O R I G I N A L A R T I C LE

Effects of listening to music on pain intensity and pain distress after

surgery: an intervention
Anne Vaajoki, Anna-Maija Pietila, Paivi Kankkunen and Katri Vehvilainen-Julkunen

Aims. To evaluate the effects of music listening on pain intensity and pain distress on the first and second postoperative days in
abdominal surgery patients and the long-term effects of music on the third postoperative day.
Background. Music has been found to relieve pain intensity in surgery patients. There are only a few studies on music
intervention in abdominal surgery. Music intervention studies assessing multidimensional pain such as pain intensity and pain
distress are also scarce.
Design. Prospective clinical study with two parallel groups.
Methods. Patients undergoing elective abdominal surgery (n = 168) were divided into either a music group (n = 83) or a control
group (n = 85). Patients assessed pain intensity and pain distress in bed rest, during deep breathing and in shifting position once
in the evening of the operation day and on the first and second postoperative days in the morning, at noon and in the evening.
On the third postoperative day, the patients assessed their pain intensity and pain distress only once.
Results. In the music group, the patients pain intensity and pain distress in bed rest, during deep breathing and in shifting
position were significantly lower on the second postoperative day compared with control group of patients. On the third
postoperative day, when long-term effects of music on pain intensity and pain distress were assessed, there were no significant
differences between music and control groups.
Conclusion. This study demonstrates that the use of music alleviates pain intensity and pain distress in bed rest, during deep
breathing and in shifting position after abdominal surgery on the second postoperative day. Music intervention is safe, inexpensive and easily used to improve the healing environment for abdominal surgery patients.
Relevance to clinical practice. Music intervention should be offered as an adjunct alternative to pharmacological pain relief
after abdominal surgery in nursing practice.
Key words: abdominal surgery, CAM, intervention, music, nursing, postoperative pain
Accepted for publication: 5 September 2010

Introduction
In Finland, approximately 4800 people fall ill each year with
gastroenterological cancer. In 2007, 866 people in Kuopio
University Hospital district developed gastroenterological

Authors: Anne Vaajoki, MNSc, RN, Doctoral Student, Department

of Nursing Science, University of Eastern Finland; Anna-Maija
Pietila, PhD, RN, Professor, Department of Nursing Science,
University of Eastern Finland; Paivi Kankkunen, PhD, RN, Senior
Lecturer, Department of Nursing Science, University of Eastern
Finland; Katri Vehvilainen-Julkunen, PhD, RN, Professor,
Department of Nursing Science, University of Eastern Finland and
Research Unit, Kuopio University Hospital, Kuopio, Finland

708

cancer. The most common cancers in both women and men

are colorectal, gastric and pancreatic cancers (Finnish Cancer
Registry 2007). Upper abdominal surgery is painful because the
wound is in the breathing area and interferes with abdominal
muscle use for deep breathing, coughing and moving (Ashburn

Correspondence: Anne Vaajoki, Doctoral Student, Department of

Nursing Science, University of Eastern Finland, Kuopio Campus,
Kauppakatu 1 B 23, 70100 Kuopio, Finland. Telephone: +358
505403017.
E-mail: anne.vaajoki@pp.inet.fi

2011 Blackwell Publishing Ltd

Journal of Clinical Nursing, 21, 708717, doi: 10.1111/j.1365-2702.2011.03829.x

Original article

et al. 2004). Pain is most severe immediately after the operation

when the effect of anaesthetic analgesia ends. Pain is severe
during the first two days and especially in ambulation (Good
et al. 2001a). The postoperative pain is managed usually by
administering parenteral opioids. Epidural analgesia and
opioids are common in postoperative pain management.
The purpose of listening to music is to facilitate healing
and enhance the feeling of wellness (McCaffrey & Locsin
2002). It has been stated that music causes changes in
physiology (i.e. reduction in heart and respiratory rate),
behaviour (i.e. enhances sense of relaxation) and emotions
(i.e. reduce anxiety, improves mood) (Kemper & Danhauer
2005). For a long time, music has been used in addition to
analgesia to soothe patients suffering from pain, anxiety and
a variety of illnesses and injuries (Kemper & Danhauer 2005,
Lim & Locsin 2006).
In postoperative pain management, music listening means
the recorded and controlled use of music at specific times via
headphones. Elements of music (rhythm, melody, pitch), the
listeners age, education, culture (Kemper & Danhauer 2005)
and musical preferences (McCaffrey & Locsin 2002, Mok &
Wong 2003, Kemper & Danhauer 2005) have to be taken
into account in the choice of music (Leardi et al. 2007). In
terms of feeling well and healing, it is important that the
music is the kind the patient likes and suits their mood
(McCaffrey & Locsin 2002, Leardi et al. 2007). The nurses
role in postoperative pain management is important. Pharmacological methods are generally prescribed to relieve
postoperative pain, but a non-pharmacological method such
as listening to music is not routine care. Better postoperative
pain management may be achieved through a combination of
analgesia and music intervention. However, little is known
about music as a non-pharmacological intervention in
patients with major abdominal surgery.

Background
Pain is a complex and subjective experience, which includes
physiological, sensory, affective, cognitive, behavioural and
sociocultural components (Bond & Simpson 2006). Young
age, female gender, the surgical procedure, such as large
incision size, preoperative pain severity (Kalkman et al. 2003),
previous pain experiences and psychological aspects such as
fear and anxiety can affect a persons postoperative pain
experiences (Munos Sastre et al. 2006). Studies about music
listening in the postoperative pain management of adults have
been conducted on patients with hernia (Nilsson et al. 2003,
2005), after cardiac surgery (Voss et al. 2004, Sendelbach
et al. 2006, Nilsson 2009), orthopaedic patients (McCaffrey
& Locsin 2006), gynaecological patients (Ikonomidou et al.
2011 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 708717

Postoperative pain and music intervention

2004) and after nasal surgery (Tse et al. 2005). The study
results were consistent: the pain intensity after surgery was
milder in the groups that had listened to music than in the
control groups. In the music intervention studies, the number
or music-listening sessions varied from onefour between the
operation day and third postoperative day; the duration of
music listening varied from 2060 minutes.
In earlier studies, there were different opinions as to what
kind of music would be most suitable for the patients. In
some studies, the authors allowed the patients to select the
genre of music (Voss et al. 2004, Masuda et al. 2005, Tse
et al. 2005), whereas others used the same type of music
(Ikonomidou et al. 2004) for all patients. The music was
usually instrumental (Nilsson et al. 2003), classical (Masuda
et al. 2005) or soporific and relaxing (Nilsson et al. 2005).
Past experiences of music listening, cultural background
(Good et al. 2000) and personality type effect music preferences and have to be taken into account when creating a
healing environment (McCaffrey 2008).
Pain was measured using either the visual analogue scale
(VAS) or the numbering rating scale (NRS). In the study by
Tse et al. (2005), the patients rated their pain intensity using
the verbal rating scale. Masuda et al. (2005) assessed the pain
of patients using both VAS and face scale.
Because of the multidimensional aspect of pain, it is
important to assess pain from the perspective of pain
intensity and pain distress (Good et al. 2001b). Both Voss
et al. (2004) and Good and Ahn (2008) evaluated pain
intensity and pain distress after surgery. Voss et al. (2004)
stated that patients who listened to music during chair rest on
the first day after cardiac surgery were less anxious and that
their pain intensity and pain distress were milder than those
of scheduled rest groups or standard care groups. Good and
Ahn (2008) demonstrated that on the first and second days
after gynaecological surgery, patients in the music group
experienced less pain intensity and pain distress than patients
in the control group.
There are conflicting results of previous music intervention
studies because of small sample sizes, lack of a control group
and non-objective outcome measures. It is important to
investigate the effects of music on both pain intensity and pain
distress in patients who have undergone major abdominal
surgery on the first and the second postoperative days and to
find easy and inexpensive non-pharmacological intervention
practices that contribute to recovery and feeling well.

Aim and objectives of the study

The aim of the study was to evaluate the effects of listening to
music on pain intensity and pain distress after abdominal

709

A Vaajoki et al.

surgery. The hypothesis was that patients in the experimental

group who get standard care and listen to music after surgery
have less pain intensity and pain distress than those in the
control group who only get standard care.

Between March 2007 and April 2009

Alternate week arrangement: music was listened to every second week
Music group
n = 83

Preoperative interview and information prior to the day of surgery

- Informed consent
- Patients were taught pain VAS
- Music preference

Methods
Study design

08.0009.00 13.0015.00

This was a prospective clinical study with one music group

and one control group. Patients undergoing major abdominal
surgery were allocated into either the music group or the
control group using an alternate week arrangement. Music
was listened to every second week according to a yearly
calendar from the starting point of the study. This assignation
process was repeated until each group had at least 83
patients. Ten pilot study patients were excluded from the
main study because changes were made to the pain assessment (Fig. 1).
Pain intensity and pain distress in rest, when breathing
deeply and when shifting position were measured eight times
before and after intervention: on admission to the ward on
the operation day, in the morning (08000900), at noon
(13001500) and in the evening (18002000) on the first
and second postoperative days, at a time agreeable to the
patients and on the third postoperative day, when music was
not listened to, to evaluate the long-term effects of music
intervention. Patients in the music group listened to music
seven times between the operation day and the second
postoperative day. One researcher (AV) collected all of the
data (Fig. 2).

Abdominal surgery patients = 280

During March 2007April 2009

Patients who
refused to
participate in
study = 22

Patients
excluded before
study = 46

Pilot
tested = 10

Patients who agreed to participate and met the inclusion criteria = 202

Patients excluded
during data
collection = 19

Allocated to
music group = 83

Figure 1 Study flow chart.

710

Control group
n = 85

Patients stopped
through own
choice = 15

Allocated to
control group = 85

Operation day

18.0020.00

Third

First and second postoperative days postoperative day

Music group
Pain intensity and
pain distress
In rest
Breathing deeply
Shifting position
Pain VAS

Music listening 30 min

Music group
Pain intensity and
pain distress
In rest
Breathing deeply
Shifting position
Pain VAS

Control group
Pain intensity and
pain distress
In rest
Breathing deeply
Shifting position
Pain VAS

Music and control

groups
Pain intensity and
pain distress
In rest
Breathing deeply
Shifting position
Fear about
postoperative pain

No music

Control group
Pain intensity and
pain distress
In rest
Breathing deeply
Shifting position
Pain VAS

Figure 2 Study design.

Patients and setting

Between March 2007April 2009, the sample of patients
consisted of elective abdominal surgery adult (2185 years
old) patients at Kuopio University Hospital in Finland, a
total of 280 patients (Fig. 2). The patients were randomised
into the music group (n = 83) or the control group (n = 85).
Their estimated hospital stay was at least four days. The
anaesthesia classification was 13 according to the American Society of Anaesthesiologists (ASA) Physical Status
Classification 15. The participants underwent major upper
abdominal incisions and were expected to use epidural
analgesia after surgery. The exclusion criteria were drug
abuse, psychiatric disorders, hearing impairment, dementia
and chronic pain problems or whether the patients were
admitted to another department. Twenty-two patients
refused to participate, 15 patients stopped because they
were very tired or the surgeon had given them bad news
after the operation, 19 patients were excluded for research
reasons, for example, they were not given epidural analgesia
despite the anaesthetic plan, and 46 patients did not meet
the inclusion criteria.

2011 Blackwell Publishing Ltd

Journal of Clinical Nursing, 21, 708717

Original article

Measures
The sense of pain after surgery was measured by how intense
the physical feeling is. The distress of pain is described as how
emotionally unpleasant the pain is (Good et al. 2001b). The
participants assessed pain intensity and pain distress during
bed rest, when breathing deeply and while shifting position on
the VAS. The VAS is a 100-mm horizontal line with anchors
of no pain (0 mm) and worst possible pain (100 mm). The
pain intensity and pain distress were marked and scored in a
manner similar to the VAS with the same range, from
0100 mm. The VAS is reported in the literature as being
sensitive and reliable for the assessment of adult postoperative
pain intensity (Good et al. 2001b, Breivik et al. 2008) and
pain distress (Good et al. 2001b). Patients were taught to use
the VAS the day before surgery during interviews. One
participant was blind and assessed pain intensity and pain
distress on the 11-point NRS. Fear about postoperative
pain was assessed using the statement, I feared postoperative
pain before surgery on the third postoperative day.

The music intervention procedure

The researcher screened departments operation plan lists
every week and counted patients who might meet the inclusion
criteria. Prior to the day of surgery, the researcher familiarised
herself with the patients papers that estimated exclusion and
inclusion criteria and examined the final operation and
anaesthetic plan. The researcher interviewed and informed
patients and told them whether they belonged to the music
group or the control group prior to the day of surgery. The
interview lasted from half an hour to an hour and a half.
In the light of discussions with the music therapist and
data from earlier studies (Wang et al. 2002, Mok & Wong
2003, Leardi et al. 2007), the participants were given the
music they liked to listen to. There were two sets of
headphones (Sennheiser HD 555; Sennheiser, Tullamore,
Ireland and AKG K28NC; AKG, Vienna, Austria) and two
MP3-players (Apple-iPod 8GB, Palto Alto, CA, USA). Different kinds of the most popular and classic music in Finland
were recorded on the MP3-player, and in total, 2000 songs
were written to the file from which the participants chose their
favourite music. This file was shown when the researcher
interviewed the patients prior to the day of surgery. Selections
of music were added according to participants wishes during
the study. The alternatives were domestic or foreign hit songs,
dance, pop, rock, soul, blues, spiritual or classical music.
Intervention began on the evening of the operation day if
the patients returned to the ward from the post-anaesthesia
care (PACU) unit. The researcher first instructed the patients
2011 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 708717

Postoperative pain and music intervention

to assess their pain intensity and pain distress in rest, then

when breathing deeply and finally while shifting position
from their backs to their sides. There were a few minutes
break between each assessment condition. After assessment,
the patients in the music group listened to their choice of
music via the headphones for about 30 minutes. A few
patients, less than five, did not complete the full 30 minutes
because of fatigue or severe pain. In the control group, pain
was measured at half-hour intervals, but they did not listen to
music. The music intervention was repeated on the first and
second postoperative days. The two groups of patients were
measured using the same method. All participants were given
epidural analgesia after surgery. They were also given pain
analgesia during intervention if necessary. Intervention was
carried out in the patients room together with normal care.

Data analysis
The computer program SPSS 16.0 for Windows (SPSS Inc.,
Chicago, IL, USA) was used for all statistical analyses. A
power analysis was performed with respect to VAS pain. A
mean of 35 and SD 24 were expected. A clinically significant
difference of 30% and statistically significant level of
a < 005 were expected. With a power of 80%, the sample
size of 83 patients for each group was calculated as being
appropriate.
Complete data consist of 280 potential abdominal surgery
patients. The data were presented as frequencies, percentages,
mean values and standard deviations. Descriptive statistics
were used to describe the characteristics of the groups. The
chi-square (v2) test was used to examine associations between
the groups and demographic factors. The Kolmogorov
Smirnov test was used to examine the normality of the
continuous data. The results suggested that non-parametric
tests were appropriate. The fear about postoperative pain
statements was included as two categories: agree (completely
and partly agree) and disagree (completely disagree and
partly disagree). The parametric test ANOVA was used for
repeated measurements to analyse pain intensity and pain
distress over time between the two groups. On the first and
second postoperative days, pain measurements were presented as means and standard deviations. The long-term
effects of music on pain intensity and pain distress were
analysed by the non-parametric MannWhitney U-test for
independent groups. Because missing data on the operation
day totalled over 50%, this was dropped from the analysis.
One patient in the control group was blind and assessed pain
on the NRS. This patient was excluded from the VAS
analysis. In addition, one patient in the control group had
delirium on the third postoperative day and could not assess

711

A Vaajoki et al.

pain intensity or pain distress on that day (Burns & Grove

2005). One-hundred and sixty-eight patients were recruited
for complete data collection (Fig. 1).

Ethical approval
Before data collection, the study was approved by the
Research Ethics Committee Hospital of the District of
Northern Savo. Before any decision was made to participate,
all of the patients were told about the purpose of the study by
the researcher. All participants were given a written informed
consent form that was read out loud before they signed it.
Participation was voluntary, and refusal to participate did not
affect the care received during hospitalisation. It was also
possible to stop participation without any specific reason.

Results
Demographics
There were 42 men and 41 women in the music group, and
their mean age was 60 (SD 13). There were 48 men and 37
women in the control group, and their mean age was 63 (SD
12). More than half of the music group were pensioners (47/
83), and most were married or in common-law partnerships
(60/83). In the control group, most were pensioners (55/85)
and most were married or in common-law partnerships (65/
85). Most of the surgeries in the music group (56/83) and in
the control group (54/85) were cancer procedures (Table 1).
The mean duration of anaesthesia was almost the same in
both groups: three hours 29 minutes in the music group and
three hours 25 minutes in the control group. In terms of the
mean duration of surgery, there were no statistical differences
between the music group (two hours 37 minutes) and the
control group (two hours 32 minutes). There was significant
difference between the two groups regarding fear about
postoperative pain: 50/83 in the music group and 37/85 in the
control group feared postoperative pain before they underwent surgery (Table 1). There were no significant differences
between the two groups in regard to patient age, sex,
education, occupation, marital status, diagnosis, type of
surgery, ASA classification, duration of anaesthesia and
surgery, duration in the PACU, duration of epidural analgesia
or doses of analgesia (Table 2).

Pain intensity and pain distress on the first and second

postoperative days
The means and standard deviations of pain intensity and pain
distress of both groups are reported in Tables 35. There were

712

no significant differences between the two groups in pain

intensity and pain distress in bed rest, during deep breathing
or shifting position on the first postoperative day. There were
differences in scores after intervention in pain distress in bed
rest on the first postoperative day, but these did not approach
statistical significance (Table 3). On the second postoperative
day after intervention, pain intensity and pain distress in bed
rest, during deep breathing and shifting position decreased in
the music group significantly more than in the control group.
There were also clinically observed differences in pain
intensity and pain distress during deep breathing.
Pain intensity registered VAS 10 in bed rest in the music
group and 15 (p = 002) in the control group. Pain distress
in bed rest in the music group registered VAS 09 and in the
control group 15 (p = 001) (Table 3).
Pain intensity during deep breathing in the music group
registered VAS 13 and in the control group VAS 19
(p = 003). Pain distress during deep breathing in the music
group registered VAS 13 and in the control group VAS 18
(p = 004) (Table 4).
Pain intensity when shifting position in the music group
registered VAS 25 and in the control group VAS 33
(p = 002). Pain distress when shifting position in the music
group registered VAS 25 and in the control group VAS 32
(p = 004) (Table 5).

Pain intensity and pain distress on the third postoperative

day
On the third postoperative day, the patients did not listen to
music but their pain intensity and distress in bed rest, during
deep breathing and when shifting position were assessed one
more time at noon (13001500). There were no significant
differences between the two groups in this evaluation of the
long-term effects of music on pain intensity and pain distress
(Table 6).

Discussion
The present study demonstrates that on the second postoperative day, patients who listened to music experienced
milder pain intensity and pain distress in bed rest, during
deep breathing and in shifting position. This result is partly
consistent with the findings of Good and Ahn (2008), who
found that the pain intensity and pain distress of gynaecological patients after listening to music were lower on both
the first and second postoperative days compared with the
control group.
In the present study, pain intensity and pain distress in bed
rest, during deep breathing and in shifting position were
2011 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 708717

Original article
Table 1 Background data of the abdominal
surgery patients in the music and control
groups

Postoperative pain and music intervention

Music group
(n = 83)
n%

Background variables

Age (mean, SD)

60 (13)
Gender (M/F)
42/41
Education
No education
20 (24)
Vocational school
35 (43)
College
14 (17)
Polytechnic/university or other
13 (16)
Employment status
Higher/lower office worker
12 (14)
Employee/entrepreneur
22 (27)
Student/other
2 (2)
Retired
47 (57)
Marital status
Married/common-law marriage 60 (72)
Single
8 (10)
Widow
8 (10)
Divorced/separated
7 (8)
Diagnosis
Ventral hernia
3 (4)
Diverticulitis
5 (6)
Ca intestinal
39 (47)
Ca ventriculi
7 (8)
Ca pancreas
10 (12)
Colitis ulcerosa/Mb Crohn
15 (18)
Other
4 (5)
American Society of Anaesthesiologists (ASA)
1
5 (6)
2
33 (40)
3
45 (54)
Epidural analgesia
Mild mixture
38 (46)
Strong mixture
12 (15)
Other mixture
33 (40)
Fear of postoperative pain
50 (61)

Control group
(n = 85)
n%
63 (12)
48/37

Chi-square

df

p-value

058

0149
0466

20
37
15
13

(24)
(43)
(18)
(15)

004

0998

9
18
3
55

(11)
(21)
(3)
(65)

085

0652

65
7
5
8

(77)
(8)
(6)
(9)

100

0801

3
8
35
7
12
6
14

(4)
(10)
(41)
(8)
(14)
(7)
(17)

1048

0106

2 (2)
34 (41)
48 (57)

139

0499

36
9
40
37

139

0498

477

0029*

(42)
(11)
(47)
(44)

Ca, carcinoma; Mb, morbus.

*p-value <005.

Missing data of education (n = 82).

Missing data of ASA classification (n = 84).

Table 2 Background variables of the abdominal surgery patients in music and control groups
Background variables

Music group (n = 83)

Control group (n = 85)

MannWhitney U-test

p-value

Duration of anaesthesia
Duration of surgery
Duration in post-anaesthesia care
Duration of epidural analgesia after surgery
Opioid analgesia after surgery (4 days)

3 hours 29 minutes
2 hours 37 minutes
5 hours 58 minutes
3 days 3 hours 53 minutes
21 mg (4 days)

3 hours 25 minutes
2 hours 32 minutes
6 hours 38 minutes
3 days 3 hours 19 minutes
24 mg (4 days)

33400
33950
32395
32455
34235

0552
0674
0361
0371
0739

lower before intervention in the music group than in the

control group on both the first and the second postoperative
days. The reason for this remains somewhat unclear, because
2011 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 708717

there were no significant differences in socioeconomic status,

ASA classification, diagnosis or analgesia between the two
groups. Neither were there any differences between the two

713

A Vaajoki et al.
Table 3 Comparison of pain intensity and pain distress in bed rest
scores between the music group and control groups before and after
intervention on the first and second postoperative days (VAS)
Music group
(n = 83)
Mean (SD)
Pain intensity in bed rest (VAS)
First postoperative day
Pre-VAS
14 (15)
Post-VAS
12 (13)
Second postoperative day
Pre-VAS
13 (15)
Post-VAS
10 (12)
Pain distress in bed rest (VAS)
First postoperative day
Pre-VAS
14 (15)
Post-VAS
11 (13)
Second postoperative day
Pre-VAS
13 (15)
Post-VAS
09 (11)

Control group
(n = 84)
Mean (SD)

p-value

18 (18)
16 (17)

014
026

16 (18)
15 (18)

087
002*

18 (19)
16 (16)

016
024

16 (18)
15 (20)

008
001*

VAS, visual analogue scale; pre-VAS, pain intensity or pain distress

before intervention; post-VAS, pain intensity of pain distress after
intervention.
Repeated measures analysis of variance (ANOVA ) *p < 005.

One patient assessed pain on the NRS.

Clinically observed difference 30%.

Table 4 Comparison of pain intensity and pain distress during deep

breathing between patients listening to music and controls before
and after intervention on the first and second postoperative days
(VAS)
Music group
(n = 83)
Mean (SD)

Control group
(n = 84)
Mean (SD)

Pain intensity during deep breathing (VAS)

First postoperative day
Pre-VAS
21 (18)
24 (20)
Post-VAS
18 (17)
22 (20)
Second postoperative day
Pre-VAS
17 (16)
19 (20)
Post-VAS
13 (14)
19 (20)
Pain distress during deep breathing (VAS)
First postoperative day
Pre-VAS
19 (19)
22 (21)
Post-VAS
17 (18)
21 (21)
Second postoperative day
Pre-VAS
17 (17)
19 (20)
Post-VAS
13 (14)
18 (20)

p-value

029
048
015
003*

035
049
016
004*

VAS, visual analogue scale; pre-VAS, pain intensity or pain distress

before intervention; post-VAS, pain intensity or pain distress after
intervention.
Repeated measures analysis of variance (ANOVA ) *p < 005.

One patient assessed pain on NRS.

Clinically observed difference 30%.

714

Table 5 Comparison of pain intensity and pain distress in shifting

position between patients listening to music and controls before and
after intervention on the first and second postoperative days (VAS)
Music group
(n = 83)
Mean (SD)

Control group
(n = 84)
Mean (SD)

Pain intensity in shifting position (VAS)

First postoperative day
Pre-VAS
34 (23)
36
Post-VAS
27 (22)
34
Second postoperative day
Pre-VAS
31 (22)
34
Post-VAS
25 (19)
33
Pain distress in shifting position (VAS)
First postoperative day
Pre-VAS
33 (24)
35
Post-VAS
26 (23)
33
Second postoperative day
Pre-VAS
31 (23)
33
Post-VAS
25 (29)
32

p-value

(24)
(24)

056
038

(23)
(23)

005
002*

(27)
(26)

059
058

(24)
(24)

011
004*

VAS, visual analogue scale; pre-VAS, pain intensity and pain distress
before intervention; post-VAS, pain intensity and pain distress after
intervention.
Repeated measures analysis of variance (ANOVA ) *p < 005.

One patient assessed pain on NRS.

groups with regard to pain before surgery or pain experience.

The only significant difference between the two groups was
fear about postoperative pain, which was asked about on the
third postoperative day. Over half of the patients in the music
group feared postoperative pain. It is possible that these
patients were relieved when the pain was not as severe as they
had expected, which is why they assessed the pain as less
severe than the control group. The thought that the operation
is over, the tumour has been removed and the patient has
survived brings a feeling of relief (Worster & Holmes 2009).
Additional studies are needed to determine how fear and pain
correlate.
It seems that there were no long-term effects of music on
pain intensity and pain distress. Although on the third
postoperative day pain intensity and pain distress in bed rest,
during deep breathing and in shifting position were higher in
the control group, there were no significant differences
between the two groups. This partly supports the findings
by Nilsson et al. (2003), who studied patients who listened to
music from the time of arrival at the PACU for one hour. The
effect of music on pain intensity only lasted for two hours,
whilst the effect of the anaesthesiaanalgesia was still strong.
In the present study, the patients were provided with plenty
of musical options so that they could choose their favourite
music (Leardi et al. 2007). Most of the patients listened
2011 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 708717

Original article

Postoperative pain and music intervention

Table 6 Comparison of pain intensity

and pain distress between patients on the
third postoperative day (VAS)
Pain intensity (VAS)
In bed rest
During deep
breathing
Shifting position
Pain distress (VAS)
In bed rest
During deep
breathing
Shifting position

Music group
(n = 83)
Mean (SD)

Control group
(n = 83)*
Mean (SD)

MannWhitney U-test

p-value

10 (16)
13 (18)

13 (17)
16 (19)

31860
30505

037
019

23 (21)

29 (23)

29550

011

10 (15)
13 (18)

13 (17)
16 (18)

30685
30835

019
022

22 (22)

29 (23)

29095

008

VAS, visual analogue scale.

*One patient assessed pain on NRS.

(seven times) to different artists. The most popular songs

were domestic dance and hit music. Listening to music for
half an hour was an appropriate amount of time; the patients
were able to listen to music and half an hour did not interrupt
the daily routine on the ward.
In this study, all of the patients were given epidural and
paracetamol analgesia after surgery. Overall, the pain scores
were low in both groups. These low ratings may be the result
of well-managed pain. A few of the patients in both groups
received analgesia (epidural bolus or paracetamol) during
intervention, but this was not recorded. This might have
influenced the patients pain assessment responses. Because
pain in bed rest after surgery was mild and moderate during
deep breathing or when shifting position, it is possible that
the effect of music intervention remained low.
Some of the patients could not separate pain intensity from
pain distress but rather assessed them as being the same.
These patients felt that no matter how mild or severe the pain
was, it was always distressing and it bothered them. Further
studies are needed to assess postoperative pain intensity and
distress because of the sensory and affective components of
pain.
In future studies, it will be important to evaluate the effects
of music on pain in abdominal surgery patients who cannot
have epidural analgesia after surgery. Further studies are also
needed to ascertain the optimal times and number of sessions
for listening to music after surgery. It is important to continue
non-pharmacological intervention studies in other patient
groups as well to develop practices that contribute to the
health and well-being of all patients. Another recommendation for further study would be to evaluate the effects of
listening to music on behavioural indicators, with a greater
emphasis on patients experiences and self-reports on music
intervention.
2011 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 708717

Limitations of the study

A limitation of the study was that the music intervention took
place in the patients rooms during the daily routines of
normal nursing practice. This meant that the patients were
occasionally disrupted during the intervention by doctors
rounds, nursing actions, telephone calls or visits by relatives.
These interruptions occasionally disturbed and irritated
patients.
The reliability of the study is good as sample size was based
on a power analysis, randomisation was used and one
researcher (AV) collected all of the data. The pain assessment
was always taken in the same way, and the VAS used in this
study is reported to be sensitive (Good et al. 2001b, Jensen
et al. 2002) for assessing the efficacy of non-pharmacological
interventions in pain management after surgery. In this study,
the assessment of pain intensity and pain distress of both the
younger and older patients was easy with the VAS. Some
participants felt confused when assessing pain intensity and
pain distress as they found it difficult to distinguish one from
the other. All of the data were collected in one hospital, and
the results cannot be generalised.

Conclusion
Listening to music can alleviate pain intensity and pain
distress after abdominal surgery, but further studies are
needed to verify these results. Music should be offered to
patients as a non-pharmacological method adjuvant to
pharmacological methods in pain management after surgery
because of its potential benefit. Music may be useful in the
distraction of attention away from pain, influencing better
moods and emotions. Music intervention is easy to use, safe
and simple and does not require musical proficiency.

715

A Vaajoki et al.

Relevance to clinical practice

The results of this study can be used to improve postoperative
pain management after abdominal surgery. Music intervention should be offered as an adjunct alternative to pharmacological pain relief after abdominal surgery in nursing
practice. Nursing professionals should be motivated by using
non-pharmacological methods in postoperative pain management.

University Hospital EVO funding, Finnish Association of

Caring Sciences and Foundation of Nurse Education.

Contributions
Study design: KV-J, A-MP, PK, AV; data collection and
analysis: AV and manuscript preparation: AV, A-MP, PK,
KV-J.

Conflict of interest

Acknowledgements
The authors thank Vesa Kiviniemi for sharing his expertise
in statistics. The study was financially supported by Kuopio

The authors declare that they have no conflicts of interest.

References
Ashburn MA, Caplan RA, Carr DB, Connis RT, Ginsberg B, Green CR, Arbor
A, Lema MJ, Nickinovich DG & Rice
LJ (2004) Practice guidelines for acute
pain management in the perioperative
setting: an updated report by the
American Society of Anesthesiologists
Task Force on Acute Pain Management. Anesthesiology 100, 1573
1581.
Bond MR & Simpson KH (2006) Pain: Its
Nature and Treatment. Churchill Livingstone Elsevier, London.
Breivik H, Borchgrevink PC, Allen M,
Rosseland LA, Romundstad L, Breivik
Hals EK, Kvarstein G & Stubhaug A
(2008) Assessment of pain. British
Journal of Anaesthesia 101, 1724.
Burns N & Grove SK (2005) The Practice of
Nursing Research. Conduct, Critique
and Utilization, 5th edn. Elsevier
Saunders, Philadelphia, PA.
Finnish Cancer Registry (2007) Suomen
Syoparekisteri. Finland. Available at:
http://www.cancerregistry.fi/stats/fin/
vfin0016il.html (accessed 10 March
2009).
Good M & Ahn S (2008) Korean and
American music reduces pain in Korean
women after gynecologic surgery. Pain
Management Nursing 9, 96103.
Good M, Lee Picot B, Salem SG, Chin C-C,
Fulton Picot S & Lane D (2000) Cultural differences in music chosen for
pain relief. Journal of Holistic Nursing
18, 245260.
Good M, Stanton-Hicks M, Jeffrey G,
Anderson GC, Salman A & Duber C
(2001a) Pain outcomes after intestinal

716

surgery. Outcomes Management for

Nursing Practice 5, 4146.
Good M, Stiller C, Zauszniewski JA,
Anderson GC, Stanton-Hicks M &
Grass JA (2001b) Sensation and distress
of pain scales: reliability, validity and
sensitivity. Journal of Nursing Management 9, 219238.
Ikonomidou E, Rehnstom A & Naesh O
(2004) Effect of music on vital signs
and postoperative pain. AORN Journal
80, 269278.
Jensen MP, Chen C & Brugger AM (2002)
Postsurgical pain outcome assessment.
Pain 99, 101109.
Kalkman CJ, Visser K, Moen J, Bonsel GJ,
Grobbee DE & Moons KGM (2003)
Preoperative prediction of severe postoperative pain. Pain 105, 415423.
Kemper KJ & Danhauer SC (2005) Music as
therapy. Southern Medical Journal 98,
282288.
Leardi S, Pietroletti R, Angeloni G, Necozione S, Ranalletta G & Del Gusto B
(2007) Randomized clinical trial
examining the effect of music therapy in
stress response to day surgery. British
Journal of Surgery 94, 943947.
Lim PH & Locsin R (2006) Music as nursing intervention for pain in five Asian
countries.
International
Nursing
Review 53, 189196.
Masuda T, Miyamoto K & Shimizu K
(2005) Effects of music listening on
elderly orthopaedic patients during
postoperative bed rest. Nordic Journal
of Music Therapy 14, 414.
McCaffrey R (2008) Music listening its
effects in creating a healing environ-

ment. Journal of Psychosocial Nursing

46, 3944.
McCaffrey R & Locsin RC (2002) Music
listening as nursing intervention: a
symphony of practice. Holistic Nursing
Practice 16, 7077.
McCaffrey R & Locsin R (2006) The effect
of music on pain and acute confusion in
older adults undergoing hip and knee
surgery. Holistic Nursing Practice 20,
218226.
Mok E & Wong K-Y (2003) Effects of
music on patient anxiety. AORN Journal 77, 369410.
Munos Sastre MT, Albaret MC, Escursell
MR & Mullet E (2006) Fear of pain
associated with medical procedures and
illnesses. European Journal of Pain 10,
5766.
Nilsson U (2009) Soothing music can
increase oxytocin levels during bed rest
after open-heart surgery: a randomised
control trial. Journal of Clinical Nursing 18, 21532161.
Nilsson U, Rawal N & Unosson M (2003) A
comparison for intra-operative or
postoperative exposure to music a
controlled trial of the effects on postoperative pain. Anaesthesia 58, 684711.
Nilsson U, Unosson M & Rawal N (2005)
Stress reduction and analgesia in
patient exposed to calming music
postoperatively: a randomized controlled trial. European Journal of Anaesthesiology 22, 96102.
Sendelbach SE, Halm MA, Doran KA,
Miller EH & Gaillard P (2006) Effects
of music therapy on physiological and
psychological outcomes for patients

2011 Blackwell Publishing Ltd

Journal of Clinical Nursing, 21, 708717

Original article
undergoing cardiac surgery. Journal
of Cardiovascular Nursing 21, 194
200.
Tse MMY, Chan MF & Benzie IFF (2005)
The effect of music therapy on postoperative pain, heart rate, systolic blood
pressure and analgesic use following
nasal surgery. Journal of Pain & Palliative Pharmacotherapy 19, 2129.

Postoperative pain and music intervention

Voss JA, Good M, Yates B, Baun MM,
Thompson A & Hertzog M (2004)
Sedative music reduces anxiety and
pain during chair rest after open-heart
surgery. Pain 112, 197203.
Wang S-M, Kulkarni L, Dolev J & Kain
ZN (2002) Music and preoperative
anxiety: a randomized controlled study.

Anesthesia & Analgesia 94, 1489

1494.
Worster B & Holmes S (2009) A phenomenological study of the postoperative
experiences of patients undergoing surgery for colorectal cancer. European
Journal of Oncology Nursing 13, 315
322.

The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of
clinically related scholarship which supports the practice and discipline of nursing.
For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://
wileyonlinelibrary.com/journal/jocn

Reasons to submit your paper to JCN:

High-impact forum: one of the worlds most cited nursing journals and with an impact factor of 1228 ranked 23 of 85
within Thomson Reuters Journal Citation Report (Social Science Nursing) in 2009.
One of the most read nursing journals in the world: over 1 million articles downloaded online per year and accessible in over
7000 libraries worldwide (including over 4000 in developing countries with free or low cost access).
Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.
Early View: rapid online publication (with doi for referencing) for accepted articles in final form, and fully citable.
Positive publishing experience: rapid double-blind peer review with constructive feedback.
Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley
Online Library, as well as the option to deposit the article in your preferred archive.

2011 Blackwell Publishing Ltd

Journal of Clinical Nursing, 21, 708717

717

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.
Users should refer to the original published version of the material.