Colonoscopy is an endoscopic examination of the large bowel and the distal part of the small bowel that is used to diagnose pathological lesions, such as ulceration, polyps, inflammation, and even cancer, via gross inspection or biopsy and as a therapeutic approach to remove suspected malignant lesions. In recent years, colonoscopy has been considered the gold standard for colon cancer screening and surveillance.1
However, the colonoscopy procedure carries risks of perforation2 and bleeding.3 Discomfort related to colonoscopy, such as abdominal pain and a sensation of fullness, is frequently experienced by patients during this procedure. Anxiety arising from this discomfort is inevitable for most patients, which may even prevent completion of the procedure in some cases. Under these circumstances, adequate patient physiological and psychological preparation is essential for a safe and successful examination and to maintain compliance during subsequent follow-up procedures. Colonoscopy under sedation is one alternative to ensure smooth performance of the procedure and is now widely applied in clinical practice.4 However, potential risks of cardiopulmonary complications exist, such as oversedation, hypoxemia, hypoventilation,5–7 aspiration pneumonia, pulmonary embolism, and myocardial infarction,8,9 which patients and clinicians should be aware of prior to sedation. Therefore, although colonoscopy with sedation is performed to reduce anxiety and discomfort in patients during the examination, the risk of undergoing the procedure under sedation is not lower than that of colonoscopy without sedation.
The American Pain Society suggested that apart from medication, pain control can be achieved by alternative nonmedication methods, which may result in improved efficacy in pain control. One nonmedication method for pain control is listening to music,10 which is a noninvasive method to reduce pain and anxiety without causing any adverse effects.11 Currently, music is employed in many medical procedures and therapies, such as in the treatment of patients suffering from malignancy,12 patients undergoing imaging-guided core-needle breast biopsy,13 burn injury patients,14 and women in labor,15 to reduce pain and anxiety. In a colonoscopy examination, music is viewed as an effective method for reducing procedure-related anxiety.16–18
The aim of this study was to explore whether music can reduce procedure-related anxiety and also to compare two styles of music, informal classical music and light music, in order to ascertain the more effective music style for reducing anxiety in patients undergoing colonoscopy without sedation in Taiwan.
We enrolled patients who underwent a colonoscopy during a general health examination without sedation from February 2009 to January 2015 in the Health Management Center, Kaohsiung Medical University Chung-ho Memorial Hospital. Patients who suffered from medical conditions, such as myocardial infarction, pulmonary embolism, cerebral vascular infarction, unstable and severe cardiac disease, or severe gastroenteritis disease, were excluded from colonoscopy examination. In addition, the data for some patients were incomplete, and these patients were also excluded from this study. In total, 138 patients were enrolled in this study. The study was approved by the ethics committee and Institutional Review Board of Kaohsiung Medical University Chung-ho Memorial Hospital, and signed informed consent was obtained and agreed from all the patients who were enrolled in this study.
2.2. Body mass index, blood pressure, and past history
In this study, prior to colonoscopy examination, basic data of the patients, including height, weight, blood pressure, and past history, were recorded. Body mass index [BMI, (kg/m2)] was calculated as weight/height2. Blood pressure was measured in a sitting position, and the patients took no drugs during the fasting period. The cutoff values used in this study were systolic blood pressure and diastolic blood pressure of 120/80 mmHg, according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure criteria).19 A BMI equal to or greater than 23 kg/m2 was defined as overweight, according to the Steering Committee of the Regional Office for the Western Pacific Region of the World Health Organization.20 Histories of hypertension, smoking, and drinking alcohol were also recorded. If patients had smoked or imbibed alcohol in the past 5 years, they were categorized as having a history of smoking or alcohol consumption.
2.3. Music and equipment
Patients were randomly classified into groups that did or did not listen to music during the colonoscopy examination. Those who were randomly classified into the group that listened to music were also randomly assigned to either a group that listened to “Canon in D” from the album “Pachelbel by The Sea” by David Tolley, which belongs to the genre of informal classical music, or a group that listened to “Blossom on the Wind” from the album “Embracing The Wind” by Kevin Kern, which belongs to the genre of light music. The music was played via an iPad with an amplifier at an adequate volume from the start of the colonoscopy examination and was stopped when the examination ended. No sedation was applied during the procedure. The music was played in the room where the procedure was performed in order to ensure that the outside noise was isolated. Finally, 81 patients were randomized into groups that listened to music, including 45 and 36 patients who listened to music by David Tolley and Kevin Kern, respectively, after exclusion of patients with incomplete data.
2.4. The State-Trait Anxiety Inventory
In this study, the State-Trait Anxiety Inventory (STAI) was used to evaluate the status of anxiety. Every patient completed the form following colonoscopy examination. The STAI Form Y is a brief, self-rating scale for the assessment of state and trait anxiety in adults. The concepts of state and trait anxiety were first introduced by Cattell and Scheier21–23 and have been further elaborated by Spielberger.24–27 Each STAI item is given a weighted score of 1 to 4 for each question (e.g., select item 1 scoring 1 for this question). For questions 1, 2, 5, 8, 10, 11, 15, 16, 19, 20, 21, 23, 24, 26, 27, 30, 33, 34, 36, and 39, the score was calculated as the reverse score (i.e., 5 minus the selected item score); scores of the other questions were simply the score of the selected item. The calculated scores for all questions were then summed up to give a total anxiety score. The lower the total score, the less anxious was the patient. A total final score of 41–80 represented mild anxiety, 81–120 represented moderate anxiety, and 121–160 represented severe anxiety.
2.5. Statistical analysis
The statistical tests employed in this study were the Student t test, Chi-square test, and one-way analysis of variance. In addition, multivariate analysis was used to estimate odds ratios and 95% confidence intervals. A trend test was also performed to analyze trends. All tests were two sided, and the significance level was set at α=0.05. The statistical analyses were performed using SPSS version 22 (SPSS Inc., Chicago, IL, USA).
Table 1 shows the basic characteristics of the 138 patients enrolled in this study. Male patients were dominant (54.3%), and the average age of the patients was 48.0±11.9 years. The percentages of patients with histories of hypertension, smoking, and alcohol consumption were 8.7%, 11.6%, and 22.5%, respectively. No significant differences in any of the basic characteristics were noted between the patients who did and those who did not listen to music during colonoscopy.
Table 2 shows the results of analysis of anxiety status in patients who did and those who did not listen to music, and the anxiety score was determined to be lower among the patients who listened to music during colonoscopy without sedation (85.3±18.6 vs. 79.9±16.8, p=0.074). However, this difference was not significant. Additionally, the differences according to sub analyses of the male and female patients were not significant. Furthermore, a moderate status of anxiety was most prevalent among all the patients. Similarly, from the results shown in Table 3, analysis of anxiety status in patients who did not listen to music, those who listened to music by David Tolley, and those who listened to music by Kevin Kern showed no significant differences between the three groups although the anxiety score was the lowest in the patients who listened to music by Kevin Kern. Due to the gradually increasing tendency toward development of a mild status of anxiety in the order of not listening to music, listening to music by David Tolley, and listening to music by Kevin Kern, as shown in Table 2, we also performed a trend test for mild anxiety among patients in all the three groups, and a significant trend was noted (Fig.1A and 1B; p=0.017 for all patients, p=0.014 for analysis by sex).
Multivariate analysis of a mild status of anxiety among patients in all three groups was also performed in this study, and patients who listened to music by Kevin Kern were found to have the lowest odds ratio (OR=0.34, 95% confidence interval=0.14–0.81, p=0.045; Table 4).
Finally, we also analyzed the relationships between blood pressure before colonoscopy examination, BMI, history of hypertension, smoking, alcohol consumption and status of anxiety; however, no significant differences between any item and status of anxiety were noted (data not shown in table).
Previous study has shown that one of the most important characteristics of music is that of reducing anxiety.28 The mechanism of music therapy is thought to arise from multiple nervous stimuli that are conducted into the brain, which are antagonists to each other, and under certain conditions, receiving the stimulus of hearing music can reduce pain or discomfort. Music can change the reaction of the autonomic nervous system in the thalamus, such as relaxing the tensive muscle, decreasing the release of adrenocorticotropic hormone, and changing the activity of the sympathetic nervous system. In addition, music influences the limbic system to evoke joyful sensations and decrease anxiety.29–31 Music can also stimulate the pituitary gland to release more endorphins, which reduce pain and, therefore, can decrease the level of anxiety.30
Previous studies have not determined which style of music (such as easy listening, jazz, rock, and country) has the best efficacy in terms of reducing anxiety.18,32–37 A study reported that anxiety was reduced in patients undergoing a transrectal ultrasound-guided prostate biopsy under local anesthesia by listening to “Twilight’s Embrace” by Kevin Kern from the album “Summer Daydreams”.38 In this study, music by Kevin Kern had the best efficacy in reducing anxiety. This may be because “Canon in D” from the album “Pachelbel by The Sea” by David Tolley is of the canon style of informal classical music. Pachelbel's canon is a variation form, which has a solid repetition formation throughout the piece. However, “Blossom on the Wind” from the album “Embracing The Wind” by Kevin Kern has a simple light musical style, which is a less serious form. Therefore, we believe that listening to light music is less stressful than listening to music of the canon style, and it is more effective in terms of reducing anxiety than the other formal musical styles.
Listening to music has been shown to reduce anxiety during cardiac vascular procedures,39,40 transrectal ultrasound-guided prostate biopsies,41 shockwave lithotripsy,42 and gastrointestinal procedures.18 One meta-analysis study analyzed the effect of listening to music on patients undergoing colonoscopy from eight randomized controlled trials published from 2002 to 2006.43 The meta-analysis concluded that music can significantly improve the patient's experience during colonoscopy, but does not shorten the duration of the procedure, decrease pain levels, or reduce the amount of sedative medications required. However, two studies did report that listening music decreased the doses of sedative medications needed.44,45 Listening to music during a colonoscopy has been shown to reduce the STAI score,16,18 and for patients undergoing esophagogastroduodenoscopy and colonoscopy, relaxing music has been shown to improve tolerance, attitude, and overall feelings about the procedure.46 Therefore, listening to music is thought to be one method by which anxiety can be reduced during the colonoscopy procedure.47 In this study, patients who listened to music had a lower STAI score, regardless of the style of music. Therefore, we believe that listening to music can reduce the status of anxiety in patients undergoing colonoscopy without sedation.
Finally, neither physiological factors, such as BMI, nor a history of hypertension, smoking, or alcohol consumption were associated with the status of anxiety. Music played during flexible sigmoidoscopy was reported to have decreased the mean arterial blood pressure and heart rate,48,49 but one study had converse results.18 In this study, blood pressure prior to colonoscopy was not related to listening to music; therefore, we believe that physiological factors have no influence on the status of anxiety during colonoscopy without sedation.
A limitation of this study was that the sample size was small, and a larger sample size might be necessary to demonstrate significant differences in statistical analysis. In addition, as the patients who underwent colonoscopy only did so as part of a general health examination, we could collect only limited data. For example, the number of patients who underwent successful colonoscopy completion and the total duration of each colonoscopy procedure were not recorded; therefore, we were unable to analyze these variables. In addition, blood pressure was not recorded after the colonoscopy examination, and therefore, we were unable to assess whether a change in blood pressure before and after colonoscopy examination was related to the status of anxiety. However, these issues will be addressed in the future.
In conclusion, listening to music can decrease a patient's STAI score and reduce their status of anxiety during colonoscopy examination without sedation, especially listening to music by Kevin Kern, which is of a light musical style. Neither physiological factors nor a history of hypertension, smoking, or alcohol consumption were associated with the status of anxiety. We believe that for patients undergoing colonoscopy examination without sedation, listening to light music, such as music by Kevin Kern, is a safe, convenient, and effective method to reduce anxiety.
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