Authors’ Disclosure Statement: This research was supported independently and internally by the Louis Armstrong Center for Music and Medicine. The authors report no actual or potential conflict of interest in relation to this article. The views expressed in this article are the authors’ and may not represent the official views of Mount Sinai Beth Israel.
Acknowledgments: For invaluable involvement and support during the study the authors would like to thank Peter D. McCann, MD, Daphne Ridley, RN, Marissa Petsakos, Brandee Raimer, Jessica Hyde, MA, MT-BC, Clarissa Lacson, MA, MT-BC, Erin Bolding, MT-BC, Crista Orefice, MA, MT-BC, Brenda Buchanen, MA, MT-BC, Soniya Brar, MA, MT-BC, Thomas Biglin, MA, MT-BC, and Emily Autrey, BM.
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.
The Appendix shows the Spine Study: Data Collection Form that was used.
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).
All outcomes were measured before and after intervention. Table 1 summarizes the demographic and clinical characteristics of the control and music therapy patients.
There were no statistically significant clinical differences between the groups in terms of any demographic or clinical characteristic. Mean age was 48 years for the control group and 49 years for the music group (P = .58). Sixty-seven percent of control patients and 50% of music patients were female (P = .24). Baseline perspectives with regard to the outcome of their surgery are also included (Ps > .05).
Table 2 lists the pre-intervention and post-intervention comparisons of the main outcomes between groups.
The groups showed significant differences in degree and direction of change in VAS pain ratings (P = .01). VAS pain levels increased slightly in the control group (to 5.87 from 5.20) but decreased by more than 1 point in the music group (to 5.09 from 6.20) (Figure 2).
The control and music groups did not differ in the rate of change in scores on HADS Anxiety (P = .62), HADS Depression (P = .85), or TSK (P = .93). Both groups had slight increases in HADS Anxiety, comparable decreases in HADS Depression, and minimal changes in TSK.
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.
This area was left broad because we think any of the listed criteria would define music as an inner resource for enhanced coping.
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.
With use of this nonverbal form of expression, patients’ reports of postoperative pain often included pain that otherwise had been perceived by patients as unrelated and therefore underreported.
