Evidence based guidelines of using music therapy in minimizing. postoperative pain and promoting rehabilitation for patients after

Transcription

1 Abstract of thesis entitled Evidence based guidelines of using music therapy in minimizing postoperative pain and promoting rehabilitation for patients after total joint replacement Submitted by Lo Ming Yan For the degree of Master of Nursing At The University of Hong Kong In July 2012 Introduction: Patients having total joint replacement often experience moderate to severe pain postoperatively. Postoperative pain can reduce patients mobility, affecting their motivation to participate in any rehabilitation activities. For patients having total join replacement, rehabilitation plays an important role in promoting their early recovery. Therefore, it is crucial for healthcare professionals to develop and evaluate intervention that can better control patients post-operative pain. In the clinical setting that I am working, pharmacological method is the major means of postoperative pain management. However, many Chinese patients are reluctant to use analgesic to control their post-operative pain

2 because of the side effects and adverse reactions of the drugs. In this dissertation, music therapy, a non-pharmacological method that can be managed by nurses, is adopted for postoperative pain control. It is used to promote rehabilitation for patients who have undergone total joint replacement. Objectives: The objectives of this study are (1) to review the published research articles that investigated the effects of music therapy in reducing the post-operative pain and promoting rehabilitation for patients having total joint replacement; and (2) to establish an evidence-based guideline for the use of music therapy by nurses to control postoperative pain and to facilitate rehabilitation for patients having total joint replacement. Methods: A comprehensive literature search on four electronic databases including CHINAL, Medline (OvidSP), PubMed and the British Nursing Index were conducted. A total of eight RCTs and two non-randomized controlled trials were eventually identified. Results: All the reviewed studies showed that music therapy has a statistically significant effect on reducing postoperative pain. Sedative or relaxation music (music which has no lyrics, sustained melodic quality; rate of beats per minutes; absence of strong rhythms or percussion) are recommended in the guideline. The target setting is a total joint replacement

3 centre in a public hospital of Hong Kong. The target clients are adult patients (aged 19 or above) that are referred by the orthopedic out-patient department and are pending for their total knee/ hip replacement in the center. The transferability and feasibility of the literature are high. The guideline is developed based on the evidence in reviewed literature. A pilot testing plan is established to detect the potential barrier and friction of the guideline before the implementation. After that, an evaluation plan for patients, healthcare providers and system outcomes was also proposed. Conclusion: An evidence based guideline is developed for the total joint replacement center. It is anticipated that, with the use of this guideline by nurses, it will not only facilitate better rehabilitation for patients having total joint replacement, but also enhances nurses autonomy in their nursing practice.

4 Evidence based guidelines of using music therapy in minimizing postoperative pain and promoting rehabilitation for patients after total joint replacement By Lo Ming Yan B.N, R.N. A thesis submitted in partial fulfillment of the requirement for the Degree of Master of Nursing at The University of Hong Kong July 2012

5 Declaration I declare that this dissertation represents my own work, except where due acknowledge is made, and that it has not been previously included in a thesis, dissertation or report submitted to this University or other institution for a degree, diploma or other qualifications. Signed: Lo Ming Yan i

6 Acknowledgement I would like to express my sincere appreciation to my research supervisor, Dr William Li from the School of Nursing of the University of Hong Kong, for his guidance, expert advice and encouragement during the process of whole dissertation. Also, I would like to thank my family, my beloved ones and friends, who provided ongoing support and encouragement throughout my study. ii

7 Contents Declaration i Acknowledge ii Contents...iii Lists of Appendices... viii Chapter 1: Introduction Background Affirming needs Objectives, Research Question and Significant of the Study Conclusion.7 Chapter 2: Critical appraisal Search and Appraisal Strategies Search Strategy Inclusion and Exclusion Criteria Method Used to Extract the Data Result Research problem and purpose Study type and level of evidence Intervention Internal validity Overall assessment of the study Synthesis of Finding Characteristics of music therapy Effect of music therapy on improving postoperative pain...17 iii

8 2.3.3 Effect of music therapy on the duration to perform music intervention Effect of music therapy on different type of music on improving postoperative pain Effect of music therapy on decreasing analgesic consumption Effect of music therapy on improving the distance of postoperative ambulation Summary of Finding Conclusion...24 Chapter 3: Translation and Application Transferability Feasibility Nurse-related aspect: Freedom in implementation of the intervention Nurse-related aspect: Interference current staff function Nurse-related aspect: Implementation of intervention and staff training Administration support and the organization climate Potential friction Availability of the equipment and facilities Measuring tools for clinical evaluation Cost benefit ratio Risk of maintaining current practice Potential risk and benefit of evidence based innovation..34 iv

9 3.3.3 Cost and benefit ratio of the proposed intervention Conclusion Chapter 4: Evidence-Based Practice Guideline Name of the guideline Purpose of the guideline Target clients Implementation of the guideline The guidelines...40 Chapter 5: Implementation plan Implementation plan Communication plan with potential users (stakeholders) Communication plan with Advanced Practice Nurses (APN) Communication plan with administrators Communication plan with front line nursing staff Communication plan with Doctors and physiotherapists Communication plan with eligible patients Pilot testing to try out the guideline Aims of the pilot test Participants and setting Target sample size and duration of the pilot test..52 v

10 5.2.4 Content Outcome measure and statistical method Feedback from frontline nursing staff and patients Refinement of the guideline Evaluation plan Identifying Outcomes Determining the nature and number of clients to be involved Deciding when and how often to take measurements Patient outcome Healthcare provider outcome Data analysis Effectiveness of the innovation Conclusion 61 References 62 Appendix..68 Appendix 1: Search Strategy 69 Appendix 2: Table of Evidence 70 Appendix 3: Quality Assessment.80 Appendix 4: Summary of the level of evidence and quality of the reviewed studies..90 Appendix 5: Cost benefit ratio of the proposed intervention...91 Appendix 6: Levels of Evidence vi

11 Appendix 7: Grades of Recommendations..93 Appendix 8: Timeline for communication plan, pilot test, implementation plan and evaluation plan 94 Appendix 9: Visual Analog Scale (VAS) assessment form...95 Appendix 10: Questionnaire for evaluation of patients in pilot test.96 Appendix 11: Questionnaire for evaluation of healthcare providers 97 vii

12 List of Appendix Appendix 1: Search Strategy 69 Appendix 2: Table of Evidence 70 Appendix 3: Quality Assessment.80 Appendix 4: Summary of the level of evidence and quality of the reviewed studies..90 Appendix 5: Cost benefit ratio of the proposed intervention...91 Appendix 6: Levels of Evidence Appendix 7: Grades of Recommendations..93 Appendix 8: Timeline for communication plan, pilot test, implementation plan and evaluation plan 94 Appendix 9: Visual Analog Scale (VAS) assessment form...95 Appendix 10: Questionnaire for evaluation of patients in pilot test.96 Appendix 11: Questionnaire for evaluation of healthcare providers 97 viii

13 Chapter 1 Introduction This chapter highlights the problem of postoperative pain and rehabilitation among patients undergoing total joint replacement in Hong Kong. In view of the increasing elderly population as well as the needs of total joint replacement, the significance of implementing a new intervention is addressed. Also, the objectives and research questions of the present study are described. 1.1 Background Patients who have undergone surgery would usually experience moderate to severe pain postoperatively. It is no doubt that orthopedic surgery is the most painful surgery. Patients usually suffer severe postoperative pain because the surgical procedure involves muscle and skeletal tissue repair or reconstruction (Pasero & McCaffery, 2007). Pain is a multidimensional phenomenon. It is a subjective sensation that individuals would very unlikely to respond in the same way. The gate control theory contains two pathways to explain why we feel pain (pain perception pathway) and how pain is relieved (pain modulation pathway) (Melzack & Wall, 1965; Melzack, 1996). In pain modulation pathway, stimuli (e.g. non pharmacological method) activate the descending inhibiting system in brain and close the gate and thus we do not have the sensation of pain. 1

14 Pain has some negative consequences. It impairs health and prolongs recovery from surgery, disease and trauma (Berman, Snyder, Kozier, & Erb, 2008). Some journal articles stated that pain reduces patients mobility and rehabilitation (Nett, 2010; Sharma, Morgan & Cheng, 2009). Patients may require a longer hospital stay and may also have a higher chance of readmission. All these may increase the operating expenses of the healthcare system (Reimer-Kent, 2004; Whitaker, 2010). Rehabilitation is another main concern in patients who have undergone total joint replacement. In my ward, there is a rehabilitation regime for patients undergoing total knee/ hip replacement. Patients are encouraged to perform toe movement and ankle pumping exercise when they are staying in bed. After removing the drainage on postoperative day two to four, patients would try to get out of bed and start walking exercise with the assistance of various kinds of walking aids (e.g. frame, quadripod and stick). Co-ordination, transfer training, and walking exercise would then be taught by physiotherapists. For the total knee replacement patient, knee flexion and extension exercise, and knee range of motion exercises are recommended after the removal of drainage. Rehabilitation is important for patients who have undergone the total joint replacement. It rejunavates the function of the joint (Dennis, 2001; Zhao & Bao, 2011), prevents stiffness of the joint (Dennis, 2001), regains the range of motion of the joint (Zhao & Bao, 2011), and helps patients to achieve independence in their routine activities (Sharma et al., 2009). Also, it 2

15 prevents deep vein thrombosis (Husted et al., 2010; Matteucci, Caple & Pravikoff, 2011), shortens the length of hospitalization (Husted et al., 2010; Munin, Rudy, Glynn, Crossett, & Rubash, 1998), and decreases the total medical cost (Larsen, Hansen, Thomsen, Christiansen, & Søballe, 2009; Munin et al., 1998). Since postoperative pain reduces patients mobility, one of the major healthcare goals for patients who have undergone total joint replacement is pain control. It helps promote rehabilitation. 1.2 Affirming needs According to the statistic from the Census and Statistic Department of Hong Kong (2002; 2006), elderly population in Hong Kong (> 65 years old) has raised from 747,052 in 2001 to 852,796 in 2006 and the proportion of older persons to the total population has also increased from 11.1% to 12.4%. A study of Yan, Chiu, & Ng (2011) showed that the number and the proportion of total knee replacement patients over 80 years old had increased from 4.8% to 13.8% from 2000 to The need of total joint replacement is increasing. From the statistic of my ward, there are 500 new cases of total joint replacement per year. The waiting time for the total knee replacement and the total hip replacement are 54 months and 52 months respectively. Due to the increased needs of total joint replacement, the Hospital Authority set up a new total joint replacement centre in Hong Kong Buddhist Hospital (HKBH). The centre 3

16 can deal with 700 cases of elective total knee/ hip replacement per year. Ninety-five percent of these patients are elderlies and the others are adults. Postoperative pain limits patient s participation of rehabilitation and it also affects patient s motivation to perform walking exercise. According to Sharma et al. (2009), adequate pain control and early rehabilitation is important for patients undergoing total joint replacement. It decreases postoperative pain, improves joints function, and increases patients self efficacy. I work in the total joint replacement centre in HKBH. My ward promotes early discharge scheme in which it encourages patients to engage in early rehabilitation. Patients are usually discharged from hospital seven to ten days after their operations. As pain reduces patients mobility and affects rehabilitation progress, pain control is important in my ward. In my ward, pharmacological method (i.e. analgesic) is the current method to manage postoperative pain. First, we assess patient s pain level in several intervals. Then, we administer the analgesic according to doctor s prescription. Some research have confirmed that analgesic such as opioid, non-steroidal anti-inflammatory drugs (NSAIDs), non-opioid drugs do exhibit benefits on patients pain relief (Reimer-Kent, 2004; Pasero & McCaffery, 2007). However, some patients refuse to take analgesic due to the side effects and the adverse reactions. These adverse outcomes include nausea and vomiting, pruritus, urinary retention, dizziness, epigastric discomfort, respiratory depression, damage to renal and liver and so on (Rice, 4

17 Warfield, Justins, & Eccleston, 2003). For the pharmacological aspect, nurses do not have the autonomy to decide which analgesic should be provided to patient. Instead, we need to follow the prescriptions that are given by doctors. When the pain increases, nurses cannot adjust the dosage of analgesic. Therefore, I consider developing a non-pharmacological intervention for postoperative pain control and the intervention can be managed by nurses for promoting the rehabilitation of patients who have undergone total joint replacement. In clinical setting, we need to select a non-pharmacological intervention that is easy to operate by nursing staff. Also, it should be cost effective, safe, and is easily acceptable by patients. Music therapy is an easy-to-use, inexpensive, and low-risk supportive intervention (Rice et al., 2003; Whitaker, 2010). It provides distraction and disassociation by focusing on the characteristics of the selected music (Black, & Hawks, 2005). The pain relief effect of music therapy can be explained by the gate control theory. When patients listen to music, the auditory pathway interacts with endogenous opiate system and activates the descending inhibiting system in brain. The descending fibres from nucleus raphe and locus ceruleus will then close the gate and achieve the effect of pain relief. 5

18 1.3 Objectives, Research Question and Significant of the Study Objectives The objectives of this study are to review the published research that investigate the effect of music on post-operative pain for patients who have undergone total joint replacement; and to establish an evidence-based guideline for nurses to use music for promoting rehabilitation among patients who have undergone total joint replacement. Research Question of the translational research What is the effect of music therapy in minimizing postoperative pain and improving the distance of postoperative ambulation among patients undergoing total joint replacement? By achieving the above objectives, nurses can provide an evidence based approach to plan and implement quality care to patients and nurses autonomy will also be enhanced. For patients, the intervention can minimize their postoperative pain, reduce the complication of pain and promote rehabilitation. For the hospital, the guidelines can reduce the costs such as the cost of hospital stay (Larsen et al, 2009; Munin et al, 1998). 6

19 Conclusion In this chapter, the main concerns relating to postoperative pain and rehabilitation are identified and the significance of the problems is also presented. It is hoped that the development of an evidence-based guideline for clinical setting will help to minimize postoperative pain and promote rehabilitation. 7

20 Chapter 2 Critical appraisal 2.1 Search and Appraisal Strategies Search Strategy Keywords used for searching the relevant literatures were arthroplasty, replacement, knee/ or total knee arthroplasty/; arthroplasty, replacement, hip/ or total hip arthroplasty ; music therapy or music ; mobilization or ambulation or walking ; pain or postoperative pain ; surgery or general surgery or operation or orthopedic surgery and rehabilitation. An electronic journals system provided by the medical library of the University of Hong Kong was used for the literature search. CHINAL, Medline (OvidSP), PubMed and the British Nursing Index were the four databases used for searching potential literature. The results were confined to studies that (1) included adult 19 and above; (2) were clinical trials, all or randomized controlled trials; (3) had available full texts and (4) were written in English. Details of the searching strategy are presented in a table in Appendix Inclusion and Exclusion Criteria Inclusion criteria of the review were primary studies which investigated the effect of music therapy on postoperative pain (especially for patients with total knee/ hip replacement) and the effect of music on ambulation/ rehabilitation. The target population in all studies 8

21 should be patients aged 19 years old or above and have undergone surgery. The studies should be written in English. Exclusion criteria of the review were unpublished studies, studies written in languages other than English, or studies whose subjects do not meet the inclusion criteria Method Used to Extract the Data After screening the titles and abstracts according to the inclusion and exclusion criteria, ten studies were extracted from the databases. Data of these ten studies are presented in the table of evidence (Appendix 2). The format of table of evidence was retrieved from the Scottish Intercollegiate Guidelines Network (2011). There are nine components in the table of evidence including study design, evidence level, number of patients, patient s characteristics, intervention, control, outcome measures, results, and sources of funding. The quality of the studies was critiqued according to the checklist that was retrieved from the Scottish Intercollegiate Guidelines Network (2011). There are two sections in the checklist, namely internal validity and overall assessment of the study. The checklists of the ten studies are attached in Appendix Result Research problem and purpose Four of the ten studies clearly addressed the research question (Allred, Byers & Sole, 9

22 2010; Ikonomidou, Rehnström & Naesh, 2004; McCaffrey & Locsin, 2006; Sendelbach, Halm, Doran, Miller & Gaillard, 2006), whereas the other six just stated the research purpose/ hypothesis/ objective instead of the research question (Ebneshahidi & Mohseni, 2008; Good & Chin, 1998; Kwon, Kim & Park, 2006; Nilsson, Rawal & Unosson, 2003; Tse, Chan & Benzie, 2005; Voss et al., 2004). Regarding the purpose of the study, all of the studies aimed at investigating the effect of music on postoperative pain. In particular, two aimed at estimating the effective time for music therapy (Ikonomidou et al., 2004; Nilsson et al., 2003), one aimed at investigating the effect of music on postoperative ambulation (McCaffrey & Locsin, 2006) and two aimed at comparing the effect of different types of music on postoperative pain (Ebneshahidi & Mohseni, 2008; Good & Chin, 1998) Study type and level of evidence Eight of the studies reviewed were randomized controlled trials (Allred et al., 2010; Ebneshahidi & Mohseni, 2008; Good & Chin, 1998; Ikonomidou et al., 2004; McCaffrey & Locsin, 2006; Nilsson et al., 2003; Sendelbach et al., 2006; Voss et al., 2004); and the other two were non-randomized controlled trials (Kwon et al., 2006; Tse et al., 2005). Grading criteria were based on The hierarchy of level of evidence (Melnyk & Fine-Overholt, 2005). According to the hierarchy, randomized controlled trials belonged to level II in the level of evidence and non-randomized control trials belonged to level III. Therefore, eight of the 10

23 studies were in level II and two were in Level III. Level II indicates the second strongest level of evidence in the hierarchy. Appendix 4 is a brief summary of the level of evidence and the quality of each of the reviewed studies Intervention All of the studies used music as the intervention and delivered the music via headphones. Standard postoperative nursing care (Kwon et al., 2006; McCaffrey & Locsin, 2006; Tse et al., 2005), quiet rest period (Allred et al., 2010; Good & Chin, 1998; Sendelbach et al., 2006), sitting in a chair and engaging usual activity (Voss et al., 2004), or listening to a blank CD (Ebneshahidi & Mohseni, 2008; Ikonomidou et al., 2004; Nilsson et al., 2003) were used to compare with the intervention group. Eight of the studies delivered the intervention postoperatively (Allred et al., 2010; Ebneshahidi & Mohseni, 2008; Good & Chin, 1998; Kwon et al., 2006; McCaffrey & Locsin, 2006; Sendelbach et al., 2006; Tse et al., 2005; Voss et al., 2004), while one study delivered the intervention intraoperatively or postoperatively (Nilsson et al., 2003) and one of the studies delivered the intervention preoperatively and postoperatively (Ikonomidou et al., 2004). For the duration of the intervention, four of them were 30 minutes (Ebneshahidi & Mohseni, 2008; Ikonomidou et al., 2004; Tse et al., 2005; Voss et al., 2004); one of them was 11

24 15 minutes (Good & Chin, 1998); two of them were 20 minutes (Allred et al., 2010; Sendelbach et al., 2006); two of them were 60 minutes (McCaffrey & Locsin, 2006; Nilsson et al., 2003) and one of them was between 30 and 60 minutes (Kwon et al., 2006). For the types of music, most of the studies used sedative music: music without lyrics; sustained melodic quality; beats per minutes; absence of strong rhythms or percussion (Allred et al., 2010; Good & Chin, 1998; Ikonomidou et al., 2004; Voss et al., 2004). Other studies used different types of music included peaceful pan flute music (Ikonomidou et al., 2004), Chinese and western music (Tse et al., 2005), patients favorite music that brought by themselves (Ebneshahidi & Mohseni, 2008), soft instrumental with slow, flowing rhythm (Nilsson et al., 2003), ballads, sacred music, classical music, foxtrot music and foreign pop music (Kwon et al., 2006), lullaby music and varies types of music (McCaffrey & Locsin, 2006); and music with no dramatic changes, consonance, instrumental music, 60 to 70 beats per minutes (Sendelbach et al., 2006) Internal validity Internal validity of the ten reviewed studies is based on the randomization of the subjects, concealment method, kept blind to the subjects and investigators, subjects characteristics of groups, outcome measure, sample size and drop out rate, analysis method and source of funding. 12

25 Half of the reviewed studies stated the method of randomization (Allred et al., 2010; Good & Chin, 1998; Nilsson et al., 2003; Sendelbach et al., 2006; Voss et al., 2004). The method of randomization used in the five reviewed studies included sealed envelope (Allred et al., 2010), sealed envelope with varied block size (Good & Chin, 1998; Voss et al., 2004), computer generated randomization list (Nilsson et al., 2003) and flipping of a coin (Sendelbach et al., 2006). Three of the studies did not state the method of randomization (Ebneshahidi & Mohseni, 2008; Ikonomidou et al., 2004; McCaffrey & Locsin, 2006). Two of the studies were non-randomized controlled trials, so randomization did not apply in these two studies (Kwon et al., 2006; Tse et al., 2005). None of the studies addressed the concealment method. None of the studies blinded both the subjects and investigators. Due to the studies design, the researchers of six of the studies only blinded the investigators (Ebneshahidi & Mohseni, 2008; Good & Chin, 1998; Ikonomidou et al., 2004; McCaffrey & Locsin, 2006; Nilsson et al., 2003; Voss et al., 2004). Two of the studies did not address blinding (Allred et al., 2010; Sendelbach et al., 2006). Other two of the studies were non-randomized controlled trials, so blinding did not apply in these two studies (Kwon et al., 2006; Tse et al., 2005). The subjects recruited by the studies were patients who had undergone surgery (gynecological surgery, open heart surgery, total knee replacement, cesarean section surgery, hip/ knee surgery, hernia inguinal, varicose veins, orthopedic surgery and nasal surgery). 13

26 Their ages ranged from 19 to 84. All of the studies compared the subjects characteristics in the intervention group and the control group before delivering the intervention. There was no significant difference between the intervention group and the control group. For the outcome measure, all of ten studies described clearly about the measuring instrument of pain. Different types of measuring instruments were used in the ten studies. Five of the studies used visual analogue scale (Allred et al., 2010; Ebneshahidi & Mohseni, 2008; Good & Chin, 1998; Ikonomidou et al., 2004; Voss et al., 2004), four of the studies used numeric rating scale (Kwon et al., 2006; McCaffrey & Locsin, 2006; Nilsson et al., 2003; Sendelbach et al., 2006) and one of the study used verbal rating scale (Tse et al., 2005). Six of the studies addressed the validity and reliability of the instruments (Allred et al., 2010; Good & Chin, 1998; Nilsson et al., 2003; Sendelbach et al., 2006; Tse et al., 2005; Voss et al., 2004) and four of them did not address the validity and reliability of the instruments, which may affect the quality of the studies (Ebneshahidi & Mohseni, 2008; Ikonomidou et al., 2004; Kwon et al., 2006; McCaffrey & Locsin, 2006). Sample size of the ten reviewed studies ranged from 38 to 151. The number of samples completed the intervention ranged from 34 to 151. Drop out rate ranged from 0% to 25%. Drop out rate was 25% in Allred et al. s study (2010). However, the effect of the intervention was not affected. It is due to the fact that calculation of the target sample size (n=56) was based on a power analysis for repeated-measures-analysis of variance with a large effect size 14

27 to achieve a power of.08 and α=.05. All of the studies addressed that the subjects were analyzed in the group that they were randomly allocated. Also, all of the studies carried out at one site only. Sources of funding were stated in three of the studies (Good & Chin, 1998; Sendelbach et al., 2006; Voss et al., 2004). They were Phi Chapter of Sigma Theta Tau International, Allina Foundation Nursing Research Trust Fund and National Institute of nursing Research. Sources of funding may be a bias in the study but the results of the studies were not likely to be affected by their grant organizations Overall assessment of the study Rating of the methodological quality of the study is based on the internal validity. The rating is divided into three codes: ++, + and -. According to the Scottish Intercollegiate Guidelines Network (2011), the code ++ means all or most of the criteria of internal validity have been fulfilled and those criteria not fulfilled are very unlikely to alter the conclusion; for the code +, it means some of the criteria of internal validity have been fulfilled and those criteria not fulfilled are unlikely to alter the conclusion; the code - means few or no criteria of internal validity have been fulfilled, the conclusions of the study are very likely to be altered. Among the ten reviewed studies, three studies were rated ++ (Nilsson et al., 2003; Sendelbach et al., 2006; Voss et al., 2004), five of the studies were rated + (Allred et al., 15

28 2010; Good & Chin, 1998; Ikonomidou et al., 2004; Kwon et al., 2006; McCaffrey & Locsin, 2006) and two of the studies were rated - (Ebneshahidi & Mohseni, 2008; Tse et al., 2005). 2.3 Synthesis of Finding The findings from all reviewed studies provided evidence for the positive effects of music therapy on adult patients had undergone surgery. The effects were reviewed in terms of the characteristics of the music therapy, improving postoperative pain, duration to perform music intervention, different types of music on improving postoperative pain, decreasing analgesic consumption, and improving the distance of postoperative ambulation. The findings are summarized as below Characteristics of music therapy Characteristics of the music therapies included distraction (Ebneshahidi & Mohseni, 2008; Good & Chin, 1998; Voss et al., 2004), relaxation (Good & Chin, 1998; Nilsson et al., 2003; Tse et al., 2005), and short term analgesic effect (Ikonomidou et al., 2004). Also, music is an intervention that is no risk or no side effect (Allred et al., 2010; McCaffrey & Locsin, 2006; Sendelbach et al., 2006; Tse et al., 2005) and is inexpensive (Sendelbach et al., 2006; Tse et al., 2005). 16

29 2.3.2 Effect of music therapy on improving postoperative pain Four studies explained the effect of music therapy on pain relief through the gating mechanism (Good & Chin, 1998; Kwon et al., 2006; Sendelbach et al., 2006; Tse et al., 2005). As mentioned in the previous chapter, the Gate Control Theory has a pain modulation pathway (Melzack & Wall, 1965; Melzack, 1996). When a patient hears music, auditory pathway interacts with endogenous opiate system and activates the descending inhibiting system in brain. The descending fibres from nucleus raphe and locus ceruleus will close the gate, which achieves the effect of pain relief. Nine studies showed significant improvement of postoperative pain after the music therapy was delivered via headphones (Ebneshahidi & Mohseni, 2008; Good & Chin, 1998; Ikonomidou et al., 2004; Kwon et al., 2006; McCaffrey & Locsin, 2006; Nilsson et al., 2003; Sendelbach et al., 2006; Tse et al., 2005; Voss et al., 2004). Also, Allred et al. (2010) stated music therapy and/ or rest period can relief postoperative pain. Three types of pain measuring instruments were employed in ten studies, including the visual analogue scale (Allred et al., 2010; Ebneshahidi & Mohseni, 2008; Good & Chin, 1998; Ikonomidou et al., 2004; Voss et al., 2004), the numeric rating scale (Kwon et al., 2006; McCaffrey & Locsin, 2006; Nilsson et al., 2003; Sendelbach et al., 2006) and the verbal rating scale (Tse et al., 2005). All of the studies showed the pain score was significantly lower in the intervention group than the control group even different kinds of measuring instrument 17

30 were used Effect of music therapy on the duration to perform music intervention The duration of the intervention in ten studies ranged from 15 minutes to 60 minutes. All studies showed the pain score was significantly lower in the intervention group regardless of the duration of the intervention. Nevertheless, most studies supported to deliver the intervention for 30 minutes (Ebneshahidi & Mohseni, 2008; Ikonomidou et al., 2004; Tse et al., 2005; Voss et al., 2004). Frequency of the intervention varies among the ten reviewed studies. In half of the reviewed studies, the intervention was performed once during the whole study period (Allred et al., 2010; Ebneshahidi & Mohseni, 2008; Ikonomidou et al., 2004; Nilsson et al., 2003; Voss et al., 2004). In study of Sendelbach and colleagues (2006), the intervention was delivered twice per day (in the morning and in the evening) for two days. In Good & Chin s study (1998) and Kwon et al. s study (2006), the interventions were delivered the intervention one time per day for two to three days during the study period. In McCaffrey & Locsin s study (2006) and Tse et al. s study (2005), the interventions were delivered four times a day in different intervals. Although the frequency of the intervention varies in the ten studies, there was no significant difference between the frequency and the pain score. 18

31 2.3.4 Effect of music therapy on of different types of music on improving postoperative pain Different types of music have different effect on patient s perception of postoperative pain. Therefore, type of music is a major factor that needs to be considered when designing an intervention. In the ten reviewed studies, a variety of music was used. Four of the reviewed studies used sedative music (music without lyrics; sustained melodic quality; rate of beats per minutes; lack of strong rhythms or percussion) as the intervention (Allred et al., 2010; Good & Chin, 1998; Ikonomidou et al., 2004; Voss et al., 2004). Other studies used different types of music such as instrument music (Nilsson et al., 2003), Chinese and western music (Tse et al., 2005), patients favorite music (Ebneshahidi & Mohseni, 2008), ballads, sacred music, classical music, foxtrot music and foreign pop music (Kwon et al., 2006), lullaby music (McCaffrey & Locsin, 2006) and music with no dramatic changes, consonance, instrumental music, 60 to 70 beats per minutes (Sendelbach et al., 2006). All of the ten studies showed significant improvement in pain level for patients in the intervention group even though they used different types of music. Nevertheless, most studies used sedative or relaxation music (music which is no lyrics, sustained melodic quality; rate of beats per minutes; lack of strong rhythms or percussion). Some studies showed that patients self-selected music or music chosen from the patients favorite list is another essential factor to enhance the intervention effect (Ebneshahidi & Mohseni,2008; Good & 19

32 Chin, 1998; Kwon et al., 2006; McCaffrey & Locsin, 2006; Sendelbach et al., 2006; Tse et al., 2005; Voss et al.,2004) Effect of music therapy on decreasing analgesic consumption Three studies suggested that music therapy may decrease analgesic consumption of patients in the intervention group (Ikonomidou et al., 2004; Nilsson et al., 2003; Tse et al., 2005). As mentioned in the previous chapter, analgesic has many side effects such as nausea and vomiting, pruritus, urinary retention, dizziness, epigastric discomfort, respiratory depression and renal and liver damage. Ikonomidou et al. (2004) found that the postoperative opioid consumption of patients in the intervention group was 2.2mg (+ 2.9) while the consumption of patients in the control group was 4.3mg (+ 2.4) (p = 0.04). Nilsson et al. (2003) also found that morphine requirement in the intra-operative group and the post-operative group were 1.6mg and 1.2mg respectively compared with 2.5mg in the control group (p < 0.05). Similar finding was found in Tse et al. s study (2005). They discovered that the mean number of analgesic tablets taken in the intervention group was 2.15 to 2.81 but in the control group was 4.20 to 5.43 (p < 0.001). These results demonstrated that music therapy may decrease the consumption of analgesic in the intervention group compared with the control group. 20

33 2.3.6 Effect of music therapy on improving the distance of postoperative ambulation McCaffrey & Locsin (2006) investigated the effect of music therapy on patient s readiness to ambulate score and number of feet to ambulate. The readiness to ambulate score is a self-rating score of patients readiness to participate in their own recovery process. The higher the score is, the more readiness of the patient to participate in the recovery process. They found that patients in the experimental group had higher score than patients in the control group (experimental group= 9.0; control group= 8.07; p =.001). Also, they examined the effect of music therapy on the mean number of feet ambulated. From postoperative day one to day three after music therapy, patients in the experimental group were able to ambulate much farther distance than patients in the control group (experimental group = to feet; control group = to feet; p = 0.001). The results showed that patients in the experimental group were more willing to ambulate on the operative day and were able to ambulate much farther distance after the music therapy. 2.4 Summary of Finding After reviewing the results of the ten selected studies, the findings were consistent to provide evidence to develop an evidence-based guideline for nursing practice to promote rehabilitation of patients undergoing total joint replacement by using music. All of the reviewed studies proved that implementing music therapy via headphones may 21

34 decrease the pain level for patients in both the intervention group and the control group because of the distraction (Ebneshahidi & Mohseni, 2008; Good & Chin, 1998; Voss et al., 2004), relaxation (Good & Chin, 1998; Nilsson et al., 2003; Tse et al., 2005), and short term analgesic effect (Ikonomidou et al., 2004). Also, music therapy has no risk or no side effect (Allred et al., 2010; McCaffrey & Locsin, 2006; Sendelbach et al., 2006; Tse et al., 2005) and is an inexpensive intervention that nurses can implement confidently for the patients who have undergone total joint replacement (Sendelbach et al., 2006; Tse et al, 2005). Most of the studies supported the use of visual analogue scale as the pain measurement (Allred et al., 2010; Ebneshahidi & Mohseni, 2008; Good & Chin, 1998; Ikonomidou et al., 2004; Voss et al., 2004). Therefore, music therapy needs to be delivered via headphones, and the visual analogue scale is used as the pain measurement in the guideline. The length of time of the intervention varied from 15mins to 60mins. However, most of the studies supported that 30 minutes of intervention can decrease the pain score of patients (Ebneshahidi & Mohseni, 2008; Ikonomidou et al., 2004; Tse et al., 2005; Voss et al., 2004). For the frequency of the intervention, there was no significant difference between the pain score and the frequency of the intervention. So, the duration of intervention for the guideline is 15 to 60 minutes before and after ambulation, in order to achieve the optimal effect of pain relief. Besides, most of the studies supported that sedative or relaxation music (music without 22

35 lyrics; sustained melodic quality; rate of beats per minutes; absence of strong rhythms or percussion) may decrease pain level of the patient (Allred et al., 2010; Good & Chin, 1998; Ikonomidou et al., 2004; Voss et al., 2004). Patient s favorite music is a factor to achieve the best effect of the intervention. (Ebneshahidi & Mohseni,2008; Good & Chin, 1998; Kwon et al., 2006; McCaffrey & Locsin, 2006; Sendelbach et al., 2006; Tse et al., 2005; Voss et al.,2004). Therefore, the guideline needs to have a variety of choices for patients to select the music that they like. On the other hand, music therapy significantly decreased the consumption of postoperative analgesic of patients in the intervention group. It also demonstrated the effect on improving the distance of postoperative ambulation. The ten reviewed studies were from medium to high quality. In addition, the research design, randomization method, validity and reliability of instrument and the sample size were strong. Although the drop out rate was high in the study of Allred et al. (2010), the researchers overcame it by the calculation of target sample size. The calculation of target sample size was based on a power analysis for repeated-measures-analysis of variance with a large effect size to achieve a power of 0.08 and α= 0.05, so the result was not affected by the high drop out rate. 23

36 2.5 Conclusion In this chapter, a total of eight randomized controlled trials and two non-randomized controlled trials were reviewed. Studies concerning the effect of music therapy in minimizing postoperative pain and promoting rehabilitation for patients had undergone total joint replacement were reviewed. The quality of the selected studies was assessed and recorded. The effect of music therapy on postoperative pain, duration of the intervention, type of music used were identified. Based on the selected studies and their evidence, a clinical evidence-based guideline is developed. 24

37 Chapter 3 Translation and Application Based on the evidence that was mentioned in the previous chapters, there is a need to develop an evidence-based protocol to implement music therapy for who have undergone total joint replacement so as to promote their rehabilitation. This chapter aims to assess the implementation potential of the proposed protocol, in terms of the transferability, feasibility and cost-benefit ratio of the innovation. 3.1 Transferability Target setting The target setting for the implementation of the innovation is a total joint replacement centre of a public hospital in Hong Kong. It is an in-patient center that is under the service of the orthopedic and trauma department. The bed state of the center is 30. The center is run by orthopedic surgeons, anesthetists and a team of nursing staff including advanced practice nurses (APNs), nurse specialists, registered nurses (RNs) and enrolled nurses (ENs). The center provides elective total knee/ hip replacement for adult patients. The majority of the patients are elderly. The patients are having surgery under general anesthesia (GA) or regional anesthesia (RA), which depends on the anesthetist s decision. Also, the center provides usual postoperative nursing care and pharmacological pain management for patients 25

38 postoperatively. The target settings of all reviewed studies were inpatient surgical units that provided preoperative and postoperative care for the adult patients. Most of the studies were conducted in western counties (Allred et al., 2010; Ebneshahidi & Mohseni, 2008; Ikonomidou et al., 2004; McCaffrey & Locsin, 2006; Nilsson et al., 2003; Sendelbach et al., 2006; Voss et al, 2004), one was in Hong Kong (Tse et al., 2005), one was in Taiwan (Good & Chin, 1998), and one was in Korea (Kwon et al., 2006). Although the culture may be different between the Western and Asian countries, the proposed innovation showed significant pain reduction in both the Western and Asian surgical units setting. Therefore, the proposed innovation is appropriate for the setting in Hong Kong. Clients The target clients of the proposed innovation are adult patients aged 19 or above who were referred by the orthopedic out-patient department and were pending to undergo total knee/ hip replacement in the center. Also, the target clients should be conscious and alert, without hearing impairment, able to communicate in Chinese or English, and with no mental disorder. There is no limit to gender, education level, and anesthesia method used during operation of the patients. This is similar to the target clients of all reviewed studies. The target clients of all studies were patients aged 19 or above, conscious and orientated 26

39 to time, place and date; with no hearing impairment, able to communicate in English, with no mental disorder, and there was no limit set to sex and education level. The only difference in the target clients is the type of surgery that the patients were to undergo. In the reviewed studies, the target clients undergo different types of surgery, including total knee/ hip replacement, orthopedic, ENT, cardiology and gynecology. However, they had similar postoperative care and music intervention. It was shown that there was significant effect on adult patients who have undergone these kinds of surgery. So, the target clients are similar to those in the reviewed studies. Philosophy of care According to the reviewed studies, the philosophy of care of the proposed innovation was to provide preoperative and postoperative care to patients. Preoperative care included fasting, skin preparation and bowel preparation before surgery, administrate premedication, and ensuring the smooth progress of the surgery. On the other hand, the ultimate goals of postoperative care were pain management and restoring the function of joint. In two studies, the study aims were to minimize postoperative pain, reduce complication of pain, promote rehabilitation for patients had undergone total knee/ hip replacement, and reduce the costs of hospital (e.g. hospital stay cost, operating expenses, reduce complication) (Allred et al. 2010; McCaffrey & Locsin, 2006). Also, it aims to reduce the costs of hospital (e.g. hospital stay 27

40 cost, operating expenses, reduce complication). The proposed setting is a total joint replacement center under the management of the Hospital Authority. According to the Hospital Authority annual report (Hospital Authority, 2010), the philosophy of care of the center included to deliver quality health service to clients, promote patient-centered care, improve service quality and safety, reduce patient length of stay in acute care settings, maintain financial sustainability and train healthcare professionals to pursue excellence. Also, the center emphasizes the importance of postoperative pain management by providing routine pain assessment and pharmacological pain management for all postoperative patients to minimize postoperative pain and promote rehabilitation for patients who have undergone total knee/ hip replacement. The content of philosophy of care of the reviewed studies and the proposed setting are similar. Therefore, the proposed innovation is appropriate to be applied in the target setting. Time frame According to the reviewed studies, the intervention was delivered postoperatively. The length of time of the intervention varied from 15 minutes to 60 minutes in most of the reviewed studies (Allred et al., 2010; Good & Chin, 1998; Ikonomidou et al., 2004; Kwon et al., 2006; McCaffrey & Locsin, 2006; Nilsson et al., 2003; Sendelbach, et al., 2006; Voss, et al., 2004). The frequency of the intervention varied from one to four times per day in the 28

41 reviewed studies. However, there was no significant difference between the frequency of intervention and the pain score. Patients will start ambulation after removal of drainage on postoperative day 2 and the ambulation and mobilization exercise will continue until the day of patient discharge. The usual discharge day ranges from postoperative day 7 to 14 depending on the patient s ability to walk. Based on the reviewed studies, the intervention would be implemented one to four times per day for 15 to 60 minutes from postoperative day 2 (after removal of drainage) until day 7-14 (on discharge day) so as to accommodate the situation in Hong Kong. 3.2 Feasibility This section will discuss the feasibility of the proposed innovation. There are some aspects that need to be considered. These include the nurse-related aspect, the organization climate, potential friction, availability of the equipment and facilities, and measuring tools for clinical evaluation Nurse-related aspect: Freedom in implementation of the intervention The reviewed studies supported that music therapy is a safe, noninvasive and easy to use intervention that can reduce postoperative pain. Nurses have the autonomy to decide whether 29

42 to carry out or terminate the intervention or not. Also, nurses can use this intervention to promote a healing environment to enhance the rehabilitation of the patients and restore the optimal function state of the joints Nurse-related aspect: Interference of the current staff function Postoperative pain is one of the obstacles to patient s rehabilitation. Therefore, pain assessment and pain management for postoperative patients are parts of the nurses responsibility and routine in the current practice. In the proposed innovation, music therapy would be the complementary intervention for the patients after total joint replacement. The reviewed studies supported that using music intervention as adjacent may decrease the consumption of analgesic and reduce the side effect of the analgesic. Nurses may need additional time for education, training, demonstration of the new innovation and performing the invention. This may interfere with staff daily routine and they may not cooperate due to their busy and heavy workload. A simple regimen of the innovation may help to increase staff compliance Nurse-related aspect: Implementation of intervention and staff training Different skills were required for the staff to implement the intervention. They need to know how to introduce the intervention, use the CD player, select the music, document the 30

43 findings and maintain the equipment. Therefore, training sessions for staff are needed. Four identical training sessions (one hour each) about the music intervention will be provided to all of the nursing staff. The training sessions include introduction of the proposed clinical guideline, content of the music, demonstration and return demonstration of the use of equipment. The training sessions only demonstrate the skills of implementing the intervention; besides, there is no special training for nursing staff on caring the postoperative patients Administration support and the organization climate The proposed innovation will be discussed with the general manager of nursing, department operating manager, ward manager, nurse specialist and nursing staff in the center. Consensus and support need to be obtained from all parties in order to implement the innovation in the center. The general manager of nursing, department operating manager and ward manager will provide the administration support to the innovation. According to the Hospital Authority annual plan (Hospital Authority, 2011), the cluster aims to provide safe and quality care to the clients and enhance acute pain service for all postoperative patients. It is similar to the purpose of the proposed innovation. Therefore, the general manager of nursing may support the innovation. The orthopedic and trauma department has developed a plan for multi-disciplinary pain management by using physical, psychological and chemical interventions. As the proposed 31