Original Article The Effect of Music on Postoperative Pain and Anxiety

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Kelly D. Allred, PhD, RN, CCRN, Jacqueline F. Byers, PhD, RN, FAAN, and Mary Lou Sole, PhD, RN, FAAN

ABSTRACT:

From the University of Central Florida, Orlando, Florida. Address correspondence to Kelly Allred, PhD, RN, CCRN, P.O. Box 162210, Orlando, FL 32816-2210. E-mail: kallred@mail.ucf.edu Received July 6, 2008; Revised December 26, 2008; Accepted December 29, 2008.

The purpose of this study was to determine if listening to music or having a quiet rest period just before and just after the rst ambulation on postoperative day 1 can reduce pain and/or anxiety or affect mean arterial pressure, heart rate, respiratory rate, and/or oxygen saturation in patients who underwent a total knee arthroplasty. Fifty-six patients having a total knee arthroplasty were randomly assigned to either a music intervention group or a quiet rest group. A visual analog scale was used to measure pain and anxiety. Physiologic measures, including blood pressure, heart rate, oxygen saturation, and respiratory rate, were also obtained. Statistical ndings between groups indicated that the music groups decrease in pain and anxiety was not signicantly different from the comparison rest groups decrease in pain (F 1.120; p .337) or anxiety (F 1.566; p .206) at any measurement point. However, statistical ndings within groups indicated that the sample had a statistically signicant decrease in pain (F 6.699; p .001) and anxiety (F 4.08; p .013) over time. Results of this research provide evidence to support the use of music and/or a quiet rest period to decrease pain and anxiety. The interventions pose no risks and have the benets of improved pain reports and decreased anxiety. It potentially could be opioid sparing in some individuals, limiting the negative effects from opioids. Nurses can offer music as an intervention to decrease pain and anxiety in this patient population with condence, knowing there is evidence to support its efcacy. 2010 by the American Society for Pain Management Nursing Moderate to severe postoperative pain is experienced by over 80% of patients having surgery (Acute Pain Management Guideline Panel, 1992). If postoperative pain is inadequately treated it can lead to trouble with rest and sleep, delayed wound healing, patient dissatisfaction, longer hospitalization, and increased costs (Shang & Gan, 2003). It is in the best interest of health care providers to ensure adequate pain relief for the postoperative patient population. Total joint arthroplasty of the knee is a known painful surgical procedure. A primary nursing intervention after knee surgery is pain management (McCaffrey & Locsin, 2006). In addition to the deleterious effects noted of inadequately treating pain in the postoperative patient, delayed rehabilitation is another effect of
Pain Management Nursing, Vol 11, No 1 (March), 2010: pp 15-25

1524-9042/$36.00 2010 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2008.12.002

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undertreating pain that can have a particularly negative effect on the orthopedic surgical patient. Underestimating pain is a tendency that nurses have when treating adult surgical patients, resulting in inadequate pain management (Mac Lellan, 2004). Research done by Sloman, Rosen, Rom, and Shir (2005) found that nurses signicantly underestimated pain in a sample of 95 adult surgical patients and suggested that education for nurses regarding pain assessment is needed. Nurses tend to shy away from potent opioids owing to the fear of negative side effects that these drugs can sometimes have, such as respiratory depression, and some nurses fear patients will become addicted to opioids and limit the amounts given to patients in pain (Ersek, 1999). Nonpharmacologic interventions have been recognized as valuable, simple, and inexpensive adjuvants to pharmacologic approaches to pain management (Hyman, Feldman, Harris, Levin, & Malloy, 1989). Combining pharmacologic and nonpharmacologic methods of pain control probably yields the most effective pain relief for the patient (McCaffery, 1990). By offering a variety of nonpharmacologic methods for pain relief that can be used in combination with pharmacological treatment, the nurse may make a signicant contribution to pain control (McCaffery, 1990; McCaffery & Beebe, 1989). Several studies have been done using music to treat postoperative pain; however, these studies have mixed results, with some showing improved pain relief (Good, Anderson, Ahn, Cong, & Stanton-Hicks, 2005; Masuda, Miyamoto, & Shimizu, 2005) and others showing no improvement in pain (Heiser, Chiles, Fudge, & Gray, 1997; Ikonomidou, Rehnstrom, & Naesh, 2004). Some studies limited the music to the operating room only (Koch, Kain, Ayoub, & Rosenbaum, 1998), and others limited the music to just the postanesthesia care unit (Shertzer & Keck, 2001). Cepeda, Carr, Lau, and Alvarez (2006) authored a systematic review of randomized controlled trials on the effect of music for pain relief, including postoperative pain. Fourteen studies were included in the portion of the review concerning postoperative pain. They reported that listening to music decreases pain and opioid requirements, but the decrease is small and the clinical signicance uncertain. The authors concluded that music should not be the primary method of pain relief. They recommended that further studies examine anxiety as an outcome measure and research the effects of combinations of nonpharmacologic interventions that could potentially have a synergistic effect with music to improve pain relief. Pain causes stress, which in turn causes the cardiovascular system to respond by activating the

sympathetic nervous system, resulting in increased heart rate, blood pressure, and oxygen demand (Pasero, Paice, & McCaffery, 1999). Measuring heart rate, blood pressure, and oxygen saturation may provide evidence that music decreases the sympathetic nervous system stimulation from the stress of pain, thereby decreasing heart rate, blood pressure, and oxygen demand (as indicated by improving oxygen saturation percentages). Borgbjerg, Nielsen, and Franks (1996) reported that pain acts as a respiratory stimulant, as indicated by clinical experience. It would follow that if pain were controlled, an individuals respiratory rate would normalize. Flor, Miltner, and Birbaumer (1992) reported that in pain studies with postoperative patients, cardiovascular measures had been used to document the effects of postoperative pain in addition to the positive effects of psychologic interventions. The aim of the present study was to examine the effect of music on postoperative pain, anxiety, and physiologic parameters in patients undergoing total knee arthroplasty (TKA). The specic purpose of the study was to determine if listening to music and/or having a quiet rest period just before and just after the rst ambulation on postoperative day 1 reduces pain and anxiety in patients. This research hoped to assist in lling a gap of knowledge regarding the effects of music to reduce pain and anxiety in this specic patient population and during the specic time frame around the rst ambulation. The research questions were:
1. Does listening to music just before and just after the rst ambulation following a total joint arthroplasty of the knee decrease the perception of pain? 2. Does listening to music just before and just after the rst ambulation following a total joint arthroplasty of the knee decrease the perception of anxiety? 3. Does listening to music just before and just after the rst ambulation following a total joint arthroplasty of the knee alter physiologic parameters, such as blood pressure, heart rate, respiratory rate, and oxygen saturation? 4. Will listening to music decrease the amount of opioids consumed from the onset of the intervention up to 6 hours later?

METHODS
Study Design An experimental design was used to examine the effects of music and/or a quiet rest period on postoperative pain, anxiety, and physiologic parameters on postoperative day 1. The study was approved by the Institutional Review Boards at the University of Central Florida and Florida Hospital.

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Sample and Setting This study was conducted on a 32-bed orthopedic unit in a hospital in central Florida that performed 727 total knee replacements in 2007. The subjects consisted of all patients who were scheduled for a TKA that met these inclusion criteria: age range 45 to 84 years; American Society of Anesthesiologists physical status classication of 1, 2, or 3; no appreciable decits in hearing or vision; able to communicate in English; admitted to orthopedic oor postoperatively; alert and oriented regarding person, place, time, and situation; and patientcontrolled analgesia (PCA) ordered for postoperative pain relief. Exclusion criteria included the inability to see sufciently to mark the visual analog scale (VAS), current use of antipsychotic medications, allergy to traditional opioid medications, admission to the intensive care unit postoperatively, and/or hemodynamically unstable. The target sample size was 56 subjects. Sample size was based on a power analysis for repeated-measures analysis of variance with a large effect size to achieve a power of .80 and a .05. Preliminary data for this study and past studies indicated a large effect. Measures The measures used in this study included the McGill Pain Questionnaire Short Form (MPQ-SF), a VAS for pain, and a VAS for anxiety. Blood pressure, heart rate, respiratory rate, and oxygen saturation were also measured. Visual Analog Scale for Pain and Anxiety. The VAS was used to measure pain and anxiety. The VAS is used to measure various subjective clinical phenomena, including pain (Waltz, Strickland, & Lenz, 2005). The VAS consists of a 10-cm horizontal line with right angles at each end with word anchors depicting extremes in the phenomenon being measured. Research participants mark on the line exactly where they perceive the phenomenon to fall on the continuum. A ruler is used to measure from the far left of the scale to the subjects mark, and the score is reported as the length measured in millimeters. The VAS is quick, easy to use, and easy to score, and it provides a method to compare the ndings to previous results (St. Marie, 2002). Another advantage of the VAS is that it provides ratio-level data, allowing more robust parametric statistical analysis (Carlsson, 1983). When used to assess pain in the present study, the far left anchor indicated no pain, and the far right anchor indicated pain as bad as it could possibly be. Different dimensions of pain can also be assessed by using different word anchors on the ends of the line, but only one dimension can be measured at a time. The reliabil-

ity and validity of the VAS to assess pain has been established in a sample of 40 patients that presented to the emergency room with abdominal pain (Gallagher, Bijur, Latimer, & Silver, 2002). A VAS was also used to measure anxiety with verbal anchors at each end indicating no anxiety at the far left, and most anxious at the far right. Concurrent validity of the VAS to measure the self-report of anxiety has been demonstrated when scores were compared with Spielbergers (1983) State Anxiety Inventory (SAI) in a group of adult patients in a critical care unit with acute ischemic heart disease (Elliot, 1993). The McGill Pain Questionnaire. The MPQ is a clinical tool that assesses pain in the sensory, affective, and evaluative dimensions based on words that are selected by patients to describe their pain (Melzack & Katz, 2001). It is the most widely used multidimensional pain inventory (Wilke, Savedra, Holzemer, Tesler, & Paul, 1990) and is available in two forms, the long form (MPQ-LF) and short form (MPQ-SF). The MPQ-LF measures the location and pattern of pain over time, the sensory and affective dimensions of pain, and the pain intensity (St. Marie, 2002). The time to complete the MPQ-LF varies from 5 to 15 minutes (American Medical Association, 2003) to 30 minutes (Flaherty,1996). The MPQ-LF is also difcult for some to understand (Flaherty, 1996). The MPQ-SF was developed to obtain information when time is limited. It measures the sensory and affective dimensions of pain, along with pain intensity, and takes 2 to 3 minutes to complete (St. Marie, 2002). The MPQ-SF was studied by Melzack (1987) in adult postoperative patients, obstetrical patients, and dental patients. Concurrent validity of the MPQ-SF and MPQ-LF was established with the VAS for pain. Data on the sensitivity of the MPQ-SF has not been reported, but the MPQ-LF has shown that it is sensitive to interventions designed to reduce pain (Briggs, 1996). Physiologic Parameters. Blood pressure, heart rate, and oxygen saturation were measured with a portable bedside monitor (Medical Data Electronics Escort Series E100 ICU/CCU). The same machine was used exclusively and consistently throughout this research. The biomedical engineering department of the hospital calibrated the device according to the manufacturers directions just before the start of data collection. Respiratory rate was measured by the principal investigator by counting the number of respirations in a 30second period and multiplying by 2, which provided a respiratory rate per minute value. Survey. A four-question survey was given to assess perception of the listening experience to participants in the music group. The items were designed to determine if the participant enjoyed the experience, if they

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perceived that it helped them with their pain or changed their mood, and if the participant would rather have not listened to the music. The survey design was a Likert scale, with ve response options ranging from strongly agree to strongly disagree. Intervention The music intervention consisted of listening with headphones to a compact disc of easy-listening music for 20 minutes before the rst ambulation and for a 20-minute rest period after the ambulation. Easy-listening music was offered because music with harmonious melody and pleasant rhythms has been shown to produce a calming effect and an increased sense of well-being (MacClelland, 1982). The music had 60-80 beats per minute or less, to decrease the chance of increasing the heart rate by entrainment. The music did not have lyrics and had a sustained melodic quality, with no strong rhythms or percussion. The music had a soothing quality, because this has been shown to decrease anxiety and to improve comfort and relaxation (Heitz, Symreng, & Scamman, 1992; Good, 1996). The selection of CDs that was available to participants is shown in Table 1. Subjects in the comparative rest group did not listen to music and instead had a 20-minute quiet rest period. Data were gathered at the same points in time in both groups. Procedure All patients (n 87) scheduled for TKA who met the age requirements were approached in preadmission testing to assess criteria for inclusion in the study and to discuss potential participation in the study. Patients who met the inclusion criteria (n 83) were offered the opportunity to participate in the study, and written informed consent was obtained from those who agreed to enroll in the study (n 80). Demographic data were collected and the MPQ-SF was administered. All research participants were taught how to use the VAS for pain and anxiety. RandomizaTABLE 1. Compact Disc Selections (Compass Productions Lifescapes)
Title Celtic Flutes World Flutes Beethovens Moonlight Native American Flute and Guitar Peaceful Harp Chopins Nocturne

tion into either the comparative rest group or the experimental group was determined by a sealed envelope system. Participants randomized into the experimental music group selected their music of choice from the various CDs available. See Figure 1 for the randomization of subjects procedure. Data collection was done on postoperative day 1 and began 20 minutes before the rst physical therapy session. Coordination with each subjects nurse and physical therapist was done each morning to determine the schedule for physical therapy for the research participants. The data collected included the MPQ-SF, VAS measurement of pain and anxiety, and physiologic measurements of heart rate, blood pressure, respiratory rate, and oxygen saturation. Data collection occurred at four points during this time (T1-T4). Table 2 describes the times of data collection and which data were collected at each time point. At the conclusion of the last measurements after ambulation, subjects in the experimental group were asked to complete a questionnaire about their experience listening to music. The amount of opioid used from the initiation of the music intervention to 6 hours later was recorded. Data Analysis Procedures Statistical analysis was performed using Statistical Package for the Social Sciences for Windows, version 14. Exploratory data analyses were performed to determine if assumptions were met and to screen the data for accuracy, missing data, and outliers. Descriptive statistics were computed, and repeated-measures analyses of variance (RMANOVA) were conducted to evaluate the effect of the intervention on pain and anxiety scores and physiologic variables. Level of signicance for statistical tests set a priori at a .05 (two-tailed).

RESULTS
Demographic Data A total of 56 patients participated in the study (25 men, 31 women; mean age 63.89 years, range 46-84 years). No signicant differences were found between the comparative rest group and the experimental group regarding any of the demographic characteristics, including gender, age, ethnicity, or education (Table 3). Table 4 describes clinical characteristics of the sample. No signicant differences were found between the two groups on any of the clinical characteristics. Research Question 1: Music and Pain The mean pain scores and standard deviations for the experimental group and the comparison rest group

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FIGURE 1.

Allocation of subjects.

TABLE 2. Measurements and Times

T1 McGill Pain Questionnaire, short form Visual analog scale: pain Visual aanlog scale: anxiety Physiologic parameters Assessment of listening experience Opioid use X X X X X X X X X X X X X* X T2 T3 T4 T5

are provided in Table 5, with graphic representation in Figure 2. According to RMANOVA, subjects within groups experienced signicantly different pain scores as measured with the VAS over time (F 6.713; p .001). Post hoc pairwise comparisons with a Bonferroni correction found signicant differences in pain between T1 and T2 (p .000) and between T2 and T3 (p .000). An RMANOVA found no statistically significant differences in pain scores measured with the VAS between the two groups at any measurement point (F 1.120; p .337).

T1 20 minutes before rst physical therapy session (PT); T2 just before PT; T3 immediately after PT, T4 20 minutes after PT; T5 6 hours after intervention. *Music group only.

Research Question 2: Music and Anxiety The mean anxiety scores and standard deviations for the experimental group and the comparative rest group are provided in Table 6, with graphic

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TABLE 3. Demographic Characteristics of the Sample

Group Characteristic Gender, n (%) Female Male Age, yrs, mean (SD) [Range] Ethnicity, n Caucasian African American Hispanic Other Education <12th grade High school Some college College grad Experimental (n 28) 14 (50) 14 (50) 64.3 (9.6) [46-81] 25 1 1 1 2 6 11 9 Rest (n 28) 17 (60.7) 11 (39.3) 63.5 (9.6) [47-84] 24 1 1 2 1 7 10 10 Total (n 56) 31 (55.4) 25 (44.6) Statistical test: p value, total (n 56) Chi-squared:
p .420 t test: p .782

Chi-squared: 49 2 2 3 3 13 21 19
p .950

Chi-squared
p .917

representation in Figure 3. According to RMANOVA, subjects within both groups had signicantly different anxiety scores over time (F 4.124; p .011). Post hoc pairwise comparisons with a Bonferroni correction found signicant differences in anxiety between T1 and T2 (p .035) and between T2 and T3 (p .014). An RMANOVA showed no statistically signicant differences in anxiety scores between the two

groups at any measurement point (F 1.566; p .206). Research Question 3: Music and Physiologic Parameters Mean Arterial Pressure. A summary of physiological measures is found in Table 7. According to RMANOVA, participants in both groups had statistically

TABLE 4. Comparison of Clinical Characteristics of the Two Groups

Group Characteristic ASA number, n (%) 1 2 3 BMI, kg/m2, mean (SD) Type of anesthesia, n General Spinal Femoral block, n Yes No Type of PCA, n Dilaudid Morphine Experimental (n 28) 1 (4) 18 (64) 9 (32) 31.9 (6.3) 16 12 26 0 21 7 Rest (n 28) 0 (0) 17 (61) 11 (39) 33.6 (6.6) 16 12 26 0 Chi-squared: 15 13
p .094

Statistical test: p value Chi-squared:

p .541

t test: p .326

Chi-squared:
p 1.000

ASA American Society of Anesthesiologists; BMI body mass index; PCA patient-controlled analgesia.

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TABLE 5. Pain Data

Group Assignment VAS Pain, T1 VAS Pain, T2 VAS Pain, T3 VAS Pain, T4 MPQ-SF, preoperative MPQ-SF, postoperative Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Mean 52.4 46.4 49.4 36.5 36.2 36.4 44.5 48.0 46.3 41.2 45.1 43.2 13.4 10.3 11.9 15.9 14.9 15.4 SD 25.2 25.7 25.4 23.8 26.9 25.1 28.2 27.7 27.8 25.8 31.2 28.4 8.5 10.0 9.3 10.6 12.3 11.4 n 28 28 56 28 28 56 28 28 56 28 28 56 28 27 55 28 28 56

MPQ-LF McGill Pain Questionnaire long form; MPQ-SF McGill Pain Questionnaire short form; VAS visual analog scale; other abbreviations as in Table 2.

signicant decreases in mean arterial pressure (MAP) over time (F 9.891; p .000). Post hoc pairwise comparisons with a Bonferroni correction found significant difference in MAP between T1 and T4 (p .001) and between T2 and T4 (p .047). An RMANOVA showed no statistically signicant differences in MAP between the two groups (F .388; p .658). Heart Rate, Respiratory Rate, and Oxygen Saturation. No signicant differences were noted in heart rate, respiratory rate, or oxygen saturation across time within groups. Similarly, no signicant differences were found in any of these parameters between groups at any time period.

60

Mean VAS Scores Pain

55 50 45 40 35 30

Research Question 4: Music and Opioid Consumption All research participants received PCA following surgery, either dilaudid or morphine at equivalent doses. No participant had a basal rate of opioid administration on the PCA. All participants had their PCA discontinued the rst morning after surgery, and as needed oral pain medications were ordered by the physician. Chi-squared analysis found no signicant difference between the two groups regarding the administration of oral pain medications within 6 hours of the intervention, Pearson c2 (1; n 56) 0.747; p .388. Nearly all (93%) participants in the experimental group received oral pain medications within 6 hours, compared with 86% of the participants in the quiet rest group. No differences were noted between groups regarding which oral pain medication was administered, Pearson c2 (5; n 56) 8.083; p .152. Oxycodone (Percocet) was administered to 89% of the participants in the experimental group and to 82% of the participants in the quiet rest group. Perception of Listening Experience Listening to music was an overall positive experience for subjects in the experimental group. Most respondents (84%) agreed that the music helped them forget about their pain for a while. Additionally, 92% agreed that the music helped to improve their general mood, and 88% agreed that the music was an enjoyable experience for them. None of those questioned

Time 1

Time 2
Music Group

Time 3

Time 4

Compararive Rest Group

FIGURE 2. - Mean visual analog scale (VAS) pain: comparative rest group versus experimental group.

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TABLE 6. Anxiety Data

Group Assignment VAS Anxiety, T1 VAS Anxiety, T2 VAS Anxiety, T3 VAS Anxiety, T4 Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Mean 36.1 26.1 31.1 27.1 22.3 24.7 35.8 33.8 34.8 27.9 30.3 29.1 SD 27.4 23.3 25.6 22.7 22.3 22.4 24.5 28.8 26.5 20.8 28.7 24.8 n 28 28 56 28 28 56 28 28 56 28 28 56

Abbreviations as in Tables 2 and 5.

reported that they would rather not have listened to the music.

DISCUSSION
The difference in pain and anxiety scores between the music intervention group and the quiet rest group was not statistically signicant. These ndings differ from those reported by Voss et al. (2004), in which the effects of music and a rest period on pain and anxiety were examined. Voss et al. (2004) found a statistical difference in pain and anxiety scores between subjects in the music group and subjects in the rest group during chair rest in a sample of cardiac surgical patients. Similarly, Sendelbach, Halm, Doran, Miller, and Gaillard (2006) examined the effects of music and rest on post50

45 40 35 30 25 20

Time 1

Time 2
Music Group

Time 3

Time 4

Compararive Rest Group

FIGURE 3. - Mean visual analog scale (VAS) anxiety: comparative rest group versus experimental group.

operative pain and anxiety in cardiac surgical patients and found statistically signicant results, including less pain and anxiety in the music intervention subjects. Neither of these studies compared the effects of music just before and just after a known painful experience, as was done in the present study, which may account for the difference in ndings. The present study is the rst to compare these particular interventions at this specic point in care in this patient population, making it unique, with no availability of similar research for comparison. Another possible reason for the lack of signicant differences between groups is that the quiet rest period was also an intervention. This research began using music as an intervention to be compared with a control group who received a quiet rest period. However, the investigator ensured that the subjects in the quiet rest group would not be interrupted for 20 minutes before ambulation. Providing an environment with little interruption was changing their situation enough so that the quiet rest group did not truly act as a control group but rather as a second intervention group. The lack of a statistically signicant difference between groups in this study regarding physiologic data is consistent with other studies that have examined the effects of music and rest on physiologic parameters. Sendelbach, Halm, Doran, Miller, and Gaillard (2006) did not nd statistically signicant differences between systolic blood pressure, diastolic blood pressure, and heart rate between participants in a music intervention group (n 50) and a rest group (n 20). Although not statistically signicant, pain scores in the music intervention group decreased by 30% between T1 and T2, compared with 22% in the quiet rest

Mean VAS Scores Anxiety

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TABLE 7. Physiologic Data

Group Assignment MAP, T1 MAP, T2 MAP, T4 Heart rate, T1 Heart rate, T2 Heart rate, T4 Respiratory rate, T1 Respiratory rate, T2 Respiratory rate, T4 Oxygen saturation, T1 Oxygen saturation, T2 Oxygen saturation, T4 Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Experimental Rest Combined sample Mean 95.8 92.7 94.2 92.7 91.6 92.1 90.3 88.3 89.3 85.8 86.7 86.2 83.0 88.2 85.6 85.2 86.6 85.9 17.6 17.8 17.7 18.0 18.2 18.1 18.1 18.0 18.0 95.1 96.2 95.6 95.7 96.3 96.0 95.1 96.0 95.6 SD 12.3 13.8 13.1 12.5 14.9 13.7 13.8 15.1 14.4 13.5 13.8 13.6 14.4 12.9 13.7 14.4 11.3 12.9 1.7 1.7 1.7 1.8 1.9 1.8 1.8 2.0 1.9 3.6 2.5 3.1 2.8 2.2 2.5 2.7 2.7 2.7 n 28 28 56 28 28 56 28 28 56 28 28 56 28 28 56 28 28 56 28 28 56 28 28 56 28 28 56 28 28 56 28 28 56 28 28 56

MAP mean arterial pressure; other abbreviations as Table 2.

group during the same time period. This decrease is potentially clinically signicant and indicates that offering a music intervention may be more effective than a quiet rest period to decrease pain. Similarly, the anxiety scores in the music intervention group decreased by 25%, whereas the anxiety scores in the quiet rest group decreased by 15% between T1 and T2. This decrease is again potentially clinically signicant and indicates that offering a music intervention may be more effective than a quiet rest period to decrease anxiety. These ndings might have become statistically signicant if the sample size were larger. Patients having a TKA are fully aware that the rst time they attempt to stand following surgery that pain is certain. This anticipation of the pain in turn causes

anxiety. It has been suggested that music is more effective if patients are able to concentrate on the music (Good, et al., 1999). Despite the fact that participants in both groups were studied immediately before a known painful and anxiety-provoking point in care, the participants seemed to be able to concentrate on the music or quiet rest. However, if a music intervention or a quiet rest period were provided at other points in care, results might be different.

Limitations Several limitations of this study are noted. Despite efforts by the researcher to maintain a quiet and uninterrupted rest period for both groups, occasional disruptions occurred. It is unclear how much inuence

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the disruptions had on reports of pain and anxiety or on physiologic measures in either group. An additional limitation of the study includes the inconsistent practice of the nursing staff when providing as needed oral pain medications. Although there was no statistically signicant difference between the two groups regarding the administration of opioid medications, a difference was noted that some nursing staff provided oral medications more liberally in anticipation of pain rather than waiting for the pain to be at a certain level before administering the medication. Sample size was estimated based on a large effect size. Since the quiet rest period became an intervention, the actual effect size was small for both pain and anxiety, resulting in a sample size that was too small to detect any differences. Implications Further research using music and/or rest periods as an adjuvant to traditional pain management is needed. Research using music for longer periods of time, at varying times of the day, and at different points in care might provide evidence to support the use of music to improve pain. Research using music with a variety of populations experiencing pain could also provide evidence that would allow the use of music to be expanded in different settings. Having rest periods with caregiver presence or music available in the clinical setting to be used as an adjuvant with traditional pharmacologic interventions for pain management should be considered. The intervention poses no risks, with potential benets of improved pain reports and decreased anxiety. It potentially could be opioid sparing in some individuals, limiting the negative effects from opioids. Standardization of this practice should be considered, with understanding that the administration of pain medication in anticipation of a predicted painful event is appropriate. Educating nurses and nursing students about pain and the various treatment choices is needed. Teaching and understanding the pharmacologic options for pain management are important, but it is equally important for nurses to understand the nonpharmacologic options that can be used to provide pain relief. In light of the research presented here, nurses can be informed that there is evidence to suggest that music and rest are

both options that can lower pain and anxiety scores, and these options should be considered when treating patients in pain. Adding music and/or a quiet rest period as nonpharmacologic interventions to existing protocols to improve pain and anxiety should be considered.

CONCLUSIONS
In conclusion, the results of this study provide evidence that pain and anxiety are reduced while listening to music or having a rest period when initiated just before and just after the rst ambulation after a TKA. Additionally, the study found that, overwhelmingly, patients enjoyed the music, reporting that the music helped them to forget about their pain for a while and improved their general mood. Use of this intervention could be implemented into the routine plan of care for patients with TKA. The intervention poses no risks and has the potential to limit the amount of opioids necessary to achieve pain relief, which decreases the chances of experiencing the side effects of opioids, such as respiratory depression. Nurses can offer music as an intervention to decrease pain and anxiety in this patient population with condence, knowing that there is evidence to support its efcacy. After surgery, the focus has traditionally been on the administration of pharmacologic interventions for pain management. Current research suggests there may be a role for nonpharmacologic interventions as an adjunct to traditional pain management. The results of the present research suggest that music or a quiet rest period during the time just before and just after physical therapy for the rst ambulation after a TKA decreases pain and anxiety when used in conjunction with traditional pharmacologic interventions. The authors are grateful for the support of M. Lindell Joseph Phd, RN and the Center for Nursing Research and Innovation at Florida Hospital.
Acknowledgements The authors are grateful for the support of M. Lindell Joseph PhD, RN and the Center for Nursing Research and Innovation at Florida Hospital. The authors also thank the nurses and physical therapists on the orthopedic unit where this study was conducted and the team in preadmission testing where consenting of participants took place.

REFERENCES
Acute Pain Management Guideline Panel, Agency for Health Care Research and Quality. (1992). Clinical practice guideline: Acute pain management: Operative or medical procedure and trauma. AHCPR Pub. No. 920032. Rockville, MD: Public Health Service, US Department of Health and Human Services. American Medical Association (2003). Pain management: Pathophysiology of pain and pain assessment. Retrieved

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January 21, 2007, from http://www.ama-cmeonline.com/ pain_mgmt/module01/index.htm. Borgbjerg, F. M., Nielsen, K., & Franks, J. (1996). Experimental pain stimulates respiration and attenuates morphineinduced respiratory depression: A controlled study in human volunteers. Pain, 64, 123128. Briggs, M. (1996). Surgical wound pain: A trial of two treatments. Journal of Wound Care, 5, 456460. Carlsson, A. M. (1983). Assessment of chronic pain: I. Aspects of the reliability and validity of the visual analog scale. Pain, 16, 87101. Cepeda, M. S., Carr, D. B., Lau, J., & Alvarez, H. (2006). Music for pain relief. Cochrane Database of Systematic Reviews, 2006(2). CD004843. Elliot, D. (1993). Comparison of three instruments for measuring patient anxiety in a coronary care unit. Intensive Critical Care Nurse, 9, 195200. Ersek, M. (1999). Enhancing effective pain management by addressing patient barriers to analgesic use. Journal of Hospice and Palliative Nursing, 1, 8796. Flaherty, S. A. (1996). Pain measurement tools for clinical practice and research. Journal of the American Association of Nursing Anesthestists, 64, 133140. Flor, H., Miltner, W., & Birbaumer, N. (1992). Psychophysiological recording methods. In D. Turk, & R. Melzack (Eds.), Handbook of pain assessment. (pp. 169190). New York: The Guilford Press. Gallagher, E. J., Bijur, P. E., Latimer, C., & Silver, W. (2002). Reliability and validity of a visual analog scale for acute abdominal pain in the ED. American Journal of Emergency Medicine, 20, 287290. Good, M. (1996). Effects of relaxation and music on postoperative pain: A review. Journal of Advanced Nursing, 24, 905914. Good, M., Anderson, G. C., Ahn, S., Cong, X., & StantonHicks, M. (2005). Relaxation and music reduce pain following intestinal surgery. Research in Nursing & Health, 28, 240251. Good, M., Stanton-Hicks, M., Grass, J. A., Anderson, G. C., Choi, C., Schoolmeesters, L. J., & Salman, A. (1999). Relief of postoperative pain with jaw relaxation, music, and their combination. Pain, 81, 163172. Heiser, R. M., Chiles, K., Fudge, M., & Gray, S. E. (1997). The use of music during the immediate postoperative period. Association of Operating Room Nurses (AORN) Journal, 65, 777784. Heitz, L., Symreng, T., & Scamman, F. L. (1992). Effect of music therapy in the post anesthesia care unit: A nursing intervention. Journal of Post Anesthesia Nursing, 7, 2231. Hyman, R. B., Feldman, H. R., Harris, R. B., Levin, R. F., & Malloy, G. B. (1989). The effects of relaxation training on clinical symptoms: A meta-analysis. Nursing Research, 38, 216229. Ikonomidou, E., Rehnstrom, A., & Naesh, O. (2004). Effect of music on vital signs and postoperative pain. Association of Operating Room Nurses (AORN) Journal, 80, 269278.

Koch, M. E., Kain, A. N., Ayoub, C., & Rosenbaum, S. H. (1998). The sedative and analgesic sparing effects of music. Anesthesiology, 89, 300306. MacClelland, D. C. (1982). Therapeutic communication through music. Point of View, 19, 45. Mac Lellan, K. (2004). Postoperative pain: Strategy for improving patient experiences. Journal of Advanced Nursing, 46, 179185. Masuda, T., Miyamoto, K., & Shimizu, K. (2005). Effects of music listening on elderly orthopaedic patients during postoperative bed rest. Nordic Journal of Music Therapy, 14, 414. McCaffery, M. (1990). Nursing approaches to nonpharmacological pain control. International Journal of Nursing Studies, 27, 15. McCaffery, M., & Beebe, A. (1989). Pain: Clinical manual for nursing practice. St. Louis: Mosby. McCaffery, R., & Locsin, R. (2006). The effect of music on pain and acute confusion in older adults undergoing hip and knee surgery. Holistic Nursing Practice, 20, 218224. Melzack, R. (1987). The short-form McGill Pain Questionnaire. Pain, 30, 191197. Melzack, R., & Katz, J. (2001). The McGill Pain Questionnaire: Appraisal and current status. In D. C. Turk, & R. Melzack (Eds.), Handbook of pain assessment (pp. 35 52). New York: Guilford Press. Pasero, C., Paice, J. A., & McCaffrey, M. (1999). Basic mechanisms underlying the causes and effects of pain. In M. McCaffery, & C. Pasero (Eds.), Pain: Clinical Manual, (2nd Ed) (pp. 1534). St. Louis: Mosby. Sendelbach, S. E., Halm, M. A., Doran, K. A., Miller, E. H., & Gaillard, P. (2006). Effects of music therapy on physiological and psychological outcomes for patients undergoing cardiac surgery. Journal of Cardiovascular Nursing, 21, 194200. Shang, A. B., & Gan, T. (2003). Optimising postoperative pain management in the ambulatory patient. Drugs, 63, 855867. Shertzer, K., & Keck, J. (2001). Music and the PACU environment. Journal of Perianesthesia Nursing, 16(2), 90102. Sloman, R., Rosen, G., Rom, M., & Shir, Y. (2005). Nurses Assessment of pain in surgical patients. Journal of Advanced Nursing, 52, 125132. Spielberger, C. D. (1983). State-trait anxiety inventory. Palo Alto, CA: Mind Garden. St. Marie, B. (2002). Assessment. In B. St. Marie (Ed.), Core Curriculum for pain management nursing (pp. 149180). Philadelphia: W.B. Saunders. Voss, J. A., Good, M., Yates, B., Baun, M. M., Thompson, A., & Hertzog, M. (2004). Sedative music reduces anxiety and pain during chair rest after open-heart surgery. Pain, 112, 197203. Waltz, C. F., Strickland, O. L., & Lenz, E. R. (2005). Measurement in nursing research and health. New York: Springer Publishing Company. Wilke, D. J., Savedra, M. C., Holzemer, W. L., Tesler, M. D., & Paul, S. M. (1990). Use of the McGill Pain Questionnaire to measure pain: A meta-analysis. Nursing Research, 39, 3641.