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“Where’s the Music?

Using Music Therapy for
Pain Management
Jacqueline Redding, MSN, RN-BC; Sharon Plaugher, RN; Joanne Cole, RN;
June Crum, RN; Crystal Ambrosino, RN; Judith Hodge, RN; Lori Ladd, RN; Cynthia Garvan, PhD;
and Linda Cowan, PhD, ARNP, FNP-BC

Music therapy is readily available, low risk, inexpensive, requires little

training, and may improve the patient experience.

taff at the Malcolm Randall evidence for the use of music therapy. gling or buzzing sensation and tap-
VAMC (MRVAMC) outpa- Multiple medical databases were an- ping. Once the tip of the needle is
tient pain clinic in Gainesville, alyzed to find studies that included placed in the correct location, elec-
Florida, found that procedures total time, dose of sedative medica- trical pulses (small radiofrequency
to reduce a patient’s pain could ini- tions, pain scores, patient experience, currents) are passed through the
tially cause pain and anxiety. Typical and willingness to repeat the same needle. A lesion is formed that tem-
nursing care plans involved measures procedure in the future with use of porarily interrupts the pain messages
to reduce anxiety in patients under- music vs no music.1 The literature that the nerve sends to the brain.
going interventional procedures ex- review revealed that music therapy The procedure can take between
pected to produce pain, including demonstrated effectiveness in de- 30 and 60 minutes, which is longer
identifying and reinforcing coping creasing anxiety and pain, supporting than most pain clinic procedures.
strategies, providing reassurance and relaxation, reducing sedation medica- Radiofrequency lesioning controls
comfort, and giving patients clear tion during procedures, and improv- pain caused by degenerative disc
explanations slowly and calmly. The ing patient satisfaction. disease, facet arthropathy, sacroiliac
MRVAMC nursing staff therefore also As a result of the literature search joints, stellate ganglions, and other
advocated to add music therapy to the authors conducted a prospective, nerve conditions. Due to the length
the existing plan. randomized controlled study to inves- of the RFL procedure, patients may
tigate music therapy as an adjunct in- experience pain and anxiety (as well
BACKGROUND tervention during painful procedures. as other complications, such as vaso-
As part of a quality improvement vagal responses).
(QI) project, the authors conducted Radiofrequency Lesioning The clinic staff anticipated that
a literature search to find scientific One of the more common (and there would be 20 RFL procedures
most painful) procedures performed scheduled per week and selected it
Dr. Cowan is a research health scientist; at MRVAMC is radiofrequency le- as the study procedure for 3 reasons:
Ms. Redding, Ms. Plaugher, Ms. Cole, Ms. sioning (RFL).The procedure uses procedure length, high level of pain,
Crum, Ms. Ambrosino, and Ms. Hodge are electrical pulses to block nerves for and frequency performed.
all members of the pain clinic nursing team;
Ms. Ladd was a nurse manager in the pain clinic pain relief. Using fluoroscopy, the After receiving approval from the
at the time the article was written; all at the North physician inserts a needle adjacent University of Florida Institutional Re-
Florida/South Georgia Veterans Health System in to the nerve that innervates the view Board and VA Research and De-
Gainesville, Florida. Dr. Garvan is a research as-
sociate professor in the College of Nursing at the facet joint. The sensory and motor velopment, the MRVAMC pain clinic
University of Florida in Gainesville. nerves are stimulated, causing a tin- initiated the study from September


2013 to April 2014. The purpose of
the study was to measure the effects
Table 1. Patient Characteristics
of music on patient’s self-reported Overall, % Music, % No Music, %
anxiety and pain levels before and Characteristics (n = 44) (n = 23) (n = 21) P Valuea
after nonsedating lumbar RFL.
Gender .99
Female 9 (4) 9 (2) 10 (2)
METHODS Male 91 (40) 91 (21) 90 (19)
Study Design
Veterans aged between 21 and Mean age, y (SD) 57.6 (9.7) 56.8 (10.3) 58.4 (9.2) .59
88 years who were scheduled to re-
turn for lumbar RFL and who did Race .99
not require sedation were invited to Black 16 (7) 17 (4) 14 (3)
participate. Sixty participants con- White 80 (35) 51 (18) 81(17)
Did not disclose 5 (2) 4 (1) 5 (1)
sented. The music group had 21 men
and 2 women. The no-music group Music preference .19
had 19 men and 2 women. Table 1 No preference 2 (1) 0 (0) 5 (1)
summarizes descriptive data. Table 2 Easy 59 (26) 52 (12) 67 (14)
describes the results of the compari- Jazz 23 (10) 22 (5) 24 (5)
son analysis. Patients were randomly Classical 16 (7) 26 (6) 5 (1)
assigned to either the music interven- P value is derived from comparing groups.

tion group or no-music group. Before

and after the procedure, participants
in both groups were queried on pain Table 2. Comparison Analysis
and anxiety levels, using a visual ana-
log scale (VAS). Overall, % Music, % No Music, %
The study tools included the Characteristics (n = 44) (n = 23) (n = 21) P Valuea
global anxiety VAS (GA-VAS) for pain
Mean before procedure pain level (SD) 5.2 (1.9) 5.6 (1.9) 5.0 (1.9) .14
and anxiety and a yes/no self-reported
question, “Did music help?” for par- Mean after procedure pain level (SD) 2.5 (1.9) 2.3 (1.9) 2.6 (2.0)
ticipants in the music group. Evalu-
ation of the GA-VAS demonstrated Mean before procedure anxiety level (SD) 2.4 (0.9) 2.4 (1.0) 2.2 (0.9) .27
reliability and validity and were pa-
tient friendly.2,3 Pain was recorded Mean after procedure anxiety level (SD) 1.5 (0.8) 1.5 (0.9) 1.5 (0.7)
using a Likert scale of 0 for no pain a
P value is derived from comparing groups.
and 10 for severe pain. Anxiety was
recorded using a Likert scale of 0 for procedure. After obtaining informed Data Collection
no anxiety and 4 for extreme anxiety. consent, participants were asked to On procedure day, all participants
Study subjects were recruited from choose a music genre from 3 options: completed the anxiety scale as well
patients who were on a maintenance easy listening, jazz, or classical. Par- as a VAS pain scale (which is the
lumbar RFL schedule, did not require ticipants received a sealed envelope MRVAMC standard of care), preop-
sedation, and were willing to partic- identifying their group (30 envelopes eratively and postprocedure. Enve-
ipate. If sedation was required, the were created for each group) to be lopes were opened prior to going into
patient was excluded from the study. opened by the procedure nurse on the procedure room to prevent prior
Returning patients scheduled for RFL the day of the procedure.4,5 knowledge of who was assigned to
were informed about the music study Sixty participants consented to par- the music group. Participants in the
and asked whether they were inter- ticipate in the study. Of these 60 pa- music intervention group listened to
ested in participating. If they agreed, tients, 44 were studied. The 16 patients their preselected music on a portable
the study was explained in full, and who did not participate had either a CD player in the procedure room.
informed consent was obtained change in procedure or did not show The music was played softly so the
prior to the day of their scheduled for the appointment. patient could still hear and respond DECEMBER 2016  •   FEDERAL PRACTITIONER  •  47

Music Therapy

Figure 1. Mean Pain Score on Visual Analog Scale Before and 1.00 (0.85), respectively. In the
After Procedure no-music group, the mean de-
crease in pain and anxiety was
2.33 (1.80) and 0.69 (1.00), re-
spectively. The magnitude of pain
5 Music decrease was larger in the music
No music intervention group; however, the
difference did not reach statistical
Visual Analog Scale

4 Overall
Although there was not a statisti-
cally significant difference in pain
or anxiety reduction due to group
1 assignment, a 2-point reduction in
self-reported pain or anxiety may
0 be considered clinically important
Before Procedure After Procedure
and has been supported in older
studies.6 Importantly, 87% of par-
to the physicians instructions during Fisher exact test was used to compare ticipants in the music intervention
the procedure. The no-music group groups on categorical measures. An group reported that listening to
received everything that the music independent sample t test was used music was helpful during the proce-
intervention group received except to compare groups on the age vari- dure (Figure 1).
for music (standard care throughout able. Difference scores (formed by Anxiety levels were not as high
procedure, which consisted of nurse subtracting the after score from the as expected when measured before
monitoring, measures to reduce fear before score) were analyzed using and after the procedure, perhaps
and anxiety, and comfort measures). paired t tests. Analysis of covariance due to improvements in patient
Procedures were performed with was used to test for significant group education and continuity of care
local anesthesia; neither group re- differences on the outcome variables (Figure 2). Since all participants
ceived moderate sedation. of pain and anxiety with group as were returning patients, they al-
Gender, age, and self-reported the independent variable and the ready were familiar with the pro-
pain scores (before and after the lum- preprocedure measure as the covari- cedure and the staff. Staff turnover
ber RFL procedure) were recorded in ate. The level of significance was set rate is very low at this clinic, which
the patient’s chart and entered into at .05, and all testing was 2 sided. may have contributed to the low
the study database. Patients in both anxiety rates among participants at
groups were queried before and after RESULTS baseline. Other contributing factors
the procedure using the VAS to mea- Of the 60 consenting patients, included good communication, ex-
sure their pain and anxiety levels. 44 participated in the study. pert technique, and teamwork.
Participants in the music interven- Twenty-three were randomized to the During the study, few negative
tion group were asked whether they music intervention and 21 to the no- comments were noted. One partici-
felt that the music helped. They also music control group. Both pain and pant did not hear the music due to
were asked to provide feedback about anxiety were significantly reduced faulty equipment setup. Another
their experience. Data were stored in (P < .0001) in the total sample participant commented that the phy-
locked filing cabinets, and all forms (n = 44). The mean (SD) decrease sician doing the procedure made
were de-identified. in pain for all participants was negative remarks about the music
2.80 points (2.31) on a VAS of 0 to the patient selected. A third partici-
Statistical Analysis 10 and 0.86 points (0.93) decrease pant commented that the music was
SAS version 9.2 (Cary, NC) was in anxiety. In the music interven- too loud, and he was unable to hear
used for all analyses. Data were in- tion group, the mean decrease in the doctor’s instructions, indicating a
spected for out-of-range values. The pain and anxiety was 3.22 (2.66) and need for guidelines.


Music Therapy

T h e re w e re m a n y p o s i t i v e Figure 2. Mean Anxiety Score on Visual Analog Scale Before and

comments by participants in the After Procedure
music intervention group. Nurses
reported comments such as “The 3
music really helps”; “The music
was great, but rock ‘n’ roll would be 2.5 Music group
better”; and “Can I bring my own No music
[music] next time?” Many patients Overall

Visual Analog Scale

returning for procedures frequently
asked, “Where is the music?”

Of the 60 consenting patients, only 1
44 participated, possibly lowering
the power of the study to detect sig- .5
nificant findings. During the study,
the physician staff was reduced, re- 0
sulting in fewer RFLs performed and Before Procedure After Procedure
causing the study to take longer to
conduct and with fewer opportuni- clinic plans to implement music reflect those of Federal Practitioner,
ties to recruit participants. therapy as a standard of care dur- Frontline Medical Communications
The CD players used for the study ing RFL procedures and all proce- Inc., the U.S. Government, or any of its
were old, and because earbuds could dure appointments. Music therapy agencies. This article may discuss un-
not be used, volume was difficult to may help reduce pain and anxiety labeled or investigational use of certain
modulate consistently. Earbuds were during painful procedures. The goal drugs. Please review complete prescrib-
not used because patient participa- is to continually increase patient ing information for specific drugs or
tion was required during the pro- satisfaction and overall procedure drug combinations—including indica-
cedure. Also, having only 3 music experience through integration of tions, contraindications, warnings, and
genres to choose from limited the evidence-based practice. ● adverse effects—before administering
participant’s choice. pharmacologic therapy to patients.
CONCLUSION The authors thank the study team who REFERENCES
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