Discussion
The aim of this systematic review was to investigate the effect of perioperative music interventions
in children undergoing surgical procedures.
Two studies reported a large significant pain-reducing effect and one study a small non-significant
pain-reducing effect of music between the intervention and control group. Comparing
before and after the intervention within the intervention groups, all studies showed a large and
significant decline in pain, anxiety and distress descriptors.
The present review is the first on this topic that strictly adheres to the methods recommended
in the Cochrane Guidelines for writing a Systematic Review[8]. The findings should be
interpreted in the light of its limitations, most of which are related to the original studies. First,
the overall risk of bias was moderate. Second, there was heterogeneity in the types of music
interventions, the type of surgery across studies, patient populations and outcome measures.
Although the heterogeneity between the studies is a limitation, we were able to calculate the
standardized mean difference per group and to pool the results for the pain and anxiety and
distress descriptor outcomes. Ideally, we would have tried to adjust for the heterogeneity by
performing a meta-regression analysis or subgroup analysis, but the number of studies was
insufficient to perform such analyses. The variability in treatment effect across studies is likely
to be due to the above-mentioned heterogeneity in the types of music interventions, the type of
surgery across studies, patient populations and outcome measures.
Although only three studies could be included in this meta-analysis, the results show a significant
reduction of pain, anxiety and distress descriptors in pediatric surgical patients. Similar
results have been found in other patient populations. Thirteen Cochrane systematic reviews
have been published on music interventions in adults for various indications [3, 6, 13–23]. All
reported positive effects of music on anxiety and distress, pain and quality of life, although it was
noted that the general methodological quality of reviewed studies was moderate to low. Furthermore
authors recommended exploring possibly differential effects of live music therapy versus
recorded music interventions. Apart from the Cochrane reviews, thirty descriptive and systematic
reviews on the effects of music interventions on perioperative pain and anxiety in adults
were published[2, 24–40]. Together the body of evidence suggests that music therapy in the perioperative
setting has the potential to positively affect pain outcomes, anxiety and distress.
For future research we would like to stress the importance of rigorous study protocols, the
use of larger sample sizes and validated outcome measures. For research in children, we would
recommend to pay heed to the Consensus Statement of McGrath et al. regarding appropriate
outcomes measurements in pain research.[41]
Study populations should be more homogenous in terms of age and type of procedure.
Observer bias could perhaps be prevented by recording the patient on video while receiving
the intervention, blind the video images for the allocated intervention and have independent
assessors score the outcome measures using validated measurements while watching the
recordings[4].
Fig 3. Anxiety/distress change score (music vs. no music) before and after the intervention measured
by FAS and bipolar descriptors.
doi:10.1371/journal.pone.0133608.g003
Meta-Analysis of Perioperative Music in Pediatric Surgery
PLOS ONE | DOI:10.1371/journal.pone.0133608 August 6, 2015 8 / 11
Furthermore, we would like to suggest cost-effectiveness studies comparing live music therapy
with recorded music. Apart from the possibly different effects of live music therapy versus
recorded music, the timing of the intervention and the effect of self-selected versus therapist
selected music deserve attention[3].
This review shows that few RCTs have been performed on effects of music in pediatric
patients undergoing surgery, but that music interventions are worthwhile to further investigate
for its clinical usefulness. State-of-the-art RCTs evaluating music interventions are difficult to
perform in particular due to the inherent performance bias and detection bias. The only way to
perform a double-blinded study is to offer recorded music through headphones to patients
under general anesthesia which would preclude evaluation of the potential beneficial effect of
music pre- and post surgery[42]. Furthermore it is impossible to blind patients for live music
therapy by a music therapist.
In conclusion, this review shows that music as a non-pharmacological adjuvant intervention
has potential in reducing pain, anxiety and distress in children undergoing surgery. Its noninvasive
nature is an advantage.
Supporting Information
S1 File. Review protocol.
(DOC)
S2 File. Full list of search terms and databases.
(DOC)
S3 File. Prisma Checklist and flowchart.
(DOC)
S4 File. Excluded articles.
(DOC)
S5 File. Risk of bias. Quality assessment of studies.
(DOC)
Acknowledgments
We would like to thank Wichor Bramer, biomedical information specialist from the Medical
Library of Erasmus for assisting in the searches. Furthermore we thank Dr. Stefan Nilsson for
providing the descriptive analysis of his article used in this review. We thank Ko Hagoort for
reviewing this article.
Author Contributions
Conceived and designed the experiments: MVDH SO MVD JJ MH. Performed the experiments:
MVDH SO MVD JJ MH. Analyzed the data: MVDH SO MVD JJ MH. Contributed
reagents/materials/analysis tools: MVDH SO MVD JJ MH. Wrote the paper: MVDH SO MVD
JJ MH.
References
1. Banchs RJ, Lerman J. Preoperative anxiety management, emergence delirium, and postoperative
behavior. Anesthesiol Clin. 2014; 32(1):1–23. Epub 2014/02/05. doi: 10.1016/j.anclin.2013.10.011
PMID: 24491647.
Meta-Analysis of Perio
DiscussionThe aim of this systematic review was to investigate the effect of perioperative music interventionsin children undergoing surgical procedures.Two studies reported a large significant pain-reducing effect and one study a small non-significantpain-reducing effect of music between the intervention and control group. Comparingbefore and after the intervention within the intervention groups, all studies showed a large andsignificant decline in pain, anxiety and distress descriptors.The present review is the first on this topic that strictly adheres to the methods recommendedin the Cochrane Guidelines for writing a Systematic Review[8]. The findings should beinterpreted in the light of its limitations, most of which are related to the original studies. First,the overall risk of bias was moderate. Second, there was heterogeneity in the types of musicinterventions, the type of surgery across studies, patient populations and outcome measures.Although the heterogeneity between the studies is a limitation, we were able to calculate thestandardized mean difference per group and to pool the results for the pain and anxiety anddistress descriptor outcomes. Ideally, we would have tried to adjust for the heterogeneity byperforming a meta-regression analysis or subgroup analysis, but the number of studies wasinsufficient to perform such analyses. The variability in treatment effect across studies is likelyto be due to the above-mentioned heterogeneity in the types of music interventions, the type ofsurgery across studies, patient populations and outcome measures.Although only three studies could be included in this meta-analysis, the results show a significantreduction of pain, anxiety and distress descriptors in pediatric surgical patients. Similarresults have been found in other patient populations. Thirteen Cochrane systematic reviewshave been published on music interventions in adults for various indications [3, 6, 13–23]. Allreported positive effects of music on anxiety and distress, pain and quality of life, although it wasnoted that the general methodological quality of reviewed studies was moderate to low. Furthermoreauthors recommended exploring possibly differential effects of live music therapy versusrecorded music interventions. Apart from the Cochrane reviews, thirty descriptive and systematicreviews on the effects of music interventions on perioperative pain and anxiety in adultswere published[2, 24–40]. Together the body of evidence suggests that music therapy in the perioperativesetting has the potential to positively affect pain outcomes, anxiety and distress.For future research we would like to stress the importance of rigorous study protocols, theuse of larger sample sizes and validated outcome measures. For research in children, we wouldrecommend to pay heed to the Consensus Statement of McGrath et al. regarding appropriateoutcomes measurements in pain research.[41]Study populations should be more homogenous in terms of age and type of procedure.Observer bias could perhaps be prevented by recording the patient on video while receivingthe intervention, blind the video images for the allocated intervention and have independentassessors score the outcome measures using validated measurements while watching therecordings[4].Fig 3. Anxiety/distress change score (music vs. no music) before and after the intervention measuredby FAS and bipolar descriptors.doi:10.1371/journal.pone.0133608.g003Meta-Analysis of Perioperative Music in Pediatric SurgeryPLOS ONE | DOI:10.1371/journal.pone.0133608 August 6, 2015 8 / 11Furthermore, we would like to suggest cost-effectiveness studies comparing live music therapywith recorded music. Apart from the possibly different effects of live music therapy versusrecorded music, the timing of the intervention and the effect of self-selected versus therapistselected music deserve attention[3].This review shows that few RCTs have been performed on effects of music in pediatricpatients undergoing surgery, but that music interventions are worthwhile to further investigatefor its clinical usefulness. State-of-the-art RCTs evaluating music interventions are difficult toperform in particular due to the inherent performance bias and detection bias. The only way toperform a double-blinded study is to offer recorded music through headphones to patientsunder general anesthesia which would preclude evaluation of the potential beneficial effect ofmusic pre- and post surgery[42]. Furthermore it is impossible to blind patients for live musictherapy by a music therapist.In conclusion, this review shows that music as a non-pharmacological adjuvant interventionhas potential in reducing pain, anxiety and distress in children undergoing surgery. Its noninvasivenature is an advantage.Supporting InformationS1 File. Review protocol.(DOC)S2 File. Full list of search terms and databases.(DOC)S3 File. Prisma Checklist and flowchart.(DOC)S4 File. Excluded articles.(DOC)S5 File. Risk of bias. Quality assessment of studies.(DOC)AcknowledgmentsWe would like to thank Wichor Bramer, biomedical information specialist from the MedicalLibrary of Erasmus for assisting in the searches. Furthermore we thank Dr. Stefan Nilsson forproviding the descriptive analysis of his article used in this review. We thank Ko Hagoort forreviewing this article.Author ContributionsConceived and designed the experiments: MVDH SO MVD JJ MH. Performed the experiments:MVDH SO MVD JJ MH. Analyzed the data: MVDH SO MVD JJ MH. Contributedreagents/materials/analysis tools: MVDH SO MVD JJ MH. Wrote the paper: MVDH SO MVDJJ MH.References1. Banchs RJ, Lerman J. Preoperative anxiety management, emergence delirium, and postoperativebehavior. Anesthesiol Clin. 2014; 32(1):1–23. Epub 2014/02/05. doi: 10.1016/j.anclin.2013.10.011PMID: 24491647.Meta-Analysis of Perio
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