Music Therapy for the Relief of Postoperative Pain
September 1999; Volume 2: 89-91
By David Schiedermayer, MD, FACP
In the movie The Doctor, William Hurt’s character insists on listening to lyrics about getting drunk and having sex while he and his colleague sing along, joke, and perform heart surgery. After he develops laryngeal carcinoma, and has an epiphany about how difficult it really is to be a patient, he changes his tune. When he is finally able to return to work, he performs a heart transplant on a Hispanic patient. But instead of the raucous lyrics he used to insist on, he wants to play the patient’s favorite music, in Spanish, because the patient may hear it.1 The doctor has finally learned that the patient is the one with the illness.
The movement to find evidence-based scientific value in music therapy perhaps misses this point. Music is intrinsically valuable to patients if they find meaning or beauty in it. But given the current impetus to demonstrate clinical benefit in justifying every intervention (even common sense ones) a literature has evolved on the benefits of specific kinds of music therapy. At the risk of romancing the obvious (or actually, of missing the romance completely), the following reviews some of the current findings.
History and Tradition
Music therapy can be defined as the "controlled use of music, its elements, and their influences on the human being to aid in the physiologic, psychologic, and emotional integration of the individual during the treatment of an illness or a disability."2
Although the history of music therapy using recorded music is less than a century old and the degree programs for Registered Music Therapists and Certified Music Therapists (RMT, CMT) are less than half a century old, the use of music to calm anxious or ill patients is an age-old technique. Ancient Egyptians believed that music bestowed fertility. David, long before he fought Goliath, was invited to the palace to soothe Saul’s psychological torment with music: "...David would take his harp and play. Then relief would come to Saul; he would feel better, and the evil spirit would leave him."3
In 1914, a physician described his use of a phonograph in the operating room, noting that music had the benefit of "calming and distracting patients from the horror of the situation when going under the anesthetic and during operations performed partially or entirely with local anesthesia."4
Maureen Cunningham, RN, and her colleagues at the Memorial Sloan Kettering Cancer Center have recorded the history and tradition of music therapy in an excellent review.5 They note that the National Association of Music Therapy, which was formed in 1950, became the forum for research and development of music therapy. Helen Bonny, PhD, and Deforia Lane, PhD, have provided leadership in music therapy, with respective relationships to guided imagery and immune system research in hospitalized children. Dr. Lane also views music from a spiritual perspective; she believes that music has transcendent powers to heal and to touch people at deep personal levels.6
Physiological Effects
Music’s effects are related to its various elements (tempo, pitch, harmony, melody, rhythm), listener characteristics (age, language, culture, education, musical preferences), and means of delivery (headphones, speakers, open air).7
Reduced heart rate and blood pressure have been noted when the music played is familiar and desirable to the patient, and when it is played directly into the ears through the use of headphones.8
The deleterious physiological effects of postoperative pain are well known: inanition, tissue breakdown, coagulopathy, fluid retention, poor appetite, and diminished sleep.9 Since narcotics are available to counter many of these effects, music therapists are not advocating replacing effective pain management. Studies have been performed to evaluate whether music may have a narcotic-sparing effect, working through a mechanism other than the opiate receptors. A number of mechanisms of action for music have been proposed, but as the following discussion of clinical studies demonstrates, it is not yet clear whether music alone can reverse the adverse physiologic effects of postoperative pain.
Mechanisms of Action
The actual mechanisms of action of music therapy are unknown, but a number of theoretical mechanisms are discussed in the literature.
The gate control theory explains that the results of music therapy may be due to distraction, the relaxation response, the reduction of anxiety, increased sense of control, or endorphin modulation.9 All of these are broadly included under the gate theory model, although in classic medical definition the gate theory of pain addresses only how nociception is transmitted and modulated. Distraction and relaxation seem to be common elements of most of the theories of mechanism of action, rather than any actual effect of music on endorphins or opiate receptors.
The more holistic nursing model suggests that the relief of pain is related to a coping intervention, resulting from cognitive behavioral preparation for pain relief, which decreases anxiety and pain.
A meta-analysis of 21 studies of music therapy in 15 journals revealed that eight studies were atheoretical, nine were based on gate control theory, three were based on endorphin activity, and one on active placebo action. The effectiveness of the intervention was unrelated to the theoretical basis for the study.9
Clinical Studies
Clinical studies that have examined music therapy’s effectiveness in pain relief have had mixed results. In the meta-analysis referenced above, effectiveness was found in six of 12 studies in which sensory pain was measured, 10 of 13 studies in which reported affective pain was measured, four of seven studies in which reported uni-dimensional pain was measured, all four studies in which observed pain was measured, and only five of the 15 studies in which opiate intake was measured. One of these studies revealed no difference in the 24-hour narcotic intake in abdominal surgery patients between relaxation, music, relaxation and music, and control groups.10
In a study of 59 patients undergoing a gastrointestinal endoscopic procedure, randomly assigned to either relaxation music or no music, there was no difference in the overall tolerance score. However, a significantly higher proportion of patients in the no-music group described the experience as being at least moderately unpleasant. Eighty-two percent in the music group stated they would have music again if they required sedation. The authors concluded that even in patients who are sedated, relaxation music can reduce the number who find the experience of endoscopy to be unpleasant.11
Increased patient satisfaction was also found in a study of music therapy after coronary artery bypass grafting. Subjects in the music group showed significant improvement in mood, even though no differences in anxiety ratings or any physiologic measures were found.12
Formulation
Music therapy can be improvisational, creative, composition-related, or receptive. This review has focused on receptive music therapy because of the interest in reducing postoperative pain. Other modes of therapy can involve creating music spontaneously or working on an existing song with a therapist.13
Clinical studies on the effectiveness of music have shown:
a. a difference in narcotic intake between control and study group.
b. reduction in observed pain.
c. an increase in perceived unpleasantness of GI procedures.
d. decreased patient satisfaction in the study group.
Dosage
When studying receptive music therapy, most researchers used music with a meter of 60-80 beats a minute. Preoperative staff check the function of the cassette/CD and adjust the volume to the patient’s preference. Examples of relaxation music used include Country Western Instrumental, Fresh Aire by Mannheim Steamroller, Winter Into Spring by George Winston, and Prelude or Comfort Zone, both by Steven Halpern. All of these recordings also manifest soothing harmonies and melodies, which facilitate relaxation.12
Cost
The capital costs of setting up a music therapy program include those incurred with the purchase of a stereo system and two good speakers, an adequate number (e.g., 20 for a start-up program) of individual CD players with headphones and rechargeable batteries, additional headphones and disposable headphone covers, a locked cabinet, battery recharge units, and labor costs. The Sloan-Kettering group found this equipment to have a total cost of $7,326 several years ago.3
Side Effects
Despite parental fears to the contrary, the main injury inflicted by rock or rap music is damage to the cochlear apparatus of the inner ear. For patients in a clinical setting this side effect should not be an issue. However, music in the clinical setting might possibly distract doctors, nurses, and others from their work. The hospital staff might be dancing to a groovy tune or induced into a tranquil state by the sounds of sea waves or waterfalls when immediate action is needed. All of these are theoretical concerns only, with no data whatsoever supporting them.
Conclusion
Studies on the effects of music therapy in the postoperative setting have revealed mixed results and effects more consistent with improved patient satisfaction than improved clinical outcomes. Nonetheless, the intervention is relatively inexpensive (less than $10,000 for a full practice or institutional setup) and is of low risk and low invasiveness. Given the known aesthetic benefits of music, music therapy is a promising adjunctive modality in a comprehensive postoperative pain and anxiety control program.
Recommendation
Because patients seem to like music, it should be strongly considered as part of a program to relieve postoperative pain.
Music’s effects are related to which of the following elements:
a. tempo.
b. pitch.
c. listener characteristics.
d. means of delivery.
e. All of the above.
References
1. La Puma J, et al. Talking to comatose patients. Arch Neurol 1988;45:20-22.
2. Munro S, Mount B. Music therapy in palliative care. Can Med Assoc J 1978;119:1029-1034.
3. 1 Samuel 16:23. The New International Bible. Grand Rapids, MI: Zondervan Publishing House; 1984.
4. Kane EO. Phonograph in the operating room. JAMA 1914;62;1929.
5. Cunningham MF, et al. Introducing a music program in the perioperative area. AORN J 1997;66:674-682.
6. Lane D, Wilkins W. Music as Medicine: Deforia Lane’s Life of Music, Healing, and Faith. Grand Rapids, MI: Zondervan Publishing House; 1994.
7. Bonny HL. The Role of Taped Music Programs in the Guided Imagery and Music Process: Theory and Product. Baltimore, MD: ICM Books; 1980.
8. Standley JM. Music research in medical/dental treatment: Meta-analysis and clinical applications. J Music Ther 1986;23:56-122.
9. Good M. Effects of relaxation and music on postoperative pain: A review. J Adv Nurs 1996;24:905-914.
10. Good M. A comparison of the effects of jaw relaxation and music on postoperative pain. Nurs Res 1995;44: 52-57.
11. Bampton P, Draper B. Effect of relaxation music on patient tolerance of gastrointestinal endoscopic procedure. J Clin Gastroenterol 1997;25:343-345.
12. Barnason S, et al. The effects of music interventions on anxiety in the patient after coronary bypass grafting. Heart Lung 1995;24:124-132.
13. American Health Consultants. Not all sounds the same. Patient Edu Manage 1999;6:63.
September 1999; Volume 2: 89-91
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