Effect of music on vital signs and postoperative pain

Patients scheduled to undergo surgical procedures often say that they sense a loss of control and autonomy. This may induce anxiety and a feeling of helplessness, which also could be related to being in an unfamiliar environment. (1-4) Postoperative pain and nausea may prolong recovery, and the experience of psychological tension may affect the cardiovascular and immune systems. (5) Pharmacological methods to improve postoperative pain and nausea are well documented, but an increasing interest in nonpharmacological methods--particularly pleasant auditory stimulation-has prompted research in this field. The use of music during and after surgery has attracted attention recently, and several studies and reviews on the topic have been published. (6-8) Although many of these have not fulfilled standard criteria for randomization and control of circumstances, some recent studies point to a direct pain-reducing effect from patients' perioperative exposure to music. (9-14) Traditional and pharmacological therapeutic interventions for the relief of perioperative anxiety and pain are being challenged by an increasing demand for complementary and more holistic approaches. (15) Furthermore, there is increasing pressure on perioperative staff members to rush patients through the perioperative period. (16) Current therapeutic methods may, in fact, impair patient flow through recovery. Benzodiazepines and opioids--current standards of treatment for postoperative pain--have well-known sedative and emetic side effects. Reducing the dosages of these medications is essential for improving the logistics of postoperative care. PURPOSE The purpose of this study was to test the hypothesis that listening to relaxation music preoperatively and postoperatively would affect patients' experience of pain, nausea, or wellbeing and that it would have an effect on vital signs in women undergoing laparoscopic gynecological surgery. Questions asked in the study include the following. 1. Does preoperative relaxation music influence patients' experience of well-being, and does it have any measurable impact on vital signs (ie, heart rate [HR], blood pressure [BP], and respiratory rate [RR])? 2. Does relaxation music played during the immediate recovery period affect patients' experience of pain, nausea, and well-being? 3. Does relaxation music played in the immediate recovery period affect the amount of analgesics and antiemetics administered during this period?

4. Does relaxation music played in the immediate recovery period affect HR, BP, and RR? STUDY SIGNIFICANCE The use of nonpharmacological and noninvasive methods increasingly is considered a means of alleviating anxiety and pain. If a measure as simple as playing music could influence patients' experience of perioperative anxiety and postoperative discomfort, it would have implications for the daily treatment of patients undergoing surgery. If effective, it might decrease the use of medications implicated in prolonging the recovery period. Such all effect would be especially important for same-day surgery because an uneventful and comfortable recovery period could reduce time spent in the physician's office or ambulatory surgery center. METHODS The study was conducted in a 1,200-bed hospital in Lund, Sweden. The hospital's ethics committee approved the study, and written informed consent was obtained from 60 patients with an American Society of Anesthesiologists' (ASA) rating of one to two who were between 25 and 45 years of age and were scheduled to undergo gynecologic laparoscopy under general anesthesia. Exclusion criteria based on the preoperative anesthesia care provider's review and a short interview by one of the authors on the morning of surgery were * an ASA rating of greater than two, * any psychiatric disorders, * a history of alcohol or drug abuse, * neurological disease, * a first language other than Swedish, * chronic pain problems, * analgesic medication taken within the last week, * allergy to any of the planned perioperative medications, and * past complications during anesthesia or surgery. The sample consisted of 60 consecutive patients having either laparoscopic sterilization or laparoscopic tubal dyeing as part of an infertility program. The patients were assigned randomly to either M group, who listened to peaceful pan flute music or C group, who listened to a blank compact disc (CD) prepared specifically for the study. The CDs were unmarked, and the content was unknown to the nurse starting the CD player.

Investigators called the patients one or two days before surgery for information and for their consent to participate in the study. A written consent form was obtained on the day of surgery. The dependent variables measured were pain, nausea, well-being, vital signs, and total dose of analgesics and antiemetics administered during the recovery period. Pain was measured using a visual analogue scale (VAS) consisting of a blank line with endpoints of zero, indicating no pain, and 100, signifying the worst thinkable pain. Nausea was measured on a similar scale (ie, zero equals no nausea and 100 equals worst thinkable nausea). Well-being was measured on a VAS with endpoints of "calm" and "very anxious." The measuring device was a 10-cm, horizontal line with markings only at the ends (ie, "calm" and "very anxious"), and all measurements were taken by one of the researchers. The clinical use of VAS and verbal rating scales has been supported extensively in the literature. (5-17) The reliability estimate for the use of the VAS in this study was not calculated and, therefore, could not be reported. Before and after listening to the CD through headphones for 30 minutes preoperatively and postoperatively, patients were asked to complete a VAS for pain, one for nausea, and one for well-being. Preoperatively, patients marked the scales before any medication was given. All were told about the randomization, that they might or might not be listening to music during the headphone session, and that the investigators were to remain blinded as to which CD was used. Before surgery, patients were cared for lying in bed in a separated area (ie, behind curtains) of the recovery room. Patients were given headphones, and a CD (ie, M or C) was played for 30 minutes as the patient remained undisturbed. Before and after the session, HR, noninvasive BP, mid RR were measured by an attending nurse who was unaware of the CD's content. All patients were given 1 mg of midazolam IV and taken to the OR within 20 minutes. Anesthesia was standardized for all patients. The anesthesia was started with preoxygenation (ie, 2:1 oxygen:room air), droperidol 0.5 mg, according to the routine of the department, propofol 2 mg/kg to 3 mg/kg, fentanyl 2 mcg/kg, and rocuronium bromide 0.6 mg/kg. Anesthesia was maintained with nitrous oxide/oxygen (ie, 67%/33%) and an end-tidal sevoflurane concentration of 1.4%. All patients were given 1 g of acetaminophen rectally before surgery. Every five minutes, BP, HR, and end-tidal sevoflurane concentration were recorded. Fentanyl was supplied with 1 mcg/kg whenever HR increased by more than 20% of the initial value. At the end of surgery, the neuromuscular blockade was reversed in all patients with atropine and neostigmine IV (ie, 0.5 mg and 2.5 mg, respectively). All patients had an IV drip running with 1,000 mL of dextrose 2.5% in 0.9% sodium chloride throughout the perioperative period. In the recovery room, patients once again were given headphones, and the CD was restarted 15 minutes after arrival. Patients were allowed IV ketobemidone 2.5 mg for pain if their VAS score was greater than three or at the recovery room nurses' discretion. An antiemetic (ie, first choice-0.5 mg droperidol, second choice--tropisetron 2 mg IV) was given, according to the routine of the department, whenever patients complained of nausea. Before discharge on the same day, patients filled in the final VAS regarding postoperative well-being and also were asked about their overall attitude toward the use of music during hospitalization. STATISTICS

Before the study, a power analysis was performed with respect to VAS pain. From the literature, a standard deviation (SD) of 20 mm was expected, and the analysis was carried out with respect to detecting a difference of at least 20 mm for this parameter. The value for [alpha] was chosen at 0.05. With a power of 80%, a sample size for each group of at least 21 patients was calculated as being appropriate. Student's two-tailed t test was used for the intragroup (ie, paired) and intergroup (ie, unpaired) analysis. RESULTS There were no differences between the two groups (ie, M and C) regarding demographic data (Table 1). Five patients--three from M group and two from C group--were excluded from the calculations because of extended surgery or various technical problems on the ward. Anesthesia and surgery were considered uncomplicated in both groups. There were only minor intraoperative differences in analgesic administration between the two groups. Table 2 shows absolute values for vital signs and for pain, well-being, and postoperative opioid consumption. Preoperatively, patients in the M group showed a highly significant (P < .01, t = 4.5) reduction in RR after the session compared to patients in the C group (P < .09, t = 1.8). There was a significant difference between the groups (P = .02, t = 2.3). Postoperatively, patients in neither group showed any significant changes in RR. Heart rate was not significantly affected preoperatively, although a decrease (P = .05, t = 2) was observed in the control group. Postoperatively, patients in both groups showed highly significant postsession decreases, but there was no significant difference between patients in the two groups (P = .6, t = -0.6) for this parameter. Blood pressure tended toward overall lower values after the sessions both preoperatively and postoperatively. The decrease was significant preoperatively among patients in the C group (P = .05, t = 2.1) (M group P = .07, t = 1.9) and postoperatively among patients in the M group (P = .04, t = 2.2) (C group P = .06, t = 2), but there were no significant differences between patients in either group preoperatively or postoperatively. Pain scores were significantly lower for patients in both groups after the session, but there was no significant difference between the groups. Postoperative cumulative opioid consumption was, however, significantly lower among patients in the M group (P = .04, t = -2.2). Preoperatively, well-being was significantly higher among patients in both groups after the session but showed no intergroup difference. Postoperatively, patients in the music group tended toward an improved well-being (P = .07, t = 1.9) as opposed to no detectable change among patients in the control group (P = .7, t = 6.4). There was no difference between the groups preoperatively or postoperatively. Postoperative nausea was observed in only four patients in M group and in three patients in the C group. Thus, no statistical evaluation of the effect of music was attempted. DISCUSSION

In this study, the researchers were able to demonstrate a statistically significant effect of pre- and postoperative music therapy. Based on the results, the intervention lowers RR preoperatively and decreases postoperative opioid consumption. It appears from the data, however, that the mere interposing of a period of peaceful, undisturbed rest immediately before surgery alone has a positive effect on patients' feelings of well-being and is appreciated by the majority of patients. Such a period of rest also has a positive influence on postoperative pain and vital signs (ie, decreases in BP and RR), but based on study data, this effect is unrelated to whether the patient actually listens to music. This is the only study that has been undertaken using headphones in both groups and playing a blank CD for the control group, ensuring comparable isolation. This is of major importance in avoiding any confounding factors in the environment and to achieve the same circumstances in both groups. A study comparing a group with headphones to a group with no headphones or to a group with headphones but no CDs is, in the researchers' opinion, not as valid as the present design. Circumstances were fully comparable because patients in both groups had an intervention and differed only with respect to that intervention being music or no music. It could be argued that patients were not blinded to the variable of interest (ie, music) because they were told that they would either listen to music or to no music. The researchers concluded that if patients were told that they would be listening to a CD, the group for whom no music played might think that something was wrong and the confusion this might cause could interfere with the study. It is possible, however, that simply the intervention of being given a CD to listen to could account for the study results because the study did not include a third group of patients who had no intervention. Overall, patients (ie, 74%) enjoyed the kind of music (ie, peaceful pan flutes) that was played. There were no negative comments. The data, however, point to the effects of a calm preoperative resting period, with or without music. Most studies in the literature have not been carried out according to standard principles for randomization or controlled circumstances, and statistical methods have been poorly documented (6,9) Thus, advocates of music therapy have referred to an empirical database for the positive effects of this intervention, and statements such as "appeared to affect" or "can be safely used" dominate the literature. (14,18,19) Although patients' perception of pain has been shown to be affected in several studies, the few randomized, controlled studies using standardized measuring scales have been able to show only minor but statistically significant analgesic effects of music. (8,10,11,13,14,20) Several authors have claimed improved patient satisfaction and alleviation of anxiety in the perioperative and intensive care settings, whereas others have not been able to detect any such effect. (2,4,8,21) The findings of these recent studies are in full agreement with the results of this study. The postoperative pain scores were relatively low for patients in both groups, and because rescue medication was allowed, any effect of music would be difficult to detect in this setting. Trying to verify a possible minor postoperative analgesia sparing effect of music therapy would require that music be administered before any rescue analgesic and in a far larger group of patients. For ethical reasons, the researchers did not attempt such a study. There was, however, statistically

significantly more rescue analgesia administered to patients in the control group, implying an opiate-sparing effect of postoperative relaxation music. Only a few patients experienced postoperative nausea, so any statistical evaluation would be meaningless. The low scores may be ascribed to the department's routine use of droperidol. The effect of music or quiet rest on vital signs as shown in this study is quite subtle and may be more of academic interest. There are several ways in which music is assumed to modulate physiological responses. It may act as a nonverbal stimulus that can affect the auditory cortex and further be related to deeper structures affecting emotional pathways as well as the autonomic nervous system. Music has been shown to affect the nondominant side of the brain and give rise to the release of endorphins. (12,22-24) This study points to an anxiety-reducing effect of a period of peaceful rest both before and after surgery. One recent paper advocates establishing a "department of sound" to reduce environmental noise pollution in a hospital setting. (25) The results of this study support a quiet perioperative environment; however, such a setting is most unusual in contemporary hospitals. The addition of music therapy in the perioperative period thus stands out more as a complementary measure for improved patient comfort and satisfaction, although an opioidsparing effect seems to be attainable with the use of postoperative music therapy.
TABLE 1 Patient Group Characteristics Music group * (n = 29) 34 63 26 53 (25-45) (52-96) (12-61) (37-85) Control group * (n = 26) 34 64 25 52 (22-42) (43-100) (10-56) (30-80)

Variable Age (years) Weight (kg) Surgery (minutes) Anesthesia (minutes)

* Expressed as median and range. TABLE 2 Preoperative and Postoperative Effects of Music Variable Preoperative Before compact disc (CD) ----After CD -----

Group * Music Pain No music Music Opioid No music

Music

24 [

or -] 20.7

13.8 [ or -] 15.6 ** (P = .0001; t = 4.8) 26.6 [ or -] 26.8 ** (P = .015; t = 2.6) 14 [ or -] 2 ** (P = .0001; t = 4.5) 15 [ or -] 2 (#) (P = .023; t = 2.3) 114 [ 112 [ 69 [ 68 [ or -] 9 or -] 8 or -] 8 or -] 8

Well-being No music 32.2 [ or -] 27.4

Music Respiratory rate (breaths per min)

16 [

or -] 1

No music

15 [

or -] 2

Blood pressure (mm Hg) Heart rate (beats per min) Variable

Music No music Music No music

117 [ 115 [ 71 [ 71 [

or -] 10 or -] 9 or -] 7 or -] 7

Postoperative Before CD 31.7 [ or -] 20.2 After CD 19.9 [ or -] 13.9 ** (P = .005, t = 3.1) 24.7 [ or -] 18.1 ** (P = .037, t = 2.2) 2.2 [ or -] 2.9

Group * Music

Pain No music 34 [ or -] 22.9

Music Opioid No music

---

4.3 [ or -] 2.4 (#) (P = .04, t = 2.2) 22.5 [ 18.9 [ 12 [ or -] 15.2 or -] 21.9 or -] 2

Music Well-being No music Respiratory rate breaths) per min) Music

18.1 [ 20.4 [

or -] 10.2 or -] 23.4

14 [

or -] 2

No music Music

15 [ 111 [

or -] 2 or -] 8

14 [

or -] 2

Blood pressure (mm Hg) No music 111 [ or -] 9

108 [ or -] 8 ** (P = .04, t = 2.2) 108 [ or -] 8

Music Heart rate (beats per min)

64 [

or -] 8

60 [ or -] 7 ** (P = .018, t = 2.5) 60 [ or -] 7 ** (P = .007, t = 2.9)

No music

65 [

or -] 9

Pain, nausea, and well-being were measured on a visual analogue scale (ie, 0 mm to 100 mm) before and after laparoscopic gynecologic surgery. Figures are given as men [ or -] standard deviation. * Music group (M), n = 29; no music group (C), n = 26. ** Significant difference within the group. (#) Significant intergroup difference.

Editor's note: The authors wish to thank the nursing staff members of the gynecological wards, surgical theater, and postanesthesia care unit at University Hospital in Lund for their enthusiasm and help in carrying out this study and Professor D. Lundberg for his helpful discussions. NOTES (1.) D Tusek, J M Church, V W Fazio, "Guided imagery as a coping strategy for perioperative patient," AORN Journal 66 (October 1997) 644-649. (2.) E Mok, K Y Wong, "Effects of music on patient anxiety," AORN Journal 77 (February 2003) 396-410. (3.) C K Szeto, P M Yung, "Introducing a music programme to reduce preoperative anxiety," The British Journal of Theatre Nursing 9 (October 1999) 455-459. (4.) P M Yung et al, "A controlled trial of music and pre-operative anxiety in Chinese men undergoing transurethral resection of the prostate," Journal of Advanced Nursing 39 (August 2002) 352-359. (5.) R M Heiser et al, "The use of music during the immediate postoperative recovery period," AORN Journal 65 (April 1997) 777-785. (6.) D Evans, "The effectiveness of music as an intervention for hospital patients: A systematic review," (Review) Journal of Advanced Nursing 37 (January 2002) 8-18. (7.) M E Koch et al, "The sedative and analgesic sparing effect of music," Anesthesiology (August 1998) 300-306. (8.) U Nilsson et al, "Analgesia following music and therapeutic suggestions in the PACU in ambulatory surgery: A randomized controlled trial," Acta Anaesthesiologica Scandinavica 47 (March 2003) 278-283.

(9.) M Good, "Effects of relaxation and music on postoperative pain: A review," Journal of Advanced Nursing 24 (November 1996) 905-914. (10.) U Nilsson et al, "Improved recovery after music and therapeutic suggestions during general anaesthesia: A double-blind randomised controlled trial," Acta Anaesthesiologica Scandinavica 45 (August 2001) 812-817. (11.) L K Taylor et al, "The effect of music in the postanaesthesia care unit on pain levels in women who have had abdominal hysterectomies," Journal of Perianesthesia Nursing 13 (April 1998) 88-94. (12.) R McCraty et al, "The effects of different types of music on mood, tension, and mental clarity," Alternative Therapies in Health and Medicine 4 (January 1998) 75-84. (13.) M Good et al, "Relaxation and music reduce pain after gynecological surgery," Pain Management Nursing 3 (June 2002) 61-70. (14.) M Good et al, "Relaxation and music to reduce postsurgical pain," Journal of Advanced Nursing 33 (January 2001) 208-215. (15.) R McCaffrey, R C Locsin, "Music listening as a nursing intervention: A symphony of practice," Holistic Nursing Practice 16 (April 2002) 70-77. (16.) D W Wilmore, H Kehlet, "Management of patients in fast track surgery," British Medical Journal 322 (Feb 24, 2001) 473-476. (17.) P Schofield, "Using assessment tools to help patients in pain," Professional Nurse 10 (August 1995) 703-706. (18.) J M White, "State of the science of music interventions. Critical care and perioperative practice," Critical Care Nursing Clinics of North America 12 (June 2000) 219-225. (19.) M E Cadigan et al, "The effects of music on cardiac patients on bed rest," Progress in Cardiovascular Nursing 16 (Winter 2001) 5-13. (20.) M Good et al, "Relief of postoperative pain with jaw relaxation music and their combination," Pain 81 (May 1999) 163-172. (21.) L L Henry, Music therapy. A nursing intervention for the control of pain and anxiety in the ICU: A review of the research literature," Dimensions of Critical Care Nursing: DCCN 14 (November/December 1995) 295-304. (22.) P A Updike, D M Charles, "Music Rx: Physiological and emotional responses to taped music programs of preoperative patients awaiting plastic surgery," Annals of Plastic Surgery 19 (July 1987) 29-33.

(23.) P Orn, "Biomusikvetenskap--lanken mellan musik och biologi," Lakartidningen 97 (2000) 3400-3403. (24.) D G Campell, The Mozart Effect: Tapping the Power of Music to Heal the Body, Strengthen the Mind and Unlock the Creative Spirit (New York: Avon Books Inc, 1997). (25.) I N Cabrera, M H Lee, Reducing noise pollution in the hospital setting by establishing a department of sound: A survey of recent research on the effects of noise and music in health care: A review," Preventive Medicine 30 (April 2000) 339-345. Eleni Ikonomidou, RN, is a staff nurse in the anesthesia department at University Hospital, Lund, Sweden. Amette Rehnstrom, RN, is a staff nurse in the anesthesia department at University Hospital, Lund, Sweden. Ole Naesh, MD, PhD, is a consultant, anesthesiologist, and associate professor at University Hospital, Lund, Sweden. COPYRIGHT 2004 Association of Operating Room Nurses, Inc. COPYRIGHT 2004 Gale Group Eleni Ikonomidou "Effect of music on vital signs and postoperative pain". AORN Journal. FindArticles.com. 24 Nov, 2010. http://findarticles.com/p/articles/mi_m0FSL/is_2_80/ai_n6159718/ COPYRIGHT 2004 Association of Operating Room Nurses, Inc. COPYRIGHT 2004 Gale Group