Effect of Music on Pain After Open Heart Surgery
Effect of Music on Pain After Open Heart Surgery
The study used a quasiexperimental design. The study was carried out in the Cardiovascular Surgery Intensive Care Unit, Research Hospital, Atatürk University, Erzurum, in the east of Turkey, between September 15, 2007, and February 15, 2008. The study used a two-group pretest-posttest design.
Patients were assigned via convenience sampling to either the music or the control group. Strict inclusion and exclusion criteria were established to minimize sample variability. Patients were eligible to participate if they were ≥18 years old, could speak Turkish, and were on their first postoperative day after CABG or valve replacement. Exclusion criteria were an emergency operation, chronic pain problems, or any hearing impairment, cognitive impairment, difficulties cooperating during measurements, and hemodynamic instability.
The literature indicates that if data collected in experimental studies are evaluated by measurement and the number in all groups is >30, parametric tests should be used in data analysis (Aksakoğlu, G, 2001, Özdamar, 2003, Sümbüloğlu & Sümbüloğlu 1997). In the present study, in acknowledging this requirement, earlier studies in this area were used as a reference to evaluate pain intensity and physiologic parameters with a parametric test. (Nilsson, 2009, Sendelbach et al., 2006, Twiss et al., 2006). For each group, it was assumed that the power analysis of the study would be 99% when 45 patients with .05 alpha level and 95% reliability levels were included in the study. Thus, a total of 90 patients fulfilling the inclusion criteria were assigned to the control or the experimental group (45 in the music group, 45 in the control group). During the study, one patient in the music group and two patients in the control group withdrew. On completion, the statistical power of the study was found to be 99% in the power analysis made with pain variables in the music group.
The study instrument was divided into three parts:
Demographic Variables Demographic variables were age, gender, marital status, education level, and region of incisional pain.
For the patients undergoing open heart surgery, incisional pain from a median sternotomy is generally located along the site of the chest incision. This pain for the patients with CABG surgery may also radiate to the subclavicular regions, because an internal mammary artery is generally taken from the inside of the chest wall. Alternatively, if saphenous veins from the legs are harvested rather than the mammary arteries, then the pain might also be experienced in the leg. This pain is said to be intense during the first 3 days after surgery (Zimmerman et al., 1996).
In the present study, data were collected from the patients undergoing CABG surgery or valve replacement surgery. For those patients undergoing valve replacement surgery, the incision region was in the sternum. However, in patients undergoing CABG surgery, the incision regions were sternum and leg where the saphenous vein was removed. Thus, two different pain regions were determined by taking the region of incisional pain into consideration (1 = chest incisional pain region; 2 = chest and leg incisional pain regions).
Physiologic Parameters Physiologic parameters were systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), oxygen saturation (SpO2), and respiratory rate (RR), measured by using the GE Healthcare Datex-Ohmeda S/5 Critical Care Monitor (GE Healthcare Finland, Helsinki, Finland).
Unidimensional Verbal Pain Intensity Scale It is suggested that pain evaluation instruments should be used to determine the intensity of pain in clinical practices. These instruments comprise both unidimensional and multidimensional scales. It is pointed out in the literature that features of the patient group to whom the scale is applied influence which scale is to be used. A nontime-consuming, accurate, simple pain evaluation instrument is important in the intensive care unit (ICU) (Eti Aslan, 2006, Karayurt and Akyol, 2008). The advantages of a unidimensional verbal pain intensity scale are that it is easily applied and its classification is simple. In this scale, the patient chooses the most suitable word that describes pain intensity. (Eti Aslan, 2006). To describe the intensity of pain,Melzack and Katz (1992) used the terms: "hurts a little bit," "hurts a little more," "hurts even more," "hurts a whole lot," and "hurts worst." Participants in the present study were the ICU patients on the first day after their surgery. A unidimensional verbal pain intensity scale was used so that participants could self-report their pain intensity. The measurement instrument described as unidimensional verbal pain intensity scale in literature is composed of one question (Eti Aslan, 2002, Güdücü Tüfekçi and Erci, 2005, Karataş, S, 2010). In this measurement instrument, the participants are asked a question: "Which of the following phrases best describes your current pain? The participants answered this question choosing one of the phrases "hurts a little bit," "hurts a little more," "hurts even more," "hurts a whole lot," and "hurts worst." In this study, each pain statement was scored by the researchers from 1 to 5 where "hurts a little bit" = 1, "hurts a little more" = 2, "hurts even more" = 3, "hurts a whole lot" = 4, and "hurts worst" = 5 (Eti Aslan, 2006). The participants' pain intensities were calculated by taking the mean of pain scores converted to numerical values. The lowest pain intensity was 1 and the highest one was 5.
The study was approved by the Ethics Committee of Health Sciences Institution, Atatürk University, and verbal consent was obtained from each participant. Furthermore, written permission to conduct this study was obtained from the Head of the Cardiovascular Surgery Department. Following the completion of data collection, patients in the control group listened to music for 30 minutes with earphones via a portable cassette player, selecting the music they would like to listen to from the researcher's collection. To avoid bias, participants were not told whether they were part of the study group or the control group.
Data were collected first from the music group and second from the control group. All patients in both groups received standard postoperative care according to protocols developed by the cardiovascular surgeons and nurses. The data were collected between 3.00 p.m. and 4.00 p.m. when the traffic in ICU was not intense and the patients were not receiving invasive or noninvasive procedures. All patients were scheduled to rest in bed at 3.00 p.m. on the first postoperative day in ICU. All of the patients also received oxygen support, and analgesia was standardized for all patients. All of the patients received 50 mg pethidine HCl (Aldolan), a narcotic analgesic. This medically prescribed analgesic was given via intramuscular injection at 8:00 a.m. by the ICU nurse, who was one of the researchers. At 2:45 p.m., the researcher helped the patients to lie down in bed at an angle of 30-40 degrees. Demographic and physiologic data were then collected; to assess the pain, patients were asked to complete a unidimensional verbal pain intensity scale while in their beds. Physiologic data (SBP, DBP, HR, and SpO2) were measured in the ICU with the bedside patient monitor. The researcher observed each participant's chest movements and counted their RR for 1 minute.
The patients allocated to the music group were asked what kind of music they liked, and they selected the music from the researcher's collection of 20 musical pieces, which comprised a variety of different types of music, including Turkish classical music, Turkish folk music, and Turkish art music. The participants listened to music through earphones via a portable cassette player for 30 minutes. The music was soft and relaxing and played at a volume of 50-60 dB. The earphones helped the participants to focus on the music. Because the participants were listening to music through earphones, external noises were diminished. The researcher stayed with the patients during the whole intervention period for data collection. The music volume was adjusted to a satisfactory level based on the subjects' facial expressions and verbal feedback; they smiled and looked calm when satisfied with the volume or expressed their dissatisfaction with the volume verbally if it was too loud or too soft. Physiologic parameters and pain intensity were assessed and recorded immediately after 30 minutes of music was completed.
Data were collected from the control group at the same intervals as from the music group, but without making them listen to music. After recording pretest physiologic parameters and pain intensity, the patients remained in their resting period until posttest evaluation time. During this period, the researcher was in the ICU. During the rest period the environment was enhanced to reduce stimuli for the control group. After recording the posttest data, patients in the control group were able to listen to music upon request.
The questions regarding the pain intensity scale were read aloud to each participant who gave a verbal response. It took ~20 minutes to take the two measurements of pain level and physiologic parameters for each patient. The intervention and data collected were carried out by the same researcher.
Data were analyzed using the Statistical Package for the Social Sciences software (version 10.0; SPSS, Chicago, IL).
The participants' demographic features were evaluated through a nonparametric test because they were count data, and demographic characteristics of individuals in each group were compared using chi-square (Aksakoğlu, G, 2001, Özdamar, 2003, Sümbüloğlu & Sümbüloğlu 1997). Pain intensity and physiologic parameters were analyzed through parametric tests because they were metric values (Aksakoğlu, G, 2001, Özdamar, 2003, Sümbüloğlu & Sümbüloğlu 1997). To make a comparison of the means of physiologic parameters and pain intensity gained through measurement between groups, independent-samples t test was used. Paired t test was conducted to determine any significant difference between pretest and posttest physiologic parameters and pain scores for each group. The statistical significance level was set at .05. The independent research variable was music intervention, and the physiologic parameters and pain scores formed the dependent variables.
Methods
Subjects and Setting
The study used a quasiexperimental design. The study was carried out in the Cardiovascular Surgery Intensive Care Unit, Research Hospital, Atatürk University, Erzurum, in the east of Turkey, between September 15, 2007, and February 15, 2008. The study used a two-group pretest-posttest design.
Patients were assigned via convenience sampling to either the music or the control group. Strict inclusion and exclusion criteria were established to minimize sample variability. Patients were eligible to participate if they were ≥18 years old, could speak Turkish, and were on their first postoperative day after CABG or valve replacement. Exclusion criteria were an emergency operation, chronic pain problems, or any hearing impairment, cognitive impairment, difficulties cooperating during measurements, and hemodynamic instability.
The literature indicates that if data collected in experimental studies are evaluated by measurement and the number in all groups is >30, parametric tests should be used in data analysis (Aksakoğlu, G, 2001, Özdamar, 2003, Sümbüloğlu & Sümbüloğlu 1997). In the present study, in acknowledging this requirement, earlier studies in this area were used as a reference to evaluate pain intensity and physiologic parameters with a parametric test. (Nilsson, 2009, Sendelbach et al., 2006, Twiss et al., 2006). For each group, it was assumed that the power analysis of the study would be 99% when 45 patients with .05 alpha level and 95% reliability levels were included in the study. Thus, a total of 90 patients fulfilling the inclusion criteria were assigned to the control or the experimental group (45 in the music group, 45 in the control group). During the study, one patient in the music group and two patients in the control group withdrew. On completion, the statistical power of the study was found to be 99% in the power analysis made with pain variables in the music group.
Instruments
The study instrument was divided into three parts:
Demographic Variables Demographic variables were age, gender, marital status, education level, and region of incisional pain.
For the patients undergoing open heart surgery, incisional pain from a median sternotomy is generally located along the site of the chest incision. This pain for the patients with CABG surgery may also radiate to the subclavicular regions, because an internal mammary artery is generally taken from the inside of the chest wall. Alternatively, if saphenous veins from the legs are harvested rather than the mammary arteries, then the pain might also be experienced in the leg. This pain is said to be intense during the first 3 days after surgery (Zimmerman et al., 1996).
In the present study, data were collected from the patients undergoing CABG surgery or valve replacement surgery. For those patients undergoing valve replacement surgery, the incision region was in the sternum. However, in patients undergoing CABG surgery, the incision regions were sternum and leg where the saphenous vein was removed. Thus, two different pain regions were determined by taking the region of incisional pain into consideration (1 = chest incisional pain region; 2 = chest and leg incisional pain regions).
Physiologic Parameters Physiologic parameters were systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), oxygen saturation (SpO2), and respiratory rate (RR), measured by using the GE Healthcare Datex-Ohmeda S/5 Critical Care Monitor (GE Healthcare Finland, Helsinki, Finland).
Unidimensional Verbal Pain Intensity Scale It is suggested that pain evaluation instruments should be used to determine the intensity of pain in clinical practices. These instruments comprise both unidimensional and multidimensional scales. It is pointed out in the literature that features of the patient group to whom the scale is applied influence which scale is to be used. A nontime-consuming, accurate, simple pain evaluation instrument is important in the intensive care unit (ICU) (Eti Aslan, 2006, Karayurt and Akyol, 2008). The advantages of a unidimensional verbal pain intensity scale are that it is easily applied and its classification is simple. In this scale, the patient chooses the most suitable word that describes pain intensity. (Eti Aslan, 2006). To describe the intensity of pain,Melzack and Katz (1992) used the terms: "hurts a little bit," "hurts a little more," "hurts even more," "hurts a whole lot," and "hurts worst." Participants in the present study were the ICU patients on the first day after their surgery. A unidimensional verbal pain intensity scale was used so that participants could self-report their pain intensity. The measurement instrument described as unidimensional verbal pain intensity scale in literature is composed of one question (Eti Aslan, 2002, Güdücü Tüfekçi and Erci, 2005, Karataş, S, 2010). In this measurement instrument, the participants are asked a question: "Which of the following phrases best describes your current pain? The participants answered this question choosing one of the phrases "hurts a little bit," "hurts a little more," "hurts even more," "hurts a whole lot," and "hurts worst." In this study, each pain statement was scored by the researchers from 1 to 5 where "hurts a little bit" = 1, "hurts a little more" = 2, "hurts even more" = 3, "hurts a whole lot" = 4, and "hurts worst" = 5 (Eti Aslan, 2006). The participants' pain intensities were calculated by taking the mean of pain scores converted to numerical values. The lowest pain intensity was 1 and the highest one was 5.
Procedures
The study was approved by the Ethics Committee of Health Sciences Institution, Atatürk University, and verbal consent was obtained from each participant. Furthermore, written permission to conduct this study was obtained from the Head of the Cardiovascular Surgery Department. Following the completion of data collection, patients in the control group listened to music for 30 minutes with earphones via a portable cassette player, selecting the music they would like to listen to from the researcher's collection. To avoid bias, participants were not told whether they were part of the study group or the control group.
Data were collected first from the music group and second from the control group. All patients in both groups received standard postoperative care according to protocols developed by the cardiovascular surgeons and nurses. The data were collected between 3.00 p.m. and 4.00 p.m. when the traffic in ICU was not intense and the patients were not receiving invasive or noninvasive procedures. All patients were scheduled to rest in bed at 3.00 p.m. on the first postoperative day in ICU. All of the patients also received oxygen support, and analgesia was standardized for all patients. All of the patients received 50 mg pethidine HCl (Aldolan), a narcotic analgesic. This medically prescribed analgesic was given via intramuscular injection at 8:00 a.m. by the ICU nurse, who was one of the researchers. At 2:45 p.m., the researcher helped the patients to lie down in bed at an angle of 30-40 degrees. Demographic and physiologic data were then collected; to assess the pain, patients were asked to complete a unidimensional verbal pain intensity scale while in their beds. Physiologic data (SBP, DBP, HR, and SpO2) were measured in the ICU with the bedside patient monitor. The researcher observed each participant's chest movements and counted their RR for 1 minute.
The patients allocated to the music group were asked what kind of music they liked, and they selected the music from the researcher's collection of 20 musical pieces, which comprised a variety of different types of music, including Turkish classical music, Turkish folk music, and Turkish art music. The participants listened to music through earphones via a portable cassette player for 30 minutes. The music was soft and relaxing and played at a volume of 50-60 dB. The earphones helped the participants to focus on the music. Because the participants were listening to music through earphones, external noises were diminished. The researcher stayed with the patients during the whole intervention period for data collection. The music volume was adjusted to a satisfactory level based on the subjects' facial expressions and verbal feedback; they smiled and looked calm when satisfied with the volume or expressed their dissatisfaction with the volume verbally if it was too loud or too soft. Physiologic parameters and pain intensity were assessed and recorded immediately after 30 minutes of music was completed.
Data were collected from the control group at the same intervals as from the music group, but without making them listen to music. After recording pretest physiologic parameters and pain intensity, the patients remained in their resting period until posttest evaluation time. During this period, the researcher was in the ICU. During the rest period the environment was enhanced to reduce stimuli for the control group. After recording the posttest data, patients in the control group were able to listen to music upon request.
The questions regarding the pain intensity scale were read aloud to each participant who gave a verbal response. It took ~20 minutes to take the two measurements of pain level and physiologic parameters for each patient. The intervention and data collected were carried out by the same researcher.
Data Analysis
Data were analyzed using the Statistical Package for the Social Sciences software (version 10.0; SPSS, Chicago, IL).
The participants' demographic features were evaluated through a nonparametric test because they were count data, and demographic characteristics of individuals in each group were compared using chi-square (Aksakoğlu, G, 2001, Özdamar, 2003, Sümbüloğlu & Sümbüloğlu 1997). Pain intensity and physiologic parameters were analyzed through parametric tests because they were metric values (Aksakoğlu, G, 2001, Özdamar, 2003, Sümbüloğlu & Sümbüloğlu 1997). To make a comparison of the means of physiologic parameters and pain intensity gained through measurement between groups, independent-samples t test was used. Paired t test was conducted to determine any significant difference between pretest and posttest physiologic parameters and pain scores for each group. The statistical significance level was set at .05. The independent research variable was music intervention, and the physiologic parameters and pain scores formed the dependent variables.
