Effects of Music Interventions on Pain and Anxiety

1. Effects of Music Interventions on Pain and Anxiety

2. Effects of Music Interventions on Pain and Anxiety History • Pythagoras (6th century) – Greek philosopher • Florence Nightingale (1800’s) – Crimean War • Kane (1914) – intraoperative music • Ilsen (1926) – National Association for Music in Hospitals established. (Nilsson, 2008)

3. Effects of Music Interventions on Pain and Anxiety Introduction • Inadequate pain control can have long term, detrimental effects. Music therapy interventions have been used in health care settings to reduce pain and anxiety. Objective • A review of the literature was conducted focusing on the efficacy of music therapy on pain and anxiety reduction. Methods • A systemic review of music therapy articles between 2008-2010 that focused on pain and anxiety reduction. The search of Pubmed data base produced 82 articles; four articles were selected for further review.

4. Therapy to Reduce Anxiety in Children with Cancer Undergoing Lumbar Puncture: A Randomized Clinical Trial Nguyen, T.N., Nilsson, S., Hellström, A.L., Bengtson, A. (2010). Music therapy to reduce pain and anxiety in children with cancer undergoing lumbar puncture: a randomized clinical trial. Journal of Pediatric Oncology Nursing. May-Jun; 27(3):146-55.

5. PICOT • Population: 40 children aged 7-12 with Leukemia • Intervention: Patients choose music to listen to beginning 10 minutes prior to lumbar puncture until the end of the procedure • Comparison: Whether music reduces pain perception and anxiety before and during lumbar puncture • Outcomes: music greatly reduces anxiety and pain before and during the procedure • Time: November 2007-July 2008

6. Introduction Pain associated with medical procedures is often viewed as the worst experience in a child with cancer Listening to music as treatment for pain and anxiety offers potential advantages of low cost, ease of provision and safety Music acts as a distracter, by focusing the patients pain away from negative stimuli to something pleasant and encouraging Nurses level of education and lack of time cofounding factors in many non-pharmacological methods Objective • Evaluate the effect and experience of using earphones with music as the only effect with regard to pain and anxiety relief in children with leukemia who are undergoing lumbar puncture

7. Method: • 40 patients with previous lumbar puncture • 20 patients given earphones and choice of music • Pain and Anxiety measured before, during and after procedure • Results: • Pain and Anxiety scores significantly lower versus control • Heart Rate, and Respiratory Rate lowered • Strengths: • Ease of implementation • Inexpensive alternative therapy method • Limitations: • Earphones may increase risk of transmission of infection • Low number of participants • Control group may have a sense of missing something

8. Conclusion • Listening to music with earphones as a form of non-pharmacological intervention reduced pain and anxiety in children with Leukemia who underwent lumbar puncture. • The music reduced pain scores, heart rate, respiratory rate, and anxiety scores. • Implementation is low cost and easy to administer. “I didn’t feel any pain. I felt less afraid than last time. The last time, I had to hold my mother’s hand very tightly during the LP. I didn’t need to do that this time . . . [smiles].”

9. Music for Pain and Anxiety in Children Undergoing Medical Procedures: A Systematic Review of Randomized Controlled Trials Klassen, J.A., Liang, Y., Tjosvold, L., Klassen, T.P., Hartling, L. (2008). Music for pain and anxiety in children undergoing medical procedures: a systematic review of randomized controlled trials. Ambulatory Pediatric Journal. Mar-Apr; 8(2): 117-28.

10. Clinical Question Among children undergoing medical procedures, how does the use of music therapy compare to standard procedures or other interventions in managing pain and anxiety? Music for Pain and Anxiety in Children Undergoing Medical Procedures • Objective • A systematic review of the efficacy of music therapy as an intervention in the management of pain and anxiety in children undergoing medical procedures.

11. Music for Pain and Anxiety in Children Undergoing Medical Procedures • Methods • Search of 16 electronic databases of published and unpublished studies. • Subject bibliographies, reference lists of relevant articles, and trials registries. • 4559 articles were screened and assessed reviewed the full manuscript of 393 studies. Criteria • Randomized controlled trial. • Children aged 1 month to 18 years. • Music used as an intervention. • Pain and/or anxiety measured.

12. Music for Pain and Anxiety in Children Undergoing Medical Procedures • Strengths • Quality assessment performed independently by two reviewers. • Systematic review of data including meta-analysis. Limitations • Validity may be limited by the heterogeneity of assessment methods (e.g. Self reporting pain scales are not as reliable or valid in younger children due to lack of cognitive ability to rate pain). • Small sample size (19 included trials involved 1513 subjects). • Observed vs. self reported measures of pain and anxiety • (can possibly represent a bias in outcome measures).

13. Music for Pain and Anxiety in Children Undergoing Medical Procedures Results* • Music therapy showed a significant reduction in pain and anxiety: standardized mean difference (SMD) -0.35, 95% confidence interval (CI) -0.55 to -0.14. • The data above was interpreted from 9 studies, N=704. • * Refer to article for further data analysis information • Conclusions • Music has shown to be effective in reducing pain and anxiety in children undergoing medical procedures. • Music as an adjuvant intervention demonstrates clinical importance by possibly reducing the amount of pharmaceutical intervention needed, resulting in a decrease in adverse side effects associated • with pharmacological therapy. • Further research is suggested.

14. Relaxing music as pre-medication before surgery: a randomized controlled trial Bringman, H., Giesecke, K., Thörne, A., Bringman, S. (2009). Relaxing music as pre-medication before surgery: a randomised controlled trial. Acta Anaesthesiologica Scandinavica. Jul; 53(6): 759-64.

15. PICOT Population: Patients >18y scheduled for elective-day or short stay-surgery in a Scandinavian hospital. Intervention: Patients chose one of six different music genres to listen to 1 hour before surgery. Comparison: Whether relaxing music has a greater anxiolytic effect than a standard dose of Versed. Outcomes: Relaxing music reduced anxiety to a greater extent than Versed before surgery. Time: Implementation started October 2004, completed May 2007.

16. Relaxing music as pre-medication before surgery: a randomized controlled trial • Objective • This randomized controlled trial compared the anxiety reducing therapeutic effects of Versed versus that of relaxing music. • Introduction • Patients awaiting surgery have some form of anxiety • Anxiety is often relieved by Versed • Relaxing music may help relieve anxiety

17. Relaxing music as pre-medication before surgery: a randomized controlled trial • Methods • 327 patients • 177 patients completed the music protocol • 150 patients received Versed • Music therapist gave the State Trait Anxiety Inventory (STAI X-1) form for all patients to complete and record blood pressure and heart rate before and after the intervention • Results • Music group: STAI score was 34 before and 30 after • Versed group: STAI score was 36 before and 34 after

18. Relaxing music as pre-medication before surgery • Conclusion • Relaxing music has a greater anxiolytic effect than a standard dose of Versed. • Strengths • Quantitative, objective analysis of data • Sample size of 372 participants • Limitations • Music had an effect from the beginning of the intervention • Duration of the intervention may have influenced results • Nursing Implications • We suggest that patients be given the option of: • - using pre-op relaxing music OR • - Versed (mention adverse effects and benefits) • Further studies are needed

19. The Anxiety- and Pain-Reducing Effects of Music Interventions:A Systematic Review Nilsson, U. (2008). The anxiety- and pain-reducing effects of music interventions: a systematic review. Association of Peri-Operative Registered Nurses. Apr; 87(4): 780-807.

20. Clinical Question How does the use of music therapy interventions effect the perception of pain among adults undergoing sugical procedures? The Anxiety- and Pain-Reducing Effects of Music Interventions Objective To provide a systematic review of recent studies describing the clinical effects of music interventions for hospitalized patients in perioperative settings

21. The Anxiety- and Pain-Reducing Effects of Music Interventions • Method • A search of AMED, CINAHL and Medline electronic databases, as well as a maual search of relevant journals by researcher was coducted. • Search terms included, music, therapy, preoperative, intraoperative, postoperative, perioperative, surgery, anaesthesia, anesthesia, pain, and anxiety.Music used as an intervention. • 182 articles were screened and 42 relevant studies consisting of 3,936 patients assessed for methodological quality, validity and reliability. Criteria • Randomized controlled trial. • Published between 1995-2007. • Adults aged 17 years and over. • Music used as an intervention. • Pain and/or anxiety measured.

22. The Anxiety- and Pain-Reducing Effects of Music Interventions • Strengths • Quality assessment using a previously published 3 point 4 feature tool, with an added “sample size” criteria was performed. • All studies were randomized clinical trials. • Sample size included a total number of 3,936 patients • A comparison of intervention techniques was performed. Limitations • Meta-analysis was not performed because the intervention and the dose were not constant. • Only articles published in English were used. • Out of 42 studies 11 (25%) received low quality assessment scores (ie. No blinding, nonvalidated questionaires, no report of validity of equipment used to test VS). • Search was limited to three data bases. • Live music studies were omitted.

23. The Anxiety- and Pain-Reducing Effects of Music Interventions Results • Music intervention showed a significant reduction in anxiety in 12 of 24 studies (50%) where evaluated, and a reduced need of sedative was shown. • Pain was significantly reduced in 13 of 22 trials (59%), and 7 of 15 (47%) found a significant reduction in the amount of analgesic required. • * Please refer to article form further data analysis information • Conclusion • Music has shown to be effective in reducing pain and anxiety in adults undergoing medical procedures. • Music as an adjuvant intervention demonstrates clinical importance by possibly reducing the amount of pharmaceutical intervention needed, resulting in a decrease in adverse side effects associated with pharmacological therapy. • Further research is suggested.

24. Effects of Music Interventions on Pain and Anxiety • Results • A significant reduction in perception of pain and anxiety in many children and adults with music therapy interventions. • A reduction in the necessary dosage of sedatives and analgesia required in pre-operative, peri-operative, and post-operative patients receiving music therapy interventions . Conclusion • Music demonstrates clinical importance as an integral part of a multimodal intervention in reducing the perception of pain. • The exact mechanism of how music reduces pain is unknown, however the literature revealed that music therapy most likely works by distracting conscious thought from pain and anxiety. • Results of this literature review could provide a foundation for future evidence based practice in the hospital setting.

25. Effects of Music Interventions on Pain and Anxiety • Recommendations • Approximately 60 to 80 BPM (slow & flowing) • Nonlyrical • Maximum volume at 60 dB • Patient’s choice (of preselected music options) • Minimum duration of 30 minutes • Institute cross contamination controls • Combine with other interventions • (meditation, aroma, touch, etc.) • Benefits of Music Interventions • Cost effective • Improved client perception of healthcare experience • Very little training – No extra staff • Minimal risk

26. The Anxiety- and Pain-Reducing Effects of Music Interventions Questions?

27. References Bringman, H., Giesecke, K., Thörne, A., Bringman, S. (2009). Relaxing music as pre-medication before surgery: a randomized controlled trial. Acta Anaesthesiologica Scandinavica. Jul; 53(6): 759-64. Klassen, J.A., Liang, Y., Tjosvold, L., Klassen, T.P., Hartling, L. (2008). Music for pain and anxiety in children undergoing medical procedures: a systematic review of randomized controlled trials. Ambulatory Pediatric Journal. Mar-Apr; 8(2): 117-28. Nguyen, T.N., Nilsson, S., Hellström, A.L., Bengtson, A. (2010). Music therapy to reduce pain and anxiety in children with cancer undergoing lumbar puncture: a randomized clinical trial. Journal of Pediatric Oncology Nursing. May-Jun; 27(3):146-55. Nilsson, U. (2008). The anxiety- and pain-reducing effects of music interventions: a systematic review. Association of Peri-Operative Registered Nurses. Apr; 87(4): 780-807.