NIHR DC Discover

Music in surgery

NIHR Signal Music can reduce pain and anxiety following surgery

Published on 7 August 2018

doi: 10.3310/signal-000631

Recorded music played before, during or after surgery in adults reduces self-reported post-operative pain and anxiety, compared with usual care. The average effect is equivalent to a reduction in anxiety of 21 percentage points and a 10 percentage point reduction in pain within a few days of surgery.

It is thought that placebo and distraction effects probably play a role, but in this review music still improved pain when used for patients under a general anaesthetic.

Nearly two-thirds of patients experience severe pain after surgery. Anxiety can amplify perceptions of pain and lead to slower recovery. This systematic review included over 90 small-scale trials with a small effect, and it was not possible to blind conscious patients to which intervention they had received. However, despite the caveats, the direction of effect was consistent, and the intervention comes with minimal risks for the patient.

Evaluation of the positive and negative impacts on patients and clinicians could help better clarify the selection, timing and delivery of music. For example, what genre to select and would it be best delivered through headphones and throughout surgery?

Share your views on the research.

Why was this study needed?

The NHS carries out about 11 million surgical procedures annually. These include therapeutic and diagnostic procedures. Acute pain following surgery can affect patients’ quality of life, increase the use of pain-relieving drugs with their side effects, and lengthen hospital stays.

There has been a long-standing interest in music’s potential to improve patient wellbeing around the time of surgery. Hospital teams may play music for the patient, or a music therapist may carry out a defined intervention. Surgical teams sometimes play their own favourite tracks during operations.

This review assessed the impacts of music interventions on postoperative pain and anxiety following general or regional anaesthetic. An earlier systematic review in 2015 was the first to pool data across a range of surgeries for both pain and anxiety, but the focus was on less invasive procedures done under local anaesthesia.

What did this study do?

This systematic review included 92 randomised controlled trials in which music was offered by researchers or music therapists either live or recorded. The 7,385 adults undergoing surgery had an average age of 52 years. Only a quarter of studies included more than 110 patients. Musical styles ranged from relaxing classical music to heavy rock and were often chosen by the patient. Around a fifth of studies used a non-active control intervention, such as headphones without music or with alternative noises.

Most studies evaluating anxiety outcomes used an index of a visual scale and the studies evaluating pain outcomes used a visual scale or numerical rating scale.

The review was well conducted but limited by poor or unclear quality of the underlying trials. Taking measures to ensure people did not know whether they were getting the trial intervention (the music) was not common, and this may have inflated the results. The trials were also substantially different in their patient populations, surgical procedures and types of music intervention making it difficult to pick the target group who might benefit most.

What did it find?

  • Overall, patients receiving a music intervention experienced less pain and anxiety up to seven days following surgery compared with usual care or placebo-type interventions (standardised mean difference [SMD] for anxiety ‑0.69, 95% confidence interval [CI] -0.88 to -0.50, 47 trials, 3,928 patients; SMD for pain ‑0.50, 95% confidence interval [CI] -0.66 to -0.34, 42 trials, 3,272 patients).
  • Music was effective for decreasing anxiety when used before, during or after surgery. There was a larger difference in post-operative anxiety between intervention and control groups when music was played before surgery (SMD ‑1.10, 95% CI ‑1.53 to ‑0.66; 13 trials) than after surgery (SMD ‑0.66, 95% CI ‑1.07 to ‑0.25; 10 trials).
  • Music remained effective for pain when used during general anaesthesia (SMD ‑0.41, 95% CI ‑0.64 to ‑0.18; 5 trials).
  • When analysing the higher quality trials, patients receiving a music intervention still had less pain and anxiety than people in the control groups (SMD for anxiety ‑0.61, 95% confidence interval [CI] -0.94 to -0.29, 16 trials, 1,788 patients; SMD for pain ‑0.34, 95% confidence interval [CI] -0.55 to -0.13, 15 trials, 1,454 patients).

What does current guidance say on this issue?

There is no current UK guidance for surgeons or anaesthetists on music and surgery. The Faculty of Pain Medicine’s Core Standards for Pain Management Services (2015) does not mention music.

The British Anaesthetic and Recovery Nurses Association includes in its Standards of Practice (2012) that the nurse will ensure that the patient is reasonably pain-free by means of analgesia, distraction therapy and comfort measures. The environment should be planned to reduce anxiety including the use of music.

What are the implications?

NICE is developing a guideline on perioperative care in adults and will cover support for patients before, during and after operations, including pain management services.

More practical evaluations of how to integrate music into usual practice might answer residual concerns and help refine the intervention.

At first glance, music seems a cheap and safe intervention which might suit a larger evaluation.

Citation and Funding

Kühlmann AYR, de Rooij A, Kroese LF, et al. Meta-analysis evaluating music interventions for anxiety and pain in surgery. Br J Surg. 2018;105(7):773-83.

This project was funded by Stichting Coolsingel and Stichting Swart-van Essen in The Netherlands.

Bibliography

BARNA. Standards of practice. London: British Anaesthetic and Recovery Nurses Association; 2012.

FPM. Core standards for pain management services in the UK. London: Faculty of Pain Medicine of the Royal College of Anaesthetists; 2015.

NHS website. Having an operation (surgery). London: Department of Health; updated 2018.

NICE. Guideline scope: perioperative care in adults (final). London: National Institute for Health and Care Excellence; 2018

Weldon S, Korkiakangas T, Bezemer J, Kneebone R. Music and communication in the operating theatre. J Adv Nurs. 2015;71(12):2763-74.

Why was this study needed?

The NHS carries out about 11 million surgical procedures annually. These include therapeutic and diagnostic procedures. Acute pain following surgery can affect patients’ quality of life, increase the use of pain-relieving drugs with their side effects, and lengthen hospital stays.

There has been a long-standing interest in music’s potential to improve patient wellbeing around the time of surgery. Hospital teams may play music for the patient, or a music therapist may carry out a defined intervention. Surgical teams sometimes play their own favourite tracks during operations.

This review assessed the impacts of music interventions on postoperative pain and anxiety following general or regional anaesthetic. An earlier systematic review in 2015 was the first to pool data across a range of surgeries for both pain and anxiety, but the focus was on less invasive procedures done under local anaesthesia.

What did this study do?

This systematic review included 92 randomised controlled trials in which music was offered by researchers or music therapists either live or recorded. The 7,385 adults undergoing surgery had an average age of 52 years. Only a quarter of studies included more than 110 patients. Musical styles ranged from relaxing classical music to heavy rock and were often chosen by the patient. Around a fifth of studies used a non-active control intervention, such as headphones without music or with alternative noises.

Most studies evaluating anxiety outcomes used an index of a visual scale and the studies evaluating pain outcomes used a visual scale or numerical rating scale.

The review was well conducted but limited by poor or unclear quality of the underlying trials. Taking measures to ensure people did not know whether they were getting the trial intervention (the music) was not common, and this may have inflated the results. The trials were also substantially different in their patient populations, surgical procedures and types of music intervention making it difficult to pick the target group who might benefit most.

What did it find?

  • Overall, patients receiving a music intervention experienced less pain and anxiety up to seven days following surgery compared with usual care or placebo-type interventions (standardised mean difference [SMD] for anxiety ‑0.69, 95% confidence interval [CI] -0.88 to -0.50, 47 trials, 3,928 patients; SMD for pain ‑0.50, 95% confidence interval [CI] -0.66 to -0.34, 42 trials, 3,272 patients).
  • Music was effective for decreasing anxiety when used before, during or after surgery. There was a larger difference in post-operative anxiety between intervention and control groups when music was played before surgery (SMD ‑1.10, 95% CI ‑1.53 to ‑0.66; 13 trials) than after surgery (SMD ‑0.66, 95% CI ‑1.07 to ‑0.25; 10 trials).
  • Music remained effective for pain when used during general anaesthesia (SMD ‑0.41, 95% CI ‑0.64 to ‑0.18; 5 trials).
  • When analysing the higher quality trials, patients receiving a music intervention still had less pain and anxiety than people in the control groups (SMD for anxiety ‑0.61, 95% confidence interval [CI] -0.94 to -0.29, 16 trials, 1,788 patients; SMD for pain ‑0.34, 95% confidence interval [CI] -0.55 to -0.13, 15 trials, 1,454 patients).

What does current guidance say on this issue?

There is no current UK guidance for surgeons or anaesthetists on music and surgery. The Faculty of Pain Medicine’s Core Standards for Pain Management Services (2015) does not mention music.

The British Anaesthetic and Recovery Nurses Association includes in its Standards of Practice (2012) that the nurse will ensure that the patient is reasonably pain-free by means of analgesia, distraction therapy and comfort measures. The environment should be planned to reduce anxiety including the use of music.

What are the implications?

NICE is developing a guideline on perioperative care in adults and will cover support for patients before, during and after operations, including pain management services.

More practical evaluations of how to integrate music into usual practice might answer residual concerns and help refine the intervention.

At first glance, music seems a cheap and safe intervention which might suit a larger evaluation.

Citation and Funding

Kühlmann AYR, de Rooij A, Kroese LF, et al. Meta-analysis evaluating music interventions for anxiety and pain in surgery. Br J Surg. 2018;105(7):773-83.

This project was funded by Stichting Coolsingel and Stichting Swart-van Essen in The Netherlands.

Bibliography

BARNA. Standards of practice. London: British Anaesthetic and Recovery Nurses Association; 2012.

FPM. Core standards for pain management services in the UK. London: Faculty of Pain Medicine of the Royal College of Anaesthetists; 2015.

NHS website. Having an operation (surgery). London: Department of Health; updated 2018.

NICE. Guideline scope: perioperative care in adults (final). London: National Institute for Health and Care Excellence; 2018

Weldon S, Korkiakangas T, Bezemer J, Kneebone R. Music and communication in the operating theatre. J Adv Nurs. 2015;71(12):2763-74.

Meta-analysis evaluating music interventions for anxiety and pain in surgery

Published on 18 April 2018

Kuhlmann, A. Y. R.,de Rooij, A.,Kroese, L. F.,van Dijk, M.,Hunink, M. G. M.,Jeekel, J.

Br J Surg , 2018

BACKGROUND: This study aimed to evaluate anxiety and pain following perioperative music interventions compared with control conditions in adult patients. METHODS: Eleven electronic databases were searched for full-text publications of RCTs investigating the effect of music interventions on anxiety and pain during invasive surgery published between 1 January 1980 and 20 October 2016. Results and data were double-screened and extracted independently. Random-effects meta-analysis was used to calculate effect sizes as standardized mean differences (MDs). Heterogeneity was investigated in subgroup analyses and metaregression analyses. The review was registered in the PROSPERO database as CRD42016024921. RESULTS: Ninety-two RCTs (7385 patients) were included in the systematic review, of which 81 were included in the meta-analysis. Music interventions significantly decreased anxiety (MD -0.69, 95 per cent c.i. -0.88 to -0.50; P < 0.001) and pain (MD -0.50, -0.66 to -0.34; P < 0.001) compared with controls, equivalent to a decrease of 21 mm for anxiety and 10 mm for pain on a 100-mm visual analogue scale. Changes in outcome corrected for baseline were even larger: MD -1.41 (-1.89 to -0.94; P < 0.001) for anxiety and -0.54 (-0.93 to -0.15; P = 0.006) for pain. Music interventions provided during general anaesthesia significantly decreased pain compared with that in controls (MD -0.41, -0.64 to -0.18; P < 0.001). Metaregression analysis found no significant association between the effect of music interventions and age, sex, choice and timing of music, and type of anaesthesia. Risk of bias in the studies was moderate to high. CONCLUSION: Music interventions significantly reduce anxiety and pain in adult surgical patients.

Invasive surgery involves an incision made in the body, in contrast to surgery carried out using lasers or endoscopes. Regional anaesthesia involves numbing of a larger or deeper part of the body than with local anaesthesia so that patients stay conscious whilst pain-free.

Pain and anxiety are often measured by asking patients to give their subjective perceptions using a Visual Analogue Scale (a 10 cm line) e.g. “on a scale of 1 to 100, with 1 equalling no pain and 100 equalling intolerable pain, how much pain are you in?”

Expert commentary

Patients who come to surgery will have been prepared for surgery by fitness for surgery activities, pain relief, and outcomes education.

Planned coping strategies including the use of psychological support of music therapies, need to be engaged with by perioperative surgical care teams, through the patient’s surgical journey. The availability of portable music devices such as mobile phones, tablets and radios, can support use intra-operatively as adjuncts to sedation and pain relief interventions.

Patient-controlled aural support should be encouraged to achieve benefits demonstrated in this articles conclusion. Music interventions significantly reduce anxiety and pain in adult surgical patients.

Adrian Jones, President, Association for Perioperative Practice