Burn Pain and Anxiety: The Use of Music Relaxation

During Rehabilitation
S. L. Ferguson, MSPT, K. V. Voll, OTR/L

Pain and anxiety are well-documented problems during the rehabilitation of patients with
burns. This study examined the effect of music on anxiety and pain during range of motion.
Eleven subjects with partial-thickness or deeper burns were randomly assigned to a control
group (without music intervention) or experimental group (with music intervention). Vital
signs, pain, and anxiety were recorded before and after treatments. There was no difference
in pretest and posttest anxiety across the groups; however, there was a difference in anxiety
between the groups. Conversely, there was a difference in pretest and posttest pain across
the groups but no difference in pain between the groups. Results showed no significant reduction in anxiety and pain during therapy with music relaxation. Limitations included
nonhomogenous groups, small sample size, potentially unrepresentative sample, variation in
exercise protocol, and small musical selection. Further research is recommended. (J Burn
Care Rehabil 2004;25:8 14)

Burn injuries are a major medical condition, often

resulting in hospital admissions, surgeries, and extensive therapies. Patients with burns as their primary
diagnosis comprise 700,000 emergency department
visits and 45,000 hospitalizations in the United States
per year.1 Occupational and physical therapists are
actively involved in the treatment of patients who
have sustained burns with the goals of achieving maximal physical and functional recovery. Burns are one
of the most painful types of trauma,2 and pain management for this injury is a well-documented problem
in all aspects of recovery.3-7 Specifically, pain control
is a common obstacle limiting occupational and physical therapy treatments.8
Patients with burns experience resting pain secondary to tissue damage and procedural pain
caused by interventions such as wound care and
range-of-motion exercises.3,6,7 Although the latter
type of pain is generally shorter in duration, it is
greater in intensity.3,6 Management of this procedural pain is critical for optimal outcomes in therapy
because range-of-motion exercises are essential in
From the Department of Rehabilitation Services, Sentara Norfolk
General Hospital, Norfolk, Virginia.
Address correspondence to Kari V. Voll, Sentara Norfolk General
Hospital, 2K Rehab, 600 Gresham Drive, Norfolk, Virginia
23507.
Copyright 2004 by the American Burn Association.
0273-8481/2004
DOI: 10.1097/01.BCR.0000105056.74606.9E

combating contractures and promoting functional

use of the involved extremities. Opioid drugs are the
primary pharmacological treatment for pain management of burn injuries,4,6 but they often do not provide complete alleviation of pain during therapeutic
interventions.8,9 High doses of opioid drugs may also
limit a patients ability to function.
In addition, repetition of these painful procedures
often creates anticipatory anxiety for patients with
burns.4,6,7 Research has demonstrated that anxiety
and pain are interrelated3,5,7,10 and that an individuals level of anxiety directly influences his or her perception of pain.5,7 This concept is supported by the
gate control theory of pain, which states that there is
a gating mechanism in the nervous system that can
block the transmission of pain sensation at the level of
the spinal cord.11 The gate control theory supports
the use of music as a distraction from noxious input.
For example, the gate control theory suggests that
cognitive processes, such as relaxation, can exert control over painful stimuli.12 Additionally, anxiety creates a state of physiological stress arousal that is manifested by increased activation of the sympathetic
nervous system.13 Literature shows that sympathetic
nervous system activity can be effectively decreased
through the use of relaxation music.14
Historically, music has been used in medical settings, such as hospital waiting rooms and dental offices, to promote relaxation;15 however, it has only
been in recent years that researchers have examined

Journal of Burn Care & Rehabilitation

Volume 25, Number 1

Ferguson and Voll

the use of therapeutic music in controlled environments for specific patient populations and procedures. Patients with cancer had decreased pain perception12 and patients with myocardial infarction had
decreased anxiety16 with the use of music. Studies
have also shown decreased anxiety for patients on
ventilator support,13 during surgical procedures,14
and during flexible sigmoidoscopy.17 Literature suggests specific guidelines for the therapeutic use of
music in medical settings. Musical selections should
have a tempo between 60 and 80 beats per
minute13,14,15 and a low pitch14,15. The patient
should choose the musical selection15,1720 and
volume.17,19,20
Given the high levels of pain and anxiety experienced by patients with burns during rehabilitation, it
has been theorized that a more comprehensive management should include not only opioid drugs but
also adjunctive techniques, such as distraction.5,7 To
date, little experimental research has been conducted
on the use of music for patients with burns.
The purpose of this study was to determine the
effects of relaxation music on levels of anxiety and
perceived pain during range of motion exercises for
patients with burns. It was hypothesized that there
would be a statistically significant reduction in measured anxiety and perceived pain during range of motion therapy for patients with burns receiving music
relaxation intervention as compared with those patients receiving no music intervention. If music relaxation is determined to be an effective adjunctive
method of pain management, an inexpensive and
therapeutic program can be developed that may improve tolerance for occupational and physical therapy
and ultimately improve functional outcomes. Future
research would then be indicated to assess the impact
of the use of music relaxation on functional out-

comes, length of hospital stay, quality of treatment,

and the cost of hospitalization.

METHODS
Sample
All adult English-speaking patients admitted to the
trauma service between January 2000 and January
2001 who had partial-thickness or deeper burns that
crossed at least one major joint and who scored 100%
on the cognitive screening tool were asked to participate. The cognitive screening tool included categories on attention, memory, orientation, command
following, and level of alertness. A score of 100% was
determined to be necessary to accurately complete
testing and actively participate in the exercises. Eleven
subjects met all criteria and consented to participate
in the study (Table 1).

Instrumentation
Pain. The self-report visual analog scale was used
for pain measurement (Figure 1). This scale has been
found to be not only valid and reliable2123 but also
effective in measuring a change in pain level during a
specific treatment.24
Anxiety. The State-Trait Anxiety Inventory
(STAI) was used to measure anxiety. It is a self-report
instrument designed to measure both state (STAI-S)
and trait anxiety (STAI-T) that consists of two scales.
The A-Trait, or trait anxiety scale, evaluates an individuals disposition to experience anxiety,10 and the
A-State, or state anxiety scale, measures situationrelated anxiety.10 The inventory is easy to score and
possesses good validity and reliability.25,26
Vital Signs. Vital signs of blood pressure, respiratory rate, and heart rate were taken before and after

Table 1. Demographic summary

Sex
Male
Female
Ethnicity
African American
Caucasian
Etiology
Flame
Steam
TBSA (%), mean
Number of joints, mean
Age (years), mean

Control

Experimental

Percent

4
2

4
1

73
27

0
6

2
3

18.2
81.8

6
0
26.8, range 750, SD 17.1
3.8, range 16, SD 2.1
38.3, range 1857, SD 16.3

4
1
14.4, range 1215, SD 1.3
2.2, range 13, SD 0.8
45.4, range 2275, SD 19.3

91
9

Journal of Burn Care & Rehabilitation

January/February 2004

10 Ferguson and Voll

Figure 1. Pain visual analog scale.

treatment using standard techniques and equipment

that met guidelines for standardization. For patients
in the burn/trauma unit, vitals signs were measured
by the Hewlett-Packard Component Monitoring
System (Hewlett-Packard, Palo Alto, CA), and for
patients in step-down units the Dinamap 8100 Portable Vital Signs Monitor (GE Medical Systems,
Schenectady, NY) was used.

Procedure
Evaluations by the occupational and physical therapists were initiated upon consultation by the physician and were conducted in accordance with the
guidelines established by the acute care rehabilitation
department. After completion of the evaluations,
consent was obtained from patients meeting the inclusion criteria and demographic information was
gathered. Subjects were randomly assigned to an experimental group (with music intervention) or a control group (without music intervention). Subjects in
both groups then completed the trait anxiety form.
Morning therapy sessions were scheduled before
daily dressing changes. At the initiation and completion of each morning therapy session, specific testing
was performed. Data were collected for pain and anxiety scores, heart rate, blood pressure, and respiratory
rate. Additionally, length of range-of-motion treatment, music selection, and pain medications administered were recorded.
Patients in the experimental group chose a musical
selection before each morning treatment session from
a choice of six cassette tapes (Lifescapes series)2732
that met guidelines for the therapeutic use of music in
medial settings. Music was played during the rangeof-motion exercises. The number of repetitions and
type of exercise (active, active-assistive, or passive)
were based on the needs of each patient.
For both groups of patients, a controlled environment was created to minimize additional variables:
treatment in the patients room with the door closed,
a research in progress do not disturb sign posted,
minimal-to-no interruptions, lights turned on, and
television turned off. Afternoon therapy sessions focused on functional activities, did not include music
intervention, and were not included in the study.
Frequencies were computed to summarize the sex,
ethnicity, and etiology of burn injuries. Tests (2)

were used to assess potential differences in the distribution of these variables between treatment groups.
Descriptive statistics were computed for interval and
ratio level variables. Independent sample t-tests were
computed to identify potential differences between
treatment groups in STAI-T scores, age, length of
treatment, TBSA, and number of joints involved. Repeated measures analysis of variances were calculated
to compare pretest and posttreatment ratings for
pain, anxiety, blood pressure, heart rate, and respiratory rate between the treatment and control groups.
Pearson correlation coefficients were computed to
examine the relationships between age and change in
ratings of pain and anxiety and also between length of
treatment session and change in ratings of pain and
anxiety. Kendalls tau b were computed to assess the
relationship between gender and change in ratings of
pain and anxiety. For all statistical analyses, a P value
of .05 was considered to be statistically significant.

RESULTS
Many variables were examined to rule out potential
differences between treatment and control subjects.
Independent sample t-tests were computed to assess
group differences based on trait anxiety (STAI-T)
scores, age, length of treatment, TBSA, and number
of joints involved (Table 2). No significant differences were found between the two groups based on
length of treatment session (P 9.72, t 4.81, df
62), trait anxiety scores (P .09, t 1.92, df 8),
or age (P .55, t .62, df 8). There was a statistically significant difference between the two groups
based on TBSA affected (P .00, t 4.74, df 10,
treatment group mean, 14.4%, range, 1215, SD
1.34; control group mean, 26.8%, range, 750, SD
17.07) and number of joints involved (P .02, t
2.72, df 12, treatment group mean, 2.2 joints,
range, 13, SD 0.84; control group mean, 3.8 joints,
range, 1 6, SD 2.14). Tests (2) were computed to
assess group differences based on sex, ethnicity, etiology, and medication (premedicated vs not premedicated) (Table 3). There was no significant difference

Table 2. Group differences by t-test analysis

Trait anxiety
Age
Length of session
TBSA (%)
Number of joints

Independent Sample
t-Test

Significance

P .09 t 1.92 df 8
P .55 t .62 df 8
P 9.72 t 4.81 df 62
P .00 t 4.74 df 10
P .02 t 2.72 df 12

No
No
No
Yes
Yes

Journal of Burn Care & Rehabilitation

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Ferguson and Voll

Table 3. Group differences by 2 analysis

2 Test
Sex
Ethnicity
Etiology
Medication

Significance

P .00
P .00
P .00
P .40

Yes
Yes
Yes
No

based on medication (P .40, treatment group: 42%

no medication, 31% premedication, 27% patient-controlled analgesia; control group: 56% no medication,
29% premedication, 15% patient-controlled analgesia). However, there was a statistically significant difference between the two groups based on sex (P
.00, treatment group: 92% male and 8% female; control group: 46% male and 54% female), ethnicity (P
.00, treatment group: 58% African American and 42%
Caucasian; control group: 100% Caucasian), and etiology (P .00, treatment group: 69% flame and 31%
steam; control group 100% flame).
Repeated-measures mixed analysis of variances
were computed to compare pretreatment and posttreatment ratings of pain, state anxiety, blood pressure, heart rate, and respiratory rate between the experimental and control groups (Table 4). Results
were computed for both across-group and betweengroup effects. First, the results were analyzed for significance across groups to look for differences in pretest and posttest scores within each group of subjects.
There were statistically significant differences between pretreatment and posttreatment ratings for
pain (P .04, F 4.22, df 1) and respiratory rate
(P .002, F 10.91, df 1) across the groups.
Subjects in both the control and experimental groups
demonstrated a statistically significant increase in
posttreatment pain and respiratory rate as compared
with pretreatment scores. There were no statistically
significant differences between preteatment and posttreatment ratings for heart rate (P .27, F 1.27, df
1), systolic blood pressure (P .27, F 1.23, df

11

1), diastolic blood pressure (P .75, F .11, df 1)

or state anxiety (P .94, F .01, df 1) across the
groups. Next, the results were analyzed for significance between groups to look for differences overall
between each group of subjects. There was a statistically significant difference between the two groups
based on state anxiety (P .04, F 4.47, df 1).
The mean pretreatment and posttreatment state anxiety scores for the control group were greater than
those for the experimental group. There were no statistically significant differences between the two
groups based on ratings of pain (P .38, F .79, df
1), heart rate (P .29, F 1.13, df 1), respiratory rate (P .54, F .38, df 1), systolic blood
pressure (P .30, F 1.12, df 1), or diastolic
blood pressure (P .84, F .04, df 1).
Further analysis included correlations to examine
relationships between variables. Pearson correlation
coefficients indicated no significant relationship between age and change in pain (r .27), age and
change in state anxiety (r .20), length of treatment session and change in pain (r .09), or length
of treatment and change in state anxiety (r .01).
Kendalls tau b indicated no significant relationship
between sex and change in pain (r .01) or sex and
change in state anxiety (r .11; Table 5).

DISCUSSION
In recent years, researchers have examined the effects
of therapeutic music on pain and/or anxiety in specific patient populations and during procedures. Because of the limited research on the use of music in
patients with burns and the well-documented problems of pain and anxiety during rehabilitation for
these patients, this study was undertaken to determine the effect of relaxation music on perceived levels
of pain and anxiety during range of motion exercises.
The results did not indicate any statistically significant
reduction in anxiety or pain during range of motion
therapy for patients with burns receiving music relax-

Table 4. Group differences by ANOVA analysis

Heart rate
Systolic blood pressure
Diastolic blood pressure
Respiratory rate
Pain rating
Anxiety score
ANOVA, analysis of variance.

Across-Group
ANOVA

Across-Group
Significance

Between-Group
ANOVA

Between-Group
Significance

P .27 F 1.27 df 1
P .27 F 1.23 df 1
P .75 F .11 df 1
P .00 F 10.91 df 1
P .04 F 4.22 df 1
P .94 F .01 df 1

No
No
No
Yes
Yes
No

P .29 F 1.13 df 1
P .30 F 1.12 df 1
P .84 F .04 df 1
P .54 F .38 df 1
P .38 F .79 df 1
P .04 F 4.47 df 1

No
No
No
No
No
Yes

Journal of Burn Care & Rehabilitation

January/February 2004

12 Ferguson and Voll

Table 5. Correlations

Age
Length of treatment
Sex

Change in
Pain

Change in
Anxiety

r.27
r.09
r.01

r.21
r.01
r.11

ation intervention as compared with those patients

receiving no music intervention.
Data analysis indicated that each group experienced a change in the level of perceived pain as well as
a change in respiratory rate, but it did not indicate a
change across the groups for heart rate, blood pressure, or state anxiety (Figures 2 4). Subjects in both
the experimental and control groups experienced an
increase in respiratory rate and perceived pain with
range of motion without a change in anxiety. When
examining differences between groups, it was noted
that although there was no difference between the
experimental and control groups for pain and vital
signs, there was a significant difference for anxiety.
Although the change in anxiety was not significant
across the groups, the difference was significant between the two groups. It was noted that he experimental group experienced less anxiety than the control group (Figure 4). Results of the correlations
revealed that the change in pain and change in anxiety
scores were not related to age, sex, or length of
treatment.
Several limitations to this study have been identified that included a difference in group characteristics, a small sample size, a potentially unrepresentative
sample, a small musical selection, a variation in exercise protocol, and the implementation of a new burn

Figure 2. Pain rating across groups. VAS, visual analog

score.

Figure 3. Respiratory rate (breaths per minute) across

groups.

Figure 4. State anxiety score across groups.

pathway which limited the number of appropriate

subjects. A combination of these factors may have
affected the results. Despite careful study design and
random assignment of subjects, it was found that the
two groups of subjects were not homogenous with
respect to TBSA, number of joints involved, sex, ethnicity, or etiology. They were, however, similar based
on age, medication, length of treatment, and trait
anxiety. The small sample size affected these results.
The two characteristics that were controlled through
the study design were length of treatment session and
premedication, which were similar between the two
groups.
These differences were at least in part the result of
a small sample size. There were 64 burn admissions
with a greater than 48-hour length of stay during the
time of the study (Sentara Norfolk General Hospital
Burn/Trauma Service, Norfolk, VA). However,
many patients were excluded based on cognitive status and lack of joint involvement. A large portion of

Journal of Burn Care & Rehabilitation

Volume 25, Number 1

potential subjects did not demonstrate the ability to

participate because of a medical need for sedation.
Additionally, a small percentage of potential subjects
required immediate surgical management of their injuries, which excluded them from participating in the
study. This small sample size limited the significance
of our results and the ability to generalize the results
to the national burn population.
Although this sample was comparable with the national statistics for proportion of male and Caucasian
patients, this study indicated greater TBSA involvement
that may not be representative of the burn population as
a whole.1 The average size of a burn injury for patients
admitted to a burn center is 13.4% TBSA nationally,33
whereas this studys sample yielded a mean of 21%
TBSA. These characteristics of the sample may have limited the ability to generalize the results.
The authors also limited the musical selection to six
cassette tapes that were characterized as relaxing in nature. Review of other medical research showed no standard technique for the amount of musical selection provided. All studies reviewed except one allowed the
patient to choose their selection from the available options.13,14,18,20,26,27 Of the studies that documented
the number of musical selections provided, the choices
ranged from 4 to 50.13,14,18,20,27 This studys offering
of six tapes fell within the range of music provided in
other research. Although no complaints were voiced,
enabling the patient to listen to his or her own selection
may have impacted the level of relaxation and subsequently the levels of pain and anxiety.
The authors did not standardize the number of
repetitions of each exercise or the type of exercise
performed to allow the needs of each patient to be
met. This variability may have impacted the level of
pain and anxiety experienced.
During the course of this study, the hospital implemented the use of a new burn dressing that required
immobilization of the involved extremity for 24 to 48
hours, thus reducing the need for early therapeutic intervention. This drastically limited the number of potential participants and resulted in termination of this
study.
Despite these limitations, this study has sound theory and suggests an adjunctive treatment approach
that may be beneficial in the rehabilitation of patients
with burns. This study would be worthy of duplication and further exploration.

CONCLUSIONS
The results of this research indicated that there was
not a statistically significant reduction in anxiety and
pain during range of motion therapy for patients with

Ferguson and Voll

13

burns receiving music relaxation intervention as compared with those patients receiving no music intervention. However, further research in this area is recommended in facilities with the potential for a larger
sample size.
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