ORI GI NALARTI CLEMusictherapyforpatientsreceivingspinesurgeryPi-ChuLin,Man-LingLin,Li-ChingHuang,Hsiu-ChuHsuandChiong-ChuLinAimsandobjectives.Theaimofthisstudywastoevaluatetheeffectsofmusictherapyonanxiety, postoperativepainandphysiologicalreactionstoemotionalandphysicaldistressinpatientsundergoingspinalsurgery.Background.Surgery-relatedanxietyandpainarethegreatest concernof surgical patients, especiallyforthoseundergoingmajorprocedures.Design.Aquasi-experimentalstudydesignwasconductedinamedicalcentreinTaiwanfromAprilJuly2006.Methods.Sixty patients were recruited. The study group listened to selected music from the evening before surgery to the seconddayaftersurgery. Thecontrol groupdidnotlistentomusic. Patients levelsofanxietyandpainweremeasuredwithvisualanaloguescales(VAS).Physiologicalmeasures,includingheartrate,bloodpressureand24-hoururinalysis,wereperformed.Results.The average age of the 60 patients was 6218 (SD 1876)years. The mean VAS score for degree of anxiety in the studygroup was 0820, compared with 2151 in the control group. The mean VAS score for degree of pain in the study group was1730,comparedwith4460inthecontrolgroup.ThedifferencesbetweenthetwogroupsinVASscoresforbothanxiety(p=00180001) andpain(p=0001) werestatisticallysignicant. Onehouraftersurgery, themeanbloodpressurewassignicantly lower in the study group than in the control group (p=0014), but no signicant differences were found betweenthe two groups in urine cortisol (p=01450495), norepinephrine (p=02280626) or epinephrine values (p=00740619).Conclusions.Musictherapyhassomepositiveeffectsonlevelsofanxietyandpaininpatientsundergoingspinalsurgery.Relevanceto clinicalpractice.Complementary music therapy can alleviate pain and anxiety in patients before and after spinalsurgery.Keywords:anxiety,musictherapy,nurses,nursing,pain,spinalsurgeryAcceptedforpublication:14July2010IntroductionPostoperative pain is the greatest concern of surgical patients,especially for those undergoing major procedures such asspinal surgery (Lin etal. 2001). Failure to ease pain canincreasetheburdenonmanyorgansofthebody,negativelyinuencing postoperative rehabilitation and possibly contrib-uting to chronic pain (Brown etal. 2004, Cheng & Lu 2007).Pain also interferes with patients emotions, activities, qualityof sleepandappetiteandmayprolonghospitalisationandincreasemedicalexpenses(Chung&Lui2003).Properpainmanagement is both a demand and a right of patients, as wellas a responsibility of nursing personnel (Acute Pain Manage-ment Guideline Panel 1992). Orthopaedic oftenhave highlevelsofanxiety, especiallythoseundergoingacomplicatedproceduresuchasspinal surgery(Huangetal. 2004, Stark-weatheretal.2006).Theyhaveconcernsaboutwoundpainafter surgery and possible complications such as paralysis, soAuthors: Pi-Chu Lin, EdD, RN, Associate Professor, School ofNursing, Collegeof Nursing, Taipei Medical University; Man-LingLin, BSN, RN, Professional Nurse, Department of Nursing, TaipeiVeterans General Hospital; Li-Ching Huang, BSN, RN, ProfessionalNurse, Department of Nursing, Taipei Veterans General Hospital;Hsiu-Chu Hsu, BSN, RN, Professional Nurse, Department ofNursing, Taipei Veterans General Hospital; Chiong-Chu Lin,Diploma, RN, Head Nurse, Department of Nursing, TaipeiVeteransGeneralHospital,Taipei,TaiwanCorrespondence: Pi-Chu Lin, Associate Professor, School of Nursing,CollegeofNursing, Taipei Medical University, 250WuxingStreet,TaipeiCity110,Taiwan.Telephone:886227361661.E-mail:pclin02@gmail.com960 2011BlackwellPublishingLtd,JournalofClinicalNursing,20,960968doi:10.1111/j.1365-2702.2010.03452.xtheiranxietyand fearisnatural(Bridwell& DeWald1997).Ifpatientslevelsofanxietybeforeandaftersurgerycanbereduced, they will require less anaesthesia and analgesia aftersurgeryandanxiety-relatedcomplications maybe reduced(Lepageetal.2001,Zhangetal.2005).Music as a therapeutic intervention is a developmentlargelyofthemid-20thcenturybutithasexistedinvariousformsinmost culturesformanycenturies(Evans2002). Itinvolves the use of music under controlled conditions torestore, maintainandimprovepatients physiological, psy-chological and emotional health (Joanna Briggs Institute2009). In clinicalpractice, it is regarded as a complementarytherapy (Avers etal. 2007). It has been described as aneffective non-invasive technology that can shift patientsattention, promote relaxation, alleviate anxiety about sur-gery, improve emotional health and relieve pain (Evans 2002,Lee etal. 2005). Peng etal. (2009) found that listening to softmusic increased the level of relaxation, as indicated by a shiftof theautonomicbalancetowardsparasympatheticactivityinyounghealthyindividuals. Inareviewof musictherapyresearch,thisinterventionwasfoundtohavepositiveeffectsonpatients anxietyandpaininapproximatelyhalf of thestudies (Nilsson 2008). Fewstudies have been performedusingmusictherapyforpatientsundergoingspinal surgery,andnosuchresearchhas beenconductedinTaiwan. Thisstudy was conducted to evaluate the effects of music therapyonanxiety,painand physiologicalreactionsofpatientswithspondylopathybeforeandaftersurgery.BackgroundPainandanxietyinpatientsundergoingspinalsurgeryAsthepopulationages,anincreasingnumberofindividualsare undergoing surgery for degenerative spondylosis. Theprospectof sucha majorsurgery usuallycausesconsiderablefear andapprehensioninthe patient (Bridwell &DeWald1997). Patients worry about whether the surgery will result inspinalnerveinjury,possiblyleadingtohemiplegiaorincon-tinence,aswellaspossiblecomplicationsofanaesthesiaandeven death during the procedure (Mitchell 2000, Walker2002). This anxiety may be associatedwithphysiologicalsymptoms, includingelevatedbodytemperature, urgencyofurination, thirst, mydriasis, increasedpulseandrespirationrates, elevated blood pressure, constriction of peripheralvessels, loss of appetite, nausea anddiaphoresis (Mitchell2000,Walker2002).Patientswithnopriorexperiencewithsurgeryhaveespeciallyhighlevelsofanxiety(Kindleretal.2000). Patients with high anxiety before surgery usually havemore pain after surgery (Kain etal. 2000), a longer period ofphysical recoveryandaneedformoreanaesthesia(Buffumetal.2006).Lee (2004) reported that approximately 7798%ofpatients have pain after surgery; of this group, 4080% havemoderate-to-severe pain. Approximately 4050%of thesepatientshavelessthanidealpainmanagement.Theincisionfrom spinal surgery is on the patients back and bed rest aftersurgery may involve direct pressure on the wound; therefore,postoperative paintends tobe greater thanthat of othersurgical procedures (Lin etal. 2001). Postoperative pain has asignicant impact on the patients psychological and physicalhealthandwell-being. Intermsofpsychological health, thepaincausesanxiety, fearandevendepression, oftenleadingtotenserelations betweenpatients andnurses (Brunges &Avigne2003). Physiologically, painaffectsthefunctionsofdifferentsystemsandcancauseinsomniaandpoorappetite(Brunges & Avigne 2003). Alleviating patients postoperativepain and anxiety is a primary responsibility of nursingpersonnel.MusictherapyAccordingtotheNational Associationfor MusicTherapy,musictherapyis theuseof musictorestore, maintainandimproveanindividuals physical andmental healthandtobringaboutpositivebehavioural change. Lai (2002)denesmusic therapy as the use of a special sonic wave, whichcontainscheerful beatsandmelodies, tohelpindividualstoenter a peaceful state; its purpose is toalleviate patientsdiscomfort, maintain and improve physical and mentalhealth. Music therapy can prompt physical and mentalreactions, mainlybecause melodies andrhythms affect theperimetersystemofthebrainandhypothalamus,whichcanalterthefunctionsoftheneuroendocrinesystem,reducethesecretionofcatecholamine, affect theregulativefunctionofautonomicnerves andtherebyinuencephysiological reac-tions(JoannaBriggsInstitute2009).Atawavefrequencyof813Hz, musical melodies stimulate the production ofregular, coordinatedalpha(a) brainwaves, leadingtotherelaxation of consciousness to a steady state and thus helpingtoalleviatepainanddiscomfort(Shi2003).Music therapy was initially provided to psychiatricpatients; subsequently, it was gradually expanded to patientsin surgery, dentistry, obstetrics, paediatrics, rehabilitationandhospicecare(Brunges&Avigne2003, Chang&Chen2005, Sendelbach etal. 2006). The provision of musictherapy to clinical patients has been found to reduce anxiety,elevate mood, relax muscles and lower pulse rate, bloodpressure and respiration rate (Evans 2002, Wu &Chou2008). As earlyas 1989, Kaempf andAmodei foundthatOriginalarticle Musictherapy2011BlackwellPublishingLtd,JournalofClinicalNursing,20,960968 961patients who listened to music before surgery had lowerlevels of anxiety. Several scholars have found that listening tomusicafter surgeryreduces thelevel of postoperativepain(Good etal. 2002) and the amount of analgesia used bypatients who have listened to music is less than that ofpatients who have not listened to music (Cepeda etal. 2006).Buttwostudiesreportedthattherewerenoeffectsofmusictherapy on reduction in opioid usage for patients undergoingcardiacsurgeryoronthedosageofsedativemedicationsforpatientsundergoingcolonoscopyorcardiacsurgery(Sendel-bachetal. 2006, Bechtoldetal. 2009). Wangetal. (2002)studied patients undergoing anaesthesia and surgery wholistenedtoa 30-minute patient-selectedmusic sessionandfoundthattherewerenogroupdifferencesonelectrodermalactivity, blood pressure, heart rate, cortisol and catechol-amine data. Buffumetal. (2006) foundthat patients whowere scheduled for vascular angiography and who listened tomusic signicantly reduced their anxiety level and pulse rate,comparedtoagroupthatdidnotlistentomusicbeforetheprocedure.Thisstudywasconductedtoevaluatetheeffectsof musictherapyonanxiety, postoperativepainandphys-iological reactions to emotional and physical distress, such asincreasedbloodpressure, respirationrate andsecretionofcortisol and epinephrine in patients undergoing spinalsurgery.MethodsStudyparticipantsandsettingThis study was conducted using a quasi-experimental pretestandpost-test designinvolvingastudygroupandacontrolgroup. The study participants were selectedfrompatientswhounderwentspinalsurgeryata2900-bedmedicalcentreinTaipei City, Taiwan, fromAprilJuly2006. All patientsscheduledfornon-emergencyspinesurgerywereeligibletoparticipateinthestudy. Patientswereassignedtothestudygrouportoacontrol group, dependingonthedayoftheirsurgery. The surgery schedule was arranged by doctorsunawareoftherecruitmentprocessandallpatientsreceivedthe identical anaesthetic regimen and postoperative analgesia.Acointoss decidedthe assignment sequence. All patientsscheduled for surgery on Tuesdays and Thursdays wereassigned to the study group, while those scheduled for surgeryonWednesdays andFridays were assignedtothe controlgroup. Monday was excluded because it was not available forspinesurgery. Sixtypatientswereenrolledinthestudy; 30per group. Inclusion criteria were as follows: age >18years,nomental orcognitiveimpairment, abilitytocommunicateandwillingnesstoparticipateinthestudy.InstrumentsTheprimaryoutcomeswereanxietyandpain, asexaminedby self-reported psychological instruments, the State-TraitAnxietyInventory(STAI), visual analoguescales(VAS)andphysiologicalmeasures.Basic information: Basic information about the studyparticipants was collected, including sex, age, educationalstatus, occupation, religion, marital status, medical illnessesandhistoryofanyprevioussurgeries.STAI: The STAI was compiled by Spielberger etal. in 1970and translated into Chinese by Chung and Long (1984). Onlythe state measure of anxiety was used in this study to measurethe patients current state of anxiety, as this study wasinterestedintheeffect of musicinterventiononapatientsstate anxiety and not the impact of the stable personality traitof anxiety. The state inventory includes 20 items, each with ascoringrangeof14;thetotalpossiblescoreis2080,withhigher scores indicating higher levels of anxiety. Thisinstrument has been widely used to measure patients anxietybeforesurgeryandhasbeenfoundtohavegoodreliabilityand validity(Lee etal. 2004).In thisstudy,the Cronbach a-valuewas093.VAS: This studyusedtwoVAStomeasure anxietyandpain, respectively; this scale has been widely used to evaluatesubjective phenomena, suchas sensations, perceptions andreactions. Subjectsindicatedtheirdegreeofanxietyorpainon a scale of 010, with 0 indicating the least amount and 10the greatest amount. This scale has been found to be reliableas well as easy and convenient to use (Wewers &Lowe1990).Bloodpressureandpulsemonitor(PhilipA12-in-1bloodpressure monitor; Philips Healthcare, Andover, MA, USA): Ablood pressure monitor was used for automatic measurementof heart rate and systolic, diastolic and mean blood pressure.Urinecortisol,norepinephrineandepinephrineconcentra-tions: Cortisol excretionin24-hoururinesampleshasbeendemonstrated to correlate reliably with daily secretion of thehormone fromthe adrenal glands. Another advantage ofcollecting urine samplesis that the procedure is non-invasiveand is not in itself a stressor that might increase stresshormone production in the patient as is, for instance,venipuncture(Doeringetal.2000).Twenty-four-hour urine specimens were collected fromsubjects, with a 15ml sample thoroughly stirred and used formeasurement. High-performance liquid chromatography andanelectrochemistry detector (ECD) were usedtosimulta-neouslyseparateandacidifyurinefortesting.Validity: The VASandmusic therapyeffects evaluationformwerecheckedbyvespecialistsforvalidityandwereP-CLinetal.962 2011BlackwellPublishingLtd,JournalofClinicalNursing,20,960968given scores of 14 points according to the tness of content.The content validity index (CVI) was between 0810, meanscore=3238.MusictherapyMusic: The songs usedinthis studyhad6072beats perminute and were mid- to low-pitch, soft melodies in Chinese,the native language of Taiwan, including pop music, classicalmusic, sounds found in nature and sacred music. Researchersstoredalargenumber of examples of thesefour genres ofmusicinapersonalcomputerandtheneachpatientselectedhis or her favourite songs. The researchers copied thisfavouritemusicontoanMP3playerforeachpatientsuse.MP3player (TopfoxDigital MP3player; TopfoxTech-nologyCo., Ltd., Taipei, Taiwan): Eachpatient listenedtomusicthroughear-canal-typeearphones,amethodoflisten-ingfoundtoreduceambientnoise,whichmayinuencethecurativeeffect(JoannaBriggsInstitute2009).Environment: A sign was placed outside the patients door,theceilinglight turnedoffand thecurtainpulledaroundthetwinbedtokeepthepatientsareaquietandundisturbed.Acomfortable position was encouraged while listening to musicandresearchersremainedtoensurethatthepatientwasnotinterrupted. Forpatientsinthecontrol group, theenviron-mentwaskeptquietandthepatientwasundisturbedwhilerestinginbed.DatacollectionTwoorthopaedic nurses involvedinthe protocol screenedpatients undergoingspine surgeryfrompatient lists inthenursingstationinanefforttoidentifypotential candidates.Theresearcherthenapproachedthepotential candidatestoexplain the study and to offer them an opportunity to sign theinformed consent form. Patients who consented to participatewerethenassignedtoeithergroupdependingonthedayofsurgery. Patientsinthestudygroupselectedtheirfavouritemusic and the researchers prepared the music and MP3players for the patients use and demonstrated how to use themachine. Theresearchershelpedthepatientslistentotheirselected music for 30minutes at a time at 7PM PM the day beforethe surgery,onehour beforesurgery and at3PM PMonthe rstandseconddayaftersurgery.Inaddition,thepatientswereencouraged to listen to music at any other times they wanted.Measurements of the patients pulse rate, blood pressure andVAS scores were recordedbefore andafter the scheduledlisteningtimes. Onthe eveningbefore surgeryandonthesecond day after surgery, the STAI instrument was completedbythepatient. Patients urinewascollectedfrom7PM PMtheday before the surgery to 7AM AM the third day after surgery, foratotal of84hours, withtestingofcortisol, norepinephrineand epinephrine concentrations performed at 7AM AMeach day.Forpatientsinthecontrol group, datacollectionwasthesame as that in the study group, except that these patients didnot listentomusicbut restedinbedfor30minutesbeforemeasurement of their levels of painandanxiety. Measure-ments of the patients pulse rate, bloodpressure andVASscores were recorded at 7PM PMthe day before the surgery, onehourbeforesurgeryandat3PM PMontherstandseconddayafter surgery. On the evening before surgery and on thesecond day after surgery, the STAI instrument was completedbythepatient. Patients urinewascollectedfrom7PM PMtheday before the surgery to 7AM AM the third day after surgery, foratotal of84hours, withtestingofcortisol, norepinephrineand epinephrine concentrations performed at 7AM AMeach day.EthicalconsiderationsThis study was approved by the institutional review board ofa hospital in Taipei, where we proceded the study. Theresearchers explained the purpose and process of the researchto all patients. All patients provided written informed consenttoparticipate inthe studyandwere informedabout theirrights in the research process. Patients were assigned anidenticationnumberandtreatedanonymouslyinall anal-yses.StatisticalanalysisMeanand standarddeviation(SD)weregiventocontinuousvariables; number and percentage were calculated and shownfor categorical variables. To compare the differences betweentwo groups, an independent t-test was used. In addition,repeatedanalysis of variance(ANOVA ANOVA) was implementedtoexamine the differences among various time-points. Allstatistics were two-sidedandanalysedwith SPSS SPSS statisticalsoftware(version14.0,SPSSInc.,Chicago,IL,USA).ResultsDemographicdataAtotal of 60 spinal surgery patients were recruited andassignedtothestudy(30patients)andcontrol(30patients)groups. The mean age of the patients was 622 (SD188)years, with 36 patients older than 65years (60%).The participants included 31 male patients (517%), 12employed patients (20%), 54 married patients (90%) and 19patients with a primary-school educational backgroundOriginalarticle Musictherapy2011BlackwellPublishingLtd,JournalofClinicalNursing,20,960968 963(317%). Fifty-nine patients had caregivers (983%), of which28patientswerecaredforbyspouses(475%), 45patientshadothermedical illnesses(75%), ninepatientshadunder-gone previous spinal surgery (15%) and 30 patients hadundergoneothersurgicalprocedures(50%,Table1).EffectsofmusictherapyonpatientsanxietyAccordingtotheresultsoftheVASinstrument,theaverageanxietyscoresof thestudygroupaftermusictherapywerefrom08(SD13)to20(SD21). Inthecontrolgroup, themean anxiety scores after bed rest were from 21 (SD 19)51(SD 27); the highest score was recorded in the evening beforesurgery, and the lowest score was recorded on the second dayafter surgery. Comparison by t-test showed statistically asignicant difference in anxiety score between the two groupsregardlessoftime(p=00180001,Table2).The results of the STAI instrument showedthat for thestudy group, the mean pretest score (the evening beforesurgery) was 381 (SD 115) and the mean post-test score (theseconddayaftersurgery)was382(SD89).Forthecontrolgroup, themeanpretest scorewas 434(SD112) andthemeanpost-test score was 406(SD82). Twogroups hadsimilar STAI scores presurgery and postsurgery; also, theSTAI score was not signicantly changed after the surgery inbothgroups(p=00740286).EffectsofmusictherapyonpatientspainAccordingtotheresultsoftheVASinstrument,theaveragepain scores of the study group after music therapy ranged from17 (SD 15)30 (SD 23); the worst pain was on the rst dayaftersurgeryandtheleastpainwasontheseconddayaftersurgery. In the control group, the mean pain scores after bedrest were from44 (SD19)60 (SD25); the worst pain was inthe evening before surgery and the least pain was on the seconddayaftersurgery. Comparisonbyt-testshowedstatisticallysignicant differences betweenthe twogroups throughoutthe entire observation period, with the lower pain level of thestudy group after music therapy (all: p=0001, Table2).PhysiologicalmeasuresofanxietyandpainComparisonof systolic, diastolicandmeanbloodpressurevalues andpulse rates betweenthe twogroups fromdatacollectedonehouraftersurgeryrevealedsignicantlylowersystolic levels (p=0007) and meanblood pressure levels(p=0014) inthe studygroupthaninthe control group.Moreover, in both groups, the highest systolic and meanTable1Characteristicsof60patientsVariables Number(%)Age(years)[mean SD] 622 18865 24(400)>65 36(600)Malegender 31(517)EducationIlliterate 8(133)Elementaryschool 19(317)Juniorhighschool 7(117)Seniorhighschool 11(183)Collegeorabove 15(250)Married 54(900)Employed 12(200)Otherdisease 45(750)HistoryofoperationNone 21(350)Spinalsurgery 9(150)Othersurgery 30(500)Maincaregiver*Spouse 28(475)Children 23(390)Parents 6(102)Nurseaid 2(34)SD,standarddeviation.*Onepatientdidnothaveaprimarycaregiver.Table2MeananxietyandpainscoreofVAS(010score)of60patients

Meananxiety(SD)p-valueMean pain score (SD)p-valueMeanSTAI(SD)p-valueStudy(n=30)Control(n=30)Study(n=30)Control(n=30)Study(n=30)Control(n=30)Beforesurgery 13 21 51 27