Effect of Music on Postoperative Pain and Physiologic Parameters of Patients After Open Heart Surgery

Nadiye zer, PhD, RN, Zeynep Karaman zl, MSc, RN, Sevban Arslan, PhD, RN, Nezihat Gnes, RN

Abstract and Introduction

Abstract The aim of this study was to investigate the effect of listening to personal choice of music on self-report of pain intensity and the physiologic parameters in patients who have undergone open heart surgery. The study design was quasiexperimental. Patients were selected through convenience sampling in the Cardiovascular Surgery Intensive Care Unit at a university hospital. The study was conducted with a total of 87 patients who underwent open heart surgery: 44 in the music group, 43 in the control group, ages between 18 and 78 years. Through pretest-posttest design, postoperative first-day data were collected. First, physiologic parameters (blood pressure, heart rate, oxygen saturation, and respiratory rate) were recorded and a unidimensional verbal pain intensity scale applied to all participants. Later, the control group had a rest in their beds while the music group listened to their choice of music for 30 minutes. Physiologic data were then collected and the pain intensity scale applied once more. In the music group, there was a statistically significant increase in oxygen saturation (p = .001) and a lower pain score (p = .001) than in the control group. There was no difference between the groups in the other physiologic parameters. Results of this research provide evidence to support the use of music. Music might be a simple, safe, and effective method of reducing potentially harmful physiologic responses arising from pain in patients after open heart surgery. Introduction Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Although pain is a predictable part of the postoperative experience, inadequate management of pain is common and can have profound implications. Unrelieved postoperative pain may result in clinical and psychologic changes that increase morbidity, mortality, and costs and decrease the quality of life (Apfelbaum, Chen, Mentha, & Gan, 2003; Tse, Chan, & Benzie, 2005). Moreover, negative clinical outcomes resulting from ineffective postoperative pain management include deep vein thrombosis, pulmonary embolism, coronary ischemia, myocardial infarction, pneumonia, poor wound healing, insomnia, and demoralization (Apfelbaum, Chen, Mentha, & Gan, 2003). Moderate to severe postoperative pain is experienced by >80% of patients having surgery (Allred, Byers, & Sole, 2010). Pain has also been reported as one of the primary sources of concern for cardiac surgery patients, and postoperative pain management is important owing to the increasing number of patients

undergoing open heart surgery (Mueller et al., 2000, Sendelbach et al., 2006, Twiss et al., 2006, Voss et al., 2004). Postoperative pain for the cardiac surgery patients has many facets. Pain can be caused by incisions, intraoperative tissue retraction and dissection, multiple intravascular cannulations, chest tubes left after surgery, and multiple invasive procedures that patients undergo as part of their therapeutic regimen (Mueller et al., 2000). In one study, patients reported chest incision pain as a problem after coronary artery bypass graft (CABG) surgery (Puntillo & Weiss, 1994). Because of pain, patients cannot take deep breaths, cough, or start moving around as soon as they should, and this delays their recovery. Poorly controlled pain also contributes to hemodynamic instability, which can lead to myocardial ischemia (D'Arcy, 1999). Associated with these complications are economic and medical implications, such as extended lengths of stay and patient dissatisfaction with medical care (Apfelbaum et al., 2003). It is proposed that effective management of postoperative pain in patients who have undergone CABG surgery can be an important factor in overall recovery. Pharmacologic management should continue to be the cornerstone of the treatment of postoperative pain (Zimmerman, Nieveen, Barnason, & Schmaderer, 1996); however, nonpharmacologic methods of pain management are advantageous, in part because they can enhance the effect of pain-relieving medications. In addition, these techniques can help patients achieve a sense of control over pain (VanKooten, 1999). Nurses spend more time with patients experiencing pain than any other health care professional and are therefore in an ideal position to consider other pain-relieving strategies to complement the analgesics currently used (Dunn, 2004). Cognitive-behavioral intervention, such as music, for pain management is recommended by the Agency for Healthcare Research and Quality (Sendelbach et al., 2006). The commonly accepted theory explaining the pain-, anxiety-, and stress-reducing effects of music is that music acts as a distracter, focusing the patient's attention away from negative stimuli to something pleasant and encouraging. Music also occupies the patient's mind with something familiar and soothing, which allows the patient to escape into his or her own world (Nilsson, 2008). Additionally, Watkins (1997) indicated that music exerts its effect through the entrainment of body rhythms. Entrainment is defined as the tendency for two oscillating bodies to lock into phase and thus vibrate in harmony (Chlan, 1998); this is like individual pulsing heart muscle cells, which, when they are brought close together, begin pulsing in synchrony (Watkins, 1997). Listening to music is theorized to release endorphins and to reduce catecholamine levels, thereby resulting in lower blood pressure and a decreased need for analgesics. In addition, heart rate and respiratory rate are improved and oxygen consumption decreases (Chan et al., 2006, Twiss et al., 2006). Additional advantages of using music therapy in pain relief are that it is not harmful to patients, it has minimal risks, and its costs are low, which means that music therapy has great potential to reduce suffering (Chan et al., 2006). As a specific nursing intervention, music was found to be advantageous, particularly owing to its lack of adverse reactions and as a noninvasive therapy, its relative inexpensiveness, and its ease of administration (Lim & Locsin, 2006). Therefore, it can be said that music therapy is important to relieve pain and improve (balance) some physiologic parameters, such as blood pressure, heart rate, respiratory rate, and oxygen saturation in the postoperative period.

Our nursing degree programs are designed for working nurses like you Learn how our accredited nursing degree programs make higher education more accessible. Explore our flexible learning options Information from Industry In examining the effects of music on patients who have undergone CABG surgery, a number of studies have demonstrated decreases in postoperative pain (Aragon, Farris & Byers. 2002; Sendelbach et al., 2006, Voss et al., 2004, Zimmerman et al., 1996), whereas Nilsson (2009) found no difference in pain. In researching the effect of music intervention on physiologic parameters, some studies have indicated that music intervention improves some physiologic parameters, such as systolic blood pressure, diastolic blood pressure, or heart rate (Aragon et al., 2002, Byers and Smyth, 1997), whereas others showed that music has no effect on these parameters (Nilsson, 2009, Sendelbach et al., 2006). Due to the differences in these study findings (Aragon et al., 2002, Byers and Smyth, 1997, Nilsson, 2009, Sendelbach et al., 2006), further studies are necessary to investigate the effectiveness of music to alter physiologic parameters and control pain. In addition, there are minimal studies investigating the effect of music on patients who have undergone open heart surgery (Aragon et al., 2002; Byers & Smyth, 1997; Nilsson, 2009, Sendelbach et al., 2006) and there is no descriptive and experimental study that investigates the effect of music on these patients in Turkey. This underpinned the need for the present study. The aim of this study was to investigate the effect of listening to personal choice of music on self-report of pain intensity and the physiologic parameters in patients who have undergone open heart surgery.

Section 1 of 6 Next: Methods

Subjects and Setting The study used a quasiexperimental design. The study was carried out in the Cardiovascular Surgery Intensive Care Unit, Research Hospital, Atatrk University, Erzurum, in the east of Turkey, between September 15, 2007, and February 15, 2008. The study used a two-group pretest-posttest design. Patients were assigned via convenience sampling to either the music or the control group. Strict inclusion and exclusion criteria were established to minimize sample variability. Patients were eligible to participate if they were 18 years old, could speak Turkish, and were on their first postoperative day after CABG or valve replacement. Exclusion criteria were an emergency operation, chronic pain problems, or any hearing impairment, cognitive impairment, difficulties cooperating during measurements, and hemodynamic instability.

The literature indicates that if data collected in experimental studies are evaluated by measurement and the number in all groups is >30, parametric tests should be used in data analysis (Aksakolu, G, 2001, zdamar, 2003, Smblolu & Smblolu 1997). In the present study, in acknowledging this requirement, earlier studies in this area were used as a reference to evaluate pain intensity and physiologic parameters with a parametric test. (Nilsson, 2009, Sendelbach et al., 2006, Twiss et al., 2006). For each group, it was assumed that the power analysis of the study would be 99% when 45 patients with .05 alpha level and 95% reliability levels were included in the study. Thus, a total of 90 patients fulfilling the inclusion criteria were assigned to the control or the experimental group (45 in the music group, 45 in the control group). During the study, one patient in the music group and two patients in the control group withdrew. On completion, the statistical power of the study was found to be 99% in the power analysis made with pain variables in the music group. Instruments The study instrument was divided into three parts: Demographic Variables Demographic variables were age, gender, marital status, education level, and region of incisional pain. For the patients undergoing open heart surgery, incisional pain from a median sternotomy is generally located along the site of the chest incision. This pain for the patients with CABG surgery may also radiate to the subclavicular regions, because an internal mammary artery is generally taken from the inside of the chest wall. Alternatively, if saphenous veins from the legs are harvested rather than the mammary arteries, then the pain might also be experienced in the leg. This pain is said to be intense during the first 3 days after surgery (Zimmerman et al., 1996). In the present study, data were collected from the patients undergoing CABG surgery or valve replacement surgery. For those patients undergoing valve replacement surgery, the incision region was in the sternum. However, in patients undergoing CABG surgery, the incision regions were sternum and leg where the saphenous vein was removed. Thus, two different pain regions were determined by taking the region of incisional pain into consideration (1 = chest incisional pain region; 2 = chest and leg incisional pain regions). Physiologic Parameters Physiologic parameters were systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), oxygen saturation (SpO2), and respiratory rate (RR), measured by using the GE Healthcare Datex-Ohmeda S/5 Critical Care Monitor (GE Healthcare Finland, Helsinki, Finland). Unidimensional Verbal Pain Intensity Scale It is suggested that pain evaluation instruments should be used to determine the intensity of pain in clinical practices. These instruments comprise both unidimensional and multidimensional scales. It is pointed out in the literature that features of the patient group to whom the scale is applied influence which scale is to be used. A nontime-consuming, accurate, simple pain evaluation instrument is important in the intensive care unit (ICU) (Eti Aslan, 2006, Karayurt and Akyol, 2008). The advantages of a unidimensional verbal pain intensity scale are that it is easily applied and its classification is

simple. In this scale, the patient chooses the most suitable word that describes pain intensity. (Eti Aslan, 2006). To describe the intensity of pain,Melzack and Katz (1992) used the terms: "hurts a little bit," "hurts a little more," "hurts even more," "hurts a whole lot," and "hurts worst." Participants in the present study were the ICU patients on the first day after their surgery. A unidimensional verbal pain intensity scale was used so that participants could self-report their pain intensity. The measurement instrument described as unidimensional verbal pain intensity scale in literature is composed of one question (Eti Aslan, 2002, Gdc Tfeki and Erci, 2005, Karata, S, 2010). In this measurement instrument, the participants are asked a question: "Which of the following phrases best describes your current pain? The participants answered this question choosing one of the phrases "hurts a little bit," "hurts a little more," "hurts even more," "hurts a whole lot," and "hurts worst." In this study, each pain statement was scored by the researchers from 1 to 5 where "hurts a little bit" = 1, "hurts a little more" = 2, "hurts even more" = 3, "hurts a whole lot" = 4, and "hurts worst" = 5 (Eti Aslan, 2006). The participants' pain intensities were calculated by taking the mean of pain scores converted to numerical values. The lowest pain intensity was 1 and the highest one was 5. Procedures The study was approved by the Ethics Committee of Health Sciences Institution, Atatrk University, and verbal consent was obtained from each participant. Furthermore, written permission to conduct this study was obtained from the Head of the Cardiovascular Surgery Department. Following the completion of data collection, patients in the control group listened to music for 30 minutes with earphones via a portable cassette player, selecting the music they would like to listen to from the researcher's collection. To avoid bias, participants were not told whether they were part of the study group or the control group. Data were collected first from the music group and second from the control group. All patients in both groups received standard postoperative care according to protocols developed by the cardiovascular surgeons and nurses. The data were collected between 3.00 p.m. and 4.00 p.m. when the traffic in ICU was not intense and the patients were not receiving invasive or noninvasive procedures. All patients were scheduled to rest in bed at 3.00 p.m. on the first postoperative day in ICU. All of the patients also received oxygen support, and analgesia was standardized for all patients. All of the patients received 50 mg pethidine HCl (Aldolan), a narcotic analgesic. This medically prescribed analgesic was given via intramuscular injection at 8:00 a.m. by the ICU nurse, who was one of the researchers. At 2:45 p.m., the researcher helped the patients to lie down in bed at an angle of 30-40 degrees. Demographic and physiologic data were then collected; to assess the pain, patients were asked to complete a unidimensional verbal pain intensity scale while in their beds. Physiologic data (SBP, DBP, HR, and SpO2) were measured in the ICU with the bedside patient monitor. The researcher observed each participant's chest movements and counted their RR for 1 minute. The patients allocated to the music group were asked what kind of music they liked, and they selected the music from the researcher's collection of 20 musical pieces, which comprised a variety of different types of music, including Turkish classical music, Turkish folk music, and Turkish art music. The participants listened to music through earphones via a portable cassette player for 30 minutes. The music was soft and relaxing and played at a volume of 50-60 dB. The

earphones helped the participants to focus on the music. Because the participants were listening to music through earphones, external noises were diminished. The researcher stayed with the patients during the whole intervention period for data collection. The music volume was adjusted to a satisfactory level based on the subjects' facial expressions and verbal feedback; they smiled and looked calm when satisfied with the volume or expressed their dissatisfaction with the volume verbally if it was too loud or too soft. Physiologic parameters and pain intensity were assessed and recorded immediately after 30 minutes of music was completed. Data were collected from the control group at the same intervals as from the music group, but without making them listen to music. After recording pretest physiologic parameters and pain intensity, the patients remained in their resting period until posttest evaluation time. During this period, the researcher was in the ICU. During the rest period the environment was enhanced to reduce stimuli for the control group. After recording the posttest data, patients in the control group were able to listen to music upon request. The questions regarding the pain intensity scale were read aloud to each participant who gave a verbal response. It took ~20 minutes to take the two measurements of pain level and physiologic parameters for each patient. The intervention and data collected were carried out by the same researcher. Data Analysis Data were analyzed using the Statistical Package for the Social Sciences software (version 10.0; SPSS, Chicago, IL).
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The participants' demographic features were evaluated through a nonparametric test because they were count data, and demographic characteristics of individuals in each group were compared using chi-square (Aksakolu, G, 2001, zdamar, 2003, Smblolu & Smblolu 1997). Pain intensity and physiologic parameters were analyzed through parametric tests because they were metric values (Aksakolu, G, 2001, zdamar, 2003, Smblolu & Smblolu 1997). To make a comparison of the means of physiologic parameters and pain intensity gained through measurement between groups, independent-samples t test was used. Paired t test was conducted to determine any significant difference between pretest and posttest physiologic parameters and pain scores for each group. The statistical significance level was set at .05. The independent research variable was music intervention, and the physiologic parameters and pain scores formed the dependent variables.

Demographic Data The two groups were compared regarding gender, age, marital status, education, and region of pain. There were no statistically significant differences between the two groups regarding their demographic characteristics (Table 1). More than one-half of the participants forming the music and control groups were male (control 75%, music 67.4%), and almost all of them were married (control 88.4%, music 97.7%). The participants' level of education was completion of secondary school in both groups (control 31.8%, music 44.2%). There were 54.5% of the patients in the control group and 67.4% of the patients in the music group who indicated their pain intensity in both the chest incisional pain region and leg incisional pain region. The mean ages were 57.34 12.49 years in the control group and 51.25 16.29 years in the music group. Physiologic Parameters and Pain Measures
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The comparison of the mean SBP, DBP, HR, SpO2, RR, and pain intensity at pretest and posttest between the groups is presented in Table 2. The difference between the mean pain intensity of the music group after the music therapy and the mean pain intensity of the control group after the resting period was demonstrated to be statistically significant (p = .000; 1.20 in the music group and 2.20 in the control group), but there was no difference between the pretest means. The difference between the posttest average SBP, DBP, HR, SpO2, and RR of the music group and control group was not demonstrated to be statistically significant (Table 2). The comparison of the mean SBP, DBP, HR, SpO2, RR, and pain scores at pretest and posttest within the groups are shown in Table 3. After the music therapy, the decrease in the mean pain intensity of the music group was statistically significant (p = .000): 2.13 before music and 1.20 after music. After the music therapy, the increase in the mean SpO2 score of the music group was statistically significant (p = .000): 91.7 before music and 93.1 after music. But no statistically significant differences were found for the other four variables. In the control group, no statistically significant differences were found for all variables (Table 3).

Previous Page Section 3 of 6 Next: Discussion

Discussion
In the present study, music intervention was offered to patients to relieve pain after open heart surgery to examine some physiologic parameters as a complementary therapy in addition to medical treatment. On the first postoperative day, medical treatment records of all of the patients included in the research indicated that they all received the following medications: narcotic analgesic (pethidine), vasodilator (glycerol trinitrate), antihypertensive (sodium nitroprusside), and beta-receptor blocker (metoprolol succinate). The patients also received oxygen delivered by nasal cannula. The control group and the music group were composed of patients having similar features regarding medical treatment, and the effects of the medical treatment on the findings of the reasearch were minimized as much as possible. The first major finding of this study was that listening to music used as a nursing intervention after surgery reduced the pain of patients who had undergone CABG or valve replacement. It was considered that analgesic drug intake would not affect this finding, because the control and music groups received the same analgesic treatment. The finding that listening to music was effective in relieving postoperative pain is consistent with other studies that examined the effects of music on pain for patients undergoing cardiac surgery (Aragon et al., 2002, Sendelbach et al., 2006, Kshettry et al., 2006, Voss et al., 2004, Zimmerman et al., 1996). In Sendelbach et al.'s (2006) experimental study investigating the physiologic and psychologic effect of music on patients who had undergone cardiac surgery, they found a decrease in the pain levels of the music group.Voss et al. (2004) investigated the effect of music on pain during chair rest after open heart surgery and reported that the pain level of the sedative music group was lower than in the scheduled-rest or treatment-as-usual groups.Aragon et al. (2002) investigated the effect of harp music in vascular and thoracic surgical patients by using a visual analog scale (VAS) to measure patients' pain. The VAS was completed just before harp playing, 20 minutes after harp playing was started, and 10 minutes after completion. Results indicated that listening to live harp music had a positive effect on patient perception of pain (p = .000).Zimmerman et al. (1996) demonstrated that music intervention decreased postoperative pain in CABG patients.Kshettry et al. (2006) found that pretreatment and posttreatment pain and tension scores decreased significantly in the complementary alternative medical therapies group on postoperative days 1 (p < .01) and 2 (p < .038). Other investigators identified similar results of music therapy in controlling pain with surgical patient populations (Good et al., 2002, Good et al., 2001, Nilsson et al., 2003, Tse et al., 2005), whereas others found no difference in pain (Nilsson, 2009). The second major finding of this study was that a statistically significant difference occurred within the music group in the average SpO2 score. In the postoperative first day, medical treatment of all patients included in this study was pethidine (IM injection) used to relieve pain. Pethidine is an opioid analgesic that might cause respiratory depression, although respiratory depression is associated with the dose administered. In the present study, it can be said that SpO2 values of both groups (control and music) were at the expected levels for the postoperative first day even though the patients received pethidine. Listening to music increased SpO2, with SpO2 results of 91.7 before music listening and 93.1 after music listening. Although there was no statistical difference between the SpO2 values of the control group and the group listening to

music after cardiac surgery inNilsson's (2009) study, prevalue of the music group was 95.8 and postvalue was 96.4. However, it was found that pre- and postvalues of the control group did not change.Yilmaz et al. (2003) conducted a study to evaluate the effect of music on the hemodynamic parameters in extracorporeal shock wave lithotripsy treatment. The increase in oxygen saturation at the end of treatment was statistically significant in the music group. The commonly accepted theory explaining the pain-, anxiety-, and stress-reducing effects of music is that music acts as a distracter, focusing the patient's attention away from negative stimuli to something pleasant and encouraging. Therefore, patients' vital signs could be stabilized and SpO2 increase (Yilmaz et al., 2003). The findings from the present study support earlier research and literature findings that suggest that music increases SpO2 values in the participants.
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SBP, DBP, HR, and RR were not statistically different before and after music therapy. In this study, patients were given prophylactic beta-blockers after cardiac surgery in an attempt to prevent the development of atrial fibrillation or to control the ventricular rate of atrial fibrillation. According to the literature, the physiologic effects of beta-blockers and other cardiac medications, such as digitalis and antihypertensive agents, could be a factor affecting HR and BP results after music therapy (Sendelbach et al., 2006). The findings of the present study are supported by the studies of Barnason et al., 1995, Kshettry et al., 2006, Nilsson, 2009, and Sendelbach et al. (2006), in which no significant changes were observed for the physiologic measures in patients who listened to music after cardiac surgery.Uan, Ovayolu, Sava, Torun, and Glen (2006) also reported that music did not have any significant effect on pulse rate, blood pressure, or oxygen saturation in preoperative endoscopy patients. Results of the present study show that pain is reduced after open heart surgery in patients who listen to music compared with those who do not. Again, SpO2 significantly increased within the music group, but there was no difference in the other physiologic parameters between the groups or within each group. Although only showing a minor effect, these findings support the use of music in combination with pharmacologic treatment to stabilize patients' vital signs after cardiac surgery. Future research should be undertaken to determine the effects of music on physiological parameters for patients after cardiac surgery.

Clinical Implications
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Music, as a nursing intervention, is a noninvasive and safe therapy for health promotion of patients. However, the music listened to by patients should be of a sedative quality, and culturally appropriate selections should be offered. Nurses who can use music listening as an intervention for patients who have undergone open heart surgery promote nursing autonomy and the idea that nurses are able to affect patients' environment. It is advisable that music become a part of nursing care offered to patients experiencing pain, because music is a low-cost therapy that has no side effects.

Study Limitations
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This study had several limitations. The study was conducted in only one ICU, and the study sample reflects only one area of Turkey. The findings therefore cannot be generalized to all patients with CABG surgery in Turkey. The method of data collection could also be regarded as another limitation. Because those who planned the study and gathered the data were the same people, the patients in the experimental and control group were not blinded. The patients were chosen through convenience sampling; randomization was not applied. The available selection of music included only 20 musical pieces, and this limited participants' choice. Therefore, the findings must be interpreted cautiously because of these study limitations. Future studies are recommended to include larger samples from different regions in Turkey and should also include a larger selection of music.