Original Article
Relaxation Training
From the *The University of Iowa
Hospitals and Clinics, Iowa City,
Iowa; The University of Iowa School
of Music, Iowa City, Iowa; The
University of Iowa College of Nursing,
Iowa City, Iowa.
Address correspondence to Kirsten
Nelson, MA, MT-BC, The University of
Iowa Hospitals and Clinics, 200
Hawkins Dr., Rehabilitation
Therapies, 0733 JPP, Iowa City,
IA 52242. E-mail: Kirsten-nelson@
uiowa.edu
Received January 24, 2016;
Revised October 6, 2016;
Accepted October 12, 2016.
Funding for this study was provided
by the American Music Therapy As-
sociation and the University of Iowa
Obermann Center for Advanced
Studies. These sponsors had no role
in the study design or collection,
analysis, or interpretation of data.
1524-9042/$36.00
2016 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2016.10.005
and Postoperative Music
Therapy for Adolescents
Undergoing Spinal
Fusion Surgery
--- Kirsten Nelson, MA, MT-BC,*
Mary Adamek, PhD, MT-BC,
and Charmaine Kleiber, PhD, RN
- ABSTRACT:
Spinal fusion for idiopathic scoliosis is one of the most painful sur-
geries experienced by adolescents. Music therapy, utilizing music-as-
sisted relaxation with controlled breathing and imagery, is a
promising intervention for reducing pain and anxiety for these pa-
tients. It can be challenging to teach new coping strategies to post-
operative patients who are already in pain. This study evaluated the
effects of introducing music-assisted relaxation training to adoles-
cents before surgery. Outcome measures were self-reported pain and
anxiety, recorded on 0-10 numeric rating scale, and observed behav-
ioral indicators of pain and relaxation. The training intervention was a
12-minute video about music-assisted relaxation with opportunities to
practice before surgery. Forty-four participants between the ages of 10
and 19 were enrolled. Participants were randomly assigned to the
experimental group that watched the video at the preoperative visit or
to the control group that did not watch the video. All subjects received
a music therapy session with a board certified music therapist on post-
operative day 2 while out of bed for the first time. Pain and anxiety
were significantly reduced from immediately pre-therapy to post-
therapy (paired t-test; p).
2016 by the American Society for Pain Management Nursing
BACKGROUND
Spinal fusion (SF) for adolescent idiopathic scoliosis (AIS) is one of the most pain-
ful surgeries experienced by adolescents. Despite pharmacologic intervention,
pain scores are frequently above five (on a zero to 10 scale) in the first few post-
operative days (Kleiber, Suwanraj, Dolan, Berg, & Kleese, 2007; Kotzer, 2000;
LaMontagne, Hepworth, Salisbury, & Cohen, 2003; Rullander, Jonsson,
Lundstrom, & Lindh, 2013). Teaching pain coping strategies (Logan & Rose,
2005) and anxiety reducing strategies (Caumo et al., 2000; Gillies, Smith, &
Pain Management Nursing, Vol 18, No 1 (February), 2017: pp 16-23
 Music Therapy for Adolescents
Parry-Jones, 1999) can positively impact postoperative
pain. Cognitive-behavioral techniques such as relaxa-
tion and deep breathing are recommended to relieve
pain and anxiety in adolescents (Sieberg et al., 2013;
Srouji, Ratnapalan, & Schneeweiss, 2010).
Although much is known about preparing chil-
dren for hospitalization, little is written about the
best methods for preparing adolescents for elective
surgery. In a rare study of teenagers and surgery,
LaMontagne and colleagues (2003) reported that
providing coping training, such as instruction on
deep breathing, relaxation and positive self-talk, to
adolescent spinal fusion patients was associated with
lower pain levels on the second postoperative day.
The training interventions were provided about
2 days before surgery. Replication of this study has
not been reported in the literature. Broad guidelines
for preparing children and teens for cardiac proced-
ures have been published (LeRoy, et al., 2003) recom-
mending that adolescents from 12 to 15 years benefit
from peer counseling and coping skills training.
Music Interventions for Surgical Pain
Music interventions have been shown to decrease
postoperative pain intensity and anxiety in adults
(Allred, Byers, & Sole, 2010; Easter et al., 2010;
Good, Anderson, Stanton-Hicks, Grass, & Makil, 2002;
Good et al., 2010; Kemper & Danhauer, 2005;
Pelletier, 2004; ehuda, 2011) and children (Bradt,
2010; Chetta, 1981; Klassen, Liang, Tjosvold, Klassen,
& Hartling, 2008; Nilsson, Kokinsky, Nilsson,
Sidenvall, & Enskar, 2009; Suresh, De Oliveria, &
Suresh, 2015). Passive music listening interventions,
which involve listening to preselected genres of
recorded music on headphones, typically are utilized
by nurses to provide additional comfort for patients.
Studies using this intervention often lack justification
for the selection of music, making it difficult to
generalize results, replicate studies, and apply results
to clinical practice (Tan, Yowler, Super, & Fratianne,
2012). A music therapy session differs from a passive
music listening intervention. Music therapists assess in-
dividual patient needs and carefully select and apply
music based on factors including the musics psycho-
physical properties (speed, volume, complexity) and
the patients musical preference (Tan et al., 2012).
The music therapist often performs live music for the
patient to adapt the music to the patients specific
needs.
The mechanism by which music ameliorates the
pain response includes an emotional component. Pos-
itive emotional responses to preferred music increase
cerebral blood flow to pleasure and reward centers
in the brain and decrease amygdala activity, which
17
also is involved in the affective component of pain
perception (Blood & Zatorre, 2001). The emotional
valence (pleasant vs. unpleasant) experienced by the
patient while listening to music is central to the effec-
tiveness of music for relieving pain. Music that induces
positive emotions is significantly correlated to
decreased pain intensity, whereas music that induces
a negative emotional response has no significant
pain-modulating effect (Roy, Peretz, & Rainville,
2007; Hsieh et al., 2014). Therefore, the careful
selection of music individualized to each patient is
necessary in order to provide therapeutic benefit.
Music therapy may be especially useful in helping
school-aged children and young adolescents deal with
postoperative pain and distress. Robbs contextual sup-
port model (Robb, 2003) proposed that contextual
support affects a childs ability to cope with hospitali-
zation by buffering the negative effects of stress and
increasing the childs engagement with the environ-
ment. According to this model, music therapy is uti-
lized to re-engage patients with the environment
through: (1) Structure: music interventions provide
children with opportunities for success and mastery
within the environment, (2) Autonomy Support: music
interventions provide children opportunities to make
choices and direct the course of activities, and (3)
Involvement: within the session the therapist ex-
presses unconditional acceptance of children and rein-
forces their efforts. In this way, music therapy
promotes adaptive coping skills by allowing choice
and control within a structured session in relationship
with the therapist.
Preliminary Work
Over the past few years the authors hospital used
music-assisted relaxation within music therapy ses-
sions to help AIS patients manage pain. However, the
authors observed that when the adolescents were
engaged in physical activity like moving from bed to
chair on postoperative day 2, they were sometimes in
too much pain to learn new techniques to help them
cope. In an effort to help these patients develop
coping skills to use after surgery, the authors investi-
gated ways to teach coping skills prior to surgery.
When the authors asked previous SF patients about
their recollection of music therapy, a common theme
was the need for preoperative information about
how to cope with pain (Kleiber & Adamek, 2013).
Preoperative anxiety is correlated with higher
postoperative pain intensity (Chieng et al., 2013;
Logan & Rose, 2005); therefore, preoperative training
was developed to mitigate this effect. In a 9-month
feasibility study, the authors developed and pilot tested
a preoperative training program with 10 SF patients.
18 Nelson, Adamek, and Kleiber
Patients were able to learn and practice music-assisted
relaxation via a preoperative web-based training pro-
gram developed by the authors. Most patients found
that the training helped them engage in the relaxation
process during postoperative music therapy while
sitting in a chair for the first time after surgery.
Based on the information gathered in the feasi-
bility study, the authors developed a protocol to test
the effectiveness of the preoperative training program
in a randomized controlled study. The purpose of the
study was to evaluate the effectiveness of a preopera-
tive training program on AIS patients pain and anxiety
perception after SF surgery.
METHODS
The hypothesis was that adolescents who received pre-
operative training in music-assisted relaxation would
experience less pain and anxiety during their first
out-of- bed experience following SF surgery than ado-
lescents who did not receive the training. A random-
ized study design was used to test the hypothesis.
Intervention
The research team developed a 12-minute video
training program that provided the following: 1) a brief
description of music therapy in the pediatric hospital,
2) a brief description of music-assisted relaxation, 3) a
demonstration and an opportunity to practice music-
assisted relaxation and breathing techniques with
quiet guitar music and breathing cues, 4) and a sample
music therapy session with a model SF patient. An
informational video for parents also was developed to
help parents understand some potential reactions of
their child after surgery and what to expect from the
postoperative music therapy session.
Ethics
This study was approved by the institutional review
board for protection of human subjects. Written
informed consent was obtained from parents of minors
and written assent was obtained from participants un-
der the age of 18.
Setting and Sample
This study was performed in a large Midwestern ter-
tiary hospital. AIS patients between the ages of 10
and 19 years who were scheduled for SF surgery, spoke
English, and had no hearing deficits were approached
for participation in this study during their preoperative
clinic visit. This visit was typically the day prior to
surgery.
Instruments
Data collection included self-reported pain and anxiety
before and after the music therapy session. Individual
pain and anxiety change scores (difference between
self-report before therapy started and immediately af-
ter therapy) were the primary outcome measures. A
0 to 10 numeric rating scale (NRS) was used to mea-
sure the variables of pain and anxiety, with anchors
of no pain at all (or no stress at all) to pain as bad
as it could be (or very bad stress). In the pilot study,
the authors asked teens what words they would use
to describe the anxiety they felt in the hospital and
the term they used most frequently was stress. There-
fore, the authors used the term stress on the anxiety
scale. The NRS was used because it is the same scale
routinely used by the hospital nursing staff to assess pa-
tient pain.
Observation of pain behaviors is an important
step in assessing pain intensity (American Academy
of Pediatrics and American Pain Society, 2001;
Joestlein, 2015). Because patient populations may
express pain and anxiety in different ways, it
sometimes is necessary in clinical research to adapt
tools to fit the needs of the group being studied
(Malone, 1996; Tan, Yowler, Super, & Fratianne,
2010). The development of the authors observation
tool was guided by the Faces, Legs, Activity, Crying,
and Consolability Pain Scale (FLACC), a commonly
used behavioral pain assessment tool (Joestlein,
2015; Srouji et al., 2010). Because the authors
experience working with this population indicated
that SF patients tend to sit very still with minimal
movement to help them limit additional pain, a
behavioral observation tool was created to document
clinically observed relaxed or distressed patient
behaviors. Relaxed behaviors were slow breathing,
humming along with the therapist, relaxed facial
muscles, and relaxed hands. Distress behaviors were
crying, complaining, tight facial muscles, and tight
fists. Content validity was established by consultation
with 3 board certified music therapists familiar with
pain behaviors of adolescents after SF surgery. Inter-
rater reliability for this measurement tool was 90%.
Behavioral observations of distress and relaxation
behaviors were recorded during the music therapy ses-
sion using time sampling at 30-second intervals.
Behavior codings were not exclusive; all behaviors
could be coded together during an observation time
if they occurred. A research assistant blind to group
assignment made the observations.
At the study hospital, all SF patients are given pa-
tient controlled analgesia (PCA) with morphine titrated
to body weight. The number of PCA attempts by the
patient and actual injections infused during the time
 Music Therapy for Adolescents
out of bed were tracked as another indicator of pain
intensity.
Parents were asked to evaluate the effect of the
music-assisted relaxation session for their children. A
parent survey developed for this study used open-
ended questions to solicit parent feedback. The
following questions were included on the survey: Did
the music therapy session help your child relax? Did
the music therapy help your child manage pain? How
would you describe your childs comfort after the mu-
sic therapy session? Parents also were asked for any
advice for making the experience better.
Procedures
Participants were assigned randomly into either the
treatment or the control group. At the preoperative
visit, participants in the treatment group viewed the
training video and had the opportunity to practice
the breathing technique along with the video. Parents
of adolescents in the treatment group viewed the
parent video. Noise reducing headphones and iPads
were used to present the videos simultaneously to
the patients and their parents. The research assistant
remained in the room with them to ensure treatment
fidelity and to answer questions. All patients were
asked to identify their musical preferences by asking
them to name a favorite song and/or select a preferred
musical genre (e.g., pop, country, or other common
musical genre). The pre-operative training session
took approximately 20-30 minutes. Patients and par-
ents in the control group did not view the videos.
Postoperatively, two board certified music thera-
pists (MT-BC) provided the music therapy sessions
for participants in both the control and the treatment
groups. Both therapists were trained to use the same
protocol and they were assigned to sessions based on
availability. The music therapists and behavioral
observer were blinded to the treatment condition. All
participants received a music therapy session on post-
operative day 2 in their hospital room for approxi-
mately 30 minutes while they sat in a chair for the
first time after surgery. A physical therapist assisted
the patient with moving from the bed to a chair and
paged the music therapist to coordinate timing of ser-
vices. The research assistant asked the participant to
rate pain and anxiety levels with the NRS prior to the
music therapist entering the room. The session con-
sisted of 5 minutes of breathing awareness and oral di-
rection to inhale through the nose and exhale through
pursed lips. Following the breathing, 10-15 minutes of
guided autogenic relaxation and safe place imagery
was facilitated by the music therapist. The music ther-
apist accompanied the relaxation exercise with a
19
simple and repetitive musical progression performed
on the guitar. The final 10-15 minutes consisted of
the participants preferred songs sung by the music
therapist with guitar accompaniment. Although songs
may have been from popular and country genres, they
were performed with a slow tempo, low rhythmic
complexity and consistently soft volume. At the
completion of the session, the therapist left the room
and the research assistant asked the participant to
rate post-session pain and anxiety using the same
NRS instrument used before the therapy. The research
assistant also left the parent survey with the parents
and asked them to return it to the unit clerk when
completed.
Data Analysis
Data were analyzed using SPSS 22.0 (Armonk, NY: IBM
Corp.). Categorical data were compared with nonpara-
metric tests such as Chi-square, Fischers exact and
Mann-Whitney U. Independent t-tests for group differ-
ences were used to examine pain and anxiety change
scores (e.g., the differences between pre-intervention
and post-intervention pain and anxiety scores). Paired
student t-tests were used to examine paired data (e.g.,
the pre-intervention and post-intervention pain and
anxiety scores of individual participants). Pearson cor-
relation was used to assess relationships among
variables.
RESULTS
All of the subjects were scheduled for SF surgery to cor-
rect AIS. Forty-five adolescents between the ages of 10
and 19 were approached to participate in the study
and 44 agreed to participate. Participants were as-
signed randomly to the control or treatment group.
There were no significant group differences for sex,
age, or length of music therapy session, as shown in
Table 1. Three participants were dropped from analysis
(one from the treatment group and two from the con-
trol group) because of inability to complete the music
therapy session. One participant had delayed surgery
and two participants experienced hemodynamic insta-
bility after surgery.
Group analyses for pain and anxiety scores are
found in Table 2. Both groups had significant decreases
in pain and anxiety following music therapy. The Co-
hens d effect size for change in pain score for the treat-
ment group was 1.09 vs. 0.99 for the control group; for
change in anxiety, the treatment group effect size was
0.88 vs. 0.86 for the control group. Although the treat-
ment group had slightly greater changes for pain and
anxiety, the differences between groups were not sta-
tistically significant.
20 Nelson, Adamek, and Kleiber

TABLE 1.
Characteristics of Control and Treatment Group Participants
Control Group Treatment Group Significance
Characteristics (n 22) (n 19) (p Value)

Number of females/males 19/3 18/1 .610*

Median age in years (range) 14 (11-15) 14 (10-19) .214
Median number of behavioral observations (range) 30 (18-40) 30 (20-45) .977
*Fischers exact test.

Mann-Whitney U test.

Observations of behavior indicating relaxation or
distress were made on a time sampling schedule of
every 30 seconds. The most frequently observed be-
haviors were calm, relaxed, and fidgeting. The fre-
quency of each behavior for the control and
treatment groups was similar. The control group was
calm during 91% of the observations vs. 88% for the
treatment group, relaxed for 87% vs. 80%, and fidgeting
14% vs. 19%.
For the entire sample there was a significant rela-
tionship between change in pain score and change in
anxiety (r .70; p < .00). There were no significant re-
lationships between age and change in pain (r .01;
p .96), age and change in anxiety (r .05;
p .78) or age and the amount of calm behavior during
music therapy (r .17; p .31). There were too few
male subjects to investigate the effect of sex.
The authors attempted to quantify pain by
recording the number of PCA attempts and injections
made by participants during the music therapy session
and during the following hour. However, technical dif-
ficulties such as not getting the pump history cleared
in a timely fashion resulted in too much missing data
for meaningful analysis.
Only 14 parents from each group returned the
written surveys. In the treatment group, 11 of 14 par-
ents said the therapy helped with pain management
and 12 of 14 said it helped the child be more relaxed.
Similarly, in the control group, 13 of 14 said the ther-
apy helped with pain and 12 of 14 said the child was
more relaxed. Several parents in each group noted
that the therapy was relaxing for the family members
as well as the child.
DISCUSSION
Although the results from this study trended toward
positive outcomes, the hypothesis was not sup-
ported. The patients in the treatment group had
only one brief training session during which they
viewed the video and could practice on their own.
Presurgical training may have been more effective if
the patients had additional opportunities to practice
the music-assisted relaxation and breathing

TABLE 2.
Differences for Pain and Anxiety
Pre/Post Pain and Anxiety Control Group Treatment Group Significance* (p Value)

Pain
Pre-MT pain, M (SD) 7.6 (1.8) 7.7 (2.0) .789
Post-MT pain, M (SD) 5.4 (2.5) 5.1 (2.7) .700
Change in pain, M (SD) 2.1 (2.1) 2.6 (2.7) .521
Significance (p value) <.001 .001
Anxiety
Pre-MT anxiety, M (SD) 6.1 (2.6) 6.0 (3.0) .879
Post-MT anxiety, M (SD) 3.7 (2.9) 3.5 (2.7) .762
Change in anxiety, M (SD) 2.4 (2.0) 2.5 (2.7) .855
Significance (p value) <.001 .001
M mean; MT music therapy; SD standard deviation.
*Independent t-test.

Paired t-test.

Statistical significance set at values <.05.
 Music Therapy for Adolescents
techniques beyond the one session at intake. The
training was completed in a single session to control
for variability in the amount of time spent practicing
and a member of the research team was with the pa-
tient as he or she viewed the video. To increase prac-
tice time, the initial viewing might be done with the
research team member and then the patient could be
directed to view the video and practice again prior to
the surgery.
According to LeRoy (2003), the best time to pre-
sent preoperative coping information to adolescents
is about 1 week before surgery. Often the adolescents
preoperative visit is the time when information about
anesthesia, what to expect in the hospital, pain man-
agement, and recovery is discussed. In the clinical
setting, however, it is not possible to dictate the timing
between the preoperative visit and surgery. In the au-
thors tertiary care setting, many patients travel long
distances to the hospital and spend the night before
surgery at a hotel. This means that they receive
detailed information about the surgical procedure
and recovery just a day before the operation. One
possible explanation for not finding a difference be-
tween treatment and control groups in this study is
that the timing between the training intervention and
the music therapy was too short. The current findings
differ from the study by LaMontagne (2003) who
administered coping instructions via videotape the
day before SF surgery and found a significant difference
between treatment and control groups for reduction in
pain scores on the second postoperative day. More
research is needed on how and when to train adoles-
cents on managing their postoperative pain.
Parents of the adolescents in the treatment group
were invited to view a video made specifically for par-
ents of teens having surgery. The video described
typical behavior of postsurgical teens and how parents
could help. Although this study did not address the ef-
fects of the parent video directly, the authors believe
that including parents in hospitalized childrens pain
management is very important. The model of pain
empathy states that there is a complex series of reac-
tions in which automatic behaviors of the child, such
as facial expression, elicit emotional reactions and be-
haviors from the caregiver (Craig, Versloot, Goubert,
Vervoot, & Crombez, 2010; Goubert et al., 2005).
The pediatric fear-avoidance model emphasizes the
reciprocal influences of parent and child in the experi-
ence of pain behaviors. When highly anxious parents
see their child in pain, they become more upset,
causing the child to display high emotional distress
and report higher pain intensity (Esteve, Marquina-
Aponte, & Ramirez-Maestre, 2014). Many parents sur-
veyed in this study commented that they felt more
21
relaxed after their childs music-assisted relaxation ses-
sion. Based on this model, it is possible that parents in
the room may benefit from the music therapy interven-
tions during a very stressful time, consequently
decreasing their childs pain and distress.
Patients demonstrated wide variability in their
observed relaxed and distress behaviors, and there
was no significant difference between the treatment
and control groups. This variability could be related
to individual patients abilities to cope with anxiety
and pain in the hospital setting. These were all novice
patients who were not used to being hospitalized and
they had not developed coping skills to deal with the
hospital experience.
Specific data were not collected on the length of
time needed by the patient to engage with the thera-
pists; however, this was noted in discussion with the
therapists at the conclusion of the study. When the
therapists were unblinded to treatment groups after
conclusion of the study, they recognized a difference
in the groups related to the length of time needed by
the subjects to engage in the music-assisted relaxation
and breathing techniques. Subjects who had viewed
the training video were familiar with the concept of
music-assisted relaxation with controlled breathing,
and they knew what to expect from the music therapy
session. Many of these subjects began the breathing as
directed as soon as the therapist began the session.
Some even started using the breathing techniques as
soon as they saw the therapist enter the room. Subjects
in the control group took longer to engage with the
music-assisted relaxation techniques.
LIMITATIONS
Specific limitations for this study are small sample size,
missing data for PCA usage, and the parent survey
response rate. For collecting the PCA data, the authors
needed to have the participants nurse available to re-
cord and clear pump data (e.g., PCA attempts and in-
jections) for the time during the music therapy and
for the following hour. In the authors hospital, that ac-
tion required the additional step of logging the infor-
mation into the electronic medical record. As with all
clinical research, the availability of busy staff nurses
can be unpredictable. To relieve staff nurse burden
and still collect the needed information for research,
it might be best for future studies to have a nurse on
the research team who would be free to help. Lack
of study personnel time also probably contributed to
the low return of parent surveys. If the authors had
told the parent that the research assistant would return
the following day to pick up the survey, return rates
might have improved.
22 Nelson, Adamek, and Kleiber
The authors acknowledge that perception of pain
intensity is influenced by many factors, such as medica-
tions other than those delivered by PCA, the amount of
tissue damage resulting from surgery, previous experi-
ence with pain and anxiety-reducing strategies, and in-
dividual personality characteristics. These are factors
that could be controlled for in a larger study.
NURSING IMPLICATIONS
Preoperative preparation for adolescents who are un-
dergoing significant surgical procedures is compli-
cated. These young people need to be prepared with
coping strategies and realistic expectations for recov-
ery, but care must be taken not to make them overly
anxious about the upcoming hospital stay. With
restricted time available for teaching and a large
amount of information to convey, it is imperative that
the health care disciplines collaborate to design preop-
erative education programs that are effective and
feasible. The authors suggest that surgeons, anesthesi-
ologists, pain management nurses, postoperative
nurses, physical therapists, psychologists, music thera-
pists, and past patients come together to develop a
comprehensive integrated teaching package that is
supported by the entire team. Testing of the integrated
package then should be done in an interdisciplinary
fashion.
In this study, a board-certified music therapist pro-
vided music therapy, using live music as opposed to re-
corded music, specifically chosen to engage and calm
the individual patient, along with instructions for
controlled breathing. When music therapists are avail-
able, nurses should proactively involve them in pain
management and relaxation practices for postopera-
tive adolescents. When music therapists are not avail-
able, someone other than the parent should be
designated as the support person for adolescents
when they begin to move out of bed after surgery.
The support person should be familiar with relaxation
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It is important to note that although the results of the
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Pain and anxiety scores for both groups decreased
from pre- to post-test. An average decrease of more
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Acknowledgments
The authors wish to acknowledge the staff of the University
of Iowa orthopedics department, especially Stuart Weinstein,
M.D., and Flo Panther, R.N., for their support, communica-
tion, and assistance with enrollment; The University of
Iowa Stead Family Childrens Hospital inpatient pediatric
nursing staff, especially Heather Eastman, RN; Rehabilitation
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 Music Therapy for Adolescents
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