Running head: POSTOPERATIVE PAIN AND MUSIC THERAPY 1

Decreasing Postoperative Pain Using Music Therapy

Haley Higgins

University of South Florida

POSTOPERATIVE PAIN AND MUSIC THERAPY 2

Abstract

Clinical Problem: Less than half of all patients who undergo surgical procedures receive

adequate pain relief in the postoperative period (Chou et al., 2016). Uncontrolled pain after

surgery can lead to negative health consequences for the patient, which may result in

complications and longer hospitalizations (Drake & de C. Williams, 2017).

Objective: The purpose of this paper is to discuss the effect music therapy has on pain

management during the postoperative period. CINAHL and PubMed were accessed in order to

obtain research articles pertaining to music therapy and postoperative pain management. The key

search terms used were music, music therapy, postoperative pain, surgical pain, and pain

management.

Results: The literature supports the hypothesis that music therapy is an effective means of

improving pain control. Research by Graversen and Sommer (2013) found that music therapy

was associated with a statistically significant reduction in pain levels reported by patients at

postoperative day seven (p=.014). In a study conducted by Liu and Petrini (2015), the music

therapy intervention group reported significantly less pain, compared to the control group

(p=.019). Mondanaro et al. (2017) found similar results, demonstrating that average pain levels,

reported using the visual analog scale (VAS), decreased from 6.2 to 5.09 in the music therapy

intervention group.

Conclusion: Postoperative patients could benefit from the use of music therapy, in addition to

standard pharmacological therapy, to enhance pain relief. Further research is needed to determine

the length of time required for music therapy to have a beneficial impact on pain level.

Additional research should be conducted to determine if music therapy has the same beneficial

effects in the pediatric population.

POSTOPERATIVE PAIN AND MUSIC THERAPY 3

Decreasing Postoperative Pain Using Music Therapy

Management of postoperative pain after a surgical procedure is a common occurrence in

the acute care setting. Pharmacological pain management is often the first line of treatment for

postoperative pain; however, research has shown that fewer than half of patients receive optimal

pain relief (Chou et al., 2016). Uncontrolled pain after surgery can lead to negative health

consequences for the patient, which may result in complications and longer hospitalizations

(Drake & de C. Williams, 2017). Complementary and alternative medicine therapies such as

music therapy, in combination with pharmacological therapies, have the potential to improve

pain control in postoperative patients.

This paper will evaluate the effect of music therapy in the management of postoperative

pain. Among postoperative adult patients, does music therapy, compared to no music therapy,

affect self-reported pain levels over six months? The expected outcome measure for clinical

improvement is a reduction in pain intensity within this population.

Literature Search

CINAHL and PubMed were accessed to obtain three peer-reviewed research articles and

one practice guideline related to music therapy and postoperative pain. The key search terms

used were music, music therapy, postoperative pain, surgical pain, and pain management. The

publication years searched where 2012 to 2017.

Literature Review

Graversen and Sommer (2013) tested the hypothesis that listening to music would

decrease the pain, nausea and fatigue experienced by patients after laparoscopic cholecystectomy

surgery. The sample size of the study was 75 adult patients, between 35 and 58 years of age,

undergoing same-day laparoscopic cholecystectomy surgery. The participants were randomized

POSTOPERATIVE PAIN AND MUSIC THERAPY 4

into a music therapy intervention group (n=40) or a control group (n=35). Participants in the

intervention group received a pillow with a built-in MP3 player preprogrammed with soft,

soothing music from MusiCure. The participants used the pillow throughout the entire

perioperative period until they were discharged. A baseline pain level was obtained prior to

surgery, and pain level was assessed at one hour and three hours postoperative using the visual

analog scale (VAS). Fatigue was assessed by measuring changes in C-reactive protein levels

before and after the surgery. Follow-up was performed at days one and seven postoperatively,

when pain level was reassessed over the phone using the numeric rating scale (NRS). The results

of the study indicated that music therapy was associated with a statistically significant reduction

in pain levels reported by patients at postoperative day seven (p=.014). Strengths of the study

included an RCT design, concealment of random assignment from those enrolling participants

into the study, and the use of valid and reliable instruments to measure pain level. Additionally,

rationale was provided to explain attrition, participants were analyzed within the group to which

they were assigned, and follow-up assessments were conducted at time intervals that were

appropriate to ascertain the full effect of the intervention. Further strengths of the study were the

use of an appropriate control group and the inclusion of subjects in each group that were similar

in demographic and baseline clinical variables. One weakness of the study was that neither the

participants nor the providers were blind to the group assignments.

Liu and Petrini (2015) assessed the effect of music therapy on postoperative pain,

anxiety, and vital signs. The sample size was 112 adult patients, between 52 and 70 years of age,

undergoing thoracic surgery. The participants of the study were randomized into a music therapy

intervention group (n=56) or a control group (n=56). The intervention group received standard

medical care plus 30 minutes of music therapy for three consecutive days. An MP3 player
POSTOPERATIVE PAIN AND MUSIC THERAPY 5

preloaded with soft music, containing 60-80 beats per minute or less, was used to administer

music therapy to the intervention group. During the first three postoperative days, a researcher

visited participants to administer the music therapy intervention. The researcher obtained vital

signs (blood pressure, heart rate and respiratory rate), pain level and anxiety level before and

after the music therapy session. Pain was measured using the faces pain scale (FPS). Anxiety

was measured using the state-trait anxiety inventory (STAI). After three days of music therapy,

the intervention group reported significantly less pain (p=.019). Additionally, 68% of

participants in the intervention group perceived a reduction in pain that they attributed to the

music therapy intervention. Strengths of the study included an RCT design, use of an appropriate

control group, and the use of valid and reliable instruments to measure pain level in participants.

Additionally, subjects in the control group possessed similar demographics and baseline clinical

variables as the intervention group. Further strengths of the study included providing

explanations for attrition, conducting follow-up assessments at appropriate time intervals, and

analyzing subjects within the group to which they were randomly assigned. Weaknesses of the

study were that random assignment was not concealed from the individuals enrolling participants

into the study and neither the participants nor the providers were blind to allocation.

The use of music therapy to alleviate postoperative pain following spinal fusion surgery

was studied by Mondanaro et al. (2017). The sample size was 60 adult patients between the ages

of 40 and 55 years of age, who were undergoing spinal fusion surgery. The participants were

randomized into a music therapy intervention group (n=30) or a control group receiving standard

pharmacological therapy only (n=30). The intervention group received one 30-minute music

therapy session that involved live singing and/or rhythmic drumming. Participants in the

intervention group were allowed to choose the type of music to which they were exposed. Pain
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was assessed 30 minutes after the music therapy session using the visual analog scale (VAS),

where a score of zero is associated with no pain and a score of ten is associated with the worst

imaginable pain. A statistically significant difference in pain levels was found between the

intervention and control groups (p=.01). Average pain levels in the control group increased from

5.2 to 5.87, whereas the average pain level in the intervention group decreased from 6.2 to 5.09.

Strengths of the study included the use of an RCT design, the concealment of random assignment

from the research assistants enrolling participants, and the use of a valid and reliable instrument

to measure pain. Follow-up assessments were conducted long enough to determine the effects of

the intervention and participants were analyzed in the group to which they were originally

assigned. Additionally, the participants in each group were similar in terms of demographics and

baseline clinical variables. Subjects in the control group closely matched those in the

intervention group in terms of gender, age, past surgical history and type of spinal fusion to be

performed. Additional strengths of the study included the use of an appropriate control group and

providing explanations for participant attrition. A weakness of the study was that neither the

participants nor the providers were blind to the group allocation.

The American Pain Society, along with the American Society of Regional Anesthesia and

Pain Medicine and the American Society of Anesthesiologists, developed guidelines for the

management of postoperative pain (Chou et al., 2016). The guidelines provide recommendations

for the management of pain during the perioperative period based on a systematic review of

RCTs. The guidelines recommend initiating pain control in the preoperative period and

incorporating the use of cognitive-behavioral methods of pain control, such as guided imagery,

hypnosis and music therapy, to achieve maximum pain relief in the postoperative period (Chou

et al., 2016).
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Synthesis

Graversen and Sommer (2013) observed a statistically significant reduction in pain levels

when music therapy was incorporated into patients pain management plan (p=.014). Liu and

Petrini (2015) reported significantly less pain among participants when music therapy was

provided for several days in the postoperative period (p=.019). Mondanaro et al. (2017) showed

that a single 30-minute music therapy session enhanced pain control, as statistically significant

differences in pain levels were observed between the intervention and control groups (p=.01).

Furthermore, the American Pain Society, along with the American Society of Regional

Anesthesia and Pain Medicine and the American Society of Anesthesiologists, support the use of

music therapy in adult postoperative patients as a means to provide enhanced pain relief (Chou et

al., 2016).

All three RCTs observed a decrease in postoperative pain that could be attributed to the

implementation of music therapy. However, there were several differences between the studies

that could impact the proposed practice change. Mondanaro et al. (2017) allowed participants in

the intervention group to choose between two types of music therapy. However, the participants

in the Graversen and Sommer (2013) and Liu and Petrini (2015) studies were exposed to a type

of music therapy chosen by the researchers. Additionally, Mondanaro et al. (2017) exposed the

intervention group to live music, whereas the studies by Graversen and Sommer (2013) and Liu

and Petrini (2015) exposed the intervention group to prerecorded music. Another difference

between the studies was the period during which music therapy was administered. Graversen and

Sommer (2013) exposed participants in the intervention group to music therapy during the entire

perioperative period. Liu and Petrini (2015) and Mondanaro et al. (2017) only exposed

participants to music therapy in the postoperative period. Furthermore, Liu and Petrini (2015)
POSTOPERATIVE PAIN AND MUSIC THERAPY 8

provided three 30-minute music therapy sessions over a three day period, whereas Mondanaro et

al. (2017) provided a single 30-minute music therapy session.

In the Graversen and Sommer (2013) study, patients in the control group experienced

longer pre-operative wait times and gallbladder lesions during surgery, which could have

affected the results. Liu and Petrini (2015) provided more time and attention to participants in the

intervention group, which could have impacted the perceived level of pain in these participants.

All three studies were performed at single sites and included only one type of surgical patient,

which could impact generalizability to other patient populations.

Research indicates that the implementation of music therapy has profound effects on

patients perceived postoperative pain. Providing adequate pain relief is imperative to patients

emotional and physical wellbeing in the postoperative period. A limited number of studies have

been conducted in the pediatric population. Additionally, there is no consensus on when to

initiate music therapy and for how long music therapy should be offered.

Clinical Recommendations

Research confirms that music therapy can be utilized in combination with

pharmacological therapy to provide more effective pain management in the postoperative patient.

Further research needs to be performed to determine the length of time for which music therapy

should be administered to achieve maximum pain relief. Additional research should be

performed to determine if the same benefits of music therapy can be extrapolated to the pediatric

population.
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References

Chou, R., Gordon, D.B., de Leon-Casasola, O.A., Rosenberg, J.M., Bickler, S., Brennan, T.,

Wu, C.L. (2016). Guidelines on the management of postoperative pain: Management of

postoperative pain: A clinical practice guideline from the American Pain Society, the

American Society of Regional Anesthesia and Pain Medicine, and the American Society

of Anesthesiologists Committee on Regional Anesthesia, executive committee, and

administrative council. Journal of Pain, 17(2), 131-157. doi:10.1016/j.jpain.2015.12.008

Drake, G., & de C. Williams, A.C. (2017). Nursing education interventions for managing acute

pain in hospital settings: A systematic review of clinical outcomes and teaching methods.

Pain Management Nursing, 18(1), 3-15. doi:10.1016/j.pmn.2016.11.001

Graversen, M., & Sommer, T. (2013). Perioperative music may reduce pain and fatigue in

patients undergoing laparoscopic cholecystectomy. Acta Anaesthesiologica Scandinavica,

57(8), 1010-1016. doi:10.1111/aas.12100

Liu, Y., & Petrini, M.A. (2015). Effects of music therapy on pain, anxiety and vital signs in

patients after thoracic surgery. Complementary Therapies in Medicine, 23(5), 714-718.

doi:10.1016/j.ctim.2015.08.002

Mondanaro, J.F., Homel., P., Lonner, B., Shepp, J., Lichtensztejn, M., & Loewy, J.V. (2017).

Music therapy increases comfort and reduces pain in patients recovering from spine

surgery. The American Journal of Orthopedics, 46(1), E13-E22.