23 (2015) 714718

Contents lists available at ScienceDirect

Complementary Therapies in Medicine

journal homepage: www.elsevierhealth.com/journals/ctim

Effects of music therapy on pain, anxiety, and vital signs in patients

after thoracic surgery
Yang Liu , Marcia A. Petrini
HOPE School of Nursing, Wuhan University, Wuhan, China

a r t i c l e

i n f o

Article history:
Received 8 November 2014
Received in revised form 15 July 2015
Accepted 1 August 2015
Available online 4 August 2015
Keywords:
Anxiety
China
Music therapy
Pain
Thoracic surgery
Vital signs

a b s t r a c t
Objective: To examine the effectiveness of music listening on pain, anxiety, and vital signs among patients
after thoracic surgery in China.
Design and setting: A randomized controlled clinical trial was conducted in the thoracic surgery department of two tertiary hospitals in Wuhan, China. 112 patients were recruited and randomly assigned to
either experimental (n = 56) or control (n = 56) group respectively.
Intervention: The experimental group received standard care and a 30-min soft music intervention for
3 days, while the control group received only standard care. Measures include pain, anxiety, vital signs
(blood pressure, heart rate and respiratory rate), patient controlled analgesia, and diclofenac sodium
suppository use.
Results: The experimental group showed statistically signicant decrease in pain, anxiety, systolic blood
pressure and heart rate over time compared to the control group, but no signicant difference were
identied in diastolic blood pressure, respiratory rate, patient controlled analgesia and diclofenac sodium
suppository use.
Conclusion: The ndings provide further evidence to support the practice of music therapy to reduce
postoperative pain and anxiety, and lower systolic blood pressure and heart rate in patients after thoracic
surgery in China.
2015 Elsevier Ltd. All rights reserved.

1. Introduction
Thousands of patients undergo surgery everyday throughout the
world and experience pain.1 Postoperative pain, a kind of acute
pain, is an anticipated but unwanted outcome of all surgeries.2
Pain after thoracotomy is a severe acute traumatic pain resulting from incision3 and has been reported to be a most painful
clinical experience.4 Literature yielded that postoperative pain in
patients undergoing thoracotomy is still an important problem
attracts attention of numerous studies.5
Anxiety usually accompanies pain,6 patients have a high level of
anxiety when they are in the hospital.7 Anxiety is a psychological
disorder that can cause many adverse effects. Patients may experience fatigue, have difculty sleeping and digesting, lose appetite
and weight, have elevated heart rate, develop more stress, feel

Corresponding author at: 115 Donghu Road, HOPE School of Nursing, Wuhan
University, Wuhan, China.
E-mail addresses: 1041407891@qq.com (Y. Liu), 2845map@gmail.com
(M.A. Petrini).
http://dx.doi.org/10.1016/j.ctim.2015.08.002
0965-2299/ 2015 Elsevier Ltd. All rights reserved.

helpless and pessimistic, lose condence to ght against disease, all

are adverse effect that harm the patient and delay their recovery.8,9
Thus much more attention is required to nd an effective way to
reduce patient anxiety.7
Music therapy as a nonpharmacological adjuvant has been
widely used in clinical practice.10 In 2005, the American Music
Therapy Association denes music therapy as music interventions
that are both clinically and evidence- based. The goal of music interventions by nurses or therapists, educated in an approved music
therapy program is to develop a therapeutic relationship. Music
therapy can be implemented as a nursing procedure.11 Research
determined that listening to music can increase comfort and relaxation, relieve pain, lower distress, reduce anxiety, improve positive
emotions and mood, and decrease psychological symptoms.8,1214
Although there are growing studies of music therapy in China
in recent years, the quantity and quality of the studies are sparse
and inadequate,15 and inconsistent ndings were reported. This
study was conducted to investigate the effectiveness of music on
patients postoperative pain, anxiety, and vital signs after thoracic
surgery and to provide further evidence to support the practice of
music therapy for patients in China.

Y. Liu, M.A. Petrini / 23 (2015) 714718

715

Fig. 1. Flowchart of the study.

2. Methods
2.1. Study design and participants
A randomized controlled trial with repeated measures design
(Fig. 1). The experimental group received a 30-min music intervention for three days plus standard care while the control group
received only standard care. Two tertiary hospitals in Wuhan,
China, provided the setting from November 2013 to March 2014
for the clinical trial.
A convenience sample of 112 patients was recruited. Inclusion
criteria for participants included: (a) inpatients scheduled for thoracic surgery; (b) aged 18 or older; (c) able to understand, read and
speak Chinese, so they may complete the informed consent and
questionnaires; (d) conscious, oriented to person, place, time and
situation. Patients with vision and hearing decits and inability to
complete questionnaires, not willing to participate, or underwent
emergency surgeries were excluded.
2.2. Randomization and sample size
Participants with odd admission day numbers were assigned
to the experimental group while those with even numbers were
assigned to the control group. There was no blinding as the
researcher and participants knew the allocation.
The sample size was determined with GPower3.1.9.16 Alpha
value was set at 0.05 and a power of 0.95; the resulting minimum
sample size was 92 patients. Considering an attrition rate of 20%,
therefore the total sample size required was 112 subjects.

from no hurts to hurts the worst. Although faces pain scale is

widely used to assess childrens pain, a study determined it was the
most accurate, easy to understand, and with highest response rate
among ve commonly used pain scales in patients with vascular
surgery.18 The faces pain scale has a strong positive correlation with
other pain scales (r = 0.810.95; p < 0.001), and it is valid, reliable
and easy to use for clinical pain assessment of mature adults or
very ill patients.19
The state-trait anxiety inventory (STAI) is widely used for measuring anxiety. It has 20 items for state anxiety; all items are
rated on a 4-point scale from 1 = almost never to 4 = almost
always. Higher scores indicate higher anxiety level, low anxiety ranges from 20 to 39, the moderate anxiety ranges from
40 to 59, and high anxiety ranges from 60 to 80.7 The STAIs
internal consistency coefcients have ranged from 0.86 to 0.95
with test-retest reliability coefcients ranging from 0.65 to 0.75.20
STAI is also used expansively in Chinese populations21,22 and has
been applied to many studies, the test-retest coefcient of SAI is
0.88.23
Vital signs (systolic blood pressure [SBP], diastolic blood pressure [DBP], heart rate [HR], and respiratory rate [RR]) were
measured at each test point. Patient controlled analgesia (PCA) use
was counted, and the consumption (mg) of diclofenac sodium suppository (DSS) use was recorded each day for three days. A survey
was also conducted with the music group to ascertain participants
opinions of the music intervention.

2.4. Procedures

2.3. Measurements
The pain was measured using faces pain scale.17 Patients can
choose the face that best represents their pain intensity ranging

After ethical approval was obtained, the researcher

invited eligible patients, introduced the study protocol to
them, had the informed consent signed, asked participants

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Y. Liu, M.A. Petrini / 23 (2015) 714718

Table 1
Demographic characteristics of participants.
Variables

Age (years) [mean SD]

Experimental group (n = 47)

Control group (n = 51)

54.45 15.90

t/2

P Value

t = 0.76

0.45

 = 0.13

0.72

2 = 0.93

0.63

2 = 0.70

0.87

2 = 1.02

0.31

2 = 0.39

0.53

2 = 0.55

0.46

2 = 0.16

0.69

52.02 15.62

Gender
- Male
- Female

33
18

64.7
35.3

32
15

68.1
31.9

Education
- Primary school or below
- Middle school
- College or above

22
20
9

43.1
39.2
17.7

19
16
12

40.4
34.0
25.6

Marital status
- Single
- Married
- Divorced
- Widow

8
38
1
4

15.7
74.5
2.0
7.8

7
33
2
5

14.9
70.2
4.3
10.6

Job
- Yes
- No

28
23

54.9
45.1

21
26

44.7
55.3

Hospitalization payment
- Own expense
- Health insurance

26
25

51.0
49.0

21
26

44.7
55.3

Religious belief
- No
- Yes

47
4

92.2
7.8

45
2

95.7
4.3

Previous surgery
- No
- Yes

35
16

68.6
31.4

34
13

72.3
27.7

to complete demographic data, and then assigned them to

groups.
The experimental group were visited by the researcher on
post-operative day 1, collected pre-test data (pain, anxiety, and
vital signs), and then provided 30-min music session, after that,
post-tests (pain, anxiety, and vital signs) were recorded. On postoperative day 2 and 3, after the 30-min music intervention, the
same post-tests were conducted. Soft music with 6080 beats per
minute or less was offered24 because melodious music with pleasant rhythms has shown to yield a calming effect and a sense of
well-being.25 Music was transferred to the MP3 players before
the intervention, with earphones connected, and volume was controlled by participants. In preparation for the intervention, the
researcher prepared the patient and environment well (turned off
cell phones, shut the door, and eliminated distractions), and tried
to keep the patients from being disturbed.26 The researcher guided
patients to keep their breathing smooth, relaxed, and focused on the
music.27 After all data had been collected, a survey was conducted
to collect participants opinions about the music intervention.
For the control group, music intervention was absent, participants received only standard care, and same pre-test and post-tests
were conducted regard to the experimental group. After all data had
been collected, the same music was provided if the participants
wanted.

2.5. Ethical considerations

The Human Ethical Committee of Wuhan University HOPE
School of Nursing and the two tertiary hospitals approved the study.
The research protocol was explained to participants, and they were
told that participation is voluntary. Also, if they wanted to drop
out at any time throughout the study, no harm to them would be
experienced. Prior to study participation, all subjects gave informed
consent.

2.6. Statistical analysis

Data was analysed using SPSS (version 21.0 for Windows). Participant characteristics and the survey results were analyzed with
descriptive statistics. Chi-square tests were utilized to identify any
signicant difference between groups regarding demographic data.
Independent t-test was used to detect any signicant differences
in the baseline anxiety, SBP, DBP, HR, and RR. Repeated measures
of analysis of variance (RENOVA) were used to examine anxiety,
SBP, DBP, HR, and RR through the study. The marginal modeling
approach (GEE analysis) was used to detect any signicant difference in pain over time.28 Signicance was <0.05.
3. Results
3.1. Demographic and baseline characteristics of participants
Tables 1 and 2 present the demographic and baseline characteristics of participants.
3.2. Pain, anxiety, and vital signs (Table 3)
After the intervention, a signicant difference between groups
regarding pain (Wald 2 = 5.498, p = 0.019), anxiety, SBP, and HR
was noted. No signicant difference existed in respect to DBP, RR,
DSS use, and PCA use (2 = 0.29, p = 0.59) ().
89.4% (n = 42) of participants like the music, 68.1% (n = 32)
thought the music alleviated their pain, and 76.6% (n = 36) thought
the music decreased their anxiety.
4. Discussion
This study examined the effectiveness of a 3-days music
intervention on patients pain, anxiety, and vital signs after thoracic surgery. Major ndings are congruent with other studies

Y. Liu, M.A. Petrini / 23 (2015) 714718

717

Table 2
The baseline assessment of major study variables.
Variables

Pain
Anxiety
SBP
DBP
HR
RR

Group (mean SD)

Experimental (n = 47)

Control (n = 51)

50.92 6.02
132.92 14.73
83.76 7.81
87.59 11.04
20.24 3.58

51.04 6.68
132.51 15.05
83.06 8.27
88.79 12.37
20.28 3.48

z/t

P Value

z = 0.167
t = 0.094
t = 0.137
t = 0.431
t = 0.507
t = 0.058

0.867
0.925
0.892
0.667
0.613
0.954

Table 3
Repeated measures ANOVA on major study variables.
Variables

Group (mean SD)

Experimental (n = 47)

Control (n = 51)

Anxiety
[-] - 1st Post-test
[-] - 2nd Post-test
[-] - 3rd Post-test

50.10 5.50
42.73 4.92
35.53 5.08

50.79 6.72
46.62 6.51
41.43 5.49

SBP
[-] - 1st Post-test
[-] - 2nd Post-test
[-] - 3rd Post-test

129.31 12.28
122.63 10.18
114.29 7.67

132.02 14.67
128.68 12.33
125.02 8.45

DBP
[-] - 1st Post-test
[-] - 2nd Post-test
[-] - 3rd Post-test

81.55 7.99
75.86 6.68
71.61 7.51

82.77 7.83
77.30 6.60
73.91 6.70

HR
[-] - 1st Post-test
[-] - 2nd Post-test
[-] - 3rd Post-test

85.61 10.71
80.63 9.22
76.92 9.31

88.62 10.86
86.57 8.89
82.21 8.92

RR
[-] - 1st Post-test
[-] - 2nd Post-test
[-] - 3rd Post-test

19.49 2.99
18.51 3.18
17.53 2.53

20.21 3.22
19.19 2.43
17.62 2.15

DSS use (mg)

[-] - 1st Post-day
[-] - 2nd Post-day
[-] - 3rd Post-day

62.73 18.26
36.67 21.51
14.17 14.21

62.91 20.72
37.93 22.78
14.66 15.69

P Value

5.560

0.020*

4.495

0.037*

0.670

0.415

4.379

0.039*

0.710

0.402

0.011

0.918

Note: post-day = postoperative day.

*
p < 0.05.

identied that music may help to relieve postoperative pain,29,30

help subjects feel less anxious and more relaxed,31 decrease SBP,32
and lower HR.33 The results did not reveal a signicant impact on
DBP and RR. This nding was similar to other studies in RR,24,29 but
inconsistent with previous studies in DBP,32 RR.33 A study reported
that subjects required fewer opioids or analgesics after listening to
music,34 but no such impact was detected regarding PCA use and
DDS use in this study, which is similar to previous studies.24,35
Music therapy is safe, inexpensive, simple to learn, and may
be used easily by nurses in hospitals.36 In nursing practice,
music may be used alone, or combined with other methods
like jaw relaxation29 and therapist guidance26 ; it may be practiced in various settings, situations and populations for different
purposes.13,24,26,29,3739 Studies suggested that 2090 min of music
therapy is an adequate treatment period.40,41 The kinds of
music included: Sedative music,39 researcher-provided music and
subject- preferred music,38 smoothing music,42 and easy-listening
music.24
A Balance between analgesia and side effects43,44 was used as
the conceptual framework for this study that proposes that nurses
can use a combination of pharmacological and nonpharmacological
measures to relieve acute pain and avoid side effects. This theory
provided a very good theoretical foundation for the management
of acute pain in clinics. It is imperative for health care professionals

to know that there are other methods, such as music, to relieve

clinical pain and anxiety.
4.1. Limitations and implications
There are several limitations: rst, independent variables (the
type of surgery, health status, and diagnosis) often inuence the
dependent variables. Second, the music choice was limited and
was chosen by the researcher, which may have hindered the effect
of music. Third, the music therapy group received special attention (music intervention) from the researcher. While the control
group did not receive the same attention, the effect of special attention on the results cannot be ruled out. Therefore, the results may
not be exclusively attributed to the music intervention. Fourth, the
research was only conducted for 3 days. Future studies may provide
more music choices to participants based on their preferences. A
study of the long term benets and other outcome measures, as well
as conduct similar studies in other settings and groups is advised.
5. Conclusion
This study provides further evidence to support the practice of
music therapy to reduce postoperative pain and anxiety, and lower
systolic blood pressure and heart rate in patients after thoracic

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Y. Liu, M.A. Petrini / 23 (2015) 714718

surgery in China. Additionally, the study learned that the majority

of patients with the music therapy thought that music may alleviate
pain and decrease anxiety.
Conict of interests
None declared.
Funding
No funding.
Authors contribution
Study design YL, M.A.P; data collection and analysis: YL;
manuscript preparation: YL, M.A.P.
Acknowledgements
Sincere gratitude to the patients who participated in this study;
and to the two thoracic surgery departments for their support is
given.
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