AANA Journal August 2011 Vol. 79, No. 4 Special Research Edition S21
There is increasing interest in evaluating the use of
nonpharmacologic interventions such as music to
minimize potential adverse effects of anxiety-reducing
medications. This study used a quasi-experimental
design to evaluate the effects of a perioperative music
intervention (provided continuously throughout the
preoperative, intraoperative, and postoperative peri-
ods) on changes in mean arterial pressure (MAP),
heart rate, anxiety, and pain in women with a diagno-
sis of breast cancer undergoing mastectomy. A total of
30 women were assigned randomly to a control group
or to the music intervention group. Findings indicated
pain, treatment regimens, financial burdens of care, and
disruptions of their personal and professional lives.1,2
Traditional methods of reducing anxiety in presurgical
patients have been focused primarily on the use of phar-
macologic interventions. However, such medications may
result in delayed awakening and discharge from postop-
erative care and sometimes an untoward reaction to the
A nonpharmacologic intervention such as music may
improve postoperative outcomes by reducing potential
untoward effects of the pharmacologic agents. Music
consists of “a complex web of expressively organized
sounds” and includes the basic elements of tone, dura-
tion, loudness, and pitch.4 Although findings from some
studies have indicated significant effects of music on
selected outcomes, such as blood pressure, heart rate,
anxiety, and pain,5-20 others have reported no effects.21-29
Because of the limitations of existing studies and incon-
sistency of findings across studies, there is a need for
further research to evaluate the use of music during the
perioperative period. The purpose of this study was to
that women in the intervention group had a greater
decrease in MAP and anxiety with less pain from the
preoperative period to the time of discharge from the
recovery room compared with women in the control
group. Music is a noninvasive and low-cost interven-
tion that can be easily implemented in the periopera-
tive setting, and these findings suggest that periopera-
tive music can reduce MAP, anxiety, and pain among
women undergoing mastectomy for breast cancer.
Keywords: Anxiety, blood pressure, music, pain, peri-
Perioperative Music and Its Effects on
Anxiety, Hemodynamics, and Pain in Women
Pamela G. Binns-Turner, CRNA, PhD
Lynda Law Wilson, RN, PhD, FAAN
Erica R. Pryor, RN, PhD
Gwendolyn L. Boyd, MD
Carol A. Prickett, PhD, MT-BC
he diagnosis of breast cancer in women engen-
ders stress and anxiety related to future prog-
nosis and potential mortality and uncertainty
about changes in their body image and treat-
ment options. The anxiety may include con-
cerns about the surgical experience, coping with acute
examine the effects of a perioperative music intervention
(provided continuously throughout the preoperative,
intraoperative, and postoperative periods) on changes in
mean arterial pressure (MAP), heart rate (HR), anxiety,
and pain in women with a diagnosis of breast cancer un-
dergoing mastectomy. The 4 study hypotheses were that
women who received a perioperative music intervention
would have a greater decrease from the preoperative to
postoperative period in the following: (1) MAP, (2) HR,
(3) anxiety, and (4) pain compared with women in a
randomly assigned control group.
The study was approved by the institutional review
boards of the University of Alabama at Birmingham and
the Jackson-Madison County General Hospital, Jackson,
Tennessee. A quasi-experimental design was used to test
the study hypotheses. A convenience sample (n = 30) of
women with a breast malignancy was assigned randomly
to the control group or music intervention group.
The women in the sample were recruited from 2
general surgery practices after having received a diag-
nosis of breast cancer and deciding to undergo mastec-
tomy. These women received their surgery in 1 urban
hospital in a city in western Tennessee. Exclusion cri-
teria included patients evaluated as ASA physical status
4 or 5. Additional exclusions were previous diagnosis
S22 AANA Journal August 2011 Vol. 79, No. 4 Special Research Edition www.aana.com/aanajournalonline.aspx
and treatment of breast cancer, diagnosis of chronic
obstructive pulmonary disease, diagnosis of mental dis-
orders (eg, bipolar disorder, schizophrenia, or cognitive
impairment), use of antipsychotic and benzodiazepine
medications, inability to receive midazolam, and use of
hearing aids. Use of antidepressant medications (eg, es-
citalopram, bupropion, and fluoxetine) did not exclude
a participant from the study. Cognitive impairment and
other psychological disorders were assessed by a medical
diagnosis included within the participant’s history and
physical examination report in the preoperative chart.
Information flyers that were used for recruitment were
posted in the waiting room of the surgeon’s offices, and
an office staff member identified potential participants
who met sample selection criteria and informed them
about the study. The staff member asked women who
were interested in learning more about the study to sign
permission forms allowing an investigator to contact
them. One of us (P.G.B.-T.) called potential participants
who signed the permission forms to explain the study
in further detail, answer questions, determine eligibil-
ity, and inform potential participants that they would
be asked to provide written consent on the day of their
surgery. Each participant who was approached by an in-
vestigator (P.G.B.-T.) agreed to participate in the study,
was enrolled, and completed the study. On the day of
the scheduled surgery, one of us (P.G.B.-T.) met the
participant preoperatively to review the study, answer
questions, and obtain written informed consent.
Women in the intervention group listened to music
throughout the perioperative period (during the pre-
operative, intraoperative, and postoperative periods),
and women in the control group received standard care
without the music intervention. Data on all study vari-
ables were collected preoperatively at time 1 (T1) in
the presurgical area and postoperatively at time 2 (T2)
when the participant was ready for discharge from the
postanesthesia care unit (PACU). At the time of PACU
discharge, each participant received a music CD as a
thank you for being in the study.
The MAP was measured by using HP M3000A nonin-
vasive blood pressure monitoring instrument. Accuracy
is reported to be within ± 5 mm Hg maximum mean
error (HP M3000-A Multi-Measurement Server, Hewlett-
Packard Co, Palo Alto, California). Reliability of the auto-
mated noninvasive blood pressure monitoring was tested
before data collection by measurement and calculation of
a MAP with a manual sphygmomanometer in 3 volun-
teers. When compared with the automated noninvasive
blood pressure monitoring MAP, both readings were
within 5 points 100% of the time.
The HR was measured by using the HP M3000A elec-
trocardiograph. Reliability of the electrocardiograph was
tested before data collection by manual measurement of
the carotid pulsation for 60 seconds to obtain beats per
minute in 3 volunteers. When compared with the auto-
mated HR readings, both readings were within 5 points
of each other 89% of the time.
Interrater reliability of measures of MAP and HR
was assessed between an investigator (P.G.B.-T.) and a
PACU nurse on a random sample of 6 (20%) of the 30
participants at T1 and T2 using a percentage agreement
method (counting as agreement if the readings were
within 5 points of each other). The percentage of agree-
ment across these 12 readings was 83% (10/12) for MAP
and 92% (11/12) for HR.
Anxiety was measured by using the 20-item Spielberger
State Anxiety Scale (SAI). Spielberger et al30 reported an
α reliability coefficient of .91 and evidence of construct
validity for female college students by noting that SAI
scores were lower after relaxation training and higher
under stressful examination conditions. Internal consis-
tency values in the present study for the SAI were 0.958
at T1 and 0.973 at T2.
Pain was measured by using a 100-mm visual analog
scale (VAS) that had anchors of “no pain” (0 mm) and
“the worst pain” (100 mm). Bijur et al31 reported test-
retest reliability of 0.97 for a VAS for pain. The validity of
the VAS has been supported through correlation studies
with other self-reported measures of pain intensity such
as the McGill Pain Questionnaire and the Visual Rating
Scale, which is a Likert-type scale.32 Because of the many
potential scoring values, the VAS is extremely sensitive
to pain intensity.33 Bijur et al31 reported a correlation of
0.94 between the VAS and a numerical rating scale for
Additional data were collected preoperatively to ensure
that there were no differences between intervention and
control groups in the following variables that might in-
fluence the study results: age, race, ASA status, marital
status, and medications taken before surgery. Additional
data that were collected intraoperatively or postopera-
tively included surgical times, amount of fentanyl given
intraoperatively, presence or absence of intraoperative
complications, morphine equivalents administered post-
operatively in the PACU, and time in the PACU to ensure
that these variables were distributed equally between the
intervention and control groups.
After the participants were checked into the preopera-
tive area and signed the informed consent form, one of
us (P.G.B.-T.) collected T1 baseline measurements and
participants were then assigned randomly to the inter-
vention or control group by drawing numbers from a re-
closable plastic bag. An investigator (P.G.B.-T.) then pro-
vided the participant with an iPod (Apple Inc, Cupertino,
California) with earphones that allowed ambient conver-
sation to be heard. Each iPod was enclosed in a carrying
case covering the display. Women in the control group
also wore earphones attached to an iPod, but there was
no music playing, to minimize bias that might result if
AANA Journal August 2011 Vol. 79, No. 4 Special Research Edition S23
anesthesia, surgical, and recovery staff were aware of the
women’s treatment group assignment. Women in both
groups were asked not to mention the absence or pres-
ence of music.
Women in the intervention group chose 1 of 4 types of
music after listening for 5 minutes to a selection of each
genre (classical, easy listening, inspirational, and new
age). The order in which the participant heard the genre
selection was randomly presented each time to each
participant. The participants’ music selections contained
4 hours of continuous nonrepeating music to prevent
potential satiation. The maximum volume setting on the
iPod was locked so that the volume would not exceed a
level of 70 dB, substantially lower than the permissible
exposure limit of 90 dB for more than 8 hours to prevent
permanent hearing damage established by the National
Institute for Occupational Safety and Health.34
The music intervention began after the participant
received midazolam preoperatively. To minimize differ-
ences in anesthesia care that might influence the study
outcomes, all anesthesia was provided by 3 Certified
Registered Nurse Anesthetists (CRNAs) familiar with
the study protocol. All CRNAs used the same anesthesia
protocol, using a combination of intravenous drugs that
was standardized. Unless contraindicated by patient al-
lergies, each participant received 2 mg of intravenous
midazolam preoperatively. The anesthetic began with
preoxygenation of 100% oxygen for 3 minutes. The fol-
lowing drugs were given: fentanyl, 1.5 µg/kg; lidocaine,
1.5 mg/kg; propofol, 2 mg/kg; and succinylcholine, 1.5
mg/kg. The airway was then secured by placement of an
endotracheal tube, and ventilator support was provided
to ensure normocarbia. Anesthesia was maintained with
a 1:1 nitrous oxide–oxygen mixture and an end-tidal
desflurane concentration of 5%. Fentanyl, 1 µg/kg, was
given whenever the patient’s HR increased by more than
20% over the baseline value. Ondansetron, 4 mg, was
given for prevention of nausea and vomiting 15 minutes
before emergence. The CRNA administered intravenous
fluids (lactated Ringer’s) to appropriately replace each
participant’s fluid deficit due to fasting, blood loss, and
insensible losses from the surgical field and to maintain
the hourly maintenance fluid rate. No reversal medica-
tions were necessary or given.
In the PACU when the patient had an Aldrete score of
9 or more and was ready for discharge, data collection for
T2 began. This Aldrete score indicated that respiratory
effort was adequate, vital signs were within 20% to 50%
of baseline measures, skin was warm with good color,
and the patient was alert and oriented and had purpose-
All statistical analyses were performed using SPSS,
version 15.0 (SPSS Inc, Chicago, Illinois). Statistical tests
performed for comparisons of groups at baseline includ-
ed independent sample t tests for continuous variables
and χ2 analyses for categorical variables, as appropriate.
Independent sample t tests were also used for compari-
son of change scores for the main study outcomes and
for other intraoperative and postoperative variables. A P
value of .05 was considered significant.
The age of the participants ranged from 42 to 70 years,
with a mean of 56.63 years. A total of 24 participants
were white (80%) and 6 were black (20%). All but 2
participants completed high school, and 14 (47%) had
between 1 and 6 years of college education. Results of χ2
analyses indicated that there were no significant differ-
ences at baseline between the women in the intervention
and control groups in age or for the variables of race,
ASA status, or marital status (Table 1). The interven-
tion and control groups were also similar in the number
Variable Intervention Control P b
Table 1. Comparison of Demographic Characteristics for the Intervention and Control Groupsa
a Data are given as number (percentage).
b χ2 tests of homogeneity.
c Fisher exact P value.
d Single, divorced, or widowed.
S24 AANA Journal August 2011 Vol. 79, No. 4 Special Research Edition www.aana.com/aanajournalonline.aspx
of subjects with diabetes (2 vs 3) and number taking a
preoperative β-blocker (1 in each group). The groups
were examined for differences in other intraoperative and
postoperative variables that may have affected results.
The intervention and control groups did not differ in the
mean amount of fentanyl received or in average operat-
ing room time. They also did not differ in mean mor-
phine dose equivalents received in the PACU or the time
between the last opioid dose and measurement of pain
via the VAS at T2 (Table 2).
One factor that could not be controlled was which
surgeon provided the surgery for each patient. Surgeon
1 performed 18 of the procedures (60%), 10 in the inter-
vention group and 8 in the control group. Surgeon 2 per-
formed 8 of the procedures (27%), 2 in the intervention
group and 6 in the control group. Four different surgeons
performed the remaining 4 procedures, 1 in the control
and 3 in the intervention group.
Results of independent sample t tests indicated that
there were no differences between the women in the in-
tervention and control groups in baseline measurements
of the main study variables (MAP, HR, anxiety, and
pain). The difference from T1 to T2 resulted in a change
score from which an independent sample t test was cal-
culated for each dependent variable, comparing the in-
tervention and control group means. The P values for the
Levene test for homogeneity of variance were more than
.05 for all dependent variables. The observed power of all
dependent variables except 1 was greater than 80%: MAP,
0.892; HR, 0.207; anxiety, 0.999; and pain, 0.810. Table
3 illustrates the means and SDs for T1 and T2 and the
change scores (T1 – T2) for MAP, HR, anxiety, and VAS
pain scores for women in the intervention and control
groups and also indicates which T1-T2 change scores
were significant at a probability level of .05.
The findings presented in Table 3 indicate there was a
statistically significant difference (P = .003) in the MAP
T1-T2 change scores when comparing the women in the
intervention and control groups, supporting the first
study hypothesis. In addition to statistical significance,
there was clinical significance supporting this hypothesis
because the MAP for the control group increased post-
operatively by a mean of 4.5 mm Hg, whereas the MAP
for the intervention group decreased postoperatively by
15.1 mm Hg.
There was no significant difference between the
women in the intervention and control groups in the
T1-T2 change scores in HR (P = .248), and, thus, the
second hypothesis was not supported. The women in the
intervention group had a smaller increase in HR from T1
to T2 (2/min) than did women in the control group (6.8/
min), but this difference was not statistically or clinically
Women in the intervention group had a significantly
greater decline in anxiety levels from T1 to T2 compared
with women in the control group (P < .001), supporting
the third study hypothesis. The postoperative anxiety
score for the control group increased by a mean of 7.7,
whereas the anxiety score for the music group decreased
by 10.8. The ranges of these change scores for anxiety
were from –24 to +1 for the intervention group and –8 to
+33 for the control group.
Finally, women in the intervention group reported a
significantly greater decrease in pain levels (as measured
on the VAS) from T1 to T2 (P = .007) compared with the
control group, supporting the fourth study hypothesis. It
is interesting that results of independent sample t tests
indicated that there were no differences in the amount
of postoperative opioid morphine dose equivalents re-
ceived by women in the intervention and control groups
(P = .538), suggesting that the differences in perceived
pain reported on the VAS were not due to differences
in the amount of analgesics received postoperatively. In
addition to statistical significance, there was clinical sig-
nificance in this result because the VAS for the control
group increased by a mean of 50.7, whereas the VAS
Table 2. Comparison of Potentially Extraneous Variables for the Intervention and Control Groups
Abbreviations: PACU indicates postanesthesia care unit; T2, time 2 (when the participant was ready for discharge from the PACU); and
VAS, visual analog scale.
a Independent sample t test; equal variances assumed; df = 28.
mean t a P
Length of procedure, min 77.7 71.7 0.642 .526
Amount of opioid (fentanyl, µg) 220 233 –0.807 .426
Morphine equivalents in PACU, mg 17.7 22.1 –0.623 .538
Time in PACU, min 52.8 50.0 0.495 .624
Time of last opioid to T2 VAS, min 19.1 28.3 –1.31 .201
AANA Journal August 2011 Vol. 79, No. 4 Special Research Edition S25
for the intervention group increased by only 29.7. The
women in the intervention group experienced a 41.4%
smaller increase in pain compared with women in the
The study findings indicated that levels of MAP, anxiety,
and pain were significantly lowered or improved post-
operatively in the intervention group compared with the
control group. Women in the intervention group had
lower postoperative HR levels, but the difference was not
statistically different from the change in HR for women
in the control group.
A number of previously reported studies have evalu-
ated the effects of music interventions during the periop-
erative period on 1 or more of the 4 dependent variables
examined in this study (MAP, HR, anxiety, and pain). A
total of 14 studies of music intervention were identified
that included blood pressure as an outcome variable, and
findings from 8 of these studies indicated that music had
a significant effect on lowering blood pressure, consistent
with the findings from the present study.5,6,8,10,11,19,20,27
In 7 of the 8 studies that reported significant effects of
music on blood pressure, patients were allowed to choose
the type of music,5,6,10,11,19,20,27 and in 4 of these studies
with significant effects on blood pressure, the music
intervention was initiated preoperatively.5,10,19,20 These
findings suggest that music interventions may be most ef-
fective in reducing blood pressure if patients are allowed
to choose the type of music and if the music intervention
is initiated preoperatively.
A total of 15 studies were identified that examined
the effects of a music intervention on anxiety levels. In
11 of these studies, authors reported reduced anxiety fol-
lowing a music intervention, consistent with the findings
in the present study.5,7,11,14-16,18,20,22,25,29 The remaining
4 studies that included anxiety as a dependent variable
reported no effect of music on anxiety.13,21,23,27 The State
Trait Anxiety Inventory was used more often than the
VAS in studies that reported significant effects of music
We found 11 studies evaluating perioperative music
interventions in which pain was examined as an outcome
variable. In 8 of these studies, pain was reduced following
a music intervention, consistent with the results of the
Of 13 previous studies that included HR as an outcome
variable, 6 reported a significant effect of music on
HR.5,6,8,10,11,19 In contrast, 7 of these studies did not find
significant effects on HR, consistent with findings from
the present study.14,20,22,23,25,26,29 The sample sizes in the
7 studies that did not report significant effects on HR
ranged from 10 to 75, but only 2 of these studies had more
than 15 participants per treatment group. The sample
sizes in the 6 studies that reported significant effects on
HR ranged from 10 to 100, and 5 of these studies included
at least 20 participants per treatment group.
The review of the existing literature indicates consid-
erable variability in findings related to the effects of music
during the perioperative period on blood pressure, HR,
anxiety, and pain. Studies evaluating the effects of music
interventions in surgical patients have examined music
provided at different times (preoperatively, intraopera-
tively, and/or postoperatively), with different patient pop-
ulations, and using different types of musical selections.
Because of these differences, it is difficult to compare
Table 3. Mean and SD for Time 1, Time 2, and Change Scores for MAP, HR, Anxiety, and Pain for Women in the
Intervention (Music) and Control Groups
Abbreviations: MAP , mean arterial pressure; HR, heart rate.
a Independent sample t test; equal variances assumed; df = 28.
b Significant at P < .05.
mean (SD) ta P
S26 AANA Journal August 2011 Vol. 79, No. 4 Special Research Edition www.aana.com/aanajournalonline.aspx
findings across studies. Many of the existing studies have
limitations that preclude generalizing their findings, such
as uncontrolled confounders,6,8,10,13,16,17,23,25,27,28 small
samples,14,18,19,20,22,23,25,26,29 nonrandom assignment to
groups,5,11,19 and the use of music selected by the re-
searcher rather than by the patient.8,12-17,21,22,24,25 The
design of the present study addressed many of these
limitations, including control of potentially confounding
variables, random assignment to intervention and control
groups, and the use of music selected by the patient rather
than the researcher.
There were many strengths in the design of this study.
The power for the t tests for all dependent variables was
greater than 0.80 with the exception of HR. One reason
for the failure to identify an effect of music on HR in the
current study may have been an inadequate sample size,
resulting in inadequate power, to detect the effect of music.
A homogenous sample that included only women
with the same diagnosis and undergoing the same surgi-
cal procedure provided control of selected extraneous
variables. The use of random assignment further con-
trolled for potentially confounding variables in partici-
pant characteristics. Including women with breast cancer
as the study population helped avoid a floor effect in
anxiety and pain because numerous studies have sug-
gested that women with breast cancer have high levels
of anxiety and pain. An additional strength of the study
was the use of the Spielberger SAI rather than a VAS to
measure state anxiety as recommended by several re-
searchers.6,11,15,16,18,20,22,25,29 Another strength was the
finding that there were no differences between the in-
tervention and control groups in numerous potential
extraneous variables, including race, ASA status, and
marital status (Table 1) and length of procedure, amount
of intraoperative opioids received, amount of morphine
dose equivalents in the PACU, average time in the PACU,
and the time between the last opioid dose and measure-
ment of pain via the VAS at T2 (Table 2). It must be
acknowledged, however, that there were no measures of
other potential extraneous or confounding variables such
as socioeconomic status, baseline medications, or differ-
ences in outcomes based on the surgeon.
All enrolled participants completed the study proce-
dures. The observers were blinded to the participant’s
group assignment, although the participants could not be
blinded because of the nature of the music intervention.
Participants in this study were allowed to choose from 4
categories of music and began listening preoperatively, as
recommended on the basis of previous studies.5-7,9-11,18-
20,27,29 The music intervention was noninvasive, with no
apparent deleterious effects on MAP, HR, anxiety, and
pain for the participants listening to music.
There were several limitations in this study that
must be acknowledged. Because participants knew that
their levels of pain and anxiety were being studied, a
Hawthorne effect may have been present because of
the nature of the self-reported instruments used and
may have introduced an element of response bias. The
Hawthorne effect reflects the possibility that women may
have responded differently from the way they normally
would because of awareness that they were participating
in a study. Although this study was carefully designed to
control for confounders, we were unable to control the
hospital perioperative environment (eg, noise and tem-
perature). However, because random assignment resulted
in groups that were similar, the intervention and the
control groups were exposed to these same conditions.
The study used a convenience sample, and the sample
was relatively small; thus, the results should be general-
ized with caution to women undergoing mastectomy for
breast cancer. Because only women were included as par-
ticipants, the ability to generalize the results of this study
to men is limited.
Future research is needed to determine whether periop-
erative music interventions might be helpful for other
populations, including children, men, and patients un-
dergoing other types of surgical procedures and other
types of anesthesia. Expanding the timeline for data col-
lection into the first several days to several weeks during
the postmastectomy timeframe would provide additional
information regarding the effects of music beyond the im-
mediate perioperative period. Additional research is also
needed to more specifically examine the mechanisms by
which music produces beneficial effects to further test
the conceptual framework proposed for this study.
The findings from this study provide new evidence
about the effects of perioperative music on MAP, anxiety,
and pain. Most previous studies have examined music
that was provided only during the preoperative, intraop-
erative, or postoperative period and, rarely, throughout
the perioperative period. The findings of this research
are not only statistically significant, but they also dem-
onstrate clinical significance. Music is a noninvasive and
low-cost intervention that can be easily implemented in
the perioperative setting and can reduce MAP, anxiety,
and pain among women undergoing mastectomy for
breast cancer. Several participants receiving music volun-
teered comments postoperatively about how much they
enjoyed hearing the music and that it provided comfort to
them. As healthcare providers search for ways to provide
services to their clients that produce greater satisfaction,
perioperative music may be an efficacious and cost-
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Pamela G. Binns-Turner, CRNA, PhD, is associate professor and program
director, Nurse Anesthesia Track, Union University, School of Nursing,
Jackson, Tennessee. Email: firstname.lastname@example.org.
Lynda Law Wilson, RN, PhD, FAAN, is professor and assistant dean
for International Programs, School of Nursing, University of Alabama at
Birmingham, Birmingham, Alabama.
Erica R. Pryor, RN, PhD, is associate professor and doctoral program
coordinator, School of Nursing, University of Alabama at Birmingham.
Gwendolyn L. Boyd, MD, is professor, Department of Anesthesiology,
University of Alabama at Birmingham.
Carol A. Prickett, PhD, MT-B, is professor of music therapy, University
of Alabama School of Music.
This research was supported in part by a grant from Sigma Theta Tau,