The Effect of Music on Postoperative Pain 2

The Effect of Music Therapy on Postoperative Pain: A Research Proposal. Carolyn

Niles RN, Florence LeFevre RN, Lidia Mallon; Nurse, Department of
Nursing/Cardiothoracic ICU, Long Island Jewish Medical Center

ABSTRACT
Music Therapy is one of the many Complementary and Alternative Medicine (CAM)
treatments that are used in conjunction with pharmacological pain management to
decrease postoperative pain. CAM has grown to become a globally accepted intervention
in the medical field. Pain control in the postoperative period is important in preventing
negative patient outcomes and promoting healing. The purpose of this study is to analyze
the effect of a nurse-directed music therapy intervention on postoperative pain in adults
who have had abdominal surgery. A 3-month randomized quasi-experimental
intervention study will be performed using convenience sample of 100 participants who
will be randomized to groups. Participants will be recruited from three large teaching
hospitals on Long Island, New York. Ages will range from 18 to 90 years old. The
intervention group will receive traditional postoperative pharmacological pain
management and 30 minutes of Relaxation or Classical music to listen to via headphones
and a CD player. The control group will receive standard postoperative pain
management. It is anticipated that pain scores will be decreased in the intervention
group. Pain scors will be collected once the patient is out of the operating room then 30
minutes and 60 minutes in the PACU. Both the sensory and affective aspects of pain will
be assessed using the Visual Analogue Scale (VAS) with zero for no pain and 10 for the
worst thinkable pain. Demographic data will be analyzed using descriptive statistics and
pain scores will be collected from both groups and compared using independent t tests
and MANCOVA.

I NT R ODUC T I ON

Pr oblem Statement

Acute postoperative pain can be challenging for both patients and nurses.

Sometimes the sole use of pain medication is not enough to keep patients comfortable.

The use of CAM offers an adjunctive alternative and alternative method of pain relief. It

is the duty and responsibility of the nurse to regularly assess and treat patients’ pain;

however, nurses often encounter difficulty managing postoperative pain. The

significance of using music therapy to decrease postoperative pain is that it provides the

patient with another non-pharmacologic option for comfort.

M usic T her apy

The Effect of Music on Postoperative Pain 3

The independent variable in the proposed study is the music therapy intervention.

According to the American Music Therapy Association (2010), “Music Therapy is the

clinical and evidence-based use of music interventions to accomplish individualized goals

within a therapeutic relationship by a credentialed professional who has completed an

approved music therapy program”. Activation of the anterior cingulated cortex and

thalamus, which are integral components of the auditory pathway, affect the emotional

aspect of the patients’ pain experience (Shertzer & Keck, 2001). According to Good,

Anderson, Ahn, Cong, Stanton-Hicks (2005), “the perception of pain is decreased by

gates, which are diverse points in the central nervous system where the transmission of

noxious impulses to the cortex is repeatedly modulated, filtered, and abstracted by

physical, cognitive, and emotional factors” (p. 241). The amygdala and the

hypothalamus have an effect on the anxiety and distress associated with pain (Shertzer &

Keck, 2001). According to Shetzer & Keck (2001), “The sensory component of pain is

mediated in part through inhibitory neurons in the spinal cord and thalamus” (p. 92).

There are also distraction and relaxation components at work when patients listen to

music (Good et al., 2005).

Postoper ative Pain

The dependent variable is postoperative pain after abdominal surgery. Post-

Surgical pain is defined as “a complex response to tissue trauma during surgery that

stimulates hypersensitivity of the central nervous system” (“Post-surgical pain”, n. d.).

Adequate pain relief is one of the primary focuses of nurses caring for postoperative

patients because it has proven to improve patient outcomes (Shertzer & Keck, 2001).

Inadequate pain management activates the human stress response which results in
The Effect of Music on Postoperative Pain 4

negative consequences (Shertzer & Keck, 2001). The cardiovascular, respiratory,

gastrointestinal, renal, neuroendocrine, and autonomic nervous systems are all examples

of systems affected by pain (Shertzer & Keck, 2001).

The theory that provides this study with its conceptual framework is called the

gate control theory (Good et al., 2005). Good et al. (2005) states that, “the perception of

pain is decreased by gates, which are diverse points in the central nervous system where

the transmission of noxious impulses to the cortex is repeatedly modulated, filtered, and

abstracted by physical, cognitive, and emotional factors” (p. 241).

Nurses need to be aware that pain is a phenomenon in which there is no exact

science and must be cognizant of all pain management options available to patients.

What works for some patients will not necessarily work for another. According to Good

et al. (2001), “The sensory component of pain is the unpleasant, physical perception of

hurt, measured with the visual analogue scale (VAS) sensation of pain scale. The

affective component of pain is the amount of distress or emotional discomfort

experienced with the sensation” (p. 211). Pain has both sensory and affective aspects and

both must be assessed and treated post-operatively.

G aps in L iter atur e

There are not many articles found addressing music therapy and pain control in

abdominal surgery patients. Some studies only provided patients with one type of music.

This neglects to provide variety and music preference to the participants in the study.

Many studies included the effects of music on other variables including anxiety, nausea

and vomiting, and vital signs (Ikonomidou, Rehnstrom, & Naesh, 2004; Good et al.,

2001). Further studies are needed that solely focus on the effects of music on
The Effect of Music on Postoperative Pain 5

postoperative pain and not other variables. Some studies included other interventions,

such as environmental changes and relaxation techniques, which makes it difficult to say

how much of the results are from music therapy (Good et al, 2001; Shertzer & Keck,

2001).

Pur pose Statement

The purpose of this study is to determine the effect of a nurse-directed music

therapy intervention on postoperative pain in adults who have had abdominal surgery.

H ypothesis

The hypothesis to be tested is that participation in music therapy is associated

with decreased postoperative pain.

R esear ch Question

The proposed research question is, “What is the effect of a nurse-directed music

therapy intervention on postoperative pain management in adults who have had

abdominal surgery?”

M ethod

Study Design

A quasi-experimental, after-only, nonequivalent, control group design (LoBiondo-

Wood & Haber, 2010) is needed due to the study’s circumstances. Participants are to be

randomized into groups. A three-month intervention study will be conducted to analyze

the effect music therapy has on postoperative pain. This study focuses primarily on the

effect music therapy has on postoperative pain. An advantage to this design is that no

other variables are included that could possibly confound the study. Based on the data
The Effect of Music on Postoperative Pain 6

collected from the demographic questionnaire statistical analysis can pinpoint whether or

not there is a variation among age groups and postoperative pain scores.

Disadvantages of the design need to be taken in to consideration. Participant

knowledge, beliefs and values may or may not affect his or her willingness and ability to

accurately report postoperative pain scores, possibly affecting internal validity. Also,

participants involved in the study may have a pre-existing interest in CAM or music

therapy prior to participating in the study. This may be a potential threat to internal

validity. External validity can be affected by the Hawthorne effect, which is when

“subjects may respond to the investigator not because of the study procedures, but merely

as an independent response to being studied” (LoBiondo-Wood & Haber, 2010, p.172).

Sample

Time constraints made a convenience sample necessary in order to obtain the

appropriate number of participants. The sample will consist ideally of 100 participants.

There will be 50 participants in the control group and 50 participants in the experimental

group. A computer minimization program will be used to randomly assign patients to

one of the two groups.

I nclusion cr iter ia. Included in the study will be adults who are immediately

post-abdominal surgery who have the ability to hear, speak and read in English. Ages of

participants will range from 18-90 years old.

E xclusion cr iter ia. Patients excluded from this study are those with hearing

impairments, a history of chronic pain issues, patients currently on a pain management

regime, patients with psychiatric disorders, and patients that cannot read, write or speak

English.
The Effect of Music on Postoperative Pain 7

E xper imental gr oup. Immediately post-operatively, participants randomly

assigned to the experimental group will first be assessed for pain, then provided with a

CD of their preference, a CD player with headphones, and thirty minutes of listening

time. Their pain level will be assessed after listening to the music selection of their

choice for 30 minutes and then reassessed once more at 60 minutes. The CD player and

headphones will be all the same make and model and approved by bio-med prior to the

start of the study. Standard infection control will be practiced and a protocol will

developed to maintain cleanliness of equipment.

C ontr ol gr oup. Immediately post-operatively, participants randomly assigned to

the control group will be assessed for pain, then provided with a blank CD, a CD player

with headphones, and thirty minutes of listening time. After listening to the blank CD

for 30 minutes their pain level will be assessed and then reassessed once more at 60

minutes. The CD player and headphones will be all the same make and model and

approved by the bio-med department prior to the start of the study. Standard infection

control protocol will be practiced and policy will be implemented to maintain equipment

cleanliness.

Setting

Participants will be recruited from three local teaching hospitals in Long Island,

New York. Trained registered nurses in the pre-surgical testing area at each hospital will

be instructed on the recruitment process and will attempt to recruit participants Monday

through Friday when patients come in for preoperative screening. Patients will be

interviewed to make sure that they are eligible for the study and will be asked about their

music preference between relaxation and classical music at this time. Informed consent
The Effect of Music on Postoperative Pain 8

will also be obtained. They will be advised that they may or may not be listening to

music via the provided CD player with headphones post-operatively depending on what

group they are assigned to.

I nstr uments

Demogr aphic questionnair e. There will be 11 items on the demographic

questionnaire (Appendix A). Participants will be provided with hard copy and a pen to

fill out during pre-operative testing. Patients will be advised that any questions can be

answered by the research nurse. The questionnaire will be collected and reviewed by the

same research nurse, then given by the research nurse to the research conductors.

I nter vention. The name of the intervention is MT-EPP (Music Therapy-Effect

on Postoperative Pain). Approval from the Investigational Review Board of each of the

hospitals needs to be obtained prior to initiating the study. Nurses interested in

participating in the study will be required to attend the same three hour in-service. Both

research nurses working in the pre-surgical screening area and in the PACU will be

required to obtain training and demonstrate competency. Nurses located in the pre-

surgical testing area will be responsible for recruiting the appropriate participants,

obtaining informed consent and assisting with the demographic questionnaire. They will

also educate the patient on the VAS pain scale and CD player and ensure proper use of

tool and equipment. Each, patients’ desired volume level will be determined and

documented at this time.

Information provided by the patients on the demographic questionnaires will then

be handed by the pre-surgical testing nurses to the research study conductors. Then

participants will be put into a computer database which will randomly assign them to
The Effect of Music on Postoperative Pain 9

either the control or experimental groups. The correct CD will be inserted into the CD

player by the researcher and then given to the PACU nurses to provide the participants

with the appropriate music selections or blank CD (depending on which group they

belong to). The PACU nurses will not be able to identify which group the participants

belong to. The CD players will be labeled A, B, and C and the PACU nurses will refer to

a list provided by the research conductors as to which CD players should go to which

participants and at what volume level. The list will be placed in a binder labeled

“research study” along with patients reported pain levels.

The PACU nurses will be responsible for delivery of the actual music therapy

intervention. Patients’ pain will be assessed immediately upon arrival to the PACU with

the VAS pain scale as discussed previously. Then the PACU research nurses will place

the appropriate CD player headphones on participant, adjust volume to patients’ pre-

decided level and press play on the CD player. After 30 minutes the PACU research

nurse will reassess patients’ pain level using the VAS. Pain level will be reassessed a

final time 60 minutes after arrival to PACU. Throughout this study pharmacological

means of pain control will not be withheld. This study is testing the ability of music

therapy to be an adjunctive method to standard pharmacological pain management.

V isual A nalogue Scale

The instrument used to measure patients’ post-operative pain is the VAS pain

scale. The scale consists of a continuum from 0 to 10. The sensory aspect of pain is

assessed on the continuum as none (0), annoying (1-2), uncomfortable (3-4), dreadful (5-

6), horrible (7-8), agonizing (9-10). The affective aspect is assessed on the continuum

from 0 being no distress to 10 being unbearable distress. Patients will be shown the VAS
The Effect of Music on Postoperative Pain 10

analogue scale and asked to verbally report both sensory and affective pain levels. The

research nurse will be responsible for recording this number. The VAS scale is used in

most hospitals to assess patient pain. The validity of the McGill Pain Questionnaire’s

Pain Rating Scale has been proven in numerous studies. (Good et al., 2001) The VAS

pain scale has proven to have concurrent validity (Good et al., 2001) Based upon the

literature review, reliability of the VAS has not been established.

Data C ollection M ethod

Demographic data on the participants will be obtained one time by the

questionnaire filled out and collected during the pre-surgical testing areas. Pain scores

will be documented and collected by the research nurses stationed in the PACU. A

baseline pain score will be collected upon arrival to the PACU prior to placing

headphones on the patient. Pain will be assessed at 30 minutes and reassessed

60 minutes after patients’ arrival to the PACU.

E xper imental gr oup. Data collected from the experimental group includes

demographic data and patients’ sensory and affective pain scores.

C ontr ol gr oup. The data collected and data collection method in the control

group is the same as the experimental group.

Data A nalysis

Descr iptive statistics. Demographic data will be organized using descriptive

statistics. Age, gender and music preference must be analyzed using mean, median and

mode. They can also be described using percentages.

I nfer ential statistics. All other data will be analyzed using inferential statistics.

Based on prior studies, pain scores collected from both groups should be compared and
The Effect of Music on Postoperative Pain 11

analyzed using independent t-tests and MANCOVA (Shertzer & Keck, 2001; Good et al.,

2001; Good et al., 2005). Standard deviation must be looked at to determine variation

between pain scores. These statistics have been chosen due to the design of the study.

L imitations of Study

This study consists of a one time exposure to the music intervention. Also, pain

scores are only reflected in the immediate post-operative period. A more longitudinal

study, where music is played more than once, and pain scores are assessed at more

frequent intervals, may yield different results.

Another limitation is that the study depends upon patients self reports of pain. A

number of individual aspects may interfere with accurate reporting, including culture and

past pain experiences. Pain medication is not standardized and may result in varying

levels of pain.

C onclusions

This study is of importance due to its potential implications for nurses and

patients. Music Therapy is a low risk intervention and is generally affordable. Adequate

pain control in the post-operative period provides patients with an overall positive

experience and a quicker recovery (Shertzer & Keck, 2001).

I mplications for Nur sing Pr actice

Nurses in the field can benefit from the findings of this study and previous

studies. Since music preference can vary and be age-specific, patients can be encouraged

to listen to their own music in an attempt to alleviate pain. One concern may include the

fact that nurses may or may not be open to a nurse-directed music intervention. Based on

established knowledge, attitudes and beliefs making an organizational change could be

The Effect of Music on Postoperative Pain 12

difficult. Research needs to be done in order to determine the best way to implement a

new policy.

I mplications for E ducation

A music therapy initiative would require adequate nursing education. In-services

and classes must be provided for all and competency must be assessed. A designated

resource person must be available for staff at all times to facilitate a smooth transition.

Collaborative research councils can be formed to promote communication and distribute

up-to-date information. Further research must be done to determine the best way to

educate staff on CAM/music therapy.

I mplications for Policy

Administration and nursing education must work collaboratively to create a

descriptive policy and procedure using CAM/music therapy. Adequate communication is

essential to publicize innovative nursing interventions. Use of equipment must be

specified to ensure a standardized procedure. Infection control measures must be

implemented if equipment is utilized between one patient to the next. All equipment

must be declared safe to use and approved by the appropriate department.

I mplications for R esear ch

More research is required to reinforce the findings of previous studies regarding

music therapy and post-operative pain. A possible outcome of this study is that music

therapy will decrease pain after surgery. Music therapy may also be helpful in

minimizing use of pain medication and benzodiazepines. Just like with other methods of

pain management, what works for some people may not necessarily work for others,
The Effect of Music on Postoperative Pain 13

including music therapy. Culture, age, socioeconomic status and religion will affect

music preferences and must be taken into account. Findings from this research may not

be generalizable to all populations since the sample used was one of convenience and the

setting is limited to three hospitals on Long Island, New York.

References

American Music Therapy Association (1998-2010). What is the profession of Music

Therapy? Retrieved from http://www.musictherapy.org/

Ebneshahidi, A. & Mohseni, M. (2008). The effect of patient selected music on early

postoperative pain, anxiety, and hemodynamic profile in cesarean section surgery.

The Journal of Alternative and Complementary Medicine, 14(7), 827-831.

Good, M., Anderson, G. C., Ahn, S., Cong, X. & Stanton-Hicks, M. (2005). Relaxation

and music reduce pain following intestinal surgery. Research in Nursing and

Health, 28, 240-251.

Good, M., Stanton-Hicks, M., Grass, J., Anderson, G. C., Lai, H., Roykulcharoen, V. &

Adler, P. (2001). Issues and innovations in nursing practice: Relaxation and

music to reduce postsurgical pain. Journal of Advanced Nursing, 33(2), 208-215.

The Effect of Music on Postoperative Pain 14

Ikonomidou, E., Rehnstrom, A. & Naesh, O. (2004). Effect of music on vital signs and

postoperative pain. Association of Perioperative Registered Nurses Journal,

80(2), 269-278.

LoBiondo-Wood, G., & Haber, J. (2010). Nursing research: Methods and critical

appraisal for evidenced based practice. (7th ed.). St. Louis: C.V. Mosby.

Post-surgical pain. (n.d.) . In Encyclopedia of Surgery. Retrieved from

http://www.surgeryencyclopedia.com/Pa-St/Post-Surgical-Pain.html

Shertzer, K. & Keck, J. (2001). Music and the PACU environment. Journal of

PeriAnesthesia Nursing, 16(2), p. 90-102.

Appendix A: Demographic Questionnaire

Please read questions carefully and circle your answers.

1. Gender:

a. Male

b. Female

2. Age

a. 18-30

b. 31-50

c. 51-70

d. 71-90

3. Ethnicity

a. Caucasian
The Effect of Music on Postoperative Pain 15

b. African-American

c. Asian

d. Other

4. Race

a. White

b. Hispanic/Latino

c. Not Hispanic/Latino

d. Other

5. Music preference

a. Relaxing (calm/meditation)

b. Classical

6. Are you hearing impaired?

a. yes

b. no

7. Do you have a history of any psychiatric disorders?

a. yes

b. no

8. Do you have a history of chronic pain?

a. yes

b. no

9. Are you on long term pain management?

a. yes

b. no
The Effect of Music on Postoperative Pain 16

10. Are you scheduled for abdominal surgery?

a. yes

b. no

11. Are you able to read, write and speak English?

a. yes

b. no

Appendix B
The Effect of Music on Postoperative Pain 17

Appendix C