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Music Therapy to Reduce Pain and Anxiety in Children with Cancer Undergoing Lumbar Puncture: A Randomized Clinical Trial

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Journal of Pediatric Oncology
Nursing
http://jpo.sagepub.com/

Music Therapy to Reduce Pain and Anxiety in Children With Cancer Undergoing Lumbar Puncture: A
Randomized Clinical Trial
Thanh Nhan Nguyen, Stefan Nilsson, Anna-Lena Hellström and Ann Bengtson
Journal of Pediatric Oncology Nursing 2010 27: 146
DOI: 10.1177/1043454209355983
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Music Therapy to Reduce Pain
and Anxiety in Children With Cancer
Undergoing Lumbar Puncture:
A Randomized Clinical Trial

Journal of Pediatric Oncology Nursing
27(3) 146­–155
© 2010 by Association of Pediatric
Hematology/Oncology Nurses
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1043454209355983
http://jopon.sagepub.com

Thanh Nhan Nguyen, RN, MSc,1 Stefan Nilsson, RN, MSc,2
Anna-Lena Hellström, RN, PhD,2 and Ann Bengtson, RNT, PhD3

Abstract
A nonpharmacological method can be an alternative or complement to analgesics.The aim of this study was to evaluate
if music medicine influences pain and anxiety in children undergoing lumbar punctures. A randomized clinical trial was
used in 40 children (aged 7-12 years) with leukemia, followed by interviews in 20 of these participants.The participants
were randomly assigned to a music group (n = 20) or control group (n = 20). The primary outcome was pain scores
and the secondary was heart rate, blood pressure, respiratory rate, and oxygen saturation measured before, during,
and after the procedure. Anxiety scores were measured before and after the procedure. Interviews with open-ended
questions were conducted in conjunction with the completed procedures. The results showed lower pain scores and
heart and respiratory rates in the music group during and after the lumbar puncture.The anxiety scores were lower in
the music group both before and after the procedure. The findings from the interviews confirmed the quantity results
through descriptions of a positive experience by the children, including less pain and fear.
Keywords
anxiety, music, nonpharmacological therapy, pain

Introduction
Pain associated with medical procedures is often viewed
as one of the worst experiences in children with cancer
(Hedstrom, Haglund, Skolin, & von Essen, 2003; Ljungman,
Gordh, Sorensen, & Kreuger, 1999). There are many different approaches in the treatment of pain from medical
procedures in children, including pharmacological and
nonpharmacological methods (Windich-Biermeier, Sjoberg,
Dale, Eshelman, & Guzzetta, 2007).
About 250 new patients are registered per year on the
Oncology Ward at the National Hospital of Paediatrics
(NHP) in Hanoi, Vietnam. In 2008, 313 children with leukemia were offered a program that included 3½ years of
treatment. The treatment of leukemia in children involves
several needle-related procedures (Jacob, Hesselgrave,
Sambuco, & Hockenberry, 2007). Lumbar puncture (LP)
is usually one of the most painful and distressing procedures associated with cancer treatment (Jacob et al.,
2007). Pain that is left untreated or is poorly treated often
leads to significantly prolonged changes in behavior,
alterations in self-concept, fear, anxiety, and depression
(Blount, Piira, Cohen, & Cheng, 2006; von Baeyer,
Marche, Rocha, & Salmon, 2004). The goal of adequate

pain treatment in conjunction with these procedures is
sometimes difficult to fulfill. A lack of knowledge of
children’s perception of pain and illness, the use of
inappropriate drug doses, and difficulties in understanding the value of supportive and nonpharmacological
methods all contribute to widespread inadequacy in the
control of pain in children with cancer (Blount et al.,
2006; Weisman, Bernstein, & Schechter, 1998). Knowledge from clinical trials regarding nonpharmacological
methods does not automatically lead to increased use in
clinical practice. The nurses’ level of education and lack
of time are confounding factors in many nonpharmacological methods (Polkki, Laukkala, Vehvilainen-Julkunen,
& Pietila, 2003). Improper application of pharmacological and nonpharmacological therapies is the main reason
1

National Hospital of Paediatrics, Hanoi,Vietnam
Sahlgrenska University Hospital, Gothenburg, Sweden
3
Sahlgrenska Academy at the University of Gothenburg, Gothenburg,
Sweden
2

Corresponding Author:
Stefan Nilsson, RN, MSc, Department of Paediatric Anaesthesia and
Intensive Care Unit, The Queen Silvia Children’s Hospital, Sahlgrenska
University Hospital, SE-416 85 Gothenburg, Sweden
Email: [email protected]

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147

Nhan et al.
for inadequate procedural pain relief (Segerdahl, 2008).
Pain management strategies that are easy to prepare and use
for children and nurses need to be found. Costly and
advanced methods will remain at a theoretic level and
never reach clinical practice (Wright, Stewart, Finley, &
Buffett-Jerrott, 2007). Nonpharmacological methods in
pain management are evaluated briefly in Asian countries
such as Vietnam. A study of pain management conducted
in China found that music was a commonly used nonpharmacological method (He, Vehvilainen-Julkunen, Polkki,
& Pietila, 2007).
Listening to music is one of several nonpharmacological methods to relieve pain and anxiety in both adults and
children (Klassen, Liang, Tjosvold, Klassen, & Hartling,
2008; U. Nilsson, 2008). There are theories explaining its
mode of action. It appears that music reduces the s-cortisol
(U. Nilsson, 2009a) and also causes an increase in the
levels of s-oxytocin (U. Nilsson, 2009b). A commonly
accepted hypothesis is that the music acts as a distracter,
focusing the patient’s attention away from negative stimuli to something pleasant and encouraging. Various other
hypotheses have been proposed to explain the mechanism
by which music reduces pain, including modification of
cognitive states, moods, and emotions. Relaxation from
music can also be demonstrated to be a pleasant distraction that serves as a mild sedative (Balan, Bavdekar, &
Jadhav, 2009). The review by Klassen et al. (2008)
divides music therapy into passive and active therapy.
Active music therapy requires the involvement of a music
therapist so that the music can be used for interactive
communication, whereas passive music therapy entails
listening to music for a particular purpose, recorded or
live, without the involvement of a music therapist. Listening to prerecorded music has also been defined as music
medicine as opposed to active music therapy (Dileo &
Bradt, 2005). Previous research has found music medicine or passive music therapy to be as effective as active
music therapy (Klassen et al., 2008). In addition, listening
to music as a treatment for pain and anxiety offers potential advantages of low cost, ease of provision, and safety
(Cepeda, Carr, Lau, & Alvarez, 2006).
To our knowledge, few studies have evaluated the
effects of music in children with cancer who undergo LP.
The aims of this study were to evaluate the effect and
experiences of using earphones with music as the only
effect with regard to pain and anxiety relief in children
with leukemia who were undergoing LP.

Methods
Participants
Between November 2007 and July 2008, children with leukemia, aged 7 to 12 years, who were due to undergo LP at

the Oncology Ward at NHP, Hanoi, were consecutively
asked to participate in the study. All of the children had
undergone an LP in conjunction with their cancer at least
once before. The children were not included in the study if
they had any significant hearing or visual impairments or
cognitive disorder. Written and oral information was given
to the children and their parents. Oral informed consent was
obtained from all the children and their parents and they
were informed that they could interrupt their participation
at any point without citing a reason for their decision. The
Ethic Committee of NHP approved the study protocol and
the researcher complied with the Helsinki Declaration.

Self-Report Instruments
Pain. The Numeric Rating Scale (NRS) was used to
measure the child’s self-reported pain during 3 distinct
phases: before, during, and after LP. The child rated the
pain intensity on a scale, with point 0 being no pain and
point 10 being the worst pain. During the procedure, the
highest recorded value was registered. The NRS is an
internationally used method to measure subjective experiences of pain intensity in children older than the age of
6 years. Self-reported NRS scores agreed with selfreported pain scores on a Faces Pain Scale in a validation
study that included 150 children (aged 6-12 yers) in
Thailand (Jongudomkarn, Angsupakorn, & Siripul, 2008).
An advantage of the NRS is its ease and speed of use
(Stinson, Kavanagh, Yamada, Gill, & Stevens, 2006).
Anxiety. The 6-item short form of the Spielberger
State-Trait Anxiety Inventory (STAI) is a validated scale
(Marteau & Bekker, 1992) and was used to measure
anxiety. The short STAI scale evaluated the procedure in
2 distinct phases: before and after LP. The range of the
short STAI scale would be 6 to 24 points in the end, with
6 points signifying no anxiety and 24 points signifying
the highest level of anxiety.

Design and Procedure
The study design was a randomized clinical trial followed
by interviews with open-ended questions. After informed
consent, the children were randomized to either use earphones with music (music group) or earphones without
music (control group). Randomization was carried out
using opaque envelopes, half of which contained a paper
that said “music” and half a paper that said “no music.”
The children in the music group chose songs they liked to
be played into earphones from an iPod®, that is, a portable music player with earphones. In the control group,
earphones without music were used. All the children
were given identical preprocedural information about the
procedures and the study. The children were instructed
on how to use the iPod® before entering the procedure

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Journal of Pediatric Oncology Nursing 27(3)

Table 1. The Analysis Process From the Condensed Meaning Units of the Text, Codes, Subcategories and Categories
Condensed Meaning Unit

Code

I felt calmer than last time. Last time, I had to hold my
mother’s hand very tightly during the lumbar puncture
I liked these songs very much. I felt very calm
I was very afraid of pain... I just wanted to go home. I
didn’t want to be injected any more
I was very worried about the result of the treatment. I
was afraid of an unsuccessful treatment
I felt less pain than last time
I felt a lot of pain, here . . . [showed the place that was
injected. Crying] . . . I can’t explain
I liked listening to the music. Music helps me to stay
calm and feel less pain. I like the song: “Count the
fingers” a lot
I just focused on the music . . . it helped. I liked listening
to the music. Effective if I can listen to the music that
I like. Feel happier, more comfortable and less pain

Subcategory

Less afraid

Calm and relaxed

Felt calm
Wanted to go home

Fear and anxiety

Worried about the
treatment
Less painful
The place that was
injected
Liked the song
Focused on the music
Liked listening to the
music
Effective

room. The researcher and the physician did not know to
which group the patient belonged.
In the investigation room, the child put on the earphones and did or did not listen to music, according to his
or her group, 10 minutes before the LP procedure started.
At the same time, the physician and nurses washed their
hands and prepared the chemotherapy. Apart from the
child, the parent, physician, and nurse were present in the
room during the procedure.
Data collection started immediately before the procedures. Heart rate (HR), blood pressure (BP), and oxygen
saturation (SpO2) were recorded, and the respiratory rate
(RR) was measured manually by the researcher. The pain
scores (NRS) and the anxiety scores (short STAI) were
also recorded before the LP. The NRS, HR, BP, RR, and
SpO2 were monitored and recorded throughout the procedure, with the children listening or not listening to music
according to their groups. Directly after the procedure
had finished, the procedure (the administration of the
short STAI after the LP was finished) was repeated with
the short STAI scale. No local anesthetics or other analgesics were administrated during the procedure. This
pain management met the standard care offered to children in most of the hospitals in Vietnam.

Interviews
10 children in each group were chosen consecutively
according to a predetermined schedule. The interviews
were carried out after informed consent and in connection
with the completion of the LP procedure to avoid the
impact of memory bias.
The interview guide included 3 open-ended questions:
“Please tell me about your feelings right now,” “Please

Category
Feelings of fear

Specific pain

Feelings of pain

Liked listening

Enjoyment of music

Focused on the
music

describe your emotions, feelings and thoughts when you
were using the earphones,” and “Would you like to have
earphones with music next time, why or why not?”
In addition, the researcher asked supportive questions
such as the following: “Can you explain, tell me more
about this?” The children’s answers were quoted verbatim.

Data Analysis
A post hoc power analysis was performed for pain during
the LP procedure and the Cohen’s effect size calculated.
In this study, an effect size above 0.5 was needed for a
sufficient result with clinical significance. An effect size
of 1.49 and a power of 0.99 were calculated for a sample
size of 20 participants in each group. This result reached
a sufficient number of participants. The assumption was
also supported by another study in this area that recommended a clinical difference for a new treatment of 13 to
18 mm on a visual analogue scale (0-100 mm; Heden,
von Essen, Frykholm, & Ljungman, 2009). All the data in
this study are presented as descriptive statistics and calculated using nonparametric statistics. The c2 test was
used for categorical data, and the Mann–Whitney U test
was used to compare data between 2 groups, that is, pain
scores, HR, BP, RR, SpO2, and anxiety scores, as well as
to compare age and the total duration of the music.
The interviews with the children were read and analyzed using qualitative content analysis (Krippendorff,
2004). The interviews were transferred to one text. The
text was read and reread until a sense of the whole was
obtained. The meaning units relating to the aim of the
study were condensed, extracted, and coded. After the
processes of coding and decoding, subcategories were
identified and divided into categories (Table 1). The

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Nhan et al.

The Consort E-Flowchart

Assessed for eligibility (n = 49)

Excluded (n = 9)
Enrollment

Did not meet inclusion criteria (n = 0)
Refused to participate (n = 8)

Randomized (n = 40)

Allocated to intervention (n = 20)
Received allocated intervention (n = 20)

Other reasons (n = 1)

Allocated to intervention (n = 20)
Allocation

Did not receive allocated intervention (n = 0)

Received allocated intervention (n = 20)
Did not receive allocated intervention (n = 0)

Lost to follow-up (n = 0)

Lost to follow-up (n = 0)

Discontinued intervention (n = 0)

Follow-Up

Analyzed (n = 20)

Discontinued intervention (n = 0)

Analyzed (n = 20)

Excluded from analysis (n = 0)

Analysis

Excluded from analysis (n = 0)

Figure 1. Randomization diagram of included children

Children were randomized to either earphones with or earphones without self-selected music.

process of identifying categories and subcategories
included alternation between the text as a whole and its
parts. The analysis was carried out individually and in
cooperation until there was agreement between the
authors.

Results
A total of 49 children were asked to participate in the
study and, of these, 40 agreed to participate. Eight children withdrew because their parents declined for reasons

of time or money, which made an extended stay at the
hospital impossible. One child did not want to participate because he was shy. The 40 children, 25 boys and
15 girls, were randomly assigned to 1 of the 2 groups:
the music group (n = 20) or the control group (n = 20;
Figure 1). No significant differences were found between
the 2 groups with respect to age or gender and total time
with earphones. The characteristics of the 2 groups of
children are presented in Table 2. The children’s choices
of music were traditional Vietnamese songs and children’s songs.

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Journal of Pediatric Oncology Nursing 27(3)

Table 2. Demographic and Clinical Procedural Characteristics


Music
Control
P value

Mean (Range, SD)
Age (Years)

Total Time With Earphones (Minutes)

Boys (n)

Girls (n)

8.8 (7-12, 1.59)
9.4 (7-12, 1.93)
Nonsignificant

23.1 (18-27, 2.6)
21.5 (17-25, 2.61)
Nonsignificant

12
13
Nonsignificant

8
7
Nonsignificant

Table 3. Comparison of Pain Scores and Anxiety Scores Before, During, and After the Procedure



Pain, Mean (Range, SD)
Music (n = 20)

Before   1.2 (0-5, 1.40)
During
2.35 (0-7, 1.90)
After   1.2 (0-5, 1.36)

Control (n = 20)

Anxiety, Mean (Range, SD)
P Value

1.75 (0-5, 1.77)
Nonsignificant
5.65 (1-10, 2.50)
<.001
3 (0-7, 2.0)   .003

Findings From Self-Reports (NRS and Short STAI)
The pain scores during the procedures were significantly
lower (P < .001) for the music group (mean = 2.35, SD =
1.9) than for the control group (mean = 5.65, SD = 2.5).
The pain scores after the procedures were also significantly lower (P < .003) for the music group (mean = 1.2,
SD = 1.36) than for the control group (mean = 3, SD = 2).
The anxiety scores after 10 minutes of music medicine, in
the music group, but before LP, were significantly lower
(P < .001) for the children in the music group (mean =
8.6, SD = 2.78) than for the children in the control group
(mean = 13.25, SD = 3.73). These reductions in anxiety
scores were also obvious after LP in the music group
(mean = 8.1, SD = 2.22) compared with the control group
(mean = 13.0, SD = 4.17; Table 3).

Findings From Vital Signs
There were statistically significant differences in reductions of HR (P = .012) and RR (P = .009) during the
procedure in the music group (mean = 102.7, SD = 9.24
and mean = 25.1, SD = 3.60) compared with the control
group (mean = 117.7, SD = 19.49 and mean = 28.5, SD =
3.86). There were also significant differences in RR
(P = .003) after LP in the music group (mean = 24.45,
SD = 3.49) compared with the control group (mean =
28.1, SD = 3.72). The SpO2 and BP did not differ
between the groups (Table 4).

Findings From Interviews
In all, 10 children from the music group and 10 from the
control group were interviewed immediately after the

Music (n = 20)

Control (n = 20)

P Value

8.6 (6-16, 2.78)

13.25 (7-22, 3.73)

< .001

8.1 (6-13, 2.22)   13.0 (6-21, 4.17)

< .001

Table 4. Comparison of the Variables HR, RR, SpO2, and BP
Before, During, and After the Procedure

Biological
Indicators

Mean (Range, SD)
Music (n = 20)

Control (n = 20)

HR
Before
102.6 (85-125, 10.01) 103.1 (87-135, 14.46)
During
102.7 (86-123, 9.24) 117.7 (91-152, 19.49)
After
100.8 (80-123, 11.4) 111.1 (88-145, 17.23)
RR
Before
25.0 (16-30, 4.08)
25.5 (18-35, 4.47)
During
25.1 (18-32, 3.60)
28.5 (22-37, 3.86)
After
24.5 (18-32, 3.49)
28.2 (20-37, 3.72)
SpO2

Before
99.6 (98-100, 0.60)
99.7 (97-100, 0.73)
During
99.2 (96-100, 1.14)
98.0 (90-100, 2.77)
After
99.7 (99-100, 0.49)
99.2 (94-100, 1.47)
Systolic BP
Before
96.2 (84-112, 6.82)
98.0 (79-116, 9.98)
During
97.1 (84-116, 8.57) 105.6 (82-141, 15.97)
After
98.5 (85-119, 10.13) 102.4 (84-128, 11.26)
Diastolic BP
Before
61,8 (53-68, 3.82)
63.0 (53-77, 5.85)
During
65.2 (55-80, 6.83)
69.8 (58-105, 11.67)
After
62.75 (57-80, 4.82)
64.2 (50-94, 9.40)

P Value
NS
.012
NS
NS
.009
.003
NS
NS
NS
NS
NS
NS
NS
NS
NS

NOTE: HR = heart rate; RR = respiratory rate; SpO2 = oxygen
saturation; BP = blood pressure.

procedure. Categories and subcategories were derived
from analyses of the interview text. These showed the
children’s experiences in terms of how they felt and their
thoughts after the procedure (Table 1).
Feelings of fear. There were differences between the 2
groups when they talked about their emotions. Most of
the children in the music group favored this new experience of the LP procedure over their previous experience.

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Nhan et al.
Listening to their favorite music helped them feel calm
and relaxed and take their minds off the harm the procedure might cause: “I felt calmer than last time. I didn’t
think about the injection. I just focused on the music. It
encouraged me. I was successful.” They did not worry to
the same extent as they did before being injected: “I didn’t
feel any pain. I felt less afraid than last time. The last
time, I had to hold my mother’s hand very tightly during
the LP. I didn’t need to do that this time . . . [smiles].”
Listening to music of their choice through earphones was
a new experience in this group of children. The children
also found it exciting: “It felt very interesting because I had
never listened to music during the procedure like this . . .
and I was relaxed before the LP too.” One child in the
control group said that he felt calmer when wearing the
earphones. The others in the control group did not mention anything about this.
Before the procedure, most of the children felt fear
and anxiety. Listening to the music, however, made them
focus on it and they seemed to forget the fear they had
before: “At the beginning of the procedure, I was a little
bit worried because I was afraid of being injected twice,
but I felt calm because I was listening to the music in the
earphones from the start . . . [smiles].” At the time of the
interview, all the children stated that listening to music
made them feel less anxious about what would happen
next during the procedure, though some children already
had anxiety about the next planned procedure that day
and began to talk about that: “I felt calm and relaxed, but
I’m very worried about the other injection when I come
back to the treatment room—a vein puncture to get an
antibiotic.” One child said that he was worried about the
next time he would undergo LP: “Will I be able to listen
to music or not?”
There were differences between the children in the
music group and the children in the control group. All of
the children in the control group talked about their fear
and anxiety. Just wearing earphones did not appear to
help. Feelings of fear were expressed very strongly in the
interview text. Their fears had to do with the pain relating
to the LP, their disease, and death: “I was very afraid of
pain . . . [crying] . . . I just wanted to go home. I didn’t
want to be injected any more [crying] . . .”; “I was very
scared and I was in pain. I couldn’t think about anything.
This was very terrible!” After the LP, the children’s fear
continued and they felt sad because of their bad experience of the procedure: “I’m still scared [crying], I’m
afraid to be injected. It’s very painful. When the doctor
came in, my heart seemed to act in chaos until he left
[crying] . . .” They also started to worry about the next
planned procedure. Some children in the control group
spoke about their anxiety and were worried about how
their disease would affect them in the future. It could be

expressed as their anxiety being related to a fear of
dying: “I was very worried about the result of my treatment. I was afraid of unsuccessful treatment”; “I was
very sad because I was being injected again. I was sad
because of the disease. I was very scared of death.”
Feelings of pain. The music reduced the experience of
pain during the LP procedure. Almost all of the children
in the music group said that they felt less pain compared
with their previous experiences. “I didn’t think. I just
focused on the music. I felt a little bit of pain. Not like the
last time when I felt 10 points of pain [laugh] . . .” A child
in the music group said that he felt a lot of pain because it
was his third injection of the day: “I felt a lot of pain.
Today, I was injected 3 times. I had pain and I was very
disappointed.”
There were differences between the levels of pain felt
by the 2 groups. All the children in the control group
experienced a lot of pain as a result of the LP. The children with earphones and no music did not find the
earphones useful and, at the time of the interviews, they
could still feel pain: “I felt pain very much. I couldn’t
think about anything else.” The children felt pain in their
backs, legs, and abdomens: “I felt very painful, here . . .
[showed the place that was injected, crying]”; “I’m still
scared and I am in pain. I had pain in my belly and in my
back. I felt a sharp sensation [crying].” Some of the children tried to focus on thinking about their family staying
at home to decrease the pain that they were feeling:
“Thinking of her [mother] made me feel less pain. I couldn’t
focus on the earphones.”
Enjoyment of music. All the children in both groups
wanted to have earphones with music the next time,
though some of the children found the earphones uncomfortable to wear and hard to lie on during the procedure.
The children in the music group liked the music a lot.
They found that the music helped them cope with the LP
procedure. They were able to focus on listening to the
music: “The music was nice.” Choosing music they liked
helped them to focus on the music and forget the procedure: “I liked listening to the music. I like the song ‘Count
the fingers’ a lot. I focused on the music . . . it helped.”
The children in the control group said that if they
could have earphones with music next time, it would
probably be very helpful. They thought that music
would make them more comfortable and happy and not
so tired afterward: “This time, I didn’t have music with
earphones. I think music will help me to be calm and feel
less pain. I was unlucky to pick the no music paper.”

Discussion
This study showed that music medicine is a distracter and
helps the children endure the amount of perceived pain

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Journal of Pediatric Oncology Nursing 27(3)

and anxiety. The children chose their own music styles.
Most of the songs were familiar to them and associated
with earlier pleasant situations. The music may have
helped the children gain control of the unpleasant situation
and give them a feeling of being in a familiar environment.
The children probably felt control and engagement in their
music medicine when they chose well-known Vietnamese
and children’s songs. Unlike active music therapy, the
children were not limited to the music therapist’s repertoire. Music medicine is not time-consuming, and the
time available is a complicating factor in many psychological techniques (Polkki et al., 2003). The effectiveness
of a particular distracter probably depends on the children and their engagement in the distraction activity
(Murphy, 2009). The importance of the children being
able to choose and make their own decisions about the
music has also been shown in another study (S. Nilsson,
Kokinsky, Nilsson, Sidenvall, & Enskar, 2009) and with
other distraction techniques such as Virtual Reality
(S. Nilsson, Finnstrom, Kokinsky, & Enskar, 2009).
Patient-selected music has also been superior in adults
compared with prechosen relaxing New Age Music (Leardi
et al., 2007).
In this study, music medicine was used as the only
treatment for pain and anxiety relief in children with
leukemia who were undergoing an LP procedure.
Although this result shows benefits of nonpharmacological intervention, music medicine should be combined
with pharmacological treatment to offer optimal pain
management (Zernikow et al., 2005).
The present study showed that music 10 minutes
before the LP reduced the preprocedural anxiety level.
Music before the LP shifted the children’s attention away
from the procedure to something more pleasant. This
result encourages the use of music medicine starting
already before procedures such as LP. To date, studies of
music interventions have predominantly evaluated preoperative anxiety rather than anxiety before procedures
without anesthesia. Most of these studies have also
focused on active rather than passive music therapy
(Klassen et al., 2008; Wright et al., 2007). Distraction
appears to be an easy and effective method to reduce pain
and anxiety in children undergoing procedures (Piira,
Hayes, Goodenough, & von Baeyer, 2006).
In this study, the quantitative analysis was combined
with a qualitative method. There was previously a lack
of knowledge about children’s experiences with music
medicine when undergoing LP (Cepeda et al., 2006;
Klassen et al., 2008). The interviews in this study also
validated the quantitative data and confirmed the painand anxiety-reducing effects of music medicine. Music
medicine can help children improve their quality of
life. It may also help them reduce the symptoms and

side effects of treatment such as pain, anxiety, and the
effects on the heart and respiratory rate (Cepeda et al.,
2006; Klassen et al., 2008). Pain and anxiety are
common in conjunction with LP, and it is therefore
important, whenever possible, to reduce these problems
in the care of children with cancer. Treatment-related
pain occurs in about 50% of patients in paediatric
oncology care, whereas other disease-related pain occurs
in only about 25% (Blount et al., 2006). Moreover, after
an unsuccessful procedure the individual pain experience will be modified to create a negative pain memory.
Some children also show increased distress over time.
In some instances, the pain is so traumatic that children
suffer long-lasting psychological consequences and
develop a fear of hospitals and medical staff (von
Baeyer et al., 2004).
Most of our knowledge about children is gained from
interviews with adults who know them well, for example,
parents, teachers, and peers (Kortesluoma, Hentinen, &
Nikkonen, 2003). Furthermore, the information about
children’s experiences of LP is mostly compiled in
Europe and North America, and there are few earlier
studies that do not use analgesics or sedative drugs. In
this study, interviews with children and quantitative data
both confirmed that music medicine reduced pain and
anxiety. This result supports the hypothesis that music
actually affects people in general, irrespective of the individual’s cultural background. A similar result was found
in India where Indian music reduced pain in Indian children (Balan et al., 2009).
The experiences of earphones with or without music
for pain and anxiety reduction in children with leukemia
were described in the interviews in this study. The qualitative content analysis identified 3 categories: feelings of
fear, feelings of pain, and enjoyment of music. There
were differences between the study groups. All the children in the control group spoke of pain, fear, and anxiety.
They expressed these feelings very strongly. They felt
anxiety relating to LP, their disease and ultimately a fear
of dying. These findings confirm the results of an earlier
study (Jacob et al., 2007). In comparison, the children
who had earphones with music felt less pain and were
calmer and more relaxed during the procedure. They
were interested in the songs they had chosen. Some of
them did not realize when they were injected. All the
children in the music group wanted to use earphones with
music when undergoing future procedures, and the children in the control group wanted to try it the next time.
Music medicine has shown beneficial results in other
clinical trials (Cepeda et al., 2006; Klassen et al., 2008),
though none of them evaluated the children’s experiences
through interviews in a mixed method such as in the
present study.

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153

Nhan et al.
There are some methodological considerations with
this study. The STAI scale was originally designed and
validated for adults, though it has previously been used
in its original form for female adolescents watching
music videos when undergoing colposcopy (Rickert,
Kozlowski, Warren, Hendon, & Davis, 1994). The short
STAI is easy to use and showed a significant decrease
between before and after day surgery in children aged 7
to 16 years (Nilsson et al., 2009). The short STAI may be
preferable to the STAI or the STAI for children (STAIC),
which involve a long checklist and many items that
sometimes become a hindrance (Marteau & Bekker,
1992). The short STAI has not been validated in children
but is frequently used and appears to form a valuable
complement to other collected data. The limitation of the
intervention in the present study was the earphones.
Although earphones were found to have valuable effects,
they were not sufficiently comfortable in all of the positions in which the children found themselves during the
procedure. In another study, loudspeakers were shown to
block unpleasant sounds in the environment and make
patients feel more relaxed (Thorgaard et al., 2005). Earphones may, however, increase the risk of transmitting
infections associated with health care to sensitive children (U. Nilsson, 2009a).
Another limitation is that the children in the control
group were recruited with the knowledge that they might
be given music intervention but were then randomized to
the group without music. This might have led to a sense
of missing something.
The data collection involved some outcomes that did
not show any significant differences between the music
group and the control group, that is, BP before, during,
and after LP. This result confirms earlier studies with
music (Hatem, Lira, & Mattos, 2006; Megel, Houser, &
Gleaves, 1998). BP does not seem to be an important outcome for the effects of music therapy. This is an important
finding as many children probably find it disturbing to
have their blood pressure measured.
In the study, listening to music using an iPod® as the
only effort was found to be effective with regard to pain
and anxiety reduction in children and could help nurses
and physicians in clinical practice. Further research is
needed to examine whether the choice of music and
equipment needs to be individualized or if a “gold standard” exists, and to compare and combine music with
other distraction techniques such as Virtual Reality (Riva,
Grassi, Villani, Gaggioli, & Preziosa, 2007).

Conclusions
Listening to music with earphones as a form of nonpharmacological intervention reduced pain and anxiety in

children with leukemia who underwent LP, involved low
cost and was easy and safe to use. The music reduced
pain scores, heart rate, respiratory rate, and anxiety
scores. Qualitative analysis of open-ended interviews
gave 3 categories: feelings of fear, feelings of pain, and
the enjoyment of music. When the children had earphones with music, they felt less pain and were calmer
and relaxed during and after the procedure. All these children definitely wanted to have earphones with music the
next time they were treated. Almost all the children in the
control group expressed pain, fear, and anxiety.
Acknowledgments
The authors would like to thank the children and their parents in
the Oncology Ward of the National Hospital of Paediatrics,
Hanoi, Vietnam, for their contributions. We would also like to
acknowledge all the staff of the Oncology Ward. Finally, we
would like to thank Lasse Persson for reviewing the statistics.

Declaration of Conflicting Interests
The authors declared no conflicts of interest with respect to the
authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/
or authorship of this article.

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Bios
Thanh Nhan Nguyen, MSc, is a registered nurse at the Department of Paediatric Oncology, the National Hospital of Paediatrics, Hanoi, Vietnam.

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Nhan et al.
Stefan Nilsson, MSc, is a registered nurse and pain management nurse at the Queen Silvia Children’s Hospital, Sahlgrenska
University Hospital, Gothenburg, and a PhD student at the
Department of Nursing Science, School of Health Sciences,
Jönköping University.

Hospital, Gothenburg, and the Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg.
Ann Bengtson, PhD, is a registered nurse (RNT) and senior
lecturer at the Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden.

Anna-Lena Hellström, PhD, is a registered nurse and professor
at the Queen Silvia Children’s Hospital, Sahlgrenska University

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