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Music as a Postoperative Pain Management

Michael J. Poulsen, DNP, RN, FNP-C, Jeffrey Coto, DNP, MS-CNS, RN, CCRN,
Maureen F. Cooney, DNP, FNP-BC

PAIN IS A COMMON and frequently reported ef- cedures that provide at least one nonpharmacologic
fect of surgical intervention. The World Health pain management approach.4
Organization estimates 266 to 360 million surgeries
are performed yearly.1 Studies have shown that 40% To achieve adequate pain control and opioid
to 65% of postoperative patients report moderate to reduction, multimodal therapies are essential.
severe pain.1 The most common treatment for mod- Nonpharmacologic pain management approaches
erate to severe pain continues to be opioid medica- may be used as components of multimodal pain
tions because of immediate effects, multiple management plans of care. One nonpharmaco-
delivery forms, and ease of administration. The US logic approach to pain management includes the
Department of Health and Human Services has con- use of music during the perioperative process. Mu-
cerns with increasing opioid-related deaths and sic interventions have been shown to result in sig-
opioid use disorder, causing the medical community nificant decreases in postoperative pain.5-10 When
to rethink the approach to pain management pain is well controlled, there is a significant
regarding the use of opioid medications.2 reduction in anxiety and opioid use during the
perioperative period.5-8,10 Music is a safe and
For the past several years, opioid reduction has been inexpensive intervention that nursing staff and
a major focus in American health care. In 2016, the patients can perform without provider orders.5-10
United States Drug Enforcement Agency started re- Although music is considered a distraction, a
stricting companies from producing opioid medica- small study using both Positron Emission
tions by 25% and plans to continue these Tomography (PET) scan and functional magnetic
restrictions into 2017 and beyond.3 On January 1, resonance imaging (fMRI) found music activated
2018, the Joint Commission implemented new and the caudate and nucleus accumbens regions of
modified pain standards, which address the need the brain.10 These regions of the brain respond
for improvements in pain assessment and manage- to pleasurable experiences leading to a dopamine
ment, and include the need to implement measures release and euphoric state.11 With an understand-
to improve opioid safety.4 The standards include a ing of the physical response to pleasurable music,
focus on opioid reduction strategies to minimize developing protocols for practice utilization is a
risks associated with opioid use. The new standards logical next step.10
require accredited hospitals to have policies and pro-
The purpose of this article is to review the current
evidence regarding the use of music in periopera-
tive nursing practice and its effect on postopera-
Michael J. Poulsen, DNP, RN, FNP-C, St. Joseph Regional Med- tive pain and opioid use during perioperative
ical Center Mishawaka, IN; Jeffrey Coto, DNP, MS-CNS, RN, recovery. Recommendations for the use of music
CCRN, Valparaiso University, IN; and Maureen F. Cooney,
DNP, FNP-BC, Pain Management, Westchester Medical Center, as an intervention to reduce postsurgical pain
Valhalla, NY. and opioid use are deduced and summarized
Conflict of interest: None to report. from the review of the evidence.
Address correspondence to Maureen F. Cooney, Pain Man-
agement, Westchester Medical Center, Rm 2108 Macy Literature Review
Pavilion, 100 Woods Road, Valhalla, NY 10595; e-mail
address: maureen.f.cooney@gmail.com.
Ó 2019 by American Society of PeriAnesthesia Nurses An extensive review of the literature was
1089-9472/$36.00 completed using PubMed, CINAHL, MEDLINE,
https://doi.org/10.1016/j.jopan.2019.01.003 Cochrane Library, and Joanna Briggs Institute

Journal of PeriAnesthesia Nursing, Vol -, No - (-), 2019: pp 1-5 1


databases. Boolean operators used to narrow the tion. The authors concluded music could posi-
search included music, postoperative, and pain. tively impact pain and other variables such as
Search limiters, to narrow the search results, anxiety, muscle tension, and mood in hospitalized
were publication years between 2009 and 2018 patients. The results of the systematic review pro-
and English language. The inclusion criteria for ar- vide support for the use of music as an indepen-
ticles in this review included systematic reviews, dent nursing practice in the postoperative
meta-analysis, and best practice recommenda- setting.5
tions. This review focuses on the adult patient pop-
ulation aged more than 18 years, any surgical Hole et al8 completed an extensive systematic re-
intervention, and therapeutic music interventions view analyzing the effect of music on acute post-
used to reduce perioperative pain, anxiety, and operative pain and other outcomes. The authors
opioid use. searched MEDLINE, Embase, CINAHL, and Co-
chrane Central search engines and identified 72
A total of 263 titles were identified over the five randomized control trials (RCTs) that met inclu-
databases, with 20 meeting the inclusion criteria. sion criteria. The RCTs involved the effects of
After thorough review, four articles were chosen the use of any type of music played preopera-
to be critically appraised using the John Hopkins tively, intraoperatively, or postoperatively on
Evidence-Based Practice tool.12 A quality grade postoperative pain, anxiety, analgesia use, and pa-
was assigned to each article based on the compo- tient satisfaction. The comparators included
nents of the John Hopkins Evidence-Based Practice routine care, white noise, headphones without
tool. music, and uninterrupted bed rest. The types of
music interventions varied in the different
Cole and LoBiondo-Wood5 conducted an extensive studies. In many RCTs, varying types of music
systematic review, which included a search of were played 20 to 60 minutes during the preoper-
CINAHL, MEDLINE, Natural Standard, and Scopus ative, intraoperative, and postoperative periods.
for evidence-based articles. Seventeen articles The authors noted music was predominately clas-
met inclusion criteria and examined the effect of sical, relaxing, or calming. A standardized mean
music and several other nonpharmacologic inter- difference (SMD) score was calculated to stan-
ventions on pain in different patient populations. dardize the outcomes of the various results. Music
The review included seven studies that examined was associated with reduced postoperative pain
the effects of music on pain in postsurgical pa- scores (SMD 20.77, 95% confidence interval) in
tients who had undergone intestinal surgery, or- 45 RCTs. An average pain score reduction of
thopaedic surgery, cardiac surgery, neurologic 23 mm on a 100 mm visual analog scale was re-
surgery, and abdominal surgery.5 The studies also ported. A reduction in analgesic use (SMD
examined the effects of other nonpharmacologic 20.37) was found in 34 RCTs. Music played pre-
interventions including relaxation exercises and operatively was more effective in reducing pain
patient teaching on pain and other outcomes and analgesic use than music played intraopera-
(opioid consumptions, vital signs, anxiety scores, tively or postoperatively. Music was also shown
and cortisol levels). Most music interventions to increase patient satisfaction and decrease anx-
were 20 to 30 minutes long and consisted of 60 iety. Using music during the entire perioperative
to 80 beats per minute. The music interventions process shows the most positive results when
varied from patient choice from a provided list to compared with single phases of the perioperative
instrumental only. In some studies, music was pro- process. The authors recommend the use of mu-
vided by a music therapist. Outcomes in the music sic as an independent nursing intervention
intervention groups were compared with control because of the safety and noninvasive nature of
groups that included usual care or 20-minute rest the therapy.8
periods without music. Music intervention groups
reported significantly less pain in five of the seven Kuhlmann et al1 also completed a systematic re-
studies compared with control groups. In the two view in which the effect of music on pain and
studies where music did not significantly impact anxiety in adult patients during the preopera-
pain, positive outcomes were reported for anxiety, tive, intraoperative, and postoperative periods
relaxation, stress, and perception of hospitaliza- compared with control groups was examined.

Control groups were standard care with or difference in opioid consumption between the
without a resting period, or with sham sounds music intervention group and the control
or headphones without music. The systematic group.9
review included 91 RCTs with 7,385 postopera-
tive patients; 46 of the RCTs included analysis Poulsen and Coto10 conducted an in-depth liter-
of the effects of music on pain.1 Most studies ature review of the use of music as an interven-
(42 RCTs) involved the use of recorded music tion to reduce postsurgical pain. As a result of
whereas four involved live music therapy pro- their literature search, they retrieved seven
vided by a music therapist.1 Music in the RCTs large systematic reviews, meta-analyses, and
was provided at different times: preoperatively, RCTs, which the authors used to develop best
intraoperatively, postoperatively, and at multiple practice recommendations for a perioperative
times, or unspecified times. An SMD was used to music protocol. To optimize analgesia and
calculate the effect size between variables. reduce opioid use, the authors recommended
the following:
Pooling of the different outcome measures of pain
1. Music should be used consistently throughout
in this systematic review resulted in findings that
the perioperative process from preoperative
music interventions were found to have a moderate
through intraoperative and maintained in
effect on pain reduction (SMD 20.50, P , .001)
postoperative periods.
and a moderate to large statistically significant
2. The most beneficial effect was noted when
reduction in anxiety (SMD 20.69, P , .001). On
patients were provided with lists of available
average, pain was reduced by 10 mm on a
music that included calming, relaxing, and
100 mm visual analog scale. Multiple music inter-
mostly instrumental choices.
ventions were more effective than a single music
3. Therapeutic music should be of a calming na-
intervention. Greater effects were noted when pa-
ture with rhythms played at 60 to 80 beats per
tients selected music from a list, compared with
minute to best synchronize with preferred
those who individually selected their own music.
heart rates.
In eight of 14 studies in which music was used dur-
4. Music should be played at least two times
ing regional anesthesia, a moderate and statistically
daily and throughout the entire periopera-
significant effect on pain reduction was noted. Mu-
tive process for at least 15 to 30 minutes
sic played during the postoperative period had the
each session.
largest effect on pain reduction, whereas preopera-
5. No specific music delivery system improves
tive music had the largest effect on anxiety reduc-
outcomes; however, MP3 or compact disc
tion. However, it was reported that pain and
players were most widely used.
anxiety were both reduced when music was used
6. Music should be a nursing led intervention
at any point during the perioperative process.
as it is a safe, cost effective, and individual-
The greatest benefit on both pain and anxiety
ized to each patient.10
reduction was noted when patients selected music
from a list that was provided and the smallest
benefit was realized when patients freely chose Clinical Applications of Research
their own music.1
This review identified the need for additional
9 research, as there are a limited number of studies
Van der Wal-Huisman et al published a system-
atic review, which included 17 studies that measuring the correlation between music and
examined the effects of music on postoperative opioid use. The large systematic reviews summa-
recovery of older adults (aged 60 years or older). rized in this article report less than 50% of articles
Eleven of the 17 studies described the effects of addressed the relationship between music and
music on postoperative pain, and in all the opioid use. As shown in this review, music can
studies, the effects were positive, although the significantly reduce reported pain scores in the
timing of music introduction and frequency var- perioperative patient.5-10 These systematic
ied.9 Five of the studies examined analgesic use, reviews have found if pain is appropriately
and in three of the five studies, although there controlled, reductions are seen in anxiety1,5,8-10
were lower pain scores, there was no significant and opioid use.1,5,8,10 Medical professionals

have a duty to protect their patients from harm Implications for Nursing
and adverse effects of medications. It is
necessary to assure a balance between the Nurses are the front-line professionals delivering
benefits of opioids for pain relief and the care to patients around the clock. Providing
reduction of risks of misuse, opioid use therapies and tools for nurses to use in their
disorder, accidental death, and other serious practice is important for timely relief of symp-
consequences. Music is only one of many toms. Music and complimentary therapies create
complimentary and alternative medicine opportunities for nurses to directly impact and
therapies that can be used in nursing practice to shape opioid reduction policy. Also, these
promote opioid reduction. The use of therapies may help build the nursing and patient
therapeutic tools such as music by nursing staff relationship, as music preferences become com-
and patients has led to good outcomes in the monalities for nurses and their patients. Music is
postoperative period and may lead to an overall cost effective and can be provided in multiple
significant opioid reduction after forms such as radio, MP3 player, CD player, or
discharge.1,5,8,10 live performance. Music is a common experi-
ence shared by most cultures and access to
Some reasons for success of music and other personal preferences is easier than ever with
complimentary and alternative medicine thera- on-demand streaming and widely available
pies are their low cost, low risk for adverse ef- Internet access.
fects, and ease of administration.5,8-10 Music
can be used at the discretion of nursing staff Conclusions
and patients. For music interventions to be
effective, it is important for nurses to Music can play an effective role in the perioper-
understand the therapy and educate patients ative process. Music is effective in reducing pain
about its purpose and benefits. The use of and anxiety, which may lead to effective and sig-
music does not replace the need for oral or nificant opioid reduction. Reducing the poten-
intravenous analgesic therapy.1,5,8,10 Analgesic tial adverse effects of opioids and the risks of
medication may be necessary for music to be misuse are outcomes that can be impacted by
effective.1,5,8,10 nurses. Giving nursing staff the proper tools to
provide symptom relief will not only improve
The challenges of inadequate postoperative pain patient satisfaction, but also reduce patients’
control and the continued opioid crisis continue opioid requirements. Offering music throughout
to increase risks of life-threatening opioid-related the perioperative experience continues to yield
adverse effects.2 Although many national and positive results for reducing pain and opioid
local initiatives may eventually prove beneficial, use for postoperative patients. There is a need
it is critical to offer nursing interventions that for more RCTs to confirm the magnitude of
offer nonopioid and nonpharmacologic options the effect on opioid reduction. However, as
for acute postoperative pain management. Music the benefits far outweigh risks, the present is
is one intervention that can be easily put into an optimal time to implement music interven-
practice. tions into practice.

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