Running head: THE EFFECTIVENESS OF MUSIC THERAPY ON POSTOPERATIV 1

The Effectiveness of Music Therapy on Postoperative Pain

Jeff Hershberger, Eric Biedenbach, Jane Sewell, Katie Smith, and Jeannine St Clair

The University of Akron

 The Effectiveness of Music Therapy on Postoperative Pain

As patients prepare to undertake surgical procedures, one might believe the greatest

causes for anxiety will be their safety, expenses, or burdens on family and work. All of these

factors do contribute to the stress level of a patient preparing for even the most non-invasive

operation, but one element of concern stands above the rest; pain. Failure to compensate for

postoperative pain can tax many organs of the body, subsequently setting rehabilitation back and

possibly resulting in chronic pain (Lin, Lin, Huang, Hsu, & Lin, 2011). Additionally,

uncontrolled pain can negatively impact the appetite, quality of sleep, activity patterns, and

emotions thus increasing hospitalization time and medical expenses (Lin et al., 2011).

The gold standard of pain management for postoperative procedures has been by

pharmacological means, but patients do not always receive sufficient pain relief from opioids,

and may have undesired side effects. These limitations bring about a need for complimentary

interventions. Music therapy is considered a non-invasive technology that can steady patients’

emotions and reduce anxiety levels (Lin et al., 2011). A commonly accepted theory explaining

the pain, stress, and anxiety reducing effects of music is that it acts as a distracter; focusing the

patient’s attention away from negative stimuli to something pleasant and encouraging (Nilsson,

Kokinsky, Nilsson, Sidenvall, & Enskar, 2009). Music has been used throughout history as a

healing force to alleviate illness and distress, but most readily and effectively in the 20th century

(Economidou, Klimi, Vivilaki, & Lykeridou, 2012).

Will there be a difference in self-reported pain levels from patients receiving strictly

pharmacological pain management interventions after undergoing surgical procedures and those

receiving both pharmacological interventions and music therapy? This can be a difficult

question to answer because pain is a subjective experience and many healthcare institutions have
not considered music therapy as a complimentary intervention. There is, however, a plethora of

research to suggest that a significant difference exists, and it is the purpose of this paper to

examine the benefits of music therapy to control postoperative pain levels.

The use of music under controlled conditions has been shown to restore patients’

physiological, psychological, and emotional health (Lin et al., 2011). Several studies have been

conducted involving the use of music therapy as an intervention for postoperative patients and

this paper will examine 5 of them. A recent study involved 6 randomized controlled trials of 886

patients. These patients underwent 1 of the following surgeries: varicose vein correction,

inguinal hernia repair, stomach surgery, or a hysterectomy. Patient controlled analgesia (PCA)

was provided to all of the participants involved in the study; however half of them additionally

received music therapy. Using the Visual Analogue Scale (VAS) patients’ pain levels were

evaluated. Each surgical group that received the musical therapy in addition to the PCA

intervention reported lower pain levels than the control group (Economidou et al., 2012).

A major surgical intervention associated with high levels of postoperative pain is spinal

surgery. The second study was conducted using a quasi-experimental pretest and post-test design

involving a study group and a control group. The clinical practice setting was a 2900 bed unit in

Taipei City, Taiwan. 60 patients undergoing spinal surgery were selected. A coin flip assigned

30 patients into 2 separate groups. At this point, a surgeon, unaware of the recruitment process,

assigned an equal number of patients for surgery Tuesday through Friday. Tuesday and Thursday

represented the study group and Wednesday and Friday composed the control group.

Participants were over 18 years old with no mental or cognitive impairments. This experiment

assessed levels of anxiety using the State-Trait Anxiety Intervention (STAI) instrument and pain

using the VAS. The music selection included classical pieces, sacred melodies, sounds found in
nature, and pop. The control and study groups experienced the most anxiety the evening before

surgery and the least anxiety on the second day post-op. Comparison by t-test showed the study

group reported less anxiety than the control group in both instances. Next the research

examined the outcomes with regards to pain. The control group reported the most pain during

the evening prior to surgery and the least amount of pain during the 2nd day post-op. The study

group reported the most pain during post-op day 1 and the least pain during post-op day 2. As

observed in the anxiety findings, comparison by t-test showed statistically significant lower

levels of pain in the study group from the preoperative period through the 2nd day postoperative.

The validity of these results was checked by 5 independent specialists (Lin et al., 2011).

Children are especially vulnerable to pain after surgery because they often cannot express

their feelings as well as adults. An experimental design using a two group pretest and post-test

format and semi-structured qualitative interviews explored whether or not postoperative music

listening reduces morphine consumption and influences pain, distress, and anxiety after day

surgery in school-aged children. In the study, data was collected from 80 children between the

ages of 7 and 16 years from the pediatric day surgery unit at the Queen Silvia Children’s

hospital. 40 participants were randomized into a music therapy group. The music chosen was

soft and relaxing, placed at the bedside, and started at the time of admission to the post-

anesthesia care unit (PACU) for the intervention group. Another 40 participants were assigned to

a control group. These children were offered the typical standard of care. The surgeries that the

children underwent were for arthroscopy, endoscopy, extraction of a pin or nail, hernia, or

superficial surgery. All observations were made by 1 researcher, and 2 experienced nurses. Self-

reported pain, distress, and anxiety were recorded before and after surgery. The Faces, legs,

Activity, Cry, and Consolability Test (FLACC) was used to analyze pain scores, Colored
Analogue Scale (CAS) for self-report of pain, Facial Affective Scale (FAS) to rate levels of

distress, and the STAI for anxiety. Interviews were conducted the day after surgery. The study

showed that significantly fewer children in the music group, 1 out of 40, compared to the control

group, 9 out of 40, received morphine. Pain scores greater than 4 were found in 5 children in the

intervention group and 7 in the control group. FAS scores were found to be significantly

improved in the study group, though changes in anxiety levels were statistically insignificant

(Nilsson et al., 2009).

A common practice observed in today’s society is mothers giving birth by means of

cesarean section (C-section). The 4th study this paper will evaluate is the effectiveness of music

therapy on mothers that underwent this surgical procedure in relation to pharmacological

management of pain. In this single blind study, 100 women between the ages of 20-40 years

who were to undergo elective cesarean section surgery were randomly assigned to 2 groups of

50. One group of 50 women listened to music of their choice through headphones for 1 hour

prior to their cesarean section surgery. This was the study group. The other group of 50 women

did not listen to any music prior to their cesarean section surgery. This was the control group.

The anesthetic technique was standardized for the 2 groups and each woman was given a PCA

device when they were able to respond to commands as they were brought out of the anesthesia.

The patient’s level of satisfaction of their perioperative care was assessed by a 10-cm visual

analogue scale and their post operative pain was assessed with VAS. The results of the study

showed a significant reduction in pain levels in the study group when compared to the control

group. This was best illustrated by a 21% reduction in the consumption of tramadol for pain

relief in the group of women who listened to music. It was also noted that the women who
listened to music expressed a significantly lower level of anxiety prior to their surgery and their

babies scored higher on their Apgar scores (Şen et al., 2009).

The final study this paper will examine deals with a surgical procedure that many patients

find most fearful; open heart surgery. Hundreds of thousands of patients undergo heart surgery

every year in this country (Cutshall et al., 2011). Despite many scientific advances, open heart

surgery remains a major medical event that is tied to significant issues for patients, including

pain and anxiety (Cutshall et al., 2011). This particular study examines a specific style of music

that is interwoven with sounds found in nature (Cutshall et al., 2011). The study involved 100

patients who underwent cardiac bypass graft or valve procedures for the first time (Cutshall et

al., 2011). The research sample was based on convenience, but group assignment was

randomized. The study also employed a pretest post-test format utilizing visual analog scales.

Postoperative open heart patients who were exposed to this specific type of music were found to

have a reduction in pain and an increase in relaxation when compared to patients who received

standard care (Cutshall et al., 2011).

The focus of this paper centered on postsurgical pain, however the positive effects of

musical therapy were observed to temper localized pain and anxiety levels, making it relevant to

all of our clinical practices. Patients on a cardiac step-down unit may not experience episodes of

pain comparable to patients on a surgical unit, but could experience equal amounts of stress.

Evidence suggests that stress and pain in the hospital setting are often positively correlated, thus

managing stress can assist with managing pain (Lin et al., 2011). Most respiratory step-down

units don’t deal with much postoperative pain, but that isn’t to say they do not manage chronic or

acute occurrences of pain. Many respiratory step-down units contain rooms that have a

television with the option of light, soothing music. It relaxes patients and decreases anxiety,
making for a more calming and comfortable environment. Most modern-day preoperative

surgical units are accommodating to both the staff and patients, however this does not mean they

offer musical therapy. Typically, hospitals do not discourage the intervention, which is evident

by allowing patients to bring music devices such as iPods with them right up until the time of

surgery. It would seem reasonable for the hospital to actively offer music therapy before, after,

and even during the surgical procedure and would be justified by current evidence.

Unfortunately, even the most simple and inexpensive changes can be met with resistance

and obstacles. Barriers may occur on hospital units regarding the use of music therapy for

several reasons. Quite often it is not part of the healthcare institution’s or patient’s culture.

Additionally, healthcare providers may lack motivation. This can be a substantial barrier since

nearly everything we do is driven by an internal force. Individual skills and personal beliefs also

impact the way we behave. Some staff may find it difficult to implement change if it conflicts

with their personal views. Others may not have the skills to physically do it. External factors

also play an important role in change. Financial systems, time constraints, and resource

availability can all be barriers to change (Nilsson et al., 2009).

Overcoming these hurdles is paramount because evidence-based-practice shows music

therapy is an inexpensive intervention; free of side effects and offers only beneficial

opportunities for the patient. Music therapy should be fairly simple to employ within nursing

practice. Environmental alterations would have to take place prior to beginning musical

intervention. The treatment would ideally take place in private patient rooms with solid doors

and walls. These physical characteristics are commonplace in large modern medical centers, but

may not be present in facilities that are older or smaller in size. Additionally, patient rooms

would have to be equipped with compact disc players or other musical devices. Accommodating
the individual musical tastes of each patient is also important. Patients could choose from a

variety of musical styles on hand or they could bring in their own music of choice prior to their

procedure. Finally, enlisting the support from key people within the healthcare facility is critical

when advocating change. One way to gather support would be to develop a well-organized

presentation outlining the research-based medical benefits of music. This presentation could be

delivered to members of the administrative team as well as nursing and medical staff leaders.
 References

Economidou, E., Klimi, A., Vivilaki, V. G., & Lykeridou, K. (2012, July-September). Does music

reduce postoperative pain? Health Science Journal, 6(3), 365-377.

Lin, P., Lin, M., Huang, L., Hsu, H., & Lin, C. (2011). Music therapy for patients receiving spine

surgery. Journal of Clinical Nursing, 20, 960-968.

Nilsson, S., Kokinsky, E., Nilsson, U., Sidenvall, B., & Enskar, K. (2009). School-aged

children’s experiences of postoperative music medicine on pain, distress, and anxiety.

Pediatric Anesthesia, 19, 1184-1190.

Şen, H., Sizlan, A., Yanarateş, Ö., Kul, M., Kılıç, E., Özkan, S., & Dağlı, G. (2009). The effect of

music therapy on postoperative pain after caesarean section. TAF Preventative Medicine

Bulletin, 8, 107-112.

Cutshall, S. M., Anderson, P. G., Prinsen, S. K., Wentworth, L. J., Olney, T. L., Messner, P. K.,

Brekke, K. M., Li, Z., Sundt, T.M., Kelly, R.F., & Bauer, B.A. (2011). Effect of the

combination of music and nature sounds on pain and anxiety in cardiac surgical patients:

A randomized study. Alternative therapies, 17(4), 16-21.