Journal of Pediatric Oncology Nursing http://jpo.sagepub.com
Music Therapy to Reduce Pain and Anxiety in Children With Cancer Undergoing Lumbar Puncture: A Randomized Clinical Trial Thanh Nhan Nguyen, Stefan Nilsson, Anna-Lena Hellström and Ann Bengtson Journal of Pediatric Oncology Nursing 2010; 27; 146 DOI: 10.1177/1043454209355983 The online version of this article can be found at: http://jpo.sagepub.com/cgi/content/abstract/27/3/146
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Music Therapy to Reduce Pain and Anxiety in Children With Cancer Undergoing Lumbar Puncture: A Randomized Clinical Trial
Journal of Pediatric Oncology Nursing 27(3) 146–155 © 2010 by Association of Pediatric Hematology/Oncology Nurses Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043454209355983 http://jopon.sagepub.com
Thanh Nhan Nguyen, RN, MSc,1 Stefan Nilsson, RN, MSc,2 Anna-Lena Hellström, RN, PhD,2 and Ann Bengtson, RNT, PhD3
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 different 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 leukemia 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 procedures 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 understanding 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). Knowledge 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 nonpharmacological methods (Polkki, Laukkala, Vehvilainen-Julkunen, & Pietila, 2003). Improper application of pharmacological and nonpharmacological therapies is the main reason 1
National Hospital of Paediatrics, Hanoi,Vietnam Sahlgrenska University Hospital, Gothenburg, Sweden 3 Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden 2
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, Sweden Email:
[email protected]
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Nhan et al. 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 nonpharmacological method (He, Vehvilainen-Julkunen, Polkki, & Pietila, 2007). Listening to music is one of several nonpharmacological 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 stimuli 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 distraction 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. Listening to prerecorded music has also been defined as music medicine as opposed to active music therapy (Dileo & Bradt, 2005). Previous research has found music medicine 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 potential 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 leukemia, 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 experiences of pain intensity in children older than the age of 6 years. Self-reported NRS scores agreed with selfreported 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 earphones 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 portable 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
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Table 1. The Analysis Process From the Condensed Meaning Units of the Text, Codes, Subcategories and Categories Condensed Meaning Unit I felt calmer than last time. Last time, I had to hold my mother’s hand very tightly during the lumbar puncture I liked these songs very much. I felt very calm I was very afraid of pain... I just wanted to go home. I didn’t want to be injected any more I was very worried about the result of the treatment. I was afraid of an unsuccessful treatment I felt less pain than last time I felt a lot of pain, here . . . [showed the place that was injected. Crying] . . . I can’t explain I liked listening to the music. Music helps me to stay calm and feel less pain. I like the song: “Count the fingers” a lot I 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 pain
Code
Subcategory
Less afraid
Calm and relaxed
Felt calm Wanted to go home
Fear and anxiety
Worried about the treatment Less painful The place that was injected Liked the song Focused on the music Liked listening to the music Effective
room. The researcher and the physician did not know to which group the patient belonged. In the investigation room, the child put on the earphones 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 procedures. Heart rate (HR), blood pressure (BP), and oxygen saturation (SpO2) 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 SpO2 were monitored and recorded throughout the procedure, 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 analgesics were administrated during the procedure. This pain management met the standard care offered to children 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
Category Feelings of fear
Specific pain
Feelings of pain
Liked listening
Enjoyment of music
Focused on the music
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 recommended 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 calculated using nonparametric statistics. The c2 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, SpO2, and anxiety scores, as well as to compare age and the total duration of the music. The interviews with the children were read and analyzed 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
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The Consort E-Flowchart
Assessed for eligibility (n = 49)
Excluded (n = 9) Enrollment
Did not meet inclusion criteria (n = 0) Refused to participate (n = 8)
Randomized (n = 40)
Allocated to intervention (n = 20) Received allocated intervention (n = 20)
Allocated to intervention (n = 20) Allocation
Did not receive allocated intervention (n = 0)
Lost to follow-up (n = 0) Follow-Up
Analyzed (n = 20) Excluded from analysis (n = 0)
Received allocated intervention (n = 20) Did not receive allocated intervention (n = 0)
Lost to follow-up (n = 0) Discontinued intervention (n = 0)
Other reasons (n = 1)
Discontinued intervention (n = 0)
Analyzed (n = 20) Analysis
Excluded from analysis (n = 0)
Figure 1. Randomization diagram of included children
Children were randomized to either earphones with or earphones without self-selected music.
process of identifying categories and subcategories included alternation between the text as a whole and its parts. The analysis was carried out individually and in cooperation until there was agreement between the authors.
Results A total of 49 children were asked to participate in the study and, of these, 40 agreed to participate. Eight children withdrew because their parents declined for reasons
of time or money, which made an extended stay at the hospital impossible. One child did not want to participate because he was shy. The 40 children, 25 boys and 15 girls, were randomly assigned to 1 of the 2 groups: the music group (n = 20) or the control group (n = 20; Figure 1). No significant differences were found between the 2 groups with respect to age or gender and total time with earphones. The characteristics of the 2 groups of children are presented in Table 2. The children’s choices of music were traditional Vietnamese songs and children’s songs.
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Table 2. Demographic and Clinical Procedural Characteristics Music Control P value
Mean (Range, SD) Age (Years)
Total Time With Earphones (Minutes)
Boys (n)
Girls (n)
8.8 (7-12, 1.59) 9.4 (7-12, 1.93) Nonsignificant
23.1 (18-27, 2.6) 21.5 (17-25, 2.61) Nonsignificant
12 13 Nonsignificant
8 7 Nonsignificant
Table 3. Comparison of Pain Scores and Anxiety Scores Before, During, and After the Procedure
Pain, Mean (Range, SD) Music (n = 20)
Before 1.2 (0-5, 1.40) During 2.35 (0-7, 1.90) After 1.2 (0-5, 1.36)
Control (n = 20)
Anxiety, Mean (Range, SD) P Value
1.75 (0-5, 1.77) Nonsignificant 5.65 (1-10, 2.50) <.001 3 (0-7, 2.0) .003
Findings From Self-Reports (NRS and Short STAI) The pain scores during the procedures were significantly lower (P < .001) for the music group (mean = 2.35, SD = 1.9) than for the control group (mean = 5.65, SD = 2.5). The pain scores after the procedures were also significantly lower (P < .003) for the music group (mean = 1.2, SD = 1.36) than for the control group (mean = 3, SD = 2). The anxiety scores after 10 minutes of music medicine, in the music group, but before LP, were significantly lower (P < .001) for the children in the music group (mean = 8.6, SD = 2.78) than for the children in the control group (mean = 13.25, SD = 3.73). These reductions in anxiety scores were also obvious after LP in the music group (mean = 8.1, SD = 2.22) compared with the control group (mean = 13.0, SD = 4.17; Table 3).
Findings From Vital Signs There were statistically significant differences in reductions of HR (P = .012) and RR (P = .009) during the procedure in the music group (mean = 102.7, SD = 9.24 and mean = 25.1, SD = 3.60) compared with the control group (mean = 117.7, SD = 19.49 and mean = 28.5, SD = 3.86). There were also significant differences in RR (P = .003) after LP in the music group (mean = 24.45, SD = 3.49) compared with the control group (mean = 28.1, SD = 3.72). The SpO2 and BP did not differ between the groups (Table 4).
Findings From Interviews In all, 10 children from the music group and 10 from the control group were interviewed immediately after the
Music (n = 20)
Control (n = 20)
P Value
8.6 (6-16, 2.78)
13.25 (7-22, 3.73)
< .001
8.1 (6-13, 2.22) 13.0 (6-21, 4.17)
< .001
Table 4. Comparison of the Variables HR, RR, SpO2, and BP Before, During, and After the Procedure Biological Indicators
Mean (Range, SD) Music (n = 20)
Control (n = 20)
HR Before 102.6 (85-125, 10.01) 103.1 (87-135, 14.46) During 102.7 (86-123, 9.24) 117.7 (91-152, 19.49) After 100.8 (80-123, 11.4) 111.1 (88-145, 17.23) RR Before 25.0 (16-30, 4.08) 25.5 (18-35, 4.47) During 25.1 (18-32, 3.60) 28.5 (22-37, 3.86) After 24.5 (18-32, 3.49) 28.2 (20-37, 3.72) SpO2 Before 99.6 (98-100, 0.60) 99.7 (97-100, 0.73) During 99.2 (96-100, 1.14) 98.0 (90-100, 2.77) After 99.7 (99-100, 0.49) 99.2 (94-100, 1.47) Systolic BP Before 96.2 (84-112, 6.82) 98.0 (79-116, 9.98) During 97.1 (84-116, 8.57) 105.6 (82-141, 15.97) After 98.5 (85-119, 10.13) 102.4 (84-128, 11.26) Diastolic BP Before 61,8 (53-68, 3.82) 63.0 (53-77, 5.85) During 65.2 (55-80, 6.83) 69.8 (58-105, 11.67) After 62.75 (57-80, 4.82) 64.2 (50-94, 9.40)
P Value NS .012 NS NS .009 .003 NS NS NS NS NS NS NS NS NS
NOTE: HR = heart rate; RR = respiratory rate; SpO2 = oxygen saturation; BP = blood pressure.
procedure. Categories and subcategories were derived from analyses of the interview text. These showed the children’s experiences in terms of how they felt and their thoughts after the procedure (Table 1). Feelings of fear. There were differences between the 2 groups when they talked about their emotions. Most of the children in the music group favored this new experience of the LP procedure over their previous experience.
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Nhan et al. Listening to their favorite music helped them feel calm and relaxed and take their minds off the harm the procedure might cause: “I felt calmer than last time. I didn’t think about the injection. I just focused on the music. It encouraged me. I was successful.” They did not worry to the same extent as they did before being injected: “I didn’t feel any pain. I felt less afraid than last time. The last time, I had to hold my mother’s hand very tightly during the LP. I didn’t need to do that this time . . . [smiles].” Listening to music of their choice through earphones was a new experience in this group of children. The children also found it exciting: “It felt very interesting because I had never listened to music during the procedure like this . . . and I was relaxed before the LP too.” One child in the control group said that he felt calmer when wearing the earphones. The others in the control group did not mention anything about this. Before the procedure, most of the children felt fear and anxiety. Listening to the music, however, made them focus on it and they seemed to forget the fear they had before: “At the beginning of the procedure, I was a little bit worried because I was afraid of being injected twice, but I felt calm because I was listening to the music in the earphones from the start . . . [smiles].” At the time of the interview, all the children stated that listening to music made them feel less anxious about what would happen next during the procedure, though some children already had anxiety about the next planned procedure that day and began to talk about that: “I felt calm and relaxed, but I’m very worried about the other injection when I come back to the treatment room—a vein puncture to get an antibiotic.” One child said that he was worried about the next time he would undergo LP: “Will I be able to listen to music or not?” There were differences between the children in the music group and the children in the control group. All of the children in the control group talked about their fear and anxiety. Just wearing earphones did not appear to help. Feelings of fear were expressed very strongly in the interview text. Their fears had to do with the pain relating to the LP, their disease, and death: “I was very afraid of pain . . . [crying] . . . I just wanted to go home. I didn’t want to be injected any more [crying] . . .”; “I was very scared and I was in pain. I couldn’t think about anything. This was very terrible!” After the LP, the children’s fear continued and they felt sad because of their bad experience of the procedure: “I’m still scared [crying], I’m afraid to be injected. It’s very painful. When the doctor came in, my heart seemed to act in chaos until he left [crying] . . .” They also started to worry about the next planned procedure. Some children in the control group spoke about their anxiety and were worried about how their disease would affect them in the future. It could be
expressed as their anxiety being related to a fear of dying: “I was very worried about the result of my treatment. I was afraid of unsuccessful treatment”; “I was very sad because I was being injected again. I was sad because of the disease. I was very scared of death.” Feelings of pain. The music reduced the experience of pain during the LP procedure. Almost all of the children in the music group said that they felt less pain compared with their previous experiences. “I didn’t think. I just focused on the music. I felt a little bit of pain. Not like the last time when I felt 10 points of pain [laugh] . . .” A child in the music group said that he felt a lot of pain because it was his third injection of the day: “I felt a lot of pain. Today, I was injected 3 times. I had pain and I was very disappointed.” There were differences between the levels of pain felt by the 2 groups. All the children in the control group experienced a lot of pain as a result of the LP. The children with earphones and no music did not find the earphones useful and, at the time of the interviews, they could still feel pain: “I felt pain very much. I couldn’t think about anything else.” The children felt pain in their backs, legs, and abdomens: “I felt very painful, here . . . [showed the place that was injected, crying]”; “I’m still scared and I am in pain. I had pain in my belly and in my back. I felt a sharp sensation [crying].” Some of the children tried to focus on thinking about their family staying at home to decrease the pain that they were feeling: “Thinking of her [mother] made me feel less pain. I couldn’t focus on the earphones.” Enjoyment of music. All the children in both groups wanted to have earphones with music the next time, though some of the children found the earphones uncomfortable to wear and hard to lie on during the procedure. The children in the music group liked the music a lot. They found that the music helped them cope with the LP procedure. They were able to focus on listening to the music: “The music was nice.” Choosing music they liked helped them to focus on the music and forget the procedure: “I liked listening to the music. I like the song ‘Count the fingers’ a lot. I focused on the music . . . it helped.” The children in the control group said that if they could have earphones with music next time, it would probably be very helpful. They thought that music would make them more comfortable and happy and not so tired afterward: “This time, I didn’t have music with earphones. I think music will help me to be calm and feel less pain. I was unlucky to pick the no music paper.”
Discussion This study showed that music medicine is a distracter and helps the children endure the amount of perceived pain
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and anxiety. The children chose their own music styles. Most of the songs were familiar to them and associated with earlier pleasant situations. The music may have helped the children gain control of the unpleasant situation and give them a feeling of being in a familiar environment. The children probably felt control and engagement in their music medicine when they chose well-known Vietnamese and children’s songs. Unlike active music therapy, the children were not limited to the music therapist’s repertoire. Music medicine is not time-consuming, and the time available is a complicating factor in many psychological techniques (Polkki et al., 2003). The effectiveness of a particular distracter probably depends on the children and their engagement in the distraction activity (Murphy, 2009). The importance of the children being able to choose and make their own decisions about the music has also been shown in another study (S. Nilsson, Kokinsky, Nilsson, Sidenvall, & Enskar, 2009) and with other distraction techniques such as Virtual Reality (S. Nilsson, Finnstrom, Kokinsky, & Enskar, 2009). Patient-selected music has also been superior in adults compared with prechosen relaxing New Age Music (Leardi et al., 2007). In this study, music medicine was used as the only treatment for pain and anxiety relief in children with leukemia who were undergoing an LP procedure. Although this result shows benefits of nonpharmacological intervention, music medicine should be combined with pharmacological treatment to offer optimal pain management (Zernikow et al., 2005). The present study showed that music 10 minutes before the LP reduced the preprocedural anxiety level. Music before the LP shifted the children’s attention away from the procedure to something more pleasant. This result encourages the use of music medicine starting already before procedures such as LP. To date, studies of music interventions have predominantly evaluated preoperative anxiety rather than anxiety before procedures without anesthesia. Most of these studies have also focused on active rather than passive music therapy (Klassen et al., 2008; Wright et al., 2007). Distraction appears to be an easy and effective method to reduce pain and anxiety in children undergoing procedures (Piira, Hayes, Goodenough, & von Baeyer, 2006). In this study, the quantitative analysis was combined with a qualitative method. There was previously a lack of knowledge about children’s experiences with music medicine when undergoing LP (Cepeda et al., 2006; Klassen et al., 2008). The interviews in this study also validated the quantitative data and confirmed the painand anxiety-reducing effects of music medicine. Music medicine can help children improve their quality of life. It may also help them reduce the symptoms and
side effects of treatment such as pain, anxiety, and the effects on the heart and respiratory rate (Cepeda et al., 2006; Klassen et al., 2008). Pain and anxiety are common in conjunction with LP, and it is therefore important, whenever possible, to reduce these problems in the care of children with cancer. Treatment-related pain occurs in about 50% of patients in paediatric oncology care, whereas other disease-related pain occurs in only about 25% (Blount et al., 2006). Moreover, after an unsuccessful procedure the individual pain experience will be modified to create a negative pain memory. Some children also show increased distress over time. In some instances, the pain is so traumatic that children suffer long-lasting psychological consequences and develop a fear of hospitals and medical staff (von Baeyer et al., 2004). Most of our knowledge about children is gained from interviews with adults who know them well, for example, parents, teachers, and peers (Kortesluoma, Hentinen, & Nikkonen, 2003). Furthermore, the information about children’s experiences of LP is mostly compiled in Europe and North America, and there are few earlier studies that do not use analgesics or sedative drugs. In this study, interviews with children and quantitative data both confirmed that music medicine reduced pain and anxiety. This result supports the hypothesis that music actually affects people in general, irrespective of the individual’s cultural background. A similar result was found in India where Indian music reduced pain in Indian children (Balan et al., 2009). The experiences of earphones with or without music for pain and anxiety reduction in children with leukemia were described in the interviews in this study. The qualitative content analysis identified 3 categories: feelings of fear, feelings of pain, and enjoyment of music. There were differences between the study groups. All the children in the control group spoke of pain, fear, and anxiety. They expressed these feelings very strongly. They felt anxiety relating to LP, their disease and ultimately a fear of dying. These findings confirm the results of an earlier study (Jacob et al., 2007). In comparison, the children who had earphones with music felt less pain and were calmer and more relaxed during the procedure. They were interested in the songs they had chosen. Some of them did not realize when they were injected. All the children in the music group wanted to use earphones with music when undergoing future procedures, and the children in the control group wanted to try it the next time. Music medicine has shown beneficial results in other clinical trials (Cepeda et al., 2006; Klassen et al., 2008), though none of them evaluated the children’s experiences through interviews in a mixed method such as in the present study.
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Nhan et al. There are some methodological considerations with this study. The STAI scale was originally designed and validated for adults, though it has previously been used in its original form for female adolescents watching music videos when undergoing colposcopy (Rickert, Kozlowski, Warren, Hendon, & Davis, 1994). The short STAI is easy to use and showed a significant decrease between before and after day surgery in children aged 7 to 16 years (Nilsson et al., 2009). The short STAI may be preferable to the STAI or the STAI for children (STAIC), which involve a long checklist and many items that sometimes become a hindrance (Marteau & Bekker, 1992). The short STAI has not been validated in children but is frequently used and appears to form a valuable complement to other collected data. The limitation of the intervention in the present study was the earphones. Although earphones were found to have valuable effects, they were not sufficiently comfortable in all of the positions in which the children found themselves during the procedure. In another study, loudspeakers were shown to block unpleasant sounds in the environment and make patients feel more relaxed (Thorgaard et al., 2005). Earphones may, however, increase the risk of transmitting infections associated with health care to sensitive children (U. Nilsson, 2009a). Another limitation is that the children in the control group were recruited with the knowledge that they might be given music intervention but were then randomized to the group without music. This might have led to a sense of missing something. The data collection involved some outcomes that did not show any significant differences between the music group and the control group, that is, BP before, during, and after LP. This result confirms earlier studies with music (Hatem, Lira, & Mattos, 2006; Megel, Houser, & Gleaves, 1998). BP does not seem to be an important outcome for the effects of music therapy. This is an important finding as many children probably find it disturbing to have their blood pressure measured. In the study, listening to music using an iPod® as the only effort was found to be effective with regard to pain and anxiety reduction in children and could help nurses and physicians in clinical practice. Further research is needed to examine whether the choice of music and equipment needs to be individualized or if a “gold standard” exists, and to compare and combine music with other distraction techniques such as Virtual Reality (Riva, Grassi, Villani, Gaggioli, & Preziosa, 2007).
Conclusions Listening to music with earphones as a form of nonpharmacological intervention reduced pain and anxiety in
children with leukemia who underwent LP, involved low cost and was easy and safe to use. The music reduced pain scores, heart rate, respiratory rate, and anxiety scores. Qualitative analysis of open-ended interviews gave 3 categories: feelings of fear, feelings of pain, and the enjoyment of music. When the children had earphones with music, they felt less pain and were calmer and relaxed during and after the procedure. All these children definitely wanted to have earphones with music the next time they were treated. Almost all the children in the control group expressed pain, fear, and anxiety. Acknowledgments The authors would like to thank the children and their parents in the Oncology Ward of the National Hospital of Paediatrics, Hanoi, Vietnam, for their contributions. We would also like to acknowledge all the staff of the Oncology Ward. Finally, we would like to thank Lasse Persson for reviewing the statistics.
Declaration of Conflicting Interests The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.
Funding The authors received no financial support for the research and/ or authorship of this article.
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Bios Thanh Nhan Nguyen, MSc, is a registered nurse at the Department of Paediatric Oncology, the National Hospital of Paediatrics, Hanoi, Vietnam.
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Nhan et al. Stefan Nilsson, MSc, is a registered nurse and pain management nurse at the Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Gothenburg, and a PhD student at the Department of Nursing Science, School of Health Sciences, Jönköping University.
Hospital, Gothenburg, and the Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg. Ann Bengtson, PhD, is a registered nurse (RNT) and senior lecturer at the Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden.
Anna-Lena Hellström, PhD, is a registered nurse and professor at the Queen Silvia Children’s Hospital, Sahlgrenska University
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