









































Volume 5 - No. 2 2017

Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 5 - No. 2 2017 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 5

How Is Intraoperative Music Therapy Beneficial to Adult Patients Undergoing General 
Anesthesia? A Systematic Review

D. A. Flanagan, MSN, CRNA, DNPc1

Athena Kerin, MS, CRNA2

Affiliation:
1 Columbia University, New York. Doctoral Candidate at Columbia University in New York, New York. Graduate of Samford University Masters of Science in Nursing with an 
Anesthesia concentration

2SUNY Downstate Medical Center, New York, NY. Associate Program Director, Nurse Anesthesia, College of Nursing, SUNY Downstate Medical Center

Funding/Conflict of Interest Disclosure: 
There was no financial support for the study. The authors have no conflicts of interest to report. Columbia University School of 
Nursing had no role in the design or conduct of the study; the collection, management, analysis, or interpretation of the data; the 
preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

KEYWORDS: Music Therapy, General Anesthesia, Surgery, Intraoperative, Headphones, Pain

INTRODUCTION
The use of music for the treatment of disease processes and ailments can be traced back for millennia. Light et al1 found 
evidence of the use of music for medical treatment as far back as 2500 BC. For centuries, the benefits were observational at 
best, but music remained as an acceptable adjunct therapy for patients in the health care arena. In English hospitals in the 19th 
century, musicians were hired to play for sick patients.1 Physicians and scientists began to study the effects on physiology and 
the benefits of music at the turn of the 20th century. It was then that physicians across the world began to record the changes 
caused by music on vital signs. Farr1 pioneered the idea of music in operation suites as early as 1929. In the late 1940s, Pickrell 
and his research team spent 6 years studying the effects of music therapy on preoperative, intraoperative, and postoperative 
surgical patients.2 Their research findings suggest that patients experience decreased fear and apprehension when music is 
an added element of the surgical experience. Pickrell et al2 also noted the use of headphones to be beneficial, not only for 
delivering the intervention but also as a tool for blocking out nonreassuring noise and conversation inside the surgical arena. 
Theses surgeries were exclusively performed on sedated patients receiving local, spinal, or regional anesthesia. Systematic 
reviews to date have included regional anesthesia (ie, epidural, spinal, and local anesthesia), monitored anesthesia care, and 
general anesthesia3; however, the present systematic review focused only on those interventions done under general anesthesia.

Abstract
Today’s expanding role of technology and the internet-of-things has become an integral aspect of the treatment 
modalities of health care providers throughout health care systems. With the advent of new devices and online music 
services, every genre of music is merely a finger touch away for each and every patient. Music therapy has been accepted 
as a beneficial tool used for the treatment of anxiety and pain relief for the conscious patient. Research has also been 
conducted to examine the analgesic benefits of music therapy on the patient undergoing general anesthesia. This 
systematic review focused on answering the aforementioned question regarding the added effects of music therapy. After 
thorough examination of the literature, it was concluded that the incorporation of volume-protective headphones and 
patient-chosen music therapy can be an effective and inexpensive intervention during general anesthesia with statistically 
significant results for decreased pain, decreased opioid needs, and increased patient satisfaction.

AEJ



Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 5 - No. 2 2017 Page 6

REVIEW OF THE LITERATURE
Looking at the effects of music during the intraoperative 
care of the patient under general anesthesia is a subject that 
has received little scrutiny and study compared with that of 
patients undergoing regional or spinal anesthesia or sedation. 
Numerous studies have been completed to show the benefit and 
perceived benefit of music therapy on the anxiety level of patients 
preoperatively and intraoperatively, but few have specifically 
addressed the analgesic effects intraoperatively and under general 
anesthesia.4

Anecdotally, in the 1950s music therapy was believed to have 
a limited effect on the patient undergoing general anesthesia 
beyond anxiety relief. Light et al1 writes of physicians proclaiming 
that music would have no ability to diminish pain or pain 
perception. One of the leading pioneers helping to demystify 
or debunk that concept was composer and researcher Linda 
Rodgers Emory (professionally: Linda Rodgers). In an interview, 
Hershenson5 expresses how Rodgers challenged this theory by 
writing music designed for patients to listen to via headphones 
throughout the perioperative period. Patients undergoing general 
anesthesia or spinal anesthesia showed a decrease in analgesic 
narcotic intervention compared with patients who did not receive 
supplemental music therapy during their surgical course.5

At least 2 studies have documented the stress responses of 
sound therapy intraoperatively on patients undergoing general 
anesthesia. Migneault et al6 conducted a pilot study of 30 
patients that examined the stress response of female patients 
intraoperatively while listening to their choice of music during 
the administration of general anesthesia. The patients chose 1 
of 4 genres of music in the preoperative department and then 
had intraoperative blood drawn from an arterial line that had 
been placed during the induction of anesthesia. Blood samples, 
collected at timed intervals, measured comparable blood levels 
of epinephrine, norepinephrine, cortisol, and adrenocorticotropic 
hormone between a music therapy group and a control group. 
The second study utilized hemispheric-synchronization (Hemi-
Sync; Monroe Products, Lovingston, VA) therapy. Hemi-Sync 
therapy is the process of listening to sound waves through 
headphones that theoretically cause the brain to create a 
third sound, the binaural beat, which synchronizes both sides 
of the brain and aids in relaxation, pain response, and sleep 
patterns.7 The implementation of intraoperative hemispheric-
synchronization therapy provided evidence for a reduction in 
hormonal stress response for patients during surgery.8 These 
studies serve as a springboard into the potential benefits of the 
adjunct, noninvasive, and cost-effective treatment modality of 
intraoperative music therapy for patients undergoing general 
anesthesia.
Given the side effects associated with opioids, including nausea, 
prolonged time to wake up, and decreased respiratory effort, 
it would be beneficial to add a noninvasive, low-cost, patient-
empowering intervention that would significantly increase 
analgesia while simultaneously decreasing side effects associated 
with narcotic administration. The aim of this systematic review 
was to determine whether intraoperative music therapy for adult 
patients is an effective modality to be used in the practice of 
general anesthesia. The 2 variables used to measure outcomes were 

the patient pain score on a visual analogue scale (VAS) and the 
amount or quantity of pain medicine administered via anesthesia 
staff or postoperative nurse (as morphine-equivalent dosing).
SEARCH STRATEGY METHOD
A literature search of articles published from January 1980 to 
January 2016 was performed on the Ovid MEDLINE database 
(Ovid, New York, NY), the Cumulative Index to Nursing and 
Allied Health Literature (CINAHL; EBSCO, Ipswich, MA), 
PubMed (National Library of Medicine, Bethesda, MD), Embase 
(Elsevier, Amsterdam, Netherlands), and the Cochrane Library 
(The Cochrane Collaboration, London, United Kingdom). 
Articles reporting findings from studies on human subjects 
and written in English were considered. The following search 
terms were used: music, surgery, therapy, anesthesia, anaesthesia, 
pain, preoperative, intraoperative, and postoperative. The search 
was executed with words individually and with combined 
searches including music/surgery, music/therapy, and music/
surgery/therapy to gather the widest range of research articles. 
Exclusion criteria for articles included patients aged less than 18 
years; studies that used regional anesthesia, local anesthesia, or 
monitored anesthesia care; and any nonrandomized clinical trials 
as well as studies that only measured anxiety scores as an outcome 
variable. Inclusion criteria included randomized clinical trials 
(RCTs) written in English and those whose outcome measures 
were pain score, narcotic amount received, and/or patient 
satisfaction. Minimally, studies needed to explicitly include the 
music therapy intervention during the intraoperative period.
Following the primary search, a secondary search using Scopus 
(Elsevier, Amsterdam, Netherlands), The Virtual Health Library 
(World Health Organization, Geneva, Switzerland), and hand 
searching was conducted. Duplicate articles were removed 
while studies including RCTs and performed in adult patients 
were included in the second screening. The remaining articles 
were analyzed and those measuring only anxiety as an outcome 
measure were discarded.
Music interventions were limited to those carried out both 
preoperatively and intraoperatively, intraoperatively alone, 
intraoperatively and postoperatively together, as well as those 
RCTs that performed the music interventions throughout the 
surgical experience.
Quality Appraisal
A quality appraisal of each study was achieved by using the 
PEDro scale to rate articles. The PEDro scale was established 
to aid readers in determining the external and internal validity 
of RCTs, specifically those trials stored on the PEDro database. 
The scale does not measure the validity of conclusions but does 
take into account whether an RCT has sufficient statistical data 
to make interpretations. The PEDro scale questions, which are 
depicted in Figure 1, are answered on a yes or no basis. Each yes 
is rewarded 1 point for a total potential score of 10. RCTs that 
score >6 to 10 are regarded as moderate to high-quality RCTs 
with respect to methodology. Verhagen and partners at the 
Department of Epidemiology, University of Maastricht, derived 
these criteria from the Delphi list.



Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 5 - No. 2 2017 Page 7

Figure 1. The PEDro Scale for Determining the External and 
Internal Validity of Randomized Clinical Trials. Source: Centre 
for Evidence-Based Physiotherapy (https://www.pedro.org.au).

The PEDro scale was used to assign each article a total 
quality score for methodology and was subsequently analyzed 
for outcome measures. Quality appraisals were completed 
individually by both the author and the co-author and then 
compared and discussed to come to a consensus of ratings.
RESULTS
The primary search yielded 103 articles, whereas a secondary 
search using Scopus, the Virtual Health Library, and hand 
searching yielded an additional 438 articles. After accounting 
for duplicate articles, a total of 504 articles were screened for 
eligibility for the review. Of the 504 screened, 426 were excluded, 
leaving only RCTs for adult patients. The remaining 78 articles 
were further analyzed and articles that did not meet the inclusion 
criteria, such as those measuring only anxiety as an outcome 
measure, were discarded.
As outlined in Figure 2 on the PRISMA flowchart,9 8 RCTs met 
the inclusion criteria following this literature search.10-17 All of 
the 8 studies assessed were published between 1995 and 2013.
Figure 2. PRISMA Study Flowchart.
The 8 RCTs differed in patient characteristics and type of surgery. 
The musical intervention varied by type as well as the timing of 
the intervention, which included preoperative and postoperative 
music therapy in addition to the mandated intraoperative period.
Baseline Characteristics
The 8 RCTs appraised included a total of 610 patients. The range 
of sample sizes for each study was from a study13 of 10 to the 
largest study16 of 151. The mean age of the patients ranged from 
35 years in one study14 to 61 years in the study11 with the most 
advanced age. Three10,14,15 of the studies included only female 
participants and the remaining 5 RCTs11-13,16,17 included both men 
and women as participants.
The patients in the RCTs underwent a number of elective 
surgeries. The variety of surgeries included gynecology, cardiac, 

abdominal, breast, and orthopedic surgeries. One study of 
gynecological surgical patients had a broader inclusion criterion 
for the types of surgeries performed.14 The other 7 studies had 
specific criteria for the type of patients within the study so that all 
participants were undergoing the same surgical procedure.10-13,15-17

Intervention
The vast majority of RCTs included the musical intervention both 
intraoperatively and postoperatively (n=7). Of those 7 studies, 
3 also included the musical intervention preoperatively.10,12,14 
Only one study placed the musical intervention solely during the 
intraoperative period.15

The type of music varied among the studies. Two of the studies 
gave participants a choice of the genre of music.10,13 The choices of 
genre included classical, easy listening, new age, and inspirational 
in one study10 versus classical, country, and instrumental in the 
other study.13 The other 6 studies supplied patients with no 
consistent musical intervention.11,12,14-17 Despite the differing 
musical intervention, researchers in each study chose music that 
had been deemed soothing and calming, from Musicure (Gefion 
Records, Copenhagen, Denmark)12 to sea waves and calm sounds 
to Dreamflight II by Herb Ernst.11

Records identified through database 
searching PubMed, Embase, 
CINAHL, Cochrane Library 

(n =103) 

 Additional record identified 
through other sources: Scopus 
Virtual Health Library and hand 

searching (n=438)

Records after duplicates removed (n = 504)

Records screened 
(n = 504) 

Records excluded 
(n = 426) 

Full-text articles  
assessed for eligibility 

 (n = 78) 

Full-text articles excluded, with 
reasons (n= 70) 

10 Wrong anesthetic (regional) 
 
21 Wrong comparator (anxiety/
time) 
 
8 Wrong intervention (hemi-sync/
dance/hypnosis)  
 
2 Wrong population  
 
29 Wrong study design  

Studies included in 
qualitative synthesis 

(n = 8)

Ide
nti

fic
ati

on
s

Sc
re

en
ing

El
igi

bil
ity

Inc
lud

ed
Figure 2

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred 
Reporting Items for Systematic Reviews and Meta- Analyses: The PRISMA Statement. PLoS 

Med 6(6): e1000097. doi:10.1371/journal.pmed1000097

For more information, visit w ww.prisma-statement.org.



Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 5 - No. 2 2017 Page 8

The majority of studies used headphones for the participants 
(n=7). One of the studies used a musical pillow for the 
participants.12 The volume of music differed among participants 
from study to study. Three studies set the audio level at the 

same level for each participant.15-17 Two10,13 studies allowed the 
patients to set their preferred volume level with only one10 of 
these 8 RCTs setting a maximum decibel level (70 dB). The study 
characteristics are summarized in Table 1.

Table 1. Characteristics of the 8 Studies Included in the Systematic Reviewa

Study Authors, 
Year, Setting & 
Study Type

Quality 
Score

N, Surgery Type & Mean Patient Age 
(y)

Tool Used 
to Assess 
Outcome

Intervention 
Period

Groups

Binns-Turner et al10

2011, USA
Quasi-Experimental 
Study

10 • N = 30 F (convenience sample)
• Mastectomy for breast cancer
• Mean Age = 57

VAS for pain • Preop
• Intraop
• Postop

1. Music therapy
2. Control 

Blankfield et al11

1995, USA
Single-Blind Trial

9 • N = 95 (30 F, 65 M)
• Coronary artery bypass
• Mean Age = 61 

Amount of 
narcotic 
administered 
postop

• Intraop
• Postop: 30 min 
twice daily

1. Suggestion therapy
2. Music therapy
3. Control

Graversen & Sommer12

2013, Denmark
RCT

9 • N = 75 (55 F, 20 M)
• Laparoscopic cholecystectomy
• Mean Age = 47

VAS for pain 
and amount 
of narcotic 
administered 
postop

• Preop
• Intraop
• Postop

1. Music therapyb
2. Control 

Heiser et al13

1997, USA
Repeated-Measures 
Experimental Design

8 • N = 10 (5 F, 5 M)
• Lumbar microdiscectomy
• Mean Age = 39

VAS for pain • Intraop
• Postop

1. Music therapy
2. Control

Laurion & Fetzer14

2003, USA
Experimental Pilot 
Study

8 N = 84 F
Gynecological laparoscopic surgery
Mean Age = 35 

VAS for pain • Preop: at least 
2 times a day

• Intraop
• Postop

1. Guided imagery
2. Music therapy
3. Control

Nilsson et al15

2001, Sweden
Double-blind RCT

10 • N = 89 F
• Hysterectomy
• Mean Age = 51

VAS for pain • Intraop 1. Music therapy
2. Combined: music 

and therapeutic 
suggestions

3. Control
Nilsson et al16

2003, Sweden
RCT

10 • N = 151 (44 F, 107 M)
• Inguinal hernia repair or varicose veins
• Mean Age = 54

VAS for pain • Intraop
• Postop

1. Intraop music 
therapy

2. Postop music 
therapy

3. Control 
Nilsson et al17

2005, Sweden
RCT

10 • N = 75 (3 F, 72 M)
• Open hernia
• Mean Age = 56 

VAS for pain • Intraop
• Postop

1. Intraop
2. Postop
3. Control 

aAbbreviations: F, female; Intraop, intraoperative; M, male; Postop, postoperative; RCT, randomized clinical trial; VAS, visual analogue scale.
bTherapy chosen per day and not per patient.



Quality
Four of the 8 RCTs were evaluated to have the maximum quality 
methodology score of 10 as measured by the PEDro scale.10,15-17 
The range of scores was from 8 to 10 with a mean score of 9. 
Two11,12 studies received a 9 and the two13,14 remaining studies 
received an 8.

The majority of the included studies (n=7) utilized a valid and 
reliable measurement for the outcome measures. These 7 studies 
all used a VAS in order to measure the level of pain of each 
participant.10,12-17 The one11 remaining study used continuous 
measurements in order to measure the overall quantity of 
narcotics administered for comparison.
Blinding
Six of the studies were single-blind studies.10,11,13,14,16,17 These 
studies placed headphones on all participants. Researchers would 
then provide the intervention group with the music therapy CD 
or tape and the control group listened to a blank tape or CD. One 
study was double-blinded for the patients and the researchers, as 
headphones were placed on the participants intraoperatively.15 
Neither the researcher nor the participant knew to which group 
the participant was ascribed. One study had no blinding as the 
therapy was provided aloud without headphones compared with 
the control group without any music.12

Three of the 8 studies had true computer-generated 
randomization to groups for participants.15-17 Another 3 of the 
RCTs did not offer specific terms for randomization.11,13,14 These 
studies did mention that patients were randomly assigned to 
groups. The remaining 2 studies drew numbers from resalable 
bags.10,12 One study10 drew numbers for group determination, 
whereas the other study12 drew numbers for that day’s 
intervention (music therapy day vs control or non-music-therapy 
day). The quality appraisal results are graphed in Figure 3.
Figure 3. Randomized Clinical Trial Quality Appraisal 
According to PEDro Score.

Outcome Measures
All of the 8 articles reviewed had the common outcome measure 
of pain. Pain was measured in 2 different ways, either with a VAS 
or by the amount of analgesic administered.

Seven of the RCTs used a VAS to measure the pain of the 
participants at various stages during the study.10,12-17 One study 
showed a significantly greater decrease in pain levels for the 
intervention group and a lower pain score postoperatively.10 In 
another study, half of patients who listened to the music stated 
that it was helpful and these same satisfied participants also 
received fewer analgesics than did the control group.11 In one 
article, the participants of the music group had less pain on 
postoperative day 7.12

When comparing analgesic use, 6 articles reviewed used 
morphine equivalents as the outcome measure of pain.11-13,15-17 
Two studies showed no difference in the amount of morphine 
equivalents.11,12 It is important to note that general anesthesia 
can induce physiological fluctuations that require immediate 
and active intervention. Opioid analgesics, such as morphine 
or hydromorphone hydrochloride (Dilaudid, Purdue Pharma), 
are administered when pain is considered a differential 
diagnosis. Studies are lacking regarding treatment thresholds 
in managing the patient’s hemodynamic status intraoperatively 
when treating pain. However, 4 studies showed that the 
music therapy group required less analgesic medicine after 
discharge.13,15-17 Table 2 highlights the data collection measures 
and results of each study.

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Volume 5 - No. 2 2017 Page 9



Table 2. Study Interventions, Results, and Limitations for the 8 Studies Included in the Systematic Reviewa 
Study Data Collection Intervention Results Limitations
Binns-Turner et al10

2011, USA Preop and dis-
charge

• Music selection: participants chose 
between classical, easy listening, 
inspirational, or new age

• Headphones: Yes
• Limited volume 70 dB
• Double-blind

• Women in intervention group reported 
significantly greater decrease in pain levels

• Pain significantly lowered and improved 
postoperatively in intervention group

1. Type II error (need larger sample size)
2. Hawthorne effect: patients knew pain was being 

measured

Blankfield et al11

1995, USA Discharge and 1 mo 
after discharge

• Music selection: patient had no choice; 
Dreamflight II by Herb Ernest

• Headphones: Yes
• No mention of volume
• Double-blind

• No significant difference in amount of morphine 
equivalents

1. Suggestion group had background music (music 
vs. suggestion)

2. Patients only listened for a short period
3. No preop listening 

Graversen & Sommer12

2013, Denmark 1 h postop, 3 h 
postop, 1 d postop, 
and 7 d postop

• Music selection: patient had no choice; 
Musicure

• Headphones: no (musical pillow)
• No mention of volume
• Single-blind

• No significant difference in amount of morphine 
in recovery

• No difference at primary endpoint at 3 h
• Music group reported less pain at day 7

1. Minimally invasive surgery not painful enough to 
show difference at end of surgery

2. Music could be heard from small distance
3. Participants could not shut out external sounds of 

unit
4. Study design did not allow blinding
5. Patient personal music selection

Heiser et al13

1997, USA 1 h in PACU and 
24 h after surgery 
before discharge

• Music selection: participant chose 
between country, instrumental, 
classical

• Headphones: Yes
• Patient chose preferred volume level
• Single-blind

• Music group required less analgesic 
medications after discharge

1. Type II error (need larger sample size)
2. No preop/baseline for pain levels

Laurion & Fetzer14

2003, USA
Experimental 
Pilot Study

On arrival to PACU, 
1 h, and discharge 

• Music selection: participant had no 
choice (piano); Naparstek “Health 
Journeys for People Undergoing 
Surgery”

• Headphones: Yes
• No mention of volume
• Double-blind

• Control group had higher pain score at 
discharge to home

1. Type II error (need larger sample size)
2. Patient personal music selection
3. Ethnically homogeneous sample (all white)

Nilsson et al15

2001, Sweden Every hour for 1st 
24 h, then every 3 h 
until no pain

• Music selection: participants had no 
choice; sea waves and calm sounds

• Headphones: Yes
• Same audio levels for each patient
• Double-blind

• Day of surgery: music/therapeutic suggestions 
group required less analgesic medication than 
control group

• First day after surgery, music group had more 
effective analgesia with less pain and less 
pain medication administered

• Although not statistically significant, total dose 
of pain meds was lower in music group

1. Music better than soothing message (no difference 
added with combined verbal message)

2. Patient personal music selection

Nilsson et al16

2003, Sweden Every 0.5 h for 2 h 
postop, every 1 h for 
1st 24 h, then every 
3 h until no pain

• Music selection: participants had no 
choice; instrumental

• Headphones: Yes
• Same audio levels for each patient
• Double-blind

• Intraop group and postop group both had 
significantly lower pain scores at 1 h and 2 h 
postop

• Postop music group required less morphine at 
1 h

• No difference in music intraop vs postop (but 
beneficial)

1. Patient personal music selection

Nilsson et al17

2005, Sweden Data collection: 30 
min before anes-
thesia, 1 h after in 
PACU 

• Music selection: participants had no 
choice; soft new age synthesizer

• Headphones: Yes
• Same audio levels for each patient
• Double-blind

• Both groups had lower pain scores than control 
group at 1 h in PACU

• Postop group: less pain and required less 
morphine after 1 h in PACU

• Total morphine requirement was significantly 
lower than control group (intraop morphine 
requirement was lower as well but not 
significantly so)

• Increased pain relief and decreased morphine 
consumption

1. Subcutaneous local anesthesia infiltration at end 
of surgery

2. Patient personal music selection

aAbbreviations: intraop, intraoperative; PACU, post-anesthesia care unit; postop, postoperative; preop, preoperative.

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Volume 5 - No. 2 2017 Page 10



Almost 90% (7 of 8) of the articles reviewed showed a lower 
pain score for the music intervention group after arrival in the 
post-anesthesia care unit (PACU) or during the subsequent 
recovery period.10,12-17 One study measured both a preoperative 
pain score and a postoperative pain score.10 The participants in 
the music therapy group experienced a 41.4% smaller increase 
in pain compared with the pain levels of the women in the 
control group. Six studies compared the total quantity of opioids 
needed to achieve pain relief between the control group and 
the intervention group. Four of the 6 studies (67%) showed 
a decrease in morphine-equivalent dosing for patients in the 
music intervention groups.13,15-17 The other 2 studies showed 
no difference in the amount of dosing between control and 
intervention groups.11,12 Even when the dose of narcotics did not 
change, the pain perception was lowered as evident in the lowered 
pain scores recorded. In the 3 studies that used questionnaires 
to measure patient satisfaction with the surgical experience, all 3 
studies (100%) showed a higher patient satisfaction score for the 
music intervention groups than for the control groups.11,13,16

DISCUSSION

The results of this systematic review show that intraoperative 
music therapy for the patient receiving general anesthesia can 
reduce pain during the perioperative period as well as increase 
patient satisfaction with the surgical experience. By far, the most 
important finding among the 8 studies is that 5 studies resulted 
in significantly decreased pain scores in the music therapy 
groups who received intraoperative interventions.10,14-17 As an 
inexpensive intervention, with controllable volume-limiting 
damage perimeters, ie, the ability to increase the volume up or 
down to acceptable levels, intraoperative music has been shown to 
be beneficial for pain control and the overall surgical experience 
of patients.
This review shows the importance of music delivery as well as 
music selection on the outcomes of a music intervention for 
patients undergoing general anesthesia. Two studies allowed 
the participants in the intervention group to choose their type 
of music.10,13 The patients in these studies showed decreased 
pain and expressed positive surgical satisfaction. Patient music 
selection did not have a profound effect on the success of the 
music intervention nor a direct correlation to increased patient 
satisfaction, but it did allow control and autonomy in an 
otherwise unfamiliar, outsider-controlled environment. Allowing 
patients to choose their music empowers them with a sense of 
autonomy and control previously lost when entering the surgical 
suite.
Patient safety, both short- and long-term consequences, 
was regarded in the application of the music therapy. The 
Occupational Safety and Health Administration (OSHA) reports 
that sustained sounds above 70 dB can cause permanent hearing 
damage in humans.18 With operating room sounds easily reaching 
levels greater than 70 dB, various hazards associated with unsafe 
decibel levels are heard during surgery by staff and even worse, 
the anesthetized patient, who cannot attenuate audible sounds 
due to the muscle-relaxing effect of the anesthetic agents or 
drugs.19 Headphones are the best means of blocking out ambient 
operating room sound while also supplying the patient with a 
sustained safe decibel volume of music therapy. The majority of 

the studies, 5, either used devices with limits on volume output 
or allowed the participants to choose a suitable volume for their 
comfort level.10,13,15-17 The device that supplies the music should 
have a maximum volume <68 dB to prevent the risk of permanent 
hearing damage. With the National Institute for Occupational 
Safety and Health having declared that sound exposure to 90 dB 
for greater than 8 hours has the potential to cause irreversible 
hearing damage, OSHA18 concludes that a 25% decrease in 
volume ensures a healthy listening experience for the patient. Any 
music therapy implemented would need to ensure no harm to 
the patient and providing volume-limiting headphones resolves 
this issue. Given the results of this systematic review showing 
the benefits on patient pain scores, decreased narcotic use, and 
increased patient satisfaction of intraoperative music therapy for 
the patient under general anesthesia, Figure 4 outlines 5 major 
components to ensure the success of an intraoperative music 
therapy intervention.

Figure 4. Five Components of a Successful Intraoperative 
Music Therapy Intervention.

At the forefront of this discussion on music therapy and 
patient selection is an area for improved medical care. 
As a complementary method of improving pain control, 
patient-chosen music therapy offers the advantage of patient 
empowerment and patient-centered care. In the new landscape 
of medical access and knowledge, patients expect autonomy and 
decision-making authority from medicine as a service industry. 
Patient empowerment is a leading care model used throughout 
the health system and offers numerous benefits, including but not 
limited to patient satisfaction and patient accountability.20 Giving 
the patient the option to choose both empowers and increases 
patient satisfaction scores, and music therapy with its limited cost 
and additional analgesic benefits offers an inexpensive patient-
centered solution for patient care, comfort, and pleasure.

Future Research

As Zusman21 details, given the reimbursement change under 
the Patient Protection and Affordable Care Act, value-based 
patient care, measured by patient satisfaction scores, has taken 
a larger role in the management of care within American 
health care systems. The Hospital Consumer Assessment of 
Healthcare Providers and Systems (HCAHPS) survey is the 
national standard by which hospitals and patient experiences are 
measured and has become one of the elements that determine 
how much reimbursement facilities receive from the Centers for 
Medicare and Medicaid Services (CMS).22 As reimbursement 
changes, the effectiveness of intraoperative music therapy can 
prove very beneficial for increased reimbursement numbers for 
facilities throughout the health care system. With the decreased 

Checklist for Music Therapy in General Anesthesia

• Headphones (as procedure permits)
• Adjustable Volume not to exceed <68 dB
• Patient chosen genre
• Application upon OR entry (prior to induction)
• Discontinue >1 hour after PACU admission

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Volume 5 - No. 2 2017 Page 11



pain scores and added patient satisfaction, it will be important to 
dissect more details of the music therapy intervention.
These 8 studies included various types of music genres and 
selections as well as variously timed implementations. As more 
research is carried out, more details should emerge adding 
more validity to the specific genre of music that should be 
most beneficial to the patient. However, as the battle continues 
between patient-centered care and patient empowerment, 
surveys should be administered regarding the preferences of the 
patient themselves. If patients were actually given the choice of 
genre supplied during music therapy, would more satisfaction be 
obtained from the choice of “medically appropriate compositions” 
or a patient’s individual preference? Does the evidence outweigh 
the broad spectrum of music in a way that limiting options to 
“medically appropriate compositions” would suffice for patient 
satisfaction and adequate analgesic benefit? These are questions 
that need to be explored with future research.
The delivery and supply of safe headphones should be 
investigated further as well. Many hospitals have protocols in 
place that require materials management to inspect every piece 
of electrical equipment brought forth by a visitor for use within 
the hospital setting. Because of the effectiveness of intraoperative 
music therapy on the patient receiving general anesthesia, systems 
should be designed and studied to determine best practices for 
safe, uncontaminated headphones to be used in the operating 
room. These options vary immensely from patients supplying their 
own headphones to the facility providing a pair of sealed and 
clean headphones to each patient upon arrival in the operating 
room. These are just a few of the logistical concerns that must be 
further investigated to move forward with the implementation of 
music therapy across all facility platforms.

Limitations

This systematic review included only articles published in 
English. This could have introduced a language bias for the 
assessed outcomes. Publication bias is also a risk because not all 
RCTs are published owing to a lack of significant conclusions.23 
This systematic review examined 3 divisions of the surgical 
process with a focus on the intraoperative period. The review 
is limited in its conclusion of which time period of the music 
therapy intervention provided the best success. There were 
no direct comparisons between the 5 possible combinations 
of when the music therapy could be applied in relation to 
the intraoperative period (ie, preoperative vs postoperative or 
intraoperative exclusively or any combination of the 3).

Another limitation was that the 8 reviewed studies were not 
evaluated on the basis of sample size nor respective sample size 
calculations. At least 2 of the 8 studies included sample sizes of 
30 or fewer owing to convenience sampling and the subtraction of 
excluded participants and data. Decreased sample sizes have the 
potential of creating a type 2 error as well as drawing conclusions 
that are nongeneralizable. Nilsson et al3 used the explanation and 
inclusion of sample size calculations as an aspect of the quality 
appraisal of research assessed in a past systematic review.
CONCLUSION
As clinicians search for ways to improve outcomes while 
satisfying the needs, wants, and expectations of their consumers, 
music therapy is one of the simplest and least expensive avenues 
for success that both benefits the patient by decreasing pain while 
also potentially increasing revenue for clinicians. In this setting, 
music therapy is an underused technique that has demonstrated 
numerous patient benefits as well as positive effects on the 
patient experience and that could lead to increased government 
reimbursement. Hospitals and clinicians wishing to improve the 
surgical experience for consumers, while being innovative leaders 
in the modalities of pain management, should consider adopting 
intraoperative music therapy as an option for surgery.

Summary of Key Points

Music therapy with headphones under general anesthesia is 
effective in reducing pain, reducing narcotic needs, and increasing 
patient satisfaction scores. Allowing patients to choose the genre 
of music increases autonomy and is a way to empower patients in 
an otherwise irrepressible situation.

Checklist for Music Therapy in General Anesthesia
Checklist for Music Therapy in General Anesthesia

• Headphones (as procedure permits)
• Adjustable Volume not to exceed <68 dB
• Patient chosen genre
• Application upon OR entry (prior to induction)
• Discontinue >1 hour after PACU admission

Acknowledgment
The authors acknowledge Kristine Kulage, MA, MPH, Columbia 
University School of Nursing, for her review of this manuscript 
and significant contribution to the organization of the review.

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Volume 5 - No. 2 2017 Page 12



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