Running head: EFFECTS OF MUSIC THERAPY ON PAIN CONTROL
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Effects of Music Therapy on Postoperative Pain Control in Adult Patients:
An Analysis of Evidence
Kathryn Fox, Kimberlee Gurizzian, Mary Nason, Leah Schmidt, and Jennifer J. Smith
Ferris State University
EFFECTS OF MUSIC THERAPY ON PAIN CONTROL
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Abstract
The purpose of this review is to identify what the nursing literature reveals about music therapy
and its effects on postoperative pain control for adults. This article provides an analysis of four
research articles, three are systematic reviews, and one is a randomized controlled trial.
Measurements of pain include pain rating scales, opioid consumption, and physiologic measures
(such as vital signs). Analysis of the evidence provided in these articles reveals that music is a
cost efficient nursing intervention effective for reducing postoperative pain and promoting a
calm and relaxing environment. No patients reported any increased discomfort or adverse effects
from music as an intervention making it a low risk intervention. This review provides evidence
to support the efficacy of music as a tool to reduce postoperative pain. Continued research is
needed to support and advocate for the efficacy of music therapy as a nursing intervention to
decrease patient distress in the perioperative period.
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Effects of Music Therapy on Postoperative Pain Control in Adult Patients
Pain is a sensory process felt in the body influenced by the psychological and emotional
processes of each individual. Postoperative pain is common after surgery and despite increased
knowledge regarding pain management; many patients still suffer from inadequate pain control
postoperatively (Engwall & Sörensen Duppils, 2009). Nurses are in a unique position to apply
noninvasive methods such as music therapy in the clinical setting to decrease patients’ distress
and create a calming environment. Music is a fundamental aspect of the human experience and
is strongly linked to our emotions. It is a source of pleasure and is thought to elicit physiological
and psychological responses in many people.
Nurses have a key role in the reduction of pain and can provide optimal pain relief for
patients with the use of adjunctive therapies. Music therapy, as a tool, can assist in creating a
calm environment by providing distraction and promoting relaxation for optimizing emotional
and spiritual well-being. The main goal of this review is to focus on the potential of musical
therapy in the postoperative setting and to evaluate the efficacy of music to reduce pain intensity
or analgesic requirements. The research question of “what does the nursing literature reveal
about music therapy and its effects on post-operative pain control for adults?” guided this
review.
Method
A search for scientific articles evaluating the effects of music on postoperative pain was
conducted using online databases. Inclusion criteria were articles published in English, adult
populations, level I or II evidence, primarily nursing research, in peer reviewed journals, and
those utilizing music as their primary intervention. Table 1 (see Appendix) shows the evaluation
matrix used for article inclusion. Exclusion criteria included studies that did not use music as the
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primary intervention, studies that were not primarily nursing research and studies that used
sounds instead of music.
Ten articles were found and four ultimately selected for this review (see Appendix).
Three articles are systematic reviews and one is a randomized controlled trial (RCT). Three of
the chosen articles were written in the United States of America and one in Sweden with all
being published between 2004 and 2012.
Analysis of Evidence
Types of Music
In Engwall and Sörensen Duppils (2009) systematic review, the aim was to examine the
effect of music on postoperative pain. The studies included in this review had various methods
of music choice; the researchers chose the music in nine studies, participants chose from offered
selections in four studies, and in one study, participants provided their own music. The rest of
the participants had a choice to bring music, choose from a selection, or listen to live harp music
(selected by the musician). When the music was chosen or offered by the researchers, soft, easy
listening, or classical music was offered (Engwall & Sörensen Duppils, 2009).
In Dunn’s literature review (2004), the majority of the studies provided the patient with a
selection of music to choose from preoperatively and two of the studies utilized music brought
from home. Allowing the patient to choose music from a selection motivated the patient to be
involved in their plan of care and afforded the positive effect of listening to a preferred music
genre (Dunn, 2004). Nilsson’s (2008) systematic review included 15 RCTs that were performed
postoperatively to determine the effect of music therapy on postoperative pain control for adults.
Chosen music was soothing and self-selected in the majority of studies (Nilsson, 2008).
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Allred, Byers, and Sole’s (2010) study of 56 postoperative patients provided several easy
listening compact discs to the experimental group. The characteristics of the music included
melodic like rhythms with no lyrics, calming and soothing tones, and 60-80 beats per minute.
Through review of other studies, Allred, Byers, and Sole (2010) found that music with these
qualities promoted an increased sense of well-being, decreased anxiety, and increased comfort
and relaxation.
Types of Interventions
Some of the articles reviewed by Engwall and Sörensen Duppils (2009) explained to the
subjects prior to surgery what the purpose and effect of music in relation to pain was followed by
a coaching session on how to use the music postoperatively to distract or relax them. One study
provided patients with tapes to listen to at home twice daily before surgery in preparation for the
trial (Engwall & Sörensen Duppils, 2009). Environmental manipulation was used in many
studies in addition to music therapy. Noise reduction, low lighting, and stimuli reduction were
often employed in the selected studies (Engwall & Sörensen Duppils, 2009). In Engwall and
Sörensen Duppils (2009) review, the treatment time in most studies ranged from immediately
upon arrival to the recovery room to three days postoperatively.
In Nilsson’s (2008) review, headphones were utilized in the majority of the studies. The
duration of postoperative listening time lasted from five minutes to four hours with the majority
varying from 15-30 minutes per session. Similarly, Dunn’s (2004) review of selected studies,
the time of the intervention also varied, four were initiated in the post anesthesia care unit
(PACU) and continued until discharge and four were begun the day after surgery and continued
until discharge from the hospital (Dunn, 2004).
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In Allred, Byers, and Sole’s (2010) experiment, listening time was 20 minutes before and
after the first ambulation, while the control group had a rest period without music. Patients were
educated prior to surgery on the purpose of the study and proper use the pain scale (Allred,
Byers, & Sole, 2010). Subjects were also encouraged to choose their music selection
preoperatively.
Outcome Measurements
In the chosen studies by Engwall and Sörensen Duppils (2009), pain was assessed before,
during, and after interventions with a treatment time starting in surgery and ranging to discharge
from the hospital. Apart from pain, other outcome measures were: sleep, mastery of the use of
the technique, vital signs, nausea, anxiety, and well-being (Engwall & Sörensen Duppils, 2009).
In these studies, the most common ways to assess pain were to use the visual analogue scale
(VAS) or the numeric rating scale (NRS); although the verbal rating scale (VRS) was also
employed (Engwall & Sörensen Duppils, 2009). Instruments for measuring consumption of
analgesics were patient records in all studies (Engwall & Sörensen Duppils, 2009).
In Nilsson’s (2008) review of 42 RCTs, 22 of the RCT’s evaluated the effect of music on
pain utilizing the VAS, NRS, and the McGill Pain Questionnaire. Additional outcome measures
included vital signs, and various blood indicators for stress levels including cortisol levels to
measure pain. In Dunn’s (2004) literature review, pain measurement utilized in the articles
varied. The majority of the studies utilized patient self-reported scales and measurement of
analgesia use. Four of the studies Dunn reviewed utilized the physiologic measures of heart rate,
respirations, and blood pressure. The articles referred to in the review contained many varying
factors that according to Dunn (2004) made them difficult to compare.
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Allred, Byers, and Sole (2010) utilized similar tools to measure pain control, including
the VAS for pain and anxiety, the McGill Pain Questionnaire, opioid consumption, and
physiologic measures including heart rate, blood pressure, and oxygen saturation. The use of the
VAS is used in the majority of the studies and articles critiqued making comparison more
accurate. According to Allred, Byers, and Sole (2010) the VAS is quick, easy to use and
understand, and provides methods for comparison with other studies and experiments.
Effects on Postoperative Pain
Engwall and Sörensen Duppils (2009) found significantly less postoperative pain
(through the use of rating scales) in the treatment group compared to the control group in 15 of
the 18 studies; however, three studies revealed no significant difference in pain with the music
group. Engwall and Sörensen Duppils (2009) revealed that all but three of the 18 studies in their
review cited a lower cumulative consumption of analgesics in their treatment groups compared
to the control groups. Patient controlled analgesic (PCA) use in the postoperative period was
cited as decreasing 9% to 29% with music interventions in one study (Engwall & Sörensen
Duppils, 2009). However, acetaminophen and ibuprofen requirements did not differ
significantly between the groups in any study in Engwall and Sörensen Duppils (2009) review.
Dunn (2004) identified that half of the studies were successful in supporting the use of
music in the reduction of pain in the postoperative phase. This was evidenced by lower pain
scale ratings and decreased use of analgesics. Nilsson’s (2008) review demonstrated that music
had a significant pain-reducing effect in 59% of the trials (reflected by decreased pain scores).
Additionally, 47% of the studies in Nilsson’s (2008) review reported a significant decrease in
analgesic use because of their music therapy interventions.
Analysis in the Allred, Byers, and Sole (2010) study found no difference in opioid
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consumption between the experimental and control groups. Furthermore, physiologic measures
were unremarkable in both groups with no significant differences found. Analysis of pain scores
measured with the VAS in Allred, Byers, and Sole’s (2010) study also found no statistically
significant changes. While their study found no statistically significant changes, listeners found
that the music was a relaxing and positive experience, stating that it helped to take their mind off
of the pain for some time (Allred, Byers, & Sole, 2010).
Application of Evidence
Postoperative nursing is unique in that all of the patients experience discomfort of some
sort. Postoperative nurses can use music interventions to promote pain relief and well-being.
Music therapy can guide patients through otherwise painful and traumatic procedures with ease.
Nurses have a responsibility to provide the best care possible for their patients. The results of this
review should encourage nurses to use music as a noninvasive measure for the relief of
postoperative pain. The results also indicate that music therapy can raise the quality of care for
postoperative patients by increasing their comfort and relaxation and thus their well-being.
Engwall and Sörensen Duppils (2009) findings suggest that music, because of its relaxing
and distracting effects, reduces pain but does not eliminate it. The authors cite the gate-control
theory as one explanation for these effects. Additionally seven out of the 11 articles reviewed by
Dunn (2004) overtly stated that the gate control theory was utilized and as a result distraction
provided additional pain relief. This theory states that the spinal cord has a mechanism that acts
as a gate inhibiting or facilitating transmission of painful impulses from the body to the brain
which can be influenced by music (Engwall & Sörensen Duppils, 2009).
Barriers to Implementation
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Implementation barriers must be addressed to successfully integrate music therapy into
postoperative nursing practice. Common obstacles include resistance from physicians,
administration, as well as some patients and/or families. In order to overcome these potential
barriers and provide information to other health care professionals, an educational program
containing the evidence should be presented. A patient specific presentation needs to be provided
during preoperative teaching allowing patients to be informed in their decision-making about
music therapy. Another potential barrier is the use of headphones, which are uncomfortable for
some individuals. Providing a selection of headphones or earplugs preoperatively can promote
patient compliance. Education is the key to increasing awareness of music as an adjunct therapy
for pain management and minimizing the barriers to implementation postoperatively.
Recommendations
The results of this review demonstrate the beneficial effects for implementing music
interventions to improve patient outcomes and patient satisfaction. Nurses have a key role in
managing postoperative pain and can use music therapy as a non-pharmacological method to
enhance pain control. The data has shown that music therapy is a simple and cost effective
nursing intervention that can assist patients in coping with their postoperative pain. Offering
music therapy to patients is an inexpensive technique to reduce anxiety, discomfort, and improve
the patient’s surgical experience. Nilsson (2008) stresses the importance of educating
perianesthesia nurses with the data that proves the positive effects of music therapy
interventions. Additional research studies concerning type of music, music versus combined
non-pharmacological methods, and low compared with high pain ratings pre-intervention are
needed to continue the study of the efficacy of music as a pain reducing intervention.
Conclusion
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Music therapy as an intervention to reduce pain postoperatively was shown to be
effective in three of the four articles critiqued. Although no decreasing pain scores were found,
the fourth article did find that listening to music promoted a calm and restful state, and provided
distraction from postoperative pain (Allred, Byers & Sole 2010). These findings overwhelmingly
support the use of music as a nursing intervention to help adult patients control pain
postoperatively. Music is a low risk intervention, which has the potential to decrease the use of
analgesics thus decreasing negative side effects often associated with their use. Nurses are in
unique positions to promote well-being. The evidence provided with this review encourages
nurses to offer music as a pain reducing intervention in the postoperative period.
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References
Allred, K. D., & Byers, J. F. (2010). The effect of music on postoperative pain and anxiety. Pain
Management Nursing 11(1), 15-25.
Dunn, K. (2004). Music and the reduction of post operative pain. Nursing Standard, 18(36), 3339.
Engwall, M., & Sörensen Duppils, G. (2009). Music as a nursing intervention for postoperative
pain: A systematic review. Journal of PeriAnesthesia Nursing 24(6), 370-383.
doi:10.1016/j.jopan.2009.10.013
Nilsson, U. (2008). The anxiety- and pain-reducing effects of music interventions: A systematic
review. AORN Journal 87(4), 780-807. doi:10.1016/j.aorn.2007.09.013
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Appendix
Table 1
Evaluation Matrix for Included Studies
Author,
Year,
Nationality
Population
Study
Design/
Level of
Evidence
Nursing
Research
Y/N
Peer
Reviewed
Journal
Primary
Intervention
1
Engwall &
Duppils, 2009,
USA
Adult
postoperative
patients
Systematic
Review,
Level I
Yes
Yes, Journal of
PeriAnesthesia
Nursing
Music
2
Dunn, 2004,
USA
Adult
postoperative
patients
Systematic
Review,
Level I
Yes
Yes, Nursing
Standard
Music, noise
control, and
relaxation
techniques
3
Allred, Byers,
& Sole, 2012,
USA
Adult,
orthopedic
postoperative,
n=56
Randomized
Controlled
Trial, Level II
Yes
Yes, Pain
Management
Nursing
Music versus
quiet time
4
Nilsson, 2008,
Sweden
Adult
postoperative
patients
Systematic
Review,
Level I
Yes
Yes,
Association of
periOperative
Registered
Nurses
(AORN)
Journal
Music,
massage, and
rest