Most surgical procedures cause fear and anxiety with increasing heart rate, blood pressure, and other changes in patients, which can negatively affect the induction of anesthesia and then recovery process. Surgical procedures performed using regional anesthesia present a challenge to the anesthesiologist since the patients are awake during the procedure and are exposed to a multiple anxiety-provoking visual and auditory stimuli. A calm and quite environment is desired where surgery is performed. Mottahedian TE noted that cortisol levels are increased in patients undergoing spinal anesthesia and music therapy is associated with reduction in cortisol levels which are indicators of stress in the patient undergoing surgery. Palmer JB noted a potential for music therapy as an adjunct to standard surgical care. Various pharmacological therapies are used in the management of perioperative anxiety in patients and pain management. However, these can be associated with significant adverse reactions.
Hence, we conducted this study to see the effect of music therapy in patients undergoing abdominal and lower limb surgeries under spinal anesthesia. Primary aim of study was to evaluate the effect of music therapy on intraoperative hemodynamics, and secondary aim was to see its effect on postoperative pain perception and anxiety.
MATERIALS AND METHODS
Due ethical clearance was obtained from institutional ethics subcommittee before start of the study. Informed consent was obtained from the patients after explaining to them aims and objectives of the study in their native language. Patients were educated about visual analog scale (VAS) and Spielberger State-Trait Anxiety Inventory (SSTAI) scale during their preoperative visit.
Patients of either gender with age between 18 and 65 years and physical status American Society of Anesthesiologists (ASA) Grade I and II were included in the study. Valid written informed consent was taken from all the study participants. Patients with significant comorbid conditions, ASA Grade III and above and patients with malignancies were excluded from the study.
Sample size calculation
In the study by Maeyama et al., postsurgery mean anxiety score STAI in the two groups was 29.7 ± 7.2 in M group and 38.8 ± 10.3 in C group. To get at least this much of difference in the study groups, minimum sample size required was calculated using 95% confidence interval and power of study 80%. Minimum required total sample size was 34 (17 in each group). Considering exclusion and dropouts during study, we took total sample size 60 (30 in each group).
Sixty patients undergoing abdominal and lower limb surgery under spinal anesthesia were randomized using computer-generated random number table into Group M (those who listened to music, n = 30) and Group C (those who did not listen to music, n = 30). After the induction of spinal anesthesia with injection bupivacaine heavy 3.5 ml and injection fentanyl 25 micrograms and after achieving the desired level up to thoracic vertebra T8, headphones were applied to all the patients, Boat sports wireless Bluetooth head phones, imported and marketed by iMAGINE, Mumbai Maharashtra and music was started in headphones in Group M, while music was not played in the headphones in Group C patients. The intraoperative parameters such as electrocardiogram, heart rate, blood pressure, and Spo2 are monitored continuously and recorded at the interval of 15 min. The VAS was recorded in the recovery room every 30 min till 2 h, and the SSTAI scale was recorded in the preoperative room and recovery room at the end of 2 h and compared in both the groups. Patient satisfaction was also recorded before shifting patient from recovery to ward. Anesthesiologist monitoring the patient and recording the parameters was unaware of the group allocation of patient.
All the data were collected, compiled, and tabulated. For statistical analysis, unpaired t-test was used for quantitative data and Chi-square test was used for qualitative data. Primer of biostatistics software was used for statistical analysis. P < 0.05 was considered as statistically significant.
Total 65 patients assessed for participation in the study but 1 was excluded while 4 denied to participate in the study. [Figure 1] 60 patients were included in the study, 30 in each group. [Table 1]
[Tables 2 and 3] and Figures 2 and 3 shows heart rate and mean arterial blood pressure were comparable in the study at all time intervals.
Table 4 and Figure 4 VAS score was significantly less in Group M as compared to Group C up to 2 h postoperatively.
Table 5 and Figure 5 anxiety score (SSTAI) was significantly less in Group M as compared to Group C.
Table 6 and Figure 6 shows more than 90% of patients in Group M were satisfied about their perioperative care as compared to 50% patients in Group C.
The mean age of the patients in Group M was 38.3 ± 12.28 years and in Group C was 44 ± 14.49 years with a nonsignificant difference and P = 0.102. Majority of the patients in both the groups were aged between 30 and 39 years. 23 patients in Group M and 22 patients in Group C were male. Both the groups were comparable in respect to age, weight, gender, and duration of surgery. However, significant difference was noted in VAS score, SSTAI scores, and patient satisfaction. These parameters were significantly better in the music group, corresponding to the beneficial effect of music therapy. There was nonsignificant difference between mean heart rates and mean arterial pressure subsequent to induction and in the postoperative period.
Various studies have evaluated benefit of music therapy. Mondanaro et al. noted that music therapy increases comfort and reduces pain in patients recovering from spine surgery. VAS pain levels increase slightly in the control group (from 5.20 to 5.87) but decreased by more than 1 point in the music group (from 6.20 to 5.09). Aris et al. evaluated patients undergoing total knee arthroplasty (TKA) found that pain score decreases over time among patients in the music therapy group while no effect is seen for anxiety. Patients in music therapy group showed significantly lower numerical pain score at 60 min (P = 0.045) whereas there was no significant difference between the two groups at all time points for anxiety scores (P > 0.05). Comparable to the above studies, in our study also, we noted that postoperative VAS score in music group was less as compared to control group.
Maeyama et al. assessed the music therapy on reducing anxiety of patients under spinal anesthesia using BIS and interview type psychology test, STAI. They observed that music therapy reduced BIS value and was effective to reduce patient’s anxiety during spinal anesthesia.
Lee et al. noted that music listening alleviates anxiety and physiological responses in patients receiving spinal anesthesia. The mean score of the STAI in the study group decreased from a pretest score of 59.0 to a posttest score of 31.20 (t = 28.63, P < 0.001). Physiological indices such as heart rate (t = 2.61, P = 0.012), respiration rate (t = 2.29, P = 0.026), systolic blood pressure (t = 2.30, P = 0.026), and diastolic blood pressure (t = 3.02, P = 0.004) decreased significantly as well. Control group was not seeing significant changes from preoperative values.
Ilkkaya studied the effects of music, white noise, and ambient noise on sedation and anxiety in patients under spinal anesthesia during surgery. At 5 min before surgery, the STAI-State Anxiety Inventory (SA) value was significantly lower in Group M than the other groups. At 30-min recovery, Group M showed significantly lower STAI-SA values than the other groups. Patient satisfaction was highest in Group M. In the study by Kukreja et al., STAI-Trait scores were similar preoperatively but significantly less postoperatively in the music group (28.14 ± 1.0) as compared to the control group (34.71 ± 2.31); P = 0.01. Patient satisfaction scores with their perioperative experience were higher in the music group (P = 0.009). Our study was in synchronization with the above-mentioned studies which depicts adjunct value of music therapy. In our study, we found more decrease in anxiety score in music group as compared to control group and more patient satisfaction in music group.
Apart from utility in surgical care, various studies have as well tried to establish the benefit of music therapy in cancer patients, critically ill patients, depression, premedication, postoperative recovery, and perioperative anxiety[16,17] among other patient subsets.
It was noted that there was a higher patient satisfaction with better VAS and SSTAI scores in patients receiving music therapy. Music therapy is noninvasive and a simple procedure, considering improvement in the patient satisfaction; this can be potentially used in various surgeries as a routine adjunct in surgical care.
Limitations of the study
Our sample size was small, so results may differ with larger sample size. Age group included in the study was 18–65 years, with average age 38 years in Group M and 44 years in Group C, so result may not be applicable to extremes of ages. Baseline anxiety was not considered in evaluation. Effect of anesthesia on VAS scores and patient satisfaction cannot be separately evaluated.
Financial support and sponsorship
This is a self-funded study.
Conflicts of interest
There are no conflicts of interest.
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