Running head: REDUCING POSTOPERATIVE PAIN USING MUSIC 1

Using Complementary Music Therapy to Reduce Post Operative Pain in Adults

Julissa Cambero, Melissa Gotcher, Kristina Maldonado

University of South Florida

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Abstract

Clinical Problem: Postoperative patients often times experience insufficient pain relief from

opioids; inadequate pain relief can elicit postoperative complications, prolong hospital stay, and

interfere with the patient’s eating and sleeping processes which can be detrimental to the

patient’s condition (Economidou, Klimi, Vivilaki, & Lykeridou, 2012).

Objective: The objective of this synthesis paper is to examine if whether using complementary

music therapy plus, standard care as compared to standard care alone, will reduce postoperative

pain in adult patients. Databases PubMed and CINAHL were used to search randomized control

trials (RCT) in nursing regarding the use of music therapy to reduce post-operative pain. The

key search terms were postoperative pain, music interventions, music therapy, and vital signs.

Results: There was a statistically significant reduction in postoperative pain in adult

postoperative patients who received complementary music therapy with standard

pharmacological care, compared to those who received standard care. Liu et al. (2015)

demonstrated a significant difference between the intervention and control groups regarding pain

after music therapy was implemented (p= 0.019). Mondanaro et al. (2017) demonstrated a

significant decrease in pain ratings between those who received music therapy as an intervention

(P=. 01). Wang et al. demonstrated that the music therapy intervention group’s mean visual

analogue pain scores were significantly lower than the control group (p<0.01). Music therapy is

an inexpensive and non-invasive intervention that can be implemented alongside standard care in

the postoperative setting to decrease pain in postoperative adult patients.

Conclusion: Although music therapy combined with standard care is shown to further alleviate

postoperative pain than standard care alone, more research should be conducted to determine if
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there are greater therapeutic effects if the music therapy session is delivered live through a music

therapist, rather than through headphones.

Using Complementary Music Therapy to Reduce Postoperative Pain in Adults

Introduction

Over 51 million surgical procedures are done each year in the United States, and the

postoperative period is an undeniably difficult time for patients (Hole, Hirsch, Ball & Meads,

2015). Pain is described as an uncomfortable sensory and emotional state due to potential or

literal damage to tissue (Economidou, Klimi, Vivilaki, & Lykeridou, 2012). Pain is an expected

outcome after surgery, but patients continue to experience unrelieved postoperative pain.

Oftentimes, postoperative patients do not receive adequate pain relief from opioids alone, and

experience undesirable side effects attributed to them (Economidou, Klimi, Vivilaki, &

Lykeridou, 2012). The use of music to improve patient's' hospital experience has had an

extensive history in medical care, and was recommended and used by Florence Nightingale

herself. Listening to music reduces the patient’s sensation of pain by diminishing the perceived

intensity and unpleasantness of pain (Hole, Hirsch, Ball & Meads, 2015). Music can aid in

creating a therapeutic environment for the patient, which can facilitate a positive hospital

experience. It is found that adjunct music therapy is an easy intervention with no adverse effects,

and that listening to music postoperatively can diminish the use of analgesia. Pharmacological

interventions combined with music therapy may provide greater pain relief than using

pharmacological interventions alone (Vankkunen & Vaajoki, 2014). This synthesis paper will

address the following question: in adult postoperative patients, how does complementary music

therapy with standard care, compared to the use of standard care alone, reduce postoperative

pain, over three months?

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Literature Search

The database used to access the literature pertaining to randomized clinical trials (RCT)

of nursing interventions for reducing postoperative pain through the use of music therapy was

PubMed. The criteria for the search included the following key terms: adult patients reduce

postoperative pain and music therapy and the publication years were between 2012 and 2017.

Literature Review

To evaluate the effectiveness of music therapy as a postoperative pain intervention, three

RCTs were examined, as well as a clinical guideline. According to Chou et al. (2016), music is a

guideline intervention to treat postoperative pain along with other relaxation methods. Liu &

Petrini (2015) studied the effectiveness of music therapy in reducing anxiety, pain, and

improving vital signs among those recovering from thoracic surgery. The sample size was 112

post-thoracic surgery patients who were randomized to either the music therapy plus standard

care intervention group (n = 56) or the standard care control group (n = 56). The intervention

group patients were visited on the first postoperative day, and pre-intervention data assessing

pain, vital signs, and anxiety were collected. The intervention group participants were provided

with a 30-minute music session, followed by post intervention data collection after the

session. Post intervention data collection continued after the soft music intervention of 30-

minute music sessions for three consecutive postoperative days, playing music with no more than

80 beats per minute. The control group patients only received standard care and completed the

same pre and post test measures. The faces pain scale was used to evaluate pain among

patients. Patients chose the face that best represents their pain ranging from “no hurts” to “hurts

the most.” A significant difference was seen between the groups, with the intervention group

reporting significantly less pain, systolic blood pressure (SBP), heart rate (HR), and anxiety as
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compared to the control group after music therapy was implemented (p = 0.019). There was not

a significant difference in diastolic blood pressure (DBP) between the control group and the

intervention group (p = 0.59), which is an expected finding, as DBP does not correspond with the

sympathetic nervous system activity associated with the pain response. Also, 68.1% (n = 32) of

participants believed the music helped alleviate their pain.

Mondanaro et al. (2017) evaluated the effectiveness of a music therapy intervention

for patients recovering from spine surgery. The study included a total of 60 spine surgery

patients, who were randomized to the music therapy intervention (n = 30) and the control (n =

30) groups. Patients in the intervention group received one 30-minute music therapy

session. The session consisted of a “warm up phase” with musical or verbal discussion. Next

was the “treatment phase,” which gave the patient options of live music such as singing with or

without rhythmic drumming through “incentive-based clinical improvisation” that would support

relaxation. After the session with the music therapist, patients were interviewed on their

feelings, impressions, and any issues that may have risen during the process which contributed to

the experience and the results were recorded. Patients in the control group received standard

postoperative care. A visual analog faces scale (VAS) was used to measure the patient’s level of

pain, ranging from 0 (no pain) to 10 (intense pain). In the control group, VAS pain levels

increased slightly from 5.20 to 5.87 while in the intervention group, pain levels decreased by

more than one point from 6.20 to 5.09

Wang, Dong, & Li (2014) examined the effects of a psychological and music intervention

on perioperative changes in heart variability (HRV), postoperative pain, and anxiety in elderly

patients undergoing elective surgery. The study included a total of 40 subjects who were

randomized to either the combination psychological and music intervention (n = 20) or control (n
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= 20) groups. In the intervention group, patients received an educational psychological

intervention preoperatively that covered anxiety reduction, plus listening to 30 minutes of soft

music before and during the elective operative procedure. Patients in the control group received

preoperative standard care. Pain was measured using a VAS ranging from 0 (no pain) to 10

(intense pain). The mean VAS score was 3.50 + 1.05 in the intervention group 6 hours after

surgery, which was significantly, lower than that of the control group, 4.85+1.31, p<0.01.

Synthesis

Lui & Petrini (2015) reported a significant reduction of pain as measured by the VAS

faces pain scale, SBP, and HR among the intervention group compared to the control group (p =

0.019). Similarly, Mondanaro et al. (2017) found a significantly lower VAS pain score in the

music therapy intervention as compared to the control group. (p = .01). Wang, Dong, & Li

(2014) also reported that the mean VAS pain ratings were lower in the music therapy

intervention group, as compared to the control group (p = <0.01). Furthermore, Wang, Dong, &

Li (2014) reported a significant difference between the psychological plus music therapy

intervention group in HRV, as compared to the control group (p = <0.01). Concurrently, the

American Society of Regional Anesthesia and Pain Medicine, and the American Society of

Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and

Administrative Council (Chou et al., 2016) propose the addition of music therapy and other

nonpharmacological interventions as an adjunct to standard postoperative care for the treatment

of postoperative pain.

Each study used a patient-reported pain scale as a measurement of pain, which is a

reliable and valid means of assessing the patient’s subjective experience of pain. Additionally,

Lui & Petrini (2015) as well as Wang, Dong, & Li (2014) included objective measures of heart
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rate as a physiological indication of pain. Lui & Petrini (2015) also included other biomarkers of

pain such as systolic blood pressure, diastolic blood pressure, and respiratory rate. However, the

heart rate measurement of HRV assessed by Wang, Dong, & Li (2014) is much more specific

than the standard measurement of heart rate. HRV measures the central nervous system’s

regulation of heart rate by monitoring vagal and sympathetic stimulation of cardiac activity

through a ratio of high and low frequencies (Bailey, Fitzgerald, & Applegate, 1996). This

measurement is more descriptive of the body’s response to pain as reflected in sympathetic

activity, which is a clearer indication of the patient’s experience of pain while unable to self-

report. It is not well understood, however, in what ways music-listening affects sympathetic

versus parasympathetic activity.

The major weakness of all three studies is that bias may not have been eliminated in the

data collection process. Lui & Petrini (2015) did not conceal random assignment from the

individuals enrolling the study subjects. Mondanaro et al. (2017) did not conceal random

assignment from the individuals who were enrolling subjects into the study. Wang, Dong, & Li

(2014) did not blind providers to the study group. This lack of anonymity may have been

necessary for the studies data collection process, but also may have an affect on patient responses

and may introduce study bias in the data collection or analysis.

Clinical Recommendations

Research demonstrates that music therapy is an effective adjunctive treatment for

postoperative pain, in addition to standard pain control measures. The research suggests that 30

minutes of listening to music, whether preoperatively or intraoperatively, significantly reduces

postoperative pain (Lui & Petrini, 2015; Mondanaro et al., 2017; Wang, Dong, & Li,

2014). Pain management is an integral part of postoperative recovery. Music therapy is an

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effective, noninvasive, and inexpensive intervention which has been demonstrated to positively

affect patient outcomes, with no known adverse effects. Further research is needed to fully

understand the relationship between cognition and how patients experience pain.

Word Count

Kristina: 543

Julissa: 705

Melissa: 539
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References

Bailey J. R., Fitzgerald D. M., & Applegate R. J. (1996). Effects of constant cardiac autonomic

nerve stimulation on heart rate variability. The American Journal of Physiology, 270(6 Pt

2), H2081-7. https://www.ncbi.nlm.nih.gov/pubmed/8764259

Chou, R., Gordon, D. B., De Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T.,

Carter, T., Cassidy, C. L., Chittenden, E. H., Degenhardt, E., Griffith, S., Manworren, R.,

McCarberg, B., Montgomery, R., Murphy, J., Perkal, M. F., Suresh, S., Sluka, K.,

Strassels, S., Thirlby, R., Viscusi, E., Walco, G. A., Warner, L., Weisman, S. J., Wu, C.

L. (2016). Management of postoperative pain: A clinical practice guideline for from the

American pain society, the American society of regional anesthesia and pain medicine,

and the American society of anesthesiologists’ committee on regional anesthesia,

executive committee, and administrative council. The Journal of Pain, 17(2), 131-157.

doi: http://doi.org/10.1016/j.jpain.2015.12.008

Hole, J., Hirsch, M., Ball, E., Meads, C. (2015). Music as an aid for postoperative recovery in

adults: a systematic review and meta-analysis. The Lancet, 386, 1659-1671. Retrieved

from http://dx.doi.org/10.1016/S0140-6736(15)60169-6

Economidou, E., Klimi, A., Vivilaki, V. G., Lykeridou, K. (2012). Does music reduce

postoperative pain? A review. Health Science Journal, 6(3), 365-377. Retrieved from

http://www.hsj.gr/medicine/does-music-reduce-postoperative-pain-a-review.pdf

Kankkunen, P., Vaajoki, A. (2014). Songs for silent suffering: could music help with

postsurgical pain? Pain Manage, 4(1), 1-3. doi: 10.2217/pmt.13.65

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Lui, Y., & Petrini, M. A. (2015). Effects of music therapy on pain, anxiety, and vital signs in

patients after thoracic surgery. Complementary Therapies in Medicine, 23(5), 714-718.

https://doi.org/10.1016/j.ctim.2015.08.002

Mondanaro, J. F., Homel, P., Lonner, B., Shepp, J., Lichtensztejn, M., & Loewy, J. V. (2017).

Music therapy increases comfort and reduces pain in patients recovering from spine

surgery. American Journal of Orthopedics, 46(1), E13-E22.

http://www.mdedge.com/amjorthopedics/article/129437/spine/music-therapy-increases-

comfort-and-reduces-pain-patients

Wang, Y., Dong, Y., & Li, Y. (2014). Perioperative psychological and music interventions in

elderly patients undergoing spinal anesthesia: Effect on anxiety, heart rate variability, and

postoperative pain. Yonsei Medical Journal, 55(4), 1101-1105.

doi:10.3349/ymj.2014.55.4.1101