Running head: MUSIC THERAPY FOR REDUCING CHRONIC PAIN 1
Evidence Based Project: Music Therapy for Reducing Chronic Pain
Melissa R. Roy University of South Florida
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Abstract The clinical problem under review is how health care professionals can more adequately manage and treat hospitalized adult patients who suffer from chronic pain. The purpose of this paper is to extensively review four evidence based research articles in order to create a project proposal of how to implement new evidence based practices into an organization. The current evidence based practice under review is the effects of music therapy in the reduction of chronic pain in hospitalized adult patients. The search engines utilized to locate the randomized controlled trial studies were CINAHL, EBSCOhost, and ScienceDirect. The key search words used were music and chronic pain. Results of the studies indicate that patients who received both music therapy intervention and standard care (analgesics) had a statistically significant reduction in chronic pain as opposed to the control groups who only received standard care. In conclusion, the results of the studies under review confirm that the use of music therapy intervention in the management of chronic pain is beneficial to the hospitalized adult patient population. Additional benefits discovered throughout the studies were that music therapy was also effective in managing anxiety, depression, decrease the consumption of pain medications, and provides a safe, side effect free alternative to managing pain.
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Evidence Based Project: Music Therapy for Reducing Chronic Pain In 2011, the Institute of Medicine (IOM) released a report stating that chronic pain affects nearly 100 million Americans across the nation which results in close to $635 billion in medical treatment and lost productivity each year (IOM, 2011). Proper pain management is a problem for many organizations as not only are patients dealing with constant physical discomfort from pain, but they are more likely to be depressed, have a decreased quality of life, and an increase amount of hospital stays which ultimately drives up medical expenses for both the patient and hospital (American Academy of Pain Medicine [AAPM], n.d.). The clinical question being asked is in hospitalized adult patients who are experiencing chronic pain, how does nurse driven interventions of music therapy compare to the use of standard care (analgesics) in the reduction of stated pain level of patients over a six month period? The infrastructure needed to support a change in the proposed setting involves the Charge Nurse, Director of Nursing, Quality Improvement Committee and the Board of Directors. The charge nurses are an imperative part of the infrastructure as they see the need for change first hand and can introduce the proposed change to the Director of Nursing. The Director of Nursing can then present the evidence based practice change to the Quality Improvement Committee for review and discussion. The head of the Quality Improvement Committee may then present the proposal to the Board of Directors at one of their meetings for final approval and proposed implementation date for the facility. Literature Search The primary search engine used to complete the literature search were CINAHL, EBSCOhost. The key words used to find two articles with significant evidence towards the paper was music and chronic pain. The third and fourth articles were found through a link to ScienceDirect which provided two additional studies that were appropriate for the project. MUSIC THERAPY FOR REDUCING CHRONIC PAIN 4
Literature Review The study completed by Guetin et al. (2012) was conducted to assess the effects of music intervention to the management of patients with chronic pain. The study involved 87 participants with (n= 44) in the intervention group and (n= 43) in the control group. The control group received standard drug therapy, whereas the intervention group received both standard drug therapy and music intervention. The music intervention sessions were initiated twice a day for 60 days with each session lasting 20 minutes. The measures of this study included the visual analog scale (VAS) for determining the patients pain level. The investigators reported that at day 60, the reduction of pain score was significantly greater in the intervention group as they noted a relative improvement of 54% as opposed to just 25.8% in the control group (p<0.001). The study had many strengths including being a randomized controlled trial, participants had similar demographic and clinical variables, and a blind outcome assessment was performed. A weakness of the study is that it is single-blinded. The study conducted by Gutgsell et al. (2013) was performed to determine if a single music therapy session can reduce pain in palliative care patients. The study had 200 total participants for the intervention (n= 100) and control (n= 100) groups. A clinical nurse specialist (CNS) assessed the patients pain level using the Number Rating Scale (NR), Face, Legs, Activity, Cry, Consolability (FLACC), and functional Pain Scale (FPS) prior to and after the intervention. The intervention group was given a calm environment, verbal instructions for autogenic relaxation, and was led into autogenic muscle relaxation by the therapist. The same harp piece was played for each patient. For the control group, the therapist encouraged relaxation but gave no specific instructions. After 20 minute sessions for both groups, the CNS reassessed their pain. In order for the results to be statistically significant, (p<0.05) must be achieved. MUSIC THERAPY FOR REDUCING CHRONIC PAIN 5
Results indicate a significant difference between the two groups for the NRS scale (p<0.0001), and the Functional Pain Scale (p<0.0001), but no significant difference for the FLACC Scale (p>0.05). The strengths of this study include it being a randomized controlled trial, similar patient demographics and baseline pain severity, primary and secondary outcomes were clearly stated, and a blind outcome assessment was completed. Weaknesses of this study include it not being double-blinded and the music therapy intervention was only performed once. The randomized controlled clinical study conducted by Onieva-Zafra et al. (2013) was performed to investigate the effects of music on pain and depression in those diagnosed with fibromyalgia (FM). The study had 60 participants for the intervention (n= 30) and control (n= 30) groups. The intervention group was given a CD to listen to at least four days per week the first week and then every day the second week, as well as a visual analog scale (VAS) to complete on the days they listened to music. The same criteria were followed for the final two weeks. The scales used to measure pain and depression included the VAS scale, the McGill Pain Questionnaire Long Form (MPQ-LF), and Beck Depression Scale (BDI). Patient measurements were taken at baseline and after the fourth week. Results indicate a significant difference between groups for VAS and MPQ-LF pain scores (p= .041). However, although improved, there was no significant difference in the VAS and BDI for depression. Weaknesses of this study include not discussing how the subjects were randomized, neglecting to define standard care for the control group, and it is unknown if the participants were blinded to their groups. Strengths of this study include homogenous demographics and baseline clinical characteristics, valid and reliable instruments, and the study is a randomized controlled trial. MUSIC THERAPY FOR REDUCING CHRONIC PAIN 6
The study conducted by Huang, Good, and Zauszniewski (2010) was performed to examine the effects of relaxing music on cancer pain. The study had a total of 126 participants, for the intervention (n= 62) and control (n= 64) groups. The patients pain and sensation level was rated by on 100mm visual analog scale (VAS) prior to and 30 minutes after the intervention. The intervention group was asked to listen to sedative music of their choice for 30 minutes, while the control group was instructed to rest in bed for 30 minutes. The initial pain score assessment indicated that participants in both groups had a moderate pain and sensation level (49-50mm). At the end of the intervention, post sensation and distress pain in the music intervention group was now mild (28-31mm) as compared to the control group who remained at moderate (49-50mm) which indicates that those who listen to relaxing music experience less cancer pain than those who do not. Strengths of this study include it being a randomized controlled trial, similar patient demographics and baseline severity pain, and the participants were blinded to their groups. Weaknesses of this study include only being single blinded and the music intervention was only performed for one 30 minute session. Synthesis There has been an abundance of statistically significant evidence through each of the research articles reviewed that support the effectiveness of music therapy in the management of chronic pain. The music therapy groups were assessed using a visual analog scale (VAS) in three studies, and a number rating scale (NRS) in the final study to measure the outcome of pain relief in patients throughout the interventions. Studies utilizing similar evaluation tools proves to be beneficial in research as it provides consistency throughout the studies, making evidence more comparable. A notable difference between the studies was the amount of time each music MUSIC THERAPY FOR REDUCING CHRONIC PAIN 7
intervention was conducted. For example, participants of the music intervention group in one study was only required to listen to music one time for 30 minutes, and another study listened to the music one time for 20 minutes. In contrast, the other two studies were completed over a longer period of time with one study performed over 60 days with two 20 minute therapy sessions per day, whereas the other study was completed over two weeks with at least four music therapy sessions per week. The selected articles, although they have many similarities and differences equally support the proposed practice change with significant evidence in favor of the use of music therapy in reducing chronic pain. What is known and unknown in the field is also important to evaluate when determining the effects of music therapy on the treatment of chronic pain. Across each study music therapy provided a significant reduction of reported pain. In addition to the decrease in pain, music therapy has also proven to be effective in managing anxiety, depression, reducing the consumption of medications, and provides no additional side effects. An unknown of the studies is if sequential interventions will have the same pain lowering effect over time. Additionally, it is unknown if giving the patient the option to choose a specific genre of music to listen to makes a greater difference in the level of pain reported compared to if the patient was required to listen to a preselected piece. Further research is recommended to determine if the unknowns will make a significant difference in the reported pain scores of the current studies. Proposed Practice Change Given the significant evidence in favor of music therapy in reducing the effects of chronic pain in hospitalized adult patients, it is recommended that my clinical setting begin to provide patients with the choice of trying music therapy to help control their pain level as opposed to only analgesics, while in the hospital. It is also recommended that patients rooms be MUSIC THERAPY FOR REDUCING CHRONIC PAIN 8
kept as quiet as possible with dimmed lights to promote relaxation and healing. Based on current research, practice should change to become evidence based by providing patients with a headset and a recording of relaxing music of their choice to listen to once per day for 30 minutes. Many studies have shown that listening to music for as little as 20 minutes per day significantly reduces the symptoms of chronic pain. Nurses will still be required to assess the patients pain scale before and after therapy with a number rating scale (0-10) just as they would when providing medication therapy to determine if the intervention has been successful. Change Strategy Strategies that can be used to promote staff engagement include involving staff in the process by determining their priorities and what they believe needs improvement in relation to managing chronic pain. According to Melnyk and Fineout-Overholt (2011), it may also be required to provide more education and information regarding evidence based practice and the process in which changes are implemented in order for all staff to understand the reason for change. Involving all stakeholders such as the doctors, respiratory therapists, and physical therapists is also important in order to evaluate how the changes will impact their delivery of care. Implementation of the new evidence based practice will be most successful when staff members understand the reason for change, are excited about the new processes and feel passionately about the improvements. The EBP model that will be used to guide the implementation of this project is the Model for Evidence Based Practice Change, as each of the steps in this model are closely associated with the current processes being followed to implement the proposed practice change. Roll Out Plan Step 1: Assess the Need for Change in Practice (May 2014- June 2014) MUSIC THERAPY FOR REDUCING CHRONIC PAIN 9
Review the state of chronic pain management o Millions of people live with inappropriately managed chronic pain. o Long term use of pain medications may lead drug tolerance, drug dependency, and in some cases, drug addiction. o Alternative nurse driven interventions such as music therapy to relieve pain may be a benefit. Step 2: Locate the Best Evidence (June 2014- July 2014)
Locate evidence to support a nurse driven intervention for pain management, such as music therapy. o Utilize search engines: CINAHL, EBSCOhost, and ScienceDirect Step 3: Critically Analyze the Evidence (July 2014- July 2014) Identified and analyzed four evidence based articles that support music therapy as a nurse driven intervention for pain management. Step 4: Design Practice Change (July 2014- September 2014) Implement music therapy in conjunction with standard care (analgesics) to the amount of pain in people who suffer from chronic pain. o Resources needed include headsets for patients, relaxing music selections, and training time for the nurses. Step 5: Implement and Evaluate Change in Practice (October 2014- March 2015) Implement pilot study to determine if music therapy is beneficial in reducing chronic pain for our patient population. o Explore results and seek recommendations from staff on the new practice change Step 6: Integrate and Maintain Change in Practice (April 2015- July 2015) MUSIC THERAPY FOR REDUCING CHRONIC PAIN 10
Inform all nurses, providers, and specialists of the new practice change o Monitor process for new change by running reports and completing random chart reviews for appropriate documentation for the effectiveness of the intervention. Project Evaluation The goal of implementing the new practice change is to reduce the pain score reported by patients who suffer from chronic pain. The specific data to be collected in order to evaluate the effectiveness of the change is the numeric pain score rating before music therapy treatment and after it. Parameters that indicate success would be dependent on each individuals starting pain score, but the goal is to reduce the patients overall pain score by at least two tenths according to the number scale. If the patients pain score does not improve or stays the same as it was before treatment, the change would be considered a failure. The data will be collected by running specific reports that extract the documented pain scales for each patient both before and after the intervention, according to their patient record. The success of the intervention can then be assessed by reviewing the pain scores and determining if pain levels were improved after music therapy. Dissemination of EBP The plan to disseminate the change at my facility includes holding a podium presentation at the next charge nurse meeting as they are going to be the lead in implementing the change. There will also be grand rounds that will include an oral presentation from the director of nursing so that all clinicians from each department in the hospital will have the opportunity to be involved and ask questions. At the regional level, the plan is to disseminate evidence by writing a health policy issue brief. As described by Melnyk and Fineout-Overholt (2011), providing a well written brief that clearly identifies the reason for change, how the change will provide better MUSIC THERAPY FOR REDUCING CHRONIC PAIN 11
outcomes for the organization and the patients, as well as the supporting evidence in favor of the change can potentially increase regional participation of managing chronic pain with music therapy. The dissemination of the practice change will remain the same for all other units, hospitals, and regions. Since the patient population of hospitalized adult patients who suffer from chronic pain is so common, each facility could implement the proposed change into their practices in the same sequence as my facility. MUSIC THERAPY FOR REDUCING CHRONIC PAIN 12
References American Academy of Pain Medicine. (n.d.). AAPM facts and figures on pain. Retrieved from http://www.painmed.org/patientcenter/facts_on_pain.aspx Guetin, S., Ginies, P., Siou, D. K. A., Picot, M., Pommie, C., Guldner, E., Touchon, J. (2012). The effects of music intervention in the management of chronic pain: A single blind, randomized, controlled trial. Clinical Journal of Pain, 28(4), 329-337. Gutgsell, K. J., Schluchter, M., Margevicius, S., DeGolia, P. A., McLaughlin, B., Harris, M., Wiencek, C. (2013). Music therapy reduces pain in palliative care clients: A randomized controlled trial. Journal of Pain and Symptom Management, 45(5), 822-831. http://dx.doi.org/10.1016/j.jpainsymman.2012.05.008 Huang, S., Good, M., & Zauszniewski, J. A. (2010). The effectiveness of music in relieving pain in cancer patients: A randomized controlled trial. International Journal of Nursing Studies, 47, 1354-1362. http://dx.doi.org/10.1016/j.ijnurstu.2010.03.008 Institute of Medicine. (2011). Relieving pain in america: a blueprint for transforming prevention, care, education, and research. Retrieved from http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for- transforming-Prevention-Care-Education-Research/Report-Brief.aspx Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence based practice in nursing & healthcare: A guide to best practice (2 nd ed.). Philadelphia, PA: Wolters Kluwer Health Lippincott Williams & Wilkins. Onieva-Zafra, M. D., Castro-Sanchez, A. M., Mataran-Penarrocha, G. A., & Moreno-Lorenzo, C. (2013). Effect of music as nursing intervention for people diagnosed with MUSIC THERAPY FOR REDUCING CHRONIC PAIN 13
Reference Aims Design and Measures Sample Outcomes / statistics Guetin, S., Ginies, P., Siou, D. K. A., Picot, M., Pommie, C., Guldner, E., Touchon, J. (2012). The effects of music intervention in the management of chronic pain: A single blind, randomized, controlled trial. Clinical Journal of Pain, 28(4), 329-337. To assess the effects of music intervention to the management of patients with chronic pain. Randomized Controlled Trial. The measures included the visual analog scale (VAS) for determining the patients pain level. The study involved 87 participants. 44 in the intervention group who received standard drug therapy (analgesics) and music therapy, and 43 participants were in the control group and only received standard care.
Statistically significant number of VAS scores between groups who received music therapy and those who did not. At day 60 (p<0.001) which indicates a relative improvement of pain of 54% in the intervention group compared to 25.8% in the control group. Gutgsell, K. J., Schluchter, M., Margevicius, S., DeGolia, P. A., McLaughlin, B., Harris, M., Wiencek, C. (2013). Music therapy reduces pain in palliative care clients: A randomized controlled trial. Journal of Pain and Symptom Management, 45(5), 822-831. http://dx.doi.org/ 10.1016/j.jpainsy mman.2012.05.0 08
To determine if a single music therapy session can reduce pain in palliative care patients. Randomized Controlled Trial. The measures include the Number Rating Scale (NRS), Face, Legs, Activity, Cry, Consolability (FLACC), and functional Pain Scale (FPS) for determining the patients pain level. The study had 200 total participants. 100 in the intervention group who was given a calm environment, verbal instructions for autogenic relaxation, and was led into autogenic muscle relaxation by the therapist, and 100 in the control group who was only encouraged to relax without instructions. Significantly different numbers for NRS between the two groups was observed with (p<0.001). For the FLACC scale, both control and intervention groups scores declined, but with no significant difference between the two (p>0.05). For the FPS scale, the mean decline was significantly greater in the intervention verses the control group (p<0.0001). MUSIC THERAPY FOR REDUCING CHRONIC PAIN 15
Huang, S., Good, M., & Zauszniewski, J. A. (2010). The effectiveness of music in relieving pain in cancer patients: A randomized controlled trial. International Journal of Nursing Studies, 47, 1354-1362. http://dx.doi.org/ 10.1016/j.ijnurst u.2010.03.008
To examine the effects of relaxing music on cancer pain. Randomized Controlled Trial. The patients pain and sensation level was rated by on 100mm VAS. The study had a total of 126 participants. 62 in the intervention who listened to music for 30 minutes, and 64 in the control group who was instructed to rest in bed for 30 minutes. The patients in the intervention group had 37% sensation and 47% less distress at posttest than the control group. In comparing the results on a scale of 0-10, the average improvement for the intervention group was a sensation pain reduction of 1.5 compared to the control group. Onieva-Zafra, M. D., Castro- Sanchez, A. M., Mataran- Penarrocha, G. A., & Moreno- Lorenzo, C. (2013). Effect of music as nursing intervention for people diagnosed with fibromyalgia. Pain Management Nursing, 14(2), e39-346. http://dx.doi.org/ 10.1016/j.pmn.2 010.09.004
To investigate the effects of music on pain and depression in those diagnosed with fibromyalgia. Randomized Controlled Trial. The measures included the VAS scale for pain and depression, the McGill Pain Questionnair e Long Form (MPQ-LF), and Beck Depression Scale (BDI). The study had 60 participants with 30 in the intervention group who listened to a CD at least four days a week, and 30 in the control group who were not given a CD. At week 4, the intervention group reported a significant difference in pain on movement (p=.002) and pain at rest (p=.001), compared to the control group who had no pain reduction after 4 weeks. Their pain on movement was (p=.42) and pain at rest (p=.08). The intervention group also showed significant differences in the MPQ-LF whereas the control group showed no improvement with that scale.