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Music Therapy to Reduce Pain and Anxiety in Children With Cancer Undergoing Lumbar Puncture: A
Randomized Clinical Trial
Thanh Nhan Nguyen, Stefan Nilsson, Anna-Lena Hellstrm and Ann Bengtson
Journal of Pediatric Oncology Nursing 2010 27: 146
DOI: 10.1177/1043454209355983
The online version of this article can be found at:
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Abstract
A nonpharmacological method can be an alternative or complement to analgesics.The aim of this study was to evaluate
if music medicine influences pain and anxiety in children undergoing lumbar punctures. A randomized clinical trial was
used in 40 children (aged 7-12 years) with leukemia, followed by interviews in 20 of these participants.The participants
were randomly assigned to a music group (n = 20) or control group (n = 20). The primary outcome was pain scores
and the secondary was heart rate, blood pressure, respiratory rate, and oxygen saturation measured before, during,
and after the procedure. Anxiety scores were measured before and after the procedure. Interviews with open-ended
questions were conducted in conjunction with the completed procedures. The results showed lower pain scores and
heart and respiratory rates in the music group during and after the lumbar puncture.The anxiety scores were lower in
the music group both before and after the procedure. The findings from the interviews confirmed the quantity results
through descriptions of a positive experience by the children, including less pain and fear.
Keywords
anxiety, music, nonpharmacological therapy, pain
Introduction
Pain associated with medical procedures is often viewed
as one of the worst experiences in children with cancer
(Hedstrom, Haglund, Skolin, & von Essen, 2003; Ljungman,
Gordh, Sorensen, & Kreuger, 1999). There are many different approaches in the treatment of pain from medical
procedures in children, including pharmacological and
nonpharmacological methods (Windich-Biermeier, Sjoberg,
Dale, Eshelman, & Guzzetta, 2007).
About 250 new patients are registered per year on the
Oncology Ward at the National Hospital of Paediatrics
(NHP) in Hanoi, Vietnam. In 2008, 313 children with leukemia were offered a program that included 3 years of
treatment. The treatment of leukemia in children involves
several needle-related procedures (Jacob, Hesselgrave,
Sambuco, & Hockenberry, 2007). Lumbar puncture (LP)
is usually one of the most painful and distressing procedures associated with cancer treatment (Jacob et al.,
2007). Pain that is left untreated or is poorly treated often
leads to significantly prolonged changes in behavior,
alterations in self-concept, fear, anxiety, and depression
(Blount, Piira, Cohen, & Cheng, 2006; von Baeyer,
Marche, Rocha, & Salmon, 2004). The goal of adequate
Corresponding Author:
Stefan Nilsson, RN, MSc, Department of Paediatric Anaesthesia and
Intensive Care Unit, The Queen Silvia Childrens Hospital, Sahlgrenska
University Hospital, SE-416 85 Gothenburg, Sweden
Email: stefan.r.nilsson@vgregion.se
147
Nhan et al.
for inadequate procedural pain relief (Segerdahl, 2008).
Pain management strategies that are easy to prepare and use
for children and nurses need to be found. Costly and
advanced methods will remain at a theoretic level and
never reach clinical practice (Wright, Stewart, Finley, &
Buffett-Jerrott, 2007). Nonpharmacological methods in
pain management are evaluated briefly in Asian countries
such as Vietnam. A study of pain management conducted
in China found that music was a commonly used nonpharmacological method (He, Vehvilainen-Julkunen, Polkki,
& Pietila, 2007).
Listening to music is one of several nonpharmacological methods to relieve pain and anxiety in both adults and
children (Klassen, Liang, Tjosvold, Klassen, & Hartling,
2008; U. Nilsson, 2008). There are theories explaining its
mode of action. It appears that music reduces the s-cortisol
(U. Nilsson, 2009a) and also causes an increase in the
levels of s-oxytocin (U. Nilsson, 2009b). A commonly
accepted hypothesis is that the music acts as a distracter,
focusing the patients attention away from negative stimuli to something pleasant and encouraging. Various other
hypotheses have been proposed to explain the mechanism
by which music reduces pain, including modification of
cognitive states, moods, and emotions. Relaxation from
music can also be demonstrated to be a pleasant distraction that serves as a mild sedative (Balan, Bavdekar, &
Jadhav, 2009). The review by Klassen et al. (2008)
divides music therapy into passive and active therapy.
Active music therapy requires the involvement of a music
therapist so that the music can be used for interactive
communication, whereas passive music therapy entails
listening to music for a particular purpose, recorded or
live, without the involvement of a music therapist. Listening to prerecorded music has also been defined as music
medicine as opposed to active music therapy (Dileo &
Bradt, 2005). Previous research has found music medicine or passive music therapy to be as effective as active
music therapy (Klassen et al., 2008). In addition, listening
to music as a treatment for pain and anxiety offers potential advantages of low cost, ease of provision, and safety
(Cepeda, Carr, Lau, & Alvarez, 2006).
To our knowledge, few studies have evaluated the
effects of music in children with cancer who undergo LP.
The aims of this study were to evaluate the effect and
experiences of using earphones with music as the only
effect with regard to pain and anxiety relief in children
with leukemia who were undergoing LP.
Methods
Participants
Between November 2007 and July 2008, children with leukemia, aged 7 to 12 years, who were due to undergo LP at
Self-Report Instruments
Pain. The Numeric Rating Scale (NRS) was used to
measure the childs self-reported pain during 3 distinct
phases: before, during, and after LP. The child rated the
pain intensity on a scale, with point 0 being no pain and
point 10 being the worst pain. During the procedure, the
highest recorded value was registered. The NRS is an
internationally used method to measure subjective experiences of pain intensity in children older than the age of
6 years. Self-reported NRS scores agreed with selfreported pain scores on a Faces Pain Scale in a validation
study that included 150 children (aged 6-12 yers) in
Thailand (Jongudomkarn, Angsupakorn, & Siripul, 2008).
An advantage of the NRS is its ease and speed of use
(Stinson, Kavanagh, Yamada, Gill, & Stevens, 2006).
Anxiety. The 6-item short form of the Spielberger
State-Trait Anxiety Inventory (STAI) is a validated scale
(Marteau & Bekker, 1992) and was used to measure
anxiety. The short STAI scale evaluated the procedure in
2 distinct phases: before and after LP. The range of the
short STAI scale would be 6 to 24 points in the end, with
6 points signifying no anxiety and 24 points signifying
the highest level of anxiety.
148
Table 1. The Analysis Process From the Condensed Meaning Units of the Text, Codes, Subcategories and Categories
Condensed Meaning Unit
Code
Subcategory
Less afraid
Felt calm
Wanted to go home
Interviews
10 children in each group were chosen consecutively
according to a predetermined schedule. The interviews
were carried out after informed consent and in connection
with the completion of the LP procedure to avoid the
impact of memory bias.
The interview guide included 3 open-ended questions:
Please tell me about your feelings right now, Please
Category
Feelings of fear
Specific pain
Feelings of pain
Liked listening
Enjoyment of music
Focused on the
music
Data Analysis
A post hoc power analysis was performed for pain during
the LP procedure and the Cohens effect size calculated.
In this study, an effect size above 0.5 was needed for a
sufficient result with clinical significance. An effect size
of 1.49 and a power of 0.99 were calculated for a sample
size of 20 participants in each group. This result reached
a sufficient number of participants. The assumption was
also supported by another study in this area that recommended a clinical difference for a new treatment of 13 to
18 mm on a visual analogue scale (0-100 mm; Heden,
von Essen, Frykholm, & Ljungman, 2009). All the data in
this study are presented as descriptive statistics and calculated using nonparametric statistics. The c2 test was
used for categorical data, and the MannWhitney U test
was used to compare data between 2 groups, that is, pain
scores, HR, BP, RR, SpO2, and anxiety scores, as well as
to compare age and the total duration of the music.
The interviews with the children were read and analyzed using qualitative content analysis (Krippendorff,
2004). The interviews were transferred to one text. The
text was read and reread until a sense of the whole was
obtained. The meaning units relating to the aim of the
study were condensed, extracted, and coded. After the
processes of coding and decoding, subcategories were
identified and divided into categories (Table 1). The
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Nhan et al.
Excluded (n = 9)
Enrollment
Randomized (n = 40)
Other reasons (n = 1)
Lost to follow-up (n = 0)
Lost to follow-up (n = 0)
Discontinued intervention (n = 0)
Follow-Up
Analyzed (n = 20)
Discontinued intervention (n = 0)
Analyzed (n = 20)
Analysis
Children were randomized to either earphones with or earphones without self-selected music.
Results
A total of 49 children were asked to participate in the
study and, of these, 40 agreed to participate. Eight children withdrew because their parents declined for reasons
150
Boys (n)
Girls (n)
12
13
Nonsignificant
8
7
Nonsignificant
Table 3. Comparison of Pain Scores and Anxiety Scores Before, During, and After the Procedure
Control (n = 20)
Music (n = 20)
Control (n = 20)
P Value
< .001
< .001
Control (n = 20)
HR
Before
102.6 (85-125, 10.01) 103.1 (87-135, 14.46)
During
102.7 (86-123, 9.24) 117.7 (91-152, 19.49)
After
100.8 (80-123, 11.4) 111.1 (88-145, 17.23)
RR
Before
25.0 (16-30, 4.08)
25.5 (18-35, 4.47)
During
25.1 (18-32, 3.60)
28.5 (22-37, 3.86)
After
24.5 (18-32, 3.49)
28.2 (20-37, 3.72)
SpO2
Before
99.6 (98-100, 0.60)
99.7 (97-100, 0.73)
During
99.2 (96-100, 1.14)
98.0 (90-100, 2.77)
After
99.7 (99-100, 0.49)
99.2 (94-100, 1.47)
Systolic BP
Before
96.2 (84-112, 6.82)
98.0 (79-116, 9.98)
During
97.1 (84-116, 8.57) 105.6 (82-141, 15.97)
After
98.5 (85-119, 10.13) 102.4 (84-128, 11.26)
Diastolic BP
Before
61,8 (53-68, 3.82)
63.0 (53-77, 5.85)
During
65.2 (55-80, 6.83)
69.8 (58-105, 11.67)
After
62.75 (57-80, 4.82)
64.2 (50-94, 9.40)
P Value
NS
.012
NS
NS
.009
.003
NS
NS
NS
NS
NS
NS
NS
NS
NS
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Nhan et al.
Listening to their favorite music helped them feel calm
and relaxed and take their minds off the harm the procedure might cause: I felt calmer than last time. I didnt
think about the injection. I just focused on the music. It
encouraged me. I was successful. They did not worry to
the same extent as they did before being injected: I didnt
feel any pain. I felt less afraid than last time. The last
time, I had to hold my mothers hand very tightly during
the LP. I didnt need to do that this time . . . [smiles].
Listening to music of their choice through earphones was
a new experience in this group of children. The children
also found it exciting: It felt very interesting because I had
never listened to music during the procedure like this . . .
and I was relaxed before the LP too. One child in the
control group said that he felt calmer when wearing the
earphones. The others in the control group did not mention anything about this.
Before the procedure, most of the children felt fear
and anxiety. Listening to the music, however, made them
focus on it and they seemed to forget the fear they had
before: At the beginning of the procedure, I was a little
bit worried because I was afraid of being injected twice,
but I felt calm because I was listening to the music in the
earphones from the start . . . [smiles]. At the time of the
interview, all the children stated that listening to music
made them feel less anxious about what would happen
next during the procedure, though some children already
had anxiety about the next planned procedure that day
and began to talk about that: I felt calm and relaxed, but
Im very worried about the other injection when I come
back to the treatment rooma vein puncture to get an
antibiotic. One child said that he was worried about the
next time he would undergo LP: Will I be able to listen
to music or not?
There were differences between the children in the
music group and the children in the control group. All of
the children in the control group talked about their fear
and anxiety. Just wearing earphones did not appear to
help. Feelings of fear were expressed very strongly in the
interview text. Their fears had to do with the pain relating
to the LP, their disease, and death: I was very afraid of
pain . . . [crying] . . . I just wanted to go home. I didnt
want to be injected any more [crying] . . .; I was very
scared and I was in pain. I couldnt think about anything.
This was very terrible! After the LP, the childrens fear
continued and they felt sad because of their bad experience of the procedure: Im still scared [crying], Im
afraid to be injected. Its very painful. When the doctor
came in, my heart seemed to act in chaos until he left
[crying] . . . They also started to worry about the next
planned procedure. Some children in the control group
spoke about their anxiety and were worried about how
their disease would affect them in the future. It could be
Discussion
This study showed that music medicine is a distracter and
helps the children endure the amount of perceived pain
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Nhan et al.
There are some methodological considerations with
this study. The STAI scale was originally designed and
validated for adults, though it has previously been used
in its original form for female adolescents watching
music videos when undergoing colposcopy (Rickert,
Kozlowski, Warren, Hendon, & Davis, 1994). The short
STAI is easy to use and showed a significant decrease
between before and after day surgery in children aged 7
to 16 years (Nilsson et al., 2009). The short STAI may be
preferable to the STAI or the STAI for children (STAIC),
which involve a long checklist and many items that
sometimes become a hindrance (Marteau & Bekker,
1992). The short STAI has not been validated in children
but is frequently used and appears to form a valuable
complement to other collected data. The limitation of the
intervention in the present study was the earphones.
Although earphones were found to have valuable effects,
they were not sufficiently comfortable in all of the positions in which the children found themselves during the
procedure. In another study, loudspeakers were shown to
block unpleasant sounds in the environment and make
patients feel more relaxed (Thorgaard et al., 2005). Earphones may, however, increase the risk of transmitting
infections associated with health care to sensitive children (U. Nilsson, 2009a).
Another limitation is that the children in the control
group were recruited with the knowledge that they might
be given music intervention but were then randomized to
the group without music. This might have led to a sense
of missing something.
The data collection involved some outcomes that did
not show any significant differences between the music
group and the control group, that is, BP before, during,
and after LP. This result confirms earlier studies with
music (Hatem, Lira, & Mattos, 2006; Megel, Houser, &
Gleaves, 1998). BP does not seem to be an important outcome for the effects of music therapy. This is an important
finding as many children probably find it disturbing to
have their blood pressure measured.
In the study, listening to music using an iPod as the
only effort was found to be effective with regard to pain
and anxiety reduction in children and could help nurses
and physicians in clinical practice. Further research is
needed to examine whether the choice of music and
equipment needs to be individualized or if a gold standard exists, and to compare and combine music with
other distraction techniques such as Virtual Reality (Riva,
Grassi, Villani, Gaggioli, & Preziosa, 2007).
Conclusions
Listening to music with earphones as a form of nonpharmacological intervention reduced pain and anxiety in
Funding
The authors received no financial support for the research and/
or authorship of this article.
References
Balan, R., Bavdekar, S. B., & Jadhav, S. (2009). Can Indian
classical instrumental music reduce pain felt during venepuncture? Indian Journal of Pediatrics, 76, 469-473.
Blount, R. L., Piira, T., Cohen, L. L., & Cheng, P. S. (2006).
Pediatric procedural pain. Behavior Modification, 30, 24-49.
Cepeda, M. S., Carr, D. B., Lau, J., & Alvarez, H. (2006). Music
for pain relief. Cochrane Database Systematic Review, (2),
CD004843.
Dileo, C., & Bradt, J. (2005). Medical music therapy: A metaanalysis & agenda for future research: Cherry Hill, NJ:
Jeffrey Books.
Hatem, T. P., Lira, P. I., & Mattos, S. S. (2006). The therapeutic
effects of music in children following cardiac surgery. Jornal de Pediatria, 82, 186-192.
He, H. G., Vehvilainen-Julkunen, K., Polkki, T., & Pietila, A. M.
(2007). Childrens perceptions on the implementation of
methods for their postoperative pain alleviation: An interview study. International Journal of Nursing Practice, 13,
89-99.
Heden, L., von Essen, L., Frykholm, P., & Ljungman, G. (2009).
Low-dose oral midazolam reduces fear and distress during
needle procedures in children with cancer. Pediatric Blood
& Cancer, 53, 1200-1204.
Hedstrom, M., Haglund, K., Skolin, I., & von Essen, L. (2003).
Distressing events for children and adolescents with cancer:
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Bios
Thanh Nhan Nguyen, MSc, is a registered nurse at the Department of Paediatric Oncology, the National Hospital of Paediatrics, Hanoi, Vietnam.
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Nhan et al.
Stefan Nilsson, MSc, is a registered nurse and pain management nurse at the Queen Silvia Childrens Hospital, Sahlgrenska
University Hospital, Gothenburg, and a PhD student at the
Department of Nursing Science, School of Health Sciences,
Jnkping University.
Hospital, Gothenburg, and the Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg.
Ann Bengtson, PhD, is a registered nurse (RNT) and senior
lecturer at the Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden.