MUSIC THERAPY AND SPIRITUAL TREATMENT TO REDUCE PAIN IN PATIENTS WITH SEVERE BURNS

Introduction :Pain is a problem experienced by patients with burns. Pain reduction is the main focus in the management of burn patients. Non-pharmacological treatment options with music therapy and spiritual care approaches are part of nursing care. Objective : The study was conducted to identify the effectiveness of music therapy and spiritual care in reducing pain during dressing changes for burn patients. Materials and methods :The study used a quasi experiment pre-post test method on 30 burn patients with the music therapy and other with spiritual care intervention. Samples were taken using accidental sampling. Patients were measured for pain level using Numeric rating scale (NRS). Data were analysed using univariate analysis, dependent t-test and an independent t-test to compare between music therapy and spiritual care. Result : Music therapy and spiritual care have a significant effect on the measurement results before and after the intervention resulting in a value of (P=0.000) p <  (0.005). While the mean difference between music therapy and spiritual care after after dressing change (P=0.000) and (t= 5.875). Conclusion : There is an effect of music therapy intervention and spiritual care on reducing pain in burn patients undergoing dressing change procedures. Spiritual care had a higher average reduction than music therapy.


INTRODUCTION
The incidence of burn trauma in Indonesia is one of the causes of death, in one of the Central Hospitals in West Java In the span of January 2021-October 2022 there were 165 patients who needed treatment and 30 of them died < 48 hours (RSHS, 2022).In fact, burns are the fourth most common type of trauma in the world (Peck, 2011).
The impact of burn trauma can be fatal as patients can go into hypovolemic shock in the acute phase.
In addition, burns often cause nursing problems such as pain, physical disability, and psychological problems.Burns are the most painful trauma that a person can experience because the skin as the body's outermost defense has been damaged (McLatchie et al., 2013).Similarly, the treatment of burns has been often a painful and stressful experience, although the pain response is often considered to be a part of the wound that is still good in terms of sensory function (Yuxiang et al., 2012).
The process of treating burn patients should focus on reducing the pain response first.Therefore, various methods of reducing pain have been studied, which is a major challenge in burn health care (Kipping et al., 2012).Pharmacological measures have been implemented in several large hospitals with the use of painkillers to relieve the pain of burn patients, pain reduction is still a major challenge (Mendoza & Noldin, 2016;Small et al., 2015).However, despite these medications, the level of pain produced during wound care procedures is in the moderate to severe range (Hsu et al., 2016).Therefore, painkillers are not the only method that can be used.Non-pharmacological methods, which have lower risks, can also be applied alongside medical methods to relieve pain in a more efficient manner (Hinkle & Cheever, 2018).
Many non-pharmacological interventions have been developed and implemented as alternative interventions including music therapy, relaxation therapy, and even spiritual approaches.The American Psychological Association recommends that doctors approach their patients religiously and spiritually.This recommendation is based on the idea that the care that should be provided to a patient goes beyond curing the patient but can fulfill their basic spiritual needs (Sheini-Jaberi et al., 2014).Spiritual care is a health care program that seeks to improve quality of life and enhance feelings of well-being, and thus reduce patients' disillusionment and loss of hope (Ettun et al., 2014).At an international conference on this subject, spirituality was defined as an aspect of humanity that refers to the way individuals seek and express meaning and purpose, and the way they experience interconnectedness in the present moment, self, others, nature, and the sign or the sacred.Religious factors are also an important aspect of spirituality (Yoon et al., 2018).
Apart from the spiritual aspect, burn patients in the treatment phase need an atmosphere that makes them relaxed and calm.One of the therapies to make them calm and comfortable is music therapy.
Listening to music can provide sensory stimulation input, which can activate nerve impulses to close the gate to increase the pain threshold and reduce pain signals sent to the brain, thereby reducing the pain experience.The disorder or learned behavior applies gate control theory; music can attract their attention, reduce pain or reaction, fatigue, and redistribute pain and anxiety (James & Jowza, 2017).
The tones and melodies of music can cause vibrations that affect the hypothalamus and the interaction of the reticular activating system.This stimulates emotions and affects the autonomic nervous system and muscular system function.When accompanied by musical pitch adjustments, rhythms can cause physiological changes in blood pressure, heart rate, and respiratory rate.When music stimulates the hypothalamus and limbic system, the resulting imagery stimulates autonomic nervous reactions and the propagation of nerve impulses to the midbrain and higher centers stimulates the secretion of endorphins; this offsets negative emotions, elicits feelings of pleasure, and reduces pain (Allred et al., 2010).On this basis, it is necessary to treat burn patients in addition to the provision of pain medication.This study aims to look at the effectiveness of pain reduction using spiritual approaches, and music therapy.

Participant characteristics and research design
This study used a quasi-experimental design in patients who needed treatment for burns at the Burn Center of Hasan Sadikin Central General Hospital Bandung.

Sampling procedures
The sampling technique used was accidental sampling because patient visits with burn diagnoses could not be predicted.The research time span is a benchmark for the number of samples used as research subjects.To maintain the homogeneity of the sample and to focus the study, the researcher made sample criteria taken, including: (a) Burns within 24 hours of admission and is over 15 years old with an expected hospital stay of more than five days; (b) can communicate clearly without hearing loss; (c) has no acute or chronic psychiatric disorders, (d) is not in critical condition without the use of a ventilator.

Sample size, power, and precision
The number of patients obtained during the study period from June to December 2022 was 34 patients, but only 30 patients met the criteria and participated in the program, then the patients were grouped into two groups, namely the group with music therapy intervention, as well as the group with spiritual care intervention.
This study used as a numerical rating scale (NRS) instrument from a point range of 0-10 to measure pain intensity.0 represents no pain or anxiety, and 10 represents unbearable pain.NRS as a pain or anxiety assessment tool has been used in many articles with good reliability and validity.(Lalehgani et al., 2014;Mazlom et al., 2015).
The first group was given nursing intervention using music therapy.After the patient agreed to the intervention procedure explained, the patient listened to music in the form of classical music with a range of 50-70 decibels 15 minutes before the dressing change was carried out until 30 minutes after the dressing change was completed.As soon as the dressing change begins, the patient is measured for pain intensity using the NRS instrument.After the old dressing is opened during the wound care process, pain intensity is evaluated using the NRS.Then the last pain scale is evaluated with the NRS 30 minutes after the dressing change is complete.On average, patients listened to music for 60-90 minutes during the intervention process.
Group Two was given an intervention with the concept of spiritual care.The intervention procedure starts from 15 minutes before changing the dressing the patient will be measured on the pain scale using NRS.The second measurement is carried out during the dressing change with the patient's activity while listening to the holy Quran verse according to the patient's choice, and the third pain scale assessment is carried out after changing the dressing and resting for 30 minutes with the closest family present to provide motivation.

Data analysis
Data were analyzed statistically with several stages including data analyzed using univariate analysis to see central tendency, then data were tested for normality of data for the basis for choosing the bivariate analysis used.Then the data was tested bivariate using paired t-test, then to determine the effectiveness between the two interventions, an independent t-test was conducted.Under the conditions of 80% sample strength and statistical significance of p <.05 (two-sided test), basic patient information, demographic data, and pain NRS.

RESULTS AND DISCUSSION
The results showed that the characteristics of the female patients were slightly more, totaling 16 patients who were divided into the music therapy intervention group 11 patients and the spiritual care intervention group 5 patients.Meanwhile, when viewed in table 2, most of the burns suffered by patients were in grade 3, in the music therapy intervention group 12 patients and in the spiritual care intervention group 13 patients.The results of the t-independent analysis showed that there was an effect of the two interventions on pain reduction in each phase, both phases before dressing change, during dressing change, or after dressing change.The results showed that the majority of patients who received music therapy and spiritual care interventions had grade 3 burns.The average pain response before the intervention ranged from 8.07 -8.13.this is due to grade 3 burns experiencing damage to the epidermis and even part of the dermis.
The results also show that between the two therapies, both music therapy and spiritual care have a significant effect in reducing pain according to the comparison of mean values before and after intervention.Both interventions are pharmacological therapies that have often been used as a companion to analgesic pharmacological therapy.The similarity of the two interventions is to make the body relax so that it can reduce the dominance of the hormone cortisol when pain, it agrees with the results of research on the application of music therapy according to (Ortega et al., 2019).
Music with appropriate tunes can stimulate the limbic system of the right brain, which regulates emotions, feelings and sensory centers to produce sedative effects and enhance patients' negative emotions.When patients listen to comfortable and sweet-sounding music, they generate pleasant associations, which can create a comfortable mood and a contented mood to relieve anxiety (Dai et al., 2020).This is reinforced by several studies conducted stating that music therapy can relieve pain in various conditions such as in patients with mechanical ventilation assistance, music therapy performed on preoperative patients can effectively relieve acute pain associated with surgery, and other studies show that music therapy can help reduce anxiety, pain and opioid use during surgical dressing changes in burn patients (Ernsten et al., 2019;Rohilla et al., 2018).Music therapy can also have a beneficial effect in stabilizing the patient's heart rhythm and maintaining hemodynamic balance (Ortega et al., 2019).The music used should have an appropriate tune in order to produce a significant effect.The music should use soft and lyrical melodies, simple chords, soft tones and a musical rhythm of 60 to 80 beats/minute.(Nilsson, 2008).
In addition to music therapy, researchers intervened with other types of spiritual care in an effort to reduce pain responses in burn patients during dressing changes.Spiritual care in recent years, has been widely developed in the application of holistic medicine.(Keivan et al., 2019).Thus, attention to spirituality has been recognized as part of holistic nursing care that can improve patients' quality of life.In the phase before dressing change, there was no significant difference in the average pain scale using both music therapy and spiritual care interventions.Whereas in the phase when the dressing was changed, there was a significant difference in the average pain scale using both music therapy and spiritual care interventions, although the average pain did not look much different with the results of the average pain scale performed by spiritual care being slightly lower than those using music therapy.Whereas in the phase after dressing change, there was a significant difference between the two interventions, and spiritual care therapy had a lower mean pain scale compared to music therapy.This is because for patients facing persistent pain, the use of positive spiritual care interventions, such as asking God for strength and support, can help patients adjust better to pain and have much better mental health (den Hollander et al., 2020;Siddall et al., 2015).
Various studies around the world have shown that religion is a supportive force that helps reduce psychological distress and increase life satisfaction.In a study investigating the effectiveness of meditation, the positive effects of meditation depended on the spiritual focus.Participants were divided into groups that used either secular relaxation and meditation or spiritual meditation that included the use of phrases with spiritual (but not necessarily religious) content.The group that used meditation with spiritual content showed significantly greater improvements in mood and spiritual well-being, and pain tolerance increased to almost double that of the other groups.The use of spiritual practices in medicine is more often associated with increased tolerance to acute and chronic pain than reduced pain intensity.However, a review of studies using mindfulness-based interventions that often include a meditation component found that some studies also reported a reduction in pain intensity (Keivan et al., 2019).
Booker's research on pain, humans need spiritual interventions to control and cope with their pain.However, despite the increasing interest in spirituality and its widespread application by some parts of the health profession such as palliative care, spirituality has received little attention in the field of pain management in particular.Therefore, through a concrete approach, this study has attempted to measure the effect of religious and spiritual care on pain intensity and satisfaction with pain control at the time of dressing change in burn patients experiencing severe pain.The results showed a decrease in pain intensity and an increase in patient satisfaction with pain control after the experimental intervention (Booker, 2015).
This can change the mindset of a patient experiencing pain to leave everything to God's help.Both interventions are additional interventions applied to burns because patients with burns are given intravenous opioid drugs as the main choice.Perhaps future research should be able to reveal the extent to which non-pharmacological therapy as a whole can reduce pain in burn patients.

LIMITATION OF THE STUDY
This study has several limitations including intervention treatment which is a little difficult to implement because the various characteristics of different patient responses are a challenge for researchers.besides that the number of cases of patients with burns cannot be predicted so that sampling takes a long time.

CONCLUSIONS AND SUGGESTIONS
This study can be concluded that pain management using music therapy and spiritual care can significantly reduce pain in burn patients.Spiritual care can reduce the pain scale lower in the phase during dressing change or the phase after dressing change.These two interventions are alternative therapies that can be combined with other pharmacological therapies in treating burn patients.
Nuraeni and Mr. Cecep Eli Kosasih.We would also like to thank all the patients who participated in this study.

Table 1 .
Pain Measurement Time using Numeric Rating Scale (NRS)

Table 2 .
Data Demografik   In Table.3shows that both interventions have a significant effect if we look at before and after the action, although the intervention group of patients with spiritual care has a higher mean value.

Table 3
Result paired t-test

Table 4
Result Independent T-Test