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Music Therapy Increases Comfort and Reduces Pain in Patients Recovering From Spine Surgery
Take-Home Points
- Music therapists use patient-preferred live music, increasing neurologic cues that enhance movement—a seminal recovery function in postoperative spine patients.
- Music therapy is an evidence-based, integrative treatment addressing body, mind, and spirit.
- Tension release through music therapy can serve as a critical mechanism for building resilience related to pain management.
- Music therapy and music medicine are distinct forms of clinical practice that focus on mind-body integration in the healing process.
- Music therapists, board-certified and licensed by the state as recognized healthcare professionals, address pain management, which is an increasing subspecialty in postoperative care.
About 70% of people in the United States experience at least 1 episode of back pain in their lifetime,1 and more than 5 million are temporarily or permanently disabled by spinal disorders.2-4 Some require surgery, which may rectify injury, but pain during recovery is often inevitable, and the road to recovery is not guaranteed to be smooth.5-20
Postoperative spine patients are at major risk for pain management challenges.14,15,18,20 Treatment is primarily pharmacologic and based on the surgical team’s pain management orders. Nursing care consists of monitoring the airway, vital signs, and neurovascular status and having patients rate their pain on a visual analog scale (VAS; 0 = no pain, 10 = worst pain imaginable). Nurses have the challenge of monitoring and continually assessing to make sure patients are achieving the optimal outcomes, particularly during the immediate postoperative period, when pain and anxiety are prominently increased.
Variability in spine surgery outcomes can be explained at least partly on the basis of prognostic psychological factors, including hypochondriasis, hysteria, depression, and poor pain coping strategies (eg, catastrophizing).21 In spine surgery patients, kinesiophobia (fear of moving) is a common component of distress that can impede recuperation.21-23
Rationale for Live Music
Pain is subjective and personal, and warrants an individualized approach to care. There is a body of music medicine research on the use of recorded music in modulating psychological and physiological factors in pain perception.30,32,34-54 This research supports the unique relationship of music to well-being, and the understanding that controlling any of these factors affects the duration, intensity, and quality of that experience.41,43,52
These findings provide incentive for breathing-entrained music therapy interventions, which enhance the relaxation response and release of pain-related tension;32,55-58 empower patients to unlock physical and emotional tension;32,57,58 provide a channel for expression and body movement; and enhance blood flow and/or alleviate pain by activating neurologic areas involved in the experience of pain.59-62Studies have found that physical endurance may be enhanced when movement is rhythmically coordinated with a musical stimulus.63-66 Music may prolong physical endurance by inhibiting psychological feedback associated with physical exertion related to fatigue, which may translate into accelerated recovery periods. When we listen to a rhythmic sound, our brains tend to automatically synchronize, or entrain, to external rhythmic cues that can stimulate increased motor control and coordination.63 Sound can arouse and raise the excitability of spinal motor neurons mediated by auditory-motor neuronal connections on the brain stem and spinal cord level.64-66 Rhythmically organized sounds serve as a neurological function in our capacity to organize predictable timing cues that are apparent in music, and may result in an effective treatment intervention in recovery.63,64
Music Therapy in Recovery From Spine Surgery
In music therapy, music is used within a therapeutic relationship to support or affect change in the patient and the treatment regimen.32,33,56-58 Research on music therapy with patients who are recovering from spine surgery is scant.67-69 Kleiber and Adamek67 studied perceptions of music therapy in 8 adolescents after spinal fusion surgery. In their study, a music therapist provided patients with a postoperative music therapy session focusing on the use of patient-preferred live music for relaxation and expression. Although their qualitative query was based on a therapeutic approach similar to that used in the present study, only 1 session was offered during the recovery period, and follow-up was conducted by survey invitation and telephone. In addition, the number of participants was small, and there was no quantitative measure of pain or other symptoms.
Another study focused on the effects of listening to music on pain intensity and distress after spine surgery.68 Patients in the study’s music group made their selections from prerecorded classical music and domestic and international popular songs from various genres and listened to their chosen recordings 30 minutes a day. Although the study was not a music therapy study per se, it showed a positive impact of listening to music on anxiety and pain perception in 60 adults who were randomly assigned to the music group or to a non-music control group (n = 30 in each). Differences between the music and control groups’ VAS ratings of anxiety (Ps = .018-.001) and pain (P = .001) were statistically significant.
Different from our study, the aforementioned studies did not include tension release–focused live music offered within a therapeutic relationship. Our 1.5-year pilot study, conducted prior to the present study indicated that music therapy led to increased resilience and recovery mechanisms.58
Methods
Our mixed-methods study design combined standard medical treatment with integrative music therapy interventions based on pain assessments to better understand the effects of music therapy on the recovery of patients after spine surgery.
The Spine Institute of New York within the Department of Orthopedic Surgery at Mount Sinai Beth Israel provides surgical treatment of common spinal cord conditions. Prioritizing patient satisfaction and positive outcomes,27,28 the institute integrates music therapy through the Louis Armstrong Center for Music and Medicine to enhance treatment of pain symptoms.
Patients were recruited by the research team as per the daily surgical schedule, or through referral by the medical team or patient care navigator. Sixty patients (35 female, 25 male) ranging in age from 40 to 55 years underwent anterior, posterior, or anterior-posterior spinal fusion and were enrolled in the study after signing a participation consent form. Minorities, women, and patients with Medicaid and Medicare were included. Patients who received a diagnosis of clinical psychosis or depression prior to spine injury were excluded.
The experimental group received music therapy plus standard care (medical and nursing care with scheduled pharmacologic pain intervention), and a wait-listed control group received standard care only. A randomization chart created by a blinded statistician who did not have access to the patient census determined the intervention–nonintervention schedule. Patients in the music therapy group received one 30-minute music therapy session during an 8-hour period within 72 hours after surgery.
For both groups, measurements were completed before and after the study window. Control patients were offered music therapy after completion of the post-intervention surveys in order to minimize the ethical dilemma of denying potentially helpful pain intervention. For this same reason, both groups were given the option of receiving follow-up music therapy sessions for the duration of their hospitalization.
The research team consisted of 2 licensed, board-certified music therapists. In addition, Master’s-level music therapy interns completing clinical hours as part of the trajectory for board certification served on the research team over the 5-year period 2009 to 2014, and 13 blinded research assistants helped with enrolling and collecting data on patients.
Intervention
Each music therapy session included a warm-up phase of verbal or musical discourse. Next was the treatment phase, which was based on patient need as assessed during warm-up. Treatment options included use of patient-preferred live music that supported tension release/relaxation through incentive-based clinical improvisation, singing, and/or rhythmic drumming or through breathwork and visualization. Psychoeducation about mind–body awareness through the use of breath and imagery was introduced and explained by the therapist at this time.
The improvised music intervention was focused on making salient the natural harmonic tension-resolution cycles that occur in music and that were entrained to the patient’s presentation (respiratory rate, verbal report, clinical presentation). When patient-preferred precomposed songs were used, tension resolution was achieved by sustaining cadence and resolution, also entrained to the patient’s respiratory cycles.32,57,58
After the music therapy intervention, a period of closure or integration was facilitated by the therapist contingent on the patient’s degree of alertness. If awake, the patient was supported in a reflexive process of thoughts, impressions, or issues that may have contributed to the overall experience. If the patient was asleep, the researcher returned within 30 minutes for post-intervention interviewing. Interview information was recorded in a qualitative post-participation survey. To prevent bias, researchers who were not the treating clinicians conducted the surveys.
Outcome Measures
Both primary and secondary outcome measures were collected before and after the intervention. The primary outcome measure was VAS pain ratings, and the secondary outcome measures were scores on the Hospital Anxiety and Depression Scale (HADS), the Tampa Scale for Kinesiophobia (TSK), and the Color Analysis Scale (CAS).
VAS. With the VAS, images are used to rate pain. The scale has points labeled 0 to 10 and corresponding faces representing progression in pain intensity. The scale is quickly rendered and can be interpreted according to the patient’s recovery phase at time of rendering.
HADS. The HADS70 provides a specific baseline for anxiety and depression as an indicator of how the patient might fare during hospitalization (admission through recovery and discharge).
TSK. The TSK71 provides insight into the patient’s perception of fear-related movement, which is an important factor in this study because of the movement required for rehabilitation. We used a shortened version of the TSK to accommodate the sensitive threshold for pain tolerance and pharmacologic side effects commonly experienced by spine patients.
CAS. The CAS was developed at the Louis Armstrong Center for Music and Medicine to assess comorbidities and dynamic aspects of pain. Through a coloring exercise, patients illustrate their pain experience, which gives tangible form to the abstract experience of pain.
Coding
We collected patients’ demographic data, including age, sex, and diagnoses. Clinical indicators of the preoperative baseline included lifestyle, surgical history, and prior experience with music or other mind–body strategies for self-regulation.
As fundamental to qualitative methodology,72,73 the reported responses to questions were grouped into themes that were peer-tested with members of the research team before and during the coding process. 
VAS, HADS, and TSK data were tabulated by blinded research assistants and analyzed by a statistician. Patients were identified by number assignment, and their data and personal information were kept confidentially stored.
Statistical Methods
Means and standard deviations were used for continuous variables, and frequencies (percentages) for categorical variables. All outcomes were analyzed on an intent-to-treat basis. Repeated-measures analysis of variance was used to compare changes in outcomes from before to after intervention for the music and control groups. In particular, a statistically significant Group (music vs control) × Time (before vs after intervention) interaction would support the hypothesis that there would be more benefit (less pain) in the music group as a result of the music therapy. For all tests, significance was set at P < .05. SPSS Version 20 (IBM) was used for all statistical analyses. Based on previously found differences in heart rate and mobility,31 we assumed an effect size of 0.71 for the difference between music and control (no music), which would require 32 patients per group to achieve a power of 0.8 with an α of 0.05.
Results
Of the 136 patients who were asked to participate in the study, 76 were not enrolled; the other 60 were equally assigned to either the control group or the music therapy group (n = 30 in each) according to randomization indicated by a blinded statistician (Figure 1). 
Table 2 lists the pre-intervention and post-intervention comparisons of the main outcomes between groups. 
The emerging themes of the responses are listed in Tables 3 and 4 and are explained here:
Relationship with music was coded for significance and included reports of music as a resource accessed for stimulation and/or relaxation through listening; direct involvement with instrument playing; and history of music training. 
Perceptions of surgical outcome in patients’ responses were coded across 3 themes: (1) optimistic (belief and hope in returning to original baseline of functionality), (2) indifferent (neither hopeful nor cynical about results of surgery), and (3) pessimistic (belief that nothing will restore the quality of life that existed before the spinal condition).
The CAS helped us better understand the diversity and complexity of the pain experience.
Discussion
Our hospital has the unique capability of providing music therapy to postoperative and other hospitalized patients. In this study, we compared the impact of a structured postoperative music therapy program on spine patients relative to control patients who did not receive music therapy after spine surgery.
We found a significant benefit in VAS pain levels (>1 point) but no statistically significant differences in HADS Anxiety, HADS Depression, or TSK scores. Although a 2-point difference is usually considered clinically significant, the degree of change in the music group is notable for having been achieved by nonpharmacologic means with scant chance of adverse effects. We suspect the lack of significant change in HADS Anxiety, HADS Depression, and TSK scores is attributable to the narrow study window. Given the observational data from our pilot study58 and ongoing results with spine patients,32 it seems clear that both mood state and resilience in coping are enhanced through an ongoing relationship with music therapy.
The study of a population as vulnerable as patients recovering from spine surgery raises many issues for providers and researchers. Although it is worthwhile to determine the efficacy of integrative modalities in serving these patients, the request for participation in a protocol at such a vulnerable time was often resisted. During our pilot work, it became clear that the ability of potential subjects to comprehend and complete protocol surveys was impacted by adverse effects, including sedation drowsiness; respiratory depression; nausea and vomiting; pruritus; and urinary retention caused by the medications used for postoperative pain management. Consequently, after piloting 5 cases before the main study, we extended the enrollment window to 72 hours.
Other unforeseen intrinsic or external obstacles were identified: Patient-related issues—including availability, level of interest in participation, and inability to participate because of the medication adverse effects mentioned.
Staff investment/education—addressed over the first 3 study years with several in-services, starting with the surgical team and continuing with nursing and support staff in various combinations. These meetings led to the creation of an Institutional Review Board (IRB) approved educational sheet for inclusion in the information packet given to surgical patients on registration.
Programming interruptions—caused by the convergence of several unanticipated factors, including a delay in expedited review of the IRB renewal during the year of Hurricane Sandy and an interruption in the spine team’s service for administrative and program modification.
Conclusion
Music therapy interventions (eg, use of patient-preferred live music) offered within a therapeutic relationship favorably affected pain perceptions in patients recovering from spine surgery. This effect was achieved through several therapeutic entry points, including support of expression and opportunities for emotional catharsis.
At the core of music therapy’s efficacy is individualized treatment, through which patients are supported in their recovery of “self.” Measurable benefits—including increased comfort; reduced pain; improved gait; increased range of motion, endurance, and ability to relax; and empowerment to actively participate in one’s own care through daily activities imbued with an enhanced sense of agency—are of cardinal importance, as they may lead to quicker recovery perceptions and enhanced quality of life.
Am J Orthop. 2017;46(1):E13-E22. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
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Take-Home Points
- Music therapists use patient-preferred live music, increasing neurologic cues that enhance movement—a seminal recovery function in postoperative spine patients.
- Music therapy is an evidence-based, integrative treatment addressing body, mind, and spirit.
- Tension release through music therapy can serve as a critical mechanism for building resilience related to pain management.
- Music therapy and music medicine are distinct forms of clinical practice that focus on mind-body integration in the healing process.
- Music therapists, board-certified and licensed by the state as recognized healthcare professionals, address pain management, which is an increasing subspecialty in postoperative care.
About 70% of people in the United States experience at least 1 episode of back pain in their lifetime,1 and more than 5 million are temporarily or permanently disabled by spinal disorders.2-4 Some require surgery, which may rectify injury, but pain during recovery is often inevitable, and the road to recovery is not guaranteed to be smooth.5-20
Postoperative spine patients are at major risk for pain management challenges.14,15,18,20 Treatment is primarily pharmacologic and based on the surgical team’s pain management orders. Nursing care consists of monitoring the airway, vital signs, and neurovascular status and having patients rate their pain on a visual analog scale (VAS; 0 = no pain, 10 = worst pain imaginable). Nurses have the challenge of monitoring and continually assessing to make sure patients are achieving the optimal outcomes, particularly during the immediate postoperative period, when pain and anxiety are prominently increased.
Variability in spine surgery outcomes can be explained at least partly on the basis of prognostic psychological factors, including hypochondriasis, hysteria, depression, and poor pain coping strategies (eg, catastrophizing).21 In spine surgery patients, kinesiophobia (fear of moving) is a common component of distress that can impede recuperation.21-23
Rationale for Live Music
Pain is subjective and personal, and warrants an individualized approach to care. There is a body of music medicine research on the use of recorded music in modulating psychological and physiological factors in pain perception.30,32,34-54 This research supports the unique relationship of music to well-being, and the understanding that controlling any of these factors affects the duration, intensity, and quality of that experience.41,43,52
These findings provide incentive for breathing-entrained music therapy interventions, which enhance the relaxation response and release of pain-related tension;32,55-58 empower patients to unlock physical and emotional tension;32,57,58 provide a channel for expression and body movement; and enhance blood flow and/or alleviate pain by activating neurologic areas involved in the experience of pain.59-62Studies have found that physical endurance may be enhanced when movement is rhythmically coordinated with a musical stimulus.63-66 Music may prolong physical endurance by inhibiting psychological feedback associated with physical exertion related to fatigue, which may translate into accelerated recovery periods. When we listen to a rhythmic sound, our brains tend to automatically synchronize, or entrain, to external rhythmic cues that can stimulate increased motor control and coordination.63 Sound can arouse and raise the excitability of spinal motor neurons mediated by auditory-motor neuronal connections on the brain stem and spinal cord level.64-66 Rhythmically organized sounds serve as a neurological function in our capacity to organize predictable timing cues that are apparent in music, and may result in an effective treatment intervention in recovery.63,64
Music Therapy in Recovery From Spine Surgery
In music therapy, music is used within a therapeutic relationship to support or affect change in the patient and the treatment regimen.32,33,56-58 Research on music therapy with patients who are recovering from spine surgery is scant.67-69 Kleiber and Adamek67 studied perceptions of music therapy in 8 adolescents after spinal fusion surgery. In their study, a music therapist provided patients with a postoperative music therapy session focusing on the use of patient-preferred live music for relaxation and expression. Although their qualitative query was based on a therapeutic approach similar to that used in the present study, only 1 session was offered during the recovery period, and follow-up was conducted by survey invitation and telephone. In addition, the number of participants was small, and there was no quantitative measure of pain or other symptoms.
Another study focused on the effects of listening to music on pain intensity and distress after spine surgery.68 Patients in the study’s music group made their selections from prerecorded classical music and domestic and international popular songs from various genres and listened to their chosen recordings 30 minutes a day. Although the study was not a music therapy study per se, it showed a positive impact of listening to music on anxiety and pain perception in 60 adults who were randomly assigned to the music group or to a non-music control group (n = 30 in each). Differences between the music and control groups’ VAS ratings of anxiety (Ps = .018-.001) and pain (P = .001) were statistically significant.
Different from our study, the aforementioned studies did not include tension release–focused live music offered within a therapeutic relationship. Our 1.5-year pilot study, conducted prior to the present study indicated that music therapy led to increased resilience and recovery mechanisms.58
Methods
Our mixed-methods study design combined standard medical treatment with integrative music therapy interventions based on pain assessments to better understand the effects of music therapy on the recovery of patients after spine surgery.
The Spine Institute of New York within the Department of Orthopedic Surgery at Mount Sinai Beth Israel provides surgical treatment of common spinal cord conditions. Prioritizing patient satisfaction and positive outcomes,27,28 the institute integrates music therapy through the Louis Armstrong Center for Music and Medicine to enhance treatment of pain symptoms.
Patients were recruited by the research team as per the daily surgical schedule, or through referral by the medical team or patient care navigator. Sixty patients (35 female, 25 male) ranging in age from 40 to 55 years underwent anterior, posterior, or anterior-posterior spinal fusion and were enrolled in the study after signing a participation consent form. Minorities, women, and patients with Medicaid and Medicare were included. Patients who received a diagnosis of clinical psychosis or depression prior to spine injury were excluded.
The experimental group received music therapy plus standard care (medical and nursing care with scheduled pharmacologic pain intervention), and a wait-listed control group received standard care only. A randomization chart created by a blinded statistician who did not have access to the patient census determined the intervention–nonintervention schedule. Patients in the music therapy group received one 30-minute music therapy session during an 8-hour period within 72 hours after surgery.
For both groups, measurements were completed before and after the study window. Control patients were offered music therapy after completion of the post-intervention surveys in order to minimize the ethical dilemma of denying potentially helpful pain intervention. For this same reason, both groups were given the option of receiving follow-up music therapy sessions for the duration of their hospitalization.
The research team consisted of 2 licensed, board-certified music therapists. In addition, Master’s-level music therapy interns completing clinical hours as part of the trajectory for board certification served on the research team over the 5-year period 2009 to 2014, and 13 blinded research assistants helped with enrolling and collecting data on patients.
Intervention
Each music therapy session included a warm-up phase of verbal or musical discourse. Next was the treatment phase, which was based on patient need as assessed during warm-up. Treatment options included use of patient-preferred live music that supported tension release/relaxation through incentive-based clinical improvisation, singing, and/or rhythmic drumming or through breathwork and visualization. Psychoeducation about mind–body awareness through the use of breath and imagery was introduced and explained by the therapist at this time.
The improvised music intervention was focused on making salient the natural harmonic tension-resolution cycles that occur in music and that were entrained to the patient’s presentation (respiratory rate, verbal report, clinical presentation). When patient-preferred precomposed songs were used, tension resolution was achieved by sustaining cadence and resolution, also entrained to the patient’s respiratory cycles.32,57,58
After the music therapy intervention, a period of closure or integration was facilitated by the therapist contingent on the patient’s degree of alertness. If awake, the patient was supported in a reflexive process of thoughts, impressions, or issues that may have contributed to the overall experience. If the patient was asleep, the researcher returned within 30 minutes for post-intervention interviewing. Interview information was recorded in a qualitative post-participation survey. To prevent bias, researchers who were not the treating clinicians conducted the surveys.
Outcome Measures
Both primary and secondary outcome measures were collected before and after the intervention. The primary outcome measure was VAS pain ratings, and the secondary outcome measures were scores on the Hospital Anxiety and Depression Scale (HADS), the Tampa Scale for Kinesiophobia (TSK), and the Color Analysis Scale (CAS).
VAS. With the VAS, images are used to rate pain. The scale has points labeled 0 to 10 and corresponding faces representing progression in pain intensity. The scale is quickly rendered and can be interpreted according to the patient’s recovery phase at time of rendering.
HADS. The HADS70 provides a specific baseline for anxiety and depression as an indicator of how the patient might fare during hospitalization (admission through recovery and discharge).
TSK. The TSK71 provides insight into the patient’s perception of fear-related movement, which is an important factor in this study because of the movement required for rehabilitation. We used a shortened version of the TSK to accommodate the sensitive threshold for pain tolerance and pharmacologic side effects commonly experienced by spine patients.
CAS. The CAS was developed at the Louis Armstrong Center for Music and Medicine to assess comorbidities and dynamic aspects of pain. Through a coloring exercise, patients illustrate their pain experience, which gives tangible form to the abstract experience of pain.
Coding
We collected patients’ demographic data, including age, sex, and diagnoses. Clinical indicators of the preoperative baseline included lifestyle, surgical history, and prior experience with music or other mind–body strategies for self-regulation.
As fundamental to qualitative methodology,72,73 the reported responses to questions were grouped into themes that were peer-tested with members of the research team before and during the coding process.
VAS, HADS, and TSK data were tabulated by blinded research assistants and analyzed by a statistician. Patients were identified by number assignment, and their data and personal information were kept confidentially stored.
Statistical Methods
Means and standard deviations were used for continuous variables, and frequencies (percentages) for categorical variables. All outcomes were analyzed on an intent-to-treat basis. Repeated-measures analysis of variance was used to compare changes in outcomes from before to after intervention for the music and control groups. In particular, a statistically significant Group (music vs control) × Time (before vs after intervention) interaction would support the hypothesis that there would be more benefit (less pain) in the music group as a result of the music therapy. For all tests, significance was set at P < .05. SPSS Version 20 (IBM) was used for all statistical analyses. Based on previously found differences in heart rate and mobility,31 we assumed an effect size of 0.71 for the difference between music and control (no music), which would require 32 patients per group to achieve a power of 0.8 with an α of 0.05.
Results
Of the 136 patients who were asked to participate in the study, 76 were not enrolled; the other 60 were equally assigned to either the control group or the music therapy group (n = 30 in each) according to randomization indicated by a blinded statistician (Figure 1).
Table 2 lists the pre-intervention and post-intervention comparisons of the main outcomes between groups.
The emerging themes of the responses are listed in Tables 3 and 4 and are explained here:
Relationship with music was coded for significance and included reports of music as a resource accessed for stimulation and/or relaxation through listening; direct involvement with instrument playing; and history of music training.
Perceptions of surgical outcome in patients’ responses were coded across 3 themes: (1) optimistic (belief and hope in returning to original baseline of functionality), (2) indifferent (neither hopeful nor cynical about results of surgery), and (3) pessimistic (belief that nothing will restore the quality of life that existed before the spinal condition).
The CAS helped us better understand the diversity and complexity of the pain experience.
Discussion
Our hospital has the unique capability of providing music therapy to postoperative and other hospitalized patients. In this study, we compared the impact of a structured postoperative music therapy program on spine patients relative to control patients who did not receive music therapy after spine surgery.
We found a significant benefit in VAS pain levels (>1 point) but no statistically significant differences in HADS Anxiety, HADS Depression, or TSK scores. Although a 2-point difference is usually considered clinically significant, the degree of change in the music group is notable for having been achieved by nonpharmacologic means with scant chance of adverse effects. We suspect the lack of significant change in HADS Anxiety, HADS Depression, and TSK scores is attributable to the narrow study window. Given the observational data from our pilot study58 and ongoing results with spine patients,32 it seems clear that both mood state and resilience in coping are enhanced through an ongoing relationship with music therapy.
The study of a population as vulnerable as patients recovering from spine surgery raises many issues for providers and researchers. Although it is worthwhile to determine the efficacy of integrative modalities in serving these patients, the request for participation in a protocol at such a vulnerable time was often resisted. During our pilot work, it became clear that the ability of potential subjects to comprehend and complete protocol surveys was impacted by adverse effects, including sedation drowsiness; respiratory depression; nausea and vomiting; pruritus; and urinary retention caused by the medications used for postoperative pain management. Consequently, after piloting 5 cases before the main study, we extended the enrollment window to 72 hours.
Other unforeseen intrinsic or external obstacles were identified: Patient-related issues—including availability, level of interest in participation, and inability to participate because of the medication adverse effects mentioned.
Staff investment/education—addressed over the first 3 study years with several in-services, starting with the surgical team and continuing with nursing and support staff in various combinations. These meetings led to the creation of an Institutional Review Board (IRB) approved educational sheet for inclusion in the information packet given to surgical patients on registration.
Programming interruptions—caused by the convergence of several unanticipated factors, including a delay in expedited review of the IRB renewal during the year of Hurricane Sandy and an interruption in the spine team’s service for administrative and program modification.
Conclusion
Music therapy interventions (eg, use of patient-preferred live music) offered within a therapeutic relationship favorably affected pain perceptions in patients recovering from spine surgery. This effect was achieved through several therapeutic entry points, including support of expression and opportunities for emotional catharsis.
At the core of music therapy’s efficacy is individualized treatment, through which patients are supported in their recovery of “self.” Measurable benefits—including increased comfort; reduced pain; improved gait; increased range of motion, endurance, and ability to relax; and empowerment to actively participate in one’s own care through daily activities imbued with an enhanced sense of agency—are of cardinal importance, as they may lead to quicker recovery perceptions and enhanced quality of life.
Am J Orthop. 2017;46(1):E13-E22. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Take-Home Points
- Music therapists use patient-preferred live music, increasing neurologic cues that enhance movement—a seminal recovery function in postoperative spine patients.
- Music therapy is an evidence-based, integrative treatment addressing body, mind, and spirit.
- Tension release through music therapy can serve as a critical mechanism for building resilience related to pain management.
- Music therapy and music medicine are distinct forms of clinical practice that focus on mind-body integration in the healing process.
- Music therapists, board-certified and licensed by the state as recognized healthcare professionals, address pain management, which is an increasing subspecialty in postoperative care.
About 70% of people in the United States experience at least 1 episode of back pain in their lifetime,1 and more than 5 million are temporarily or permanently disabled by spinal disorders.2-4 Some require surgery, which may rectify injury, but pain during recovery is often inevitable, and the road to recovery is not guaranteed to be smooth.5-20
Postoperative spine patients are at major risk for pain management challenges.14,15,18,20 Treatment is primarily pharmacologic and based on the surgical team’s pain management orders. Nursing care consists of monitoring the airway, vital signs, and neurovascular status and having patients rate their pain on a visual analog scale (VAS; 0 = no pain, 10 = worst pain imaginable). Nurses have the challenge of monitoring and continually assessing to make sure patients are achieving the optimal outcomes, particularly during the immediate postoperative period, when pain and anxiety are prominently increased.
Variability in spine surgery outcomes can be explained at least partly on the basis of prognostic psychological factors, including hypochondriasis, hysteria, depression, and poor pain coping strategies (eg, catastrophizing).21 In spine surgery patients, kinesiophobia (fear of moving) is a common component of distress that can impede recuperation.21-23
Rationale for Live Music
Pain is subjective and personal, and warrants an individualized approach to care. There is a body of music medicine research on the use of recorded music in modulating psychological and physiological factors in pain perception.30,32,34-54 This research supports the unique relationship of music to well-being, and the understanding that controlling any of these factors affects the duration, intensity, and quality of that experience.41,43,52
These findings provide incentive for breathing-entrained music therapy interventions, which enhance the relaxation response and release of pain-related tension;32,55-58 empower patients to unlock physical and emotional tension;32,57,58 provide a channel for expression and body movement; and enhance blood flow and/or alleviate pain by activating neurologic areas involved in the experience of pain.59-62Studies have found that physical endurance may be enhanced when movement is rhythmically coordinated with a musical stimulus.63-66 Music may prolong physical endurance by inhibiting psychological feedback associated with physical exertion related to fatigue, which may translate into accelerated recovery periods. When we listen to a rhythmic sound, our brains tend to automatically synchronize, or entrain, to external rhythmic cues that can stimulate increased motor control and coordination.63 Sound can arouse and raise the excitability of spinal motor neurons mediated by auditory-motor neuronal connections on the brain stem and spinal cord level.64-66 Rhythmically organized sounds serve as a neurological function in our capacity to organize predictable timing cues that are apparent in music, and may result in an effective treatment intervention in recovery.63,64
Music Therapy in Recovery From Spine Surgery
In music therapy, music is used within a therapeutic relationship to support or affect change in the patient and the treatment regimen.32,33,56-58 Research on music therapy with patients who are recovering from spine surgery is scant.67-69 Kleiber and Adamek67 studied perceptions of music therapy in 8 adolescents after spinal fusion surgery. In their study, a music therapist provided patients with a postoperative music therapy session focusing on the use of patient-preferred live music for relaxation and expression. Although their qualitative query was based on a therapeutic approach similar to that used in the present study, only 1 session was offered during the recovery period, and follow-up was conducted by survey invitation and telephone. In addition, the number of participants was small, and there was no quantitative measure of pain or other symptoms.
Another study focused on the effects of listening to music on pain intensity and distress after spine surgery.68 Patients in the study’s music group made their selections from prerecorded classical music and domestic and international popular songs from various genres and listened to their chosen recordings 30 minutes a day. Although the study was not a music therapy study per se, it showed a positive impact of listening to music on anxiety and pain perception in 60 adults who were randomly assigned to the music group or to a non-music control group (n = 30 in each). Differences between the music and control groups’ VAS ratings of anxiety (Ps = .018-.001) and pain (P = .001) were statistically significant.
Different from our study, the aforementioned studies did not include tension release–focused live music offered within a therapeutic relationship. Our 1.5-year pilot study, conducted prior to the present study indicated that music therapy led to increased resilience and recovery mechanisms.58
Methods
Our mixed-methods study design combined standard medical treatment with integrative music therapy interventions based on pain assessments to better understand the effects of music therapy on the recovery of patients after spine surgery.
The Spine Institute of New York within the Department of Orthopedic Surgery at Mount Sinai Beth Israel provides surgical treatment of common spinal cord conditions. Prioritizing patient satisfaction and positive outcomes,27,28 the institute integrates music therapy through the Louis Armstrong Center for Music and Medicine to enhance treatment of pain symptoms.
Patients were recruited by the research team as per the daily surgical schedule, or through referral by the medical team or patient care navigator. Sixty patients (35 female, 25 male) ranging in age from 40 to 55 years underwent anterior, posterior, or anterior-posterior spinal fusion and were enrolled in the study after signing a participation consent form. Minorities, women, and patients with Medicaid and Medicare were included. Patients who received a diagnosis of clinical psychosis or depression prior to spine injury were excluded.
The experimental group received music therapy plus standard care (medical and nursing care with scheduled pharmacologic pain intervention), and a wait-listed control group received standard care only. A randomization chart created by a blinded statistician who did not have access to the patient census determined the intervention–nonintervention schedule. Patients in the music therapy group received one 30-minute music therapy session during an 8-hour period within 72 hours after surgery.
For both groups, measurements were completed before and after the study window. Control patients were offered music therapy after completion of the post-intervention surveys in order to minimize the ethical dilemma of denying potentially helpful pain intervention. For this same reason, both groups were given the option of receiving follow-up music therapy sessions for the duration of their hospitalization.
The research team consisted of 2 licensed, board-certified music therapists. In addition, Master’s-level music therapy interns completing clinical hours as part of the trajectory for board certification served on the research team over the 5-year period 2009 to 2014, and 13 blinded research assistants helped with enrolling and collecting data on patients.
Intervention
Each music therapy session included a warm-up phase of verbal or musical discourse. Next was the treatment phase, which was based on patient need as assessed during warm-up. Treatment options included use of patient-preferred live music that supported tension release/relaxation through incentive-based clinical improvisation, singing, and/or rhythmic drumming or through breathwork and visualization. Psychoeducation about mind–body awareness through the use of breath and imagery was introduced and explained by the therapist at this time.
The improvised music intervention was focused on making salient the natural harmonic tension-resolution cycles that occur in music and that were entrained to the patient’s presentation (respiratory rate, verbal report, clinical presentation). When patient-preferred precomposed songs were used, tension resolution was achieved by sustaining cadence and resolution, also entrained to the patient’s respiratory cycles.32,57,58
After the music therapy intervention, a period of closure or integration was facilitated by the therapist contingent on the patient’s degree of alertness. If awake, the patient was supported in a reflexive process of thoughts, impressions, or issues that may have contributed to the overall experience. If the patient was asleep, the researcher returned within 30 minutes for post-intervention interviewing. Interview information was recorded in a qualitative post-participation survey. To prevent bias, researchers who were not the treating clinicians conducted the surveys.
Outcome Measures
Both primary and secondary outcome measures were collected before and after the intervention. The primary outcome measure was VAS pain ratings, and the secondary outcome measures were scores on the Hospital Anxiety and Depression Scale (HADS), the Tampa Scale for Kinesiophobia (TSK), and the Color Analysis Scale (CAS).
VAS. With the VAS, images are used to rate pain. The scale has points labeled 0 to 10 and corresponding faces representing progression in pain intensity. The scale is quickly rendered and can be interpreted according to the patient’s recovery phase at time of rendering.
HADS. The HADS70 provides a specific baseline for anxiety and depression as an indicator of how the patient might fare during hospitalization (admission through recovery and discharge).
TSK. The TSK71 provides insight into the patient’s perception of fear-related movement, which is an important factor in this study because of the movement required for rehabilitation. We used a shortened version of the TSK to accommodate the sensitive threshold for pain tolerance and pharmacologic side effects commonly experienced by spine patients.
CAS. The CAS was developed at the Louis Armstrong Center for Music and Medicine to assess comorbidities and dynamic aspects of pain. Through a coloring exercise, patients illustrate their pain experience, which gives tangible form to the abstract experience of pain.
Coding
We collected patients’ demographic data, including age, sex, and diagnoses. Clinical indicators of the preoperative baseline included lifestyle, surgical history, and prior experience with music or other mind–body strategies for self-regulation.
As fundamental to qualitative methodology,72,73 the reported responses to questions were grouped into themes that were peer-tested with members of the research team before and during the coding process.
VAS, HADS, and TSK data were tabulated by blinded research assistants and analyzed by a statistician. Patients were identified by number assignment, and their data and personal information were kept confidentially stored.
Statistical Methods
Means and standard deviations were used for continuous variables, and frequencies (percentages) for categorical variables. All outcomes were analyzed on an intent-to-treat basis. Repeated-measures analysis of variance was used to compare changes in outcomes from before to after intervention for the music and control groups. In particular, a statistically significant Group (music vs control) × Time (before vs after intervention) interaction would support the hypothesis that there would be more benefit (less pain) in the music group as a result of the music therapy. For all tests, significance was set at P < .05. SPSS Version 20 (IBM) was used for all statistical analyses. Based on previously found differences in heart rate and mobility,31 we assumed an effect size of 0.71 for the difference between music and control (no music), which would require 32 patients per group to achieve a power of 0.8 with an α of 0.05.
Results
Of the 136 patients who were asked to participate in the study, 76 were not enrolled; the other 60 were equally assigned to either the control group or the music therapy group (n = 30 in each) according to randomization indicated by a blinded statistician (Figure 1).
Table 2 lists the pre-intervention and post-intervention comparisons of the main outcomes between groups.
The emerging themes of the responses are listed in Tables 3 and 4 and are explained here:
Relationship with music was coded for significance and included reports of music as a resource accessed for stimulation and/or relaxation through listening; direct involvement with instrument playing; and history of music training.
Perceptions of surgical outcome in patients’ responses were coded across 3 themes: (1) optimistic (belief and hope in returning to original baseline of functionality), (2) indifferent (neither hopeful nor cynical about results of surgery), and (3) pessimistic (belief that nothing will restore the quality of life that existed before the spinal condition).
The CAS helped us better understand the diversity and complexity of the pain experience.
Discussion
Our hospital has the unique capability of providing music therapy to postoperative and other hospitalized patients. In this study, we compared the impact of a structured postoperative music therapy program on spine patients relative to control patients who did not receive music therapy after spine surgery.
We found a significant benefit in VAS pain levels (>1 point) but no statistically significant differences in HADS Anxiety, HADS Depression, or TSK scores. Although a 2-point difference is usually considered clinically significant, the degree of change in the music group is notable for having been achieved by nonpharmacologic means with scant chance of adverse effects. We suspect the lack of significant change in HADS Anxiety, HADS Depression, and TSK scores is attributable to the narrow study window. Given the observational data from our pilot study58 and ongoing results with spine patients,32 it seems clear that both mood state and resilience in coping are enhanced through an ongoing relationship with music therapy.
The study of a population as vulnerable as patients recovering from spine surgery raises many issues for providers and researchers. Although it is worthwhile to determine the efficacy of integrative modalities in serving these patients, the request for participation in a protocol at such a vulnerable time was often resisted. During our pilot work, it became clear that the ability of potential subjects to comprehend and complete protocol surveys was impacted by adverse effects, including sedation drowsiness; respiratory depression; nausea and vomiting; pruritus; and urinary retention caused by the medications used for postoperative pain management. Consequently, after piloting 5 cases before the main study, we extended the enrollment window to 72 hours.
Other unforeseen intrinsic or external obstacles were identified: Patient-related issues—including availability, level of interest in participation, and inability to participate because of the medication adverse effects mentioned.
Staff investment/education—addressed over the first 3 study years with several in-services, starting with the surgical team and continuing with nursing and support staff in various combinations. These meetings led to the creation of an Institutional Review Board (IRB) approved educational sheet for inclusion in the information packet given to surgical patients on registration.
Programming interruptions—caused by the convergence of several unanticipated factors, including a delay in expedited review of the IRB renewal during the year of Hurricane Sandy and an interruption in the spine team’s service for administrative and program modification.
Conclusion
Music therapy interventions (eg, use of patient-preferred live music) offered within a therapeutic relationship favorably affected pain perceptions in patients recovering from spine surgery. This effect was achieved through several therapeutic entry points, including support of expression and opportunities for emotional catharsis.
At the core of music therapy’s efficacy is individualized treatment, through which patients are supported in their recovery of “self.” Measurable benefits—including increased comfort; reduced pain; improved gait; increased range of motion, endurance, and ability to relax; and empowerment to actively participate in one’s own care through daily activities imbued with an enhanced sense of agency—are of cardinal importance, as they may lead to quicker recovery perceptions and enhanced quality of life.
Am J Orthop. 2017;46(1):E13-E22. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
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24. Selimen D, Andsoy II. The importance of a holistic approach during the perioperative period. AORN J. 2011;93(4):482-487.
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26. Wright J, Adams D, Vohra S. Complementary, holistic, and integrative medicine: music for procedural pain. Pediatr Rev. 2013;34(11):e42-e46.
27. McCann PD. Orthopedic surgery and integrative medicine—strange bedfellows. Am J Orthop. 2009;38(2):66, 71.
28. McCann PD. Customer satisfaction: are hospitals “hospitable”? Am J Orthop. 2006;35(2):59.
29. Joanna Briggs Institute. The Joanna Briggs Institute best practice information sheet: music as an intervention in hospitals. Nurs Health Sci. 2011;13(1):99-102.
30. Spintge R. Thirty-five years of anxiolytic music (AAM) in pain and aversive clinical settings. In: Mondanaro J, Sara G, eds. Music and Medicine: Integrative Models in the Treatment of Pain. New York, NY: Satchnote Press; 2013:29-42.
31. Cepeda MS, Carr DB, Lau J, Alvarez H. Music for pain relief. Cochrane Database Syst Rev. 2006;(2):CD004843.
32. Mondanaro J. Music therapy based release strategies in the treatment of acute and chronic pain: an individualized approach. In: Mondanaro J, Sara G, eds. Music and Medicine: Integrative Models in the Treatment of Pain. New York, NY: Satchnote Press; 2013:133-148.
33. Quentzel S. Music has charms to soothe a savage breast. In: Mondanaro J, Sara G, eds. Music and Medicine: Integrative Models in the Treatment of Pain. New York, NY: Satchnote Press; 2013:11-28.
34. Ko YL. Lin PC. The effect of using a relaxation tape on pulse, respiration, blood pressure and anxiety levels of surgical patients. J Clin Nurs. 2012;21(5-6):689-697.
35. Roy M, Lebuis A, Hugueville L, Peretz I, Rainville P. Spinal modulation of nociception by music. Eur J Pain. 2012;16(6):870-877.
36. Roy M, Peretz I, Rainville P. Emotional valence contributes to music-induced analgesia. Pain. 2008;134(1-2):140-147.
37. Schröter T. Medicine needs music! Music therapy for chronic pain [in German]. Rev Med Suisse. 2014;10(415):286.
38. Bellieni CV, Cioncoloni D, Mazzanti S, et al. Music provided through a portable media player (iPod) blunts pain during physical therapy. Pain Manag Nurs. 2013;14(4):e151-e155.
39. Bernatzky G, Presch M, Anderson M, Panksepp J. Emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neurosci Biobehav Rev. 2011;35(9):1989-1999.
40. Bradshaw DH, Chapman CR, Jacobson RC, Donaldson GW. Effects of music engagement on response to painful stimulation. Clin J Pain. 2012;28(5):418-427.
41. Bradshaw DH, Donaldson GW, Jacobson RC, Nakamura Y, Chapman CR. Individual differences in the effects of music engagement on responses to painful stimulation. J Pain. 2011;12(12):1262-1273.
42. Chlan L, Halm MA. Does music ease pain and anxiety in the critically ill? Am J Crit Care. 2013;22(6):528-532.
43. Guétin S, Giniès P, Siou DK, et al. The effects of music intervention in the management of chronic pain: a single-blind, randomized, controlled trial. Clin J Pain. 2012;28(4):329-337.
44. Matsota P, Christodoulopoulou T, Smyrnioti ME, et al. Music’s use for anesthesia and analgesia. J Altern Complement Med. 2013;19(4):298-307.
45. Gooding L, Swezey S, Zwischenberger JB. Using music interventions in perioperative care. South Med J. 2012;105(9):486-490.
46. Graversen M, Sommer T. Perioperative music may reduce pain and fatigue in patients undergoing laparoscopic cholecystectomy. Acta Anaesthesiol Scand. 2013;57(8):1010-1016.
47. Ni CH, Tsai WH, Lee LM, Kao CC, Chen YC. Minimising preoperative anxiety with music for day surgery patients—a randomised clinical trial. J Clin Nurs. 2012;21(5-6):620-625.
48. Good M, Albert JM, Anderson GC, et al. Supplementing relaxation and music for pain after surgery. Nurs Res. 2010;59(4):259-269.
49. Moris DN, Linos D. Music meets surgery: two sides to the art of “healing.” Surg Endosc. 2013;27(3):719-723.
50. Nilsson U, Rawal N, Unosson M. A comparison of intra-operative or postoperative exposure to music—a controlled trial of the effects on postoperative pain. Anaesthesia. 2003;58(7):699-703.
51. Özer N, Karaman Özlü Z, Arslan S, Günes N. Effect of music on postoperative pain and physiologic parameters of patients after open heart surgery. Pain Manag Nurs. 2013;14(1):20-28.
52. Sen H, Yanarateş O, Sızlan A, Kılıç E, Ozkan S, Dağlı G. The efficiency and duration of the analgesic effects of musical therapy on postoperative pain. Agri. 2010;22(4):145-150.
53. Vaajoki A, Pietilä AM, Kankkunen P, Vehviläinen-Julkunen K. Music intervention study in abdominal surgery patients: challenges of an intervention study in clinical practice. Int J Nurs Pract. 2013;19(2):206-213.
54. Vaajoki A, Pietilä AM, Kankkunen P, Vehviläinen-Julkunen K. Effects of listening to music on pain intensity and pain distress after surgery: an intervention. J Clin Nurs. 2012;21(5-6):708-717.
55. Whitaker MH. Sounds soothing: music therapy for postoperative pain. Nursing. 2010;40(12):53-54.
56. Edwards J. Developing pain management approaches in music therapy with hospitalized children. In: Loewy J, Dileo C, eds. Music Therapy at the End of Life. Cherry Hill, NJ: Jeffrey Books; 2005:57-76.
57. Loewy J. The quiet soldier: pain and sickle cell anemia. In: Hibben J, ed. Inside Music Therapy: Client Experiences. Gilsum, NH: Barcelona; 1999:69-76.
58. Lichtensztejn M. The clinical use of piano with patients suffering from breathing distress related to pain. In: Azoulay R, Loewy JV, eds. Music, the Breath and Health: Advances in Integrative Music Therapy. New York, NY: Satchnote Press; 2009:213-222.
59. Kwon IS, Kim J, Park KM. Effects of music therapy on pain, discomfort, and depression for patients with leg fractures. Taehan Kanho Hakhoe Chi. 2006;36(4):630-636.
60. Zengin S, Kabul S, Al B, Sarcan E, Doğan M, Yildirim C. Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complement Ther Med. 2013;21(6):689-696.
61. Boso M, Politi P, Barale F, Emanuele E. Neurophysiology and neurobiology of the musical experience. Funct Neurol. 2006;21(4):187-191.
62. Salimpoor VN, Benovoy M, Larcher K, Dagher A, Zatorre RJ. Anatomically distinct dopamine release during anticipation and experience of peak emotion to music. Nat Neurosci. 2011;14(2):257-262.
63. Tomaino CM. Using rhythm for rehabilitation. Institute for Music and Neurologic Function website. http://musictherapy.imnf.org/images/uploads/rhythm.pdf. Published 2006. Accessed August 21, 2007.
64. Molinari M, Leggio MG, De Martin M, Cerasa A, Thaut M. Neurobiology of rhythmic motor entrainment. Ann N Y Acad Sci. 2003;999:313-321.
65. Thaut M. Neuropsychological processes in music perception. In: Unkefer R, ed. Music Therapy in the Treatment of Adults With Mental Disorders: Theoretical Bases and Clinical Interventions. Toronto, Canada: Schirmer Books; 2002:2-32.
66. Thaut M. Physiological and motor responses to music stimuli. In: Unkefer R, ed. Music Therapy in the Treatment of Adults With Mental Disorders: Theoretical Bases and Clinical Interventions. Toronto, Canada: Schimer Books; 2002:33-41.
67. Kleiber C, Adamek MS. Adolescents’ perceptions of music therapy following spinal fusion surgery. J Clin Nurs. 2013;22(3-4):414-422.
68. Lin PC, Lin ML, Huang LC, Hsu HC, Lin CC. Music therapy for patients receiving spine surgery. J Clin Nurs. 2011;20(7-8):960-968.
69. Maeyama A, Kodaka M, Miyao H. Effect of the music-therapy under spinal anesthesia [in Japanese]. Masui. 2009;58(6):684-691.
70. Golden J, Conroy RM, O’Dwyer AM. Reliability and validity of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory (Full and FastScreen scales) in detecting depression in persons with hepatitis C. J Affect Disord. 2006;100(1-3):265-269.
71. Woby SR, Roach NK, Urmston M, Watson PJ. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain. 2005;117(1-2):137-144.
72. Humrichouse J, Chmielewski M, McDade-Montez EA, Watson D. Affect assessment through self-report methods. In: Rottenberg J, Johnson SL, eds. Emotion and Psychopathology: Bridging Affective and Clinical Science. Washington, DC: American Psychological Association; 2007:13-34.
73. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills, CA: Sage; 1985.
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31. Cepeda MS, Carr DB, Lau J, Alvarez H. Music for pain relief. Cochrane Database Syst Rev. 2006;(2):CD004843.
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34. Ko YL. Lin PC. The effect of using a relaxation tape on pulse, respiration, blood pressure and anxiety levels of surgical patients. J Clin Nurs. 2012;21(5-6):689-697.
35. Roy M, Lebuis A, Hugueville L, Peretz I, Rainville P. Spinal modulation of nociception by music. Eur J Pain. 2012;16(6):870-877.
36. Roy M, Peretz I, Rainville P. Emotional valence contributes to music-induced analgesia. Pain. 2008;134(1-2):140-147.
37. Schröter T. Medicine needs music! Music therapy for chronic pain [in German]. Rev Med Suisse. 2014;10(415):286.
38. Bellieni CV, Cioncoloni D, Mazzanti S, et al. Music provided through a portable media player (iPod) blunts pain during physical therapy. Pain Manag Nurs. 2013;14(4):e151-e155.
39. Bernatzky G, Presch M, Anderson M, Panksepp J. Emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neurosci Biobehav Rev. 2011;35(9):1989-1999.
40. Bradshaw DH, Chapman CR, Jacobson RC, Donaldson GW. Effects of music engagement on response to painful stimulation. Clin J Pain. 2012;28(5):418-427.
41. Bradshaw DH, Donaldson GW, Jacobson RC, Nakamura Y, Chapman CR. Individual differences in the effects of music engagement on responses to painful stimulation. J Pain. 2011;12(12):1262-1273.
42. Chlan L, Halm MA. Does music ease pain and anxiety in the critically ill? Am J Crit Care. 2013;22(6):528-532.
43. Guétin S, Giniès P, Siou DK, et al. The effects of music intervention in the management of chronic pain: a single-blind, randomized, controlled trial. Clin J Pain. 2012;28(4):329-337.
44. Matsota P, Christodoulopoulou T, Smyrnioti ME, et al. Music’s use for anesthesia and analgesia. J Altern Complement Med. 2013;19(4):298-307.
45. Gooding L, Swezey S, Zwischenberger JB. Using music interventions in perioperative care. South Med J. 2012;105(9):486-490.
46. Graversen M, Sommer T. Perioperative music may reduce pain and fatigue in patients undergoing laparoscopic cholecystectomy. Acta Anaesthesiol Scand. 2013;57(8):1010-1016.
47. Ni CH, Tsai WH, Lee LM, Kao CC, Chen YC. Minimising preoperative anxiety with music for day surgery patients—a randomised clinical trial. J Clin Nurs. 2012;21(5-6):620-625.
48. Good M, Albert JM, Anderson GC, et al. Supplementing relaxation and music for pain after surgery. Nurs Res. 2010;59(4):259-269.
49. Moris DN, Linos D. Music meets surgery: two sides to the art of “healing.” Surg Endosc. 2013;27(3):719-723.
50. Nilsson U, Rawal N, Unosson M. A comparison of intra-operative or postoperative exposure to music—a controlled trial of the effects on postoperative pain. Anaesthesia. 2003;58(7):699-703.
51. Özer N, Karaman Özlü Z, Arslan S, Günes N. Effect of music on postoperative pain and physiologic parameters of patients after open heart surgery. Pain Manag Nurs. 2013;14(1):20-28.
52. Sen H, Yanarateş O, Sızlan A, Kılıç E, Ozkan S, Dağlı G. The efficiency and duration of the analgesic effects of musical therapy on postoperative pain. Agri. 2010;22(4):145-150.
53. Vaajoki A, Pietilä AM, Kankkunen P, Vehviläinen-Julkunen K. Music intervention study in abdominal surgery patients: challenges of an intervention study in clinical practice. Int J Nurs Pract. 2013;19(2):206-213.
54. Vaajoki A, Pietilä AM, Kankkunen P, Vehviläinen-Julkunen K. Effects of listening to music on pain intensity and pain distress after surgery: an intervention. J Clin Nurs. 2012;21(5-6):708-717.
55. Whitaker MH. Sounds soothing: music therapy for postoperative pain. Nursing. 2010;40(12):53-54.
56. Edwards J. Developing pain management approaches in music therapy with hospitalized children. In: Loewy J, Dileo C, eds. Music Therapy at the End of Life. Cherry Hill, NJ: Jeffrey Books; 2005:57-76.
57. Loewy J. The quiet soldier: pain and sickle cell anemia. In: Hibben J, ed. Inside Music Therapy: Client Experiences. Gilsum, NH: Barcelona; 1999:69-76.
58. Lichtensztejn M. The clinical use of piano with patients suffering from breathing distress related to pain. In: Azoulay R, Loewy JV, eds. Music, the Breath and Health: Advances in Integrative Music Therapy. New York, NY: Satchnote Press; 2009:213-222.
59. Kwon IS, Kim J, Park KM. Effects of music therapy on pain, discomfort, and depression for patients with leg fractures. Taehan Kanho Hakhoe Chi. 2006;36(4):630-636.
60. Zengin S, Kabul S, Al B, Sarcan E, Doğan M, Yildirim C. Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complement Ther Med. 2013;21(6):689-696.
61. Boso M, Politi P, Barale F, Emanuele E. Neurophysiology and neurobiology of the musical experience. Funct Neurol. 2006;21(4):187-191.
62. Salimpoor VN, Benovoy M, Larcher K, Dagher A, Zatorre RJ. Anatomically distinct dopamine release during anticipation and experience of peak emotion to music. Nat Neurosci. 2011;14(2):257-262.
63. Tomaino CM. Using rhythm for rehabilitation. Institute for Music and Neurologic Function website. http://musictherapy.imnf.org/images/uploads/rhythm.pdf. Published 2006. Accessed August 21, 2007.
64. Molinari M, Leggio MG, De Martin M, Cerasa A, Thaut M. Neurobiology of rhythmic motor entrainment. Ann N Y Acad Sci. 2003;999:313-321.
65. Thaut M. Neuropsychological processes in music perception. In: Unkefer R, ed. Music Therapy in the Treatment of Adults With Mental Disorders: Theoretical Bases and Clinical Interventions. Toronto, Canada: Schirmer Books; 2002:2-32.
66. Thaut M. Physiological and motor responses to music stimuli. In: Unkefer R, ed. Music Therapy in the Treatment of Adults With Mental Disorders: Theoretical Bases and Clinical Interventions. Toronto, Canada: Schimer Books; 2002:33-41.
67. Kleiber C, Adamek MS. Adolescents’ perceptions of music therapy following spinal fusion surgery. J Clin Nurs. 2013;22(3-4):414-422.
68. Lin PC, Lin ML, Huang LC, Hsu HC, Lin CC. Music therapy for patients receiving spine surgery. J Clin Nurs. 2011;20(7-8):960-968.
69. Maeyama A, Kodaka M, Miyao H. Effect of the music-therapy under spinal anesthesia [in Japanese]. Masui. 2009;58(6):684-691.
70. Golden J, Conroy RM, O’Dwyer AM. Reliability and validity of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory (Full and FastScreen scales) in detecting depression in persons with hepatitis C. J Affect Disord. 2006;100(1-3):265-269.
71. Woby SR, Roach NK, Urmston M, Watson PJ. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain. 2005;117(1-2):137-144.
72. Humrichouse J, Chmielewski M, McDade-Montez EA, Watson D. Affect assessment through self-report methods. In: Rottenberg J, Johnson SL, eds. Emotion and Psychopathology: Bridging Affective and Clinical Science. Washington, DC: American Psychological Association; 2007:13-34.
73. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills, CA: Sage; 1985.
