NIHR Signal Listening to music reduces pain and anxiety for patients having surgery

Published on 28 October 2015

This systematic review found that music can moderately reduce pain and anxiety when played before, during or after surgery. It also strongly increased patient satisfaction. Music was equally effective whether chosen by the patient or not. It was most effective when played before surgery and when the patient was conscious, though it was still effective even when played to the patient under general anaesthetic. Playing music may improve outcomes and patient satisfaction at no or marginal cost to the NHS. The agreement of the patient and the surgical team are advised, as it may not be suitable in all settings and the choice of music genre may not please all team members.

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Why was this study needed?

Music is a non-invasive and inexpensive intervention that offers the chance of improved patient outcomes. Music is not routinely played before, during or after surgery, though there is a growing interest in its use. It is thought that listening to music can reduce pain and anxiety.

Listening to music has been studied in a large number of mostly small trials. Previous systematic reviews have investigated the effect of patients listening to music when undergoing specific surgical procedures, or at certain times before or after surgery. This is the first systematic review with meta-analyses to look at the use of music across surgery as a whole.

What did this study do?

This systematic review included 73 randomised controlled trials with up to 45 included in meta-analyses for each outcome. Trials compared any form of music that was played before, during, or after surgery with standard care or other non-drug interventions, such as headphones with no music, white noise, and undisturbed bed rest. Most music was considered “soothing”, with around half of the studies using music chosen by the patient. About half of the trials played music for the duration of the procedure, while others ranged from just a few minutes to repeated episodes of music for several days.

Most trials involved scheduled, rather than emergency surgery, ranging from minor endoscopic interventions to transplantation surgery. Surgeries involving the central nervous system or head and neck were excluded.

The authors followed reliable systematic review methods and there was no evidence of publication bias. Quality of included studies varied, and several were poorly reported. The largest trial had 458 participants but most studies were small, of less than 100 people, with the smallest just 20. Many of the trials included were difficult to find and were published in relatively obscure journals.

What did it find?

  • Music moderately reduced postoperative pain (standardised mean difference [SMD] ‑0.77, 95% Confidence Interval [CI] ‑0.99 to ‑0.56), anxiety (SMD ‑0.68, 95% CI ‑0.95 to ‑0.41), and use of painkillers (SMD ‑0.37, 95% CI ‑0.54 to ‑0.20). It also strongly increased patient satisfaction (SMD 1.09, 95% CI 0.51 to 1.68).
  • Length of stay was not significantly reduced, although this was only measured in seven of the 73 trials.
  • Music was most effective when played before surgery, rather than during or after, although it was effective at all time-points. Music had the greatest effect if played when patients were conscious, compared to when played under general anaesthetic.
  • No adverse effects were reported in any studies.

What does current guidance say on this issue?

There is no current UK guidance on the issue.

What are the implications?

Music could be offered as a way to help patients reduce pain and anxiety before, during and after surgery. It also improves patient satisfaction. Timing and delivery can be adapted according to the needs of the patient and the clinical team.

Music may not always be suitable. Reviews and qualitative studies suggest that while sometimes surgical teams might be more relaxed and attentive when listening to music that they enjoy, at other times they could be distracted from their tasks or from talking with patients. Prior agreement of the surgical team, especially during surgery, and their patients is advisable.

Some further work is needed. The authors note that the review combined data from a large number of wide-ranging studies, and so they cannot be sure whether music is effective in all settings. Much music is protected by law under copyright so the cost implications, and practicalities of seeking permission to use it, should be considered before routine use in the theatre.

Citation

Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. Lancet. 2015 Aug 12 [Epub ahead of print].

Bibliography

Way TJ, Long A, Weihing J, et al. Effect of noise on auditory processing in the operating room. J Am Coll Surg. 2013 May;216(5):933-8.

Weldon SM, Korkiakangas T, Bezemer J, Kneebone R. Music and communication in the operating theatre. J Adv Nurs. 2015. Aug 4 [Epub ahead of print].

Wilkins MK, Moore ML. Music intervention in the intensive care unit: a complementary therapy to improve patient outcomes. Evid Based Nurs. 2004;7(4):103-4.

Why was this study needed?

Music is a non-invasive and inexpensive intervention that offers the chance of improved patient outcomes. Music is not routinely played before, during or after surgery, though there is a growing interest in its use. It is thought that listening to music can reduce pain and anxiety.

Listening to music has been studied in a large number of mostly small trials. Previous systematic reviews have investigated the effect of patients listening to music when undergoing specific surgical procedures, or at certain times before or after surgery. This is the first systematic review with meta-analyses to look at the use of music across surgery as a whole.

What did this study do?

This systematic review included 73 randomised controlled trials with up to 45 included in meta-analyses for each outcome. Trials compared any form of music that was played before, during, or after surgery with standard care or other non-drug interventions, such as headphones with no music, white noise, and undisturbed bed rest. Most music was considered “soothing”, with around half of the studies using music chosen by the patient. About half of the trials played music for the duration of the procedure, while others ranged from just a few minutes to repeated episodes of music for several days.

Most trials involved scheduled, rather than emergency surgery, ranging from minor endoscopic interventions to transplantation surgery. Surgeries involving the central nervous system or head and neck were excluded.

The authors followed reliable systematic review methods and there was no evidence of publication bias. Quality of included studies varied, and several were poorly reported. The largest trial had 458 participants but most studies were small, of less than 100 people, with the smallest just 20. Many of the trials included were difficult to find and were published in relatively obscure journals.

What did it find?

  • Music moderately reduced postoperative pain (standardised mean difference [SMD] ‑0.77, 95% Confidence Interval [CI] ‑0.99 to ‑0.56), anxiety (SMD ‑0.68, 95% CI ‑0.95 to ‑0.41), and use of painkillers (SMD ‑0.37, 95% CI ‑0.54 to ‑0.20). It also strongly increased patient satisfaction (SMD 1.09, 95% CI 0.51 to 1.68).
  • Length of stay was not significantly reduced, although this was only measured in seven of the 73 trials.
  • Music was most effective when played before surgery, rather than during or after, although it was effective at all time-points. Music had the greatest effect if played when patients were conscious, compared to when played under general anaesthetic.
  • No adverse effects were reported in any studies.

What does current guidance say on this issue?

There is no current UK guidance on the issue.

What are the implications?

Music could be offered as a way to help patients reduce pain and anxiety before, during and after surgery. It also improves patient satisfaction. Timing and delivery can be adapted according to the needs of the patient and the clinical team.

Music may not always be suitable. Reviews and qualitative studies suggest that while sometimes surgical teams might be more relaxed and attentive when listening to music that they enjoy, at other times they could be distracted from their tasks or from talking with patients. Prior agreement of the surgical team, especially during surgery, and their patients is advisable.

Some further work is needed. The authors note that the review combined data from a large number of wide-ranging studies, and so they cannot be sure whether music is effective in all settings. Much music is protected by law under copyright so the cost implications, and practicalities of seeking permission to use it, should be considered before routine use in the theatre.

Citation

Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. Lancet. 2015 Aug 12 [Epub ahead of print].

Bibliography

Way TJ, Long A, Weihing J, et al. Effect of noise on auditory processing in the operating room. J Am Coll Surg. 2013 May;216(5):933-8.

Weldon SM, Korkiakangas T, Bezemer J, Kneebone R. Music and communication in the operating theatre. J Adv Nurs. 2015. Aug 4 [Epub ahead of print].

Wilkins MK, Moore ML. Music intervention in the intensive care unit: a complementary therapy to improve patient outcomes. Evid Based Nurs. 2004;7(4):103-4.

Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis

Published on 19 August 2015

Hole, J.,Hirsch, M.,Ball, E.,Meads, C.

Lancet , 2015

BACKGROUND: Music is a non-invasive, safe, and inexpensive intervention that can be delivered easily and successfully. We did a systematic review and meta-analysis to assess whether music improves recovery after surgical procedures. METHODS: We included randomised controlled trials (RCTs) of adult patients undergoing surgical procedures, excluding those involving the central nervous system or head and neck, published in any language. We included RCTs in which any form of music initiated before, during, or after surgery was compared with standard care or other non-drug interventions. We searched MEDLINE, Embase, CINAHL, and Cochrane Central. We did meta-analysis with RevMan (version 5.2), with standardised mean differences (SMD) and random-effects models, and used Stata (version 12) for meta-regression. This study is registered with PROSPERO, number CRD42013005220. FINDINGS: We identified 4261 titles and abstracts, and included 73 RCTs in the systematic review, with size varying between 20 and 458 participants. Choice of music, timing, and duration varied. Comparators included routine care, headphones with no music, white noise, and undisturbed bed rest. Music reduced postoperative pain (SMD -0.77 [95% CI -0.99 to -0.56]), anxiety (-0.68 [-0.95 to -0.41]), and analgesia use (-0.37 [-0.54 to -0.20]), and increased patient satisfaction (1.09 [0.51 to 1.68]), but length of stay did not differ (SMD -0.11 [-0.35 to 0.12]). Subgroup analyses showed that choice of music and timing of delivery made little difference to outcomes. Meta-regression identified no causes of heterogeneity in eight variables assessed. Music was effective even when patients were under general anaesthetic. INTERPRETATION: Music could be offered as a way to help patients reduce pain and anxiety during the postoperative period. Timing and delivery can be adapted to individual clinical settings and medical teams. FUNDING: None.

The standardised mean difference (SMD) is a summary statistic used in meta-analysis when studies all assess the same outcome but measure it using different scales. Standardising the results of the studies to a uniform scale allows them to be combined or pooled.

We use Cohen’s rules of thumb to interpret the standardised mean difference. These rules suggest that 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect.

Expert commentary

As much as perioperative medicine, surgical skill and excellent care support enhanced recovery of patient following surgery, a non-invasive marginal gain as demonstrated in this article, may be just what the doctor ordered. Access to person-preference music is now within everyone’s domain, from the youngest to the oldest. This psychological adjunct should be encouraged, prescribed and delivered, preferably through good headphones. Headphones are probably best, as I know of surgical teams who still argue over whose playlist is appropriate or what is enjoyed. Headphones will also ensure that the volume of the music will not damage an i-phone decibel meter!       

Adrian Jones, Surgical Care Practitioner, Orthopaedic Department, Norfolk & Norwich University Hospital. Vice President, The Association for Perioperative Practice