Music as a Nursing Intervention for Postoperative Pain: A Systematic Review¨ Margaretha Engwall, MSc, RN, Gill Sorensen Duppils, PhD, RN The purpose of this systematic review was to examine the effect of music on postoperative pain. A search for scientific articles was conducted using online databases. Included were quantitative studies published from 1998 through 2007 that considered the effect of music interventions on postoperative pain in adult patients. After the search and appraisal of quality, 18 studies were included in the review. The results in 15 of the studies included indicated a significant positive effect of music on postoperative pain. Four studies found that the use of analgesics was lower for the intervention groups. The patients in the studies were scheduled for different kinds of surgery and assessments and the interventions were performed at different times. Various types of music were used, mostly chosen by the researchers. The conclusion is that music can be used as an adjuvant for the relief of postoperative pain. Keywords: music, intervention, postoperative, pain. Ó 2009 by American Society of PeriAnesthesia Nurses THE FEAR OF PAIN is ranked second only after the fear of death.1,2 Pain is a symptom and a warning that something is wrong in the organism. Acute pain is defined as ‘‘pain of recent onset and probable limited duration. It usually has an identifiable temporal and causal relationship to injury or disease.’’3 Music is a nonpharmacological/nonchemical method used as an adjunct to traditional care and medical treatment in the management of postoperative pain.4,5 From a nursing perspective, music interventions have been used to promote patients’ health and well-being.6 The purpose of this systematic review was to examine the effect of music on postoperative pain, the methods used to measure the effect, and how the interventions were carried out. Postoperative Pain Postoperative pain, a form of acute pain, is an expected but undesirable consequence after all surgical Margaretha Engwall, MSc, RN, is a Lecturer, University College in Dalarna, Department of Health and Social Sciences, Falun, Sweden; ¨ Gill Sorensen Duppils, PhD, RN, is an Assistant Professor, University College in Dalarna, Department of Health and Social Sciences, and Surgical Department, Falu Lasarett, Falun, Sweden. ¨ Address correspondence to Margaretha Engwall, Hogskolan Dalarna/HVO, S-791 88 Falun, Sweden; e-mail address:
[email protected]. Ó 2009 by American Society of PeriAnesthesia Nurses 1089-9472/09/2406-0006$36.00/0 doi:10.1016/j.jopan.2009.10.013 370 procedures.7 Important goals for postoperative pain management are to eliminate discomfort, to make recovery easier, and to avoid complications associated with the therapy.3 Many patients experience unrelieved postoperative pain, despite increased knowledge regarding pain and pain management.3,8,9 If the relief of postoperative pain is inadequate, it has a negative influence on patient satisfaction.5 Furthermore, recovery can be prolonged and the length of hospital stay and the health care costs can be increased.5 It is accepted that all patients are entitled to good quality care,9,10 and it is unethical if a patient who suffers from pain does not receive help for relief.11 The experience of pain can also be influenced by psychological factors such as fear, anxiety, and the extent to which the patient can sense a feeling of control. Nonpharmacological methods have been used as adjuncts in the treatment of postoperative pain with the goal of increasing the patient’s experience of well-being.3 Music and Nursing Music is a source of pleasure for many people12 and has been used throughout history to alleviate sickness and suffering.13 Florence Nightingale noticed the power of music in the early 1800s. She thought that music with a continued harmony, performed by the human voice, on wind instruments and on string instruments, had a beneficial effect.14 Journal of PeriAnesthesia Nursing, Vol 24, No 6 (December), 2009: pp 370-383 methods. PubMed. reliability. process of randomizing. they have the opportunity to help. A total of 1. pain as an outcome measure. postoperative. Studies evaluating interventions that combined music with other nonpharmacological methods were also included. blood pressure. Further inclusion criteria were studies limited to adult patients that included music interventions and used postoperative Results Eighteen studies were included in this systematic review. description of the intervention.18 and for different kinds of pain conditions. The keywords used during the search were music. mood. and the generalization of the results. results/effect. music and music selection.16. selection methods.11 By carrying out measures for pain relief. and Taiwan. and sample are presented in Table 2. These articles were reviewed several times for the research aim.MUSIC AS A NURSING INTERVENTION FOR POSTOP PAIN 371 Different types of music can influence the frequency and depth of breathing. . Six studies were excluded after this appraisal. pain. design. nurses can provide optimal pain control. Their design. altogether.22 Consideration for the individual’s musical preferences and accuracy in the choice of music are crucial and contribute to the therapeutic effect. validity. These keywords were mixed in different combinations. Research questions concerned: The effect of music intervention on postoperative pain. 19 studies were excluded in accordance with the exclusion criteria. data considered relevant to the research questions were collected.631 articles were found. Fourteen of the studies were RCTs and 4 were quasi-experimental. On further evaluation. and the cardiac muscle’s need for oxygen. it is important to explore complementary strategies such as music to combat pain. studies that did not include music in the interventions. Japan. Table 1. The individual’s musical preferences and response to music are influenced by earlier experiences of music and by gender. and statistical significance (P value). and because they spend much time close to the patients. statistical analyses. type of intervention. and Elsevier/Science Direct were used and all of the included articles were published in the English language. studies with qualitative design. analgesia. music and music selection. type of surgery. and studies that used sounds instead of music. The methods used to measure that effect. methods of measurement. and how the interventions were carried out.15 Studies have investigated the effect of music on anxiety. all of which included the word music (Table 1). instruments. Sweden.23 Reilly4 notes that music is well suited to the operative environment. the heart rate. the methods used to measure the effect. How interventions were carried out with regards to type of surgery.20 Nursing is one of many disciplines that have conducted such studies.604 patients. outcome measure(s). the studies included 1. and intervening and assessing the effect on patients. and method. The 24 remaining studies were appraised according to their quality by using a set of modified and adapted questions concerning research methods. Keyword Combinations music AND postoperative AND pain music AND ‘‘postoperative pain’’ music AND analgesia music AND ‘‘postoperative pain’’ AND analgesia music AND surgery music AND ‘‘postoperative pain’’ AND surgery music AND surgery AND pain music AND therapy AND ‘‘postoperative pain’’ ‘‘music therapy’’ AND ‘‘postoperative pain’’ music AND surgery AND postoperative music AND pain Note: Two-word terms in quotes were used in search engines to ensure results would appear with those words together.6. and surgery.17 distraction. age.21 Music is a unique experience for the individual. leaving 18 studies in the final review (Table 2). China. The online databases Blackwell Synergy. identifying needs for additional measures. and manipulation of the environment and the time of the intervention.9. instructions. Inclusion criteria were quantitative studies with randomized controlled trials (RCTs) or a quasi-experimental design. inclusion and exclusion criteria. Method A search for studies evaluating the effect of music on postoperative pain between 1998 and 2007 was conducted. The first author evaluated the abstracts and articles for appropriateness.22 Nurses have a central role in the care of patients with pain. These data were author. Cinahl. culture.19. Exclusion criteria included review articles. Hong Kong. ethics. The studies were performed in the United States. Considering that nurses have a key role in pain management for postoperative patients.6. research questions. The purpose of this systematic literature review was to examine the effect of music on postoperative pain. characteristics of the subjects. method of measurement. music therapy. group design. During the critique and analysis. year. sample/population. and a total of 43 articles met the inclusion criteria. and attitude. Intervention tapes during ambulation and during rest on postoperative days 1 and 2. USA n 5 199 age 20-70 yr 1 music group 1 jaw relaxation group 1 music/jaw relaxation group 1 control group RCT Secondary analysis to Good et al 1999 Gynecological 26 Good et al. Intervention tapes during ambulation and during rest on postoperative days 1 and 2. Music listening during 15 min post-op day 1 and 2. Instructions preoperatively. The control group received usual care. USA n 5 38 Age 26-56 yr 1 music group 1 control group n 5 500 age 18-70 yr 1 music group 1 jaw relaxation group 1 music and jaw relaxation group 1 control group RCT General and gynecological 27 Good et al. The measurement was made before and after the preparation for ambulation. USA RCT Multicenter Major abdominal: gynecological gastrointestinal exploratory urinary 28 Good et al. after ambulation. Outcome measures were assessed before and after the music intervention and before and after the rest in bed. 2002. 1998. The control group received usual care. Data collector stayed in the room during the intervention. Nationality Good et al. The measurement was made before and after the preparation for ambulation. and after recovery from ambulation. and after recovery from ambulation. Intervention tapes during ambulation and during rest on postoperative days 1 and 2. Instructions preoperatively. Intervention tapes during ambulation and during rest on postoperative days 1 and 2. Taiwan. 2001. Before and after the 15 mins of rest. after ambulation.Table 2. Data collector stayed in the room during the intervention. Data collector stayed in the room during the intervention. and after recovery from ambulation. The control group rested in bed for 15 minutes. Before and after the 15 mins of rest. after ambulation. Before and after the 15 mins of rest. The measurement was made before and after the preparation for ambulation. The control group received usual care. and after recovery from ambulation. Included Studies Ref 24 Author. Year. 1999. Method and Time for Measurement The measurement was made before and after the preparation for ambulation. Instructions preoperatively. 372 25 Good et al. Teaching tape before the surgery. Before and after the 15 mins of rest. USA Sample n 5 167 age 20-70 yr 1 music group 1 jaw relaxation group 1 music/jaw relaxation group 1 control group Design RCT Secondary analysis to Good et al 1999 Surgery Intestinal Intervention Instructions preoperatively. 2005. Data collector stayed in the room during the intervention. USA n 5 468 age z 45 yr 1music group 1 jaw relaxation group 1 music/jaw relaxation group 1 control group RCT Secondary analysis to Good et al 1999 Abdominal Gynecological Gastrointestinal Urinary ENGWALL AND DUPPILS . after ambulation. The control group received usual care. Preoperative preparation for the intervention groups. One group listened to a blank CD during surgery and to music at PACU. 2003.MUSIC AS A NURSING INTERVENTION FOR POSTOP PAIN 29 Nilsson et al. and at discharge from the PACU. The intervention tapes were played from the time of the skin incision until the wound was closed. Pain intensity was assessed postoperatively every half hour until the patient reported #3 on the VAS. 1 hour from the arrival. during the first 24 hours. Sweden RCT double-blind Gynecological hysterectomy Pain intensity was assessed every hour. after 1 hour. 31 Nilsson et al. The control group had a blank CD. and then every 3 hours until the patient felt no pain. Sweden n 5 75 age mean 55 yr ASA I-II 1 intraoperative music group 1 postoperative music group 1 control group RCT Inguinal hernia Day care surgery Pain was assessed 30 min before anesthesia and 1 hour after arrival in the PACU. One group listened to music during the surgery from the end of anesthesia to the end of surgery. USA RCT Gynecological laparoscopy Ambulatory surgery The measurements were made 3 times: first upon arrival in the PACU. 30 Nilsson et al. The intervention took place throughout surgery and during the whole post-op period. Sweden n 5 183 age z 50 yr ASA* I-II 1 music group 1 music and therapeutic suggestion group 1 control group n 5 90 age z 50 yr 1 music group 1 music and therapeutic suggestion group 1 control group n 5 151 age 21-85 yr ASA I-II 1 intraoperative music group 1 postoperative music group 1 control group RCT Varicose vein and open inguinal hernia Day care surgery Each intervention tape was played from the arrival at the PACU until the patient wanted to stop. Sweden n 5 60 age 25-45 yr ASA I-II 1 music group 1 control group n 5 84 age 20-55 yr 1 music group 1 guided imagery group 1 control group RCT Gynecological laparoscopy The assessment took place before and after the intervention. One group listened to music during surgery and to a blank CD postoperative. 2003. 2001. One group had a sham CD during surgery and listened to music for 1 hour from the arrival in PACU. The control group had blank CDs at both times. 2005. (Continued on following page ) 373 . 32 Nilsson et al. 2004. The control group listened to a tape with OR sounds. Intervention during 30 min. 2003. starting 15 min after arrival in the PACU. 34 Laurion et al. The control group listened to a blank tape with no sound. 33 Ikonomidou et al. The control group had a sham CD both times. Sweden RCT Varicose vein and inguinal hernia Day care surgery Pain was assessed every half hour for 2 hours in the PACU. Postoperatively they had a sham CD. Hong Kong n 5 57 age 15-69 1 music group 1 control group Quasiexperimental Nasal surgery Pain intensity was assessed upon arrival in the PACU. 36 Masuda et al. 1998. USA n 5 86 age mean 63. Year. The control group received usual care. The control group received usual care. Instructions were given and the environment was manipulated. The music group listened to music 20 min 2 times/day on postoperative days 1-3.3 yr 1 music group 1 control group RCT Multicenter Coronary artery bypass and valve replacement 38 Voss et al. The environment was manipulated. 2006. The music group listened to music for 30 min during chair rest. 2005. Method and Time for Measurement The outcome measures were assessed every 15 min during the stay in the PACU. The intervention took place on day 3 after surgery. Pain was assessed at the same times in the control group.374 Table 2. The scheduled rest group rested with their eyes closed for 30 min. Japan RCT Orthopedic 37 Sendelbach et al. Included Studies (Cont’d) Ref 35 Author. then immediately after each intervention. No music for the headphone group. The control group received usual care. The control group rested in bed for 20 mins 2 times/day. 2004. The control group received usual care. USA n 5 61 age mean 63 yr 1 music group 1 scheduled rest group 1 control group RCT Pretest Posttest Open heart Outcome measures were assessed twice: first when patients were settled in the chair and 30 min after the interventions. It was repeated 3 times during the first 24 hours. The outcome measures were assessed before the intervention started and 10 and 20 min after the intervention. 2005. ENGWALL AND DUPPILS . Pain was assessed before and after each 20 min of intervention. The last assessment was just before discharge and with the graphic numeric pain intensity scale. USA Sample n 5 61 age 24-62 yr 1 music group 1 headphone group 1 control group n 5 44 age 60-89 yr 1 music group 1 control group Design Quasiexperimental Surgery Abdominal hysterectomy Intervention The intervention took place during the whole stay in the PACU. 39 Tse et al. Nationality Taylor et al. The music group listened to music for 20 min. The intervention began 30 min after return from surgery and lasted 30 min. The control group received usual post-op care.39 In other studies. The music/low-noise group listened to tapes with music for 1 hour.40 In nine studies.24-28.25. The research team selected the music in seven studies. gynecological and abdominal and intestinal26.29-34.37. Aragon et al41 used live music performed bedside by a harpist. varicose vein and inguinal hernia29. USA n 5 17 age 35-70 yr 1 music group No control group Quasiexperimental Vascular and thoracic Patients listened to live harp music for 20 min post-op. subjects who underwent different surgical procedures were mixed in the intervention and control groups.41 In four of the studies.37. gastrointestinal.40 MUSIC AND MUSIC SELECTION. CD. and at discharge. Six studies were designed to consist of an intervention group and a control group.38 The main study by Good et al27 and its secondary analyses24. gynecological. gastrointestinal.34. the patients underwent ambulatory surgery (Table 2). The same harpist played at all sessions. 2001.33. eg.29. A summary of the research designs and interventions is presented in Table 2.34 scheduled rest. . the subjects brought their own music and in the study by Tse et al. 30 min after. USA 40 41 Aragon et al.34.33-35 hernia repair.29-32 *ASA. In the study by Taylor et al. Pain levels were assessed 5 min before session.32 intestinal. The samples in the studies were patients scheduled for different surgical procedures with varying degrees of complexity (Table 2).30. and for 10 min after. performed in 1999.31.36-38 the participants could choose various types of music from tapes or compact discs made by the investigators.35 however.30 guided imagery. which included gynecological.36.28 and decreased noise levels (Table 2).38 jaw relaxation24.29-32. and urinary27. All studies but one41 used CD players or cassette players.31.36 open-heart.28 were designed to include four intervention groups and one control group. the intervention and control groups consisted of subjects undergoing one type of surgery.38 and nasal surgery.MUSIC AS A NURSING INTERVENTION FOR POSTOP PAIN 375 Pain intensity was assessed 3 times: upon admission to the PACU. Elective surgery Day care surgery Quasiexperimental n 5 97 age 26-86 yr 1 music/low-noise group 1 control group Shertzer et al.34. In some of the studies. preoperative judgement.28 were secondary analyses of a main study.29.26.27. and vascular and thoracic surgery. The same harpist played at all sessions and she selected the music. compact disc. Music Intervention SURGERY.29-32 Three of the five studies by Good et al24. all surgical procedures except open heart40. American Society of Anesthesiologists rating. and all but one of those40 included the use of headphones. visual analog scale. directly after the session.40 and seven studies were based on three groups: two intervention groups and one control group.25. The music used in the studies is presented in Table 3. upon admission to the PACU.41 Additional interventions used in addition to music included nonpharmacological interventions such as therapeutic suggestions.35.25. gynecological. RCT. The study by Aragon et al was a single case study and the subjects were their own controls.25.24 orthopedic.39 the participants had the choice to either bring their own music or choose from a selection made by the investigator.40 DESIGN. and urinary28. exploratory. VAS. The room was prepared to avoid interruption and to reduce extraneous noise. Half of the 18 studies included were performed by two research teams: five by Good et al24-28 and four by Nilsson et al. 2002.27 The four studies by Nilsson et al were all independent studies. randomized controlled trial.39. Nilsson et al assessed pain after. two. harp.33.’’24-28.41 Interventions also took place during surgery30 and both during surgery and in the PACU. In the study by Laurion et al. synthesizer. The instructions were given in various ways.28 the intervention groups were taught the interventions preoperatively. Some of the studies manipulated the environment in preparation for the intervention. they were given a second music tape.33. In several of the studies. Aragon et al41 avoided interruptions and reduced distraction during the intervention by reducing noise and by placing a curtain between the investigators and the patient. gospel. played on a harp Person Who Selected the Music The subjects.31 and before and after the intervention. TIME OF INTERVENTION AND ASSESSMENT. orchestral. Masuda et al36 made the intervention on postoperative day three and the assessment was made before and after the intervention. from a selection of four types The subjects.40 ‘‘pain level. Voss et al38 arranged the environment to reduce disturbing stimuli and the investigator stayed in the room with all groups.34 The intervention took place on postoperative days one and two and the pain was assessed before and after the intervention in all studies by Good. country. Type of Music and Music Selection Ref 24-28 29 30 31. All of the included studies assessed pain (Table 4).37. Various terms for pain were used—‘‘pain. piano.30 after and during. this was done in different ways. slow jazz without lyrics Soft classical music Relaxing and calming accompanied by sound of sea waves Soft instrumental.35 Tse et al39 assessed pain on arrival in the PACU and then after each intervention.’’35 ‘‘postoperative pain’’34. The subjects also were instructed on how to get out of bed and how to splint the incision during ambulation. In the main study by Good et al27 and its secondary analysis. and jazz Synthesizer. and three. The times when the intervention was performed as well as when assessments were made differed (Table 2). Sendelbach et al37 prepared the environment for rest and the research assistant gave a short relaxation session before the music started.376 ENGWALL AND DUPPILS Table 3. After that. from a selection of five types The investigator The investigator The investigator The investigator The investigator The subjects brought their own music The subjects. rock and roll.32 The assessment was done during the intervention and on discharge in the study by Laurion et al.40 the noise level was modified in the PACU for the intervention group and the light was lowered to encourage the staff to speak more quietly and to limit their conversations.* Noh songs.25.38-40 Pain was assessed before and after the intervention by Ikonomidou et al33 and by Voss et al.* Enkay Easy listening. and the assessment was made before and after the intervention.29.41 ‘‘pain intensity.35. and they were coached by the researcher on how to let the music distract or relax them.34 the subjects were provided with a music tape in advance and asked to listen to it twice per day before their operation and on the day of surgery.24. slow jazz.39. from a selection of six types Both the investigator and the subjects The investigator The harpist y *Japanese traditional music. Measurement OUTCOME MEASURES. All subjects had a data collector by their side.29 and during the intervention and at discharge by Shertzer et al40 and Taylor et al.38 .32.24-28 Sendelbach et al37 performed the intervention on postoperative days one. the subjects listened to the intervention tape with their choice of music. new-age synthesizer Peaceful pan flute music Piano music Classical. easy listening.’’29-31. INSTRUCTIONS AND MANIPULATIONS OF THE ENVIRONMENT. from a selection of three types The subjects. and flute Chinese and Western music Mozart and ocean music Slow. the intervention started immediately after arrival in the PACU.36—and six studies measured ‘‘pain sensation’’ and ‘‘pain distress. Aragon et al41 performed the intervention in the early postoperative period and the pain was assessed before and after.31. The tape explained the purpose and effect of music in relation to pain. country and rock and roll Western classical music Gagaku. soft melodies.38 during and after the intervention by Nilsson et al. In the study by Shertzer et al.’’32. 32 33 34 35 36 37 38 39 40 41 Type of Music Piano. jazz. orchestra. The intervention group in Good et al26 listened to an instruction tape before surgery. harp. light rock. Japanese popular songs. classical.34 In the study from 2001. Some of the articles describe how the subjects were given instructions before the intervention. VAS-distress Opioid intake Sleep. pain distress Pain intensity Postoperative pain VRS VAS NRS VAS FS 377 (Continued on following page ) . PCA discontinued. respiratory rate. urinary problems Heart rate. radial pulse. oxygen saturation Anxiety Morphine requirement PONV fatigue. respiratory rate Observation Interview Hospital record Observation PCA-pump Observation PCA-pump 5-grade scale 4-grade scale Pulse oximetry STAI * 4-grade scale 5-grade scale Patient diary PCA Patient record NRS Patient diary Two questions Blood sample NRS Monitoring Patient record PACU record Minutes from arrival to discharge VAS Questionnaire 5-point scale Automatic sphygmomanometer Thermograph Laser type skin blood low analysis system MUSIC AS A NURSING INTERVENTION FOR POSTOP PAIN 25 Pain sensation. nasogastric tube removal PCA-pump Question. pain distress Pain sensation. satisfaction with the perioperative care Stress marker Anxiety Vital signs. the amount of paracetamol and ibuprofen Awareness. pain distress VAS 27 28 29 Pain sensation. anxiety Sleep. well-being Nausea. VAS-distress VAS-sensation. heart rate. PONV Length of stay Anxiety Comfort/satisfaction Overall quality of the stay Vital signs Skin temperature Blood flow from finger tip 32 Pain NRS 34 38 40 36 Postoperative pain Pain sensation. radial pulse Days until bowel sound. clear liquid. length of hospital stay. analgesics use 26 Pain sensation. headache. bowel function. pain distress VAS Instruments Other Outcome Measures Sleep mastery. saturation (spO2) Analgesic use Analgesics. VAS-distress VAS 30 Pain intensity VAS 31 Pain intensity NRS Analgesic Nausea. Outcome Measure and Instruments Ref 24 Outcome Measure: Pain Pain sensation. fatigue. pain distress Pain intensity VAS-sensation. vital signs Mastery Acceptance of the music Effect of medication Mastery Opioid intake Mastery Opioid intake Fatigue.Table 4. recovery Instruments Subjects reported Observation. well-being. pain distress VAS-sensation. and a combination of music and jaw relaxation on postoperative pain.25. STAI. type of intervention.40.35. VAS. The sample consisted of patients who underwent major abdominal surgery.32. which was applied in 11 of the studies. Analgesic use was examined in all but seven of the included studies (Table 4).31 mastery with the ability of using the technique.33.29-32 The interventions in these studies were performed during surgery on patients undergoing gynecological hysterectomy.29. oxygen saturation Satisfaction Vital signs Analgesic use Vital signs Opioid use Anxiety . The aim of the study by Good et al27 was to examine the effect of music.39.31. jaw relaxation.36. The combined music and jaw relaxation group also had less pain compared with the controls. Good et al26 conducted an RCT among patients undergoing general and gynecological surgery.6.29 In two studies.24-27 vital signs. state-trait anxiety inventory. Wong-Baker Faces Scale.36.24 In these studies.34 and well-being.30 and in the PACU on ambulatory surgery patients who had varicose vein and inguinal hernia surgery.34. The most common way to assess pain was the use of a visual analogue scale (VAS).39 Masuda et al used the Wong-Baker Faces Scale (FS)36 and Taylor et al used the graphic numeric pain intensity scale (Table 4).33.378 ENGWALL AND DUPPILS PONV. EFFECT ON POSTOPERATIVE PAIN.38. Graphic numeric pain intensity scale NRS Instruments VRS Pain intensity 39 Outcome Measure: Pain VAS Pain level Pain intensity Ref Pain 37 33 35 41 Pain VAS Anxiety Vital signs. Instruments Apart from pain and analgesic use.32 Nausea.31.41 nausea. Significantly less pain was also found for the music groups compared with the control groups in all of the studies carried out by Nilsson et al.24. verbal rating scale. NRS. well-being Vital signs Analgesic VRS.39 and patient-controlled analgesia (PCA)–pump recordings (Table 4).33.41 INSTRUMENTS USED TO ASSESS PAIN.38.34.35. *Not described in the article. The intervention group listened to music and was compared with a control group that rested in bed.41 The numeric rating scale (NRS) was used in four studies.37.32. Good et al27 examined the effect of the intervention over time and between activities28 after gynecological25 and intestinal surgery.36.25. methods.24.25. and sample. Outcome Measure and Instruments (Cont’d) Other Outcome Measures VAS * * VAS Bedside monitoring 4-question survey Bedside monitor * State anxiety * Patient record The Effect of Music Intervention A summary of the effect of music intervention on postoperative pain and use of analgesics is presented in Table 2. VRS. FS.2430. PCA.27 Further. methods of measurement.26.35 Instruments for measuring consumption of analgesics were patient records31. the intervention groups had less pain compared with the control groups (Table 5). interventions were carried out both during surgery and in the PACU (Table 5).27-29 Table 4. visual analog scale.29-31. patient controlled analgesia. Results showed a decrease in distress of pain and lower sensation and distress levels caused by pain for the music intervention group. other outcome measures included sleep. as well as design. numerical rating scale.30 Taylor et al35 assessed pain level only. postoperative nausea and vomiting.40 and the verbal rating scale (VRS) in three. The music group had significantly less pain and lower sensation and distress levels caused by pain than the control group.37. and postoperative music groups had lower pain scores at 1 hour and 2 hours Less morphine in the postoperative music group after 1 hour in PACU No significant differences in the amount of ibuprofen and paracetamol The intra.s .001 n.017-. . .and postoperative music groups had lower pain scores after 1 hour in the PACU Less morphine in the postoperative music group after one hour at the PACU No significant differences between the groups Lower postoperative consumption of opioids in the music group No differences between the groups regarding pain on arrival and after 1 hour at the PACU Higher pain scores reported from the control group on discharge No significant differences between the intervention groups No significance between the groups regarding use of analgesics P value .018-.028-.05 . . .01..000 n. .01 . . .01 .000 .002 n.017-.001 .000 .000 .s n.24-.s (Continued on following page ) MUSIC AS A NURSING INTERVENTION FOR POSTOP PAIN 25 Music and music/jaw relaxation 26 27 Music Music Music/jaw relaxation 28 Music and music/jaw relaxation 29 Music Music/therapeutic suggestions Music Music/therapeutic suggestions Music 30 31 32 33 34 Music Music Music 379 .s .s .022-.05 n.01 n.01 # . .022-. .s n.s .04 n. .001 .s .046-.001 n.001 .021-.05 n.020 .11.000 .010 . .s .Table 5.000 .s . Effect of Music Intervention on Postoperative Pain and Use of Analgesics Ref 24 Intervention Music and music/jaw relaxation Effect Compared with Control Group/Other Intervention Group The treatment groups together had less posttest pain at all points on day 1 except for postambulation On day 2 less posttest pain at postpreparatory and postrest point On day 2 no significance at postambulation and postrecovery Less pain at all posttests for the intervention groups together Less pain at postambulation on day 2 for music/jaw relaxation Intervention groups with PCA 9%-29% less pain than the controls with PCA Lower sensation and distress levels on day 2 than the controls Greater decrease in distress because of pain on day 1 and sensation of pain on day 2 compared with the controls Less pain than the control group Less pain on 7 posttests Less sensation and distress because of pain Less pain than the control group Less pain on all tests No differences between the groups regarding use of morphine The intervention groups together had less posttest pain on days 1 and 2 Pain decreased from days 1 to 2 The intervention groups together had less pain than the control group over time and activities on each day No significant differences between the intervention groups No differences between the groups regarding use of morphine Lower pain intensity compared with control Lower pain intensity compared with control No differences in postoperative requirement of morphine between the groups Less pain on the first day after surgery in the music group Less requirement of ketobemidone in the combined group The intra.000 .01 .05 . revealed no significant reduction in pain with the addition of music interventions. These results also showed a decreased pain level over time.35 no significant differences regarding pain over time were found. Here. Masuda et al conducted their study on day three after orthopedic surgery and found a decrease in pain over time for the music group. the sample consisted of patients undergoing gynecological laparoscopies and the intervention was done immediately after surgery. .30 the use of ketobemidone on the day of surgery was significantly lower in the combined intervention group than in the control group. .000 Ref 35 37 36 38 40 41 39 n.33-35 however. Tse et al found that P value ..36 The study by Shertzer et al of ambulatory patients also found a significant decrease in pain for the music group across the stay at the PACU compared with the control group. however.28 Among patients who received analgesics via PCA. In two of the studies.31 In another Nilsson study.001 Table 5.s.33 In the RCT by Laurion et al. did not differ significantly between the groups. however.017 .35 EFFECT ON USE OF ANALGESICS. not significant.001 . that the control group reported higher pain scores than the intervention groups at discharge.380 ENGWALL AND DUPPILS n. PCA. In the study by Ikonomidou et al.0001 . Lower pain level compared with the control No significance between the groups regarding use of morphine Music Music Music/low-noise group Music Intervention Music Music Music Decrease in pain across the stay Differences in pain ratings over time .33 Further.s .27.00 .017 . there were no differences between the groups regarding the use of morphine.34 In the quasi-experimental study by Taylor et al.31.32 the postoperative music group required less morphine after 1 hour in the PACU compared with the controls. Use of analgesics was measured in several of the studies with varying results (Table 5). Ikonomidou et al found significantly lower cumulative consumption of opioids in the music group compared with the control groups. . The subjects in this intervention group listened to music immediately after nasal surgery. patient controlled analgesia.25 In all but one29 of the four studies by Nilsson et al. . . where the music group listened to music during chair rest after open-heart surgery. Effect of Music Intervention on Postoperative Pain and Use of Analgesics (Cont’d) Effect Compared with Control Group/Other Intervention Group No significant differences in pain ratings for both of the pain rating scales No significance over time Larger decrease in VAS at 10 and 20 min and in FS at 20 min Less pain sensation and distress at posttest than at pretest Less pain sensation and distress at posttest after intervention Lower pain scores at all points after intervention Decrease in pain over time Control group consumed more pain relief on the day of surgery and on day 1 In addition. . the intervention group had 9% to 29% less pain than the controls.40 Three studies. They found.001 .009 n. the sample also underwent gynecological laparoscopies. . visual analog scale.s . FS. the intervention took place during the stay in the PACU on patients who had an abdominal hysterectomy (Table 5).s n. VAS. In two of the studies by Good et al.38 Sendelbach et al also found lower pain ratings on postoperative days one through three after coronary bypass and valve replacement surgery.001 . Wong-Baker Faces Scale.05. Aragon et al41 used live harp music for the intervention in their quasiexperimental study after vascular and thoracic surgery. lower pain levels for the music intervention groups compared with the control groups were found in the study by Voss. however. . The requirement of paracetamol and ibuprofen. there was some influence of music interventions on the use of analgesics.001 .37 A quasi-experimental study by Tse et al39 showed lower pain ratings and decreased pain over time. 34.34 The potent effect of the drugs that are used during general anesthesia could have a negative influence on the ability to report pain immediately postoperatively. However. However. This gate can be influenced by cognitive and emotional factors. which could have affected how they reacted and responded to the interventions (the Hawthorne effect). can reduce pain6 but not eliminate it. in the other studies the music was selected by the research teams (Table 3).34. The instructions consisted of: information concerning the purpose and effect of music. Although there was no significant effect on the experience of pain.26 a teaching tape with instructions on the intervention instruction on how to get out of bed.s. although this condition should apply both to the intervention and the control groups. It was used in 11 of the 18 studies (Table 4). These findings confirm the assumption that music.31.28 and instructions on how to listen to the music and how to relax. through its distracting and relaxing effect. Laurion et al34 found that the intervention group tended to stay longer in the PACU than the control group (n. in one study by Nils- son et al. the music intervention was experienced positively and perhaps patients’ stay in the PACU was more pleasant because of the music. although the music group had lower pain scores. In the studies where the music intervention had no effect on pain. all of these studies had significant findings. to increase patients’ well-being.35.44 The VAS was the most frequently used instrument for pain assessment. a point that is discussed by Laurion et al.27-29.24. patients were nevertheless satisfied with the intervention and they felt that the music had helped them in some way. Low pain ratings among the subjects before the intervention might have had an influence on the result because initial pain scores were not severe.27 Larger samples are desirable to gather more evidence on the effect of music intervention on postoperative pain. the pain can be severe.37 The findings regarding use of analgesics have some interesting points.37 and holding a relaxation session before the music intervention.29.29 This theory states that a mechanism in the dorsal horns of the spinal cord acts like a gate inhibiting or facilitating transmission of painful impulses from the body to the brain.27 but usually decreases after. in spite of the small samples in many of the studies.25. In two studies by Nilsson et al. An interesting aspect of the choice of live harp music was that some patients declined . Negative consequences of a longer stay in the PACU might be the increasing costs.29 no significant differences between the groups were found regarding analgesic use.39 Two other studies.39 However. Ikonomidou et al33 found a significant lower consumption of opioids in the music group than in the control group.27. In the study where live harp music was used. The time for the intervention varied from during surgery30 to as many as three days after surgery.). two of those laparoscopic. The sample sizes were generally small in the included studies. just as five studies also showed no significant differences regarding use of analgesics. from major abdominal and openheart surgery to ambulatory surgery. Only three studies had a sample size of more than 100 subjects27.42. preparing the room to avoid interruptions and noise. Nevertheless.MUSIC AS A NURSING INTERVENTION FOR POSTOP PAIN 381 the controls consumed more analgesics than the music group on the day of surgery and on day one after surgery. Discussion The samples in these studies were scheduled for different surgical procedures. but they found no significant differences regarding pain ratings for the intervention group.38 The purpose of environmental manipulations was to reduce any disturbing factors for the intervention groups.32 the postoperative music groups had significantly less pain and less requirement of morphine after one hour in the PACU.39 the subjects were allowed to bring their own music.36 Certain forms of surgery cause more postoperative pain than others.30-33. revealed no differences between the groups in the use of analgesics.28 In the three studies that showed no significant findings.37 however. In two of the 18 studies.33-35 the sample consisted of patients undergoing some form of gynecological surgery. It is possible that the laparoscopic surgery might have caused a limited extent of pain. The music groups consumed fewer analgesics than the control groups in five studies. eg.41 making the environment conducive to rest. Aragon et al41 discussed whether the presence of the harpist in the room had an influence on the result. it would be possible to offer music during the postoperative time in the ward. results still indicate that music intervention could be used as an adjuvant to traditional care for patients with postoperative pain.31. The gate-control theory is one explanation for the effect of music. but it is possible that these manipulations and preparation may have influenced the results because the subjects and staff were likely to be aware of their participation in the study.43 The Performance of the Intervention Several of the studies reporting positive results from the music intervention manipulated the environment and/ or gave instructions to the intervention groups before surgery. It is possible that the cognitive ability to report pain immediately after general anesthesia may be hampered. The largest sample size (500 participants) was in a multicenter study by Good et al (Table 2).26.37 Manipulation was a part of the interventions. However. studies by Good et al and Nilsson et al included abdominal gynecological surgery that would cause more postoperative pain.26.3 On the first day after surgery.27. Reg Anesth Pain Med. The samples in the 18 studies consisted of a total of 1.9 Music is a source of pleasure. would be of interest. All of their studies presented significant findings regarding the effect of music on postoperative pain (Table 2).12:162-166.39 were the subjects allowed to bring their own music. Music intervention.3. specific surgery groups of the main study were presented.14:295-304.3. 8.604 patients. the results were presented for the total group (n 5 500). Heart Lung. Incorporating music into the surgical environment. Postoperative pain guidelines. and has been used throughout history to aid in the care of sick people. Good et al and Nilsson et al (Table 2). Further. 2003. These differed with regard to music selection. Management of Acute Pain: A Practical Guide. It is also notable that despite this.257-263.19:136-146.12-14 The results of the present review indicate that music intervention alleviates postoperative pain. music seems to have a beneficial effect on postoperative pain. Additional quantitative studies that examine the effect of music on postoperative pain on larger populations.35 there were no significant differences in outcomes between the music and control groups. as a psychological support.24. Reilly M. inexpensive. however. In: Snyder M. according to the literature.19:35-38. Perry P. 10 years of acute pain services—achievements and challenges. Dimens Crit Care Nurs.1. 1999. manipulation of the environment. the majority still reported significant findings concerning the effect of music. New York: Springer Publication Company. Int J Nurs Pract. 10. However. even if these three studies had been excluded. 1992. Summary The aim of this systematic review of the literature was to examine the effect of music on postoperative pain. further studies are needed. Seattle: IASP Publications.382 ENGWALL AND DUPPILS to participate in the study because the harp music reminded them of death and heaven. Three of the five studies performed by Good et al24.28:279-288. Bucknall T. Henry LL.22 It is therefore notable that only in two studies35. 9. Chlan L. 4. In all but three of the 18 studies (including 205 patients). eds. the studies were performed during the years 1998 through 2007. is thought to bring out physiological and psychological responses in the listener. Relaxation technique and postoperative pain in patients undergoing cardiac surgery. 1999. Methodological Considerations The quality of the studies included was high.25. More studies concerning type of music and music choice are needed. and how and when pain was assessed.28 were designed in different ways. Another aspect of bringing one’s favorite music is the fact that a favorite piece of music may then be related to and associated with painful and worrisome conditions. Miller KM. Idwall E. 2. 2002. Plast Surg Nurs. Rosenquist R. with partially different research questions.25.2 According to the literature.63:855-867.28 were secondary analyses of a main study (Table 2). Music therapy: A nursing intervention for the control of pain and anxiety in the ICU: A review of the research literature. In the three secondary studies. many patients suffer from unrelieved postoperative pain.8. Conclusion The fear of pain is ranked second after the fear of death. The results also indicate that music intervention can be one way to raise the quality of the treatment of postoperative pain. 7. 5. 4th ed. perhaps in multicenter studies. One issue that should be considered. Optimising postoperative pain management in the ambulatory patient. 3. can contribute to the therapeutic effect. Complementary/Alternative Therapies in Nursing. Rosenberg J. Botti M. According to this result. 6. The problem of postoperative pain: Issues for future research.33-35 there were significant findings that indicated lower postoperative pain in the music intervention groups and likewise in the groups that combined music with other nonpharmacological methods. as an adjuvant to analgesics. Eighteen studies were included in this review. Shang A. References 1.27 In the main study. Fourteen of the studies were RCTs and four were quasiexperimental. Manias E. 1990. how and whether the patients were instructed. 2004.6 Nurses have a responsibility to supply good care for the patient. in the study where patients brought their own music. eds.6. despite increased knowledge concerning pain and how to alleviate it. Music intervention is noninvasive. Reg Anesth Pain Med. Quality of care in postoperative pain management: What is realistic in clinical practice. The findings can be related to the power of music to enhance distraction and well-being. 1995. . 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