Journal of Pediatric Oncology of Nursing

Music Therapy to Reduce Pain and Anxiety in Children with Cancer Undergoing Lumbar Puncture: A Randomized Clinical Trial
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Transcript    NursingJournal of Pediatric Oncology online version of this article can be found at: DOI: 10.1177/1043454209355983 2010 27: 146 Journal of Pediatric Oncology Nursing  Thanh Nhan Nguyen, Stefan Nilsson, Anna-Lena Hellström and Ann Bengtson Randomized Clinical TrialMusic Therapy to Reduce Pain and Anxiety in Children With Cancer Undergoing Lumbar Puncture: A  Published by: On behalf of:  Association of Pediatric Hematology/Oncology Nurses (APHON)  can be found at: Journal of Pediatric Oncology Nursing  Additional services and information for Email Alerts: Subscriptions: Reprints: Permissions: Citations:  at CALIFORNIA STATE UNIV FRESNO on August 2, 2010 jpo.sagepub.comDownloaded from    Journal of Pediatric Oncology Nursing27(3) 146  –155© 2010 by Association of Pediatric Hematology/Oncology NursesReprints and 10.1177/1043454209355983 Music Therapy to Reduce Pain and Anxiety in Children With Cancer Undergoing Lumbar Puncture: A Randomized Clinical Trial Thanh Nhan Nguyen, RN, MSc, 1  Stefan Nilsson, RN, MSc, 2  Anna-Lena Hellström, RN, PhD, 2  and Ann Bengtson, RNT, PhD 3 Abstract A nonpharmacological method can be an alternative or complement to analgesics. The aim of this study was to evaluate if music medicine influences pain and anxiety in children undergoing lumbar punctures. A randomized clinical trial was used in 40 children (aged 7-12 years) with leukemia, followed by interviews in 20 of these participants. The participants were randomly assigned to a music group (n =  20) or control group (n =  20). The primary outcome was pain scores and the secondary was heart rate, blood pressure, respiratory rate, and oxygen saturation measured before, during, and after the procedure. Anxiety scores were measured before and after the procedure. Interviews with open-ended questions were conducted in conjunction with the completed procedures. The results showed lower pain scores and heart and respiratory rates in the music group during and after the lumbar puncture. The anxiety scores were lower in the music group both before and after the procedure. The findings from the interviews confirmed the quantity results through descriptions of a positive experience by the children, including less pain and fear. Keywords anxiety, music, nonpharmacological therapy, pain Introduction Pain associated with medical procedures is often viewed as one of the worst experiences in children with cancer (Hedstrom, Haglund, Skolin, & von Essen, 2003; Ljungman, Gordh, Sorensen, & Kreuger, 1999). There are many differ-ent approaches in the treatment of pain from medical  procedures in children, including pharmacological and nonpharmacological methods (Windich-Biermeier, Sjoberg, Dale, Eshelman, & Guzzetta, 2007).About 250 new patients are registered per year on the Oncology Ward at the National Hospital of Paediatrics (NHP) in Hanoi, Vietnam. In 2008, 313 children with leu-kemia were offered a program that included 3½ years of    treatment. The treatment of leukemia in children involves several needle-related procedures (Jacob, Hesselgrave, Sambuco, & Hockenberry, 2007). Lumbar puncture (LP) is usually one of the most painful and distressing proce-dures associated with cancer treatment (Jacob et al., 2007). Pain that is left untreated or is poorly treated often leads to significantly prolonged changes in behavior, alterations in self-concept, fear, anxiety, and depression (Blount, Piira, Cohen, & Cheng, 2006; von Baeyer, Marche, Rocha, & Salmon, 2004). The goal of adequate  pain treatment in conjunction with these procedures is sometimes difficult to fulfill. A lack of knowledge of children’s perception of pain and illness, the use of inappropriate drug doses, and difficulties in understand-ing the value of supportive and nonpharmacological methods all contribute to widespread inadequacy in the control of pain in children with cancer (Blount et al., 2006; Weisman, Bernstein, & Schechter, 1998). Knowl-edge from clinical trials regarding nonpharmacological methods does not automatically lead to increased use in clinical practice. The nurses’ level of education and lack of time are confounding factors in many nonpharmaco-logical methods (Polkki, Laukkala, Vehvilainen-Julkunen, & Pietila, 2003). Improper application of pharmacologi-cal and nonpharmacological therapies is the main reason 1 National Hospital of Paediatrics, Hanoi, Vietnam 2 Sahlgrenska University Hospital, Gothenburg, Sweden 3 Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden Corresponding Author: Stefan Nilsson, RN, MSc, Department of Paediatric Anaesthesia and Intensive Care Unit, The Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, SE-416 85 Gothenburg, SwedenEmail:  at CALIFORNIA STATE UNIV FRESNO on August 2, 2010 jpo.sagepub.comDownloaded from   Nhan et al. 147 for inadequate procedural pain relief (Segerdahl, 2008). Pain management strategies that are easy to prepare and use for children and nurses need to be found. Costly and advanced methods will remain at a theoretic level and never reach clinical practice (Wright, Stewart, Finley, & Buffett-Jerrott, 2007). Nonpharmacological methods in  pain management are evaluated briefly in Asian countries such as Vietnam. A study of pain management conducted in China found that music was a commonly used nonphar-macological method (He, Vehvilainen-Julkunen, Polkki, & Pietila, 2007).Listening to music is one of several nonpharmacologi-cal methods to relieve pain and anxiety in both adults and children (Klassen, Liang, Tjosvold, Klassen, & Hartling, 2008; U. Nilsson, 2008). There are theories explaining its mode of action. It appears that music reduces the s-cortisol (U. Nilsson, 2009a) and also causes an increase in the levels of s-oxytocin (U. Nilsson, 2009b). A commonly accepted hypothesis is that the music acts as a distracter, focusing the patient’s attention away from negative stim-uli to something pleasant and encouraging. Various other hypotheses have been proposed to explain the mechanism  by which music reduces pain, including modification of cognitive states, moods, and emotions. Relaxation from music can also be demonstrated to be a pleasant distrac-tion that serves as a mild sedative (Balan, Bavdekar, & Jadhav, 2009). The review by Klassen et al. (2008) divides music therapy into passive and active therapy. Active music therapy requires the involvement of a music therapist so that the music can be used for interactive communication, whereas passive music therapy entails listening to music for a particular purpose, recorded or live, without the involvement of a music therapist. Listen-ing to prerecorded music has also been defined as music medicine as opposed to active music therapy (Dileo & Bradt, 2005). Previous research has found music medi-cine or passive music therapy to be as effective as active music therapy (Klassen et al., 2008). In addition, listening to music as a treatment for pain and anxiety offers poten-tial advantages of low cost, ease of provision, and safety (Cepeda, Carr, Lau, & Alvarez, 2006).To our knowledge, few studies have evaluated the effects of music in children with cancer who undergo LP. The aims of this study were to evaluate the effect and experiences of using earphones with music as the only effect with regard to pain and anxiety relief in children with leukemia who were undergoing LP. Methods Participants Between November 2007 and July 2008, children with leu-kemia, aged 7 to 12 years, who were due to undergo LP at the Oncology Ward at NHP, Hanoi, were consecutively asked to participate in the study. All of the children had undergone an LP in conjunction with their cancer at least once before. The children were not included in the study if they had any significant hearing or visual impairments or cognitive disorder. Written and oral information was given to the children and their parents. Oral informed consent was obtained from all the children and their parents and they were informed that they could interrupt their participation at any point without citing a reason for their decision. The Ethic Committee of NHP approved the study protocol and the researcher complied with the Helsinki Declaration. Self-Report Instruments Pain.  The Numeric Rating Scale (NRS) was used to measure the child’s self-reported pain during 3 distinct  phases: before, during, and after LP. The child rated the  pain intensity on a scale, with point 0 being no pain  and  point 10 being the worst pain . During the procedure, the highest recorded value was registered. The NRS is an internationally used method to measure subjective expe-riences of pain intensity in children older than the age of 6 years. Self-reported NRS scores agreed with self-reported pain scores on a Faces Pain Scale in a validation study that included 150 children (aged 6-12 yers) in Thailand (Jongudomkarn, Angsupakorn, & Siripul, 2008). An advantage of the NRS is its ease and speed of use (Stinson, Kavanagh, Yamada, Gill, & Stevens, 2006).  Anxiety.  The 6-item short form of the Spielberger State-Trait Anxiety Inventory (STAI) is a validated scale (Marteau & Bekker, 1992) and was used to measure anxiety. The short STAI scale evaluated the procedure in 2 distinct phases: before and after LP. The range of the short STAI scale would be 6 to 24 points in the end, with 6 points signifying no anxiety and 24 points signifying the highest level of anxiety. Design and Procedure The study design was a randomized clinical trial followed  by interviews with open-ended questions. After informed consent, the children were randomized to either use ear- phones with music (music group) or earphones without music (control group). Randomization was carried out using opaque envelopes, half of which contained a paper that said “music” and half a paper that said “no music.” The children in the music group chose songs they liked to  be played into earphones from an iPod®, that is, a porta- ble music player with earphones. In the control group, earphones without music were used. All the children were given identical preprocedural information about the  procedures and the study. The children were instructed on how to use the iPod ®  before entering the procedure at CALIFORNIA STATE UNIV FRESNO on August 2, 2010 jpo.sagepub.comDownloaded from   148  Journal of Pediatric Oncology Nursing 27(3) room. The researcher and the physician did not know to which group the patient belonged.In the investigation room, the child put on the ear- phones and did or did not listen to music, according to his or her group, 10 minutes before the LP procedure started. At the same time, the physician and nurses washed their hands and prepared the chemotherapy. Apart from the child, the parent, physician, and nurse were present in the room during the procedure.Data collection started immediately before the proce-dures. Heart rate (HR), blood pressure (BP), and oxygen saturation (SpO 2 ) were recorded, and the respiratory rate (RR) was measured manually by the researcher. The pain scores (NRS) and the anxiety scores (short STAI) were also recorded before the LP. The NRS, HR, BP, RR, and SpO 2  were monitored and recorded throughout the proce-dure, with the children listening or not listening to music according to their groups. Directly after the procedure had finished, the procedure (the administration of the short STAI after the LP was finished) was repeated with the short STAI scale. No local anesthetics or other anal-gesics were administrated during the procedure. This  pain management met the standard care offered to chil-dren in most of the hospitals in Vietnam. Interviews 10 children in each group were chosen consecutively according to a predetermined schedule. The interviews were carried out after informed consent and in connection with the completion of the LP procedure to avoid the impact of memory bias.The interview guide included 3 open-ended questions: “Please tell me about your feelings right now,” “Please describe your emotions, feelings and thoughts when you were using the earphones,” and “Would you like to have earphones with music next time, why or why not?”In addition, the researcher asked supportive questions such as the following: “Can you explain, tell me more about this?” The children’s answers were quoted verbatim. Data Analysis A post hoc power analysis was performed for pain during the LP procedure and the Cohen’s effect size calculated. In this study, an effect size above 0.5 was needed for a sufficient result with clinical significance. An effect size of 1.49 and a power of 0.99 were calculated for a sample size of 20 participants in each group. This result reached a sufficient number of participants. The assumption was also supported by another study in this area that recom-mended a clinical difference for a new treatment of 13 to 18 mm on a visual analogue scale (0-100 mm; Heden, von Essen, Frykholm, & Ljungman, 2009). All the data in this study are presented as descriptive statistics and cal-culated using nonparametric statistics. The c 2  test was used for categorical data, and the Mann–Whitney U   test was used to compare data between 2 groups, that is, pain scores, HR, BP, RR, SpO 2 , and anxiety scores, as well as to compare age and the total duration of the music.The interviews with the children were read and ana-lyzed using qualitative content analysis (Krippendorff, 2004). The interviews were transferred to one text. The text was read and reread until a sense of the whole was obtained. The meaning units relating to the aim of the study were condensed, extracted, and coded. After the  processes of coding and decoding, subcategories were identified and divided into categories (Table 1). The Table 1.  The Analysis Process From the Condensed Meaning Units of the Text, Codes, Subcategories and CategoriesCondensed Meaning UnitI felt calmer than last time. Last time, I had to hold my mother’s hand very tightly during the lumbar punctureI liked these songs very much. I felt very calmI was very afraid of pain... I just wanted to go home. I didn’t want to be injected any moreI was very worried about the result of the treatment. I was afraid of an unsuccessful treatmentI felt less pain than last timeI felt a lot of pain, here . . . [showed the place that was injected. Crying] . . . I can’t explainI liked listening to the music. Music helps me to stay calm and feel less pain. I like the song: “Count the fingers” a lotI just focused on the music . . . it helped. I liked listening to the music. Effective if I can listen to the music that I like. Feel happier, more comfortable and less painCodeLess afraid Felt calmWanted to go home Worried about the treatmentLess painfulThe place that was injectedLiked the song Focused on the musicLiked listening to the musicEffectiveSubcategoryCalm and relaxed Fear and anxiety Specific pain Liked listening Focused on the musicCategoryFeelings of fear Feelings of pain Enjoyment of music  at CALIFORNIA STATE UNIV FRESNO on August 2, 2010 jpo.sagepub.comDownloaded from 
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