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Document 1 of 1 Using massage and music therapy to improve postoperative outcomes Author: McRee, Laura D; Noble, Stacie; Pasvogel, Alice Publication info: Association of Operating Room Nurses. AORN Journal 78.3 (Sep 2003): 433-42, 445-7.ProQuest document link Abstract: McRee et al determine whether massage and music therapy could decrease anxiety, resulting inpositive outcomes related to cardiovascular hemostasis and decreased pain for patients. After conducting avariety of studies related to the effects of massage or music therapy on patients' anxiety, results indicate thatpostoperative anxiety levels were significantly lower and postoperative prolactin levels were significantly higherfor all groups. Full text: Headnote ABATRACT * AN EXPERIMENTAL PILOT STUDY was conducted to investigate the effects of preoperative massage andmusic therapy on patients' preoperative, intraoperative, and postoperative experiences. * PARTICIPANTS were assigned randomly to one of four groups-a group that received massage with musictherapy, a group that received massage only, a group that received music therapy only, or a control group. * HEMODYNAMICS, serum cortisol and prolactin levels, and anxiety were measured preoperatively andpostoperatively. * POSTOPERATIVE ANXIETY LEVELS were significantly lower and postoperative prolactin levels weresignificantly higher for all groups. AORN J 78 (Sept 2003) 433-447. Whether surgery is emergent or elective, the experience causes patient anxiety, which can be detrimental tosurgical outcomes.1 The anticipation of pain may cause increased anxiety, and, in turn, anxiety and pain causean increase in levels of circulating catecholamines, adrenocorticotrophic hormone, growth hormone, prolactin,antidiuretic hormone, aldosterone, cortisol, glucagon, prostaglandins, and free fatty acids.2 An increase instress hormones and resulting metabolic responses can lead to a variety of morbid events, including myocardialand other organ ischemia, dysrhythmia, hypercoagulability, malnutrition, fluid and electrolyte imbalance,decreased wound healing, and immunocompromise.2 Anxiety increases oxygen consumption, cardiac output,and blood pressure.3 Furthermore, anxiety and stress can increase the need for higher doses of anestheticsand sedatives during surgical procedures, resulting in a potentially negative effect on a patient's recovery.3 Fearof pain is a significant fear ranked second only to fear of death;4 therefore, it is important for surgical teams tobe aware of interventions that could decrease anxiety and pain. LITERATURE REVIEW This study was designed to determine whether massage and music therapy could decrease anxiety, resulting inpositive outcomes related to cardiovascular hemostasis and decreased pain for patients. A variety of studiesrelated to the effects of massage or music therapy on patients' anxiety have been conducted. MASSAGE THERAPY. Massage is the art of touch and manipulation of soft tissue to achieve therapeuticresults, including mental relaxation, comfort, and healing.5 Massage has been considered a therapeuticintervention for thousands of years. There is evidence of the use and value of therapeutic massage in Chinamore than 5,000 years ago.6 A person's tactile needs do not change with health or aging; however, patientswho are acutely ill or undergoing surgery seldom are touched other than when they are receiving necessarycare.5 Caring touch, compared to technical or mechanical touch, is an important method of communication.7 There are a number of theories about the mechanisms for massage's therapeutic effects on psychological andphysical status. Most simply, massage may relieve pain through muscle relaxation and the release ofenkephalins.6,8

The gate control theory of pain also has been used to explain the effectiveness of massage in pain control.6According to this theory, tactile information from massage is carried on the large myelinated fibers, which mayclose the neurological "pain gate" at the peripheral point, thus reducing the perception of pain. Two other mechanisms for pain relief through massage have been identified: * soft tissue manipulation improves circulation, which reduces pain caused by the accumulation of irritants,including lactic acid and inflammatory substances; and * the emotional contact of caring touch may induce a sense of well-being that would diminish the perception ofpain.9 Results of previous studies have demonstrated therapeutic benefits of massage in a variety of circumstances,especially in terms of decreased anxiety, decreased stress response, and less pain. In a study of the effects ofmassage on 122 patients admitted to an intensive care unit (ICU), participants were assigned randomly toreceive massage, aromatherapy and massage, or a period of rest.10 Preintervention and postinterventionassessments included physiological stress indicators and patients' evaluations of their anxiety level, mood, andability to cope with the intensive care experience. No significant differences were reported in the physiologicalstress indicators, which included systolic and diastolic blood pressure, heart rate and rhythm, and respiratoryrate. The group that received massage and aromatherapy, however, demonstrated significant improvements inmood and reported decreased anxiety after therapy. One study evaluated the effects of massage on anxiety among older adult, institutionalized patients.11Participants were assigned randomly to a group that received a five-minute back massage and engaged inconversation with the massage therapist, a group that participated in a five-minute conversation only, or a groupthat received no interventions. Anxiety was measured using the Spielberger State-Trait Anxiety Inventory (STAI)before and after interventions and at two points in time for the group that received no interventions. The studywas conducted during four consecutive days. Mean anxiety scores indicated that anxiety levels weresignificantly lower for the group that received massage compared to the group that received no interventions. One group of researchers studied the effects of massage on 28 patients in a hospital burn unit.12 Patients wereassigned randomly to a massage therapy group or a standard treatment control group before undergoing adebridement procedure. The group that received massage demonstrated less anxiety, lower cortisol levels, lesspain, and less depression than the group that received standard care. A limitation of this study is the lack of acomparison intervention; therefore, it cannot be determined whether an intervention other than massage wouldhave produced the same effects. One researcher studied the effects of therapeutic massage on preoperative anxiety, gathering both quantitativeand qualitative data.13,14 Sixty patients undergoing general surgical or gynecological procedures wereselected from a rural hospital. The treatment group included 30 patients who received 45 minutes ofpreoperative massage. The control group did not receive any interventions. Measures included anxiety asindicated by scores on the STAI, the amount of analgesia required, and length of hospital stay. In addition,study participants were interviewed during their massages to elicit their perceptions of the experience. Theresults demonstrated that the group that received massage experienced reduced preoperative anxietycompared to the control group; however, there were no significant differences in amounts of analgesia used orlength of stay between the two groups. Analysis of participant interviews revealed that those who receivedmassage believed their vulnerability was respected and that the massage provided an environment in whichthey felt safe to talk. A limitation of this study is, again, lack of a comparison intervention.

MUSIC THERAPY. Music has been defined as the science or art of the composition of sounds that arecomprehended by the human brain as enjoyable and expressive.3 In the 1800s, music was used to aid sleep,decrease anxiety associated with surgery, and assist in the administration of local anesthesia.2 Thephysiological effects of music have been measured using blood pressure, mean arterial pressure, heart rate,electrocardiogram, respiratory rate, oxygen saturation, finger temperatures, and serum hormone levels.15 Many studies have examined the effect of music on patients' anxiety. One study examined the effects of musicuse in various medical specialties, including anesthesiology, surgery, orthopedics, dentistry, and obstetrics.Patients selected the music they preferred and listened to it during the preoperative wait. Headphones were lefton until patients were asleep. Patients who received local anesthesia wore headphones during the entireprocedure. Findings included decreased levels of anxiety, decreased blood pressure, and decreased hormonelevels, including prolactin, cortisol, adrenocorticotrophic hormone, growth hormone, and norepinephrine.16 A pilot study of 30 patients scheduled for elective orthopedic surgical procedures performed using regionalanesthesia was conducted to determine whether having patients listen to their favorite music while undergoingthe surgical procedure reduced their anxiety.3 Data were collected using questionnaires designed to obtainfeedback about patients' selections and their feelings about listening to music during surgical procedures.Patients reported that music helped the surgery go more quickly, masked background noises, and diverted theirminds from the procedure. Perioperative staff members provided positive feedback about the use of music, andanesthesia care providers noted that participants were calmer throughout the procedures, pulse and bloodpressures remained more stable, and less anesthesia was required.

The psychological and physiological effects of music have been studied in a variety of clinical settings includingICUs, surgical suites, and postanesthesia care units (PACUs). One group of researchers investigated thephysiological effects of music therapy on 22 critically ill patients in an ICU.17 Reduction in heart rate, systolicblood pressure, pain, and anxiety were reported. Another researcher conducted a six-month study in whichmusic was played for five minutes before the start of painful procedures. Patients who listened to music used30% less pain medication than those who did not listen to music.18 Studies have examined patients' perceptions of their surgical experiences, including preoperative,intraoperative, and postoperative care. One researcher investigated the effects of humorous and musical distraction on preoperative anxiety in 46

patients scheduled for same day elective surgery.19 The study included three groups: one group that listened tomusic for 20 minutes, a second group that listened to a 20-minute humorous audiotape, and a control group thatreceived standard care. No significant differences in anxiety scores were reported. Another researcher conducted a pilot study that investigated patients' perception of music during their surgicalexperience.20 The study included 25 participants who underwent elective surgery receiving either a local,spinal, or epidural anesthetic. Patients were interviewed 20 hours after surgery. Their remarks indicated thatmusic eased anxiety, provided distraction, and increased their pain thresholds. The effect of music on pain and hemodynamic measurements (ie, mean arterial pressure, heart rate,respirations) in the PACU for patients who had undergone thyroidectomy, parathyroidectomy, or modifiedmastectomy was the subject of one study.21 One group of participants wore headphones and listened to music,another group wore headphones but did not listen to music, and a control group did not wear headphones orlisten to music. Members of the group that listened to music were able to wait significantly longer beforerequiring pain medication compared to members of the group who wore headphones but did not listen to music.Members of the group that listened to music perceived their PACU experience as significantly more pleasantthan did the other two groups. No significant differences were reported in hemodynamics, respirations, pain, orlength of stay in the PACU. One group of researchers examined the influence of three interventions on anxiety during the earlypostoperative phase of patients undergoing heart surgery.22 Participants were assigned randomly to one ofthree groups. One group received music therapy, a second group received music-video therapy (ie, participantswatched a 30-minute videotape in which soft instrumental music accompanied visual images on a televisionscreen), and a third group received scheduled rest. Interventions were 30 minutes in length, and participantsreceived interventions at two separate times-on postoperative day two and postoperative day three. Mood andanxiety were evaluated before and after each session. Anxiety was measured before surgery, before theintervention session on postoperative day two, and at the completion of the session on postoperative day three.Blood pressure and heart rate were measured immediately before the intervention and at 10-minute intervalsduring the intervention. Members of all three groups reported reduced anxiety and improved moods andexperienced significant decreases in mean heart rate and blood pressure. The decreases occurred within thefirst 10 minutes of the intervention and continued for the remainder of the study period. Another researcher investigated sensory and affective pain in 84 participants who underwent nonlaparoscopic,elective abdominal surgery.23 Each participant was assigned randomly to one of four groups: a group thatpracticed jaw relaxation, a group that listened to music, a group that listened to music combined with practicingjaw relaxation, and a control group that received no intervention. The participants in the jaw relaxation groupfollowed audiotaped instructions to perform the relaxation exercises. Participants in the music group selectedand listened to one of five choices of relaxing music audiotapes. Participants in the jaw relaxation with musicgroup practiced jaw relaxation techniques while listening to their choice of one of the five music audiotapes. Nosignificant differences were reported in the areas of sensation, distress, anxiety, or narcotic intake between thethree intervention groups and the control group. In a study of the effect of music on 42 ambulatory surgery patients' anxiety, participants in the experimentalgroup listened to their choice of music after receiving preoperative instruction, and participants in the controlgroup received only preoperative instruction.24 Ten minutes before surgery, vital sign measurements weretaken and compared to baseline vital sign measurements. Participants in the experimental group demonstratedsignificantly lower heart rates than participants in the control group. PURPOSE The purpose of this pilot study was to investigate the effects of preoperative therapeutic massage and musictherapy on patients' preoperative, intraoperative, and postoperative experiences. Identifying ways to decreasepreoperative anxiety could result in the use of less anesthesia for induction, the use of less postoperative

analgesia, and fewer complications from stress-related responses-outcomes that could lead to decreased costsfor hospitals and patients. Furthermore, established empirical data may provide justification for offeringmassage and music therapy as a preoperative standard of care. RESEARCH QUESTIONS The following research questions were asked. * Are there differences between preoperative and postoperative anxiety, cortisol levels, and prolactin levelsamong the groups? * Are there differences in preoperative and postoperative anxiety, cortisol levels, and prolactin levels within eachgroup? * Are there differences between preoperative, intraoperative, and postoperative blood pressures and pulse ratesamong the groups? * Are there differences in preoperative, intraoperative, and postoperative blood pressures and pulse rates withineach group? * Is there a difference in the percentage of participants in each group who received postoperative painmedication? METHOD The study employed a four-group experimental design, including three intervention groups and one controlgroup. Patients in one group received 30 minutes of massage and listened to 30 minutes of music beforesurgery. Patients in a second group received 30 minutes of massage before surgery, and patients in a thirdgroup listened to 30 minutes of music before surgery. Patients in the control group received standard care. SETTING AND PARTICIPANTS. Data were collected at the University Medical Center (UMC), Tucson. Aprivate room was provided for the researcher to meet with study participants. Approval for the study wasobtained from the human subjects committee of the University of Arizona and from the Institutional ReviewBoard of UMC. Selection criteria included that participants be at least 18 years of age and able to read English. In addition,participants needed to be low-risk surgical patients as determined via preoperative assessment by theanesthesia care provider using the standards of American Society of Anesthesiologists scale. This scale isbased on the number and severity of preexisting medical conditions. The range is from a normal healthy patient(ie, one) to a patient who is declared brain dead and whose organs are being removed for donation (ie, six).25The surgical schedule provided information to identify potential participants who then were recruited for thestudy the morning of surgery. All patients who met the criteria were invited to participate in the study by thenurse researcher. Data were collected during a one-year period. DEFINITIONS AND INSTRUMENTS. This study was concerned with participants' state anxiety. State anxietywas defined as the intensity of apprehensive feelings experienced at a particular moment as measured by theSTAI six-item short form (STAI-6). The STAI is one of the most frequently used measures of anxiety. The STAI-6 was developed for use in circumstances in which the full form is inappropriate due to its length.26 The range of scores for the STAI-6 is zero to 36. The concurrent validity of the short form was determined bycomparing prorated scores from the six-item scale with those from the full scale. No differences in scores werereported. The reliability for the six-item scale was 0.82.26 In the present study, the reliability of the instrumentwas tested using Cronbach's alpha to determine the internal consistency of the items. The alpha was 0.79 forthis study. Systolic blood pressure is maximum blood pressure that occurs during contraction of the ventricle.27 (p2126)Diastolic blood pressure refers to the period of cardiac relaxation alternating with systole or contraction.27(p587) Pulse is defined as the rate, rhythm, condition of arterial walls, compressibility and tension, and shape ofthe fluid wave of blood traveling through the arteries as a result of each heart beat.27 (p1794) Intraoperativemeasurement for blood pressure and pulse was obtained by the anesthesia care provider using automatic

monitoring equipment. Postoperative blood pressure and pulse were obtained by the primary investigator orresearch assistant using automatic monitoring equipment. Cortisol is a glucocortical hormone of the adrenal cortex.27 (p492) The method used for cortisol determinationwas chemiluminescent immunoassay using a polyclonol rabbit antibody specific for cortisol. Prolactin is ahormone produced by the anterior pituitary gland.27 (p1761) The method used to determine prolactin levels wasa two-site sandwich antibody assay (ie, a specific chemiluminescent assay). Blood was sent to a regionallaboratory for processing. The same laboratory processed all samples. Instruments at the laboratory werecalibrated monthly or based on reagent stability. Pain control, defined as the amount and frequency of analgesia administered, was measured in the recoveryroom. Patients were asked about their levels of pain, and all medications were administered by PACU nursingstaff members. INTERVENTIONS. Patients were required to be at the hospital two hours before surgery. Interventions wereprovided during the first hour of this two-hour period. During this time, the control group waited in the waitingroom and followed the usual routine for perioperative patients. Members of the massage with music and massage only groups received 30 minutes of massage. Swedishmassage techniques were used in this study. The strokes used were effleurage (ie, long gliding strokes),petrissage (ie, lifting of the muscle, kneading), and vibration (ie, gentle shaking of the muscle). One nursemassage therapist provided all the treatments. All participants who received massage were lying face down ona massage table. Only the posterior body was massaged, including the neck, back, posterior arms, lowerextremities, and feet. Participants in the music group and the massage with music group listened to the same compilation of softpiano music selected by the primary investigator. The compilation was 30 minutes in length. The music withmassage group received both interventions simultaneously. PROCEDURES. Data were collected by the primary investigator and one research assistant who was trained inphlebotomy and oriented to the questionnaires provided to each participant. When patients agreed to participatein the study, each signed an informed consent form.

A demographic questionnaire and the STAI-6 were completed by each participant, and serum cortisol andprolactin samples were obtained. Participants then were assigned to one of the four groups by drawing of lots. Blood pressure and pulse were measured preoperatively, and then interventions were administered. Bloodpressure and pulse also were measured intraoperatively and postoperatively. Pain control was measured in therecovery room. Serum cortisol and prolactin levels were obtained again postoperatively, and each participantagain completed the STAI in the PACU. DATA ANALYSIS Descriptive statistics were used to describe the sample. Paired t tests were used to determine the differencesbetween preoperative and postoperative anxiety, blood pressure, pulse, and cortisol and prolactin levels withineach group. Analysis of variance was used to determine differences among groups in preoperative andpostoperative measures of anxiety and cortisol and prolactin levels, as well as preoperative, intraoperative, andpostoperative blood pressure and pulse. Analysis of variance was used to determine differences amongpreoperative, intraoperative, and postoperative blood pressure and pulse within each group. Chi-squareanalysis was used to determine differences among the groups for those who received postoperative painmedication. The significance level was set a priori at P <or = .05. RESULTS Fifty-two patients participated in the study. Each group included 13 participants. The age range of participantswas 19 to 67 years (mean = 43.08, standard deviation = 13.1). Nineteen participants were male, and 33participants were female. All but one of the participants were high school graduates; 19 (36.5%) were collegegraduates. Eighty-four percent had undergone previous surgeries, and 44.2% had experienced massagetherapy previously. There were no significant differences in demographic characteristics among the groups. Type of surgery varied, including cholecystectomy cystoscopy, Hickman catheter placement, hysterectomy,laparoscopy, lipoma removal, mass excision, and orthopedic hardware removal. Types of anesthesia usedduring the procedures included general, spinal, regional, and local anesthesia. Postoperative mean anxiety scores were significantly lower than preoperative scores for each of the groups (P<.05) (Table 1). There were no significant differences among the groups in mean preoperative anxiety scores(F^sub 3,48^ = 0.08, P = .97) or mean postoperative anxiety scores (F^sub 3,48^ = 1.48, P = .23).

Preoperative and postoperative prolactin levels are presented in Table 2. There were no significant differencesamong groups in mean preoperative prolactin levels (F^sub 3,46^ = 0.58, P = .63) or mean postoperativeprolactin levels (F^sub 3,48^ = 0.76, P = .52). The mean postoperative prolactin levels were significantly higherthan the mean preoperative levels for each group (P <.05). Preoperative and postoperative cortisol levels are presented in Table 3. There were no significant differencesamong the groups in mean preoperative cortisol levels (F^sub 3,45^ = 0.8, P = .5) or mean postoperativecortisol levels (F^sub 3,48^ = 0.41, P = .75). There were no significant differences among mean preoperativeand postoperative cortisol levels for any of the groups. Preoperative, intraoperative, and postoperative systolic blood pressure, diastolic blood pressure, and pulse are

presented in Table 4. There were no significant differences among the groups in mean preoperative,intraoperative, or postoperative systolic blood pressure, diastolic blood pressure, or pulse. Examining thedifferences among preoperative, intraoperative, and postoperative systolic blood pressure within each grouprevealed that mean intraoperative systolic blood pressures were significantly lower than mean preoperativesystolic blood pressures for the control group (F^sub 2,24^ = 4.58, P = .021). Mean intraoperative diastolicblood pressures were significantly lower than mean preoperative diastolic blood pressures for the massage withmusic group (F^sub 2,24^ = 5.93, P = .008) and significantly lower than mean postoperative diastolic bloodpressure (F^sub 2,22^ = 5.39, P = .012) for the control group. No significant differences were found among thegroups for pain medication received postoperatively (X^sup 2^^sub 3^ = 3.25, P = .355).

DISCUSSION The results of the study were similar to previous research findings demonstrating that patients who experiencedanxiety, stress, or pain exhibited a reduction in these symptoms when music or music with massage wasprovided.10-12,20,22 This pilot study demonstrated a significantly lower anxiety response postoperatively ineach group. The control group also demonstrated a significantly decreased level of anxiety, which could havebeen associated with a sense of relief that the surgery was finished. The stress hormone cortisol did not decrease significantly within or among the groups, although previousresearch studies reported decreases in cortisol levels after an intervention of music or massage.12,16Furthermore, this pilot study did not reflect differences in pain medication patients received in the PACU. Adecreased need for pain medication or decreased pain response after the provision of music or massage,however, has been reported in other studies.12,18,21

The interventions in this pilot study were provided before surgery. In some studies, interventions were providedduring the postoperative period in the PACU. The patients in this study also did not select the music forintervention, which, based on the literature, may make a difference in decreasing anxiety, blood pressure, heartrate, and respiration.3,24 The control group also demonstrated significantly lower systolic blood pressures intraoperatively compared topreoperative baseline measurements and significantly lower diastolic blood pressure postoperatively comparedto intraoperative measurements. This could have resulted from the investigator's presence during thepreoperative and postoperative period, anesthesia medications, or relief that surgery was finished. The mean postoperative prolactin levels were significantly higher than the mean preoperative levels for eachgroup. Prolactin levels are known to increase during the physiological response to stress and increased mentalvigilance; however, the significance and effects of the increase in prolactin are mostly unknown.28,29 Prolactinis known to elevate with general anesthesia. In one study, a five-fold increase in prolactin was seen duringmajor surgery with general anesthesia.30 A more recent study demonstrated that serum prolactin significantlyincreased after the induction of general anesthesia.31 The significant elevations of prolactin demonstrated in allgroups may have been influenced by both the physical and psychological aspects of the surgical experienceand the use of general anesthesia in some procedures. This study indicates the need to continue to establishempirical data to support the implementation of interventions, such as massage and music therapy, to decreasepatients' anxiety, cortisol and prolactin levels, and hemodynamic measures. LIMITATIONS Limitations of this study include its small sample size and that no measures were taken to ensure interraterreliability between the investigator and the research assistant during data collection. Participants underwentdifferent types of surgery, which could contribute many uncontrolled variables. Certain types of surgery may beperceived as more invasive than others, and, therefore, may have increased anxiety. Differences in types ofsurgeries also could contribute to different levels of postoperative pain. The lengths of surgeries also were

different. Anesthesia used in the various procedures included general, spinal, regional, and local. As a result, somepatients were more aware of their surroundings than others, and this could have resulted in increased ordecreased anxiety. RECOMMENDATIONS FOR FUTURE RESEARCH A more focused study could offer more meaningful results. A study that includes participants undergoing onlyone type of surgery could control for the type of procedure, sample, length of surgery, type of anesthesia, andsimilar postoperative recovery time. The interventions in this study were performed preoperatively. It would be interesting to examine the effects ofsuch interventions both preoperatively and postoperatively to determine if the treatments would influence thetime it would take to reduce prolactin to a hemostatic level. A power analysis will be performed to determine thesample size needed for additional studies based on future hypotheses. CONCLUSION Outcomes related to the stress response could be detrimental to patients undergoing surgery; therefore, clinicalresearch to identify interventions (eg, massage therapy, music therapy, guided imagery, hypnotherapy) thatcould decrease the stress response is valuable. Nurses are with patients during each phase of the surgicalexperience. Nurses, therefore, must have an understanding of the need to offer noninvasive, cost-effectiveapproaches to improving patients' surgical experiences and improving preoperative, intraoperative, andpostoperative outcomes. Sidebar Previous studies have demonstrated therapeutic benefits of massage in terms of decreased anxiety, stress, andpain. Sidebar Empirical data may provide justification for offering massage and music therapy as a preoperative standard ofcare. Sidebar State anxiety was defined as the intensity of apprehensive feelings experienced at a particular moment asmeasured by the Spielberger State-Trait Anxiety Inventory six-item short form. Sidebar This study indicates a continued need to establish data supporting implementation of interventions to decreasepatients' anxiety, cortisol and prolactin levels, and hemodynamic measures. Footnote NOTES 1. R J Hinojosa, "A research critique. Intraoperative music therapy: Effects of anxiety, blood pressure," PlasticSurgical Nursing 15 (Winter 1995) 228-231. 2. L L Henry, "Music therapy: A nursing intervention for the control of pain and anxiety in the ICU: A review ofthe research literature," Dimensions of Critical Care Nursing 14 (November/December 1995) 295-304. 3. A Eisenman, B Cohen, "Music therapy for patients undergoing regional anesthesia," AORN Journal 62(December 1995) 947-950. 4. K M Miller, P A Perry, "Relaxation technique and postoperative pain in patients undergoing cardiac surgery,"Heart &Lung 19 (March 1990) 136-146. 5. M Ching, "The use of touch in nursing practice," The Australian Journal of Advanced Nursing 10 (June-August 1993) 4-9. 6. S Watson, S Watson, "The effects of massage: An holistic approach to care," Nursing Standard 11 (Aug 13,1997) 45-47. 7. C J Stevenson, "The psychophysiological effects of aromatherapy massage following cardiac surgery,"

Complementary Therapies in Medicine 2 (January 1994) 27-35. 8. B Kaada, O Torsteinbo, "Increase of plasma beta-endorphins in connective tissue massage," GeneralPharmacology 20 no 4 (1989) 487-489. 9. M Nixon et al, "Expanding the nursing repertoire: The effect of massage on postoperative pain," TheAustralian Journal of Advanced Nursing 14 (March-May 1997) 21-26. 10. C Dunn, J Sleep, D Collett, "Sensing an improvement: An experimental study to evaluate the use ofaromatherapy, massage and periods of rest in an intensive care unit," Journal of Advanced Nursing 21 (January1995) 34-40. 11. J Fraser, J R Kerr, "Psychophysiological effects of back massage on elderly institutionalized patients,"Journal of Advanced Nursing 18 (February 1993) 238-245. 12. T Field et al, "Burn injuries benefit from massage therapy," The Journal of Burn Care &Rehabilitation(May/June 1998) 241-244. 13. P van der Riet, "Effects of therapeutic massage on pre-operative anxiety in rural hospital: Part 1," AustralianJournal of Rural Health 1 (August 1993) 11-16. 14. P van der Riet, "Effects of therapeutic massage on pre-operative anxiety in rural hospital: Part 2," AustralianJournal of Rural Health 1 (August 1993) 17-21. 15. G R Watkins, "Music therapy: Proposed physiological mechanisms and clinical implications," Clinical NurseSpecialist 11 (March 1997) 43-50. 16. R Spintage, R Droh, "Effects of anxiolytic music on plasma levels of stress hormones in different medicalspecialties," in The Fourth International Symposium on Music-Rehabilitation and Human Well-being: August 1-5, 1985, New York City, ed R R Pratt (Lanham, Md: University Press of America, 1987) 88-101. 17. S K Stone et al, "The effects of music therapy on critically ill patients in the intensive care setting," (Abstract)Heart &Lung (May 1989) 291. 18. K Johnston, J Rohaly-Davis, "An introduction to music therapy: Helping the oncology patient in the ICU,"Critical Care Nursing Quarterly 18 (February 1996) 54-60. 19. K B Gaberson, "The effects of humorous and musical distraction on preoperative anxiety," AORN Journal 62(November 1995) 784-791. 20. K Stevens, "Patients' perceptions of music during surgery," Journal of Advanced Nursing 15 (September1990) 1045-1051. 21. L Heitz, T Symreng, F L Scamman, "Effect of music therapy in the postanesthesia care unit: A nursingintervention," Journal of Post Anesthesia Nursing 7 (February 1992) 22-31. 22. S Barnason, L Zimmerman, J Nieveen, "The effects of music interventions on anxiety in the patient aftercoronary artery bypass grafting," Heart &Lung 24 (March/ April 1995) 124-132. 23. M Good, "A comparison of the effects of jaw relaxation and music on postoperative pain," Nursing Research44 (January/February 1995) 52-57. 24. P Augustin, A A Hains, "Effect of music on ambulatory surgery patients' preoperative anxiety," AORNJournal 63 (April 1996) 750-758. 25. J F Marek, M J Boehnlein, "Preoperative Nursing," in Medical Surgical Nursing: Concepts and ClinicalPractice, sixth ed, W J Phipps, J K Sands, J F Marek, eds (St Louis: Mosby, 1999) 479. 26. T M Marteau, H Bekker "The development of a six-item short-form of the state scale of the SpielbergerState-Trait Anxiety Inventory (STAI)," The British Journal of Clinical Psychology 31 (September 1992) 301-306. 27. Tuber's Cyclopedic Medical Dictionary, 19th ed (Philadelphia: F A Davis Co, 2001) 492, 587, 1761, 1794,2126. 28. C J Merkle et al, "Structural and functional effects of high prolactin levels on injured endothelial cells:Evidence for an endothelial prolactin receptor," Endocrine 13 (August 2000) 37-46. 29. U Anegg et al, "Stress-induced hormonal and mood responses in scuba divers: A field study," Life Sciences

70 (April 26, 2002) 2721-2734. 30. G L Noel et al, "Human prolactin and growth hormone release during surgery and other conditions ofstress," The Journal of Clinical Endocrinology and Metabolism 35 (December 1972) 840-851. 31. J M Brand et al, "Upregulation of IFN-gamma and soluble interleukin-2 receptor release and altered serumcortisol and prolactin concentration during general anesthesia," Journal of Interferon and Cytokine Research 21(October 2001) 793-796. AuthorAffiliation Laura D. McRee, RN; Stacie Noble, MD; Alice Pasvogel, RN AuthorAffiliation Laura D. McRee, RN, MSN, LMT, is a clinical assistant professor, University of Arizona College of Nursing,Tucson. Stacie Noble, MD, is a clinical instructor, department of anesthesiology, University of Arizona College ofMedicine, Tucson. Alice Pasvogel, RN, PhD, is a senior research specialist, University of Arizona College of Nursing, Tucson. Subject: Music therapy; Anxieties; Physical therapy; Medical research; MeSH: Adult, Aged, Anxiety -- physiopathology, Blood Pressure -- physiology, Humans, Hydrocortisone --blood, Middle Aged, Pilot Projects, Postoperative Period, Preoperative Care -- psychology, Prolactin -- blood,Pulse, Random Allocation, Treatment Outcome, Anxiety -- therapy (major), Massage (major), Music Therapy(major), Preoperative Care -- methods (major) Substance: Hydrocortisone; Prolactin; Publication title: Association of Operating Room Nurses. AORN Journal Volume: 78 Issue: 3 Pages: 433-42, 445-7 Publication year: 2003 Publication date: Sep 2003 Year: 2003 Publisher: Elsevier Limited Place of publication: Denver Country of publication: United States Publication subject: Medical Sciences--Nurses And Nursing ISSN: 00012092 Source type: Scholarly Journals Language of publication: English Document type: Clinical Trial Accession number: 14507122 ProQuest document ID: 200730865 Document URL: https://search.proquest.com/docview/200730865?accountid=46437

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