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Running head: MUSIC THERAPY FOR PEDIATRICS
Music Therapy as a Complementary Therapy for Pain in Pediatric Patients
Diane Hill, Dalton Janssen, Thuy Le, and Ben Sutherland
University of Central Arkansas
Author’s Note
Diane Hill, Department of Nursing, University of Central Arkansas; Dalton Janssen,
Department of Nursing, University of Central Arkansas; Thuy Le, Department of Nursing,
University of Central Arkansas; Ben Sutherland, Department of Nursing, University of Central
Arkansas.
Correspondence concerning this article should be addressed to Dalton Janssen,
Department of Nursing, University of Central Arkansas, Conway, AR, 72034.
E-mail:[email protected]
1
MUSIC THERAPY FOR PEDIATRICS
2
Music therapy as a Complementary Therapy for Pain in Pediatric Patients
Current use of pharmaceutical medications, such as opioids, benzodiazepines,
antidepressants, and non-steroidal anti-inflammatory drugs, are the main therapy to decrease pain
in the hospitalized patient (Ball, Bindler, & Cowen, 2008). Adverse reactions to pharmacological
methods of pain relief can include, but are not limited to the following: respiratory depression,
tolerance, urinary retention, constipation, erectile dysfunction, gastrointestinal bleeding, ulcers,
psychological dependence, nausea, vomiting, dizziness, and sedation (Ball, Bindler, & Cowen,
2008). In one study, out of 1,235 pediatric hospitalized patients, 328 patients experienced
adverse drug reactions (Rashed, et al., 2011). Prolonged hospital stays, secondary to adverse
drug reactions, and expensive pharmacological medications lead to increased healthcare costs.
According to Drug.com, 400mg of morphine in an oral solution costs $17.38, which is equivalent
to the daily needed dose of a opioid-naïve patient. Additional medications are often used to
assist in the effectiveness of this drug as well, thus raising the cost dramatically.
Nonpharmacological methods can be used as complementary therapies to enhance the
effectiveness of analgesics and decrease the required dose for the same affect (Ball, Bindler, &
Cowen, 2008). Substantial research exists on the use of many complementary therapies such as
guided imagery, distraction, breathing techniques, hypnosis, among others, but there is limited
research on the use of music therapy. Due to limited research in the pediatric population
involving the use of music therapy, a literature review was undertaken to explore the use of
music therapy with pediatric patients in the hospital setting. Current pharmacological measures
may allow for improvement in the alleviation of pain in hospitalized pediatric patients through
the implementation of complementary music therapy which would then reduce cost and rate of
adverse reactions. Thus the clinical question is: What is the effect of music therapy in
MUSIC THERAPY FOR PEDIATRICS
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conjunction with current pharmacological methods of pain management for hospitalized
pediatric patients?
Method
A search of electronic databases was conducted using the following key terms:
“children”, “music”, “therapy”, and “intensive care”. Databases used included CINAHL Plus
with Full Text and Academic Search Premier. This search yielded twenty-six results. To insure
that the review was specific we included the following limiters: the key phrase “not infant,”
scholarly (peer reviewed) articles, full text, and published between 2009-2014. This search
yielded four articles, out of which we chose three that were pertinent; two being literature
reviews. After thorough analysis of the literature reviews, only two articles were found to be
relevant. Exclusion criteria includes the following: wrong population groups, chronic pain, and
the use of music other than pain relief.
Appraisal
In 2006, Hatem, Lira, and Mattos, conducted a two-group pretest-posttest experimental
design study to investigate effects of music on children, 0-16 years old, in intensive care units
less than 24 hours post-operatively who underwent heart surgery. Eighty-four total participants
were randomly assigned to two groups, interventional and control, after consent was given by
parents or guardians. Interventional group received conventional pain medication per protocol
and classical music (Spring from the Four Seasons, Vivaldi) through headphones for a 30 minute
session. The control group received conventional pain medication per protocol and wore the
headphones while a blank CD was played for a 30 minute session. Monitoring of the dependent
variable - pain - included monitoring facial pain scale, heart rate, blood pressure, temperature,
mean arterial pressure, respiratory rate, and oxygenation saturation. Pain was assessed prior to
MUSIC THERAPY FOR PEDIATRICS
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intervention, protocol followed accordingly, and then reassessed after intervention was complete.
A nursing assistant did the pain assessments using a standardized form and tools of
measurement. The nursing assistants had proper training prior to assessments on standardizing
measurements for studies. The results reveal significant (p<0.001) decrease in facial pain score
in the interventional group compared to the control group after interventions were complete.
Heart rate and respiratory rate show significant decreases (p=0.04 and p=0.02, respectively) in
pain in the interventional group compared to the control group. All other measures showed no
statistical significant difference. The findings of the facial pain scale, although arguably
subjective and irrelevant in older children who can self report, were consistent with other finding
in previous research. The reduction in heart rate and respiratory rate is also consistent with
previous studies. The measurements that showed no significant difference were inconsistent with
some previous studies, believed to be due to unaccounted for variables and differences in studies.
This study is strong due to the randomized, placebo-controlled, parallel, two-group
pretest-posttest experimental study design. Threats to validity do exist in this study. Threat of
mortality is evident; five participants dropped from the study, all older children who refused to
listen to a blank CD (3 participants) or the music did not suit their music preference (2
participants). Threat of selection bias is possible because of a limited location and population,
although the randomization minimizes this threat. Threat of instrumentation is present; the facial
pain scale is a subjective measurement unlike the objective physiological measurements.
Although training was given to standardize the observers, it is unable to be well monitored.
Threat of reactivity by way of the Hawthorne effect is possible in that the participants receiving
music could have been affected by personal values and a desire to please the experimenters.
MUSIC THERAPY FOR PEDIATRICS
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The evidence resulting from the study by Hatem, et al,(2006), provides clinical evidence
of the effectiveness of music in conjuction with pharmaceutical intervention for post-operative
pain relief in children. This study focuses on cardiac surgery and should be generalized with
caution. However, there were no harmful effects and administration of music therapy is costeffective, non-labor intensive, time efficient, and effective in pain reduction for children.
In 2007-2008, a separate study was conducted by Nilsson, Kokinsky, Nilsson, Sidnevall,
and Enskar in Gothensburg, Sweden. This study was a randomized, experimental,
pretest/posttest study with the purpose of determining whether postoperative music listening
reduces morphine consumption and influences pain, distress, and anxiety in children, 7-16 years
old, after day surgery. Eighty participants were randomly assigned into two groups, 40
participants in interventional and 40 participants in control. Each group was offered
conventional pain medication based on predetermined guidelines. Morphine was offered to those
with a pain score >4, but the children could always abstain. The interventional group listened to
MusiCure® (soft and relaxing), beginning upon admission to PACU for 45 minutes. The same
setup was provided in the control group, but the music was never turned on. Dependent
variables, pain, anxiety, and distress, were measured using Coloured Analogue Scale (CAS),
Facial Affective Scale (FAS), Face, Legs, Activity, Cry, and Consolability (FLACC) score,
short-form State-Trait Anxiety Inventory (STAI), in conjunction with heart rate, respiratory rate,
and saturation. Observers including one researcher and two experienced nurses were all familiar
with each of the pain scales. Observations were made every 15 minutes for 45 minutes and
before participants left PACU. The results show no significant difference in FAS, CAS,
FLACC, short STAI, or vital signs between the groups, however, significantly fewer children
received morphine in the interventional group compared to control (p<0.05).
MUSIC THERAPY FOR PEDIATRICS
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The strengths of this study include a randomized, placebo-controlled, parallel, two-group
pretest-posttest experimental study design. Two threats to validity exist in this study. The threat
of selection bias is possible due to limited location. All participants of this study were recruited
from Queen Silvia Children’s hospital, Gothenburg, Sweden. Threat of reactivity is possible due
to the Hawthorne effect. Participants receiving music could have been affected by personal
values and a desire to please the experimenters.
The findings in this study provide clinical significance for music therapy as a
complementary therapy to reduce morphine consumption in the relief of pain in children postoperatively. Due to a variety of participant surgeries included in this study, the study is highly
generalizable to other clinical settings. Music therapy is a feasible intervention that is cost
effective, safe, accessible, and effective in pain reduction for children.
In 2008, Balin, Bavdekar, and Jadhav conducted a randomized controlled prospective
study in Mumbai, India to determine the effectiveness of classical Indian instrumental music
(raaga-Todi) in reducing pain levels in pediatric patients during venipuncture. In this
quantitative study, a total of 150 children, ages 5-12, being treated at a single tertiary care center,
were randomly assigned to three groups of 50. The groups were labeled local anesthetic (LA),
music, and placebo. Pain was assessed simultaneously by a parent, the patient, the investigator,
and an independent observer using a Visual Analog Scale (VAS) at the moment of the procedure
and 1 and 5 minutes after venipuncture. The independent variables used in the study were the
application of a eutectic mixture of local anesthetic (EMLA) in the first group, and the playing of
classical Indian music in the second. The control group received a placebo cream and earphones
without any music playing. The EMLA cream was applied for 45 minutes with an occlusive
dressing. The music group received 15 minutes of music therapy via earphones prior to the
MUSIC THERAPY FOR PEDIATRICS
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procedure, during the procedure, and 5 minutes thereafter. The control group represents the
current standard of care for this procedure.
The results revealed significantly higher (p<0.05) VAS scores in the control group when
compared to the other two groups. However, VAS scores from the LA group were significantly
lower (p<0.05) than the music group at only five time-points out of a possible twelve. This study
was both valid and reliable. The ratio measurement provided by VAS has shown that consistent
scores were reported by multiple viewers, therefore interrater reliability was established. Threats
of selection bias exsist because of the location, population, and reason for clinical visit. Patients
may also vary in their previous experiences with medical procedures and illness. Threat of
instrumentation is present because the VAS is a subjective measurement, although training was
given to the observers. A flaw in the design in no baseline VAS score was established prior to
the venipuncture procedure.
This study successfully demonstrates the effectiveness of music therapy in reducing VAS
scores for pain. Although the study was conducted with classical Indian music, similar results
can be expected to be seen in different cultures with varying genres of music. When EMLA
cannot be utilized, music therapy is a possible alternative to reduce pain in the venipuncture
procedures.
Each of these studies has limitations and the results should be interpreted with caution.
However, when considered as a body of evidence, all of the findings indicate music therapy is an
effective complementary therapy. Despite the variations in populations, measures, types of
music, and procedures, the evidence supports the use of music therapy in pain alleviation. Music
therapy is inexpensive, easy to use and individualize, accessible, and has no adverse effects.
MUSIC THERAPY FOR PEDIATRICS
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Recommendations
Music therapy is an effective complementary therapy when utilized with pharmacological
measures to decrease pain in the acute care of pediatrics. It has a low risk for adverse effects, it
is easily accessible, and can be easily implemented due to social acceptability. The cost of
music therapy is low. The initial cost of music and equipment (mp3 player, headphones,
speakers, etc.) is minimal and recurrent costs are nonexistent. Initial cost will be absorbed as the
intervention is utilized. With this low-cost intervention, nurses will see a decrease in pain
medication, adverse effects of those pain medications, and occurrence of "never events" as
defined by The Joint Commission.
Based on a per diem schedule, music therapy should be implemented on a routine basis.
This per diem schedule includes pediatric patients who are open to receiving music therapy, with
the ability to hear, and experiencing acute pain. Routine basis is implemented in order to ensure
use of music therapy and should be utilized at thirty minute intervals every four hours or as
indicated by patient. To evaluate effectiveness, an assessment protocol should be implemented;
prior to administration of music therapy, a nurse should assess for pain using the facial pain scale
and record baseline vital signs for comparison (blood pressure, heart rate, respiratory rate, and
oxygen saturation). The nurse should initiate music therapy and follow the same assessment
protocol after each implementation. A decrease in vital signs and/or facial pain scale supports the
use of music therapy for this patient.
The findings of this study can be disseminated by providing literature to hospital staff
with step-by-step instructions and other informational handouts to patients. Additional research
is required to determine most effective music selection per diem.
MUSIC THERAPY FOR PEDIATRICS
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References
Ball, J., Bindler, R., & Cowen, K. (2008). Pain assessment and management. In Principles of
Pediatric Nursing Fifth Edition Caring for Children (pp. 370-391). Upper Saddle River,
NJ: Pearson Education, Inc.
Hatem, T., Lira, P., & Mattos, S. (2006). The therapeutic effects of music in children following
cardiac surgery. Jornal de pediatria, 186-192.
Matsota, P., Christodoulopoullou, T., Smyrnioti, M., Pandazi, H., Kanellopoulos, I., Koursoumi,
E., . . . Kostopanagiotou, G. (2010). Music's use for anesthesia and analgesia. The
Journal of Alternative and Complentary Medicine, 298-305.
Nilsson, S., Kokinsky, E., Nilsson, U., Sidenvall, B., & Enskar, K. (2009). School-aged
children's experiences of postoperative music medicine on pain, distress, and anxiety.
Pediatric Anesthesia, 1184-1190.
Rashed, A., Wong, I., Cranswick, N., Tomlin, S., Rascher, W., & Neubert, A. (2011). Risk
factors associated with adverse drug reactions in hospitalized children: international
multicentre study. European Journal of Pharmacology , 801-810.
Running head: MUSIC THERAPY FOR PEDIATRICS
Article
Purpose of study
Dependent
variable
Pain and
distress
scales
Nilsson, Kokinsky,
Nilsson, Sidenvall,
Enskar (2009). Schoolaged children’s
experiences of
postoperative music
medicine on pain,
distress, and anxiety.
Pediatric Anesthesia.
To test whether
postoperative music
listening reduces
morphine consumption
and influence pain
distress, and anxiety after
day surgery.
Balan, Bavdekar,
Jadhav (2009). Can
Indian Classical
Instrumental Music
Reduce Pain Felt
During Venipuncture?
Indian Journal of
Pediatrics, Vol .76.
To determine
comparative efficacy of
local anesthetic cream,
Indian classical
instrumental music and
placebo, in reducing pain
due to venipuncture in
children.
Pain
Hatem, Lira, Mattos
(2006). Therapeutic
Effects of Music on
Children Undergoing
Cardiac Surgery.
Journal de Pediatria,
Volume 82.
To determine the effect of
music on heart rate, blood
pressure, respirations,
temperature, mean arterial
pressure, and oxygenation
immediately post
operatively.
Pain
10
Independent
variable
»Intervention:
MusiCure. If score
greater than 4 on
FLACC scale or on
CAS scale given
analgesic
»Control group: no
music applied. If
score greater than 4
on FLACC scale or
on CAS scale
given analgesic
»Intervention:
Music
»Intervention:
Local anesthetic
(EMLA)
»Control: Placebo
»Intervention:
Music CD
»Control: Placebo
Blank CD
Subjects
N=80 (40 in each
group)
children ages 1016 years old who
had dental, ear,
nose, or throat
surgery.
Source of
Measurement
»Coloured
Analogue
Scale(CAS)
»Facial
Affective
Scale (FAS)
N=150 (50 in each
group)
children ages 5-12
years old
requiring
venipuncture
Visual
Analogue
Scale (VAS)
N = 79
(control=19;
experimental=60)
Ages 1-6 years
old requiring
cardiac surgery
»Facial Pain
Score
»Heart Rate
»Respirations
Results
Interpretation
»CAS:
preoperatively
(p=0.439)
PACU (p=0.654)
1hour after PACU
(p=0.472)
»FAS:
Preoperatively
(p=0.087)
PACU (p=0.624)
1hr after PACU
(p=0.329)
»VAS:
(comparison of
pain between
music v. local
anesthesia at 0,1,5
minutes)
»0 min:
Investigator
(p=0.030)
»1min:
Parent (p=0.033)
Investigator
(p=0.003)
»5 min:
Investigator
(p=0.003)
Independent
Observer(p=0.038
)
»Facial Pain
Scale: (p<0.001)
»Heart Rate:
(p=0.04)
»Respirations:
(p=0.02)
Music therapy
was not found
to have a
significant
effect on pain
or distress.
Music therapy
was associated
with decreased
morphine
dosage (p<0.05)
in PACU.
Pain scores
were
significantly
lower in both
the EMLA and
music groups
when compared
to placebo.
Although,
significance
varies between
observers,
music therapy
showed equal to
marginally
higher pain
levels when
compared to
EMLA.
Music therapy
was found to
have significant
levels of pain
relief compared
to the placebo
group.
MUSIC THERAPY FOR PEDIATRICS
11