Music's Use for Anesthesia and Analgesia

Abstract

This review article provides an overview of published data regarding the involvement of music in anesthesia practice. Music is an important topic for research in different fields of anesthesiology. The use of music preoperatively is aimed at reducing anxiety, stress, and fear. However, the effect of music on perception of pain intraoperatively is controversial, according to studies of both adults and children undergoing various surgical procedures under general and/or regional anesthesia. In postoperative pain management, postanesthesia care, and neonatal intensive care, music can be a complementary method for reducing pain, anxiety, and stress. Music is a mild anxiolytic, but it is relatively ineffective when a pain stimulus is severe. However, music is inexpensive, easily administered, and free of adverse effects, and as such, can serve as complementary method for treating perioperative stress and for acute and chronic pain management, even though music's effectiveness depends on each individual patient's disposition and severity of pain stimulus.

Introduction

R elieving pain has always been an essential objective of medical practice. The capacity of music to soothe patients who are in pain has been used in many traditional forms of medicine. Many alternative methods for pain management are in use and have been studied to determine their effects for treating both physical and emotional pain in patients in hospital settings. The American Music Therapy Association (2005) defines music therapy as the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.¹ Music is used in general hospitals to alleviate pain in conjunction with anesthesia or pain medication, elevate patient's mood and counteract depression, promote movement for physical rehabilitation, calm or sedate, often to induce sleep, counteract apprehension or fear and lessen muscle tension for the purpose of relaxation, including the autonomic nervous system.^2

–8

A literature search was conducted using the PubMed database to assess the effect of music on pain and anxiety during perioperative period and music's effect on chronic pain. The objective of this review was to determine the effect of music on perioperative stress and anxiety, perception of pain during procedures, postoperative pain intensity or analgesic requirements, and treatment of chronic pain.

The inclusion criteria were randomized controlled trials, meta-analyses, and reviews and controlled clinical trials written in English, included on PubMed during the last 20 years, and based on holistic care perioperatively. The search terms used were: music, anesthesia, analgesia, and chronic pain. Abstracts, case reports, and studies that did not refer to statistically significant results were not included. Because there is a vast scope of literature on alternative and complementary methods in anesthesiology, this review concentrated on the effect of music in anesthesiology practice.

Music in the Preanesthetic Stage

Several investigators studied the effect of music during the preanaesthetic stage on patients' preoperative stress and anxiety levels as well as patients' postoperative analgesia requirements. The researchers used questionnaires, anxiety/stress scales, and physiologic parameters that were mainly supportive of the information provided by the patients (Table 1). Lee et al. showed that listening to music during the preoperative stage is a safe, inexpensive, and effective method of reducing the stress and anxiety in surgical patients.⁹ Ganidagli et al. stated that patients who listened to music after premedication with midazolam presented with an increased level of sedation preoperatively, compared with what occurred in a control group (patients who did not receive music), as shown by a lower electroencephalograph bispectral index (BIS).¹⁰ Bringman and colleagues also compared preoperative midazolam with relaxing music and concluded that relaxing music decreased the level of anxiety in a preoperative setting to a greater extent than orally administrated midazolam did, as shown by State-Trait Anxiety Inventory state anxiety scores.¹¹

Table 1.

Studies Investigating Effect of Music During Preoperative Stage on Patients' Preoperative Anxiety/Stress and on Postoperative Analgesic Requirements

Authors (year)/kind of study	N	Method/kind of music	Results	Evidence	p-Value
Lee et al. (2004)/controlled clinical study⁹	13	Vital signs/STAI scale/music of patient's choice	Reduced physiologic parameters/anxiety	+	p<0.005
Ganidagli et al. (2005)/randomized controlled study¹⁰	54	OAAS score & BIS value favorite music	Enhanced sedation & reduced BIS value	+	p<0.05
Bringman et al. (2009)/randomized controlled study¹¹	372	Anxiety scores relaxing music	Decreased anxiety level with music vs. midazolam	+	p<0.001
Allen et al. (2001)/randomized controlled study¹³	40	BP, HR, patient reported stress & coping levels/music of patients' choice	Reduced BP & decreased stress	+	p<0.001
Tusek et al. (1997)/clinical trial¹⁴	130	Patients' anxiety levels, pain perceptions, narcotic medication requirements/music and guided imagery tapes	Reduced preoperative anxiety & postoperative pain (50% lower narcotic medication requirement in intervention patients than in controls)	+	p<0.05

N=number of participants.

Evidence: + indicates that there were supportive data.

STAI, State-Trait Anxiety Inventory; OAAS, Observer Assessment of Alertness/Sedation Scales; BIS, bispectral index, BP, blood pressure, HR, heart rate.

Some studies evaluated the effect of preoperative use of music on perioperative hemodynamic response related to stress. Yung et al. observed a reduction in arterial pressure and stress assessed by a stress questionnaire in patients undergoing transurethral resection of the prostate and who listened to slow-rhythm soft music preoperatively.¹² Allen et al. studied the effects of selected music themes on elderly patients scheduled for elective ophthalmologic day-care surgery.¹³ The study showed showed that stress, as assessed by a 7-point Likert-type scale, was reduced and observed that fewer hypertensive episodes occurred during surgery.

Tusek et al. found that the preoperative use of music tapes along with postoperative use of guided imagery tapes (narrated relaxation and imagery instructions accompanied by soothing music) in patients undergoing elective colorectal surgical procedures resulted in less postoperative pain, anxiety, and analgesic demands as well as earlier bowel mobility.¹⁴

Music in the Operating Room

The effect of music during surgery under general or regional anesthesia has also been studied.

There are limited and conflicting data regarding the role of music during surgery under general anesthesia on both intraoperative anaesthetic and postoperative analgesic requirements. Relaxing music during gynecologic surgery under general anesthesia has been found to decrease intraoperative analgesic requirements, produce better quality of analgesia during the first postoperative day, and allow earlier mobilization of patients.¹⁵ However, music did not reduce bispectral index (BIS)–guided sevoflurane requirements during laparoscopic cholecystectomy or postoperative analgesic demands.¹⁶

Surgical procedures under regional anesthesia usually require sedation to reduce patients' fear or anxiety related to ambient operating room noise (technical discussions by surgical staff members or the sounds of surgical instruments). The effect of music on patients' sedative and/or analgesic requirements during regional anesthesia is shown in Table 2.

Table 2.

Studies Investigating Effect of Music During Regional Anesthesia on Patients' Intraoperative Anxiety/Stress and Analgesic Requirements

Authors (year)/kind of study	Surgery	N	Method/kind of music	Results	Evidence	p-Value
Maeyama et al.¹⁷ (2009)/RCT	NM	58	BIS value & anxiety levels/favorite music	Decreased BIS values and anxiety levels	+	p<0.01
Koch et al.¹⁸ (1998)/RCT	Urologic procedures	35	Sedatives & analgesics requirements, recovery room duration & adverse outcomes/favorite music	Decreased patient-controlled sedative & analgesic requirements.	+	p<0.001 Duration of stay in PACU: NM
Ayoub et al.¹⁹ (2005)/controlled study	Urologic procedures	80	Propofol requirements/favorite music	Decreased propofol requirements	+	p<0.05
Browning et al.²³ (2000)/clinical trial	Labor	11	Interview/classical, relaxing rock music	Reduced pain & stress during labor & birth	+	NM
Phumdoung & Good²⁴ (2003)/RCT	Labor	110	VAS scale/sedative music	Reduced pain during active phase of labor (first 3 hours)	+	p<0.05
Durham & Collins²⁵ (1986)/clinical trial	Labor	30	Interview/self selected music	Subjective significance	±	NM

N=number of participants.

Evidence: + indicates the presence of supportive data and±indicates conflicting findings.

NM, not mentioned; BIS, bispectral index; RCT, randomized controlled trial; PACU, postanesthesia care unit; VAS, visual analogue scale.

There is evidence that music during urologic procedures under spinal anesthesia and sedation was effective for reducing BIS value and patients' anxiety¹⁷ and for decreasing propofol and opiate demands.¹⁸

The comparative effect of music and blocking noise on patient' sedation during procedures under regional anesthesia has been also investigated, but yielded in contradictory findings. ^19,20 Ayoub et al. reported that music decreased propofol demands significantly, compared to decreased noise perception of patients.¹⁹ (Table 2)

However, Kang and colleagues found out that blocking noise was more effective than playing music for reducing BIS scores during propofol sedation in a noisy environment.²⁰

Reports about the effect of music on labor pain are conflicting (Table 2). Clark et al. originally found music decreased sensation of pain during labor and delivery.²¹ A few years later, studies supported the concept that music reduced levels of laboring women's anxiety, decreased cardiovascular and endocrinologic stress responses, and significantly abated the need for drugs, such as sedatives and analgesics.^22,23 The positive effect of music on the sensation and distress of pain during labor was also supported by Phumdoung and Good.²⁴ Contradicting these results, Durham and Collins noticed no difference in the frequency of use of analgesics between couples who did use music and couples who did not do so.²⁵ Similarly, Kusollearjariya concluded that neither Thai classical music nor Thai folk music significantly reduced labor pain in Thailand women.²⁶

Music for Diagnostic and Interventional Procedures

Music can also be useful for interventional procedures or diagnostic tests that require the use of pharmaceutical agents in order to cope with the patient's anxiety or secure his collaboration, especially when the process is painful (Table 3).

Table 3.

Music During Gastrointestinal Endoscopic Procedures

Authors (year)/kind of study	N	Method/kind of music	Results	Evidence	p-Value
Binek et al.³⁵ (2003)/prospective study	301	Questionnaire/classical, light music	Positive attitude about music	+	NM
Lee et al. (2002)³⁰/ prospective RCT	165	Pain scores, satisfaction scores, propofol sedation requirements/classical music	Audio distraction decreases sedation requirements & pain scores	+	p<0.01
Harikumar et al.³¹ (2006)/RCT	78	Midazolam requirements, pain & discomfort scores/duration, recovery time, willingness to repeat procedure/self selected music	Music reduced midazolam requirements & discomfort scores but not pain	+	p<0.007 (midazolam) p<0.001 (discomfort)
Tam et al.³² (2008)/meta-analysis	722	Procedure time & amount of sedation/self selected music	Reduced procedure time and amount of sedation	+	p=0.08 (time) p=0.01 (sedation)
Bechtold et al.³³ (2009)/meta-analysis	712	Procedure time, sedative dose, pain, experience & willingness to repeat procedure scores/self selected music	Increased overall experience	±	p=0.09 (pain) p=0.1 (dose) p=0.06 (time) p=0.1 (willingness)
Bechtold et al.³⁷ (2006)/ randomized trial	167	Procedure time, sedation requirements & pain scores/relaxing music	Decreased discomfort	±	p=0.8 (pain)
Rudin et al.³⁴ (2007)/meta-analysis	641	Anxiety levels, sedation & procedure time	Decreased anxiety levels, sedation and proceduretime	+	0.004 (anxiety) 0.001 (sedation) 0.002 (procedure time)

A visual analogue scale was used for pain assessment.

N=number of participants.

Evidence: + indicates the presence of supportive data and±indicates conflicting findings.

RCT, randomized controlled trial; NM, not mentioned.

The supportive effect of intraoperative music on patients' discomfort during minor procedures under monitored anesthesia care (MAC) has been investigated. It seems that music produced the same sedative and anxiolytic results as 2 mg of midazolam in patients undergoing extracorporeal shock wave lithotripsy.²⁷ However, Cepeda et al. found that several nonpharmacological therapies had minimal impact when a painful stimulus was moderate-to-severe.²⁸ According to that study, 183 patients who underwent lithotripsy were divided into two groups: Patients in the first group (n=97) listened to music from 10 minutes before the beginning of the procedure until 10 minutes after its conclusion, while patients in the second group (n=96) listened to music for 10 minutes after the conclusion of lithotripsy. Alfentanil requirement, pain levels, side-effects, quality of analgesia, and patient satisfaction were similar in both groups.

The positive effect of music during gastrointestinal endoscopic procedures has not been well-established, despite the supportive data that exists. There are studies that support music therapy as an effective tool for stress relief and analgesia in patients undergoing endoscopic procedures in the digestive system.²⁹ Lee et al. have shown that classical music induced a decreased pain sensation and reduced the dose of sedative drugs required during colonoscopy.³⁰ Similar conclusions were stated by Harikumar and colleagues in a randomized controlled trial.³¹ In addition, a recent meta-analysis of studies investigating the effect of music on procedure time and amount of sedation used during colonoscopic procedures showed that listening to music is effective for achieving both goals and should be promoted.³² In addition, two other meta-analyses concluded that patients' overall experience scores were significantly improved with music.^33,34

However, Binek et al. pointed out that, although music did not alter patients' tolerance for endoscopy, a majority of patients mentioned that music helped them and that they would prefer to have music in a potential prospective examination.³⁵ Finally, Lazzaroni and Bianchi Porro, after reviewing relative studies, concluded that the role of music during colonoscopy is unclear.³⁶ Furthermore, while it has been shown that music does not result in shortened procedure times, lower doses of sedative medications, or perceived patient pain, patients who have music playing during their colonoscopic procedures report modestly greater satisfaction.³⁷

Colposcopy is another intervention, for which patients' favorite music can minimize anxiety and pain.³⁸ However, the beneficial effects of music do not apply for all endoscopic procedures as it did not reduce anxiety level in patients scheduled for bronchoscopy or sigmoidoscopy.³⁹

Music During the Postoperative Period

Pain and anxiety are common problems in postanesthesia care units (PACUs). Studies during the last decade have suggested that music reduces psychophysiologic stress, and pain and anxiety levels, as well as isolating patients from noisy PACU environments (Table 4).

Table 4.

Studies Investigating Effect of Music in PACUs

Authors/ (year) kind of study	N	Method/kind of music	Results	Evidence	p-Value
Nilsson et al.⁴⁰ (2003)/controlled study	182	If music or music in combination with therapeutic suggestions improves postoperative recovery in immediate postoperative period after daycare surgery/soft, classical music	Music with or without therapeutic suggestions in early postoperative period has a beneficial effect on patients' experience of analgesia	+	p=0.002 (pain) p<0.001 (oxygen saturation)
Nilsson et al.⁴¹ (2003)/controlled trial	151	Pain, anxiety & discomfort	Decreased pain, anxiety & discomfort	±	p<0.05
Shertzer et al.⁴² (2001)/controlled trial	97	Pain intensity/Mozart & ocean music	Music has positive effect on pain intensity	+	p=0.2
Fredriksson et al.⁴³ (2009)/randomized crossover trial	33	Degree of well-being, difference over time, importance of acoustic environment & if patients prefer listening to music during stay/relaxing music	Patients' increased well-being & preference for listening to music during PACU stay	+	p<0.001
Good et al.⁴⁴ (2002)/RCT	311	Effect of relaxation, music & combination of relaxation and effect music on pain following gynecologic surgery/self selected soothing music	Three interventions produced similar effects on pain	±	p=0.022–0.001

N=number of participants.

Evidence: + indicates the presence of supportive data and±indicates conflicting findings.

PACU, postanesthesia care unit; RCT, randomized controlled trial.

Nilsson et al. studied 182 patients who underwent day case surgery (varicose vein or open inguinal hernia repair surgery).⁴⁰ The researchers reported that patients under general anesthesia, who listened to music alone or in combination with therapeutic suggestions during the immediate postoperative period, experienced significantly less postoperative pain and had higher oxygen saturation in a PACU, compared to a control group. In another trial with 151 patients by Nilsson et al., preoperative use of music resulted in a significant decrease in pain intensity in the first 2 hours after surgery, while postoperative use of music resulted in lower use of morphine during the first hour after surgery, compared with the control group.⁴¹ Shertzer et al. and Fredriksson et al. showed that, although music did have different effects on patients' pain perception during their stay in a PACU, music decreased patients' anxiety and discomfort.^42,43 Postoperative use of music has been extended to the patients' ward. Good et al. observed 311 patients after gynecologic surgery and concluded that those who received patient-controlled analgesia (PCA) plus music as a complementary therapy had significantly less pain than those who used PCA alone.⁴⁴

Music and Postoperative Immune–Neuroendocrine Responses

Although the positive effect of music on the immune–neuroendocrine system in normal nonsurgical subjects have been proven,^45
–47 music's effect in the perioperative setting is controversial. Miluk-Kolasa et al. have found that listening to music by patients scheduled to undergo surgery resulted in a decrease in their salivary cortisol levels 1 hour after the operation.⁴⁸ Nilsson et al. also investigated the effect of music on postoperative blood cortisol levels.⁴⁹ These researchers studied 75 patients who listened to music perioperatively while undergoing open hernia repair under general anesthesia. The patients were randomly allocated to three groups: (1) intraoperative music; (2) postoperative music; and (3) silence (the control group). It appeared that patients who listened to music had significant decreases in blood cortisol levels, compared to the control group after a 2-hour stay in a PACU. The patients also had decreases in anxiety level, pain intensity, and total amount of morphine used. In contrast to these findings, Migneault and coworkers showed that music during gynecologic surgery did not affect the neurohormonal response to surgical stimuli: Plasma levels of epinephrine, norepinephrine, cortisol, and adrenocorticotropic hormone were not changed.⁵⁰

Music and Pediatric Anesthesia

Many studies have investigated the influence of music in pediatric patients (Table 5), because needle phobia and anxiety are common during the preanesthetic period, and induction of anesthesia and could affect postoperative behavior in these patients by causing sleep disorders and enuresis.⁵¹

Table 5.

Studies Investigating Effects of Music on Pediatric Anesthesia

Authors (year)/kind of study	N	Method/kind of music	Results	Evidence	p-Value
Loewy et al.⁵² (2005)/comparative study	60	Comparison of chloral hydrate & music therapy in sleep/sedation for EEG/live music	Positive	+	p<0.05
Loewy et al.⁵³ (2006)/comparative study	60	Comparison of chloral hydrate & music therapy in sleep/sedation for EEG/live music	Positive	+	p<0.05
Chetta et al.⁵⁴ (1981)/PCS	75	If music can reduce stress & anxiety during induction music therapy	Positive	+	p<0.05
Kain et al.⁵⁵ (2004)/RCT	123	If music therapy is effective treatment for preinduction anxiety; 3 groups of children: interactive music therapy (n=51); oral midazolam (n=34); or control (n=38)	Depending on the music therapist, interactive music therapy may relieve anxiety on separation & entrance in OR but appears less effective during anesthesia induction	±	p<0.05
Yip et al.⁵⁶ (2009)/meta-analysis	1796	Nonpharmacologic methods for reducing anxiety & improving cooperation	Promising nonpharmacologic interventions need to be investigated further; no effect of music therapy	±	p<0.05^a
Arts et al.⁵⁷ (1994)/RCT	180	Compare emla® & music distraction in pain during venipuncture/contemporary, upbeat music	emla product more effective	_	p<0.001
Balan et al.⁵⁸ (2009)/prospective RCT	150	Pain experienced by children undergoing venipuncture/Indian classical instrumental music	Pain during venipuncture significantly reduced by using emla or Indian classical instrumental music	+	p<0.05
Barrera et al.⁵⁹ (2002)/PCS	65	Faces pain scales for children ages ≥3; parental ratings of child's play performance using play–performance scale & satisfaction questionnaires/music therapy & playing instrument	Beneficial effects of interactive music therapy in patients hospitalized for pediatric hematology/oncology	+	p<0.01
Molassiotis & Cubbin.⁶⁰ (2004)/PCS	49	Questionnaire favorite music	Beneficial effects of music & other complementary & alternative therapies	+	NM

relative risk=0.66; 95% confidence interval=0.45 to 0.95.

N=number of participants.

Evidence: + indicates the presence of supportive data;±indicates conflicting findings, and – indicates no effect.

EEG, electroencephalographic; RCT; randomized controlled trial; emla®; a brand of lidocaine-prilocaine; OR, operating room; NM; not mentioned; PCS, prospective controlled study.

Among the published studies, there are two published by Loewy et al., comparing chroral hydrate and music therapy, in which live music was used actively and was sufficient to sedate babies and toddlers for electroencephalographic testing.^52,53

Chetta et al. investigated, if, during the perianesthetic period, music would help transmit adequate information about the surgical experience to children and if music reduces anxiety- and fear-related behaviors during induction of preoperative medication in 75 children ages 3–8.⁵³ Children who received verbal preoperative instruction plus music immediately prior to induction of preoperative medication on the morning of the surgery has lower levels of anxiety before and during induction of preoperative medication, compared to children who had verbal instruction with added music on the evening before surgery or children who had only verbal instruction on the evening before surgery. Another study showed that music therapy might help children separate from their parents when entering an operating room but has no effect on children's anxiety during induction of anesthesia.⁵⁵ In a meta-analysis, the reviewers concluded that the presence of parents during induction of general anesthesia does not reduce their children's anxiety, but the roles of nonpharmacologic interventions, such as music, clown doctors, hypnotherapy, low sensory stimulation, and video games need to be investigated further.⁵⁶

Arts et al. compared the efficacy of a lidocaine-prilocaine (emla®) emulsion versus music distraction for reducing or preventing pain caused by needle puncture (intravenous cannulation) and found out that emla was more effective than music.⁵⁷ However, a similar study showed that pain experienced during venipuncture can be reduced significantly by using either emla or Indian classical instrumental music; thus, the choice between emla and music could be decided according to logistic factors.⁵⁸

The use of music therapy in hospitalized children has been documented, but its effectiveness has not been well-established. Barrera et al. performed a study on the effectiveness of music therapy (listening to music or playing a musical instrument) for reducing anxiety in hospitalized children with cancer.⁵⁹ Sixty-five (65) children and their parents answered a questionnaire before and after therapy. Music therapy improved children's behavior. Molassiotis and Cubbin also showed that a great percentage of children and young people with cancer used alternative therapies such as aromatherapy or music therapy.⁶⁰ The results of these treatments were reinforcement of conviction, pain relief, and ability to confront anxiety.

Finally, Aucott et al. noted that low-intensity music in neonatal intensive care units (NICUs) contributed to better neurophysiologic development of premature neonates.⁶¹

Music and Chronic Pain

Chronic pain is, by definition, resistant to conventional pharmaceutical interventions. There are a few studies investigating the effect of music on chronic pain (Table 6). Siedliecki and Good investigated the effect of music on patients with nonmalignant chronic pain. The researchers concluded that music—whether provided by a researcher or chosen by individual patients—increased patients' sense of power and decreased their levels of self-reported pain, depression, and disability, compared to a control group.⁶² Music has also proven to be an effective complementary intervention for chronic pain management in patients with osteoarthritis⁶³ and rheumatoid arthritis.⁶⁴ Kenny and Faunce investigated active music therapy for patients with chronic pain.⁶⁵ The researchers concluded that active singing did have an impact on coping skills and mood as well as on perceived pain; however, these results were inconclusive and require further investigation. The impact of music and music therapy on chronic headaches has started to be examined only recently. There was only one study that met the inclusion criteria for the current review. Oelkers-Ax et al. conducted a study on 58 primary-school children with migraine.⁶⁶ Frequency of migraine attacks in these children was reduced, and, during post-treatment, a music therapy group had significant improvement, compared to other experimental groups in that study.

Table 6.

Studies Investigating Effect of Music on Chronic Pain

Authors (year)/ type of study	N	Method/kind of music	Results	Evidence	p-Value
McCaffrey & Freeman⁶³ (2003)/RCT	66	Short-form McGill pain questionnaire/self-selected music	Reduced chronic osteoarthritis pain	+	NM
Schorr⁶⁴ (1993)/clinical study	30	McGill pain questionnaire/patients' preferred music	Reduced chronic rheumatoid arthritis pain	+	NM
Beck⁷⁰ (1991)/clinical study	15	McGill pain questionnaire/VAS/free choices among 7 types of relaxing music versus a 60-cycle hum (control)	Decreased pain from using either the music or sound but no effect on mood	±	p<0.05
Kenny & Faunce⁶⁵ (2004)/clinical study	77	POMS, ZDI, PSSQ, Pain Rating Self-Statement, & Oswestry Low Back PDQ/singing simple songs with lively tempo & syncopated rhythm, accompanied on a clavinova (digital piano)	Improvement from pre- to postintervention active coping, although not maintained in follow-up; lessened pain duration; no significant effect on mood and other pain-related variables	±	p=0.033 (pain disability) p=0.08 (active coping) p=0.04 (self-efficacy)
Siedliecki & Good⁶² (2006)/RCT	60	Short form Mc Gill pain questionnaire, Centre for Epidemiology Studies Depression Scale, Pain Disability Index & Power as Knowing Participation in Change Tool (II)/ researcher-provided music versus patients' preferred music	Increased sense of power & produced less pain, depression & disability	+	NM
Oelkers-Ax et al.⁶⁶ (2008)/prospective randomized study	58	Kinder DIPS/Depression Inventory for Children and Adolescents/ Child Behavior Checklist/Stress questionnaire for children (SSK)/music therapy	Music therapy superior to placebo & butterbur (Petasites spp.) root extract post-treatment; superior to placebo in follow-up.	+	p=0.005 (post-treatment) p=0.018 (follow-up)
Gallagher et al.⁶⁹ (2006)/prospective study	200	VAS/Roger's Happy/Sad FacesAssessment Tool & adapted behavioral scale/music therapy	Improved anxiety, body movement, mood, facial expression, pain, & verbalization & reduced shortness of breath in patients; improved families' facial expressions, mood & verbalizations	+	p<0.001
Pothoulaki et al.⁷⁴ (2008)/control study	60	VAS/McGill pain questionnaire & customized music evaluation questionnaire/patients' preferred music	Lower levels of state anxiety & pain intensity in post-test phase.	+	p=0.001

N, number of participants.

Evidence: + indicates the presence of supportive data and±indicates conflicting findings.

RCT, randomized control trial; NM, not mentioned; VAS, visual analogue scale (for pain assessment); POMS, Profile of Mood States; ZDI, Zung Depression Inventory; PSSQ; Pain Self-Efficacy Questionnaire; PDQ, Pain Disability Questionnaire; Kinder DIPS, semi-structured diagnostic interview for mental disorders in children and adolescents; SSK, Stresserleben and Stressbewältigung in Kindesalter.

There are also several studies that evaluated the effects of music therapy on quality and length of life in patients diagnosed with terminal cancer who were either hospitalized or receiving hospice care. The results of these studies were not conclusive. Quality of life (QoL) has been shown to be better in patients with terminal cancer who received music therapy in addition to routine hospice services, compared to patients who did not. Igawa-Silva et al. highlighted the role of music as an effective distracter during invasive procedures and chemotherapy for cancer.⁶⁷ Most research findings confirmed the importance of music in end-of life care as a means of reducing stress and anxiety; and enhancing patient receptivity, satisfaction, movement, verbalization, and overall QoL^68,69; however, there were no significant differences between groups in physical functioning, length of life, or time of death.⁷⁰ The most intriguing aspect of two of the abovementioned studies^68,69 was their focused attention on family and caregivers. Music facilitated interaction and expressed emotion profoundly among dying patients and their loved ones,⁶⁸ thus calming patients and their families/caregivers.⁶⁹

As systematically as it has been proven that music generally decreases anxiety and improves mood and experience in hospitalized patients the mechanisms of this are not yet fully understood.^69

–73 Most researchers seem to agree that music can affect the perception of pain by distracting individuals from the experience of pain.^64,67 Few studies have focused on the characteristics of music used. Kemper et al. did include in their sample different kinds of music and the emotional reactions they induced; however, the researchers did not mention the effect of each genre of music on pain management.⁶⁸ Siedliecki et al.⁶² did not find any difference between music chosen by patients or provided by a researcher—a result that was contradicted by Pothoulaki et al., who concluded that preferred music listening was more effective for lowering anxiety and pain in patients undergoing hemodialysis treatment.⁷⁴ An interesting objection to this finding came from McCraty et al., who compared the emotional reactions induced by four different types of music.⁷⁵ Classical music was effective only for decreasing tension and New Age music was effective only for increasing relaxation. Relaxation music proved the most effective because it succeeded both in increasing relaxation, mental clarity, vigor, and in decreasing tension and fatigue. Grunge/rock music induced consistently negative psychologic and emotional feelings, even when this kind of music was chosen by the patients. Zhao & Chen, however, were the only researchers who examined music characteristics in relation to pain management in particular⁷⁶ findings of these researchers suggested that only the valence of music (pleasant versus unpleasant) was associated with lower pain rates while mood (happy versus sad) was not. Boyd-Brewer and McCaffrey underscored the therapeutic effect of sound vibrations rather than music per se.⁷⁷

Discussion

Most published research suggests that music improves patients' psychologic status and reduces stress during the preoperative period by decreasing anxiety and fear.

The effectiveness of music during the operative period is unclear. Use of music during operations seems to contribute to lowering blood pressure, heart rate, and analgesic drug requirements. Music has a greater positive impact on patients who undergo surgical procedures under regional anesthesia, because music reduces the anxiety and fear of being awake and becoming apprehensive when hearing sounds in the operating room. Music also improves patients' psychologic status and tolerance during endoscopic colposcopy or colonoscopy procedures. Music also seems to affect acute pain perception during painful procedures, by reducing both analgesic requirements and pain scores, depending on stimuli severity. Using music during delivery may reduce parturients' anxiety and pain perception, and decrease use of analgesic and anesthetic drugs.

Moreover, there is evidence that perioperative use of music may decrease neuroendocrine responses to surgery. Music is beneficial as a complementary therapy in PACUs, both in adults and in children, by reducing their anxiety and discomfort. When using music, patients report less embarrassment from noise caused by staff members voices and equipment, greater perception of availability of nurses and medical staff members, and significantly more positive perception of their stays in the PACUs. Furthermore, using low-intensity music in NICUs enhances neurophysiologic development of premature infants.

In children, music therapy seems to facilitate easier separation from parents and entrance into the operating room, but it is controversial whether music affects children's preoperative stress and anxiety.

Finally, music has an important role in managing chronic pain, although this topic is still open for discussion. Patients suffering from nonmalignant chronic pain or who have been diagnosed with terminal cancer may benefit from use of music as a cost-effective complementary treatment for pain, anxiety, and depression; and to improve QoL and communication with loved ones. However, it has been noted that some research findings have failed to support music as an effective pain-management method at all, especially given that the magnitude of music's benefits is rather small.

In this review, investigation of the effectiveness of specific types of music used in studies to determine if one type of music is better than other types was not possible. There were issues, such as too few studies, different circumstances of the study populations, and different outcomes presented. The majority of the studies reviewed utilized recorded music of patients' choice, a fact that can make sense given the music preferences vary among people according to age or cultural or social backgrounds. A study by Siedlecki demonstrated that music can be an effective intervention for individuals with chronic nonmalignant pain and that individuals from different racial backgrounds may respond differently to various kinds of music.⁷⁸ Yet, Nilsson et al. found no difference between music and control groups regarding any trial endpoints or gender-related differences.⁷⁹ Further studies are needed to understand these differences in responses to music.

Conclusions

According to the reviewed, use of music is recommended as an inexpensive, easy-to-provide complementary therapy that is without side-effects for addressing preoperative, operative and postoperative stress as well as for managing acute and chronic pain, although music's effectiveness depends on individual patients' dispositions.

Footnotes

Disclosure Statement

No competing financial interests exist.

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