Running head: IMPLEMENTATION OF MUSIC THERAPY

Implementation of Music Therapy in Chronic Pain Management

Narjess Yazback
University of South Florida

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Abstract
According to the Institute of Medicine (2011) chronic pain affected an estimated 100 million
American adults in 2011, which resulted in an average of $635 billion spent in medical treatment
of pain management. This paper explores multiple evidenced-based clinical trials to compare the
effectiveness of the adjuvant treatment of pain with music therapy to standard analgesics alone
on patients experiencing chronic pain. Three studies were explored involving patients with
various chronic conditions such as: fibromyalgia, neurological disease, inflammatory diseases
and potentially self-limiting conditions. Based on the research conducted, music therapy as a
nursing intervention in addition to standard pain treatment was found to decrease the level of
pain, anxiety, and depression that the patient experienced, as well as reduce the amount of
analgesics consumed. By reducing the amount of analgesics consumed using inexpensive
alternative therapy, medical treatment costs may potentially be decreased. In completing this
research, the search engines CINAHL and PubMed were utilized.
Keywords: music therapy, chronic pain management, alternative treatment

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Implementation of Music Therapy in Chronic Pain Management

In 2011 alone, 100 million American adults were affected with chronic pain which
resulted in expenses of $635 billion in medical treatment. This number exceeded that of patients
affected with heart disease, diabetes and cancer combined (Institute of Medicine, 2011).
Focusing on Bayfront Medical Center in St. Petersburg Florida, 9% of patients say that their pain
was sometimes or never well controlled, 70% state that pain was always well controlled, and
21% say that pain was usually well controlled (American Hospital Directory, 2014). Better pain
management and reduction of medical treatment costs for pain could be achieved with the
implementation of a nurse driven intervention involving music therapy in hospitals settings and
at home as an adjuvant treatment to standard therapy for pain. Evidenced based randomized
controlled trials were found to support the effectiveness of music therapy on chronic pain. In
order to further evaluate the efficiency of the proposed intervention, the following PICOT
question was developed: In hospitalized adult patients with chronic pain, how does the nursedriven implementation of music therapy in addition to analgesics compared to standard care with
analgesics alone affect the level of pain reported by patients using a numeric pain scale over a six
month period? Based on previous studies conducted on this specific topic, music therapy
significantly decreased chronic pain levels in adult patients.
Literature Search
In order to support the nurse driven intervention of music therapy to reduce chronic pain,
multiple searches were conducted through the Shimberg Health Science Library using CINAHL
and PubMed as search engines. The supporting evidence was found after multiple searches with
the various following key terms: Music therapy & pain, chronic pain management & alternative

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treatment, pain & music, pain reduction and music therapy, and standard treatment & music
therapy.
Literature Review and Synthesis
Three randomized controlled trials (RCT) and one clinical guideline were used to support
the proposed implementation of music therapy as an adjuvant treatment for chronic pain. A study
by Guetin et al.( 2012) published in the clinical journal of pain assessed how patient-preferred
music therapy as an intervention in a addition to standard treatment contributed to better
management of patients with chronic pain. A sample of 87 patients with various sources of
chronic pain was included. The study consisted of an intervention arm (n=44) which received
two daily sessions of music therapy, and a control arm (n=43) which received standard treatment
alone (Table 1). The study was conducted over 3 months and data was collected at baseline, on
day ten, day 60, and day 90 using a visual analog scale (VAS) and anxiety-depression scale
(ADS). Results at the end of the study showed a significant reduction in pain (p<0.001) in the
intervention group (6.3 1.7 at day 0 vs. 3 1.7 at day 60) compared to the control group (6.2
1.7 at day 0 vs. 4.6 1.7 at day 60). Additional benefits of the music intervention also included
reduced anxiety and depression levels along with decreased consumption of anxiolitic agents
(Guetin et al., 2012). Strengths of the study included (1) explanation and chart for subjects who
did not complete the study, (2) random assignment to intervention and control group, (3) detailed
recording of any other medications patients consumed during the study, and (4) measurement of
all important clinical outcomes. Some weaknesses were that (1) the study was not double
blinded, and (2) different diagnoses were included in the study which could also lead to biased
results.

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A second study by Gutgsell et al. (2013) demonstrated how music therapy reduces pain in
palliative care patients. A sample size of 200 was collected from one hospital through daily
referrals from the palliative care team. Inclusion criteria were established for this study (Table 1).
The intervention group received music therapy and therapist guided autogenic relaxation in
addition to standard care with analgesics, whereas the control group received just standard
pharmacological care for pain management. Using three different scales (Table 1), levels of pain
were assessed in both groups. Results on 2 of the 3 scales showed significant reduction of pain in
the music intervention group (p<0.0001) proving the efficacy of the intervention (Gutgsell et al.,
2013). Weaknesses of the study were (1) no clear time frame of the study was provided, and (2)
45% of originally referred patients did not consent to participate, thus reducing the sample size
from 400 to 200. The study had several strengths including (1) appropriate control group, (2)
clearly defined interventions and outcomes, (3) pre and post test were conducted by a clinical
nurse who was blind to the study to avoid bias, (4) clear reasons were provided to explain why
subjects did not complete the study, and (5) multiple different scales were used to assess
outcome.
A third study conducted by Zafra, Castro-Sanchez, Mataran-Penarrocha, & MorenoLorenzo (2013) focused on the effects of music therapy on pain and depression in patients
diagnosed with fibromyalgia (FM). In a sample size of 60, half of the patients were assigned to
an intervention group which provided them with music once a day for a period of four weeks,
and the other half consisted of the control group who received no music. Pain and depression
levels were assessed using three different scales (Table 1), and data was collected at baseline and
at four weeks. Based on the documentation by Zafra et al. (2013) the intervention group
demonstrated a significant reduction in pain compared to baseline data and to the control group,

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(p=0.042) after four weeks. Please refer to table 1 for more details. The control group reported
no pain reduction after four weeks. Some weaknesses of the study were that (1) the sample size
dropped to 55 but no explanations were given as to why, (2) the sample size was small, and (3)
recordings of medication consumption by patients during the length of the study were not
available. Strengths of the study included (1) a clearly stated intervention, (2) similar
demographic characteristics in both groups, (3) subject randomization, (4) baseline clinical
variable collected in both groups, (5) the control group was appropriate, and (6) this is a feasible
treatment in the clinical setting.
Based on the strengths provided and the significant reduction in pain experienced in the
three different intervention groups, all studies utilized appear to be valid. Findings in all three
studies are consistent with each other and support the beneficial practice and need for further
research regarding music therapy in managing pain. Some differences found among the studies
involved time frame of the trial and frequency of the music therapy received. In two of the
studies patients received music once a day as opposed to twice daily in the third study. In the
study conducted by Zafra et al. music therapy was carried out once a day for a period of four
weeks, whereas the patients in the study by Guetin et al. received music therapy twice a day for a
period of three months. Regardless of these differences, all three randomized controlled trials
demonstrate that the implementation of music therapy can contribute to overall reduction of
patients pain, and is a more cost-effective adjuvant therapy in the clinical setting. Furthermore,
the guideline of assessment and management of chronic pain states in its recommendations that
medications are not the sole focus of treatment in managing pain and should be used when
needed to meet overall goals of therapy in conjunction with other treatment modalities ( Hooten
et al., 2013, p. 8). Although the guideline did not specifically include music therapy, it stressed

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that non-pharmacological methods in general such as acupuncture as one example may be more
appropriate for certain types of pain.
Proposed Practice Change
Based on numerous research and evaluations of RCTs, music therapy has been proven to
be a cost-effective adjuvant therapy to standard pain treatment that can be utilized by nurses in
decreasing chronic pain levels in patients. Music therapy was also found to have additional
positive effects such as reducing levels of depression and anxiety in patients. Therefore, hospitals
around the nation should consider implementing 30 min to one hour of music therapy daily for
the patient during their stay in order to decrease pain, increase patient comfort and provide better
overall care. Upon discharge, a compact disc (CD) containing the music will also be offered to
the patient to take home.
Change Strategy
In order to implement a change, the Evidenced Based Practice Model will be followed.
Evidence- Based Practice is defined by Sackett and colleagues, (2000), as the integration of best
research evidence with clinical expertise and patient values to facilitate clinical decision making
(Melnyk & Fineout-Overholt, 2011, p. 242). Following the steps of the Evidence-Based Practice
model, a PICOT question will be initially developed to identify the problem and assess the need
for change in the target setting. Step two of the model will focus on conducting the necessary
research, followed by step three which will require appraisal and assessment of evidence found
to determine both benefits and risks involved with the suggested practice. Step four and five will
require proposal of the change while respecting the organizations culture, design and
implementation of a pilot study, and evaluation of the results. In order to promote staff
engagement with the project, interactive floor meetings will be conducted weekly to explain and

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review the change as well as allow the staffs input on the music choices and patient
assessments. Visual and auditory displays will be provided for the staff to take home and review
prior to starting the practice. If successful and clinically significant, the last step will focus on
integration and maintenance of the new practice by involving all stakeholders affected in the
healthcare setting and monitoring the process (Melnyk & Fineout-Overholt, 2011).
Roll Out Plan
Evidence-Based
Practice Model Steps
Step 1: Assess the need
for change in practice
setting.

Actions

Step 2: Research and

locate the best
evidence.

Step 3: Analyze the

evidence found.

Timeline

Include stakeholders involved and

affected in practice change: nurses,
physicians, nurse managers,
hospital board members.
Collect internal and external data
on current pain management
practices. Include pain levels, cost
of standard pain treatments, and
patient satisfaction.
Compare and contrast internal and
external data.
Develop a PICOT question stating
intervention and expected outcome.

Assessed May 2014

Utilize valid databases such as

CINAHL and PubMed to conduct
research
Focus on evidenced-based research
and randomized controlled trials
that support the intervention of
music therapy.
Review current guidelines and
research concepts.

Research completed
May2014-June 2014

Analyzed June 2014

Critically appraise the evidence
found using a checklist. Assess
validity, reliability, and significance
of the research.
Assess the possible benefits and

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Step 4: Design a
practice change.

Step 5: Implement and

evaluate change in
practice

Step 6: Integrate and

maintain change in
practice.

risks of implementing music

therapy as an adjuvant treatment for
pain management.
Are results clinically significant or
unimportant?

Define the proposed practice

change using PICOT statement
Support with the research found.
Identify and reach out to needed
resources
Design a pilot study and
implementation plan for music
therapy in the clinical setting: This
will include 30 minutes to an hour
of music therapy daily. Music
therapy must be provided after pain
medicine has been dispensed, and
before the next dose is due.

July 2014

Implement designed pilot study

utilizing the music intervention and
evaluate the outcomes and costs
involved.
Evaluate the process of
implementation.
Based on the pilot study, develop
recommendations and conclusions
for implementing music therapy.

Implement: August 2014

Evaluation: November
2014

Integrate: December
Identify the affected stakeholders
2014
(nurses, physicians, nurse
managers) and communicate the
recommended changes to practice.
Use results from the pilot study to
support implementation of the
suggested practice.
Monitor the process and outcomes
of integrating the practice by
meeting with nurse managers and
clinical nurses to discuss the
intervention, and assessing patients
pain levels overall.

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10

Celebrate and disseminate results of

the successful project by attending
conferences with other hospitals,
displaying posters and submitting a
journal.

Model of evidence-based practice change (Melnyk & Fineout-Overholt, 2011, p. 255)

Project Evaluation
In order to evaluate the effectiveness of the change, data on pain levels experienced will
be collected from patients involved in the pilot study. The numeric pain scale (0-10) will be
utilized by clinical nurses to collect the results from patients receiving music therapy in addition
to standard care with analgesics, and patients receiving only standard pain management. Results
will then be compared to determine if there is a statistically significant (p<0.05) and clinically
significant better outcome when implementing music therapy as an intervention. During the
evaluation, a 15% increase in patients who state that their level of pain is always well controlled
at Bayfront Medical Center is expected. If no significant change is seen between the intervention
and control group during the six month study period, the project will then be terminated.
Dissemination of EBP
In order to disseminate the evidence found from implementing music therapy as an
adjuvant treatment for pain management locally and regionally, various methods may be
employed. Staff meetings, short courses, oral presentations, and educational pamphlets will be
used to disseminate the project throughout the hospital setting. Oral and poster presentations will
be used at various conferences with different hospitals and healthcare workers to clearly convey
the benefits of the implementation. Publishing will also be utilized to communicate findings to
the larger population and will enable availability of data through a major source of promotion

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known as the internet. Evidenced-based practice and research are important in the health field
because they continuously allow for better care of the patient.

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12

References
Guetin, S., Ginies, P., Kong-Siou, D., Picot, M., Pommie, C., Guldner, E., Touchon, J. (2012).
The effect of music intervention in the management of chronic pain. Clinical Journal of
Pain, 28(4), 329-337).
Gutgsell, K., Schluchter, M., Margevicius, S., DeGolia, P., McLaughlin, B., Harris, M.,
Wiencek, C. (2013). Music therapy reduces pain in palliative care patients: A
randomized controlled trial. Journal of Pain and Symptom Management, 45(5), 822-831.
Hooten, W.M., Timming, R., Belgrade, M., Gaul, J., Goertz, M., Haake, B.,Walker, N.
(2013). Assessment and management of chronic pain. Institute for Clinical Systems
Improvement (ICSI).
Institute of Medicine. (2011). Relieving Pain in America: A Blueprint for Transforming
Prevention, Care, Education, and Research. Retrieved from
http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-forTransforming-Prevention-Care-Education-Research/Report-Brief.aspx
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing &
Healthcare (2nd ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams & Williams
Zafra, M., Castro-Sanchez, A., Mataran-Penarrocha, G., & Moreno-Lorenzo, C. (2013). Effect of
music as nursing intervention for people diagnosed with fibromyalgia. Pain Management
Nursing, 14(2), e39-e46.

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13

Table 1
Literature Review
Reference

Aims

Design and
Measures
Guetin,S., Ginies, To determine The visual
P., Kong-Siou, D., how patient- analog scale
Picot, M.,
preferred
(VAS) was used
Pommie, C.,
music
to determine the
Guldner, E.,
therapy as an reduction in pain.
Touchon, J.
intervention
Depression and
(2012). The effect in addition to anxiety were
of music
standard
assessed using
intervention in the treatment
the Hospital
management of
contributed
Anxiety and
chronic pain.
to the
Depression scale
Clinical Journal
management (HADS).
of Pain, 28(4),
of chronic
Consumption
329-337.
pain.
rates of
medication were
recorded by
nurses between
D0-D10. At D60
and D90 rates
were evaluated at
home using a
telephone
interview.

Sample

Gutgsell, K.,
Schluchter, M.,
Margevicius, S.
DeGolia, P.,
McLaughlin, B.,
Harris, M.,

Sample size was 200

referred patients.
Inclusion criteria
included:
Potentially
life limiting

To determine
the efficacy
of one music
therapy
session in
reducing

Pre and post tests

were
administered by
a clinical nurse
using a numeric
scale (NRS), the

87 patients
presenting with
different sources of
chronic pain:
mechanical,
inflammatory,
fibromyalgic, and
neurological were
included.
Intervention arm
(n=44), control arm
(n=43).

Outcomes /
statistics
Results showed a
significant reduction
in pain (p<0.001) in
the intervention
group (6.3 1.7 at
day 0 vs. 3 1.7 at
day 60) compared to
the control group
(6.2 1.7 at day 0 vs.
4.6 1.7 at day 60).
Additional outcomes
included reduced
anxiety and
depression levels
along with a
decrease in
consumption of
Anxiolitic agents. At
D60 improvement
on anxiety was 50%
in intervention group
vs. 6.5% in the
control group. In
terms of depression,
there was an
improvement of
53% in the
intervention group
vs. 5% in the control
group at D60.

Using the (NRS),

both the intervention
group and control
group showed
significant declines
from pre-test to post-

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Wiencek, C.
(2013). Music
therapy reduces
pain in palliative
care patients: A
randomized
controlled trial.
Journal of Pain
and Symptom
Management,
45(5), 822-831.

Zafra, M., CastroSanchez, A.,

MataranPenarrocha, G.,
&MorenoLorenzo, C.
(2013). Effect of
music as nursing
intervention for
people diagnosed
with fibromyalgia.
Pain Management
Nursing, 14(2),
e39-e46.

pain in
palliative
care patients.

To
determine
the effects of
music
therapy on
pain and
depression in
patients
diagnosed
with
fibromyalgia.

Face, Legs,
Activity, Cry,
Consolability
Scale (FLACC),
and the
Functional Pain
Scale (FPS) to
assess results. An
independent
sample t-test was
used to compare
results between
intervention
group and
control group.

The visual
analog scale
(VAS), McGill
Pain
Questionnaire
Long Form
(MPQ-LF), and
the Beck
Depression
Inventory (BDI)
were utilized to
measure pain and
depression
levels. A t-test
was used to
analyze data in
order to
determine
treatment
effectiveness.

14

illness.
18 years or
older
Pain of 3+
on numeric
pain scale
Alert and
oriented
patient

Total sample was 60

patients with
fibromyalgia.
Intervention group
(n=30), and control
group (n=30). 5
patients did not
complete the study
for unknown
reasons.

test results, however,

a more significant
change (p<0.0001)
was noted in the
music therapy group.
Mean scores did not
differ significantly
between the
intervention and
control group using
the FLACC scale,
(p>0.05).
Using the FPS a
significantly greater
decline was seen in
the intervention
group (p<0.0001)
compared to the
control group.
After 4 weeks,
participants in the
intervention group
reported a
significant reduction
in pain on movement
p=0.002, and pain at
rest p=0.001
compared to
baseline data.
Control group
experienced no
reduction in pain on
movement p=0.42,
pain at rest p=0.08
compared to
baseline.
Significant
difference between
the two groups after
4 weeks was
(p=0.042).