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Nursing Research July/August 2010 Vol 59, No 4, 259–269
Supplementing Relaxation and Music for Pain
After Surgery
Marion Good 4Jeffrey M. Albert 4Gene Cranston Anderson 4Stephen Wotman 4Xiaomei Cong
Deforia Lane 4Sukhee Ahn
bBackground: Most postoperative patients have unrelieved
pain despite the use of patient-controlled analgesia. Nurses
need additional effective modalities. Relaxation and music
(RM), in addition to analgesics, have been shown to reduce
pain more than do analgesics alone.
bObjectives: The objectives of the study were to test an
intervention of patient teaching for pain management (PT)
and compare it with RM for immediate and general effects
on postoperative pain.
bMethods: Patients having abdominal surgery and receiving
patient-controlled analgesia aged 18Y75 years (n= 517)
were randomized to four groups: PT, RM, a combination
(PTRM), and a control. A 2 2 factorial design was used
to assess PT-Effects and RM-Effects. Immediate effects on
pain were measured on visual analogue sensation and
distress scales before and after five 20-min tests in the first
2 days. Because participants also listened independently,
general nonimmediate effects were examined at eight
other times.
bResults: Using multivariate analysis of covariance with con-
trasts and pretest control, immediate RM-Effects on pain
were found at Day 1 a.m. (pG.001), Day 1 p.m. (p=.04),
and Day 2 a.m. (p= .04). No PT-Effects or nonimmediate
RM-Effects were found.
bDiscussion: Patient teaching did not result in less pain and did
not support the theoretical proposition that PT reduces pain.
However, the immediate RM-Effects supported the proposi-
tion that nonpharmacological adjuvants to analgesics can
ease pain without adding side effects.
bKey Words: music and relaxation &patient teaching &
postoperative pain
Incomplete relief of postoperative pain remains wide-
spread despite decades of research. An estimated
50%Y75% of patients do not receive adequate pain relief
after surgery. Pain increases suffering and can contribute to
complications, delayed recovery, and higher healthcare costs
(Bell & Duffy, 2009; Carr, 2002). Opioid medication that
patients self-administer does not always provide enough
relief. Although relaxation and music (RM) used in a
previous study resulted in less pain, there was still moderate
pain (Good et al., 1999). This may have been due to lack of
patient knowledge and ineffective attitudes about their role
in obtaining sufficient opioids (Bell & Duffy, 2009).
Patients often think that pain is to be expected and
endured. They do not realize that uncontrolled pain can have
harmful effects on their mobility and recovery. They delay
obtaining analgesics or even refuse them partly because they
do not like side effects and want to avoid addiction (Carr,
2002; Sindhu, 1996). In addition, they often feel powerless,
vulnerable, and dependent on nurses (Brumfield, Kee, &
Johnson, 1996; Brydon & Asbury, 1996; Lam, Chan, Chen,
& Ngan Kee, 2001). After surgery, patients react passively
rather than acting to solve problems and help manage their
pain (Manias, Botti, & Bucknall, 2006).
Preoperative patient teaching for pain management (PT)
hasbeenusedtoinformandempowerpatientsbyincreasing
their knowledge and self-efficacy for engaging in general
postoperative care activities and patient-controlled analgesia
(PCA; Chumbley, Ward, Hall, & Salmon, 2004; Ong, Miller,
Appleby, Allegretto, & Gawlinski, 2009; Pellino et al.,
1998). Meta-analyses have shown that PT resulted in less
pain (Devine, 1992; Shuldham, 1999), but the PT interven-
tions in these older studies were lengthy, not specific to pain,
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s Web site
(www.nursingresearchonline.com).
Marion Good, PhD, RN, FAAN, is Arline H. and Curtis F. Garvin
Professor of Nursing Excellence, Frances Payne Bolton School of
Nursing, Case Western Reserve University, Cleveland, Ohio.
Jeffrey M. Albert, PhD, is Associate Professor, Department of
Epidemiology and Biostatistics, School of Medicine, Case Western
Reserve University, Cleveland, Ohio.
Gene Cranston Anderson, PhD, RN, FAAN, is Professor Emerita,
University of Florida, Gainesville, and Edward J. and Louise
Mellen Professor Emerita, Case Western Reserve University,
Cleveland, Ohio.
Stephen Wotman, DDS, is Professor, School of Dentistry, Case
Western Reserve University, Cleveland, Ohio.
Xiaomei Cong, PhD, RN, is Assistant Professor, School of
Nursing, University of Connecticut, Storrs.
Deforia Lane, PhD, MT-BC, is Director of Music Therapy,
Ireland Cancer Center, University Hospitals Case Medical Center,
Cleveland, Ohio.
Sukhee Ahn, PhD, RN, is Associate Professor, School of Nursing,
Chungnam National University, Daejeon, South Korea.
Nursing Research July/August 2010 Vol 59, No 4 259
Copyright @ 20 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.10
and not relevant to current analgesic delivery systems. Brief
PCA-specific interventions had no effect on pain, whether via
pamphlet (Chumbley et al., 2004) or anesthetist instruction
and demonstration (Lam et al., 2001). The PT intervention
we tested was comprehensive yet specific to participation in
postoperative pain management.
Patients also tend to focus their thoughts on their pain and
do not seem to realize that achieving a calm, relaxed state can
help relieve it (Ness, 2009). In our previous large trial, ab-
dominal surgery patients who received 15 minutes of relax-
ation, soft music, or the combination of relaxation and music
in addition to analgesics had less immediate pain than that
of controls who received analgesics alone. The combination
intervention in that study was the same as the RM inter-
vention in this study. Significant effects for RM were found
on Days 1 and 2, but there was no effect on opioid intake
(Good et al., 1999). Reviews of relaxation or music for pain
showed heterogeneity and small effects immediately after a
scheduled intervention when compared with control groups
(Cepeda, Carr, Lau, & Alvarez, 2006; Good, 1996; Seers &
Carroll, 1998). Small effects on opioid intake indicated un-
clear clinical significance (Cepeda et al, 2006).
Tests of relaxation, music, and the combination for pain
have resulted in patient responses that suggest some of the
mechanisms of relief: muscle relaxation, distraction, positive
emotions, sedation, and autonomic modulation. When these
interventions were used for postoperative pain, participants
reported responses of distraction and relaxation (Good,
Anderson, Ahn, Cong, & Stanton-Hicks, 2005; Good et al.,
1999). Positive emotional valence was recently demonstrated
to result in less pain when pleasant music was compared with
unpleasant music. Relief was related to self-reports of pleasant-
ness (Roy, Peretz, & Rainville, 2008). Music also improved
nighttime sleep quality in older adults (Lai & Good, 2006),
whereas relaxation and/or music modulated the autonomic
nervous system indicators of lower heart and respiratory rates
(Benson, 1975), even after surgery (Good et al., 1999, Tse,
Chan, & Benzie, 2005).
The combination of relaxation and music reported here
was started on the day of surgery. Previous studies of the early
postoperative period showed that music alone reduced pain
and opioid intake in two investigations (Ebneshahidi &
Mohseni, 2008; Nilsson, Unosson, & Rawal, 2005) but did
not reduce pain in two others (Heiser, Chiles, Fudge, &
Gray, 1997; Reza, Ali, Saeed, Abul-Qasim, & Reza, 2007).
Studies of the effect of the combination of RM on pain on
the day of surgery were not found.
In the theory of Good and Moore (1996), PT plus
nonpharmacological methods are proposed to result in less
pain in patients who also receive analgesics. This theory
guided the choice of the interventions that had differing
mechanisms for relief. PT was expected to increase opioid
intake via PCA usage, whereas RM was expected to invoke
the relaxation response and enhance a natural analgesic ef-
fect via increased parasympathetic activity and endogenous
inhibitory mechanisms (Benson, 1975; Good et al., 1999,
2005). We tested and compared the effects of PT and RM
immediately after listening to the taped intervention. We
secondarily tested for indications of effects at regular times
during the day. This was expected to lead to future studies
that would extend the theory to include duration of effects.
Primary hypotheses were the following: (a) Patients who
received audiotaped PT would have significantly less imme-
diate pain than would those who did not, and (b) patients
who received taped RM would have significantly less
immediate pain than would those who did not. Secondary
hypotheses were the following: (a) Patients who received
taped PT would have significantly less nonimmediate pain
than would those who did not, and (b) patients who received
taped RM would have significantly less nonimmediate pain
than would those who did not. In addition, modifying effects
of age, race, gender, and type of surgery were examined.
Method
An experimental 2 2 factorial design with pretests and
posttests was used to study patients in a tertiary care medical
center in a large Midwestern U.S. city over a period of 37
months (2002Y2005). Patients were assigned randomly via
minimization to four groups: PT, RM, combination of the
two (PTRM), and control. The minimization (via a comput-
erized program; Zeller, Good, Anderson, & Zeller, 1997)
was designed to balance groups according to gender, type of
surgery, chronic pain, race, smoking, and alcohol use. The ex-
perimental interventions were given in addition to standard-
care PCA with instruction and reinforcement. Patients were
encouraged to use PCA freely. To sample effects at dif-
ferent regular time points during postoperative recovery,
tests were scheduled in the morning and afternoon on the
first 2 days.
Sample
Patients aged 18 to 75 years scheduled for major abdominal
surgery were selected. Purposive sample selection was used to
increase the numbers of men, Blacks, and persons with
intestinal and urological surgeries to improve generalizability
over that in the previous study. The sample size was
calculated by power analysis, based on a power of .80, alpha
of .05, and an effect size (ES) of .21, which was the effect of
RM on pain sensation in a previous study (Good et al.,
1999). Allowing also for 12% attrition and a 9% refusal
rate resulted in a targeted minimum sample size of 452. The
actual number recruited was 621, and the analysis sample
size was 517. Included were patients who were expected to
receive PCA, cognitively intact, and able to hear and speak
English; small surgeries were excluded.
Interventions
The interventions were introduced before surgery, and 20-
min tests were on the day of surgery, after transfer to the
postsurgical nursing unit, and at 10 a.m. on Days 1 and 2.
The PT, RM, and PTRM interventions were recorded on 5- to
10-min introductory audiotapes used before surgery and 60-
min intervention tapes used postoperatively. On the basis of
the theory (Good & Moore, 1996), research (Good et al.,
1999), and acute pain clinical guidelines (Gordon et al.,
2005), the content of PT included sensory information and
information on reporting pain, obtaining medication, pre-
venting pain, managing pain during activity, modifying atti-
tudes, and participating in pain management. The audiotape
was pretested with 8 healthy adults of different ages,
cultures, and educational backgrounds. All said that they
260 Patient Teaching With Relaxation and Music Nursing Research July/August 2010 Vol 59, No 4
Copyright @ 20 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.10
learned new information that would be helpful if they were
having surgery. The tape was then pretested with 6 patients
following abdominal surgery. All said that it reflected their
experiences of pain and PCA use. They wished that they had
been given similar guidance before and after surgery. Their
suggestions were included in the script.
The RM consisted of a jaw relaxation technique with a
choice of sedative music in the background (Good et al.,
1999). The introductory tape was used to teach jaw relaxa-
tion: Relax the jaw, tongue, and lips; breathe slowly; and stop
thinking words (Good et al., 1999). Participants also heard
brief samples of six types of music and were asked to choose
music they thought would be relaxing or distracting after
surgery. Soft music was chosen from the following types:
synthesizer, harp, piano, orchestra, slow jazz, and inspira-
tional music. All music selections were chosen for quiet and
peaceful qualities. Selections were without lyrics and relaxing
or sedative in nature, which Gaston (1951) reported as having
a sustained melodic quality, a rate of 60Y80 beats per minute
(bpm), and a general absence of strong rhythms, volume, or
percussion.
For this study, a new inspirational music tape that
included (Catholic, Protestant, Jewish, and nondenomina-
tional) music was selected by a music therapist and added,
based on participant suggestions at the end of the previous
study (Good et al., 1999). The 1-min relaxation technique
was repeated twice on each 30-min side of the intervention
tape that was mainly music. In the PTRM group, the
preoperative introductory tape first presented PT, followed
by jaw relaxation, and then the music choices. The post-
operative PTRM tape consisted of 5 min of PT followed by
25minofRMoneachside.
For all treatment groups, the postoperative tape was
played in a quiet atmosphere, with television and telephone
turned off and curtains drawn; the research nurse stayed
outside the room, and a sign was posted to prevent people
from entering. After the first test on the day of surgery, the
tape was left at the bedside with a tape recorder and a remote
control. Participants were encouraged to use it as much as
possible that evening and during the first 2 days, with
reminders four times a day. For variety, those in the RM and
PTRM groups could change to another type of music because
similar effects on pain had been found (Good et al., 1999).
All groups received standard care: PCA plus intramuscular
or intravenous opioids as needed per surgeon’s order with
progression to an oral combined opioid and nonopioid
analgesic as needed. The groupsdidnotdifferinPCAdoses
and lockout times. Those in the control group received the
same attention and measures and were asked to lie quietly for
20 min during tests but did not receive a tape.
It was not feasible for the research nurses and participants
to be blinded to the assigned intervention. However, to
prevent rivalry and diffusion of treatments, all participants
consented to be assigned randomly to a self-care intervention
in addition to analgesics. They were not told the nature of the
interventions during recruitment. After randomization, they
were told only their assigned intervention and were not aware
of the other interventions because only one participant was
assigned to each room. To prevent demoralization, the
research nurses instructed all groups to splint their incision
(press a hand on their abdomen when moving or coughing)
and told the members of the control group that this teaching
was their randomly assigned treatment (Lindquist, Wyman,
Talley, Findorff, & Gross, 2007).
Measures
Pain Pain was conceptualized as having sensory and affective
components that taken together constitute pain, the symptom
known to patients and nurses. The sensory component of
acute postoperative pain is the unpleasant, localized percep-
tion of physical hurt associated with surgical tissue damage.
The affective component of pain is the emotional distress that
accompanied the sensory component (Good et al., 2001;
Johnson, 1972). The sensory and affective components of
pain were measured separately with the Sensation and Dis-
tress of Pain Visual Analogue Scales (VAS; Good et al., 2001)
but were analyzed together as the multivariate dependent
variable, pain. Each scale consisted of a 100-mm horizontal
line with verbal anchors of no sensation and most sensation
and no distress and most distress,measuredfromtheleftin
millimeters to provide interval scores. Participants marked
the sensation scale as the amount of physical pain felt in the
surgical area and the distress scale as the amount the sen-
sations bothered them emotionally. Pain was measured for
the primary hypotheses at five pretests and posttests (im-
mediate) and for the secondary hypotheses at four additional
times each day (nonimmediate).
Construct validity of the numerical 0Y10 sensation and
distress rating scales was reported by Johnson (1972). In
postoperative patients, concurrent validity with the McGill
Pain Questionnaire was r= .44, pG.001 for sensation and
r= .55, pG.001 for distress (Good, 1995). Correlations
between the visual analogue scales and the sensation and
distress scales of Johnson ranged from .89 to .92 (Good
et al., 2001).
Opioid Intake Opioid analgesics were considered as a po-
tentially confounding variable and also as an exploratory out-
come, based on effects found in some studies (Cepeda et al.,
2006; Good, 1996). As a possible confounder, the milligrams
of PCA opioids in effect at each test were recorded from the
PCA display for the previous hour and during the test.
Milligrams of intravenous, intramuscular, and oral opioids
that were in effect at the time of the test were recorded from
the chart. As an exploratory outcome, milligrams of PCA
and nurse-given opioids for the first 24 hrs (8 P.M. on the day
of surgery to 8 P.M. Day 1) and the second 24 hrs (8 P.M.Day
1to8P.M. Day 2) were recorded from the chart. Opioids
were changed to milligrams of morphine equivalent.
Additional Measures Participants in the RM and PTRM
groups were interviewed after the study and asked how they
used the music (to distract, relax, or both), how much they
liked the music (none, a moderate amount, or a lot), and
whether the tape made them sleepy (yes or no). Research
nurses assessed autonomic nervoussystem effects by counting
radial pulse and observing respiration for 1 min before and
after each 20-min test.
Demographic variables and preoperative belief in the
effectiveness of the intervention were obtained by interview or
chart review. Length of surgery was recorded from the sur-
gical records. Incision location and direction were measured
Nursing Research July/August 2010 Vol 59, No 4 Patient Teaching With Relaxation and Music 261
Copyright @ 20 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.10
by observation; length was measured with a tape in centi-
meters. Interrater reliability for observed and chart data
was assessed for every 10th participant, with Q90% agree-
ment for each response.
Procedures
The hospital and university investigational review board ap-
proved the study. In the presurgical unit, the research nurse
screened patients for cognitive ability using the Short Port-
able Mental Status Questionnaire (Pfeiffer, 1975). Those who
scored less than intact, as adjusted for race and education,
were excluded. She also screened for hearing ability and
excluded those who were unable to hear the spoken word.
She obtained informed written consent and briefly inter-
viewed for gender, type of surgery, chronic pain, race, smok-
ing, and alcohol use and entered these into a computerized
minimization program that assigned participants randomly
to the four groups, balancing the groups on these variables.
She then told each participant the assigned intervention,
which the computer concealed from both the participants
and the research nurses until groups were assigned. She also
explained the sensation and distress of pain scales to all
participants and played the introductory intervention tape in
the treatment groups. In the RM and PTRM groups, partici-
pants were coached and given feedback and positive rein-
forcement on the technique until they were able to perform it
correctly. Those in the PT group were given positive rein-
forcement for attentiveness.
The research nurse first tested the interventions on the day
of surgery soon after participants were transferred to the
postsurgical nursing unit. Pretest and posttest pain, pulse,
respiration, and milligrams of opioid received were recorded.
Those who received PT listened to the 5-min tape and then
rested quietly for 15 min; those who received RM listened to
the relaxation technique accompanied by their chosen type of
music for 20 min; those who received PTRM listened to a
tape for 20 min that contained PT followed by RM; and those
in the control group rested quietly during that time. The
research nurse observed whether participants receiving the
interventions were asleep at the end of the 20 min. If asleep,
they were awakened gently for posttest measures. At four
times each day (8 A.M., 12 noon, 4 P.M., and 8 P.M.),
nonimmediate pain scores were obtained. At the end of the
study on Day 3, participants were interviewed for use of the
tapes and how much they liked the music.
Data Analysis
The analysis focused primarily on the immediate effects of PT
(PT-Effects) and RM (RM-Effects) on pain and secondarily
on the nonimmediate effects. Participants who received PT
(PT and PTRM groups) were compared with those who did
not (RM and control groups). Similarly, those who received
RM (RM and PTRM groups) were compared with those who
did not (PT and control groups). The interaction, tested
whether there were different effects of PT with and without
RM (Table 1). The multivariate response variable was pain;
sensation and distress were analyzed together.
Means and standard deviations were obtained (Table 2).
Baseline variables were selected for inclusion in the model if
their correlation with dependent variables was at least .30.
Only pretest scores exceeded this level and were used as
covariates. Variables that were considered are listed in the
Results section. In all statistical tests of comparisons, the
intent-to-treat principle was followed; thus, all available
patients randomized to each group were used in each analy-
sis. The level of significance was set at .05, one-tailed, and the
family-wise error rate over the five time points was corrected
by using a sequentially rejective Bonferroni test (Holm,
1979).
Primary Hypotheses Todeterminewhethertherewereim-
mediate PT-Effects and RM-Effects on pain at each time point,
multivariate analysis of covariance was used with a priori
contrasts (Table 1) while controlling for pretests. The full
model including the interaction was analyzed, and the
interaction effect was tested for significance. When a
significant interaction was not found, the model was run
on the main effects without the interaction (Table 3). In-
teractions were examined between treatment and age, race,
gender, and type of surgery. In addition, post hoc tests were
performed to assess pairwise group differences; that is,
whether the PT and RM groups were different from the
control group that received usual care and whether each in-
dividual intervention (PT or RM) differed from the combi-
nation (PTRM; Table 4). Being exploratory, these tests were
conductedevenintheabsenceofasignificant interaction and
without adjustment for multiple tests.
Secondary Hypotheses To determine whether there were
nonimmediate PT-Effects and RM-Effects on pain, multi-
variate analysis of variance was used with the same a priori
contrasts on pain at 8 A.M., 12 noon, 4 P.M., and 8 P.M. each
day. The interaction of PT-Effects and RM-Effects was tested
at each point.
Explorations Effects on posttest pulse and respiration rates
were explored using the multivariate analysis of covariance
and contrasts while controlling for pretest rates. Effects on
24-hr opioid intake were explored also using ttests, with the
expectation that RM would decrease and PT would increase
it. The RM and the PT group were each compared with the
control group on milligrams of morphine equivalent
received during the first and second 24-hr periods.
Results
There were 517 patients in the final sample after 104 patients
(17%) without any data after surgery were removed; 83 of
these no longer qualified for the study after surgery because
of unexpected epidural analgesia, a changed surgery date,
q
TABLE 1. Contrasts
Effect Contrast
PT-Effect (PT + PTRM) j(RM + control)
RM-Effect (RM + PTRM) j(PT + control)
Interaction (PTRM jRM) j(PT jcontrol)
Note. PT = patient teaching for pain management; RM = relaxation and
music; PTRM = combination.
262 Patient Teaching With Relaxation and Music Nursing Research July/August 2010 Vol 59, No 4
Copyright @ 20 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.10
cancelled surgery, or illness, and 21 withdrew (PT = 8, RM =
6, PTRM = 7, control = 0). Reasons for withdrawal included
not feeling well, not wanting to be bothered, not wanting
to use the taped intervention (PT = 5, RM = 2, PTRM = 4),
and no reason. The groups were similar in size: PT (n= 129,
25%), RM (n= 132, 26%), PTRM (n= 129, 25%), control
(n= 127, 25%), #
2
(3, 517) = 0.099, p= .99 (Figure 1).
Three fourths of the final sample (n= 389, 75%)
missed at least one test, and nearly half (n= 241, 47%)
missed more than one test. At each time point, those who
missedatestwereaskedtoindicatethemainreason,andre-
sponses were aggregated into nine reasons. Response fre-
quencies did not differ between time points for four of the
reasons: adverse symptoms, too much pain, unwillingness
to use the assigned intervention, and miscellaneous. Re-
sponse frequencies differed significantly between time points
for five of the reasons: sleeping for long periods (day of
surgery), absence from the unit (Day 1 A.M.), desire to be
with visitors (Day 1 P.M.andDay2P.M.), early discharge,
andnoreason(Day2P.M.). Across the five tests, the num-
ber of participants who indicated unwillingness to use the
assigned intervention as a reason for missing a test ranged
from 3 to 7 for PT, 1 to 3 for RM, and 1 to 2 for PTRM.
Sixty-eight percent of the final sample were women (n=
353), and the mean age was 48.67 years (SD = 12.11 years,
range = 19Y75 years); 69% reported their race as White
(n= 355), 28% were Black or African American (n= 145),
0.2% were Asian, 0.2% were Hispanic or Latino ethnicity,
and 3% reported two or more racial categories (n= 16).
The majority were married (54%), had 1 year of college
education or more (68%), were employed part-time or full-
time (70%), and earned less than $60,000 a year (38%).
q
TABLE 2. Sample Means and Standard Deviations of Immediate Sensation and Distress Scores
by Group
Data points PT RM PTRM C
Day of surgery n=82 n=95 n=86 n= 103
Sensation pre 62.5 (25.6) 62.1 (24.1) 60.2 (23.7) 57.1 (27.4)
Sensation post 48.6 (24.4) 48.5 (25.2) 47.6 (23.1) 48.9 (26.9)
Distress pre 44.6 (29.3) 47.1 (27.9) 45.8 (28.5) 46.4 (33.0)
Distress post 38.0 (27.4) 36.6 (29.2) 34.3 (24.7) 37.5 (29.5)
Day 1 A.M.n=98 n=96 n=101 n= 103
Sensation pre 38.8 (24.5) 45.2 (22.3) 46.6 (25.0) 45.7 (25.2)
Sensation post 37.0 (26.1) 32.5 (21.8) 32.4 (23.1) 36.4 (25.3)
Distress pre 36.5 (27.6) 37.3 (26.3) 36.5 (30.3) 36.6 (26.4)
Distress post 34.4 (28.1) 21.3 (19.1) 22.2 (24.8) 29.4 (27.4)
Day 1 P.M.n=85 n=93 n=88 n= 106
Sensation pre 36.5 (24.7) 39.8 (24.3) 35.7 (22.7) 39.3 (24.6)
Sensation post 32.8 (27.5) 30.3 (23.6) 26.9 (23.6) 28.6 (22.0)
Distress pre 33.7 (28.0) 33.5 (26.6) 26.5 (23.0) 31.6 (23.4)
Distress post 29.7 (27.5) 22.2 (22.1) 19.8 (23.0) 24.8 (21.5)
Day 2 A.M.n=94 n=93 n=96 n=95
Sensation pre 30.9 (24.0) 33.4 (25.5) 33.2 (25.7) 29.6 (24.8)
Sensation post 24.2 (22.1) 23.0 (22.5) 22.8 (22.2) 25.3 (22.6)
Distress pre 28.6 (27.7) 28.7 (25.8) 26.3 (27.4) 24.3 (24.1)
Distress post 29.8 (2.6) 18.8 (22.4) 19.0 (22.9) 19.9 (21.3)
Day 2 P.M.n=70 n=57 n=70 n=75
Sensation pre 30.6 (26.5) 30.1 (23.0) 29.1 (23.1) 31.4 (24.8)
Sensation post 24.4 (22.6) 22.5 (21.4) 22.2 (23.1) 24.7 (22.6)
Distress pre 29.4 (28.3) 25.5 (22.4) 23.8 (23.9) 25.6 (23.4)
Distress post 22.0 (24.9) 19.4 (20.3) 17.7 (20.9) 20.5 (20.7)
Note. Values are presented as M(SD). PT = patient teaching for pain management; RM = relaxation and music; PTRM = combination; CT = control; pre = pretest;
post = posttest.
Nursing Research July/August 2010 Vol 59, No 4 Patient Teaching With Relaxation and Music 263
Copyright @ 20 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.10
Less than one fourth smoked (22%), drank alcohol (7%),
or reported chronic pain (19%). Participants underwent
major gastrointestinal (44%), gynecological (33%), or uro-
logical surgery (24%) that averaged 3 hr 5 min (SD = 1 hr,
30 min). Most had surgery previously (81%), and cancer
was found in 30% during the current surgery. Surgical in-
cisions were located in the lower abdomen (40%), upper
abdomen (29%), and across both (20%). Initial PCA de-
mand doses were M=0.87mgT0.76 mg of morphine equiv-
alent, with a lockout (when a dose was not dispensed) of
M= 9.4 min T1.68 min. Fifty-two percent had continu-
ously infused opioid and demand doses, M=0.93mg/hrT
0.84 mg/hr (see Supplemental Digital Content 1, which illus-
trates the Frequencies: Categorical Demographic and Post-
operative Variables, http://links.lww.com/NRES/A22, and
Supplemental Digital Content 2, which illustrates Frequencies:
Continuous Demographic and Postoperative Variables, http://
links.lww.com/NRES/A23).
Mean sensation and distress scores decreased over the five
tests, as would be expected after surgery. The pretest sen-
sation means were moderately severe (61 mm) on the day of
surgery, moderate on Day 1 (a.m. = 44 mm, p.m. = 38 mm),
and milder on Day 2 (a.m. = 32 mm, p.m. = 30 mm). Distress
means were 5 to 14 mm less than sensation at each point
(pG.01; Table 2).
Pretest sensation and distress were correlated with
posttests at each test (r= .65 to .77). Therefore, pretests
were used as covariates. Age, gender, education, marital
status, race (White or non-White), income, smoking,
alcohol use, chronic pain, preoperative pain, and preoper-
ative belief that the intervention would relieve pain;
number of previous surgeries; intensity of past or expected
pain sensation and distress; previous use of a relaxation
technique; type or length of surgery; PCA demand dose,
lockout, or infusion; incision location, length, or direction;
and diagnosis of cancer were not significantly different
among the groups and were not correlated with posttest
sensation or distress scores at each time point. There were
also no correlations with pain and no group differences in
milligrams of morphine equivalent in effect at the start of
or during each test.
Effects on Pain There was no evidence of immediate PT-
Effects. The first primary hypothesis, that PT would have
immediate effects on pain, was not supported. At each of
the five tests, participants who listened to the PT tapes (PT
q
TABLE 3. Estimated PT and RM Effects on Immediate Pain Sensation and Distress (
n
= 517)
Multivariate—Pain Univariate—Sensation Univariate—Distress
Contrast FdfpPartial )
2
Est Dif 95% CI pPartial )
2
Est Dif 95% CI pPartial )
2
PT-Effect
DOS 0.53 2, 361 .65 .003 1.48 j1.78, 4.73 .44 .002 0.16 j3.47, 3.80 .96 .000
D1 A.M. 1.28 2, 393 .65 .006 j1.64 j508, 1.80 .44 .002 j3.00 j6.75, 0.74 .29 .006
D1 P.M. 0.99 2, 367 .65 .005 j2.61 j6.37, 1.15 .44 .005 j2.36 j6.14, 1.42 .52 .004
D2 A.M. 0.28 2, 373 .65 .001 1.05 j2.08, 4.19 .50 .001 0.50 j2.74, 3.73 .96 .000
D2 P.M. 0.31 3, 267 .65 .002 j0.14 j3.70, 3.42 .50 .000 0.82 j2.66, 4.29 .96 .001
RM-Effect
DOS 1.39 2, 361 .50 .008 1.92 j1.32, 5.15 .21 .004 3.02 j.59, 6.62 .18 .007
D1 A.M. 16.28 2, 393 G.001*** .076 6.23 2.84, 9.62 G.001*** .032 10.47 6.85, 14.08 G.001*** .076
D1 P.M. 3.68 2, 367 .04* .020 1.30 j2.46, 5.06 .40 .001 4.40 0.64, 8.10 .05 .014
D2 A.M. 3.88 2, 373 .04* .020 3.82 0.70, 6.95 .04* .015 1.68 j1.56, 4.92 .36 .003
D2 P.M. 0.19 2, 267 .50 .001 1.13 j2.44, 4.69 .40 .001 0.88 j2.60, 4.36 .36 .001
Interaction
DOS 2.01 2, 359 .34 .011 3.95 j2.57, 10.46 .31 .004 j2.37 j9.66, 4.91 .65 .001
D1 A.M. 1.12 2, 391 .54 .006 j5.17 j11.98, 1.63 .31 .006 j4.09 j11.34, 3.15 .60 .003
D1 P.M. 1.32 2, 365 .54 .007 j5.95 j13.48, 1.59 .35 .007 j3.03 j10.58, 4.53 .65 .002
D2 A.M. 0.86 2, 371 .54 .005 1.81 j4.45, 8.07 .57 .001 3.99 j2.59, 10.38 .60 .004
D2 P.M. 0.08 2, 265 .54 .000 0.45 j6.74, 7.63 .57 .004 0.40 j6.62, 7.42 .65 .004
Note. PT = patient teaching for pain management; RM = relaxation and music; PTRM = combination; Est Dif = estimated difference; CI = confidence interval;
DOS = day of surgery, D1 = Day 1, D2 = Day 2; PT-Effect = PT group plus PTRM group compared with RM group plus control group; RM-Effect = RM group plus
PTRM group compared with PT group plus control group.
*pG.05.
**pG.01.
***pG.001; one-tailed; pvalues were adjusted for five tests using a sequentially rejective Bonferroni test (Holm, 1979).
264 Patient Teaching With Relaxation and Music Nursing Research July/August 2010 Vol 59, No 4
Copyright @ 20 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.10
and PTRM) did not have less pain than did those in the
RM and control groups, taken together. Two of the five
means were in the expected direction (PT and PTRM GRM
and control). There was no evidence of an interaction (i.e.,
differing effects of PT with and without RM; Table 3).
The RM-Effects on pain were mixed. The second primary
hypothesis, that RM would have immediate effects, was
supported partially. Immediate RM-Effects were found at
three of the five tests, Day 1 A.M., Day 1 P.M., and Day 2 A.M.
The two groups who received RM with or without PT (RM
and PTRM) had significantly less posttest pain than the pain
of those who did not use RM (PT and controls; Table 3,
Figure 2A and 2B). There were no significant differences on
the day of surgery or on Day 2 p.m., although the means
were in the expected direction (RM and PTRM GPT and
control). The RM-Effects on Day 1 A.M. resulted in 6 mm
less pain, with a medium ES, partial )
2
=.079.TheESwas
small at Day 1 P.M.andDay2A.M., each with 3 mm less
pain, partial )
2
= .02 (see Supplemental Digital Content 3,
which illustrates the Probability of Relief for Future
Cochrane Reviews, http://links.lww.com/NRES/A24). No
side effects were found for PT, RM, or PTRM.
There was no evidence of PT and RM interaction effects
(i.e., no evidence that the effect of RM on pain differed,
q
TABLE 4. Post Hoc Tests on Immediate Pain Scores (
n
= 517)
Multivariate pain Sensation Distress
Comparison FdfpFdfpFdfp
PTRM versus PT
DOS 1.81 2, 163 .08 0.02 1, 164 .45 2.18 1, 164 .07
D1 A.M. 9.38 2, 194 G.001*** 11.75 1, 195 G.001*** 18.78 1, 195 G.001***
D1 P.M. 1.62 2, 168 .10 2.24 1, 169 .07 3.24 1, 169 .04*
D2 A.M. 2.54 2, 185 .04* 1.44 1, 186 .12 0.04 1, 186 .42
D2 P.M. 0.08 2, 135 .46 0.13 1, 136 .36 0.02 1, 136 .44
PTRM versus RM
DOS 0.32 2, 176 .36 0.07 1, 177 .40 0.22 1, 177 .32
D1 A.M. 0.57 2, 192 .57 0.07 1, 193 .40 0.35 1, 193 .28
D1 P.M. 0.2 2, 176 .41 0.1 1, 177 .38 0.02 1, 177 .44
D2 A.M. 0.69 2, 184 .25 0.002 1, 185 .48 0.50 1, 185 .24
D2 P.M. 0.16 2, 122 .43 0.23 1, 123 .44 0.46 1, 123 .42
PTRM versus control
DOS 1.08 2, 184 .17 2.01 1, 185 .08 1.41 1, 185 .12
D1 A.M. 3.97 2, 199 .01* 4.11 1. 200 .02* 7.97 1, 200 .003**
D1 P.M. 1.01 2, 189 .64 0.11 1, 190 .26 0.62 1, 190 .22
D2 A.M. 3.37 2, 186 .02* 5.15 1, 187 .01* 1.16 1, 187 .14
D2 P.M. 0.24 2, 140 .39 0.12 1, 141 .14 0.46 1, 141 .25
PT versus control
DOS 2.21 2, 180 .06 2.04 1, 181 .08 0.21 1, 181 .35
D1 A.M. 2.29 2, 196 .90 3.95 1, 197 .95 4.00 1, 197 .95
D1 P.M. 2.50 2, 186 .92 5.02 1, 187 .97 2.74 1, 187 .90
D2 A.M. 0.42 2. 184 .33 0.47 1, 185 .25 0.84 1, 185 .18
D2 P.M. 0.11 2, 140 .45 0 1, 141 .49 0.11 1, 141 .32
RM versus control
DOS 1.53 2, 193 .22 3.06 1, 194 .04 0.73 1, 194 .39
D1 A.M. 7.03 2, 194 .001** 2.90 1, 195 .045* 13.60 1, 195 G.001***
D1 P.M. 2.59 2, 194 .04* 0.35 1, 195 .45 1.58 1, 195 .11
D2 A.M. 3.23 2, 183 .02* 6.40 1, 184 .006** 3.06 1, 184 .04*
D2 P.M. 0.15 2, 127 .86 0.29 1, 128 .59 0.13 1, 128 .72
Note. RM = relaxation and music; PT = patient teaching for pain management; PTRM = combination, DOS = day of surgery; D1 = Day 1; D2 = Day 2.
*pG.05.
**pG.01.
***pG.001; one-tailed; significance in this analysis is only suggestive, as pvalues were not adjusted.
Nursing Research July/August 2010 Vol 59, No 4 Patient Teaching With Relaxation and Music 265
Copyright @ 20 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.10
whether combined with PT or not). There were no interactions
between treatment and age, race, gender, or type of surgery.
When adjusted posttests were averaged, an overall RM-Effects
value was confirmed with multivariate analysis of variance,
using averaged adjusted posttest sensation and distress scores,
Wilks’ lambda F(2, 488) = 9.70, pG.001, partial )
2
= .035.
The RM and PTRM groups had 3 mm less pain on adjusted
means across five tests, compared with the PT and control
groups. There was no evidence of an overall PT-Effect or a
PT-by-RM interaction.
Post hoc tests supported the contrasts, although signifi-
cance was only suggestive. The PTRM group had less pain
compared with the PT group and also the control group on
two tests, Day 1 A.M. and Day 2 A.M., but did not differ from
the RMgroup on any test (Table 4, Figure 2). The RM group
had less pain than controls on three tests: Day 1 A.M., Day 1
P.M., and Day 2 A.M., supporting immediate RM-Effects. The
PT group did not have significantly less pain than that of the
control group on any test. Univariate results tended to
support multivariate results (Table 4).
There was no evidence for nonimmediate effects; the
secondary hypotheses were not supported. There were no
significant nonimmediate RM-Effects, PT-Effects, or inter-
action effects on pain at 8 A.M., 12 noon, 4 P.M., and 8 P.M.
each day.
Milligrams of morphine equivalent in the first 24 hr
were M=47mgT32 mg and in the second 24 hr were M=
24 mg T21 mg. Explorations indicated no significant effects
on opioid intake in the PT or the RM groups in the first or
second 24 hrs. A trend during the second 24 hrs indicated that
the PT group received a mean of 4 mg (18%) more opioid,
t(244) = 1.64, p= .05, than did the controls and pressed
the PCA button an average of 13 more times, t(70) = 1.79,
p= .04.
Additional Findings
After listening preoperatively, participants’ choices of music
in the RM and PTRM groups were jazz (33%), orchestra
(26%), inspirational (17%), piano (13%), harp (7%), and
synthesizer (4%). In the RM and PTRM groups, one third
changed music types during the 2 days: RM = 45 (34%) and
PTRM = 45 (35%). Participants in these groups reported
that they used the music in several ways: 56% used the
music to both relax and distract themselves from the pain,
24% used it only to relax, 16% used it only to distract, and
3% used neither. Of those with music, nearly all (96%)
reported that they liked their chosen music a moderate
amount to a lot. In addition, 82% reported that the music
made them sleepy. More of those in the RM and PTRM
groups (37%) were observed to be asleep after 20 min than
FIGURE 1. Intent-to-treat flow diagram showing progress through phases of the randomized trial. Sample sizes are shown for enrollment,
allocation to the intervention and control groups, follow-up, and data analysis.
266 Patient Teaching With Relaxation and Music Nursing Research July/August 2010 Vol 59, No 4
Copyright @ 20 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.10
were those in the PT group (15%). Finally, pulse and
respiration rates were significantly lower in the RM and
PTRM groups (M= 82 bpm and 16.5 rpm) than those
in the PT and control groups, M= 86 bpm and 17 rpm,
F(2, 361) = 2.60, p= .04, at the Day 1 A.M. test when there
was the most effect on pain. There were no PT-Effects on
pulse or respiration.
Discussion
The interventions with RM (RM and PTRM) resulted in
reduced pain at three important data points, but the PT
intervention used in this study (PT and PTRM) did not
supplement the RM-Effects. The PT did not result in sig-
nificantly less pain immediately after the tests or at other
time points. In addition, teaching did not result in sig-
nificantly greater 24-hr opioid intake after surgery. Al-
though the Day 2 trends in PCA attempts and opioid intake
were encouraging, morphine equivalent conversions are not
precise due to variation in drug, route of administration, and
patient factors.
The PT intervention was expected to improve knowledge
and attitudes toward taking opioids, thus reducing pain. The
failure to support PT-Effects is similar to the findings of other
recent studies in which PCA educational interventions had no
effect on pain (Chumbley et al., 2004; Lam et al., 2001;
Pellino et al., 1998). Chumbley et al. (2004) concluded that
persistent beliefs about addiction and self-efficacy, as well as
individual interpretation of information, were powerful
factors when patients were left to manage their own pain.
The PT intervention in the current study was not tailored to
patients’ changing needs postoperatively. Effective use of the
instructional PT tape may have required complex thinking
and memory at a time when patients were drowsy from the
anesthesia and opioids. Participants may have forgotten to
press the PCA button or may have been relatively passive,
confused, or lethargic, with few problem-solving skills and
low self-efficacy for using the self-care instructions (Manias
et al., 2006; Pellino et al., 1998).
The groups who heard RM (RM and PTRM) had
significantly less immediate pain compared with those with-
out RM (PT and controls) on Day 1 A.M., Day 1 P.M., and
Day 2 A.M. There was a medium ES and no differing effects
due to age, gender, race, or type of surgery. However, no
significant relief in immediate pain was found on the day of
surgery, when pain was most severe and patients were sleepy
from anesthesia. This is similar to findings of two studies
(Heiser et al., 1997; Reza et al., , 2007) and different from
two others (Ebneshahidi & Mohseni, 2008; Nilsson et al.,
2005). In addition, no relief was found on Day 2 P.M., which
was different from our previous findings (Good et al., 1999);
posttest pain scores were lower in the control group in this
study. With a more varied sample, the findings generally
support those of Good et al. (1999) with a similar ES. Post
hoc explorations suggested that the music-based groups had
less pain than that of the PT or standard care groups, but
the RM and PTRM groups were not different from each
other. This finding suggests that the music in the PTRM
group carried the PT.
Independent use of the RM-based interventions (RM and
PTRM) did not result in less pain at any of the nonimmediate
time points. There might have been no lasting effect after the
scheduled tape use at 10 A.M.and2P.M. Patients might not
have used the tapes prior to measurement, or else recent
analgesic use or painful activity may have affected pain scores
at those times. Moreover, no effect was found on 24-hr
opioid intake, which reflects the lack of agreement in the
literature (Cepeda et al., 2006; Good, 1996).
Several of the findings support mechanisms for RM.
Nearly all participants used RM to relax and distract them-
selves from the pain, suggesting a self-management mecha-
nism. In addition, sedation and sleep may be part of the
action of RM as most patients said they felt sleepy, which was
similar to previous findings of music used for sleep (Lai &
Good, 2006). The same music tapes have improved night-
time sleep quality in older adults (Lai & Good, 2006).
Emotion may have been a factor also, as nearly all par-
ticipants reported that they liked their chosen music. Liking
the music may have improved their mood and activated the
FIGURE 2. (A) Pain sensation and (B) pain distress for the four
treatment groups using posttest means adjusted for pretest scores.
DOS = Day of surgery; D1 = Day 1; D2 = Day 2; post = posttest;
RM = relaxation and music group; PT = patient teaching for pain
management group; PTRM = combination group.
Nursing Research July/August 2010 Vol 59, No 4 Patient Teaching With Relaxation and Music 267
Copyright @ 20 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.10
association between positive emotions and pain modulation
(Good et al., 2005; Roy et al, 2008). The effectiveness of pleas-
ant music on experimental pain was demonstrated recently,
while controlling for the distracting and relaxing qualities of
music (Roy et al., 2008). Further, the significant RM-Effect
(but not PT-Effect) on lower pulse and respiratory rates on
Day 1 suggests that RM had autonomic nervous system ef-
fects, along with good pain relief, which is similar to pre-
vious studies (Benson, 1975; Good et al., 1999; Tse et al., 2005).
There was no evidence that belief in the effectiveness of the
intervention was a mechanism.
Studies of both PT and RM continue to be needed to
identify the most effective doses and duration, the optimal
times to listen, and the relationships with emotion. Research-
ers of PT should examine goal setting, patient support,
coaching, self-efficacy, and more frequent measures of opioid
intake. Qualitative data are needed on patients’ knowledge,
expectations, and attitudes toward increasing their intake of
PCA opioids. In future studies of RM, researchers should use
updated equipment (e.g., MP3 players) and find ways to
measure the amount of use. RM can be compared with other
interventions, such as guided imagery. Teaching patients to
balance opioid intake with RM would introduce more self-
management elements.
Until further research is available, clinicians should
continue to use standard practice for teaching patients their
role in pain management. However, in our two large studies,
adjuvant RM resulted in less postoperative pain immediately
after the test. In the current study, RM was superior to both
the taped PT and standard pain care. Results can be
generalized to women or men, Blacks or Whites, who are
patients after gynecological, intestinal, or urological sur-
geries. Staff nurses can suggest that patients use RM along
with prescribed PCA opioids when they have significant pain.
RM u pleasant, safe, and noninvasive nursing intervention
that increases self-management of pain and provides physical
and emotional relief.
q
Accepted for publication January 12, 2010.
This study was supported by the National Institute of Nursing
Research, National Institutes of Health Grant R01 NR3933
(2001Y2005) to M. Good, PhD, FAAN, principal investigator, and
by the General Clinical Research Center, Case Western Reserve
University, currently the William T. Dahms, M.D. Clinical Research
Unit, University Hospitals, Case Medical Center, Cleveland, Ohio.
The authors thank Karen Young, Connie Bruening, Laura Bobrowski,
Mary Lawless, Lori Gyor, Carol Rovit, Shih-Tzu Huang, Yaewon Seo,
Riyad Al-Dgheim, Jennifer Schmidt, Unchalee Vealadee, Angela Chia
Chi Chang, Susannah Handley, and Patricia Wilt.
Corresponding author: Marion Good, PhD, RN, FAAN, Frances Payne
Bolton School of Nursing, Case Western Reserve University, 10900
Euclid Avenue, Cleveland, OH 44106-4904 (e-mail: mpg@case.edu).
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