Music Can Soothe the Pain in Surgical Patients

CLINICAL CONTEXT

Currently there is a trend toward performing surgical procedures such as hysteroscopy and cesarean delivery without general anesthesia. Music is a noninvasive, safe, and inexpensive intervention that could be easily administered during surgery. Several randomized controlled trials (RCTs) have shown positive effects of music on postoperative recovery.

However, music is not used routinely during the perioperative period, perhaps because of ignorance or skepticism regarding its efficacy. The goal of this systematic review and meta-analysis by Hole and colleagues was to examine the effects of music on recovery after surgical procedures.

STUDY SYNOPSIS AND PERSPECTIVE

Surgical patients who listened to music were significantly less anxious and more satisfied postoperatively compared with those who did not, according to a systematic review and meta-analysis of data from 72 trials. They also needed less pain medication and reported significantly less pain, Jenny Hole, MBBS, from Queen Mary University of London, London, United Kingdom, and colleagues report in an article published online August 12 in the Lancet.

The analysis included RCTs that compared any type of music initiated before, during, or after surgery with standard care of other nondrug interventions in adult patients undergoing any form of surgery, excluding central nervous system or head and neck procedures. The outcomes of interest were postoperative pain, analgesia needs, anxiety, infection rates, wound healing, costs, length of stay, and patient satisfaction.

The standardized mean differences (SMDs) in outcomes from the start of the study for anxiety, pain, need for pain medication, and satisfaction in the intervention group relative to the control group were, respectively, -0.68, -0.77, -0.37, and 1.09, the authors report. No differences were observed in length of stay, and none of the studies investigated the effects of music on infections, wound-healing rates, or costs, they write.

Music played preoperatively was associated with the greatest reduction in pain, analgesia, and anxiety, followed by intraoperative and postoperative music, according to the analysis.

"Music reduced pain, even when given under general anaesthetic, but the intervention had an increased effect on pain when patients were conscious," the authors report.

Nonsignificant reductions in pain and analgesia use were observed among patients who were permitted to choose the music, either from their personal playlist or one that was provided to them. "However, we recorded a slight but non-significant increase in anxiety when patients had a choice of music compared with when they had no choice," the authors note.

"Cognitive activities such as listening to music can affect perceived intensity and unpleasantness of pain, enabling patients' sensation of pain to be reduced," the authors write, suggesting a possible mechanism to explain the effects of music on outcomes. "Another potential mechanism could be reduced autonomic nervous system activity, such as reduced pulse and respiration rate and decreased blood pressure."

On the basis of their findings, the authors believe that "sufficient research has been done to show that music should be available to all patients undergoing operative procedures." Patients should be able to choose the type of music they listen to, but the music must not interfere with the medical team's communications with each other or the patient, they stress.

Paul Glasziou, PhD, from Bond University, Queensland, Australia, agrees, writing in an accompanying comment that "music is a simple and cheap intervention, which reduces transient discomforts for many patients undergoing surgery." He notes that "[a] drug with similar effects might generate substantial marketing."

The complexity of human reaction to music does introduce some uncertainties about its use medically, Dr Glasziou writes. Although the low cost and improved patient experience "make the question of whether to use music seem obvious," he says, exactly how it should be used is still unclear. "Piped Mozart or Madonna might soothe some and irritate others," he notes.

However, these remaining research questions "should not inhibit implementation of a sensible choice for patients now," he adds. "For my next surgery, I will bring some Mozart and a copy of this systematic review."

The study authors and commenter have disclosed no relevant financial relationships.

Lancet. Published online August 13, 2015. Article abstract, Comment extract

STUDY HIGHLIGHTS

• Inclusion criteria for the meta-analysis were reports published in any language of RCTs enrolling adults undergoing surgical procedures, comparing any form of music before, during, or after surgery with standard care or other nondrug interventions.
• Surgery involving the central nervous system or the head and neck was excluded.
• A search of MEDLINE, Embase, CINAHL, and Cochrane Central identified 4261 titles and abstracts, from which 73 RCTs, each enrolling 20 to 458 participants, were included in the systematic review.
• The investigators used SMDs, random-effects models, and meta-regression to conduct the meta-analysis.
• The included trials varied in choice of music, timing, duration, and comparators, which included routine care, headphones with no music, white noise, and undisturbed bed rest.
• Benefits associated with music were decreased postoperative pain (SMD, -0.77; 95% confidence interval [CI], -0.99 to -0.56), anxiety (SMD, -0.68; 95% CI, -0.95 to -0.41), and analgesia use (SMD, -0.37; 95% CI, -0.54 to -0.20). There was also greater patient satisfaction (SMD, 1.09; 95% CI, 0.51-1.68).
• Patients exposed to music were not different from control patients in length of hospital stay (SMD, -0.11; 95% CI, -0.35 to 0.12), although few of the included studies measured this variable.
• None of the included studies examined the effects of music on infections, wound-healing rates, or costs.
• Outcomes did not differ significantly with choice of music or timing of delivery, based on subgroup analysis, and music was effective even when patients received general anesthesia.
• There were no apparent causes of heterogeneity in 8 variables assessed, based on meta-regression.
• On the basis of their findings, the investigators concluded that music could be offered as a way to help alleviate postoperative pain and anxiety. Also, timing and delivery could be adapted to individual clinical settings and medical teams.
• Several potential mechanisms underlying the benefits of music include physical and psychological factors affecting the experience of pain, with cognitive activities such as listening to music to reduce the perceived intensity and unpleasantness of pain.
• Reduced autonomic nervous system activity -- with lower pulse, respiration rate, and blood pressure -- could also play a role.
• Some evidence from RCTs suggests that brain regions involved in hearing may sometimes be perceptive during general anesthesia, which may help to explain why music was beneficial even in this setting.
• On the basis of other studies and reviews, medical teams may be more relaxed and attentive when music that they enjoy is playing, although use of music might be inappropriate or distracting in some settings or may interfere with communication among the medical team.
• The investigators conclude that research to date is sufficient to show that music should be available to all patients undergoing surgery.
• The investigators suggest that patients should be able to choose the type of music, but whether it should be from their specific selection or from a playlist is unclear. Some patients even prefer to listen to recitations or natural sounds.
• Because the timing of music did not greatly affect outcomes, it could be adapted to specific clinical settings and medical teams.
• An accompanying comment notes that the very high heterogeneity of effects among trials complicates immediate implementation.

CLINICAL IMPLICATIONS

• Findings of a systematic review and meta-analysis suggest that music could be offered as a way to help alleviate postoperative pain and anxiety.
• Potential mechanisms underlying the benefits of music in the perioperative period include physical and psychological factors affecting the experience of pain, as well as reduced autonomic nervous system activity.
• Implications for the Healthcare Team: Members of the healthcare team should be aware that music played in the perioperative period may be adapted to specific clinical settings and medical teams.