Sunday, June 16, 2013

Music in Managing Pain

Music in Managing Pain

Laurie Scudder, DNP, NP
Jun 13, 2013

Music Therapy Reduces Pain in Palliative Care Patients: A Randomized Controlled Trial

Gutgsell KJ, Schluchter M, Margevicius S, et al

J Pain Symptom Manage. 2013;45:822-831

Music Therapy

Management of pain is an important element of palliative care. However, patients also express a desire to be lucid and experience good quality of life during this time, goals that may be negatively affected by the sedation, nausea, and other adverse effects that accompany treatment with opioids and other pain medications.
Music therapy offers a low-risk, nonpharmacologic, low-cost adjunct to pharmacotherapy. Previous research, much of it qualitative, examining the efficacy of this intervention in patients with a range of diagnoses has yielded variable results. The purpose of the study by Gutgsell and colleagues was to examine the efficacy of a single music therapy intervention in reducing pain in a sample of palliative care patients.

Study Summary

The study was conducted at a single university-affiliated hospital. Patients with advanced, life-limiting conditions were referred for the study by members of the palliative care team. Patients invited to participate in the study were older than 18 years, had a pain score of 3 or greater on a numeric rating scale (NRS), were able to understand English, and were alert and oriented. Patients on scheduled pain medications were not excluded, although interventions were scheduled around administration of breakthrough pain medications and immediately before scheduled doses.
The intervention was a single 20-minute music therapy session using harp music played at a low volume and slow tempo. Patients were also given the option for the session to include an ocean drum component. The music intervention accompanied a relaxation exercise that began with placing a "do not disturb" sign on the patient's door, lowering light levels, offering a blanket, turning off cell phones, and guiding the patient through an autogenic relaxation exercise that included visualization of a safe place. Control patients received the relaxation exercises without the accompanying music.
A clinical nurse specialist evaluated all patients before the intervention using 3 different scales:
  • NRS -- a widely used self-report scale that asks patients to rate their pain on a scale of 0 (no pain) to 10 (worst possible pain).
  • The Face, Legs, Activity, Cry, Consolability (FLACC) Scale -- a behavioral pain assessment tool in which pain is rated on 5 criteria by a trained observer. Each of these criteria is assigned a score of 0 (no pain) to 2, and total scores range from 0 to 10.
  • Functional Pain Scale (FPS) -- a scale that allows assessment of a patient's subjective experience of pain by asking patients whether pain is tolerable or intolerable and about its effect on the ability to engage in daily activities. A score of 0 reflects no pain, and a maximum score of 5 indicates intolerable pain with a resultant inability to communicate or perform usual activities.
The clinical nurse specialist, who was blinded to the patient's assignment, left the room following the preintervention evaluation and returned after the intervention to complete a postintervention evaluation using the same 3 scales. Patients assigned to the control group were offered the music intervention following the postintervention evaluation.

Study Findings

Although 400 patients were referred by the palliative care team, only 200 agreed to participate and were randomly assigned to the intervention or control group. NRS scores for both the music therapy and control groups showed significant declines from pre-test to post-test, although the reduction was significantly greater in the intervention group (P < .0001). FLACC scores also declined significantly in both groups and, in contrast to NRS scores, did not differ significantly between the 2 groups. FPS scores declined significantly only in the intervention group.
The researchers conducted further analyses to determine whether baseline patient characteristics, such as age, sex, diagnosis, and severity and duration of pain, were related to the efficacy of the intervention. NRS and FPS scores did not vary in different patients, although the FLACC scores indicated that the effect of the intervention was greater in patients younger than 55 years. The researchers urged caution in interpreting that result because correction for multiple testing was not conducted.

Viewpoint

This study had several limitations. First, although 400 patients were referred for potential inclusion, only one half agreed to participate, suggesting that the final sample may have consisted of individuals inherently predisposed to a musical intervention. In addition, although the researchers did a good job of blinding the clinical nurse specialist who conducted the pre- and postintervention assessments, obviously the patients themselves were not blinded. Because 2 of the 3 assessment scales use patient report, patients' knowledge of their group assignment may have affected their own self-assessment.
This study does add to a growing body of evidence that music can be an effective component of pain management. Unlike many studies of music therapy, which used patient-preferred music, this intervention used the same music in all patients, suggesting that music chosen specifically to be soothing irrespective of patient preference may be effective. Although the music was more effective at relieving pain than the relaxation exercises alone, both groups experienced pain relief.
The investigators suggest that acknowledging a patient's pain and encouraging relaxation -- particularly if accompanied by environmental adjustments, such as dimming lights and diminishing noise -- are important adjuncts to pain management. Although that conclusion is not going to be a surprise to nurses, who have long incorporated therapeutic communication into their care of patients in pain, this study is a valuable reminder of its importance and the need to include these practices in the nursing art of helping patients to manage the unique experience of pain.
 

1 comment:

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