Abstract
Purpose of Review
Music therapy has seen increasing applications in various medical fields over the last decades. In the vast range of possibilities through which music can relieve suffering, there is a risk that—given its efficacy—the physiological underpinnings are too little understood. This review provides evidence-based neurobiological concepts for the use of music in perioperative pain management.
Recent Findings
The current neuroscientific literature shows a significant convergence of the pain matrix and neuronal networks of pleasure triggered by music. These functions seem to antagonize each other and can thus be brought to fruition in pain therapy. The encouraging results of fMRI and EEG studies still await full translation of this top-down modulating mechanism into broad clinical practice.
Summary
We embed the current clinical literature in a neurobiological framework. This involves touching on Bayesian “predictive coding” pain theories in broad strokes and outlining functional units in the nociception and pain matrix. These will help to understand clinical findings in the literature summarized in the second part of the review. There are opportunities for perioperative practitioners, including anesthesiologists treating acute pain and anxiety in emergency and perioperative situations, where music could help bring relieve to patients.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
Pain is a fundamentally subjective experience. This is reflected in the revised International Association for the Study of Pain (IASP) definition of pain [1], where physiological processes of nociception are distinguished from the sensation of pain as an emotional experience. The latter distillates multiple pain mechanisms [2, 3] and converging pain pathways [4,5,6], which individually or collectively influence pain perception with varying degrees of importance. Thus, the embodiment of pain is comprised of different aspects: affective, perceptive, attentive, discriminative, and vegetative components [7•]. The multidimensional nature of pain facilitates external modulatory access to pain processing. This has led to an increased interest in and growing body of literature on non-pharmacological pain-modulating interventions [8,9,10]. We illustrate neurobiological concepts, clinical context, and possible practical applications of the pain-modulating effects of music, focusing on the intra- and postoperative setting [11, 12•, 13•]. These are outlines from the viewpoint of anesthesiologists administering music as part of a multimodal anesthesia and pain analgesia approach [14, 15]. We start from current pain theories embedded in the framework of predictive coding models for pain theory [16•]. A discussion of neurobiological modulation of pain perception and sensation through music [17•, 18, 19] and its measurability through electroencephalography (EEG) [20•] and vegetative symptoms follows. We provide an overview on clinical trials, using music as a remedy or a complimentary treatment for acute pain [21,22,23,24,25,26]. The evidence presented is meant to inform practicing clinicians adopting music into their non-pharmacologic therapeutic approach to manage pain. We will stress the application of music to the analgesic armamentarium. Its effectiveness treats pain while respecting the patient’s agency [27•].
The Neurobiology of Pain
The Pain Matrix
Following a noxious stimulus, information on the tissue injury is transmitted from the periphery to the posterior horn of the spinal cord, where primary pain nerve fibers end and synapse. The secondary neuron crosses over and ascends contralaterally in the ascending spinal pathways of the anterolateral system. Here, the signal can travel one of three ways:
-
1.
The primary nociceptive path of this ascending system is the spinothalamic tract. Information on this path travels either towards reticular formation (RF) to modulate arousal, the periaqueductal gray (PAG) in the mesencephalon (also involved in the autonomic nervous system and threat response) [28], or is further carried to the ventroposterolateral (VPL) nucleus, medial nucleus of the posterior complex (POm), and central lateral (CL) (intralaminar) nuclei of the thalamus [29]. From here, information can be disseminated to the primary somatosensory cortex (PSC, discriminative information on noxious stimulus, i.e., precise location) and to subcortical and cortical areas, including the prefrontal cortex (PFC), hypothalamus, and hippocampus (Fig. 1). This allows for generation of an emotional reaction to the noxious stimulus, modulation, and finally pain perception and vegetative responses [4, 5, 30]. The intralaminar nuclei of the thalamus have connections to the insular cortex and cingulate cortex (Fig. 2). These areas deal with information on the quality of the pain (dull, burning, crude touch) and are responsible for emotional associations.
-
2.
Spinal trigeminal projections travel to the RF and continue with other afferents, ending close to the PAG or in the ventroposteromedial nucleus (VPM; information on sharp pain) and intralaminar nuclei of the thalamus. The VPM also has connections to the primary somatosensory cortex.
-
3.
The spinoreticular tract carries information to nuclei in the reticular formation and rostral ventromedial medulla (RVM) and from there to the intralaminar nuclei of the thalamus. These pathways create a multisynaptic circuit, the pain matrix [31]. Signal transmission in the ascending pain pathways is facilitated by norepinephrine as a neurotransmitter [29].
Top-Down Control
Descending pathways originating segmentally in the spinal cord [32], as well as from the mesencephalon, specifically the periaqueductal gray (PAG) [33,34,35] and medulla oblongata (rostroventral medulla, RVM), the hypothalamus, and the prefrontal cortex, allow for further modulation of pain perception and sensation [36]. This second part of the pain pathway creates a top-down control [36,37,38] and grants access points for external pain modulation. Multiple receptor types and neurotransmitters are involved in these modulatory processes, including γ-aminobutyric acid (GABA), facilitating interaction between descending fibers and afferent pathways in the dorsal horn, blocking or amplifying pain signals. These are then further transmitted to the PAG and amygdala among others, for re-assessment [29]. Figure 1 displays the pain pathways and matrix.
Predictive Coding Models for Pain Theory
When Gardner et al. published their study on auditory analgesia in dentistry in 1959 [39], a vivid debate ensued about therapeutic potential and the physiology of analgesia mediated by music and sound [40]. The initial study had shown significant analgesia in more than 5000 patients undergoing dentistry, while listening to waterfall noise with underlying relaxing music. The patients were modulating the intensity of the noise overlayed on soothing music. It was argued that attention and concentration afforded to this task dissociated patients from nociceptive cues. Patients reported that pain was present but of inconsequential character. Another group of dentists proposed that auditory analgesia could modulate pain perception by (1) cross-modality masking, by (2) distraction or dissociation, or (3) by suggestion of positive emotions. All three could alter the threshold for pain perception. These questions remain unanswered but resonate with new concepts of pain perception and musical emotions in a very interesting way. Whether music should block out nociceptive sensations, alter the weighting of stimuli (gain) or just alter the interpretation of a potentially painful stimulus remains unclear. Current theories of predictive coding, Bayesian inference in the brain, and reinforcement learning offer conceptual depth in reflecting on the problem both in clinical-practical and scientific terms. They offer a different view on pain genesis, assisting with its comprehension but not intending to deny biomedical concepts. Under a “Bayes’ brain” assumption [41] to “make sense of the world”, the brain must integrate all sensory inputs with (social) setting information and preexisting knowledge [42•]. Adapted from the inference statistical theory, the brain processes pain by estimating the probability that a perception (unpleasant stimulus) is true, based on preexisting conceptions and knowledge [43]. This Bayesian analysis is applied continuously to incoming data (sensory inputs), generating the top-down signaling cascade. These correspond to the brain’s “predictions” about the reality. When ascending information from the afferent pain pathways clashes with the brain’s predictions—as pain perception—about an incoming stimulus, a so called “prediction error” occurs, prompting re-analysis with new top-down signals and closing the loop of the multisynaptic pain circuitry (Fig. 1) [44•].
Neurobiological Modulation of Pain Perception and Sensation Through Music
Music as part of a multimodal intra- and postoperative pain management concept has significant effects on both subjective pain levels and analgesia requirements postoperatively [45]. The modulatory influences of music on the brain seem to be multidimensional [46], encompassing effects on mood and arousal [47] and focus of attention [46].
Pain perception is dependent on the emotional valence (positive, negative, neutral) of a stimulus [48]. By changing the emotional significance of a painful stimulus, through distraction, induction of a positive frame of mind and reduced responsiveness, music can modify pain perception [18, 20•]. Comparing the neuronal networks involved in pain appraisal with those of music evaluation in the brain shows significant convergence. Especially the orbitofrontal and insular cortex, the cingulate gyrus, the amygdala, and the periaqueductal gray seem to determine both the affective valence of a nociceptive cue and pleasant music [49•]. Activity and connectivity patterns of these neuronal hubs when concomitantly activated by nociception and pleasant music may determine the threshold of a perception to be felt as pain. This corresponds to “precision” in predictive coding theory. EEG findings described by Lu et al. suggest that listening to self-chosen music directly before a painful stimulus is associated with a decrease in alphaoscillations corresponding to an activation of brain areas related to music processing, mainly the prefrontal cortex and anterior cingulate cortex [20•]. Thus, it can be hypothesized that music activates brain regions involved in descending pain pathways and amplifies top-down pain modulation.
The provoked change in emotional appraisal of an unpleasant stimulus can be viewed in the context of the positive valence musical sounds can have on the state of emotional arousal. Musical sounds perceived as pleasant by an individual can trigger a dopamine-fueled reward cascade. It leads to positive emotions and so-called musical chills as the highest state of pleasure caused by music [50,51,52] and consequently causes a shift in baseline mood and arousal. This phenomenon was electroencephalographically measured by Chabin et al. [50]. The authors were able to demonstrate a distinct neuronal activity represented by an increase in theta-bands in the prefrontal cortex amongst others, during subjective positive emotional arousal, and linked this specific EEG pattern to a state of “pleasure” [50]. Neurobiologically, connectivity between the auditory cortex, the amygdala, and a plethora of other regions involved in the emotional processing allows for modulation of stimulus perception. Consequently, the cortical representation of a painful stimulus and thus its significance and evaluation at any given time is related to the emotional state of the individual [18]. Music induces “pleasurable chills”, and this positive emotional arousal state could be identified by the distinct EEG pattern, and used to modulate pain induced neuronal activity. However, it is important to consider that both musical experiences and pain are ultimately subjective. Objectifying both is thwarted by the difficulties of quantifying the emotional dimensions an organism goes through while suffering pain or enjoying music. Along with dopamine-reward circuits, effects of music on other neurotransmitter and neuroendocrine systems have been proposed. Nilsson et al. measured rising oxytocin levels during relaxation with calming music at 60 to 80 bpm and 50 to 60 dB [53]. In addition, a stimulation of endogenous opioid release [54] has been theorized as a link to top-down pain-regulating pathways, but a direct connection between incoming auditory stimuli and decrease in pain response and perception is yet to be shown [55•].
The second pain-modulating component of listening to music presents as a shift in attentional focus (distraction). In neuroimaging methods (magnetoencephalography, MEG), this seems to be characterized by a decrease in pain-induced delta-amplitudes in the cingulate gyrus and the insular cortex. This shifts attention away from pain towards music [46].
Present-day experimental findings speak for more complicated neuropsychological processes involving preexisting expectations responsible for the analgesic effect of pleasant sounds [55•]. This is supported by the predictive model of pain perception, viewing the brain not as a behavioralist black box [56] where certain inputs mechanistically trigger an outcome, but rather as a complex matrix of prior experiences and assumptions, leading to a co-analgesic effect [42•, 44•]. The neurobiological base to this psychological theory may be viewed to be the interconnections of the pain network, the relay of spino-thalamic-cortical and subcortical connections [42•]
Measuring Pain Modulation: Neuroimaging, EEG, Hormonal, and Vegetative Markers
Functional magnetic resonance imaging (fMRI) analysis has shown different activation patterns of spinal and cortical areas to painful stimuli with music compared to without music [57]. This can be seen as neurobiological evidence for the hypothesis that music changes (secondary) pain processing. However, neuroimaging for pain has its limitations [58] as shown in numerous, contradictory, studies over the past years trying to isolate brain regions selective for pain. These limitations mainly arise from “reverse inference” used to deduce the meaning of certain signals in fMRI. There seems to be debate amongst neuroscientific researchers as to whether MRI signals can be conclusively assigned to specific neurocellular processes [59, 60].
EEG signals obtained during and after a painful stimulus furthermore suggest that preferred music decreases the unpleasantness (subcortical affective pain component of the amygdala, insular cortex, and PAG), though not the perceived pain intensity (cortical somatosensory discriminatory and attentional prefrontal pain component) [20•, 48, 61]. Lu et al. [20•] could not conclude whether an alteration of the emotional state of the participants or a diversion of attention away from the painful stimulus evoked a decrease in pain sensation. More recent findings lean towards a mechanism where assigned emotion influences the affective component of pain (unpleasantness) more than the attentional component [48]. Williams and Hine [26] found that across 39 articles, distraction (in terms of gate control theory [36]) was mostly used as an underlying mechanism to explain the analgetic effectiveness of music, followed by relaxation, emotional shift, oscillatory entrainment of neuronal activity, and endogenous analgesics stimulated by music (opioid receptor expression, interleukine-6, and morphine-6 glucuronide [62] or increase in endorphins [63, 64]). The analysis showed that despite the effort of explaining the underlying mechanisms, most of the studies did not select music with parameters conducive to these processes [26]. For example, if entrainment is to be considered a valid contributor to the pain-relieving effect of intraoperative music, this connection should be explored further through EEG studies under sedation and general anesthesia, respectively. It is hypothesized that music, with a steady rhythm and frequencies around 60 to 80 bpm, could be ideal to promote a decrease in sympathetic activity and thus stress [26, 62, 65, 66].
Brain regions involved in pain processing, namely, the PFC, amygdala, and hippocampus, are also involved in stress response [67]. These in turn have close connections to the hypothalamus and thus to the hypothalamic–pituitary–adrenal (HPA) axis and the sympathetic nervous system (SNS) by signaling to the adrenal glands [68]. When matched for time of day and circadian rhythms, Koelsch et al. [69] found lower intraoperative cortisol levels in patients receiving music during general anesthesia as well as deeper sedation stages as measured by bispectral indices (BIS). This suggests lower sedative requirements and consequently a lower activation of the SNS in patients undergoing musical intervention. This supports earlier cortisol level results from Nilsson et al. [70], but contradicts others showing no effect on stress hormone levels and BIS [71].
Measuring cortical electrical signals has been shown to be a useful and accessible tool to determine effects of both musical [72] and painful stimuli on brain activity. We propose that future studies use raw EEG sedation stages and wave patterns as an additional feasible outcome measure for intraoperative stress and pain perception. Co-analgesic effects of music characteristics matching specific EEG patterns could be analyzed for their potential to reduce pain unpleasantness.
Clinical Context: Opioid-Sparing Effects and Postoperative Recovery
To objectify the clinical analgesic effect of perioperative music interventions, the following outcome parameters seem to have been most useful: the effect on postoperative pain during the first 24 h after general anesthesia (self-reported on the NRS, quantified by reduction in opioid requirements [13•]), the effect on intraoperative analgesic requirements under general anesthesia as quantified by intraoperative opioid dosage, the influence on the duration of the hospital stay, and the effect on successful early mobilization. The most feasible measure of the effect on intraoperative stress and pain reaction to surgical intervention seems to be heart rate variability [73], with neuroendocrine measurements not being easily applicable to the daily anesthesiology practice.
So far, no significant reduction in length of hospital stays, time spent in the intensive care unit, or overall costs during hospitalization through music-analgesia could be demonstrated [13•, 74].
Most of the systematic reviews and meta-analyses, including recent publications by Fu et al. [13•] and Dale [86•], found a reduction in postoperative opioid requirements after perioperative music across all analyzed studies [75], which cemented the conclusions of Kühlmann et al. [9] pointing towards significant reductions in pain levels in patients receiving musical interventions during general anesthesia. This contrasts with an earlier meta-analysis which did not find significant differences in pain levels for patients being played music during colonoscopies [76]. However, the very limited target group must be considered here. A subsequent analysis of pain reduction through music during different endoscopic procedures showed that no significant analgesic-saving effect could be detected, especially during colonoscopies and bronchoscopies [77]. Further research is needed to determine patient subgroups who would most benefit from peri-interventional and perioperative music. Currently available publications of clinical trials and randomized-controlled studies in adults are predominantly published in the field of orthopedic surgery, urology and obstetrics, and ophthalmology, as well as interventional radiology and heart and thoracic surgery [78,79,80,81,82,83,84]. Orthopedic and thoracic surgery focused on postoperative musical interventions during recovery [10], although all studies found reductions in procedural pain through music.
Clinical Applications
The currently available body of literature is very heterogeneous, which makes concrete conclusions for practice only possible to a limited extent. In order to make use of music as a tangible co-analgesic, a feasible framework for such intervention needs to be defined. Further research needs to determine the differences and optimal timing of the intervention (solely preoperatively, solely intraoperatively, solely postoperatively, from induction of general anesthesia or sedation until after emergence). Compelling evidence for preserved auditory sensory perception under general anesthesia [85] suggests that intraoperative acoustic stimulation with music could maintain its pain-modulating effect even during deep sedation [74]. Comprehensively, the timing of the musical intervention seems to have only marginal influence on postoperative pain reduction [74]. Additionally, it needs to be determined which type of music or sounds proves to be the most beneficial (patient’s choice, classical or electronic sounds of a specific frequency, chosen from preselected playlist or free choice, nature sounds, white noise) and for which intervention [26]. It must be noted that nature sounds have not consistently shown the same analgesic effect as self-selected music [55•]. Fu et al. in their meta-analysis excluded all studies that used nature sounds during intervention and focused solely on recorded music [13•]. Future research should consider the complex mechanisms of music to determine whether the melody, harmony, or rhythm might be the determining factor for its analgesic effect [26, 75]. Overall, the evidence points to patient-preferred or self-selected music, respectively, as being the most effective in reducing postoperative pain [9, 20•, 86•].
Across all systematic reviews and meta-analysis currently available, no adverse effects of musical interventions have been reported.
There are currently two ongoing studies registered with ClinicalTrials.gov on perioperative musical intervention during general anesthesia [87, 88].
Summary and Outlook
There appears to be some consensus that auditory stimulation with music during or after surgical interventions, under sedation or general anesthesia, can be considered an effective and low-cost, low-side-effect complimentary treatment to alleviate procedural and postoperative pain. Musical interventions have a low-threshold applicability in everyday clinical practice. Offering music via headphones during operations under regional anesthesia, with or without sedation, is already common practice. Anesthesia providers seem to hope for a relaxing and distracting effect, especially during operations with high noise levels, such as orthopedics. Patients can play their own music via their mobile phones or choose from a provided music library with a selection of genres and artists. In our experience, clinicians do not seem to have concrete expectations of reduced intraoperative opioid or sedative requirements when offering musical stimulation to their patients in the operating room. Our aim was to concretize anecdotal assumptions of musical analgesia, encourage anesthesia teams to systematically use music as a co-analgesic, and suggest ways in which future research in this area can unite neuropsychological and biological, philosophical, and anesthesiologic theories of pain and consciousness and further establish pain modulatory approaches.
Availability of Data and Material
Not applicable.
Code Availability
Not applicable.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance
Raja SN, Carr DB, Cohen M, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976–82. https://doi.org/10.1097/J.PAIN.0000000000001939.
Phillips K, Clauw DJ. Central pain mechanisms in chronic pain states – maybe it is all in their head. Best Pract Res Clin Rheumatol. 2011;25(2):141. https://doi.org/10.1016/J.BERH.2011.02.005.
Chimenti RL, Frey-Law LA, Sluka KA, Chimenti RL, Frey-Law LA, Sluka KA. A mechanism-based approach to physical therapist management of pain. Phys Ther. 2018;98(5):302–14. https://doi.org/10.1093/PTJ/PZY030.
Yam MF, Loh YC, Tan CS, Adam SK, Manan NA, Basir R. General pathways of pain sensation and the major neurotransmitters involved in pain regulation. Int J Mol Sci. 2018;19(8):2164. https://doi.org/10.3390/IJMS19082164.
Ringkamp M, Dougherty PM, Raja SN. Anatomy and physiology of the pain signaling process. Essentials of Pain Medicine. Published online January 1, 2018:3–10.e1. https://doi.org/10.1016/B978-0-323-40196-8.00001-2.
Basbaum AI, Bautista DM, Scherrer G, Julius D. Cellular and molecular mechanisms of pain. Cell. 2009;139(2):267. https://doi.org/10.1016/J.CELL.2009.09.028.
• Kiverstein J, Kirchhoff MD, Thacker M. An embodied predictive processing theory of pain experience. Rev Philos Psychol. 2022;13(4):973–98. https://doi.org/10.1007/s13164-022-00616-2. An indepth overview about introspection and the concept of embodied consciousness applied to nociception and pain. Very readable and a short version of the author’s book on predictive processing.
Lee JH. The effects of music on pain: a meta-analysis. J Music Ther. 2016;53(4):430–77. https://doi.org/10.1093/jmt/thw012.
Kühlmann AYR, de Rooij A, Kroese LF, van Dijk M, Hunink MGM, Jeekel J. Meta-analysis evaluating music interventions for anxiety and pain in surgery. Br J Surg. 2018;105(7):773–83. https://doi.org/10.1002/bjs.10853.
Kakar E, Billar RJ, Van Rosmalen J, Klimek M, Takkenberg JJM, Jeekel J. Music intervention to relieve anxiety and pain in adults undergoing cardiac surgery: a systematic review and meta-Analysis. Open Heart. 2021. https://doi.org/10.1136/openhrt-2020-001474.
Fu VX, Oomens P, Sneiders D, et al. The effect of perioperative music on the stress response to surgery: a meta-analysis. J Surg Res. 2019;244:444–55. https://doi.org/10.1016/j.jss.2019.06.052.
• Fu VX, Sleurink KJ, Janssen JC, Wijnhoven BPL, Jeekel J, Klimek M. Perception of auditory stimuli during general anesthesia and its effects on patient outcomes: a systematic review and meta-analysis. Can J Anesth. 2021;68(8):1231–53. https://doi.org/10.1007/s12630-021-02015-0. An indepth overview about introspection and the concept of embodied consciousness applied to nociception and pain. Very readable and a short version of the author’s book on predictive processing.
• Fu VX, Oomens P, Klimek M, Verhofstad MHJ, Jeekel J. The effect of perioperative music on medication requirement and hospital length of stay: a meta-analysis. Ann Surg. 2020;272(6):961–72. https://doi.org/10.1097/SLA.0000000000003506. An indepth overview about introspection and the concept of embodied consciousness applied to nociception and pain. Very readable and a short version of the author’s book on predictive processing.
Koch ME, Kain ZN, Ayoub C, Rosenbaum SH. Sedative and analgestic sparing effect of music 1998. Anaesthesiology. 1998;89:300–6.
Sherman M, Sethi S, Hindle AK, et al. Multimodal pain management in the perioperative setting. Open J Anesthesiol. 2020;10(2):47–71. https://doi.org/10.4236/OJANES.2020.102005.
• Song Y, Yao M, Kemprecos H, et al. Predictive coding models for pain perception. J Comput Neurosci. 2021;49(2):107. https://doi.org/10.1007/S10827-021-00780-X. An indepth overview about introspection and the concept of embodied consciousness applied to nociception and pain. Very readable and a short version of the author’s book on predictive processing.
• Lunde SJ, Vuust P, Garza-Villarreal EA, Vase L. Music-induced analgesia: how does music relieve pain? Pain. 2019;160(5):989–93. https://doi.org/10.1097/j.pain.0000000000001452. An indepth overview about introspection and the concept of embodied consciousness applied to nociception and pain. Very readable and a short version of the author’s book on predictive processing.
Vuilleumier P. How brains beware: neural mechanisms of emotional attention. Trends Cogn Sci. 2005;9(12):585–94. https://doi.org/10.1016/j.tics.2005.10.011.
Clements-Cortes A, Bartel L. Are we doing more than we know? Possible mechanisms of response to music therapy. Front Med (Lausanne). 2018;5:255. https://doi.org/10.3389/FMED.2018.00255/BIBTEX.
• Lu X, Thompson WF, Zhang L, Hu L. Music reduces pain unpleasantness: evidence from an EEG study. J Pain Res. 2019;12:3331–42. https://doi.org/10.2147/JPR.S212080. An indepth overview about introspection and the concept of embodied consciousness applied to nociception and pain. Very readable and a short version of the author’s book on predictive processing.
Kühlmann AYR, Van Rosmalen J, Staals LM, et al. Music interventions in pediatric surgery (the music under surgery in children study): a randomized clinical trial. Anesth Analg. 2020;130(4):991–1001. https://doi.org/10.1213/ANE.0000000000003983.
Graversen M, Sommer T. Perioperative music may reduce pain and fatigue in patients undergoing laparoscopic cholecystectomy. Acta Anaesthesiol Scand. 2013;57(8):1010–6. https://doi.org/10.1111/aas.12100.
Wu PY, Huang ML, Lee WP, Wang C, Shih WM. Effects of music listening on anxiety and physiological responses in patients undergoing awake craniotomy. Complement Ther Med. 2017;32:56–60. https://doi.org/10.1016/j.ctim.2017.03.007.
Guerrero JM, Castaño PM, Schmidt EO, Rosario L, Westhoff CL. Music as an auxiliary analgesic during first trimester surgical abortion: a randomized controlled trial. Contraception. 2012;86(2):157–62. https://doi.org/10.1016/j.contraception.2011.11.017.
Wiwatwongwana D, Vichitvejpaisal P, Thaikruea L, Klaphajone J, Tantong A, Wiwatwongwana A. The effect of music with and without binaural beat audio on operative anxiety in patients undergoing cataract surgery: a randomized controlled trial. Eye (Basingstoke). 2016;30(11):1407–14. https://doi.org/10.1038/eye.2016.160.
Williams C, Hine T. An investigation into the use of recorded music as a surgical intervention: a systematic, critical review of methodologies used in recent adult controlled trials. Complement Ther Med. 2018;37:110–26. https://doi.org/10.1016/j.ctim.2018.02.002.
• Howlin C, Stapleton A, Rooney B. Tune out pain: agency and active engagement predict decreases in pain intensity after music listening. PLoS ONE. 2022;17(8 August). https://doi.org/10.1371/journal.pone.0271329. Practically relevant, as it outlines the importance of finding out what the patient wants and respecting his/her choice.
Napadow V, Sclocco R, Henderson LA. Brainstem neuroimaging of nociception and pain circuitries. Pain Rep. 2019;4(4):e745–e745. https://doi.org/10.1097/PR9.0000000000000745.
Khalid S, Tubbs RS. Neuroanatomy and neuropsychology of pain. Cureus. 2017. https://doi.org/10.7759/CUREUS.1754.
Tracey I. Neuroimaging of pain mechanisms. Curr Opin Support Palliat Care. 2007;1(2):109–16. https://doi.org/10.1097/SPC.0B013E3282EFC58B.
Melzack R. Pain and the neuromatrix in the brain. J Dent Educ. 2001;65(12):1378–82. https://doi.org/10.1002/J.0022-0337.2001.65.12.TB03497.X.
Bannister K, Dickenson AH. The plasticity of descending controls in pain: translational probing. J Physiol. 2017;595(13):4159–66. https://doi.org/10.1113/JP274165.
Lei J, Sun T, Lumb BM, You HJ. Roles of the periaqueductal gray in descending facilitatory and inhibitory controls of intramuscular hypertonic saline induced muscle nociception. Exp Neurol. 2014;257:88–94. https://doi.org/10.1016/J.EXPNEUROL.2014.04.019.
Behbehani MM. Functional characteristics of the midbrain periaqueductal gray. Prog Neurobiol. 1995;46(6):575–605. https://doi.org/10.1016/0301-0082(95)00009-K.
Koutsikou S, Apps R, Lumb BM. Top down control of spinal sensorimotor circuits essential for survival. J Physiol. 2017;595(13):4151–8. https://doi.org/10.1113/JP273360.
Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971–9. https://doi.org/10.1126/SCIENCE.150.3699.971.
Bandler R, Keay KA, Floyd N, Price J. Central circuits mediating patterned autonomic activity during active vs. passive emotional coping. Brain Res Bull. 2000;53(1):95–104. https://doi.org/10.1016/S0361-9230(00)00313-0.
Donaldson LF, Lumb BM. Top-down control of pain. J Physiol. 2017;595(13):4139. https://doi.org/10.1113/JP273361.
Gardner WJ, Licklider JC. Auditory analgesia in dental operations. J Am Dent Assoc. 1959;59(6):1144–9. https://doi.org/10.14219/JADA.ARCHIVE.1959.0251.
Carlin S, Dixon Ward W, Gershon A, Ingraham REX. Sound stimulation and its effect on dental sensation threshold. Science (1979). 1962;138(3546):1258–9. https://doi.org/10.1126/SCIENCE.138.3546.1258.
LII. An essay towards solving a problem in the doctrine of chances. By the late Rev. Mr. Bayes, F. R. S. communicated by Mr. Price, in a letter to John Canton, A. M. F. R. S. Philos Trans R Soc Lond. 1763;53:370–418. https://doi.org/10.1098/RSTL.1763.0053.
• Chen ZS, Wang J. Pain, from perception to action: a computational perspective. iScience. 2023;26(1):105707. https://doi.org/10.1016/J.ISCI.2022.105707This is a thorough review of Bayesian inference, predictive coding and reinforcing learning in relation to pain. Highly readable, expands on the idea of predictive modulatory interactions in the pain matrix.
Introna M, van den Berg JP, Eleveld DJ, Struys MMRF. Bayesian statistics in anesthesia practice: a tutorial for anesthesiologists. J Anesth. 2022;36(2):294–302. https://doi.org/10.1007/S00540-022-03044-9/FIGURES/2.
• Ongaro G, Kaptchuk TJ. Symptom perception, placebo effects, and the Bayesian brain. Pain. 2019;160(1):1. https://doi.org/10.1097/J.PAIN.0000000000001367. An indepth overview about introspection and the concept of embodied consciousness applied to nociception and pain. Very readable and a short version of the author’s book on predictive processing.
Bernatzky G, Presch M, Anderson M, Panksepp J. ARTICLE IN PRESS G Model emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neurosci Biobehav Rev. 2011. https://doi.org/10.1016/j.neubiorev.2011.06.005.
Hauck M, Metzner S, Rohlffs F, Lorenz J, Engel AK. The influence of music and music therapy on pain-induced neuronal oscillations measured by magnetencephalography. Pain. 2013;154(4):539–47. https://doi.org/10.1016/J.PAIN.2012.12.016.
Schäfer T, Sedlmeier P, Städtler C, Huron D. The psychological functions of music listening. Front Psychol. 2013;4:511. https://doi.org/10.3389/FPSYG.2013.00511/BIBTEX.
Lyu Y, Zidda F, Radev ST, et al. Gamma band oscillations reflect sensory and affective dimensions of pain. Front Neurol. 2022;12:2438. https://doi.org/10.3389/FNEUR.2021.695187/BIBTEX.
• Vuust P, Heggli OA, Friston KJ, Kringelbach ML. Music in the brain. Nat Rev Neurosci. 2022;23(5):287–305. https://doi.org/10.1038/s41583-022-00578-5. An indepth overview about introspection and the concept of embodied consciousness applied to nociception and pain. Very readable and a short version of the author’s book on predictive processing.
Chabin T, Gabriel D, Chansophonkul T, et al. Cortical Patterns of pleasurable musical chills revealed by high-density EEG. Front Neurosci. 2020;14:1114. https://doi.org/10.3389/FNINS.2020.565815/BIBTEX.
Blood AJ, Zatorre RJ. Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. Proc Natl Acad Sci U S A. 2001;98(20):11818–23. https://doi.org/10.1073/PNAS.191355898/SUPPL_FILE/INDEX.HTML.
Salimpoor VN, Benovoy M, Larcher K, Dagher A, Zatorre RJ. Anatomically distinct dopamine release during anticipation and experience of peak emotion to music. Nat Neurosci. 2011;14(2):257–62. https://doi.org/10.1038/nn.2726.
Nilsson U. Soothing music can increase oxytocin levels during bed rest after open-heart surgery: a randomised control trial. J Clin Nurs. 2009;18(15):2153–61. https://doi.org/10.1111/J.1365-2702.2008.02718.X.
Laeng B, Garvija L, Løseth G, Eikemo M, Ernst G, Leknes S. ‘Defrosting’ music chills with naltrexone: the role of endogenous opioids for the intensity of musical pleasure. Conscious Cogn. 2021;90:103105. https://doi.org/10.1016/J.CONCOG.2021.103105.
• Lunde SJ, Vuust P, Garza-Villarreal EA, Kirsch I, Møller A, Vase L. Music-Induced analgesia in healthy participants is associated with expected pain levels but not opioid or dopamine-dependent mechanisms. Front Pain Res. 2022;3:734999. https://doi.org/10.3389/FPAIN.2022.734999. Great reading together with the group’s reviews. Raises important questions for future research.
Watson JB. Psychology as the behaviourist views it. Psychol Rev. 1913;20(2):158–77. https://doi.org/10.1037/H0074428.
Dobek CE, Beynon ME, Bosma RL, Stroman PW. Music modulation of pain perception and pain-related activity in the brain, brain stem, and spinal cord: a functional magnetic resonance imaging study. J Pain. 2014;15(10):1057–68. https://doi.org/10.1016/j.jpain.2014.07.006.
Martucci KT, Mackey SC. Neuroimaging of pain: human evidence and clinical relevance of central nervous system processes and modulation. https://doi.org/10.1097/ALN.0000000000002137.
Poldrack RA. Can cognitive processes be inferred from neuroimaging data? Trends Cogn Sci. 2006;10(2):59–63. https://doi.org/10.1016/j.tics.2005.12.004.
Hutzler F. Reverse inference is not a fallacy per se: cognitive processes can be inferred from functional imaging data. Neuroimage. 2014;84:1061–9. https://doi.org/10.1016/J.NEUROIMAGE.2012.12.075.
Bushnell MC, Čeko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci. 2013;14(7):502. https://doi.org/10.1038/NRN3516.
Li XM, Yan H, Zhou KN, Dang SN, Wang DL, Zhang YP. Effects of music therapy on pain among female breast cancer patients after radical mastectomy: results from a randomized controlled trial. Breast Cancer Res Treat. 2011;128(2):411–9. https://doi.org/10.1007/S10549-011-1533-Z.
Özer N, Karaman Özlü Z, Arslan S, Günes N. Effect of music on postoperative pain and physiologic parameters of patients after open heart surgery. Pain Manag Nurs. 2013;14(1):20–8. https://doi.org/10.1016/j.pmn.2010.05.002.
Motahedian E, Movahedirad S, Hajizadeh E, Lak M, et al The effect of music therapy on postoperative pain intensity in patients under spinal anesthesia. Published online 2012.
DeMarco J, Alexander JL, Nehrenz G, Gallagher L. The benefit of music for the reduction of stress and anxiety in patients undergoing elective cosmetic surgery. Music Med. 2012;4(1):44–8. https://doi.org/10.47513/MMD.V4I1.389.
Allred KD, Byers JF, Sole ML. The effect of music on postoperative pain and anxiety. Pain Manag Nurs. 2010;11(1):15–25. https://doi.org/10.1016/J.PMN.2008.12.002.
McEwen BS, Bowles NP, Gray JD, et al. Mechanisms of stress in the brain. Nat Neurosci. 2015;18(10):1353. https://doi.org/10.1038/NN.4086.
Thoma MV, La Marca R, Brönnimann R, Finkel L, Ehlert U, Nater UM. The effect of music on the human stress response. PLoS ONE. 2013. https://doi.org/10.1371/JOURNAL.PONE.0070156.
Koelsch S, Fuermetz J, Sack U, Bauer K, Hohenadel M, Wiegel M, Kaisers UX, Heinke W. Effects of music listening on cortisol levels and propofol consumption during spinal anesthesia. Front Psychol. 2011 Apr 5;2:58. https://doi.org/10.3389/fpsyg.2011.00058. PMID: 21716581; PMCID: PMC3110826.
Nilsson U, Unosson M, Rawal N. Stress reduction and analgesia in patients exposed to calming music postoperatively: a randomized controlled trial. Eur J Anaesthesiol. 2005;22(2):96–102. https://doi.org/10.1017/S0265021505000189.
Migneault B, Girard F, Albert C, et al. The effect of music on the neurohormonal stress response to surgery under general anesthesia. Anesth Analg. 2004;98(2):527–32. https://doi.org/10.1213/01.ANE.0000096182.70239.23.
Almudena G, Manuel S, Jesús GJ, Almudena G, Manuel S, Jesús GJ. EEG analysis during music perception. Electroencephalography - From Basic Research to Clinical Applications. 2020. https://doi.org/10.5772/INTECHOPEN.94574.
Forte G, Troisi G, Pazzaglia M, De Pascalis V, Casagrande M. Heart rate variability and pain: a systematic review. Brain Sci. 2022. https://doi.org/10.3390/BRAINSCI12020153.
Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis. Lancet. 2015;386(10004):1659–71. https://doi.org/10.1016/S0140-6736(15)60169-6.
Martin-Saavedra JS, Vergara-Mendez LD, Talero-Gutiérrez C. Music is an effective intervention for the management of pain: an umbrella review. Complement Ther Clin Pract. 2018;32:103–14. https://doi.org/10.1016/j.ctcp.2018.06.003.
Bechtold ML, Puli SR, Othman MO, Bartalos CR, Marshall JB, Roy PK. Effect of music on patients undergoing colonoscopy: a meta-analysis of randomized controlled trials. Dig Dis Sci. 2009;54(1):19–24. https://doi.org/10.1007/S10620-008-0312-0.
Wang MC, Zhang LY, Zhang YL, Zhang YW, Xu XD, Zhang YC. Effect of music in endoscopy procedures: systematic review and meta-analysis of randomized controlled trials. Pain Medicine (United States). 2014;15(10):1786–94. https://doi.org/10.1111/pme.12514.
Kulkarni S, Johnson PCD, Kettles S, Kasthuri RS. Music during interventional radiological procedures, effect on sedation, pain and anxiety: a randomised controlled trial. Br J Radiol. 2012;85(1016):1059. https://doi.org/10.1259/BJR/71897605.
Drzymalski DM, Lumbreras-Marquez MI, Tsen LC, Camann WR, Farber MK. The effect of patient-selected or preselected music on anxiety during cesarean delivery: a randomized controlled trial. 2019;33(24):4062–68. https://doi.org/10.1080/14767058.2019.1594766.
Ebneshahidi A, Mohseni M. The effect of patient-selected music on early postoperative pain, anxiety, and hemodynamic profile in cesarean section surgery. https://home.liebertpub.com/acm. 2008;14(7):827–31. https://doi.org/10.1089/ACM.2007.0752.
Tsivian M, Qi P, Kimura M, et al. The effect of noise-cancelling headphones or music on pain perception and anxiety in men undergoing transrectal prostate biopsy. Urology. 2012;79(1):32–6. https://doi.org/10.1016/j.urology.2011.09.037.
Çift A, Benlioglu C. Effect of different musical types on patient’s relaxation, anxiety and pain perception during shock wave lithotripsy: a randomized controlled study. Urol J. 2020;17(1):19–23. https://doi.org/10.22037/UJ.V0I0.5333.
Cho SW, Choi HJ. Effect of music on reducing anxiety for patients undergoing transrectal ultrasound-guided prostate biopsies: randomized prospective trial. Urol J. 2016;13(2):2612–4. https://doi.org/10.22037/UJ.V13I2.3187.
Schneider MA. The effect of listening to music on postoperative pain in adult orthopedic patients. 2016;36(1):23–32. https://doi.org/10.1177/0898010116677383.
Dueck MH, Petzke F, Gerbershagen HJ, et al. Propofol attenuates responses of the auditory cortex to acoustic stimulation in a dose-dependent manner: a FMRI study. Acta Anaesthesiol Scand. 2005;49(6):784–91. https://doi.org/10.1111/J.1399-6576.2005.00703.X.
• Dale VH. The impact of perioperative music on abdominal surgery patients’ experience of postoperative pain: a systematic review and meta-analysis. J Perioper Pract. 2021;31(1–2):31–43. https://doi.org/10.1177/1750458920943375. An indepth overview about introspection and the concept of embodied consciousness applied to nociception and pain. Very readable and a short version of the author’s book on predictive processing.
Perioperative effect of music in patients undergoing general anesthesia - full text view - ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT05572437. Accessed 2 Apr 2023.
Decreasing emergence agitation with personalized music - full text view - ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT05044832. Accessed 2 Apr 2023.
Funding
Open access funding provided by University of Bern.
Author information
Authors and Affiliations
Contributions
Fabienne Frickmann, Richard D. Urman, Kaya Siercks, Gabriel Burgermeister, Markus M. Luedi, and Friedrich E. Lersch wrote the article and approved the final version. The authors have seen, reviewed, and approved the final manuscript.
Corresponding author
Ethics declarations
Ethics Approval
Not applicable
Consent to Participate
Not applicable
Consent for Publication
Not applicable
Conflict of Interest
Fabienne Frickmann, Kaya Siercks, Gabriel Burgermeister, Markus M. Luedi, and Friedrich E. Lersch declare no conflict of interest. Richard D. Urman reports fees/funding from AcelRx, Medtronic, Pfizer and Merck. No funding was involved.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Frickmann, F.C.S., Urman, R.D., Siercks, K. et al. The Effect of Perioperative Auditory Stimulation with Music on Procedural Pain: A Narrative Review. Curr Pain Headache Rep 27, 217–226 (2023). https://doi.org/10.1007/s11916-023-01138-x
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11916-023-01138-x