator The subjects brought their own music The subjects, from a selection of four types The subjects, from a selection of three types The subjects, from a selection of six types Both the investigator and the subjects The investigator The harpist

*Japanese traditional music. Japanese popular songs.

INSTRUCTIONS AND MANIPULATIONS OF THE ENVIRONMENT. Some of the articles describe how the subjects were given instructions before the intervention. The instructions were given in various ways. The intervention group in Good et al26 listened to an instruction tape before surgery. The tape explained the purpose and effect of music in relation to pain. After that, the subjects listened to the intervention tape with their choice of music, and they were coached by the researcher on how to let the music distract or relax them. In the main study by Good et al27 and its secondary analysis,24,25,28 the intervention groups were taught the interventions preoperatively. The subjects also were instructed on how to get out of bed and how to splint the incision during ambulation. All subjects had a data collector by their side. In the study by Laurion et al,34 the subjects were provided with a music tape in advance and asked to listen to it twice per day before their operation and on the day of surgery, they were given a second music tape. Some of the studies manipulated the environment in preparation for the intervention; this was done in different ways. Sendelbach et al37 prepared the environment for rest and the research assistant gave a short relaxation session before the music started. Voss et al38 arranged the environment to reduce disturbing stimuli and the investigator stayed in the room with all groups. Aragon et al41 avoided interruptions and reduced distraction during the intervention by reducing noise and by placing a curtain between the investigators and the patient. In the study by Shertzer et al,40 the noise level was modied in the PACU for the intervention group and the light was lowered to encourage the staff to speak more quietly and to limit their conversations.

TIME OF INTERVENTION AND ASSESSMENT. The times when the intervention was performed as well as when assessments were made differed (Table 2). In several of the studies, the intervention started immediately after arrival in the PACU.29,33,35,38-40 Pain was assessed before and after the intervention by Ikonomidou et al33 and by Voss et al,38 during and after the intervention by Nilsson et al,29 and during the intervention and at discharge by Shertzer et al40 and Taylor et al.35 Tse et al39 assessed pain on arrival in the PACU and then after each intervention. Aragon et al41 performed the intervention in the early postoperative period and the pain was assessed before and after.41 Interventions also took place during surgery30 and both during surgery and in the PACU.31,32,34 In the study from 2001, Nilsson et al assessed pain after,30 after and during,31 and before and after the intervention.32 The assessment was done during the intervention and on discharge in the study by Laurion et al.34 The intervention took place on postoperative days one and two and the pain was assessed before and after the intervention in all studies by Good.24-28 Sendelbach et al37 performed the intervention on postoperative days one, two, and three, and the assessment was made before and after the intervention. Masuda et al36 made the intervention on postoperative day three and the assessment was made before and after the intervention. Measurement OUTCOME MEASURES. All of the included studies assessed pain (Table 4). Various terms for pain were usedpain,32,33,41 pain intensity,29-31,37,39,40 pain level,35 postoperative pain34,36and six studies measured pain sensation and pain distress.24-28,38

Table 4. Outcome Measure and Instruments

Ref 24 Outcome Measure: Pain Pain sensation, pain distress VAS Instruments Other Outcome Measures Sleep mastery, respiratory rate, heart rate, recovery Instruments Subjects reported Observation, radial pulse Days until bowel sound, clear liquid, PCA discontinued, nasogastric tube removal PCA-pump Question, radial pulse, respiratory rate Observation Interview Hospital record Observation PCA-pump Observation PCA-pump 5-grade scale 4-grade scale Pulse oximetry STAI * 4-grade scale 5-grade scale Patient diary PCA Patient record NRS Patient diary Two questions Blood sample NRS Monitoring Patient record PACU record Minutes from arrival to discharge VAS Questionnaire 5-point scale Automatic sphygmomanometer Thermograph Laser type skin blood low analysis system

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25

Pain sensation, pain distress

VAS-sensation, VAS-distress

Opioid intake Sleep, vital signs Mastery Acceptance of the music Effect of medication Mastery Opioid intake Mastery Opioid intake Fatigue, well-being Nausea, headache, urinary problems Heart rate, oxygen saturation Anxiety Morphine requirement PONV fatigue, well-being, bowel function, length of hospital stay, analgesics use

26

Pain sensation, pain distress

VAS

27 28 29

Pain sensation, pain distress Pain sensation, pain distress Pain intensity

VAS-sensation, VAS-distress VAS-sensation, VAS-distress VAS

30

Pain intensity

VAS

31

Pain intensity

NRS

Analgesic Nausea, fatigue, anxiety Sleep, the amount of paracetamol and ibuprofen Awareness, satisfaction with the perioperative care Stress marker Anxiety Vital signs, saturation (spO2) Analgesic use Analgesics, PONV Length of stay Anxiety Comfort/satisfaction Overall quality of the stay Vital signs Skin temperature Blood ow from nger tip

32

Pain

NRS

34 38 40 36

Postoperative pain Pain sensation, pain distress Pain intensity Postoperative pain

VRS VAS NRS VAS FS

377

(Continued on following page )

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ENGWALL AND DUPPILS PONV, postoperative nausea and vomiting; FS, Wong-Baker Faces Scale; VAS, visual analog scale; NRS, numerical rating scale; VRS, verbal rating scale; PCA, patient controlled analgesia; STAI, state-trait anxiety inventory. *Not described in the article.

Instruments

Apart from pain and analgesic use, other outcome measures included sleep,24,25,31 mastery with the ability of using the technique,24-27 vital signs,25,32,33,36,37,39,41 nausea,29-31,33,34 and well-being.29,30 Taylor et al35 assessed pain level only. Analgesic use was examined in all but seven of the included studies (Table 4).24,26,35,36,38,40,41 INSTRUMENTS USED TO ASSESS PAIN. The most common way to assess pain was the use of a visual analogue scale (VAS), which was applied in 11 of the studies.2430,33,36,38,41 The numeric rating scale (NRS) was used in four studies,6,31,32,37,40 and the verbal rating scale (VRS) in three.34,35,39 Masuda et al used the Wong-Baker Faces Scale (FS)36 and Taylor et al used the graphic numeric pain intensity scale (Table 4).35 Instruments for measuring consumption of analgesics were patient records31,34,39 and patient-controlled analgesia (PCA)pump recordings (Table 4).25,27-29

Table 4. Outcome Measure and Instruments (Contd)

Other Outcome Measures

VAS * *

VAS Bedside monitoring 4-question survey

Bedside monitor * State anxiety

* Patient record

The Effect of Music Intervention A summary of the effect of music intervention on postoperative pain and use of analgesics is presented in Table 2, as well as design, methods, type of intervention, methods of measurement, and sample. EFFECT ON POSTOPERATIVE PAIN. Good et al26 conducted an RCT among patients undergoing general and gynecological surgery. The intervention group listened to music and was compared with a control group that rested in bed. Results showed a decrease in distress of pain and lower sensation and distress levels caused by pain for the music intervention group. The aim of the study by Good et al27 was to examine the effect of music, jaw relaxation, and a combination of music and jaw relaxation on postoperative pain. The sample consisted of patients who underwent major abdominal surgery. The music group had signicantly less pain and lower sensation and distress levels caused by pain than the control group. The combined music and jaw relaxation group also had less pain compared with the controls.27 Further, Good et al27 examined the effect of the intervention over time and between activities28 after gynecological25 and intestinal surgery.24 In these studies, the intervention groups had less pain compared with the control groups (Table 5). Signicantly less pain was also found for the music groups compared with the control groups in all of the studies carried out by Nilsson et al.29-32 The interventions in these studies were performed during surgery on patients undergoing gynecological hysterectomy,30 and in the PACU on ambulatory surgery patients who had varicose vein and inguinal hernia surgery.29 In two studies, interventions were carried out both during surgery and in the PACU (Table 5).31,32

Nausea, well-being Vital signs Analgesic

VRS, Graphic numeric pain intensity scale NRS

Instruments

VRS Pain intensity 39

Outcome Measure: Pain

VAS

Pain level

Pain intensity

Ref

Pain

37

33

35

41

Pain

VAS

Anxiety Vital signs, oxygen saturation Satisfaction

Vital signs Analgesic use

Vital signs Opioid use Anxiety

Table 5. Effect of Music Intervention on Postoperative Pain and Use of Analgesics

Ref 24 Intervention Music and music/jaw relaxation Effect Compared with Control Group/Other Intervention Group The treatment groups together had less posttest pain at all points on day 1 except for postambulation On day 2 less posttest pain at postpreparatory and postrest point On day 2 no signicance at postambulation and postrecovery Less pain at all posttests for the intervention groups together Less pain at postambulation on day 2 for music/jaw relaxation Intervention groups with PCA 9%-29% less pain than the controls with PCA Lower sensation and distress levels on day 2 than the controls Greater decrease in distress because of pain on day 1 and sensation of pain on day 2 compared with the controls Less pain than the control group Less pain on 7 posttests Less sensation and distress because of pain Less pain than the control group Less pain on all tests No differences between the groups regarding use of morphine The intervention groups together had less posttest pain on days 1 and 2 Pain decreased from days 1 to 2 The intervention groups together had less pain than the control group over time and activities on each day No signicant differences between the intervention groups No differences between the groups regarding use of morphine Lower pain intensity compared with control Lower pain intensity compared with control No differences in postoperative requirement of morphine between the groups Less pain on the rst day after surgery in the music group Less requirement of ketobemidone in the combined group The intra- and postoperative music groups had lower pain scores at 1 hour and 2 hours Less morphine in the postoperative music group after 1 hour in PACU No signicant differences in the amount of ibuprofen and paracetamol The intra- and postoperative music groups had lower pain scores after 1 hour in the PACU Less morphine in the postoperative music group after one hour at the PACU No signicant differences between the groups Lower postoperative consumption of opioids in the music group No differences between the groups regarding pain on arrival and after 1 hour at the PACU Higher pain scores reported from the control group on discharge No signicant differences between the intervention groups No signicance between the groups regarding use of analgesics P value .24-.01 .11, .001 n.s .022-.001 .020 .05 .05 .017-.000 .017-.000 .022-.000 .046-.000 .021-.000 n.s .018-.000 .028-.000 , .001 , .001 n.s n.s , .01 , .01 n.s , .001 , .010 , .01,, .01 # .05 n.s , .01 , .05 n.s .04 n.s .002 n.s n.s (Continued on following page )

MUSIC AS A NURSING INTERVENTION FOR POSTOP PAIN

25

Music and music/jaw relaxation

26 27

Music Music

Music/jaw relaxation

28

Music and music/jaw relaxation

29

Music Music/therapeutic suggestions Music Music/therapeutic suggestions Music

30 31

32 33 34

Music Music Music

379

380

ENGWALL AND DUPPILS n.s n.s , .05, , .001 , .001

Table 5. Effect of Music Intervention on Postoperative Pain and Use of Analgesics (Contd)

Effect Compared with Control Group/Other Intervention Group

No signicant differences in pain ratings for both of the pain rating scales No signicance over time Larger decrease in VAS at 10 and 20 min and in FS at 20 min

Less pain sensation and distress at posttest than at pretest Less pain sensation and distress at posttest after intervention Lower pain scores at all points after intervention Decrease in pain over time Control group consumed more pain relief on the day of surgery and on day 1

In addition, lower pain levels for the music intervention groups compared with the control groups were found in the study by Voss, where the music group listened to music during chair rest after open-heart surgery.38 Sendelbach et al also found lower pain ratings on postoperative days one through three after coronary bypass and valve replacement surgery.37 A quasi-experimental study by Tse et al39 showed lower pain ratings and decreased pain over time. The subjects in this intervention group listened to music immediately after nasal surgery. Aragon et al41 used live harp music for the intervention in their quasiexperimental study after vascular and thoracic surgery. These results also showed a decreased pain level over time. Masuda et al conducted their study on day three after orthopedic surgery and found a decrease in pain over time for the music group.36 The study by Shertzer et al of ambulatory patients also found a signicant decrease in pain for the music group across the stay at the PACU compared with the control group.40 Three studies,33-35 however, revealed no signicant reduction in pain with the addition of music interventions. In the study by Ikonomidou et al, the sample consisted of patients undergoing gynecological laparoscopies and the intervention was done immediately after surgery.33 In the RCT by Laurion et al, the sample also underwent gynecological laparoscopies. They found, however, that the control group reported higher pain scores than the intervention groups at discharge.34 In the quasi-experimental study by Taylor et al,35 no significant differences regarding pain over time were found. Here, the intervention took place during the stay in the PACU on patients who had an abdominal hysterectomy (Table 5).35 EFFECT ON USE OF ANALGESICS. Use of analgesics was measured in several of the studies with varying results (Table 5). In two of the studies by Good et al, there were no differences between the groups regarding the use of morphine.27,28 Among patients who received analgesics via PCA, the intervention group had 9% to 29% less pain than the controls.25 In all but one29 of the four studies by Nilsson et al, however, there was some inuence of music interventions on the use of analgesics. In two of the studies,31,32 the postoperative music group required less morphine after 1 hour in the PACU compared with the controls. The requirement of paracetamol and ibuprofen, however, did not differ signicantly between the groups.31 In another Nilsson study,30 the use of ketobemidone on the day of surgery was signicantly lower in the combined intervention group than in the control group. Ikonomidou et al found signicantly lower cumulative consumption of opioids in the music group compared with the control groups.33 Further, Tse et al found that

P value

, .017 , .017 .001 .001 , .001 , .0001

.009 n.s

.00 .000

Ref

35

37

36

38

40 41

39

n.s., not signicant; PCA, patient controlled analgesia; VAS, visual analog scale; FS, Wong-Baker Faces Scale.

Lower pain level compared with the control No signicance between the groups regarding use of morphine

Music

Music

Music/low-noise group Music

Intervention

Music

Music

Music

Decrease in pain across the stay Differences in pain ratings over time

MUSIC AS A NURSING INTERVENTION FOR POSTOP PAIN

381

the controls consumed more analgesics than the music group on the day of surgery and on day one after surgery.39 Two other studies,34,37 however, revealed no differences between the groups in the use of analgesics.

Discussion
The samples in these studies were scheduled for different surgical procedures, from major abdominal and openheart surgery to ambulatory surgery. The time for the intervention varied from during surgery30 to as many as three days after surgery.36 Certain forms of surgery cause more postoperative pain than others.3 On the rst day after surgery, the pain can be severe,27 but usually decreases after.28 In the three studies that showed no signicant ndings,33-35 the sample consisted of patients undergoing some form of gynecological surgery, two of those laparoscopic. However, studies by Good et al and Nilsson et al included abdominal gynecological surgery that would cause more postoperative pain. It is possible that the laparoscopic surgery might have caused a limited extent of pain. Low pain ratings among the subjects before the intervention might have had an inuence on the result because initial pain scores were not severe. The sample sizes were generally small in the included studies. Only three studies had a sample size of more than 100 subjects27,29,31; all of these studies had signicant ndings. The largest sample size (500 participants) was in a multicenter study by Good et al (Table 2).27 Larger samples are desirable to gather more evidence on the effect of music intervention on postoperative pain. Nevertheless, in spite of the small samples in many of the studies, results still indicate that music intervention could be used as an adjuvant to traditional care for patients with postoperative pain. In the studies where the music intervention had no effect on pain, patients were nevertheless satised with the intervention and they felt that the music had helped them in some way. Laurion et al34 found that the intervention group tended to stay longer in the PACU than the control group (n.s.). Although there was no signicant effect on the experience of pain, the music intervention was experienced positively and perhaps patients stay in the PACU was more pleasant because of the music. Negative consequences of a longer stay in the PACU might be the increasing costs. However, to increase patients well-being, it would be possible to offer music during the postoperative time in the ward. The music groups consumed fewer analgesics than the control groups in ve studies.30-33,39 However, just as ve studies also showed no signicant differences regarding use of analgesics.27-29,34,37 The ndings regarding use of analgesics have some interesting points. In two studies by Nilsson et al,31,32 the postoperative music groups had signicantly less pain and less requirement of morphine after one hour in the PACU. However, in one study by Nils-

son et al,29 no signicant differences between the groups were found regarding analgesic use, although the music group had lower pain scores. Ikonomidou et al33 found a signicant lower consumption of opioids in the music group than in the control group, but they found no significant differences regarding pain ratings for the intervention group. These ndings conrm the assumption that music, through its distracting and relaxing effect, can reduce pain6 but not eliminate it. The gate-control theory is one explanation for the effect of music.26,27,29 This theory states that a mechanism in the dorsal horns of the spinal cord acts like a gate inhibiting or facilitating transmission of painful impulses from the body to the brain. This gate can be inuenced by cognitive and emotional factors.26,42,43 The Performance of the Intervention Several of the studies reporting positive results from the music intervention manipulated the environment and/ or gave instructions to the intervention groups before surgery. The instructions consisted of: information concerning the purpose and effect of music,26 a teaching tape with instructions on the intervention instruction on how to get out of bed,24,25,27,28 and instructions on how to listen to the music and how to relax.38 The purpose of environmental manipulations was to reduce any disturbing factors for the intervention groups, eg, preparing the room to avoid interruptions and noise,41 making the environment conducive to rest,37 and holding a relaxation session before the music intervention.37 Manipulation was a part of the interventions, but it is possible that these manipulations and preparation may have inuenced the results because the subjects and staff were likely to be aware of their participation in the study, which could have affected how they reacted and responded to the interventions (the Hawthorne effect).44 The VAS was the most frequently used instrument for pain assessment. It was used in 11 of the 18 studies (Table 4). It is possible that the cognitive ability to report pain immediately after general anesthesia may be hampered, a point that is discussed by Laurion et al.34 The potent effect of the drugs that are used during general anesthesia could have a negative inuence on the ability to report pain immediately postoperatively, although this condition should apply both to the intervention and the control groups. In two of the 18 studies,35,39 the subjects were allowed to bring their own music; in the other studies the music was selected by the research teams (Table 3). In the study where live harp music was used, Aragon et al41 discussed whether the presence of the harpist in the room had an inuence on the result. An interesting aspect of the choice of live harp music was that some patients declined

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ENGWALL AND DUPPILS

to participate in the study because the harp music reminded them of death and heaven. Consideration of the individuals musical preference is crucial and, according to the literature, can contribute to the therapeutic effect.6,22 It is therefore notable that only in two studies35,39 were the subjects allowed to bring their own music. It is also notable that despite this, the majority still reported signicant ndings concerning the effect of music. Further, in the study where patients brought their own music,35 there were no signicant differences in outcomes between the music and control groups. Another aspect of bringing ones favorite music is the fact that a favorite piece of music may then be related to and associated with painful and worrisome conditions. More studies concerning type of music and music choice are needed. Methodological Considerations The quality of the studies included was high. One issue that should be considered, however, was that nine of the 18 included studies were performed by two research groups, Good et al and Nilsson et al (Table 2). All of their studies presented signicant ndings regarding the effect of music on postoperative pain (Table 2). Three of the ve studies performed by Good et al24,25,28 were secondary analyses of a main study (Table 2).27 In the main study, the results were presented for the total group (n 5 500). In the three secondary studies, specic surgery groups of the main study were presented, with partially different research questions. However, even if these three studies had been excluded, the results of the present review would not have been inuenced because of the good majority of studies with a positive response to the music interventions. Summary The aim of this systematic review of the literature was to examine the effect of music on postoperative pain. Eighteen studies were included in this review; the studies were performed during the years 1998 through 2007. Fourteen of the studies were RCTs and four were quasiexperimental. The samples in the 18 studies consisted

of a total of 1,604 patients. The results showed that all of the studies, with the exception of Good et als secondary analysis,24,25,28 were designed in different ways. These differed with regard to music selection, how and whether the patients were instructed, manipulation of the environment, the time of the intervention, and how and when pain was assessed. In all but three of the 18 studies (including 205 patients),33-35 there were signicant ndings that indicated lower postoperative pain in the music intervention groups and likewise in the groups that combined music with other nonpharmacological methods. According to this result, music seems to have a benecial effect on postoperative pain.

Conclusion
The fear of pain is ranked second after the fear of death.1,2 According to the literature, many patients suffer from unrelieved postoperative pain, despite increased knowledge concerning pain and how to alleviate it.3,8,9 Music is a source of pleasure, is thought to bring out physiological and psychological responses in the listener, and has been used throughout history to aid in the care of sick people.12-14 The results of the present review indicate that music intervention alleviates postoperative pain. The ndings can be related to the power of music to enhance distraction and well-being, as a psychological support, and to increase relaxation, as described in the literature.3,6 Nurses have a responsibility to supply good care for the patient. Music intervention is noninvasive, inexpensive, and simple to manage during the postoperative period. The results in this review may encourage nurses to use music as a nonpharmacological adjuvant for the relief of postoperative pain. The results also indicate that music intervention can be one way to raise the quality of the treatment of postoperative pain, as an adjuvant to analgesics. Because the studies included in this systematic review have proportionately small samples, further studies are needed. Additional quantitative studies that examine the effect of music on postoperative pain on larger populations, perhaps in multicenter studies, would be of interest.

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