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Effect of music intervention on burn patients’ pain


and anxiety during dressing changes

Kuo-Cheng Hsu *, Li Fen Chen, Pi Hsia Hsiep


Linkou Chang Gung Memorial Hospital Burn Center, Taiwan, ROC

article info abstract

Article history: For burn patients, the daily dressing process causes pain and anxiety. Although drugs can
Accepted 12 May 2016 relieve them, the degree of pain during dressing changes is often moderate to severe.
Therefore, relevant supporting interventions, like music as an ideal intervention, could
Keywords: alleviate the patient’s pain.
Burns This study investigated the impact of music intervention at dressing change time on
Music intervention burn patients’ pain and anxiety. This was a prospective, randomized clinical trial; patients
Pain were randomly assigned into control (standard intervention) and experimental groups
Anxiety (crystal music intervention) for five consecutive days (35 patients in each group). Patients’
pain and anxiety measurements were collected before, during, and after dressing changes
and morphine usage was recorded. The study period was October 2014 to September 2015.
There was no difference in morphine dosage for both groups. By the fourth day of music
intervention, burn patients’ pain before, during, and after dressing changes had significantly
decreased; anxiety on the fourth day during and after dressing changes had also signifi-
cantly decreased.
Nurses may use ordered prescription analgesics, but if non-pharmacological interven-
tions are increased, such as providing timely music intervention and creating a friendly,
comfortable hospital environment, patients’ pain and anxiety will reduce.
# 2016 Elsevier Ltd and ISBI. All rights reserved.

The degree of pain in burn patients resulting from dressing


1. Introduction changes is moderate to severe. To alleviate pain and anxiety,
medication can be used; however, nurses often overestimate
Management of pain caused by burns has always been a the degree of pain patients endure or fear medication side
challenging issue. Burn patients in the acute through effects and give a lower dose [5]. Every patient’s pain relief
rehabilitation phases will experience background pain at rest, needs may not be satisfied; non-pharmacological clinically
procedural pain during dressing changes, and breakthrough assistive care approaches are also rare.
pain during rehabilitation [1,2]. Among these, daily dressing ICU patients are often in critically ill or unstable condition;
changes are a main source of pain [3]; however, anxiety also nurses prioritize dealing with their health and abnormal
has a negative interaction with the pain by increasing its pathology and neglect spiritual or emotional care. However,
intensity and reducing medication’s therapeutic effects [2,4]. music intervention has been widely used in the care of various

* Corresponding author at: Linkou Chang Gung Memorial Hospital Burn Center, No. 5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan,
ROC.
E-mail addresses: email@cgmh.org.tw (K.-C. Hsu), Lifen1561@yahoo.com.tw (L.F. Chen), Pihsia406@cgmh.org.tw (P.H. Hsiep).
Abbreviation: NRS, numeric rating scale.
http://dx.doi.org/10.1016/j.burns.2016.05.006
0305-4179/# 2016 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: Hsu K-C, et al. Effect of music intervention on burn patients’ pain and anxiety during dressing changes. Burns
(2016), http://dx.doi.org/10.1016/j.burns.2016.05.006
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diseases, including examination and postoperative patients. study investigated the impact of music interventions before,
Research on reducing anxiety, pain, and stress, improving during, and after dressing changes on burn patients’ pain and
behavior problems and hospital quality of life, and reducing anxiety. We expected to provide patients with non-pharma-
physical, emotional, and mental disorder-related symptoms cological methods to alleviate pain and anxiety.
and syndromes have shown a certain degree of positive
effects; a considerable effect in stabilizing vital signs has been
found [3,6–10]. 2. Method
Music has multiple aspects. It can evoke experiences with
physical, cognitive, and emotional aspects. Music listening 2.1. Sample
can improve mood, reduce anxiety, and transfer pain and
unpleasant feelings [4,11]. In evidence-based nursing, music This study was a prospective randomized clinical trial. The
listening is an effective nursing intervention to promote study samples were collected from Chang Gung Memorial
comfort and wound healing [12]. Pain has both sensory- Hospital Burn Center, Taiwan (ROC). The research time was
discriminative and affective-motivation aspects [11]. Pharma- from October 2014 to September 2015. The inclusion criteria
cologic and non-pharmacologic treatment can be combined to were (a) burns within 24 h of hospitalization and age over 18
achieve clinical pain relief. In the sensory-discriminative with an expected stay in the hospital of more than seven days;
aspect, pain due to actual or potential tissue damage elicits an (b) able to communicate clearly with no hearing impairment;
unpleasant feeling along with a negative emotional experi- (c) no acute or chronic psychiatric disorders, hallucinations,
ence [9]. delirium, Alzheimer’s disorders, drug addiction, or abuse; (d)
A group of nerves located in the dorsal horn of the spinal non-critical condition without the use of a ventilator; and (e)
gray matter suppresses pain. When the pain from nerve no music therapy experience. The Linkou Chang Gung
signals pass receivers transmitted to gray matter in the spinal Memorial Hospital Institutional Review Board provided writ-
cord dorsal horn synapses, they act as a gate. They may close ten approval of this study, and all enrolled patients provided
or open to allow impulses to upload to the brain, thereby informed consent.
resulting in pain; this is called the gate control theory [6,9,13].
Listening to music can provide competitive sensory 2.2. Music intervention
stimulation input, causing nerve impulses to close the gate
to increase the pain threshold and decrease pain signals In this study, crystal music was used as a music intervention.
transmitted to the brain, thereby reducing the pain experi- Crystal music originated as crystal piano playing music with a
ence. Distraction or learned behavior applies the gate control clear and bright sound quality. It sounds similar to the sound
theory; music can attract their attention, reduce pain or of glass or crystal colliding. This study used crystal music that
exhaustion of the reaction, and redistribute the pain and is sold in the market, including content from genres such as
anxiety [14,15]. classical and pop music. After discussion, the researchers
In the affective-motivation aspect, musical tones and selected a crystal music compact disc (CD) for the experimen-
melodies can cause vibrations to affect the hypothalamus tal group of patients’ listening during dressing change time.
and reticular activating system interaction. This stimulates Before dressing changes in the experimental group, the CD
emotions and affects autonomic nervous system and muscu- player was placed on bedside tables, with speaker playback
lar system function. When accompanied by musical tone and volume set to 60 dB [8], every morning 15 min before
adjustment, rhythm can cause physiological changes in blood dressing changes started until 30 min after dressing changes.
pressure, heart rate, and respiratory rate [4,6]. When music
stimulates the hypothalamus and the limbic system, the 2.3. Measurements
generated imagery stimulates autonomic nervous reactions
and the spread of nerve impulses to the midbrain and higher In this study, a numeric rating scale (NRS) of 0–10 points
centers stimulates endorphin secretion; this offsets negative measured the pain intensity and anxiety level, respectively; 0
emotions, elicits feelings of pleasure, and reduces pain represented no pain or anxiety and 10 represented unbearable
[6,12,13,16]. pain or anxiety. NRS as pain or anxiety assessment tools have
Smooth flowing music, lyrical melody, simple chords, soft been used in many articles with confirmed good reliability and
tone, and rhythm tempo of 60–80 beat/min music (equivalent validity [4,8,9,17–19].
to the normal heart rate and physiological effects of the typical
adult) can produce relaxed mood and reactions, thereby 2.4. Procedure
inhibiting or offsetting pain and promoting emotional self-
regulation [4,5,8,9,16]. Music has simple, low cost, low risk, Hospitalized patients with burns meeting the criteria met with
non-invasive, and non-pharmacological characteristics easily the study research moderator or co-moderators. They dis-
accepted by the public [1,5,17]. Clinically, nurses are the first cussed the research purposes and allowed dropouts. After
line of patient contact. Nurses are responsible for dressing respondents consented, the researchers drew lots randomly.
changes and pain management. Nurses may use ordered Yellow and white table tennis balls were placed in a covered
prescription analgesics, but if non-pharmacological interven- box; yellow represented the experimental group and white
tions, such as providing timely music intervention and represented the control group. Participants were assigned
creating a friendly, comfortable hospital environment are accordingly. Then, basic patient information and demograph-
increased, patients’ pain and anxiety will reduce [18]. This ic data were collected. On the second hospitalized day, the

Please cite this article in press as: Hsu K-C, et al. Effect of music intervention on burn patients’ pain and anxiety during dressing changes. Burns
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experimental group, one patient’s condition changed and one


was automatically discharged; one control group patient in
uncomfortable pain was unwilling to continue participation in
the study. A total of 70 people completed five days of pain and
anxiety data collection.

2.5. Statistical analysis

SPSS version 18.0 for Windows was used for statistical data
analysis. Under the conditions of 80% sample power and
statistical significance of p < .05 (two-tailed test), patient basic
information, demographic data, and pain and anxiety NRS
were presented with descriptive statistics, with x2 test and
independent t-test differences between the two groups with
repeated measure analysis examined five days of pain,
anxiety, and morphine usage changes in the two groups.

3. Results

3.1. Patient basic demographic and clinical characteristics

The patients’ basic demographic and clinical characteristics


are shown in Table 2; the basic demographic information
contains gender, age, education, religion, and marital status.
Clinical characteristics included the diagnosis, injured area,
flushing before hospital, and place of injury. The gender ratio
(man/woman) was about 2:1; the average age of the music
Fig. 1 – Study procedure. group was 35.83 (SD: 13.05) and the control group was 38.41
(SD: 15.82) years. The two groups did not differ statistically in
demographics. In clinical characteristics, the two groups were
statistically no different.
Independent t-tests were used to compare pain, anxiety,
research moderator or co-moderators collected dressing morphine usage between the experimental and control groups
process pain and anxiety NRS measures and morphine usage. on the first day, respectively (Table 3). Results showed that
The procedure is presented in Fig. 1. We measured pain and anxiety was statistically significantly different before dressing
anxiety three times—before, during, and after wound dress- changes; the pain and anxiety were not statistically signifi-
ing—every morning. The experimental group listened to cantly different between during and after dressing changes
music for 15 min, then rated NRS measurements of pain and morphine usage.
and anxiety for the first time before dressing, a second time
during dressing, and after dressing, while continuing to listen 3.2. Pain
to music for 30 min, they provided ratings a third time;
patients listened to music the entire time for about 60–90 min. We used a general linear model repeated measure analysis of
The control group measured the first time before the dressing, the music and the control group NRS pain scores from the first
the second measure during dressing, and after dressing and to fifth day before, during, and after dressing changes. With
resting for 30 min, made the third measurements, completing the first day as the base, and the second to the fifth day for
the full procedure without music intervention (Table 1). comparison, Figs. 2–4 show the results.
Measurements were collected over five days (2–6 days after In Fig. 2, on the NRS pain scores before dressing changes
admission). A total of 76 cases complied with eligibility the second to fifth days compared to the first day of pain, the
criteria. Of those, 73 people consented to the study. In the experimental group had a significant decrease on the fourth

Table 1 – NRS pain and anxiety measurement time points.


Before CD 15 min Before CD During CD After CD After CD 30 min
Music Music Music+ NRS Music+ NRS Music NRS
Control – NRS NRS – NRS
NRS: numeric rating scale; CD: dressing change.
Music: received full procedure with music intervention.
Control: received full procedure without music intervention.

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Table 2 – Patient basic demographic and clinical characteristics.


Music (n = 35) Control (n = 35) p

n (%) Mean (SD) (range) n (%) Mean (SD) (range)


Gender
Men 22 (62.8%) 25 (71.4%) .44a
Women 13 (37.2%) 10 (28.6%)

Age 35.83 (13.05) (18–65) 38.41 (15.82) (18–73) .51b

Diagnosis
Scald burn 13 (37.2%) 14 (40.0%) .53a
Flame burn 17 (48.6%) 17 (48.6%)
Chemical and electric 5 (14.2%) 4 (11.4%)

Burn area (%) 18.14 (14.32) (4–55) 17.82 (15.34) (2–60) .89b

Flushing before hospital


Yes 27 (77.1%) 29 (82.8%) .41a
No 8 (22.9%) 6 (17.2%)

Flushing time n = 27 18.22 (15.11) (1–60) n = 29 15.86 (8.76) (5–45) .76b

Injuries place
At home 6 (17.2%) 11 (31.4%) .24a
Outdoor 12 (34.2%) 13 (37.2%)
Workplace 17 (48.6%) 11 (31.4%)

Education status
Less than high school 6 (17.2%) 4 (11.4%) .48a
High school 11 (31.4%) 10 (28.6)
University 18 (51.4%) 21 (60.0%)

Religion
Yes 17 (48.6%) 10 (28.6%) .08a
No 18 (51.4%) 25 (71.4%)

Marital status
Unmarried 21 (60.0%) 13 (37.2%) .06a
Married 10 (28.6%) 20 (57.1%)
Other 4 (11.4%) 2 (5.7%)
a
p-value from x2 test.
b
p-value from independent t-test.

Table 3 – Independent t-test to compare the music and control group on the first day.
Group Mean (SD) t p
Before CD pain Music 1.714 (1.177) 1.11 .27
Control 2.057 (1.392)

During CD pain Music 4.828 (2.242) 1.70 .09


Control 5.771 (2.389)

After CD pain Music 1.828 (1.403) .56 .57


Control 2.000 (1.111)

Before CD anxiety Music 1.485 (1.820) 2.25 .02*


Control 2.657 (2.472)

During CD anxiety Music 3.342 (2.622) 1.40 .16


Control 4.228 (2.635)

After CD anxiety Music .914 (1.197) .22 .82


Control .971 (0890)

Morphine usage Music 4.428 (1.820) 1.09 .27


Control 5.600 (4.393)
*
p < .05.

and fifth days. The control group had no significant differ- the experimental group had a significant decrease on the
ences; before dressing changes, pain was at the mild level. third to fifth days. The control group was not significantly
In Fig. 3, on the NRS pain scores during dressing changes different. During dressing changes, the pain was at a
the second to fifth days compared to the first day of pain, moderate level.

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Fig. 2 – Pain ratings before dressing change. Fig. 4 – Pain ratings after dressing change.

3.3. Anxiety

We used a general linear model repeated measure analysis of


the music and the control group anxiety NRS scores from the
first to fifth day before, during, and after dressing changes.
With the first day as the base and the second to the fifth day for
comparison, Figs. 5–7 show the results.
In Fig. 5, anxiety before dressing changes on the second to
fifth days compared with the first day were not significantly
different between the two groups. Anxiety before dressing

Fig. 3 – Pain ratings during dressing changes.

In Fig. 4, on the NRS pain scores after dressing changes the


second to fifth days compared with the first day of pain, the
experimental group reported pain on the fourth and fifth day
decreased significantly. The control group had no significant
differences. After dressing changes, the pain was at a mild
level.
Pain data collection found no significant changes in the
control group before, during, and after the dressing changes.
In the experimental group, there were significant decreases
the third day during dressing changes and the fourth day
before and after dressing changes. Fig. 5 – Anxiety ratings before dressing change.

Please cite this article in press as: Hsu K-C, et al. Effect of music intervention on burn patients’ pain and anxiety during dressing changes. Burns
(2016), http://dx.doi.org/10.1016/j.burns.2016.05.006
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6 burns xxx (2016) xxx–xxx

Fig. 6 – Anxiety ratings during dressing change. Fig. 8 – Morphine usage during dressing change.

Anxiety data collection found no significant change in


anxiety in the control group before, during, and after the
dressing changes. During and after dressing changes in the
experimental group, anxiety was significantly reduced by the
fourth day.

3.4. Morphine usage

We used a general linear model repeated measure analysis of


the music and the control group to analyze the amount of
morphine used from the first to fifth day during the entire
procedure of dressing changes. Results (Fig. 8) revealed that
morphine usage did not differ significantly between the two
groups.

4. Discussion

Music intervention in patients before, during, and after burn


dressing changes significantly decreased pain. Anxiety signif-
Fig. 7 – Anxiety ratings after dressing change. icantly decreased during and after dressing changes. Mor-
phine usage was not significantly different between the two
groups. Najafi et al.’s [1] research on burn patients with three
days of continuous background pain found that music therapy
changes was mild. In Fig. 6, on NRS anxiety scores during effectively reduced it. In this research, pain before dressing
dressing changes the second to fifth days compared to the first changes was similarly significantly reduced, but only after the
day of anxiety, the experimental group member’s anxiety had fourth day of pain.
significantly decreased on the fourth and fifth days; the Fratianne et al.’s [7] and Tan et al.’s [3] studies of music
control group had no significant differences. Anxiety during intervention two consecutive days before and after dressing
dressing changes was moderate. changes showed significantly reduced pain. This study’s
In Fig. 7, on NRS anxiety scores after dressing changes the music intervention group began to show significant decreases
second to fifth days compared with the first day of anxiety, the before and after dressing changes on the fourth day and
experimental group had significantly decreased anxiety on the during dressing changes on the third day. As with other
fourth day. The control group had no significant differences. studies, the control group showed no differences before,
Anxiety after dressing changes was mild. during, or after dressing changes.

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Anxiety is the most common emotional reaction to will be an interesting discussion whether only listening to
dressing changes for burn patients [19]. When told about 15 min of music before dressing changes was insufficient to
dressing changes, patients typically have an emotional reduce anxiety and whether more time to listen to music was
reaction expecting pain. Thus, the anxiety before dressings needed.
is no different between the music intervention and control The research team choice was crystal music that most
groups; Fratianne et al. [7] and Tan et al. [3] report the same people found acceptable. In Nilsson’s [8] review of other
with a downward trend in anxiety, but no statistically documents, music found on their own or selected by the
significant difference. In our study, with continued music research team does not affect findings. Other documents
playing, anxiety in patients during and after dressing changes agreed to use a smooth, lyrical melody, simple chords, soft
significantly decreased. Significant differences during and tone, and rhythm of 60–80 beat/min music. However, based on
after dressing changes began to show with music intervention each person’s different music favorites and gate control
on the fourth day. theory, the use of different types of music or intensity should
Contrary to the present findings, Allred et al. [5] found no be studied to explore whether there will be differences in pain
statistically significant differences between the music inter- or anxiety.
vention and control groups for patients receiving a total knee In the burn pain patients, opioid drugs administered
arthroplasty on first ambulation, although pain and anxiety intravenously are mainstream drug treatments [2]. In this
were reduced. The researchers believe that the reason for this study, opioid drugs (morphine) usage, there was no significant
discrepancy could be the number of intervention days. In our difference or decrease. However, in addition to opioid drugs,
study, as days of listening to music increase, a significant other types of oral analgesics are used. This study did not
decrease in pain before, during, and after the dressing and in investigate whether there were differences in non-opioid
anxiety level during and after the dressing is shown. However, drugs and oral analgesics due to the use of music intervention;
from the fourth day to the fifth day, the extent of the decrease the study may be appropriate in the future.
retards, showing that the music intervention has some clinical Robb et al. [21] mentioned music intervention should
improvement effect, but cannot completely replace conven- consider music transfer mode and volume, because the
tional therapy. environment may become an interference factor. Most studies
There was no significant difference or decrease in used headphones for patients to listen to music in order to
morphine usage. This result is consistent with Sendelbach reduce environmental noise interference factors. This re-
et al.’s [9] and Tan et al.’s [3] findings, but Najafi et al.’s [1] search adopted a CD player broadcast because during the
findings differ. Nilsson [8] also mentioned that most studies dressing changes process, the nurses engage in patient dialog
have found that music intervention can reduce usage of anti- to distract or induce deep breathing and muscle relaxation
anxiety and analgesic medications. skills (e.g., hands stretched forward, hard fist for 5 s, then
This study was a prospective randomized clinical trial to slowly relax fist) to relieve pain. The use of headphones for
investigate music intervention on burn patients’ pain and music would interfere with patients receiving nursing
anxiety about dressing changes. There were no statistically teaching skills. The volume was set to 60 dB to prevent the
significant differences in the basic demographic and clinical volume of music becoming noise. However, whether using
characteristics. Despite randomized assignment, however, headphones or broadcast really affects the findings or results
some patients in the music intervention group may have had is worth exploring.
the subjective thought ‘‘music can reduce anxiety or pain.’’
The independent t-test comparison of the experimental and
the control groups on the first day of pain and anxiety (Table 3) 5. Limitations
showed no statistical differences between the two groups
except for anxiety before dressing changes. Thus, the A double-blind design would be the ideal research method in
Hawthorne effect for this study had limited impact. order to assess intervention effectiveness. In this scenario, a
The results of this study are consistent with other studies control group would be given a ‘‘placebo.’’ However, for our
showing that music can reduce anxiety and pain. The pain of music intervention, determining an appropriate ‘‘placebo’’
burns caused by factors in addition to the wound itself can would be difficult. For instance, should control participants
include acute stress disorder or post-traumatic stress disorder listen to a blank CD, a CD playing an irritable voice, or heavy
[2]. Other studies comparing the effects of time show later rhythmic music? Many other possibilities could exist. Howev-
effects. It is worth pondering whether music therapy can er, when before dressing changes, patients heard music, they
imperceptibly alleviate patient pain and anxiety. Mandel [20] knew they belonged to the experimental group. Hence, a
found that long-term music intervention has a positive effect double-blind design would not have been feasible.
on heart rehabilitation. Thus, whether long-term listening to Burn patients suffer varying degrees of pain before, during,
music can improve burn patients’ traumatic stress syndromes and after dressing changes; acceptance of external stimuli
is worth exploring. also differs. In this study, because of the lack of a music
Music can stimulate the brain, making both physiology and therapist’s intervention, we took a passive music interven-
emotion relax to reduce anxiety. This study showed no tion approach to music listening. If timely active music
differences between groups in anxiety before dressing intervention from music therapists, such as guided medita-
changes or the music group listening to music 15 min. tion, music guided activities, or singing, etc., were provided
However, with continued playing, anxiety in patients during during the dressing change process, music intervention could
and after dressing changes showed significant decreases. It be more individualized.

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(2016), http://dx.doi.org/10.1016/j.burns.2016.05.006
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8 burns xxx (2016) xxx–xxx

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