JBUR 5160 No.

of Pages 10

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Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/locate/burns

The effects of massage and music on pain, anxiety

and relaxation in burn patients: Randomized
controlled clinical trial

T. Najafi Ghezeljeh a, * , F. Mohades Ardebili b , F. Rafii b,c

a
Department of Critical Care Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences,
Tehran, Iran
b
Department of Medical-Surgical Nursing, Faculty of Nursing and Midwifery,
Iran University of Medical Sciences, Tehran, Iran
c
Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran

article info abstract

Article history: Aim: The aim of this study was to evaluate the effects of massage and music on pain intensity,
Accepted 7 January 2017 anxiety intensity and relaxation level in burn patients.
Available online xxx Introduction: Pain and anxiety are common among burn patients, but there are many physical
and psychological consequences.
Methods: This randomized controlled clinical trial with factorial design 22 included
Keywords:
240 burn patients admitted at Shahid Motahari Burns Hospital, Tehran, Iran, between
Music
September 2013 and May 2015. The patients were allocated into the following groups: (i)
Massage
control (n=60) receiving the conventional primary care, (ii) music group (n=60) receiving
Pain
their favorite songs, (iii) massage group (n=60) receiving Swedish massage, and (iv) music-
Anxiety
plus-massage group (n=60) receiving a combination of their favorite songs and Swedish
Burn
massage, for 20min once a day for 3 consecutive days, using random permuted blocks of sizes
4 with a 1:1 ratio. To collect the data before and after the intervention, a specific Visual
Analogue Scale (VAS) was applied for pain intensity, anxiety intensity, and relaxation level.
The data were analyzed using SPSS, version 21.
Results: Our findings showed a decrease in pain and anxiety intensity and an increase in
relaxation level in all three intervention groups as compared to the control group, indicating
there was no significant difference among the interventions applied. Furthermore, following
application of each intervention, pain and anxiety intensity decreased and relaxation level
increased in the intervention groups as compared to before intervention.
Conclusion: Our results revealed that music, massage and a combination of both interventions
were effective on reducing pain and anxiety intensity and increasing relaxation level. Due to
easy, low-cost and availability of the interventions applied, these complementary therapies
are suggested for the burn patients. Although application of a single complementary therapy
is cost-effective, further studies are required to determine the most effective and cost-
effective method to improve the burn care.
2017 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author at: School of Nursing & Midwifery, Rashid Yasemi St., Valiasr St., Tehran, Iran.
E-mail address: najafi.t@iums.ac.ir (T. Najafi Ghezeljeh).
http://dx.doi.org/10.1016/j.burns.2017.01.011
0305-4179/ 2017 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: T. Najafi Ghezeljeh, et al., The effects of massage and music on pain, anxiety and relaxation in burn
patients: Randomized controlled clinical trial, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.011
JBUR 5160 No. of Pages 10
2 burns xxx (2017) xxx xxx
1. Introduction
Tissue damages resulting from burns are considered as one
of the most traumatic injuries and global health crises.
Physical and psychological consequences following pain are
so common among burn patients that eventually result in
chronic pain [1,2]. There are different types of burn pain as
follows: (i) background pain including rest pain and pain
following burn, (ii) breakthrough pain including an unex-
pected increase in pain intensity, and (iii) procedural pain
including pain due to procedures such as wound dressing [3].
Anxiety that is closely associated with pain is experienced
following burns and during wound healing process [4]. It
means that pain causes anxiety and stress that consequently
exacerbate the pain [5].
Although complete pain relief probably looks unrealistic,
the aim is the reduction of pain as much as possible [3]. The
most common method to control the pain in burn patients is
the use of opioid analgesics along with anti-anxiety drugs.
The use of narcotic analgesics cannot fully relieve pain in
burn patients. The non-pharmacological therapies are used
to reduce the need for analgesics in order to limit their side
effects, indicating that after anxiety reduction and pain
relief, the cycle of pain and anxiety will be broken and
minimized [5].
Massage is identified as the art of touching and manipulat-
ing the soft tissues in order to achieve therapeutic results,
including peace of mind, comfort, as well as healing and repair
[6]. Massage as a tradition method increases the oxygen
absorption. Furthermore, massage can increase cell prolifera-
tion that leads to eliminate the waste and detoxify the body,
resulting in peace of mind and relaxation [7]. Swedish massage
is applied to decrease the symptoms associated with some
medical disorders. This massage includes the following five
techniques to improve the blood flow to the soft tissues: (i)
effleurage, (ii) petrissage, (iii) friction, (iv) tapotement, and (v)
vibration [8].
Music affects the central nervous system and causes
distraction from the pain, leading to a state of relaxation in
a patient [9]. Musical intervention means regular use of music
to provide, maintain and improve physical and mental health;
therefore, in a therapeutic environment or stressful situation,
music directly causes desired changes in emotions and
behavior of an individual [10]. Selection of a familiar, favorite
and cultural music is considered as the key point of this
intervention [11]. In a systematic review, Chi and Young have
indicated that for maximizing the effectiveness, the music
type must be based on self-interest and individual preferences
[12]. In a meta-analysis, music has been described as an
effective method in reducing pain and anxiety after surgery
[13], but better quality methodological studies are needed to
evaluate the effect of music [13,14].
Pain management in burn patients is a complicated and
challenging problem for nurses, so it should be considered at
the top of research priorities [4]. In addition, it is necessary to
evaluate the complementary therapies such as massage and
music. Therefore, the aim of this study was to evaluate the
effects of massage and music on pain intensity, anxiety
intensity and relaxation level in burn patients.
Please cite this article in press as: T. Najafi Ghezeljeh, et al., The effects of massage and music on pain, anxiety and relaxation in burn
patients: Randomized controlled clinical trial, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.011
2. Method
2.1. Study design
This randomized controlled clinical trial with factorial design
22 included all burn patients admitted to Shahid Motahari
Burns Hospital, Tehran, Iran, between September 2013 and
May 2015. The participants were compared in terms of pain
intensity, anxiety intensity and relaxation level before and
after interventions.
2.2. Sample
The burn patients were selected by convenience sampling
method based on the following criteria: (i) over 18 years old, (ii)
no damage to respiratory system (after examination of
respiratory system), (iii) burn involving 1045% of total body
surface area (TBSA), (iv) ability to communicate, (v) three days
after burns occurred (none of participants were in acute
phaseof burn), (vi) being hospitalized during study (to access
study samples for three consecutive days), (vii) absence of
difficulty hearing or deafness, and (viii) neurological disorders
and numbness. After a pilot study, we assumed a required
sample size of 60 individuals for each group to determine the
changes in pain score with a 95% confidence level, 80% power,
effect size of 12.5 (Cohens d=12.5), and 5% drop-out rate.
Therefore, participants (n=240) were divided into 4 following
groups using random permuted blocks of sizes 4 with a 1:1 ratio:
(i) control group (n=60), (ii) massage group (n=60), (iii) music
group (n=60) and (iv) music-plus-massage group (n=60). Study
flow diagram for recruitment and allocation to study groups is
shown in Fig. 1.
2.3. Intervention protocols
2.3.1. Music intervention
On the first day of the study, the researchers asked the
patients to introduce 4 favorite songs without words. After
the preferred songs were prepared for the music group,
patients were asked to lie in a bed or chair in comfortable
position in their room. Headphone (without blocking ambi-
ent noise) was placed on the patients ear and their favorite
songs were played using MP3 player for 20min once a day
for three consecutive days, while the patient was asked
to close eyes and focus on music. During three days, the
same favorite songs were played for each patient. Adjusted
volume control was determined by the patients. A researcher
was in the room with the patient to control the treatment
process.
2.3.2. Massage intervention
Swedish massage was performed on patients of the massage
group for 20min once a day for three consecutive days by a
researcher who was already trained to perform this massage.
The patients were asked to lie in a comfortable position and
covered with a clean sheet. Only, the specific body part being
massage was undraped. Swedish massage was applied only on
the healthy tissues, at a distance greater than 45cm from the
burned tissues, using pure bitter almond oil.
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Fig. 1 Study flow diagram: recruitment and allocation to study groups.

Massage started with gliding movement as well as gentle,
mild, and intermittent pressure of palms of hand and fingers on
the skin. The pressure was increased moderately while touch-
ing tissue. The massage continued by performing the strokes
toward the heart with constant speed and pressure. Therefore,
the selected tissue was lifted, squeezed and moved forward.
We used a V-shape technique (resulting from the thumb
and fingers), one hand technique (the other hand holding the
body), two hands technique (especially for the extremities),
rotation technique (for back massage), and kneading tech-
nique (placing thumb against the other fingers to pick up the
upper layers of tissue and move forward).
The movement and compressor of soft tissue against their
underlying structures (23 movements/s) were performed by
the palm of the hand and the tip of the fingers and thumbs.
This was followed by the vibration technique that was
performed by superficial rapid movements of the hands and
wrists (1012 movements/s) using the tip of fingers on the
selected tissue. Finally, alternative, gentle, and rhythmic
movements were performed on healthy joints to improve
their normal range of motion [8].
2.3.3. Music-plus-massage intervention
In this group, the patients received the Swedish massage along
with favorite songs without words for 20min once a day for
three consecutive days, according to the protocol of two other
intervention groups.
2.4. Data collection
The primary outcomes of this study were the pain intensity,
anxiety intensity and relaxation level. The data were collected
through the questionnaires and medical records. In this study,
the demographic characteristics and Visual Analogue Scale
(VAS) were used. Demographic characteristics were collected
by a researcher on the first day of study. In order to measure
pain intensity, anxiety intensity, and relaxation level, a
specific VAS was used. The scales were as a 100-mm ruler
with the descriptive words at both ends, indicating that 0 for no
pain/anxiety or complete peace and 100 for intolerable/severe
pain, severe anxiety or lack of peace. In each group, the
patients indicated pain intensity, anxiety intensity and
relaxation level in the relevant VAS before and 510min after
the intervention. The validity and reliability of the VAS were
confirmed [15].
2.5. Procedures
After obtaining the approval of Ethics Committee of Iran
University of Medical Sciences and the permission of the

Please cite this article in press as: T. Najafi Ghezeljeh, et al., The effects of massage and music on pain, anxiety and relaxation in burn
patients: Randomized controlled clinical trial, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.011
JBUR 5160 No. of Pages 10
4 burns xxx (2017) xxx xxx
Shahid Motahari Burns Hospital, we described the purpose and
method of the research to the eligible patients before they
signed an informed consent form.
The participants were allocated into 4 groups. Then, their
favorite songs for the music and music-plus-massage groups
were determined, while the demographic characteristics were
collected from all groups by a researcher who was blinded to
the study groups.
Interventions and data collection were started on the
second day of study and continued for three days. In each
groups, the patients indicated pain intensity, anxiety
intensity and relaxation level in the relevant VAS before
and 510 min after the intervention. The interventions were
carried out in the patients room, on his/her bed and without
the presence of any family member, while room divider
curtains or folding screens were used to maintain the
patients privacy.
The principal researcher oversaw each step of the inter-
ventions. The control groups only received the conventional
primary care and were asked to stay in a bed or chair for 20min.
In order to match the effect of presence of a researcher in all
groups, a researcher was present at room where patients of
control group were resting for 20min. To improve the comfort
level and non-interference condition in the process of
intervention, the staff were aware of the scheduled
intervention.
2.6. Data analysis
To compare the groups in terms of quantitative and
qualitative variables, one-way analysis of variance (ANOVA),
Scheffe ad hoc test and Chi-square test were applied,
respectively. The Scheffe ad hoc test used where there was
a significant ANOVA test with a variable in comparison
between groups to provide information on which means
were significantly different from each other. In addition,
mean scores of changes in the variables before and after
intervention were considered to compare groups. For within
group comparison (before and after intervention), paired t-
test and Chi-square test were used for quantitative and
qualitative variables, respectively. The Statistical Package for
the Social Sciences (SPSS; SPSS Inc., Chicago, IL, USA) version
21.0 was used to analyze the study data. The significance was
considered at P.05.
3. Results
3.1. Demographic characteristics
The mean [standard deviation (SD)] age of the participants in
general was 32.23 (8.43) years. There were no statistically
significant differences regarding demographic character-
istics among 4 groups (Table 1). Furthermore, there were
no statistically significant differences regarding burn reason,
factor, degree and location among the control, music,
massage, and music-plus-massage groups. In 4 groups,
themajority of participants indicated accident for burn
reason and fire for burn factor. The mean (SD) of TBSA was
Please cite this article in press as: T. Najafi Ghezeljeh, et al., The effects of massage and music on pain, anxiety and relaxation in burn
patients: Randomized controlled clinical trial, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.011
23.92% (9.75) for all groups, while the majority of them
experienced more than 20% for TBSA, suggesting there was
no statistically significant difference in this regard among
4 groups.
3.2. Pain intensity
The results showed there were statistically significant differ-
ences regarding to the mean pain intensity before intervention
in every single session among four groups (Table 2). In
addition, there were statistically significant differences in
terms of the mean pain intensity after intervention in all
sessions between four groups. Since there were significant
differences between groups regarding to the mean scores of
pain intensity before intervention, the mean scores of changes
in this variable before and after intervention was considered to
compare groups.
The results of one-way ANOVA (Table 2) showed that
there were statistically significant differences regarding to
the mean change scores of pain intensity in every single
session among four groups (P <.001). The Scheffe ad hoc test
was used to indicate where the differences occurred between
groups. The results of Scheffe ad hoc test revealed that there
was a statistically significant difference regarding to the
mean change scores of pain intensity between the music
group and the control group in each session (P <.001).
Furthermore, there was a statistically significant difference
in terms of the mean change scores of pain intensity between
the massage and control groups in each session (P <.001). The
results of Scheffe ad hoc test also showed that there was a
statistically significant difference regarding to the mean
change scores of pain intensity between the music-plus-
massage and control groups in each session (P <.001). Mean
pain intensity reduced in three intervention groups as
compared to the control group in all sessions. According to
the results of Scheffe ad hoc test, there was no statistically
significant difference regarding to the mean change scores of
pain intensity between the massage and music-plus-mas-
sage groups at each session. However, the pain intensity
reduced more in the music group ( 31.6115.72) as
compared to the massage ( 28.77 13.05) and music-plus-
massage ( 29.69 16.34) groups, but there were no statisti-
cally significant differences in this regard between the music
group and other two intervention groups.
Also, the results of paired t-test (Table 2) showed that
there was a statistically significant difference in terms of
pain intensity before and after the music intervention in all
sessions (P<.001). There was a statistically significant
difference in terms of pain intensity before and after the
massage intervention in all sessions (P <.001). According to
the results of paired t-test, there was a statistically signifi-
cant difference in terms of pain intensity before and after the
music-plus-massage intervention in all sessions (P <.001).
These results indicated that pain intensity reduced in all
three intervention groups after intervention as compared to
before intervention (baseline) in every session. There was no
statistically significant difference regarding pain intensity in
the control group before and after the intervention in all
sessions (P =.59).
JBUR 5160 No. of Pages 10

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Table 1 Demographic characteristics of the burn patients (n=240).

Variables Groups Statistical P
results
Control Massage Music Music-plus-massage
(n=60) (n=60) (n=60) (n=60)
No (%) No (%) No (%) No (%)
Age Mean SD 32.23 (8.53) 31.67 (8.73) 32.97(8.67) 32.05 (7.91) .249 .716
Sex Female 29 (48.30) 29 (48.30) 29 (48.30) 29 (48.30) Chi-square =.001 1
Male 31 (51.70) 31 (51.70) 31 (51.70) 31 (51.70)
Marital status Single 22 (36.70) 26 (43.30) 19 (31.70) 20 (33.30) Fisher exact test .716
Married 34 (56.70) 32 (53.30) 35 (58.30) 35 (58.30)
Divorced 2 (3.30) 2 (3.30) 3 (5.00) 4 (6.70)
Widow 2 (3.30) 0 (.00) 3 (5.00) 1 (1.70)
Occupation Non-employee (Male) 10 (16.60) 10 (16.70) 7 (11.70) 6 (10.00) Chi-square =3.60 .73
Employee, male 21 (35.00) 21 (35.00) 24 (40.00) 25 (41.70)
Female 10 (16.70) 15 (25.00) 8 (13.30) 11 (18.30)
House work (Female) 19 (31.60) 14 (23.30) 21 (35.00) 18 (3.00)
Income More than adequate 14 (23.30) 7 (11.70) 14 (23.30) 13 (21.70) Chi-square =6.04 .42
adequacy Adequate 29 (48.30) 40 (66.70) 29 (48.30) 32 (53.30)
Inadequate 17 (28.30) 13 (21.70) 17 (28.30) 15 (25.00)
Burn reason Self-inflicted 2 (3.30) 3 (5.00) 1 (1.70) 1 (1.70) Fisher exact test .779
Event 57 (95.00) 56 (93.30) 58 (96.70) 59 (98.30)
criminal 1 (1.70) 1 (1.70) 1 (1.70) 0 (.00)
Burn factor Scald 11 (18.30) 7 (11.70) 6 (10.00) 10 (16.70) Fisher exact test .557
Flame 37 (61.70) 40 (66.70) 42 (70.00) 44 (73.30)
Electricity 3 (5.00) 6 (10.00) 3 (5.00) 1 (1.70)
Gas explosion 9 (15.00) 7 (11.70) 9 (15.00) 5 (8.30)
Burn locations Head & face, yes 31 (51.70) 35 (58.30) 23 (38.30) 26 (43.30) Chi-square =5.66 .129
Hand, yes 51 (85.00) 50 (83.30) 53 (88.30) 54 (90.00) Chi-square =1.442 .693
Foot, yes 54 (90.00) 46 (76.70) 45 (75.00) 49 (81.70) Chi-square =5.271 .153
Back, yes 6 (15.00) 14 (23.30) 12 (20.00) 13 (21.70) Chi-square =1.458 .692
Chest, yes 41 (68.30) 33 (55.00) 40 (66.70) 36 (60.00) Chi-square =2.916 .405
Genital, yes 1 (1.70) 3 (5.00) 0 (.00) 4 (6.70) Fisher exact test .186
Burn degree 1-2 10 (16.70) 6 (10.00) 14 (23.30) 16 (26.70) Chi-square =16.18 .07
2 10 (16.70) 5 (8.30) 4 (6.70) 6 (10.00)
2-3 25 (41.70) 32 (53.30) 25 (41.70) 18 (30.00)
1-2-3 15 (25.00) 17 (28.30) 17 (28.30) 20 (33.30)
TBSA Less than 20% 27 (45.00) 27 (45.00) 26 (43.30) 20 (33.30)
Equal or more than 20% 33 (55.00) 33 (55.00) 34 (56.70) 40 (66.70)
Mean SD 23.37 9.337 23.27 10.295 23.93 9.547 25.12 9.930 F = .452* .716

SD; standard deviation, TBSA; total body surface area.

*
Significant.

3.3. Anxiety intensity
The results showed there were statistically significant differ-
ences regarding to the mean anxiety intensity before inter-
vention in every single session between four groups (Table 3).
Also, there were statistically significant differences in terms of
the mean anxiety intensity after intervention in all sessions
between four groups. The mean change scores of anxiety
intensity before and after the intervention for each group in
each session were calculated.
The results of one-way ANOVA showed that there were
statistically significant differences (P<.001) in terms of the
mean change scores of anxiety intensity in all sessions among
four groups (Table 3). To indicate which specific two groups
differed, the Scheffe ad hoc test was conducted. According to
the results of Scheffe ad hoc test, there was a statistically
significant difference regarding to the mean change scores of
anxiety intensity between the music group and the control
group in each session (P<.001). Also, there was a statistically
significant difference regarding to the mean change scores of
anxiety intensity between the massage and control groups in
each session (P<.001). The results of Scheffe ad hoc test
revealed that there was a statistically significant difference in
terms of the mean change scores of anxiety intensity in the
music-plus-massage group as compared to the control group
in each session (P<.001). Mean anxiety intensity reduced in
three intervention groups as compared to the control group in
all sessions. The results of Scheffe ad hoc test also revealed
that there was no statistically significant difference regarding
the mean change scores of anxiety intensity between the
massage and music-plus-massage groups at each session.
However, the anxiety intensity reduced more in the music
group ( 46.5215.80) as compared to the massage ( 43.72
16.00) and music-plus-massage ( 43.5616.09) groups, but
there were no statistically significant differences in this regard
between the music group and other two intervention groups.
In addition, the results of paired t-test (Table 3) showed that
there was a statistically significant difference in terms of
anxiety intensity before and after the music intervention in all
sessions (P<.001). There was a statistically significant

Please cite this article in press as: T. Najafi Ghezeljeh, et al., The effects of massage and music on pain, anxiety and relaxation in burn
patients: Randomized controlled clinical trial, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.011
JBUR 5160 No. of Pages 10

6 burns xxx (2017) xxx xxx

Table 2 Comparison of mean scores of pain intensity within and between groups in each session (n=240).
Groups 1st session 2nd session 3rd session
MeanSD MeanSD MeanSD
Control (n = 60) Before 88.83  18.83 83.92  18.44 84.50  16.82
After 86.75 23.05 87.92 21.03 84.50 22.29
Change scores 2.08 10.38 4.00  11.81 .00 14.49
Paired t-test 1.55 2.62 .00
Massage (n =60) Before 82.50 20.96 77.42 22.179 72.92 20.93
After 55.58 30.85 46.00 24.78 44.92 22.39
Change scores 26.92 22.36 31.42 17.20 28.00 19.85
Paired t-test. 9.32* 14.15* 10.92*
Music (n =60) Before 77.75 23.04 68.16 24.11 63.00 22.70
After 44.75 31.45 36.16 26.14 33.17 27.28
Change scores 33.00 25.36 32.00 17.76 29.83 24.97
Paired t-test 10.08* 13.96* 9.25*
Music-plus-massage (n = 60) Before 76.92 25.85 66.66 24.19 58.00 25.52
After 46.33 35.28 33.25 29.55 32.92 26.48
Change scores 30.58 27.63 31.41 21.85 28.08 20.28
Paired t-test 8.57* 11.85* 9.58*
Comparing groups before intervention, ANOVA test 3.606* 7.918* 17.424*
Comparing groups after intervention, ANOVA test 24.61* 58.47* 58.47*
Comparing differences, ANOVA test 24.22* 64.42* 28.52*

SD; standard deviation, ANOVA; one-way analysis of variance.

*
P < .001.

Table 3 Comparison of mean scores of anxiety intensity within and between groups in each session (N=240).
Groups 1st session 2nd session 3rd session
MeanSD MeanSD MeanSD
Control (n = 60) Before 92.83 15.84 85.75 22.38 87.66 15.58
After 89.92 20.84 86.50 25.06 87.75 23.13
Change scores 2.92 11.90 .75 11.49 .08 15.95
Paired t-test 1.89 .51 .40
Massage (n =60) Before 88.33 20.78 81.33 19.56 73.75 21.13
After 38.00 28.95 41.17 26.17 33.08 24.43
Change scores 50.33 24.93 40.17 24.93 40.66 26.83
Paired t-test 15.63* 14.92* 11.74*
Music (n =60) Before 80.66 23.47 72.00 23.22 69.58 18.93
After 37.33 30.41 24.42 24.55 20.92 24.17
Change scores 43.33 26.29 47.58 23.55 48.67 22.93
Paired t-test 12.77* 15.65* 16.43*
Music-plus-massage (n = 60) Before 79.43 15.84 70.83 23.01 65.25 25.25
After 38.58 31.84 24.41 27.71 32.92 26.48
Change scores 40.85 27.94 46.41 21.64 43.42 29.80
Paired t-test 11.32* 16.61* 11.28*
Comparing groups before intervention, ANOVA test 4.99* 6.451* 13.428*
Comparing groups after intervention, ANOVA test 50.43* 76.94* 94.02*
Comparing differences, ANOVA test 48.89* 79.62* 50.46*

SD; standard deviation, ANOVA; one-way analysis of variance.

*
P < .001.

difference in terms of anxiety intensity before and after the
massage intervention in all sessions (P<.001). According to the
results of paired t-test, there was a statistically significant
difference in terms of anxiety intensity before and after the
music-plus-massage intervention in all sessions (P<.001).
These results indicated that the anxiety intensity reduced in
all three intervention groups after intervention as compared to
before intervention (baseline) in every session. Also, there was
no statistically significant difference regarding anxiety
intensity in the control group before and after the intervention
in all sessions (P=.53)
3.4. Relaxation level
The results showed there were statistically significant differ-
ences regarding to the mean scores of relaxation level before
intervention in every single session between groups (Table 4).
Also, there were statistically significant differences in terms of

Please cite this article in press as: T. Najafi Ghezeljeh, et al., The effects of massage and music on pain, anxiety and relaxation in burn
patients: Randomized controlled clinical trial, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.011
JBUR 5160 No. of Pages 10

burns xxx (2017) xxx xxx 7

Table 4 Comparison of mean scores of relaxation level within and between groups in each session (N=240).
Groups 1st session 2nd session 3rd session
MeanSD MeanSD MeanSD
Control (n =60) Before 93.25 14.89 86.58 23.92 90.66 16.50
After 89.75 22.24 85.08 27.52 88.83 23.62
Change scores 3.50  14.21 1.50 11.97 1.83  13.40
Paired t-test 1.91 .97 1.06
Massage (n = 60) Before 89.08 20.53 78.33 20.43 75.50 21.87
After 32.92 28.19 33.58 28.23 27.00 25.63
Change scores 56.16 25.69 44.75 28.55 48.50 30.00
Paired t-test 16.93* 12.14* 12.52*
Music (n =60) Before 81.25 21.72 73.92 24.43 70.33 19.15
After 32.47 29.22 22.83 22.97 16.50 22.84
Change scores 48.78 24.18 51.08 21.78 53.83 23.95
Paired t-test 15.62* 18.16* 17.40*
Music-plus-massage (n =60) Before 79.58 25.55 71.50 24.84 65.75 24.25
After 35.00 33.15 19.17 28.14 22.08 28.75
Change scores 44.58 29.14 52.33 25.70 43.67 30.48
Paired t-test 11.85* 15.77* 11.09*
Comparing groups before intervention, ANOVA test 5.68* 4.833* 16.497*
Comparing groups after intervention, ANOVA test 58.72* 78.03* 106.73*
Comparing differences, ANOVA test 58.51* 66.96* 52.54*

SD; standard deviation, ANOVA; one-way analysis of variance.

*
P <.001.

the mean scores of relaxation level after intervention in every
single session between four groups. Since there were signifi-
cant differences between groups regarding the mean scores of
relaxation level before intervention, mean change scores of
this variable for each group in each session before and after the
intervention were calculated.
According to the results of one-way ANOVA (Table 4),
there were statistically significant differences regarding to
the mean change scores of relaxation level in every single
session among four groups (P <.001). To indicate which
specific two groups differed, the Scheffe ad hoc test was
conducted. The results of Scheffe ad hoc test revealed that
there was a statistically significant difference regarding to
the mean change scores of relaxation level in the music
group as compared to the control group in each session
(P <.001). According to the results of Scheffe ad hoc test, there
was a statistically significant difference regarding to the
mean change scores of relaxation level between the massage
and control groups in each session (P<.001). The results of
Scheffe ad hoc test also showed that there was a statistically
significant difference regarding to the mean change scores of
relaxation level between the music-plus-massage and
control groups in each session (P <.001). Mean relaxation
level increased in three intervention groups as compared to
the control group in all sessions. According to the results of
Scheffe ad hoc test, there was no statistically significant
difference in terms of the mean change scores of relaxation
level between the massage and music-plus-massage groups
at each session. However, the relaxation level increased
more in the music group ( 51.23 14.00) as compared to the
massage ( 49.81 18.35) and music-plus massage ( 46.86
17.46) groups, but there were no statistically significant
differences in this regard between the music group and other
two intervention groups.
Also, according to the results of paired t-test (Table 4),
there was a statistically significant difference in terms of
relaxation level before and after the music intervention in all
sessions (P <.001). There was a statistically significant
difference in terms of relaxation level before and after the
massage intervention in all sessions (P <.001). According to
the results of paired t-test, there was a statistically signifi-
cant difference in terms of relaxation level before and after
the music-plus-massage intervention in all sessions
(P <.001). These results showed that the relaxation level
increased in all three intervention groups after intervention
as compared to baseline in every session. There was no
statistically significant difference in terms of relaxation level
in the control group before and after the intervention in all
sessions (P =.07).
4. Discussion
This research as part of a large study evaluated the effects of
massage and music on pain intensity, anxiety intensity and
relaxation level in burn patients.
Our findings indicated a decrease in pain and anxiety
intensity and an increase in relaxation level in the massage
group as compared to the control group. Massage relieves pain
through releasing endorphins and impact on autonomic
nervous system. Furthermore, due to prevention of muscle
spasms, massage is considered as an effective method for both
relaxation and pain relief [16]. Similarly, a number of studies
have confirmed that massage is an effective method to reduce
pain and anxiety intensity in burn patients [17,18]. Cho et al.
have reported that in rehabilitation stage, massage improves
pain intensity, itching and scar tissue in the intervention group
as compared to the control group [19].

Please cite this article in press as: T. Najafi Ghezeljeh, et al., The effects of massage and music on pain, anxiety and relaxation in burn
patients: Randomized controlled clinical trial, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.011
JBUR 5160 No. of Pages 10
8 burns xxx (2017) xxx xxx
The result of this study indicated a decrease in pain and
anxiety intensity and an increase in relaxation level in the
music group as compared to the control group [20]. Music
causes relaxation by reducing sympathetic activities and
releasing endorphins [21], so the burn patients can experience
an improvement in their symptoms. However, Ferguson has
showed that music intervention did not reduce the pain level
in 11 patients with relatively deep burns as compared to the
control group, but there was a significant reduction regarding
pain level in the music group as compared to before
intervention. Ferguson has also indicated that the limitations
of the study were non-homogenous groups, small sample size
and lower number of preferred songs [22].
Furthermore, according to the gate control theory, pain
impulses are transmitted through the peripheral nervous
system to the spinal cord and then to brain. Complementary
therapies such as massage and music block these neural
pathways to prevent the transmission of pain impulses to the
brain [3]. Therefore, they improve the control over the painful
stimuli and associated anxiety. In our study, following
interventions leading to an increase in relaxation level and
a reduction in anxiety intensity, a reduction in pain intensity
was also observed that was due to the mutual relationship
between pain and anxiety.
Our findings also indicated a decrease in pain and anxiety
intensity and an increase in relaxation level in the music-plus-
massage group as compared to the control group. In current
study, a combination of music and massage showed no
synergistic effects in reducing pain and anxiety intensity and
increasing relaxation level as compared to music or massage
method alone. Our results showed that there was no
preference in terms of intervention methods for reducing
pain and anxiety intensity and increasing relaxation. It can be
illustrated by similar impact mechanism of music and
massage through autonomic nervous system and releasing
endorphins.
However, no similar study was found in this regard. In a
study by Van Twillert et al., they have reported that mind
aversion caused by virtual reality reduced the pain intensity
during the burn dressing, but this method failed to reduce the
anxiety intensity [23]. Some studies have reported the positive
effects of virtual reality in burn patients [24,25]. However,
further research investigating the effect of virtual reality on
anxiety in burn patients is necessary [26].
Good et al. have demonstrated that music, relaxation and
music-plus-relaxation in patients undergoing abdominal
surgery decreased the pain and distress and increased the
relaxation level as compared to the control group, but there
was no significant difference among the interventions applied
[27]. The comparison of music and relaxation methods on
patients with cancer has also showed that both methods were
effective for reduction of anxiety intensity, but there was no
significant difference between two applied methods [28,29]. In
a study by Hodgson and Lafferty, they have indicated that both
Reflexology and Swedish massage reduced pain intensity and
salivary cortisol and improved mood in patients with cancer,
but there was no significant difference between two applied
methods [30]. Sritoomma et al. have also reported that both
Thai massage and Swedish massage with ginger oil reduced
pain intensity and were effective for individuals with disability
Please cite this article in press as: T. Najafi Ghezeljeh, et al., The effects of massage and music on pain, anxiety and relaxation in burn
patients: Randomized controlled clinical trial, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.011
and chronic low back pain, but the Swedish massage with
ginger oil was considered as the most effective method [31].
The differences with our results are due to different comple-
mentary interventions applied and study population.
In current study, comparison of mean change scores
showed that music had a great effect on pain intensity,
anxiety intensity and relaxation level, suggesting that there
was no statistically significant difference among intervention
groups, although there was no similar study. In another study
by Salehzadeh et al., they have assessed the effects of music
and full-body Swedish massage on patients with chronic heart
failure, while their findings have showed that both methods
were effective in reducing anxiety intensity of the patients, but
the effect of full-body Swedish massage was more significant
[32]. Comparison of their findings with the current study
suggested that their method was more effective which was due
to the different study population and larger surface area under
massage, but more studies are required in this regard.
5. Conclusion
Burn patients often have poor physical and emotional health.
Our findings revealed that music, massage and music-plus-
massage reduced pain and anxiety intensity and increased
relaxation level in burn patients, but there was no significant
difference among applied interventions. Due to easy, low-cost
and availability of the interventions applied, these comple-
mentary therapies are suggested for the burn patients.
Furthermore, it is very important to manage and reduce
pain and anxiety in burn patients; therefore, it is suggested
that healthcare providers, patients, and family members are
educated for application of these complementary therapies.
When complementary therapies like music or massage are
included in standard care, a safer approach will be developed
for further management of pain and anxiety in burn patients.
Although application of a single complementary therapy is
cost-effective, further studies are required to determine the
most effective and cost-effectiveness method to improve the
burn care. Further studies are also needed to explore the
intervention effects on burn wound healing process and
function of the immune system.
6. Limitations
There are a number of limitations in current study. Firstly,
there was no way to establish a private and quiet environment
for the patients during the intervention at the hospital, even
after taking all necessary steps. Therefore, it is suggested to
establish a special unit offering these types of complementary
therapies in burn centers. Secondly, due to nature of
interventions, it was impossible to blind the subjects to the
study process, so there was a Hawthorne effect. Thirdly, the
current study was carried out on the hospitalized patients, so
similar studies are required to evaluate burn outpatients and
compare them with a placebo group as well as to educate the
family members about the chronicity of symptoms. In the
current study, opioid intake was not measured, so it is required
to measure the level of opioid used in the future study.
JBUR 5160 No. of Pages 10
burns xxx (2017) xxx xxx
Although presence of a researcher for control group was
unrelated to the improvement of variables, it may cause
anxiety in patients, so further study is required. In addition,
one of the limitation of this study was related to the not
existing homogeneity between groups regarding main varia-
bles before intervention.
Conflict of interest statement
There was no conflict of interest in this article.
Acknowledgments
This study was registered in the Iranian Registry of Clinical
Trials (IRCT201202269143N1). The Nursing Care Research
Center financially supported this study. The authors would
like to thank the participants as well as authorities and
medical staff of the Shahid Motahari Burns Hospital and
School of Nursing and Midwifery of Iran University of Medical
Sciences.
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Please cite this article in press as: T. Najafi Ghezeljeh, et al., The effects of massage and music on pain, anxiety and relaxation in burn
patients: Randomized controlled clinical trial, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.011