Music as analgesia in the perioperative setting
Dr Elliot Anderson
Thursday, September 22nd, 2016
Pain is a complex and predictable component of the perioperative experience. Music, as a non-pharmacological pain management modality, is cheap and easy to implement as an analgesic adjunct to reduce patient pain, stress, and anxiety. It has particular benefit in healthcare settings where first-line pharmaceutical pain management options are less available. This review finds an increasing body of evidence supports the use of music to reduce pain in the perioperative setting. Certain musical elements such as a constant tempo, gentle timbre, and smooth melody combined with patient musical preference have been shown to have the greatest analgesic effect. The mechanism by which music alleviates pain is not clearly defined, but may involve distraction, or regulation of the autonomic nervous system. The perioperative utilisation of music in the perioperative remains low. Standardised guidelines are required to instruct and assist with its application. Music therapy has demonstrated benefit with minimal side effects and should be used liberally in the management of perioperative pain.
Late last year, I exited a jumbo jet and took my first steps in the Kingdom of Tonga. This marked the start of a three-week adventure that I now count as one of the best experiences of my medical degree. As part of a four-member medical volunteer delegation, I travelled to the picturesque island of Vava’u, in Tonga’s far north. There, my time was divided between undertaking free community health checks and working with the doctors and staff of the Prince Wellington Ngu Hospital. The hospital was an old sprawling collection of buildings on top of a hillside overlooking the local village. The hospital was operating at capacity and despite the resourcefulness and efficiency of the staff, the hospital suffered from a marked lack of resources. It was under these circumstances, in a sparse medical ward that I first met 63- year-old, Mrs Place (pseudonym to protect patient confidentiality).
Mrs Place had presented to the hospital three weeks prior with a large, infected foot ulcer. The ulcer had first developed after she had innocuously cut her left foot four months earlier. The severity of the wound was compounded by her poorly controlled diabetes and peripheral vascular disease. After the failure of appropriate conservative and medical management, a below-knee amputation of her left leg was conducted. When I saw Mrs Place two days after her operation, she was grimacing and moaning in pain. She reported her pain score to be 9/10 despite receiving a routine regimen of paracetamol and codeine. Her treating doctor explained that stronger opioid medication would help Mrs Place but was unavailable due to resource limitations. Instead, a novel form of pain management was used in these situations. To my amazement the nurses, doctors, and other patients began to sing local church hymns, in a contained, harmonious, and pleasant manner. No one seemed surprised and everyone was familiar with the songs. The singing continued over the course of the morning, and while doctors and nurses moved on with their daily activities and the hospital continued to operate, a constant melody echoed out of Mrs Place’s ward. Sometimes the music was loud, propagated by family members, and other times it was soft, with a lone voice maintaining the euphony. Three hours later, Mrs Place was visibly more comfortable. She described her pain score to be 6/10 and credited the lessening of her suffering to the singing for which she was very grateful. While it is unclear to what extent the patient’s pain improved directly as a result of the music, the apparent effectiveness of music as a pain management modality created an information gap in my medical knowledge that I was determined to explore. A literature review was performed using the electronic databases, Pubmed, Embase, and Medline. The search terms used were “music therapy”, “pain”, “postoperative”, “pain measurement” from 2000 until present.
Pain has been described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage . It is a complex problem that is compounded by its subjective nature and the wide spectrum of pain tolerance that exists within the community. The majority of people, at some stage of their life, will undergo a surgical procedure and although pain is a predictable component of the postoperative experience, pain management is often insufficient. The resultant clinical and psychological harm may affect patient morbidity . Negative clinical outcomes associated with inadequate postoperative pain management include deep vein thrombosis, pulmonary embolism, coronary ischaemia, myocardial infarction, pneumonia, poor wound healing, and insomnia . Effective pain management contributes to avoiding the human and economic costs of these sequelae. Pharmacological agents form the current standard of care for the management of postoperative pain . These medications are best applied according to the World Health Organization’s “pain ladder” that advocates for the controlled escalation of pain relief medication . Music, as a non-pharmacological pain management modality, is not widely utilised in the current healthcare environment, whether this relates to a paucity of information within the medical fraternity or an inherent scepticism towards complimentary analgesic methods is uncertain . However, the paradigm is now changing due to a landmark systematic review and meta-analysis conducted by Hole et al. After synthesising the results of 73 randomised control trials, they concluded that music played in the perioperative setting can reduce postoperative pain, anxiety, analgesia requirements, and increase patient satisfaction . This pivotal study adds to an existing body of research that confirms music to be a beneficial compliment to pharmacotherapy in managing perioperative pain [4,8,9].
The first use of music as a therapeutic intervention was recorded in the cuneiform writings of the early Mesopotamia, circa 4000 BC . Since then the use of music in the clinical setting has been commonly employed throughout history. Notably, Florence Nightingale was a strong advocate for its use during the Crimean War, specifically citing the effectiveness of singing and flute melodies to alleviate pain . Today, music may be used in the healthcare setting to reduce emotional distress and the patient’s perception of pain . Given the wide spectrum of music genres and the singular nature of personal preference, determining the most effective music for alleviating pain and anxiety requires careful consideration. It is suggested that there are definitive musical elements that promote analgesia; these include a consistent tempo, gentle timbre, smooth melody, and a limited percussion component [13,14]. In addition Mitchel et al. concluded that music self-selected by the individual provides greater pain control . This improved analgesic experience was postulated to stem from a greater emotional valence with music. For the greatest effect, music used to relieve pain in the perioperative setting should include the known and accepted musical components combined with patient preference .
The mechanism by which music alleviates pain is not clearly defined. Modern theories of pain are based on the gate control theory  and the subsequent neuromatrix theory . Music is thought to be able to act as a distraction and dampen the patient’s experience of pain. Physiologically, pain impulses travel from the site of injury to the brain via the spinal cord. Within the spinal cord there are neural gates that can be opened or closed to different degrees that allows for the regulation of pain impulses communicated to the brain. When these gates become obstructed, the patient’s perception of pain may be reduced. The use of music therapy may block these pain gates by causing descending signals to be sent from the brain down the efferent pathways in the spinal cord [19,20]. This means that fewer ascending pain impulses will reach the patient’s awareness. Using magnetic resonance imaging, Valet et al. showed that distraction caused an increase in the activation of the cingulofrontal cortex, the periaqueductal gray, and the posterior thalamus. Through this neural network, distraction may exert a top-down influence in order to reduce the unpleasantness or intensity of a person’s pain .
Music may also help reduce pain by acting on the autonomic nervous system activity within the body. Emotional distress adversely affects how an individual experiences pain; anxiety in particular has been identified as a risk factor for developing the chronic sequela of pain [22,23]. Anxiety occurs commonly in patients who are undergoing medical procedures and may decrease a patient’s pain threshold and tolerance causing them to experience more pain . When a person is anxious, their pituitary-adrenal axis and sympathetic nervous system are stimulated, resulting in the release of hormones that are responsible for the patient’s experience of anxiety . The physical expression of anxiety includes increases in heart rate, respiratory rate, and blood pressure . Ozer et al. conducted a case control study that was designed to investigate the impact of music therapy on a number of postoperative physiologic parameters and the patient’s perception of pain. They found that patients who received music therapy had a statistically significant increase in oxygen saturation and a decrease in their reported pain score . In this study, the patient’s oxygen saturation was used as a surrogate marker for their relaxation level and the effectiveness of music therapy as an anxiolytic. Other physiological parameters such as blood pressure, heart rate, and respiratory rate were not shown to have any significant association with music therapy, which corroborates the findings of other studies [27-29].
The role for music in the operating room is less certain. A small percentage of patients undergoing general anaesthetic retain unwanted intraoperative awareness throughout their procedure, which increases their likelihood developing post-traumatic stress disorder . The use of music intraoperatively may benefit these patients by providing distraction. What effect music has on the medical professionals treating the patient is unclear. Allen et al. found that surgeon selected music reduced autonomic reactivity and improved surgical performance, however all of the study participants were biased towards the beneficial effect of music . A more recent literature review suggests that music in the operating theatre is harmful, interrupting communication, hindering work, and risking patient safety . Individual surgical teams can therefore guide the use of intraoperative music, with the option of personal electronic music players on a patient-by-patient basis.
The effectiveness of music therapy in reducing a patient’s pain has been well demonstrated. However, due to the wide range and varying complexity of pain assessment tools that have been employed, the level of analgesic impact is difficult to quantify. A rudimentary assessment has shown that music therapy may improve a patient’s pain by 10% to 40% [9,12,27,33-35]. However, despite the apparent benefit, clinical interest in the use of music remains in its infancy. As such, there are no guidelines available to instruct and assist with its application. This lack of standardisation may damage the future endorsement of this modality due to the potential for uneven application, poor compliance, and unrealistic expectations regarding outcomes. While there are no evident physical side effects from music therapy, exposure to unappealing music may irritate patients, impacting on their mental health and overall wellbeing. Legal issues involving copyright and intellectual property need to also be considered. Further research is required to clearly demarcate the biological pathways that mediate the beneficial effects of music. Without a proper understanding of the physiological basis for the observed positive effect, the most appropriate application cannot be determined and completely explored. For example, does the proposed benefit extend to all forms of audio-visual stimulus or is there something unique about music? Active distraction through the use of electronic gaming has been shown to increase a patient’s pain tolerance as well as the amount of pain that they reported. Interestingly, this form of active distraction was shown to be superior to passive distraction (watching television), suggesting that other passive distractions, such as listening to music, might be less effective . Future research should evaluate the effects of tailored music that is designed for this specific setting or for individual patients or patient groups. For example, a three-pronged comparative study could be conducted in Tonga to explore the effectiveness of spiritual music given its strong cultural background, in addition to the broader questions regarding efficacy, protocol, and utility. Likewise, the differences in the effect of music interventions related to patients’ gender, age, and ethnicity should be further evaluated.
Music therapy should not be seen as a primary treatment option for the management of postoperative pain. In most clinical situations it will not completely alleviate the patient’s pain and should instead be used to facilitate patient functionality, improve quality of life, and reduce consumption of pharmacological analgesics. With no known side effects, wide applicability and the ability to be utilised in conjunction with other pain management therapies, the potential for music therapy is significant. In settings where first-line pain management options are not available, the benefits of this non-pharmacological management are magnified. Music therapy has demonstrated benefit and should be used liberally in the management of postoperative pain.
Conflicts of interest
 IASP. Part III: Pain Terms, A current list with definitions and notes on usage (pp 209-214). Secondary Part III: Pain Terms, A current list with definitions and notes on usage (pp 209-214) 1994. Available from: http://www.iasp-pain.org.
 Tse M, Chan MF, Benzie I. The effect of music therapy on postoperative pain, heart rate, systolic blood pressure and analgesic use following nasal surgery. J Pain Palliat Care Pharmacother. 2005;19(3):21-9.
 Apfelbaum JL, Chen C, Mehta SS, Gan aTJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth. Analg. 2003;97(2):534-40.
 Ozer N, Karaman Ozlu Z, Arslan S, Gunes N. Effect of music on postoperative pain and physiologic parameters of patients after open heart surgery. Pain Manag Nurs. 2013;14(1):20-8.
 World Health Organization. WHO’s Pain Relief Ladder. 2009. Available from: http://www.who.int/cancer/palliative/painladder/en/.
 Hupkens S. Implementation of complementary interventions in the Netherlands: experiences of pioneers. Patient Educ Couns. 2012;89(3):411-6.
 Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. The Lancet. 2015;386(10004):1659-71.
 Roy M, Peretz I, Rainville P. Emotional valence contributes to music-induced analgesia. Pain. 2008;134(1-2):140-7.
 Bernatzky G, Presch M, Anderson M, Panksepp J. Emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neurosci Biobehav Rev. 2011;35(9):1989-99.
 Conrad C, Niess H, Jauch K-W, Bruns CJ, Hartl WH, Welker L. Overture for growth hormone: Requiem for interleukin-6?*. Crit. Care Med. 2007;35(12):2709-13.
 Nightingale F. Notes on nursing: what it is, and what it is not. London: Harrison; 1859.
 Zengin S, Kabul S, Al B, Sarcan E, Dogan M, Yildirim C. Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complement Ther Med. 2013;21(6):689-96.
 Gooding L, Swezey S, Zwischenberger JB. Using music interventions in perioperative care. South Med J. 2012;105(9):486-90.
 Nilsson U. The anxiety- and pain-reducing effects of music interventions: a systematic review. AORN J. 2008;87(4):780-807.
 Mitchell LA, MacDonald RA, Brodie EE. A comparison of the effects of preferred music, arithmetic and humour on cold pressor pain. Eur J Pain. 2006;10(4):343-51.
 Zhang ZS, Wang XL, Xu CL, Zhang C, Cao Z, Xu WD, et al. Music reduces panic: an initial study of listening to preferred music improves male patient discomfort and anxiety during flexible cystoscopy. J Endourol. 2014;28(6):739-44.
 Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971-9.
 Melzack R. From the gate to the neuromatrix. Pain. 1999;Suppl 6:S121-6.
 Roy M, Lebuis A, Hugueville L, Peretz I, Rainville P. Spinal modulation of nociception by music. Eur J Pain. 2012;16(6):870-7.
 Li XM, Yan H, Zhou KN, Dang SN, Wang DL, Zhang YP. Effects of music therapy on pain among female breast cancer patients after radical mastectomy: results from a randomized controlled trial. Breast Cancer Res Treat. 2011;128(2):411-9.
 Valet M, Sprenger T, Boecker H, Willoch F, Rummeny E, Conrad B, et al. Distraction modulates connectivity of the cingulo-frontal cortex and the midbrain during pain–an fMRI analysis. Pain. 2004;109(3):399-408.
 Raichle KA, Osborne TL, Jensen MP, Ehde DM, Smith DG, Robinson LR. Preoperative state anxiety, acute postoperative pain, and analgesic use in persons undergoing lower limb amputation. Clin J Pain. 2015;31(8):699-706.
 Theunissen M, Peters ML, Bruce J, Gramke HF, Marcus MA. Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain. Clin J Pain. 2012;28(9):819-41.
 Tan X, Yowler CJ, Super DM, Fratianne RB. The efficacy of music therapy protocols for decreasing pain, anxiety, and muscle tension levels during burn dressing changes: a prospective randomized crossover trial. J Burn Care Res. 2010;31(4):590-7.
 Pittman S, Kridli S. Music intervention and preoperative anxiety: an integrative review. Int Nurs Rev. 2011;58(2):157-63.
 Nilsson U, Unosson M, Rawal N. Stress reduction and analgesia in patients exposed to calming music postoperatively: a randomized controlled trial. Eur J Anaesthesiol. 2005;22(2):96-102.
 Nilsson U. Soothing music can increase oxytocin levels during bed rest after open-heart surgery: a randomised control trial. J Clin Nurs. 2009;18(15):2153-61.
 Kshettry VR, Carole LF, Henly SJ, Sendelbach S, Kummer B. Complementary alternative medical therapies for heart surgery patients: feasibility, safety, and impact. Ann Thorac Surg. 2006;81(1):201-5.
 Sendelbach SE, Halm MA, Doran KA, Miller EH, Gaillard P. Effects of music therapy on physiological and psychological outcomes for patients undergoing cardiac surgery. J Cardiovasc Nurs. 2006;21(3):194-200.
 Leslie K, Chan MT, Myles PS, Forbes A, McCulloch TJ. Posttraumatic stress disorder in aware patients from the B-aware trial. Anesth Analg. 2010;110(3):823-8.
 Allen K, Blascovich J. Effects of music on cardiovascular reactivity among surgeons. JAMA. 1994;272(11):882-4.
 Shambo L, Umadhay T, Pedoto A. Music in the operating room: is it a safety hazard? AANA J. 2015;83(1):43-8.
 Simcock XC, Yoon RS, Chalmers P, Geller JA, Kiernan HA, Macaulay W. Intraoperative music reduces perceived pain after total knee arthroplasty: a blinded, prospective, randomized, placebo-controlled clinical trial. J Knee Surg. 2008;21(4):275-8.
 Pothoulaki M, Macdonald RA, Flowers P, Stamataki E, Filiopoulos V, Stamatiadis D, et al. An investigation of the effects of music on anxiety and pain perception in patients undergoing haemodialysis treatment. J Health Psychol. 2008;13(7):912-20.
 Salimpoor VN, Benovoy M, Larcher K, Dagher A, Zatorre RJ. Anatomically distinct dopamine release during anticipation and experience of peak emotion to music. Nat Neurosci. 2011;14(2):257-62.
 Jameson E, Trevena J, Swain N. Electronic gaming as pain distraction. Pain Res Manag. 2011;16(1):27-32.