Music for Primary Dysmenorrhea [Música Para la Dismenorrea Primaria]

El Uso de la música Para el Manejo Del Dolor Por Dismenorrea Primaria en Estudiantes de la Escuela de Medicina y Ciencias de la Salud de la Universidad Del Rosario

Primary dysmenorrhea is defined as lower abdominal pain that occurs during menses and is not secondary to any type of pelvic disease. It is considered the most common condition in reproductive age women. First line of treatment are non-steroidal anti-inflammatory drugs (NSAIDS), or oral contraceptives (OCC). This two forms of treatment have not demonstrated 100% efficacy, and adverse events and contraindications for both exist. Moreover, studies have demonstrated that an important women do not use, or don't like to use, pharmacological treatment. Music have demonstrated analgesic effects in different clinical contexts, and has emerged as an important form of complementary therapy in the management of pain. To the researcher's knowledge, no studies have been conducted to evaluate music's effectiveness in pain secondary to primary dysmenorrhea. The following is the protocol for a randomized, single blinded, clinical trial, where an experimental group listened to a 30 minute song, and was compared to a control group that rest in silence for the same time and conditions. It was expected that music will produce a larger, and significant, effect on pain reduction when compared to the control silence group according to pain measured through a 10 cm Visual Analogue Scale (VAS) in young women from the School of Medicine and Health Sciences at the Universidad del Rosario, Bogota DC, Colombia. Additionally, the investigators wanted to evaluate the clinical effect of music and analgesic requirements, anxiety and vital signs were also measured.

Primary Dysmenorrhea (PD) is defined as pain in the lower abdomen, that occurs always during menses, in the absence of pelvic pathology, and lasts about 24-72 hours. It initiates during the first 24 months after menarche. Other symptoms like, emotional lability, anxiety, nausea, headache, and others may accompany the pain. It is considered the most common condition of reproductive age women, and is considered one of the most important causes for school or work absence in this population. Music has been proposed as a complementary therapy for the management of pain, and a large body of clinical evidence supports its use on clinical context. Additionally, functional imaging research has found that music activates areas related to pain modulation and perception like the periaqueductal gray matter. Moreover music seems to modify brain activity during pain perception. Music has been shown to be effective in relieving pain secondary to surgery, in cancer related pain, and other types of pain, but it has not been studied for primary dysmenorrhea. This randomized clinical trial was designed with the following objectives General Objective: To evaluate the efficacy of music listening, compared to a control group that rested in silence, in the painful experience secondary to primary dysmenorrhea in women of 18 years or older from the School of Medicine and Health Sciences at the Universidad del Rosario, Bogotá DC., Colombia. Specific Objectives: Description of demographic data, clinical, gynecological, and obstetric background from the study population. Description of pain management, secondary to PD, used by the study population. Evaluate the usual pain secondary to PD, as reported by the study participants through a Visual Analogue Scale (VAS) To explore if the acute perception of pain secondary to PD, as reported by participants using a VAS, before the intervention, is different between the study groups. To evaluate if the acute perception of pain secondary to PD, as reported by participants using a VAS, after the intervention, differs between those that listened to music and those that rested in silence. To explore if a difference in the reduction of pain, as reported by participants using a VAS, from the moment before to the moment after the intervention exists between those in the music group compared to those in the silence group. To evaluate if the acute perception of pain secondary to PD, as reported by participants using a VAS, 3-6 hours after the intervention, differs between those that listened to music and those that rested in silence. To evaluate if the anxiety secondary to PD, as reported by participants using a validated Spanish short version of the Zung scale, differs between groups, before and after the intervention. To evaluate if a difference in the reported requirements of analgesic drugs is different between the study groups after and 3-6 hours after the intervention. To evaluate if a difference in heart rate, systolic and diastolic blood pressure is identified between groups, using a previously calibrated digital sphyngmomanometer. The investigators hypothesized that listening to an instrumental song, unknown to the patient, will have a significant effect on pain relief. Additionally, investigators hypothesized that music listening will have a clinical effect big enough to also impact analgesic requirements and anxiety scores . Primary endpoint was pain reduction from the moment before to after the intervention. Pain reduction is the better way to evaluate analgesia efficacy and was the proper approach for these protocol's main objective, which was efficacy of music on pain relief secondary to primary dysmenorrhea. For achieving these aims and answering research questions, a randomized clinical trial was designed. As patients can't be blinded from listening or not to music, a single blinded approach was decided. Furthermore, methodology for recruitment was designed to blind patients from allocation until the day of the intervention and a speech was used to avoid patients to identify the primary endpoint. Additionally, patients were explained that two interventions were used, but it was not specified that silence group was the control group, to assure proper blinding and avoid further bias of results. Silence was decided as a control intervention as comparison with drug placebo may not be adequate due to differences in the types of intervention. To isolate the music effects the investigators decided on using a completely new and unknown song. The song was planned and composed exclusively for the research, so all patients allocated to the music group listened to the exact same musical piece.

Single blinded, two parallel group, randomized clinical trial. The experimental group received listen to a son composed exclusively for this trial while control group rested for the same amount of time in silence.

Computer block randomization was used to generate allocation sequence of codes. Allocation was done on the same day of the intervention, patients were given opaque envelope according to the randomization codes. The envelop contained instructions to access the allocated intervention. After baseline data collection patients entered the intervention room and opened the envelop inside while investigator waited outside. Both patients had headphones on and used the same device to access the intervention assuring blinding of the investigator. After the intervention ended, patient closed the intervention file and account to the intervention. All patients were instructed to nor reveal or comment anything about the intervention at any time after the intervention was completed.

Patients in this arm listened through headphones to a song of 29 minutes and 32 seconds duration. The song was composed entirely by investigator Juan Martin-Saavedra and registered to copyright and authorship regulatory entities from Colombia under the name "Occasio adolore" (Musical piece No. 5-559-355 and Phonogram No. 12-105-295 of Colombia's Copyright authorship agency). Patients were instructed to avoid using cellphones or other activities during the time of the intervention. Patients receive the intervention in the same room as the Silence group, but for the intervention they were always alone. The room was located in a low transit place with low ambient noise.

Patients on the silence group listened to a 29 minute and 32 second audio file that produced no sounds with headphones on. Patients were instructed to avoid using cellphones or other activities during the time of the intervention. Patients receive the intervention in the same room as the Music group, but for the intervention they were always alone. The room was located in a low transit place with low ambient noise.

The song was composed on a C major scale and a 60 bpm tempo. The song was composed with high consonance using simple melodic progressions on the C major scale, and using natural positions for chords. No percussion or lyrics were used for the song, and the following instruments were used in the composition: electric guitar and keyboards, violin (digital), cello (digital), clarinet (digital), synthesizers (digital), and fretless bass (digital).

Pain scores were measured using a visual analogue scale (VAS) of 10 cm (0 no pain at all, and 10 the worst possible pain). Pain was measured 4 times, the first was usual pain associated to menses (VAS 1), actual pain 1-5 minutes before the intervention (Baseline) (VAS 2), actual pain 1-5 minutes after the intervention (VAS 3), and actual pain 3-6 hours after the intervention (VAS 4). Main outcome was pain difference between pain 1-5 minutes after, minus pain 1-5 minutes before the intervention (VAS 3-2).

Mean pain scores measured with a 10 cm visual analogue scale (VAS) where 0 was no pain at all and 10 the worst possible pain. Usual pain was evaluated before the intervention and was known as VAS 1.

Mean pain scores measured with a 10 cm visual analogue scale (VAS) where 0 was no pain at all and 10 the worst possible pain. Actual pain was evaluated immediately before the intervention and was known as VAS 2.

Mean pain scores measured with a 10 cm visual analogue scale (VAS) where 0 was no pain at all and 10 the worst possible pain. Actual pain was evaluated immediately after the intervention was completed, and was known as VAS 3.

Mean pain scores measured with a 10 cm visual analogue scale (VAS) where 0 was no pain at all and 10 the worst possible pain. Actual pain was evaluated 3-6 hours after the intervention was completed, and was known as VAS 4.

Using a validated short spanish version of the Zung anxiety scale, anxiety was measured before the intervention. The scale was composed of 10 items. Each item had a 4 Likert point scale (1= never, 2= some times, 3= most of the time, and 4 = always). Scores ranged from 10, minimum anxiety, and 40 maximum anxiety. For analysis, mean quantitative scores were obtained so 1 was equivalent to minimum anxiety, and 4 to maximum anxiety.

Using a validated short spanish version of the Zung anxiety scale, anxiety was measured after the intervention. The scale was composed of 10 items. Each item had a 4 Likert point scale (1= never, 2= some times, 3= most of the time, and 4 = always). Scores ranged from 10, minimum anxiety, and 40 maximum anxiety. For analysis, mean quantitative scores were obtained so 1 was equivalent to minimum anxiety, and 4 to maximum anxiety.

Using a validated short spanish version of the Zung anxiety scale, anxiety was measured 3-6 hours after the intervention. The scale was composed of 10 items. Each item had a 4 Likert point scale (1= never, 2= some times, 3= most of the time, and 4 = always). Scores ranged from 10, minimum anxiety, and 40 maximum anxiety. For analysis, mean quantitative scores were obtained so 1 was equivalent to minimum anxiety, and 4 to maximum anxiety.

Before the intervention patients were asked if they wanted to use any analgesic drug or do any kind of analgesic strategy. Patients simply answered yes or no.

After the intervention patients were asked if they wanted to use any analgesic drug or do any kind of analgesic strategy. Patients simply answered yes or no.

After the intervention, all patients had to register all analgesic drugs (e.g. ibuprofen) or strategy (e.g. local heat) that were used until last pain measurement (VAS 4, 3-6 hours after the intervention).

Systolic blood pressure in mmHg measured with a calibrated digital sphygmomanometer before the intervention.

Diastolic blood pressure in mmHg measured with a calibrated digital sphygmomanometer before the intervention.

Heart rate measured in beats per minute (bpm) with a calibrated digital sphygmomanometer before the intervention.

Mean blood pressure in mmHg measured with a calibrated digital sphygmomanometer before the intervention.

Systolic blood pressure in mmHg measured with a calibrated digital sphygmomanometer after the intervention.

Diastolic blood pressure in mmHg measured with a calibrated digital sphygmomanometer after the intervention.

Heart rate in beats per minute (bpm) measured with a calibrated digital sphygmomanometer after the intervention.

Mean blood pressure in mmHg measured with a calibrated digital sphygmomanometer after the intervention.

Inclusion Criteria: Legal and cognitive capacity for informed consent. Suffering from primary dysmenorrhea (low abdominal pain associated to menses). Being able to understand and use the measuring tools and questionnaires. Exclusion Criteria: Previous diagnosis of pelvic pathology. Diagnosis of hearing impairment. Diagnosis of neurologic or endocrinological disease. Psychiatric condition diagnosed. Known or reported previous substance abuse. Current use of psychiatric drugs. Cancer diagnosis Diagnosed diabetes mellitus or heart disease. Previous advance musical training (defined as any form of music training in addition to that received during normal school classes). Irregular menstrual cycles. Previous pregnancy. Current use or use of any hormonal contraceptive therapy in the last 2 months.

Results fromt the research will be made available as supplemental data or digital content published with the final manuscript. Additional information like the study protocol, statistic analysis plan performed, and copy of the informed consent will be available by request to the email: juans.martin@urosario.edu.co

Complete database will be made available with publication of the manuscript. Other information will be accessible by request to the email: juans.martin@urosario.edu.co

Complete database results will be available as digital content with the final manuscript. Additional data will be given by request by email and requester will require to send a letter with signature stating the reason for requesting additional information.