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Developing An Evidence Based Study Into Postoperative Pain Nursing Essay

In spite of recent advances in pain management, postoperative pain still remains a major clinical problem (Gilmartin and Wright, 2007; Manias et al., 2005; Singer et al., 2010) with about 69% of patients experiencing moderate to severe pain after surgery (Apfelbaum et al., 2003).

Postoperative pain, although expected is an undesirable experience after surgery (Good, 1995; Rosenquist and Rosenberg, 2003). When left untreated or inadequately managed, it can negatively affect an individual’s physical, psychological and social well being (Vaughn, Wichowski and Bosworth, 2007). Thus, it generates additional responsibilities for the healthcare provider (Wilmore and Kehlet, 2001) as well as creating economic difficulties for one’s family, society and the nation at large (Vaughn et al., 2007).

Pharmacological interventions have been used as the mainstay in the management of postoperative pain (Dolin, 2002). However, these interventions are not without undesirable effects such as nausea, vomiting, dizziness, drowsiness and allergic reactions (Koch et al., 1998). Analgesic techniques for perioperative pain relief are therefore, being challenged by an ever-increasing demand for complementary and holistic therapies (McCaffrey and Locsin, 2002). Thus, several non-drug techniques can be used as adjuncts in managing postoperative pain (Good et al., 2005).

The use of music as a nonpharmacological technique has prompted various research studies in the area of postoperative pain management (Ikonomidou et al., 2004). Resultantly, several studies have been published on this issue; hitherto, these have produced contradictory findings (Anderson et al., 2005; Good et al., 2001, 2002, 2005; Heiser et al., 1997; Heitz et al., 1992; Ikonomidou et al., 2004; Nilsson et al., 2001, 2003; Taylor et al., 1998).

In an attempt to find solutions to the efficiency of music as a pain management intervention, an increasing number of systematic reviews (Cepeda et al., 2006; Dunn, 2004; Engwall and Duppils, 2009; Evans, 2002; Nilsson, 2008) have been published during the past years. Nonetheless, the conclusions from these studies may be questionable for various reasons such as poor methodological quality of included studies, limited search strategies, inclusion of studies from only developed countries and being outdated.

With the evolvement of recent studies (Allred, Boyers and Sole, 2009; Cooke et al., 2010; Ebneshahidi and Mohseni, 2008; Good and Ahn, 2008; Hook, Sonwathana and Petpichetchian, 2008; Sen et al., 2009) which continuously report conflicting findings and the flaws identified in previous reviews, this issue needs to be addressed in a more rigorous manner.

The aim of this dissertation is to ascertain the efficacy of music as a postoperative pain management intervention by systematically reviewing the available literature. With the aid of the evidence from already existing literature, this dissertation will commence with the rationale for the proposed systematic review and justification of the review question. In the subsequent chapter, the systematic review methodology will be explored together with the justification for the main decisions of the review. Following this, the results of the proposed review will be presented in the next section. This will be followed by discussions and conclusions on the review. Finally, I will reflect on the learning achieved through the systematic review process and the implications of the study findings for clinical practice, research and education.

Literature Review

A review of the literature identifies the trends, strengths and limitations of the methodological approaches of a study (Dunn, 2004). Thus, it provides an orientation to the known and unknown aspects of a subject area (Blaxter et al., 1996; Parahoo, 1997; Polit et al., 2001) and directs future studies (Stevens, 1993).

In this section, the rationale and justification of the review question will be provided following the background information and literature on the use of music in managing postoperative pain.

Epidemiology of Postoperative Pain

It has been estimated that more than 73 million surgeries are per­formed every year in the United States (Apfelbaum et al., 2003). Apparently, the tissue damage and trauma caused during surgery results in acute postoperative pain which may vary in intensity from mild to excruciating pain (Hutchison, 2007).

Recent studies indicate that effective pain management remains elusive for a significant proportion of surgical patients (Dolin, Cashman and Bland, 2002; Svensson, Sjostrom and Haljamae, 2000; Werner et al., 2002). Many of them continue to experience unrelieved postoperative pain (Backstrom and Rawal, 2008) despite years of research into pain and its management (Botti, Bucknall and Manias, 2004; Hutchison, 2007). This may be partly due to the insufficient training received by healthcare professionals on pain management (American Medical Association, 2010). In addition, many patients have accepted the notion that acute postoperative pain is to be expected during hospitalisation. Thus, the resultant effect is the widespread poor management of postoperative pain (Warfield and Kahn, 1995).

The ineffective management of postoperative pain has been highlighted in the literature (Abbott et al., 1992; Bostrom et al 1997; Donovan et al. 1987). A survey conducted by Oates et al. (1994) revealed that 34% of the 206 patients experienced moderate to severe pain postoperatively. Conclusions from the National Health and Medical Research Council’s (1999) report also depicted that about 75% of patients experienced moderate to severe postoperative pain. An inquiry made by Watt-Watson and colleagues also showed that 51% of 225 postoperative patients following cardiac surgery reported of severe pain (Watt-Watson et al., 2000). Moreover, a random national study conducted by Apfelbaum and co-workers illustrated that out of the 80% of patients who reported of postoperative pain, 86% of them were experiencing moderate to severe pain (Apfelbaum et al., 2003). All these continuous reports of moderate to severe postoperative pain draw attention to the inadequacies in pain management (McCaffery & Ferrell, 1997). This is because patients often underestimate their pain due to their high expectations regarding postoperative pain experience (Hutchison, 2007).

Some clinicians and patients also have misconceptions about the use of opioid analgesics which contribute to the inadequate postoperative pain management (McCaffery and Ferrell, 1991). Other factors also include the type of surgery (Rai, 1993), patient’s gender, age, preoperative pain and psychological factors (Bisgaard et al., 2001; Edwards et al., 2004; Granot and Ferber, 2005).

Potentially, technical difficulties with intravenous (I.V.) access lines and patient-controlled analgesia (PCA) devices also serve as contributory factors (Wickstrom, Nordberg and Johansson, 2005). Pharmacokinetic and pharmaco­dynamic factors may also affect postoperative analgesia (). *A meta-analysis comparing the incidence of pain following three analgesic techniques: I.M. analgesia, PCA, and epidural anal­gesia after surgery was conducted by Dolin et al. (2002). Data stratification based on the drug administration route revealed that the pro­portion of patients with moderate-to-severe postoperative pain was highest in I.M. opioid administration group while this was lowest in the epidural opioid group.

In recent times, pain management is gaining increasing attention among healthcare providers and professional bodies (Hutchison, 2007). Thus, January 1, 2001 was declared during a United States congress as the commencement of a “decade of pain control and research” (American Academy of Pain Medicine, 2010). Furthermore, the Ameri­can Pain Society (APS) presently urges clinicians to consider pain as “the fifth vital sign” (Loeser, 2003). This initiative has stimulated more interest and attention to the management of pain. As a consequence of that, several professional and regulatory bodies have recently produced guidelines for managing postoperative pain (American Society of Anaesthesiologists, 2004; American Pain Society, 2003; European As­sociation of Urology, 2003; Veterans Health Administration and Department of Defense, 2002; Joint Commis­sion on Accreditation of Healthcare Organisations, 2001).

Definition of Postoperative Pain

The concept of pain has been a subject for discussion since antiquity. A universally accepted definition of pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage described in terms of such damage” (IASP, 1979: 250). This definition emphasises on the subjective nature of the pain experience which can be influenced by multiple factors (IASP, 2003). As a result of this, McCaffery (1983: 14) defines pain as “whatever the experiencing person says it is, existing whenever she says it does”.

Postoperative pain is thus, defined as an acute form of pain which is experienced after surgery (Fine and Portenoy, 2007).

Impact of Inadequate Postoperative Pain Relief

Unrelieved postoperative pain can be detrimental to the physiological, psychological and sociological health of patients (Reyes-Gibby, 2002; Strassels, 2000; Vaughn et al., 2007). These negative consequences are derived from various body systems such as the cardiovascular, respiratory, gastrointestinal, renal, neuroendocrine and the autonomic nervous systems (Duggleby and Lander, 2004; Tulay, 2010).

Physically, longer periods of unrelieved postoperative pain can result in physiologic alterations which include the stimulation of the pituitary-adrenal system (Yeager et al., 1987), sympathetic nervous system (Pasero, Paice and McCaffery, 1999) and restricted mobility (Yeager et al., 1987; Murray, 1990) which may result in cardiovascular, gastrointestinal and renal changes (Puntillo and Weiss, 1994; McCaffery and Pasero, 1999). All these changes in a postoperative may serve as a risk factor for the development of adverse effects such as deep vein thrombosis, pul­monary embolism, pneu­monia (APMGP, 1992), coronary ischaemia, myocardial infarction (APMGP, 1992; Jacox et al., 1994; Puntillo and Weiss, 1994; Staats, 1998; McCaffery and Pasero, 1999), reduced immunity (Ikonomidou et al., 2004), poor wound healing (Shang and Gan, 2003) and chronic pain. Psychologically, unrelieved postoperative pain may result in stress, anxiety, depression and demoralisa­tion (Murray, 1990).

In addition, the undertreatment of postoperative pain has potential negative consequences for health systems (Hutchison, 2007). This includes extended periods of hospitalisation (Heiser et al, 1997; Miaskowski, 1993), readmissions (Ikonomidou et al., 2004) and patient dissatisfaction (Shang, 2003). As a result of this, additional responsibilities are placed on the healthcare provider which may lead to staff exhaustion and its resultant sick leaves (Wilmore and Kehlet, 2001). Subsequently, these may increase the overall costs of hospitalisation and place health systems at a disadvantaged position, especially in today’s competi­tive healthcare environment (Henry, 1995). Ultimately, these negative consequences have a enormous impact on the patient’s family, society and the nation at large (Vaughn et al., 2007).

Pain Management

The importance of addressing the complex issues of pain management cannot be overemphasized (Botti, Bucknall and Manias, 2004). Apart from reducing unnecessary suffering, effective pain control improves patient outcomes (Wasylak et al., 1990; Watwill, 1989; Sydow, 1989) and enhances their quality of life (Goudas, 2001; Reyes-Gibby, Aday and Cleeland, 2002; Rogers et al., 2000a; Rogers et al., 2000b; Strassels, Cynn and Carr, 2000). It is generally accepted that needless suffering from pain in any patient is unethical (Söderhamn and Idwall, 2003) and illustrates a betrayal of the healthcare professional’s commitment to serve humanity (Ikonomidou et al., 2004). This is because patients are entitled to good quality care (Rawal, 1999; Idwall, 2004). Important goals for postoperative pain management are therefore to promote comfort, quicken recovery and avoid complications (Ready and Edwards, 1992).

Pharmacological interventions have been used as the mainstay in managing postoperative pain (Dolin, 2002). Nevertheless, these interventions are not without unwanted adverse effects such as nausea, vomiting, dizziness, drowsiness, and allergic reactions (Koch et al., 1998). Thus, nonpharmacological methods have been used as adjuncts in the treatment of postoperative pain (Ready and Edwards, 1992).

*Combining pharmacologic and nonpharmacologic methods of pain provides effective pain relief for the patient (McCaffery, 1990). Thus, the nurse may make a significant contribution to postoperative pain management by offering the patient various non-drug techniques that can be used concurrently with analgesics (McCaffery, 1990; McCaffery and Beebe, 1989).

Nonpharmacologic interventions have been known to be valuable, simple and inexpensive adjuvants to analgesic techniques (Hyman et al., 1989). As a result, several non-drug techniques can also be used as adjuncts in managing postoperative pain (Good et al., 2005). Specifically, the use of music as a nonpharmacological technique has prompted various research studies in this area (Ikonomidou et al., 2004), leading to the publication of numerous studies (Anderson et al., 2005; Good et al., 2001, 2002, 2005; Heiser et al., 1997; Heitz et al., 1992; Nilsson et al., 2001, 2003; Taylor et al., 1998) and reviews (Cepeda et al., 2006; Dunn, 2004; Engwall and Duppils, 2009; Evans, 2002; Nilsson, 2008).

History of Music Therapy

Music, as a remedy for sickness is a prehistoric concept (Todres, 2006) that has been used to influence human health (Bunt, 1994; Nilsson, 2003; White 2000).

It is the art of listening to sounds that usually have rhythm, pitch (Funk and Wagnall, 1998), melody and harmony (Steckler, 1998). Throughout history, music has been used as an alternative therapy to promote the wellbeing of patients (Guzzetta 1988). Thus, music therapy can be defined as the act of using musical sounds to support the physical, psychological and social needs of an individual during illness or disability (Aluede, 2006; Munro and Mount, 1978). Its main goal is to promote comfort by serving as a diversionary measure from an unpleasant occurrence (Nwokenna, 2006).

Archaelogical findings reveal that the sick primitive man used music as a way of pacifying the “gods” (Henry 1995). Also, the Egyptians of 1500 BC used music to enhance their fruitfulness while the Greeks and Romans strove for human body and soul integration using music (Buckwalter, Hartsock and Gaffney, 1985). Thus, Apollo, the Greek god of mythology, was considered as the giver of medicine and music (Todres, 2006).

There is anecdotal evidence from contemporary writings that music was used by Hippocrates to promote wellbeing (Storr, 1994). The sixth century Greek philosopher, Pythagoras, who is considered as the founder of music therapy and geometry, believed that music greatly influenced human health (Olson 1998). As a result, he often prescribed music and diet to reinstate and sustain the integration human body and soul (Bunt, 2001; White 2001).

Also, it was demonstrated by the Renaissance movement group that different types of music affected digestion, blood pressure, respiratory and heart rates (Cook, 1986). In a nameless article that appeared in the Columbian Magazine in 1789, a case was made for the use of musical experiences to influence and regulate emotional conditions (White 2000). Subsequently, a book entitled “the influence of music on health and life”, which describes the use of music in healing, was written by Chomat in 1846 (Biley, 2000).

From a nursing perspective, music has been used to promote patients’ health and well-being (Chlan, 2002). In the early 1800s, Florence Nightingale noticed the power of music as a vital part of the healing process for injured Crimean soldiers (Nightingale, 1992). After observing different types of music, she remarked that wind instruments with continuous sound or air created a positive effect on patients while those that lacked continuous harmony produced negative effects (Nightingale 1992, McCaffrey and Locsin 2002). Nightingale believed that, it was the nurse’s responsibility to control the environment for healing to take place (Nilsson, 2003; White, 2001; McCaffrey and Locsin, 2002; Nightingale, 1992).

After the invention of the phonograph in the late 1800s, recorded music was used in hospitals to promote sleep and relieve perioperative anxiety (Taylor, 1981). An extensive account of this occurred when healthcare professionals concurrently used music with analgesia and anaesthesia (ibid).

In 1914, music was used for the first time in the intraoperative environment to distract patients from the “horror of surgery” (Kane, 1914: p.1829). Afterwards, the National Association for Music in Hospitals was established in 1926 by a nurse named, Isa Maud Ilsen (Ilsen, 1926). After identifying rhythm as the basic therapeutic element, she advocated for the implementation of specific musical prescriptions (Ilsen 1926).

An extensive study on music was made by Hunter, in 1892, after playing a piano in the Helensburg Hospital, Scotland. He noticed that there was a reduction in the patient’s report of pain and temperature following musical exposure (Hunter, 1892). An observation made by Coring (1899) and Tarchanoff (1903) also revealed that different types of music had an effect on the patient’s heart rate, respiration and bodily secretions (Light et al 1949). Also, a group of surgeons in 1949 studied the use of music together with psychosomatic factors. They discovered that music had a calming effect on those patients who were anxious and unresponsive to routine medication (ibid).

With the advent of the technological advancements of the twentieth century, the link between health and music declined (Heitz, Symreng and Scamman, 1992). However, there has been an upsurge interest in music therapy due to its prominence in pain management (McCaffery, 1979) Thus, it is considered as a vital aspect of the nursing discipline (Paterson and Zderad, 1988).

The Analgesic Properties of Music

The mechanism by which music affects pain responses appears to be as varied as the research paradigms (Pricket and Standley, 1994). Music has been shown to affect the physical, emotional, cognitive and social aspects of the pain experience (Todres, 2006). *Thus, the question is: how does music exert its analgesic properties? In the search for answers to this query, various theories and hypotheses have been proposed (Gagner-Tjellesen et al., 2001).

The auditory stimulation of music produces a biological effect on human behaviour by engaging specific brain functions (Thaut 1990). The effect of music is perceived in the right hemisphere of the brain (Thaut 1990, Liégeois-Chauvel et al., 1998, Myskaja and Lindbaeck, 2000), whereas a greater portion of interpretation occurs in the left hemisphere (Thaut 1990, Myskaja and Lindbaeck, 2000).

Music stimuli serve as a distraction (Good et al., 2000; McCaffery and Good, 2000) and cause the prefrontal cortex to be conditioned to the music, which is more pleasant, (Nilsson, 2008), familiar, relaxing (Mok and Wong, 2003) and preferred (Siegele, 1974; McCaffery, 1992; Mok and Wong, 2003). Patients can thus, focus their awareness from the noxious input unto the music (Fernandes and Turk, 1989; Good et al., 1999; Willis, 1985) to aid relaxation (Beck, 1991; White, 2000; White, 2001; Thorgaard, 2005). Although patients are often in a transitional zone between consciousness and sleep during the perioperative period, the sense of hearing still persists amidst the impairment of other senses (Nilsson, 2003). As a result, music may be of immense benefit to this population.

The inhibition of the afferent noxious impulses causes the activation of *endogenous opiates, descending nerve impulses, and neuropeptides in the in the central nervous system (Andy, 1983; Yezierski et al., 1983). Subsequently, excitatory neurotransmitters such as substance P, prostaglandins, bradykinins are inhibited leading to reduced muscle and mental tension (Good, 1995; O’Callaghan, 1996; Taylor et al., 1998).

On the contrary, it has also been demonstrated that music, which is inappropriately used, can aggravate pain sensation and thus can increasing pain perception and experience (O’Callaghan, 1996).

The Ghanaian Context

Despite the fact that 3.5% of the world’s surgical operations are performed in developing countries (Weiser, Regenbogen, Thompson et al., 2008), the management of postoperative pain is poor in Ghana (Clegg-Lamptey and Hodasi, 2005; Murthy, Antwi-Kusi, Jabir et al., 2010). This may be due to factors such as inadequate knowledge, negative attitudes (Hall-Lord and Larsson, 2006), discrepancies between healthcare professionals’ and patients’ assessment of postoperative pain and the lack of relatively efficient analgesic techniques such as PCAs and epidural analgesia (Murthy et al., 2010). Moreover, the use of non-invasive, safe and cheap nonpharmacological interventions such as music is also underutilised.

Music plays a vital role in the life of an African; however, the origin of music therapy in African societies remains a puzzle due to the lack of indigenous written records (Aluede, 2006). Although, many Ghanaians love music (FGMSA, 2010), music therapy in Ghana is currently at its embryonic stage (Kofie, 2004).

Music, as the *stock-in-trade of traditional healers is used in the Ghanaian society. It accompanies their set of dances until they reach the semi-conscious state whereby they begin their communication with ancestral spirits. During this enterprise, music stimulates their ecstasy and they are being offered concoctions that may be used in healing the sick (Kofie, 2004). Music is also an effective form of therapy for patients who believe their ailments is a form of misdemeanour towards others and for that manner receiving punishment from the ancestral spirits (ibid).

Rationale for the Proposed Review

The use of music as a postoperative pain intervention has prompted various research studies (Ikonomidou et al., 2004), leading to the publication of numerous articles (Anderson et al., 2005; Good et al., 2001, 2002, 2005; Heiser et al., 1997; Heitz et al., 1992; Ikonomidou et al., 2004; Nilsson et al., 2001, 2003; Taylor et al., 1998). Nevertheless, these studies have reported mixed/ contradictory/ conflicting findings. While some show improved pain relief (Anderson et al., 2005; Good, 1999; Good et al., 2001; Good et al., 2002; Good et al., 2005; Heitz et al., 1992; Laurion and Fetzer, 2003; Masuda, Miyamoto, and Shimizu, 2005; McCraty et al., 1998; Mullooly et al., 1988; Nilsson et al., 2001; Nilsson et al., 2003), others showed no difference in pain management among study participants (Blankfield et al., 1995; Good, 1995; Heiser et al., 1997; Ikonomidou et al., 2004; Taylor et al., 1998). The approaches used in these studies have mainly been experimental, however, most of them lack strict control with various outcome measures ranging from psychological (pain, anxiety), physical (sleep) to physiological parameters (heart rate, respiratiory rate, blood pressure).

In an attempt to find solutions to the efficiency of music as a pain management intervention, an increasing number of systematic reviews (Cepeda et al., 2006; Dunn, 2004; Engwall and Duppils, 2009; Evans, 2002; Nilsson, 2008) have been published during the past years. Nonetheless, the conclusions from these studies may not be fully supported for various reasons such as poor methodological quality of included studies, limited search strategies, inclusion of studies from only developed countries and being outdated.

Evans (2002) conducted a systematic review on the efficacy of music as an intervention for hospitalised patients. This review included postoperative pain as well as pain occurring after certain procedures. Of the four eligible studies, three of them found no difference in pain scores and analgesic consumption (Blankfield et al., 1995; Good, 1995; Taylor et al., 1998) while the remaining study (Koch et al., 1998) reported a reduction in analgesic consumption among the music intervention group. On this basis, he concluded that music may be an effective diversion in treating pain. This assumption may be obstructive due to limited evidence as at that time and its resultant myopic inference.

A systematic review conducted on the efficiency of music in reducing postoperative pain (Dunn, 2004) was also inconclusive due to the poor methodological quality of the included studies. Moreover, it was also restricted to developed countries such as the United Kingdom and the United States of America. For this reason, such findings may not be applicable to other developing countries such as Ghana, where the clinical settings and management may be different.

Cepeda et al. (2006) systematically reviewed the literature on the use of music for relieving pain. This review included all types of pain ranging from acute, procedural, cancer and chronic pain. It was concluded that music listening reduces pain and analgesic consumption, but the magnitude of these effects is small and thus, had vague clinical significance. Based on this premise, it was recommended that music should not be used as a first line management option for pain. Although the conclusions are quiet reasonable, this review is outdated (Kaveh et al., 2007) due to the publication of new studies that specifically report on the use of music in patients experiencing postoperative pain.

Another systematic review (Nilsson, 2008) was also conducted on the efficacy of music in relieving postoperative pain and other parameters such as anxiety and stress. This review limited the inclusion criteria to studies conducted between 1995 and 2007. The review concluded that: approximately half of the reviewed randomised controlled trials favoured the pain reducing effects of music while the rest were not in support of this. In the light of this, the author recommended some additional studies to be conducted in this area [ibid].

A recently published article in 2009 concluded that music can be used as an adjuvant for pain relief (Engwall and Duppils, 2009). This conclusion may not be fully supported considering the fact that the review included other non-randomised controlled trials (which are subject to biases). Moreover, the review included the combined use of music with other nonpharmacological interventions (such as jaw relaxation, therapeutic suggestion, guided imagery and so on) which creates difficulties in determining whether the outcomes is solely due to music or the other interventions. The review also used few databases (Blackwell Synergy, CINAHL, PubMed and Elsevier/ Science Direct) and restricted the review to studies conducted between 1998 and 2007.

Considering the publication of new randomised controlled trials that have reported conflicting findings (Allred, Boyers and Sole, 2009; Cooke et al., 2010; Ebneshahidi and Mohseni, 2008; Good and Ahn, 2008; Hook, Sonwathana and Petpichetchian, 2008; Sen et al., 2009) and the limitations identified in previous reviews, an updated version of a systematic review conducted on this topic will be of immense benefit. My review, therefore intends to include randomised controlled trials irrespective of the location, and will include only music as the nonpharmacological pain intervention. I will also expand my search strategy to include other databases and will not limit it to any year range since music is not an intervention that becomes outmoded with time and largely depends on an individual’s preferences.

Summary

In this section the background information and literature on the use of music in relieving postoperative pain has been provided. Moreover, the rationale for the systematic has been thoroughly explained as well as the justification for the review question.

Chapter Two

Methodology

Once a research question has been shaped, it is useful to think about its type, as this will have an effect on what kind of research would provide us with the greatest quality evidence. The review question concentrates on music as a postoperative epain management intervention for patients after all kinds of surgery.

In providing the best evidence of effectiveness of an intervention, a systematic review is considered the most suitable way. This is because it summarises or draw conclusions from primary research on a specific subject, therefore increasing the number of subjects and enhancing the power to detect an intervention effect (Dickson, 2003).

This chapter will discuss the systematic review approach and evaluate its role in evidence-based practice. It then outlines the strengths and limitations of systematic reviews. Following this, a description of the procedural steps is given. Finally, the method used to conduct this review is discussed.

l

Definition of Systematic Reviews

Types of Systematic Reviews

Systematic Reviews Process

The Role of Systematic Reviews in Evidence-based Practice

In an era of evidence-based nursing, care providers need to base their clinical decisions on the preferences of patients, their clinical expertise, as well as the current best available research evidence relevant for practice (Beaven and McHugh, 2003; Mulhall, 1998; Sackett and Rosenberg, 1995).

Implications from the ever expanding volumes of healthcare literature (Beaven and McHugh, 2003) means that, it is impossible for a clinician to access, let alone understand, the primary evidence that informs practice (Glasziou, Irwig and Colditz, 2001; Handoll et al., 2008). As a result of this, useful research studies and valuable findings are concealed and abandoned as a whole (Beaven and McHugh, 2003). Systematic reviews of primary studies are therefore an essential aspect of evidence-based healthcare for practitioners who want to keep up to date with evidence in making informed clinical decisions (Lipp, 2005; Glasziou et al., 2001; Handoll et al., 2008; Schlosser/ FOCUS, 2010).

Commencing with a well-defined research question, such reviews utilise explicit methods to systematically identify, select, critically appraise, extract, analyse and synthesise data from relevant studies on a particular topic (Handoll et al., 2008; Petticrew and Roberts, 2006; Wright et al., 2007; Sackett et al., 2000). This process helps to minimise bias (Cook, Mulrow and Haynes, 1997), eliminate poorly conducted studies, confers power to the results that may not be given to individual studies (Lipp, 2005) and thus provide practitioners with reliable, valid and condensed evidence (Glasziou et al., 2001) in a considerably shorter period of time (Mulrow, Langhorne, and Grimshaw, 1997). Systematic reviews may involve the use of statistical methods (meta-analysis) (Handoll et al., 2008) in estimating the precision of treatment effects (Egger, Smith and O’Rourke, 2001).

Unlike traditional narrative reviews, systematic reviews allow for a more objective appraisal of the evidence and may thus contribute to resolving uncertainty when original research, and reviews disagree (Egger et al., 2001). By using an efficient scientific technique, systematic reviews also can counteract the need for further research studies and stimulate the timelier implementation of findings into practice (Lipp, 2005). They can also inform the research agenda by identifying gaps in the evidence and generating research questions that will shape future research (Eagly and Wood, 1994; Handoll et al., 2008; Lipp, 2005).

In spite of the numerous benefits of systematic reviews, they are not without challenges. Apart from being laborious (Petticrew & Roberts, 2006), they require expertise in the subject matter as well as the review process (Manchikanti, 2008).

SR Process

Search strategy

Inclusion and Exclusion Criteria

Data Extraction

Critical Appraisal

Aim and Objectives

The aim of this systematic review is to ascertain the efficacy of music as a postoperative pain management intervention.

Specific objectives are:

To examine the influence of listening to music (compared to no music) on postoperative pain.

To assess the efficacy of the combined use of music and standard treatment (use of analgesics and other routine postoperative care) compared to standard treatment in managing postoperative pain.

Justification of the Review Question

A good systematic review is based on a well-defined, answerable question. By so doing, it guides the scope of the review and assists the practitioner to assess its relevance in one’s own clinical practice (Counsell, 1997).

As a general nurse whose interest lies in the postoperative pain management of patients, there are many clinical questions that can be asked. Notwithstanding, I would like to conduct a systematic review on the efficiency of music in reducing postoperative pain. My reason for choice is due to the side effects of analgesics which can be minimised when alternative therapies such as music are used (Shertzer and Keck, 2001). In addition, music is an inexpensive, safe and easily accessible intervention that can be used in the clinical settings of Ghana.

Thirdly, the efficiency of music in reducing postoperative pain has not been established in the literature (Cepeda, Diaz, Hernandez et al., 1998; Good, 1996; Koch, 1998). This is due to the contradictory findings of studies conducted on this issue (Laurion and Fetzer, 2003; Nilsson, Rawal, Enqvist et al., 2003; Nilsson, Rawal and Unosson, 2003; Good, Anderson, Ahn et al., 2005; Masuda, Miyamoto and Shimizu, 2005; Heiser et al., 1997; Ikonomidou, Rehnström and Naesh, 2006).

With regards to the issues mentioned above, a systematic review on this topic will generate evidence that will assist practitioners in making informed decision. My research question is therefore: Does listening to music during the perioperative period reduce postoperative pain?

Applying the PICO framework (Richardson et al., 1995), this will entail the following:

Participants- Adult postoperative patients.

Intervention- Music.

Comparison- No music.

Outcomes- Pain (primary) and analgesic consumption (secondary).

Justification of the Main Decisions

As mentioned earlier, this impending systematic will include randomised controlled trials that have been conducted in various countries. It will include postoperative patients as the study population and music as the only nonpharmacological pain intervention. Pain intensity will be the main outcome, whereas, analgesic consumption would serve as the secondary outcome measure. The review will employ an extensive search strategy and will not limit the reviewed studies to any time period.

Randomised controlled trials have been recognised as the best available evidence due to the use of measures that limit bias (Counsell, 1997). As a result, they are more likely to produce valid evidence concerning the effectiveness of an intervention (Bhandari and Tornetta, 2008; Sackett and Wennberg, 1997; Cochrane, 1979; Schlosser and Raghavendra, 2004; Sibbald and Roland, 1998). By virtue of these qualities, a systematic review of randomised controlled trials on this topic would be regarded as Level I (Melnyk, 2004; The Joanna Briggs Institute, 2008) and will enhance the strength of recommendation (Schlosser, 2006). In order to make the findings of this review applicable to other settings, the review will not be restricted to both developed and developing countries.

The review will include postoperative due to the high prevalence of pain in this population following surgery (Gilmartin and Wright, 2007). In order to avoid any confounding factor from masking the efficiency of music as a nonpharmacological reducing postoperative pain (Cepeda et al., 2006), studies that involve hypnosis, acupuncture, guided imagery, therapeutic suggestion and relaxation will be excluded.

Many studies have utilised both unimodal (Nilsson, Rawal and Unosson, 2003; Good, Anderson, Ahn et al., 2005) and multimodal tools (Heiser et al., 1997) in assessing pain. For this reason, I will consider the assessment of pain intensity using any valid pain assessment tool. Analgesic consumption would be considered as a secondary outcome measure since it is not the best method of assessing pain (Apfelbaum et al., 2003).

In order to access large amounts of randomised controlled trials conducted on this topic, major (Cumulative Index to Nursing and Allied Health Literature, Medline, ) and minor databases (PScyINFO, EMBASE) would be used in searching for the eligible studies. In addition, reference lists of studies will serve as a useful source in finding additional studies that may be missed. Finally, the review will not be limited to any time interval since this can result in the elimination of high quality studies. Moreover, music is an intervention that becomes outmoded with time.

Some systematic reviews have been conducted on the use of music for pain management (Cepeda et al., 2006; Dunn, 2004; Engwall and Duppils, 2009; Nilsson, 2008), however, some of them were very generalised and included other types of pain such as chronic pain and procedural pain (Cepeda et al., 2006). The results of such a review may not be applicable to the perioperative setting due to the acute nature of postoperative pain (Tramer et al., 1998).

Method of the Systematic Review

This SR represents the available current best evidence on the efficacy of music as a postoperative pain management intervention in patients after various kinds of surgical operations.

It concentrates on RCTs, which generally provide the highest validity and causal inference on clinical treatment and its effectiveness (Cook et al., 1992).

A successful SR should have an appropriate, feasible and effective methodology to clearly address the review objectives (Evans, 2001).

The method used is gained/ obtained from the methodology for SRs adopted by the JBI Centre for Evidence-based Nursing and Midwifery and the Cochrane Collaboration (Hamer, 2005). Due to the various ways in which people interpret the same research, the review was conducted by peer-reviewers. In the next section, I will elaborate about the methodology, search strategy, critical appraisal, data extraction and analysis. Following this, the inclusion, exclusion and study selection criteria are also presented.

Search Strategy

The search strategy attempts to discover as many articles as possible that fit the inclusion criteria. A thorough search should be undertaken in order to encompass the widest range of relevant articles (Hopewell et al., 2002) and to reduce bias.

The three-step search strategy, as adapted from the *‘JB’ document mentioned earlier, was used to identify published studies reported in English up until July, 2010 due to time and resource limitations.

Initially, a limited search of major databases (Medline and CINAHL) was undertaken to identify keywords contained in the titles or abstracts and index terms used to describe relevant articles. A second extensive search using identified keywords and Mesh was then undertaken across all included databases. The databases used were: The Cochrane Library, CINAHL, Medline, AMED, PsycINFO, Embase, LILACS, Web of Science, The JBI, etc.

The advantages of using databases are that they are easy to use, least time-consuming and often provide abstracts which can show whether the paper is relevant ; however, this may not always be true as adequate detail may not be given (Cormack, 1994; Cormack, 1996; Smith et al., 1992). Some databases are free, different countries’ research can be viewed and specific headings can be searched. Databases save time and are more flexible when compared to hand-searching (Cormack, 1996). However, there are overlaps between databases and the search words used may miss out articles that use different terms (Hek and Langton, 2000; Dickersin et al., 1994; Smith et al., 1992). Indexes are not necessarily experts in the subject area so the indexing terms may not match the terms the searcher uses (Smith et al., 1992).

The third step was a hand-search of the reference lists and bibliographies of all potential studies to identify relevant articles. Hand searching was adopted as it is a good way because not all articles are on electronic databases, especially earlier articles (Cormack, 19945; Hopewell et al., 2002)., but the searcher is limited to those journals that can be easily obtained. Hand-searching may be prioritised in areas where the searcher expects to get results. Thus, the Journal of Pain and Symptom Management, etc were hand searched as they were particularly relevant.

Search Terms

A comprehensive search strategy was performed from February until July, 2010. Some helpful key components to use when searching include the status or disease of interest and the intervention or exposure being evaluated (Cochrane Handbook for SRs of Interventions 4.2.6, 2006). Thus, the search started by breaking down the research question into useful main components to make the search process more accurate and simple. This resulted in a list of synonyms and other related terms (see Table below).

Databases Used

Key Component

Keywords

Medline (1950-2010)

CINAHL (1982-2010)

PsycINFO (1774-2010)

EMBASE (1971-2010)

Web of Science (-2010)

The JBI (-2010)

The Cochrane Library (-2010)

Music

Music

Music therapy

Acoustic stimulation

Sound

Noise

Auditory evoked potentials

Postoperative pain

Pain, postoperative

Pains, postoperative

Postsurgical pain

Search Strategy

Published studies written in English language.

Initial search using keywords such as “music”, “music therapy”, “postoperative” & “pain” would be entered into CINAHL & MEDLINE.

Each article’s title, abstract & index terms would be analysed.

All identified & index terms would be searched in the databases.

Lastly, additional studies would be searched from the reference lists of the articles retrieved.

Databases

Published D: MEDLINE, CINAHL, AMED, PubMed, PsycINFO, Embase, Cochrane Central Register of CTs of the Coch Lib .

Search strategy would not be limited to any time period.

The search was launched with every keyword individually, and then by joining and grouping terms together to get the best literature. This search strategy was modified as necessary for each database. During this process, the strategy and terms in (Table )were applied to each source in electronic databases.

Inclusion and Exclusion Criteria

Types of Studies

This review considered any randomised controlled trials (RCTs) that examined/ evaluated the efficacy of music as a postoperative pain management intervention. Studies eligible for inclusion were RCTs comparing music & standard postoperative care with no music/ placebo and standard postoperative care .

Studies that are non randomised controlled studies will be excluded. These include: qualitative study designs, other quantitative studies, narrative review and systematic reviews.

Types of Participants

All studies that include adult ( 18 years and above) surgical/ postoperative patients of either gender (male and female) who have undergone any type of surgical operation (whether minor or major surgery).

Studies conducted using children will be excluded.

Type of Interventions

The review considered all studies that used any type of recorded music (patient preferred or investigator chosen) in the form of audio or video that was listened preoperatively, intraoperatively and postoperatively of any duration, frequency and intensity; single-blinded / unblinded.

Studies that combined music with other nonpharmacological interventions such as jaw relaxation, therapeutic suggestions, guided imagery and so on).

Types of outcome measures

The main outcome measured was pain (intensity) prior to and or after the music measured by any valid pain assessment tool was considered in the review (Visual Analog Scale, Verbal Rating Scale, Numerical Rating Scale and so on).

Analgesic consumption was evaluated as a secondary outcome measure since it is not an appropriate indicator of postoperative pain.

Studies that do not include pain or analgesic consumption as an outcome measure. For eg., anxiety, sleep, etc would be excluded

Critical Appraisal

Standardised critical appraisal checklist from the MAstARI would be used.

The methodological quality of each RCT will be assessed independently by 2 reviewers before inclusion in the review.

Assessment of Methodological Quality

As a part of the SR process, all studies to be included were first assessed for methodological quality. Assessing the quality of the methodology, provides the review with insight into potential comparisons and guides interpretation of the review results, while minimising possible bias (Table) (Oxman and Guyatt, 1988).

Moher et al. (1997) reported that several checklists were designed to assess the methodological quality of RCTs. This review was examined by peer-reviewers to independently verify the included studies using a standardised critical appraisal checklist from the JBI SUMARI package (Appendix ....).

Data Extraction

Data from each eligible RCT were extracted using the Cochrane Collaboration and the Centre for Reviews and Dissemination (Appendix ). Data extracted included specific details about the author and year, study design, patient demographics, inclusion criteria, interventions, outcomes, number and reason for withdrawals and dropouts. The results are discussed in the next chapter.

Additional data to be extracted would include: pt’s diagnosis, type of surgery, type of anaesthesia & anaesthetic agent(s), age, gender, duration of study, duration of study, place of study, recruitment process, drop-out rates and rationale.

Data Analysis

The aim of data analysis is to pool and summarise the findings of included studies. In this review all the included studies were evaluated to be heterogenous in terms of PICO and findings (Anderson et al., 2004). ***Thus data were presented in a narrative form instead of a meta-analysis.

Data Synthesis

Heterogeneity would be assessed using the I² test.

Study results would be pooled statistically using RevMan software (from Cochrane Collaboration).

Weighted mean differences and their 95% CI would be calculated for analysis.

Chapter Summary

In conclusion, a SR is the best method to answer the review question “what is the efficacy of music as a postoperative pain management intervention”. This chapter has discussed the importance of SR as a significant element in EBP, including/ with regards to its strengths and weaknesses. This kind of methodology can help HCPs recognise existing gaps for future research using a rigorous methodological approach.

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