This com-

mentary

Musical Healing:
proved to be
quite daunt-
ing when I
considered
the amount Music Therapy as a Supplement or
of time
I had to Replacement to Postoperative Pain Medication
research and
write on a
topic I knew little about. Choos-
Chelsea Ducille
ing a topic related to music therapy
was difficult. Music and medicine Academic Writing (Spring 2012)
cover a vast area of research and Music as Medicine
information, so narrowing my focus Professor Cary Moskovitz
was essential. When discussing our
topic ideas in class I confidently
said I would write about music
therapy and pain management, but,
to my chagrin, I was told that this
topic was extremely broad and that
I needed to narrow my focus more.
After reviewing study after study,
the topic I wanted to pursue finally
hit me: music therapy and post-
operative pain management.
The process became harder once
I magine lying in a hospital bed with severe pain after a recent surgery. Now
combine that with nausea, vomiting, headaches, dizziness, and possibly
respiratory depression.1, 2 Often it is the pain medication administered that causes
the research began. I found myself these uncomfortable and aggravating side effects. When patients have to deal with
with a large stack of papers to read these side effects it prolongs surgical recovery time.3 Pain medications are certainly
through, most of which proved necessary in postoperative care, but finding a way to lessen the amount used and
to be unusable. It was challenging therefore lessen the side effects could greatly improve patient care. Many of the pain
finding appropriate case studies and medications administered to patients postoperatively can cause complications or
articles, but trying to understand all
delay the recovery process. They also contribute to increased hospitalization costs.4
of the scientific terms and statistical
methods became tedious and over-
Alternative pain treatment methods, such as music therapy, should be
whelming. There never appeared to considered as a solution or aid to some of the problems posed by postoperative
be enough time for the amount of medications. Implementing music therapy could possibly reduce the health risk of
research I had to do. I spent hours these pain drugs and medical costs. In order to determine music therapys efficacy,
every day writing and researching. much experimentation and testing is needed. However, effectively measuring,
The greatest resources during the testing, and studying the effects of postoperative music therapy is difficult. Pain
writing process were the help and is relative to each patient; each person has his or her own level of pain tolerance.
the input of my classmates, my Several studies have succeeded in measuring the effects of music therapy both
professor, and a Duke alum and quantitatively and qualitatively.8-16 In the majority of these studies, all discussed
doctor who read my paper and in this commentary, the results of the experiments suggest that music therapy
provided input through the Duke may reduce pain and/or increase the comfort and relaxation of the patients. Some
Reader Project. Open class discus-
studies demonstrate statistically significant data that music therapy reduces the
sion provided useful suggestions.
Every week I met with a few of
need for pain medications.8-12 Others show no statistical evidence of a reduction in
my classmates to go through each pain therapy, but do acknowledge that clinically significant results exist that music
others papers thoroughly. We even therapy reduces pain in subjects.13-16 This commentary assesses the efficacy and the
had meetings together with our potential of postoperative music therapy on patient recovery.
professor to go over the more dif-
ficult issues. Frequent collaboration
Pain Medications
helped give me several perspectives Doctors can use prescription drugs effectively to treat severe pain, but with
and develop one of my better pieces an increased risk to the patient. Prescription pain medications are often opioid
of writing. analgesics or non-steroidal anti-inflammatory drugs (NSAIDs). Unlike over-
the-counter drugs, these stronger pain medications in greater dosages are more
effective at relieving pain, but also expose patients to a greater risk of side effects.
Even over-the-counter drugs, such as the analgesic acetaminophen/paracetamol,
50
pose some risk.5 Such drugs are usually safe but can cause liver and kidney damage.
In contrast, the stronger prescription NSAIDs have several side effects, which can
cause deterioration in many parts of the body. Ulcers, hearing loss, hemorrhaging,
and renal failure are a few of the side effects. Out of all of the pain medications
available, opioids pose the greatest risk. Patients experience nausea, vomiting,
and constipation, as well as the possibility of narcotic addiction and tolerance.2
Addiction and tolerance can lead to increased use of prescription drugs, which
then can result in worsened health or hypersensitivity to pain.
According to the Harvard Medical Practice, of all negative medical results,
adverse drug events were the most frequent.4 Research and studies on postoperative
pain medications adverse drug effects (ADE) have shown that minimal opioid
usage reduces the probability of ADE.6 Often times, patients are administered
several different analgesics in order to treat postoperative pain.7 The mixing of these
drugs also can lead to an increase in ADE, which then prompts more medications,
nursing care, and time in the hospital.4,6,7 When more medications are needed to
suppress side effects caused by opioids and other pain medications, the patients
risk of complication increases. The treatment of ADE also requires that doctors
and nurses spend more time assessing how to treat these side effects, which means
an extended amount of time in the hospital and greater medical expenses. Though
these opioid medications currently provide the most effective relief to postoperative
pain and are administered strictly and with great care,3 the chance of unforeseen
complications remains.
Postoperative Music Therapy
Music therapy can provide relief without the occurrence of adverse drug
events. Several studies, like one by Sen et al., show the benefits of music therapy.8 Sen
and others tested seventy patients for the effects of music therapy on postoperative
pain. In one group patients listened to music through headphones an hour after
surgery. The second group of postoperative patients did not listen to music. Patients
in both groups were connected to
Patient Controlled Analgesia (PCA). Table 1. Patients Analgesic Use8
This device allows patients to receive
self-administered pain medication. Group 1 (n=35) Group 2 (n=35) p
Sen and others found that patients in
the experimental group felt less pain Tramadol consumption at 4th hour (mg) 52.5730.32 72.0030.75 0.007
and used less PCA. After four hours,
the experimental group used 52.57 Total amount of tramadol consumption (mg) 307.4362.51 352.57109.02 0.037
30.32 milligrams of pain medication,
whereas the control group used 72.00 Tramadol delivery at 4th hour (mg) 2.631.51 3.601.53 0.007
30.75 milligrams (P=0.007). Results
obtained at different times throughout Total amount of diclofenac consumption (mg) 51.4343.70 72.8642.60 0.041
the experiment consistently showed
lower scores (See Table 1).8 All of the Patient satisfaction scores (on scale of 1-10) 8.970.78 8.341.05 0.006
pain medication administered to the
patients in total was significantly lower
in the music therapy group than the Group 1, the experimental group, listened to music for one hour after surgery. Group 2 is
group that did not listen to music. In the control group. Analgesic use was lower in the music therapy group during the four
the group that did not receive music hours after the operation.
therapy, almost 20 milligrams more
pain medication was administered to each patient on average. In their discussion,
the researchers suggest that the pain and auditory pathways in the brain inhibit
each other. Therefore, activating the auditory pathways can reduce pain. This is
particularly compelling because of the methods and data collection used. By
measuring the amount of analgesic administered by the patients through PCA,
the pain and satisfaction using the visual analog scale (VAS), and the length of
the surgical procedures and anesthesia, researchers collected both objective and
51
 subjective results. The measurement of both PCA amounts and VAS scores made
the results more accurate and allowed for better analysis due to the presence of
both subjective and objective evidence. Sen and others find that VAS scores and
the amount of analgesics used were significantly lower in the music group than in
the control group. This provides strong support that music therapy can effectively
relieve postoperative pain.
Another large study, conducted by Good et al., investigated the beneficial
effects of relaxation, music, and a combination of the two on postoperative pain.9
The subjects in this study included 468 abdominal surgery patients who were
expected to use PCA. Researchers found that patients in the music group, as well
Music therapy can as the relaxation and music group, felt significantly less pain over a two-day period
help reduce the after their surgery. Unlike Sen et al., this experiment had little objective data. Good
and others recorded VAS scores and results using the McGill Pain Questionnaire
amount of medica- Rating Scale. The data collected showed that patients in the experimental group
tions that patients felt 17-21% less pain than the control group over the two-day period after surgery.
Though most of the patients used PCA, its use and many other confounding
require, and as a variables showed no significant changes in the experiment and were not recorded.9
result, can reduce Having objective results to support the subjective data would have been ideal, but
the potential risk that the large sample size makes the results of this study very strong.
More research has been conducted with similar results. Experiments
prescriptions can that demonstrate the positive effects of music therapy increasingly support its
cause. implementation in postoperative settings. Cutshall et al. in their research of pain
and anxiety in cardiac surgery patients showed that music therapy significantly
decreased pain and anxiety on the second day after surgery.10 Vaajoki et al. also
tested the effects of music therapy on pain and distress after abdominal surgery.11
This also demonstrated that music therapy decreased pain on the second day after
surgery. Both of these studies only objectively measured pain with VAS scores;
however, the similarity of the results and measurements in both of these
studies strengthens their results. These findings also coincide with evidence
produced by Sen et al. and Good et al. A Korean study by Good and Ahn
on pain and anxiety after gynecological surgery also showed that music
therapy helped patients feel significantly less pain postoperatively as
compared with the control group.12 Researchers conclude that a balance
of pharmacologic and non-pharmacologic methods works better than the
sole use of analgesics.12 The congruency of results in all of these experiments
strengthens the claim that music therapy is effective in helping reduce pain.
Clinical versus Statistical Significance?
Clinical and statistical significance describe and classify the results of an
experiment. Clinical significance usually describes subjective results (general or
overall change), while statistical significance reflects objective data (numbers,
p-values, scores). Statistical significance is often determined by the p-values. If
results have a p-value less than 0.05, the probability is negligible that the results were
due to chance. Whereas, if p-values are greater than 0.05, the result cannot be used
to draw definitive conclusions. Doctors and clinicians require more statistically
significant results if they intend to implement music therapy as a replacement or
supplement to pain medications. In many of the experiments discussed in this
commentary, results are clinically compelling, but from an objective and statistical
perspective, the numbers lack importance.14-16
There are several other studies that argue that music therapy does not
significantly reduce postoperative pain.13-16 However, this does not mean that their
results prove music therapys ineffectiveness in treating postoperative pain. Like
the studies previously mentioned, researchers tested and recorded objective and
subjective results that usually consisted of VAS scores and the amount of analgesics
administered to patients through PCA units. The measured results may not be
statistically significant due to the small size of the experimental groups, but they
52
still show that pain decreased after surgery. Despite the lack
of statistically significant evidence, the question of chance
is diminished because several similar studies show that
music therapy decreased pain. Most of the researchers also
discuss the clinical significance of their study, and, in their
conclusions and analyses, they acknowledge that music
therapy helps better the comfort and relaxation of patients
and generally improve their well-being after surgery. Heiser
et al. conducted an experiment where 34 patients had
music played directly after surgery to test the effectiveness
of music therapy on pain.13 Researchers found that there
was no significant difference in the amount of analgesic
medications and pain, anxiety, and satisfaction scores
between the experimental and control groups. Patients did
report that they felt comforted and would use music therapy
again. Allred et al.s experiment on the effect of music on
postoperative pain and anxiety proved no significant results,
due to high p-values.14 However, in their discussion the
researchers mention that pain scores in their experimental
groups decreased 30% over their periods of data collection
as compared with their control group. Leardi et al. and
Nilsson et al. also produced similar results.15, 16
Implications
Evidence and data from these studies suggest that
music therapy effectively reduces pain. Though some of
them claim that there is not enough statistical significance to
make such a suggestion, they all recognize that music does
lower pain scores. Experiments such as Good and Ahns,
which produced no statistically significant data, stated that
music therapy is at least an effective supplemental non-
pharmacological method of reducing pain.12
One might also wonder what musical genres would
be appropriate for music therapy. Many experiments vary
in the types of music used. Sen et al. and Vaajoki et al.
allowed patients to listen to music of their own choosing.8, 11
Whereas Good and others gave patients a selection of slow
References
1
Nonsteroidal anti-inflammatory drugs (NSAID)-Oral. MedicineNet.com. http://www.
medicinenet.com/nonsteroidal_anti-inflammatory_drugs_nsaid/article.htm. Accessed April
19, 2012.
2
Benyamin R, Trescot AM, Datta S, Buenaventa R, Adlaka R, Sehgal N, Glaser SE, Vallejo R.
Opioid complications and side effects. Pain Physician Journal. 2008; 11:S105.
3
Kempczinski, H. Skype conversation. 16 April 2012.
4
Classen DC, Pestotnik SL, Evans S, Lloyd JF, Burke JP. Adverse drug events in hospitalized
patients. The Journal of the American Medical Association. 1997; 277(4): 301-306.
5
Paracetamol side effects. http://www.paracetamolsideeffects.com/ Accessed July 22, 2012.
6
Ritchey RM. Optimizing postoperative pain management. Cleveland Clinic Journal of Medi-
cine. 2006; 73(1): S72-S76.
7
Gwirtz KH, Young JV, Byers RS, Alley C, Levin K, Walker SG, Stoelting RK. The safety and
efficacy of intrathecal opioid analgesia for acute postoperative pain: seven years experience with
5969 surgical patients at Indiana University Hospital. Anesthesia & Analgesia. 1999; 88: 599-604.
8
Sen H, Yanarates O, Sizlan A, Kilic E, Ozkan S, Dagli G. The efficiency and duration of the
analgesic effects of musical therapy on postoperative pain. A r - The Journal of The Turkish
Society of Algology. 2010; 22(4): 145-150.
9
Good M, Stanton-Hicks M, Grass JA, Anderson GC, Lai H, Roykulcharoen V, Adler PA. Relax-
ation and music to reduce postsurgical pain. Journal of Advanced Nursing. 2001; 33(2): 208-215.
53
modern jazz, piano orchestra, harp, and synthesizer.9 Most
of the studies discussed vary in their music choices, which
suggest further studies are needed to determine the most
effective genres for music therapy.
Questions regarding pain measurement may also
be an issue when assessing the efficacy of music therapy.
Patients have varying levels of pain tolerance and their
answers on questionnaires and test results on VAS tests may
not be accurate or consistent. Ritchey reviews the state of
postoperative pain management and the possible methods
of improving treatments. He finds that patients who suffer
from chronic pain or have become dependent on opioids
reported high pain scores, but then inconsistently reported
overall satisfaction with pain treatment.6 It is also hard to
conduct research without some confounding ethics-oriented
variables. For instance, patients cannot be denied pain
medication in the hopes of more accurately measuring the
effects of music therapy. Despite this fact, studies with very
large sample sizes and the many similar results produced in
different studies suggest that this issue is negligible.
In most cases, music therapy was effective in
reducing pain and the overall discomfort of patients. Music
therapy, at times, may not have as powerful an effect on pain
as analgesics do. However, it poses no adverse side effects,
does not cause dangerous health problems, and requires
little more than a set of headphones and an MP3 player.11
Since more research still needs to be conducted, it is safer
to use music therapy as a supplement to postoperative pain
medications. Music therapy can help reduce the amount of
medications that patients require, and as a result, can reduce
the potential risk that prescriptions can cause. The research
presented in this commentary suggests pain treatment that
uses various methods to reduce the amount of analgesics and
opioids used is the safest way to decrease pain and lower the
risk of adverse side effects. Why not make music therapy part
of these opioid-reducing treatments, when it is a soothing,
safe, and low-risk alternative for suffering patients?
Cutshall SM, Anderson PG, Prinsen SK, Wentworth LJ, Olney TL, Messner PK, Brekke
10
KM, Li Z, Sundt TM III, Kelly RF, Bauer BA. Effect of the Combination of Music and Nature
Sounds on Pain and Anxiety in Cardiac Surgical Patients: A Randomized Study. Alternative
Therapies. 2011; 17(4): 16-23.
11
Vaajoki A, Pietila A, Kankkunen P, Vehvilainen-Julkunen K. Effects of listening to music
on pain intensity and pain distress after surgery: an intervention. Journal of Clinical Nursing.
2011; 21: 708-717.
12
Good M, Ahn S. Korean and American Music Reduces Pain in Korean Women After Gyne-
cologic Surgery. Pain Management Nursing. 2008; 9(3): 96-103.
13
Heiser RM, Chiles K, Fudge M, Gray SE. The Use of Music During the Immediate Postopera-
tive Recovery Period. AORN Journal. 1997; 65(4): 777-785.
Allred KD, Byers JF, Sole ML. The Effect of Music on Postoperative Pain and Anxiety. Pain
14
Management Nursing. 2010; 11(1): 15-25.
15
Leardi S, Pietroletti R, Angeloni G, Necozione S, Ranalletta G, Del Gusto B. Randomized
clinical trial examining the effect of music therapy in stress response to day surgery. British
Journal of Surgery. 2007; 94: 943-947.
16
Nilsson U, Rawal N, Unosson M. A comparison of intra-operative or postoperative exposure
to music - a controlled trial of the effects on postoperative pain. Anaesthesia. 2003; 58:
684-711.