The removal of the chest tube is an extremely painful procedure and can be dangerous for the palliative care patients. The patient may not be benefitted fully from the palliative acute care therapies. The purpose of this study is to assess the effectiveness of the cold and the music therapy independently on these patients as well as the amalgamation of both the interventions. Hence it can be said that the study question was stated clearly.
This study has got several nursing or clinical implications.
Describe the justification of the need for this study
The need for this study was justified as it has been found that the although painful sensation during the removal of the chest tube can be managed by the application of certain analgesics , the adverse effects posed by the use of the NSAIDs and other analgesics cannot be overlooked. One of the crucial reason behind this study is that very few literatures have actually shown the relevance of the cold therapy on CTR patients, although cold therapy has long been considered to be responsible for the conductance of the nerve stimuli and thus reducing pain. This paper has gained evidences from literature by Hassanzadeh et al., (2016). As opposed by Sauls et al., (2002), cold therapy has been found to be ineffective in managing pain. A study by Dehcheshmeh & Rafiei, (2015), Have found the association between the music therapies in labour pain.
Furthermore the effectiveness of the music therapy has also been controversial in the pain reduction in STR. In addition to this previously no studies have evaluated the effectiveness of the combined therapy in the pain reduction. Hence these are the rationale behind the need for this study.
The study design is a randomised control trial and the population for the study has been selected from the patients who have had a cardiac surgery at the Shahid Madani Hospital, Khorram Abad, Iran and then were admitted to the Cardiac Surgery Intensive Care Unit (CSICU) in 2016.
The study design was appropriate as it was based on a previously conducted study by Mazloum et al., , who examined the outcome of the application of the ice packs on the patients who has underwent chest tube removal.
One of the ethical issue that can be considered regarding this study is that the population that has been considered consists of high risk group patients.
In order to avoid any bias all the data were gathered by a nurse who was not a part of the research team. Collection of the data by the research team members may cause bias. Nurses who are part of the research team may give rise to compromised interpretation of the respondent’s data.
The sample was described in details. They were selected consecutively and was assigned randomly in groups by using an eight member block technique. Three groups were considered. Group A (cold therapy), group B (Music therapy), group C (cold and music therapy) and control (group D).
The inclusion criteria included patient within the age 18-65 years with a chest tube for more than 120 hours or not less than 24 hours. People having no past history of blindness or hearing impairment, people who are capable of responding to the questions, those having no medical history of mental disorder or those having no history of narcotics usage, or drugs and alcohols were included in the study. The exclusion criteria was included those patients who demonstrated more pain score as high as 7, or unwillingness to participate in the study, those feeling discomfort with the cold therapy or who are under the treatment of sedatives or narcotics as medications.
45 participants were allotted for each group and after the loss of the participants due to sudden discontinuation and lost to follow up finally considered 43 participants were allocated for the application of the cold therapy. Among the 180 patients, finally 45 patients were allocated for each of the application of music therapy, both music therapy and cold therapy and control and 43 -44 participants were finally analysed for the effectiveness of the treatment. Group A received the 9 inch ice pack at a temperature of about -5 degree placed above the chest tube while in contact with the underlying skin for about 20 minutes. A cloth was provided in between the patient’s skin and the ice pack.
Group B was provided with music stimulation for about 30 minutes. The music continued following the procedure of the chest tube removal. The patients were allowed to choose their choice of music from the lost. There were 15 traditional songs or the folk songs in the list. Group C got a mixture of the two interventions. Before the beginning of the CTR and the, the measurement of the pain was taken before and after the CTR.
The sample size was suitable and justified.
Ethical approval was acquired from the ethics committee of Iran. The study was further documented in the Iranian Registry of clinical trials. The patient’s were given the freedom to withdraw from the study as per their will. An informed consent was also taken from the patient and they were informed about the possible adverse effect of the trial. The patient were assured that confidentiality should be maintained regarding any clinical data. The participants were also instructed to provide a written consent before the conduction of the study.
Before the starting of the interventions the patient were instructed to mark the intensity of the pain by a pain assessment scale between 0-10. Further before commencing the interventions the patients were placed in semi fowler positions with a pillow under their shoulder and the head .Hence it can be said that the researchers maintained a proper follow up procedure.
Outcome areas. List measures used.
The outcome measures were significantly valid. The outcome areas included-
The patient reported outcome measures were in the shape of a two pat questionnaire. The first part contained the variables such as the gender, age, BMI, qualifications, marital status, occupation, and types of surgery, occupational status, and use of painkillers, presence of any chronic pain and chest tube placement before surgery.
The second part is the visual analogue scale to report the pain intensity within a scale of 0-10
Group A received a 9 inch ice pack over the chest tube when in contact with the skin. Group B was exposed to music for about 30 minutes. The music initiated 15 minutes before the starting of the CTR and continued up to 15 minutes until the completion of the procedures. 15 traditional and folk sound tracks were provided in an MP3 player with the headphones. 60 db was maintained as the maximum sound level. Group C got combined interventions. And group D received no interventions other than the routined measures.
Yes, these interventions are relevant to nursing and midwifery practice.
All the results were reported I terms of the statistical significance. There was no significant statistical difference between the groups as compared to the demographics and the base line data. It has been found that there had been no disparities in the baseline scores of the intensity of the pain between the study groups. There was a difference in the pain intensity score between the groups at the time of CTR. Differences were also found when the combined group (cold therapy and the music therapy) were compared with the control data. No significant differences were found when the music therapy and the cold therapy groups were individually compared to the control groups. No statistical differences were found by the ANOVA test in respect to the pain scores, 15 minutes after the CTR.
The study was not big enough to show some major statistical difference. As discussed by Sullivan & Feinn, (2012), statistical difference is only significant if the sample size is large. Even a small statistical difference with large sample size is significant. It can be said that the blend of the cold therapy and the music therapy can be used to reduce the pain following CTR. However individual intervention of music therapy does not lessen any pain. One of the significant finding is that the group receiving the cold therapy reported of lesser pain than those of the control group. This finding can be supported with the finding of (Demir & Khorsh?d, 2010), where ice pack was used for the duration of 20 minutes. Although several studies have reported the reduction of the pain intensity with music therapy but this study was unable to find out statistical difference.
The results are of clinical importance because the findings can be used in the future scope of practice for reducing pain using music therapy or the cold therapy. Findings from the present study shows that a synchronous application of the cold therapy and music therapy can be useful in managing pain by CTR. Hence this strategy can be used by the nurses in patients with CTR and besides the application of suitable pharmacokinetics. Clinical implication has been discussed although these clinical importance could have been discussed in more details.
One of the limitation of this study is that the CTR has been performed by five different nurses that can have an impact upon the results and requires the elimination of this limitation in the future scope of practice.
It can be concluded from the study that the application of the cold therapy and music therapy can actually mitigate the pain intensity during the CTR. The simplicity and the cost effectiveness of these complimentary therapies apart from the costly and the harmful analgesics has opened the future scope of practice of using the cold therapy and music therapy for the pain management in patients with CTR.
Pain management in patient’s are one of the integral part of nursing and needs proper pharmacological interventions. Improper management of pain can be considered as an indicator to the nursing care. As per the researches music therapy has a soothing effect on the anxiety levels, blood pressure, heart rate and the plasma stress hormones. Again cold application has long been considered as a pain relieving method. It has been utilised for years and it is believed to control pain by providing a local anaesthesia. Hence a combined effect of both these alternative treatment can be manage the pain by decreasing the edema, local blood flow or the cellular metabolism. As it has been reported that music therapy can be helpful in management of pain by providing sensory stimulation. And it can also be used to promote relaxation of the muscles, rhythmic breathing and rest. Hence the nurses and the midwives can use music therapy and cold therapy as an alternative treatment to reduce the pain in patients with CTR.
Yarahmadi, S., Mohammadi, N., Ardalan, A., Najafizadeh, H., & Gholami, M. (2018). The combined effects of cold therapy and music therapy on pain following chest tube removal among patients with cardiac bypass surgery. Complementary therapies in clinical practice, 31, 71-75.