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1. Using massage and music therapy to improve postoperative outcomes.....................................................
13 November 2013
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Using massage and music therapy to improve postoperative outcomes
Author: McRee, Laura D; Noble, Stacie; Pasvogel, Alice
Publication info: Association of Operating Room Nurses. AORN Journal 78.3 (Sep 2003): 433-42, 445-7.
ProQuest document link
Abstract: McRee et al determine whether massage and music therapy could decrease anxiety, resulting in
positive outcomes related to cardiovascular hemostasis and decreased pain for patients. After conducting a
variety of studies related to the effects of massage or music therapy on patients' anxiety, results indicate that
postoperative anxiety levels were significantly lower and postoperative prolactin levels were significantly higher
for all groups.
Full text: Headnote
* AN EXPERIMENTAL PILOT STUDY was conducted to investigate the effects of preoperative massage and
music therapy on patients' preoperative, intraoperative, and postoperative experiences.
* PARTICIPANTS were assigned randomly to one of four groups-a group that received massage with music
therapy, a group that received massage only, a group that received music therapy only, or a control group.
* HEMODYNAMICS, serum cortisol and prolactin levels, and anxiety were measured preoperatively and
* POSTOPERATIVE ANXIETY LEVELS were significantly lower and postoperative prolactin levels were
significantly higher for all groups. AORN J 78 (Sept 2003) 433-447.
Whether surgery is emergent or elective, the experience causes patient anxiety, which can be detrimental to
surgical outcomes.1 The anticipation of pain may cause increased anxiety, and, in turn, anxiety and pain cause
an increase in levels of circulating catecholamines, adrenocorticotrophic hormone, growth hormone, prolactin,
antidiuretic hormone, aldosterone, cortisol, glucagon, prostaglandins, and free fatty acids.2 An increase in
stress hormones and resulting metabolic responses can lead to a variety of morbid events, including myocardial
and other organ ischemia, dysrhythmia, hypercoagulability, malnutrition, fluid and electrolyte imbalance,
decreased wound healing, and immunocompromise.2 Anxiety increases oxygen consumption, cardiac output,
and blood pressure.3 Furthermore, anxiety and stress can increase the need for higher doses of anesthetics
and sedatives during surgical procedures, resulting in a potentially negative effect on a patient's recovery.3 Fear
of pain is a significant fear ranked second only to fear of death;4 therefore, it is important for surgical teams to
be aware of interventions that could decrease anxiety and pain.
This study was designed to determine whether massage and music therapy could decrease anxiety, resulting in
positive outcomes related to cardiovascular hemostasis and decreased pain for patients. A variety of studies
related to the effects of massage or music therapy on patients' anxiety have been conducted.
MASSAGE THERAPY. Massage is the art of touch and manipulation of soft tissue to achieve therapeutic
results, including mental relaxation, comfort, and healing.5 Massage has been considered a therapeutic
intervention for thousands of years. There is evidence of the use and value of therapeutic massage in China
more than 5,000 years ago.6 A person's tactile needs do not change with health or aging; however, patients
who are acutely ill or undergoing surgery seldom are touched other than when they are receiving necessary
care.5 Caring touch, compared to technical or mechanical touch, is an important method of communication.7
There are a number of theories about the mechanisms for massage's therapeutic effects on psychological and
physical status. Most simply, massage may relieve pain through muscle relaxation and the release of
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The gate control theory of pain also has been used to explain the effectiveness of massage in pain control.6
According to this theory, tactile information from massage is carried on the large myelinated fibers, which may
close the neurological "pain gate" at the peripheral point, thus reducing the perception of pain.
Two other mechanisms for pain relief through massage have been identified:
* soft tissue manipulation improves circulation, which reduces pain caused by the accumulation of irritants,
including lactic acid and inflammatory substances; and
* the emotional contact of caring touch may induce a sense of well-being that would diminish the perception of
Results of previous studies have demonstrated therapeutic benefits of massage in a variety of circumstances,
especially in terms of decreased anxiety, decreased stress response, and less pain. In a study of the effects of
massage on 122 patients admitted to an intensive care unit (ICU), participants were assigned randomly to
receive massage, aromatherapy and massage, or a period of rest.10 Preintervention and postintervention
assessments included physiological stress indicators and patients' evaluations of their anxiety level, mood, and
ability to cope with the intensive care experience. No significant differences were reported in the physiological
stress indicators, which included systolic and diastolic blood pressure, heart rate and rhythm, and respiratory
rate. The group that received massage and aromatherapy, however, demonstrated significant improvements in
mood and reported decreased anxiety after therapy.
One study evaluated the effects of massage on anxiety among older adult, institutionalized patients.11
Participants were assigned randomly to a group that received a five-minute back massage and engaged in
conversation with the massage therapist, a group that participated in a five-minute conversation only, or a group
that received no interventions. Anxiety was measured using the Spielberger State-Trait Anxiety Inventory (STAI)
before and after interventions and at two points in time for the group that received no interventions. The study
was conducted during four consecutive days. Mean anxiety scores indicated that anxiety levels were
significantly lower for the group that received massage compared to the group that received no interventions.
One group of researchers studied the effects of massage on 28 patients in a hospital burn unit.12 Patients were
assigned randomly to a massage therapy group or a standard treatment control group before undergoing a
debridement procedure. The group that received massage demonstrated less anxiety, lower cortisol levels, less
pain, and less depression than the group that received standard care. A limitation of this study is the lack of a
comparison intervention; therefore, it cannot be determined whether an intervention other than massage would
have produced the same effects.
One researcher studied the effects of therapeutic massage on preoperative anxiety, gathering both quantitative
and qualitative data.13,14 Sixty patients undergoing general surgical or gynecological procedures were
selected from a rural hospital. The treatment group included 30 patients who received 45 minutes of
preoperative massage. The control group did not receive any interventions. Measures included anxiety as
indicated by scores on the STAI, the amount of analgesia required, and length of hospital stay. In addition,
study participants were interviewed during their massages to elicit their perceptions of the experience. The
results demonstrated that the group that received massage experienced reduced preoperative anxiety
compared to the control group; however, there were no significant differences in amounts of analgesia used or
length of stay between the two groups. Analysis of participant interviews revealed that those who received
massage believed their vulnerability was respected and that the massage provided an environment in which
they felt safe to talk. A limitation of this study is, again, lack of a comparison intervention.
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MUSIC THERAPY. Music has been defined as the science or art of the composition of sounds that are
comprehended by the human brain as enjoyable and expressive.3 In the 1800s, music was used to aid sleep,
decrease anxiety associated with surgery, and assist in the administration of local anesthesia.2 The
physiological effects of music have been measured using blood pressure, mean arterial pressure, heart rate,
electrocardiogram, respiratory rate, oxygen saturation, finger temperatures, and serum hormone levels.15
Many studies have examined the effect of music on patients' anxiety. One study examined the effects of music
use in various medical specialties, including anesthesiology, surgery, orthopedics, dentistry, and obstetrics.
Patients selected the music they preferred and listened to it during the preoperative wait. Headphones were left
on until patients were asleep. Patients who received local anesthesia wore headphones during the entire
procedure. Findings included decreased levels of anxiety, decreased blood pressure, and decreased hormone
levels, including prolactin, cortisol, adrenocorticotrophic hormone, growth hormone, and norepinephrine.16
A pilot study of 30 patients scheduled for elective orthopedic surgical procedures performed using regional
anesthesia was conducted to determine whether having patients listen to their favorite music while undergoing
the surgical procedure reduced their anxiety.3 Data were collected using questionnaires designed to obtain
feedback about patients' selections and their feelings about listening to music during surgical procedures.
Patients reported that music helped the surgery go more quickly, masked background noises, and diverted their
minds from the procedure. Perioperative staff members provided positive feedback about the use of music, and
anesthesia care providers noted that participants were calmer throughout the procedures, pulse and blood
pressures remained more stable, and less anesthesia was required.
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The psychological and physiological effects of music have been studied in a variety of clinical settings including
ICUs, surgical suites, and postanesthesia care units (PACUs). One group of researchers investigated the
physiological effects of music therapy on 22 critically ill patients in an ICU.17 Reduction in heart rate, systolic
blood pressure, pain, and anxiety were reported. Another researcher conducted a six-month study in which
music was played for five minutes before the start of painful procedures. Patients who listened to music used
30% less pain medication than those who did not listen to music.18
Studies have examined patients' perceptions of their surgical experiences, including preoperative,
intraoperative, and postoperative care.
One researcher investigated the effects of humorous and musical distraction on preoperative anxiety in 46
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patients scheduled for same day elective surgery.19 The study included three groups: one group that listened to
music for 20 minutes, a second group that listened to a 20-minute humorous audiotape, and a control group that
received standard care. No significant differences in anxiety scores were reported.
Another researcher conducted a pilot study that investigated patients' perception of music during their surgical
experience.20 The study included 25 participants who underwent elective surgery receiving either a local,
spinal, or epidural anesthetic. Patients were interviewed 20 hours after surgery. Their remarks indicated that
music eased anxiety, provided distraction, and increased their pain thresholds.
The effect of music on pain and hemodynamic measurements (ie, mean arterial pressure, heart rate,
respirations) in the PACU for patients who had undergone thyroidectomy, parathyroidectomy, or modified
mastectomy was the subject of one study.21 One group of participants wore headphones and listened to music,
another group wore headphones but did not listen to music, and a control group did not wear headphones or
listen to music. Members of the group that listened to music were able to wait significantly longer before
requiring pain medication compared to members of the group who wore headphones but did not listen to music.
Members of the group that listened to music perceived their PACU experience as significantly more pleasant
than did the other two groups. No significant differences were reported in hemodynamics, respirations, pain, or
length of stay in the PACU.
One group of researchers examined the influence of three interventions on anxiety during the early
postoperative phase of patients undergoing heart surgery.22 Participants were assigned randomly to one of
three groups. One group received music therapy, a second group received music-video therapy (ie, participants
watched a 30-minute videotape in which soft instrumental music accompanied visual images on a television
screen), and a third group received scheduled rest. Interventions were 30 minutes in length, and participants
received interventions at two separate times-on postoperative day two and postoperative day three. Mood and
anxiety were evaluated before and after each session. Anxiety was measured before surgery, before the
intervention session on postoperative day two, and at the completion of the session on postoperative day three.
Blood pressure and heart rate were measured immediately before the intervention and at 10-minute intervals
during the intervention. Members of all three groups reported reduced anxiety and improved moods and
experienced significant decreases in mean heart rate and blood pressure. The decreases occurred within the
first 10 minutes of the intervention and continued for the remainder of the study period.
Another researcher investigated sensory and affective pain in 84 participants who underwent nonlaparoscopic,
elective abdominal surgery.23 Each participant was assigned randomly to one of four groups: a group that
practiced jaw relaxation, a group that listened to music, a group that listened to music combined with practicing
jaw relaxation, and a control group that received no intervention. The participants in the jaw relaxation group
followed audiotaped instructions to perform the relaxation exercises. Participants in the music group selected
and listened to one of five choices of relaxing music audiotapes. Participants in the jaw relaxation with music
group practiced jaw relaxation techniques while listening to their choice of one of the five music audiotapes. No
significant differences were reported in the areas of sensation, distress, anxiety, or narcotic intake between the
three intervention groups and the control group.
In a study of the effect of music on 42 ambulatory surgery patients' anxiety, participants in the experimental
group listened to their choice of music after receiving preoperative instruction, and participants in the control
group received only preoperative instruction.24 Ten minutes before surgery, vital sign measurements were
taken and compared to baseline vital sign measurements. Participants in the experimental group demonstrated
significantly lower heart rates than participants in the control group.
The purpose of this pilot study was to investigate the effects of preoperative therapeutic massage and music
therapy on patients' preoperative, intraoperative, and postoperative experiences. Identifying ways to decrease
preoperative anxiety could result in the use of less anesthesia for induction, the use of less postoperative
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analgesia, and fewer complications from stress-related responses-outcomes that could lead to decreased costs
for hospitals and patients. Furthermore, established empirical data may provide justification for offering
massage and music therapy as a preoperative standard of care.
The following research questions were asked.
* Are there differences between preoperative and postoperative anxiety, cortisol levels, and prolactin levels
among the groups?
* Are there differences in preoperative and postoperative anxiety, cortisol levels, and prolactin levels within each
* Are there differences between preoperative, intraoperative, and postoperative blood pressures and pulse rates
among the groups?
* Are there differences in preoperative, intraoperative, and postoperative blood pressures and pulse rates within
* Is there a difference in the percentage of participants in each group who received postoperative pain
The study employed a four-group experimental design, including three intervention groups and one control
group. Patients in one group received 30 minutes of massage and listened to 30 minutes of music before
surgery. Patients in a second group received 30 minutes of massage before surgery, and patients in a third
group listened to 30 minutes of music before surgery. Patients in the control group received standard care.
SETTING AND PARTICIPANTS. Data were collected at the University Medical Center (UMC), Tucson. A
private room was provided for the researcher to meet with study participants. Approval for the study was
obtained from the human subjects committee of the University of Arizona and from the Institutional Review
Board of UMC.
Selection criteria included that participants be at least 18 years of age and able to read English. In addition,
participants needed to be low-risk surgical patients as determined via preoperative assessment by the
anesthesia care provider using the standards of American Society of Anesthesiologists scale. This scale is
based on the number and severity of preexisting medical conditions. The range is from a normal healthy patient
(ie, one) to a patient who is declared brain dead and whose organs are being removed for donation (ie, six).25
The surgical schedule provided information to identify potential participants who then were recruited for the
study the morning of surgery. All patients who met the criteria were invited to participate in the study by the
nurse researcher. Data were collected during a one-year period.
DEFINITIONS AND INSTRUMENTS. This study was concerned with participants' state anxiety. State anxiety
was defined as the intensity of apprehensive feelings experienced at a particular moment as measured by the
STAI six-item short form (STAI-6). The STAI is one of the most frequently used measures of anxiety. The STAI6 was developed for use in circumstances in which the full form is inappropriate due to its length.26
The range of scores for the STAI-6 is zero to 36. The concurrent validity of the short form was determined by
comparing prorated scores from the six-item scale with those from the full scale. No differences in scores were
reported. The reliability for the six-item scale was 0.82.26 In the present study, the reliability of the instrument
was tested using Cronbach's alpha to determine the internal consistency of the items. The alpha was 0.79 for
Systolic blood pressure is maximum blood pressure that occurs during contraction of the ventricle.27 (p2126)
Diastolic blood pressure refers to the period of cardiac relaxation alternating with systole or contraction.27
(p587) Pulse is defined as the rate, rhythm, condition of arterial walls, compressibility and tension, and shape of
the fluid wave of blood traveling through the arteries as a result of each heart beat.27 (p1794) Intraoperative
measurement for blood pressure and pulse was obtained by the anesthesia care provider using automatic
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monitoring equipment. Postoperative blood pressure and pulse were obtained by the primary investigator or
research assistant using automatic monitoring equipment.
Cortisol is a glucocortical hormone of the adrenal cortex.27 (p492) The method used for cortisol determination
was chemiluminescent immunoassay using a polyclonol rabbit antibody specific for cortisol. Prolactin is a
hormone produced by the anterior pituitary gland.27 (p1761) The method used to determine prolactin levels was
a two-site sandwich antibody assay (ie, a specific chemiluminescent assay). Blood was sent to a regional
laboratory for processing. The same laboratory processed all samples. Instruments at the laboratory were
calibrated monthly or based on reagent stability.
Pain control, defined as the amount and frequency of analgesia administered, was measured in the recovery
room. Patients were asked about their levels of pain, and all medications were administered by PACU nursing
INTERVENTIONS. Patients were required to be at the hospital two hours before surgery. Interventions were
provided during the first hour of this two-hour period. During this time, the control group waited in the waiting
room and followed the usual routine for perioperative patients.
Members of the massage with music and massage only groups received 30 minutes of massage. Swedish
massage techniques were used in this study. The strokes used were effleurage (ie, long gliding strokes),
petrissage (ie, lifting of the muscle, kneading), and vibration (ie, gentle shaking of the muscle). One nurse
massage therapist provided all the treatments. All participants who received massage were lying face down on
a massage table. Only the posterior body was massaged, including the neck, back, posterior arms, lower
extremities, and feet.
Participants in the music group and the massage with music group listened to the same compilation of soft
piano music selected by the primary investigator. The compilation was 30 minutes in length. The music with
massage group received both interventions simultaneously.
PROCEDURES. Data were collected by the primary investigator and one research assistant who was trained in
phlebotomy and oriented to the questionnaires provided to each participant. When patients agreed to participate
in the study, each signed an informed consent form.
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A demographic questionnaire and the STAI-6 were completed by each participant, and serum cortisol and
prolactin samples were obtained. Participants then were assigned to one of the four groups by drawing of lots.
Blood pressure and pulse were measured preoperatively, and then interventions were administered. Blood
pressure and pulse also were measured intraoperatively and postoperatively. Pain control was measured in the
recovery room. Serum cortisol and prolactin levels were obtained again postoperatively, and each participant
again completed the STAI in the PACU.
Descriptive statistics were used to describe the sample. Paired t tests were used to determine the differences
between preoperative and postoperative anxiety, blood pressure, pulse, and cortisol and prolactin levels within
each group. Analysis of variance was used to determine differences among groups in preoperative and
postoperative measures of anxiety and cortisol and prolactin levels, as well as preoperative, intraoperative, and
postoperative blood pressure and pulse. Analysis of variance was used to determine differences among
preoperative, intraoperative, and postoperative blood pressure and pulse within each group. Chi-square
analysis was used to determine differences among the groups for those who received postoperative pain
medication. The significance level was set a priori at P <or = .05.
Fifty-two patients participated in the study. Each group included 13 participants. The age range of participants
was 19 to 67 years (mean = 43.08, standard deviation = 13.1). Nineteen participants were male, and 33
participants were female. All but one of the participants were high school graduates; 19 (36.5%) were college
graduates. Eighty-four percent had undergone previous surgeries, and 44.2% had experienced massage
therapy previously. There were no significant differences in demographic characteristics among the groups.
Type of surgery varied, including cholecystectomy cystoscopy, Hickman catheter placement, hysterectomy,
laparoscopy, lipoma removal, mass excision, and orthopedic hardware removal. Types of anesthesia used
during the procedures included general, spinal, regional, and local anesthesia.
Postoperative mean anxiety scores were significantly lower than preoperative scores for each of the groups (P
<.05) (Table 1). There were no significant differences among the groups in mean preoperative anxiety scores
(F^sub 3,48^ = 0.08, P = .97) or mean postoperative anxiety scores (F^sub 3,48^ = 1.48, P = .23).
Preoperative and postoperative prolactin levels are presented in Table 2. There were no significant differences
among groups in mean preoperative prolactin levels (F^sub 3,46^ = 0.58, P = .63) or mean postoperative
prolactin levels (F^sub 3,48^ = 0.76, P = .52). The mean postoperative prolactin levels were significantly higher
than the mean preoperative levels for each group (P <.05).
Preoperative and postoperative cortisol levels are presented in Table 3. There were no significant differences
among the groups in mean preoperative cortisol levels (F^sub 3,45^ = 0.8, P = .5) or mean postoperative
cortisol levels (F^sub 3,48^ = 0.41, P = .75). There were no significant differences among mean preoperative
and postoperative cortisol levels for any of the groups.
Preoperative, intraoperative, and postoperative systolic blood pressure, diastolic blood pressure, and pulse are
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presented in Table 4. There were no significant differences among the groups in mean preoperative,
intraoperative, or postoperative systolic blood pressure, diastolic blood pressure, or pulse. Examining the
differences among preoperative, intraoperative, and postoperative systolic blood pressure within each group
revealed that mean intraoperative systolic blood pressures were significantly lower than mean preoperative
systolic blood pressures for the control group (F^sub 2,24^ = 4.58, P = .021). Mean intraoperative diastolic
blood pressures were significantly lower than mean preoperative diastolic blood pressures for the massage with
music group (F^sub 2,24^ = 5.93, P = .008) and significantly lower than mean postoperative diastolic blood
pressure (F^sub 2,22^ = 5.39, P = .012) for the control group. No significant differences were found among the
groups for pain medication received postoperatively (X^sup 2^^sub 3^ = 3.25, P = .355).
The results of the study were similar to previous research findings demonstrating that patients who experienced
anxiety, stress, or pain exhibited a reduction in these symptoms when music or music with massage was
provided.10-12,20,22 This pilot study demonstrated a significantly lower anxiety response postoperatively in
each group. The control group also demonstrated a significantly decreased level of anxiety, which could have
been associated with a sense of relief that the surgery was finished.
The stress hormone cortisol did not decrease significantly within or among the groups, although previous
research studies reported decreases in cortisol levels after an intervention of music or massage.12,16
Furthermore, this pilot study did not reflect differences in pain medication patients received in the PACU. A
decreased need for pain medication or decreased pain response after the provision of music or massage,
however, has been reported in other studies.12,18,21
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The interventions in this pilot study were provided before surgery. In some studies, interventions were provided
during the postoperative period in the PACU. The patients in this study also did not select the music for
intervention, which, based on the literature, may make a difference in decreasing anxiety, blood pressure, heart
rate, and respiration.3,24
The control group also demonstrated significantly lower systolic blood pressures intraoperatively compared to
preoperative baseline measurements and significantly lower diastolic blood pressure postoperatively compared
to intraoperative measurements. This could have resulted from the investigator's presence during the
preoperative and postoperative period, anesthesia medications, or relief that surgery was finished.
The mean postoperative prolactin levels were significantly higher than the mean preoperative levels for each
group. Prolactin levels are known to increase during the physiological response to stress and increased mental
vigilance; however, the significance and effects of the increase in prolactin are mostly unknown.28,29 Prolactin
is known to elevate with general anesthesia. In one study, a five-fold increase in prolactin was seen during
major surgery with general anesthesia.30 A more recent study demonstrated that serum prolactin significantly
increased after the induction of general anesthesia.31 The significant elevations of prolactin demonstrated in all
groups may have been influenced by both the physical and psychological aspects of the surgical experience
and the use of general anesthesia in some procedures. This study indicates the need to continue to establish
empirical data to support the implementation of interventions, such as massage and music therapy, to decrease
patients' anxiety, cortisol and prolactin levels, and hemodynamic measures.
Limitations of this study include its small sample size and that no measures were taken to ensure interrater
reliability between the investigator and the research assistant during data collection. Participants underwent
different types of surgery, which could contribute many uncontrolled variables. Certain types of surgery may be
perceived as more invasive than others, and, therefore, may have increased anxiety. Differences in types of
surgeries also could contribute to different levels of postoperative pain. The lengths of surgeries also were
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Anesthesia used in the various procedures included general, spinal, regional, and local. As a result, some
patients were more aware of their surroundings than others, and this could have resulted in increased or
RECOMMENDATIONS FOR FUTURE RESEARCH
A more focused study could offer more meaningful results. A study that includes participants undergoing only
one type of surgery could control for the type of procedure, sample, length of surgery, type of anesthesia, and
similar postoperative recovery time.
The interventions in this study were performed preoperatively. It would be interesting to examine the effects of
such interventions both preoperatively and postoperatively to determine if the treatments would influence the
time it would take to reduce prolactin to a hemostatic level. A power analysis will be performed to determine the
sample size needed for additional studies based on future hypotheses.
Outcomes related to the stress response could be detrimental to patients undergoing surgery; therefore, clinical
research to identify interventions (eg, massage therapy, music therapy, guided imagery, hypnotherapy) that
could decrease the stress response is valuable. Nurses are with patients during each phase of the surgical
experience. Nurses, therefore, must have an understanding of the need to offer noninvasive, cost-effective
approaches to improving patients' surgical experiences and improving preoperative, intraoperative, and
Previous studies have demonstrated therapeutic benefits of massage in terms of decreased anxiety, stress, and
Empirical data may provide justification for offering massage and music therapy as a preoperative standard of
State anxiety was defined as the intensity of apprehensive feelings experienced at a particular moment as
measured by the Spielberger State-Trait Anxiety Inventory six-item short form.
This study indicates a continued need to establish data supporting implementation of interventions to decrease
patients' anxiety, cortisol and prolactin levels, and hemodynamic measures.
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70 (April 26, 2002) 2721-2734.
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Laura D. McRee, RN; Stacie Noble, MD; Alice Pasvogel, RN
Laura D. McRee, RN, MSN, LMT, is a clinical assistant professor, University of Arizona College of Nursing,
Stacie Noble, MD, is a clinical instructor, department of anesthesiology, University of Arizona College of
Alice Pasvogel, RN, PhD, is a senior research specialist, University of Arizona College of Nursing, Tucson.
Subject: Music therapy; Anxieties; Physical therapy; Medical research;
MeSH: Adult, Aged, Anxiety -- physiopathology, Blood Pressure -- physiology, Humans, Hydrocortisone -blood, Middle Aged, Pilot Projects, Postoperative Period, Preoperative Care -- psychology, Prolactin -- blood,
Pulse, Random Allocation, Treatment Outcome, Anxiety -- therapy (major), Massage (major), Music Therapy
(major), Preoperative Care -- methods (major)
Substance: Hydrocortisone; Prolactin;
Publication title: Association of Operating Room Nurses. AORN Journal
Pages: 433-42, 445-7
Publication year: 2003
Publication date: Sep 2003
Publisher: Elsevier Limited
Place of publication: Denver
Country of publication: United States
Publication subject: Medical Sciences--Nurses And Nursing
Source type: Scholarly Journals
Language of publication: English
Document type: Clinical Trial
Accession number: 14507122
ProQuest document ID: 200730865
Document URL: https://search.proquest.com/docview/200730865?accountid=46437
13 November 2013
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