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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 3 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 4 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 5 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 6 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 7 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 8 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 9 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