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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 90-94

Effect of music on preoperative anxiety in patients undergoing laparoscopic cholecystectomy


Department of Anaesthesiology, ABVIMS and Dr. RML Hospital, New Delhi, India

Date of Submission04-Mar-2020
Date of Decision10-Mar-2020
Date of Acceptance23-Mar-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. Devang Bharti
8/14, Punjabi Bagh Extension, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_19_20

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  Abstract 


Introduction: Anxiety is a common phenomenon among hospitalized patients awaiting any surgical procedure and causes acute psychological distress in the perioperative period. It activates the sympathetic nervous system, adversely affecting the induction and maintenance of anesthesia and postoperative recovery, leading to a lower level of satisfaction with the treatment. The current study aims to explore the effect of music on preoperative anxiety. Patients and Methods: In this randomized controlled study, 104 patients posted for laparoscopic cholecystectomy were randomly divided into two groups. Patients in both groups received oral alprazolam 0.25 mg on the night before surgery. In addition, patients in Group II were also exposed to 30 min of soft, soothing music, 1 h before the surgery. Vitals of patients, including heart rate (HR), blood pressure, and respiratory rate, in both the groups along with the general anxiety – visual analog scale (GA-VAS), were recorded and compared. Results: On comparing T30 vitals between the two groups, a statistically significant difference was seen in all the monitored parameters, with vitals in Group II being lower than in Group I. T60 vitals in Group II were found to be lower than Group I in all the monitored parameters, except for HR (P = 0.051). The GA-VAS scores in Group II were lower compared to Group I (P = 0.008). Conclusion: Exposure to music, as an addition to alprazolam 0.25 mg, in the preoperative period for patients who underwent laparoscopic cholecystectomy reduces the patient's anxiety compared to alprazolam alone.

Keywords: Anxiety, cholecystectomy, laparoscopic, music


How to cite this article:
Yadav N, Singhal S, Bharti D. Effect of music on preoperative anxiety in patients undergoing laparoscopic cholecystectomy. Bali J Anaesthesiol 2020;4:90-4

How to cite this URL:
Yadav N, Singhal S, Bharti D. Effect of music on preoperative anxiety in patients undergoing laparoscopic cholecystectomy. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Aug 4];4:90-4. Available from: http://www.bjoaonline.com/text.asp?2020/4/3/90/290084




  Introduction Top


Anxiety is one of the most fundamental traits of human behavior and is defined as an emotional state characterized by a feeling of worry, nervousness, or unease. It is a common phenomenon among hospitalized patients awaiting any surgical procedure and causes acute psychological distress in the perioperative period.[1] 'State - anxiety' refers to acute, situation- driven episodes of anxiety that do not persist beyond the situation that triggers them. It is a transient emotional condition that varies in intensity and fluctuates over time.[2] “Trait – anxiety” is a personality feature characterized by a lifelong pattern of anxiety.[3] People with trait anxiety are generally jittery, nervous, hypersensitive to stimuli, and psychologically more reactive. High state anxiety scores indicate high levels of anxiety at the moment of evaluation, while high levels of trait anxiety indicate an anxious personality.[4] The preoperative waiting period, with its opportunity for brooding, thinking, worrying, and fearing the forthcoming surgery, may also exacerbate anxiety. Thus, creative and supportive interventions during these uncomfortable and uncertain waiting periods may be important in ameliorating distress and improving health outcomes.[5]

Anxiety induces a psychophysiological stress response, which involves the activation of the hypothalamo-pituitary-adrenal axis and the sympathetic nervous system.[6] It is characterized by increased heart rate (HR), blood pressure, and cardiac output. It also elevates cortisol levels in the body, which may lead to slower wound healing, diminished immune response, and increased risk of infection.

High levels of anxiety may also interfere with and complicate the presurgical drug administration, adversely affect the induction of anesthesia, and impede the postoperative recovery. The increased distress associated with anxiety not only increases the intraoperative anesthetic drug requirement[6] but also makes the management of postoperative pain more difficult.[7] There is increased demand for analgesics in patient-controlled analgesia and a lower level of satisfaction with the treatment and overall perioperative experience.[8] Thus, the effect of preoperative anxiety on the course and outcome of surgical procedures has attracted much attention.

Anxiety as a trait can be measured by various scales. These include the Spielberger's State-Trait Anxiety Inventory (STAI), the General Anxiety-Visual Analog Scale (GA-VAS), the Verbal Rating Scale, the Numerical Rating Scale, and the Yale Preoperative Anxiety Scoring. Visual analog scale is easy to administer, less cumbersome to carry out, and is a validated scale.

To reduce anxiety, anxiolytics are routinely administered to patients before surgery. However, these anxiolytics have various side effects such as drowsiness and respiratory depression.[9] These agents also interact with other drugs administered during anesthesia and may lead to prolongation of recovery time and eventually, of time of discharge. Therefore, the focus is now shifting to alternative psychological measures to reduce anxiety, and various nonpharmacological measures are being explored.[9]

Music is one nonpharmacological/psychological measure. It has been used in different medical fields to meet the physiological, psychological, and spiritual needs of the patient. The psychological effects of music, including the induction and modification of moods and emotions, are well-documented and established.[10],[11],[12] The auditory stimulation mediated by music influences the limbic system, which is the center of emotions and feelings.[13],[14],[15],[16] This triggers the release of endorphins, the body's natural mood-altering substance.

The current study attempts to study the effect of music on the preoperative anxiety of patients posted for laparoscopic cholecystectomy, with the objective of comparing the level of anxiety between patients premedicated with oral anxiolytics alone and those who listened to music as well as were premedicated with oral anxiolytics.


  Patients and Methods Top


A randomized controlled study was conducted at our institute in 104 adult patients of either sex, undergoing laparoscopic cholecystectomy from September 2010 to April 2012. Ethical clearance for conducting the study was obtained from the institutional ethical and academics committee. A written, informed consent was obtained from all the selected patients.

Inclusion criteria include patients aged 18–60 years of either sex, posted for laparoscopic cholecystectomy, and categorized as the American Society of Anesthesiologists physical Class of I–II. Exclusion criteria include patient refusal, any known hepatic, renal, cardiac, or respiratory diseases, any previous history of exposure to anesthesia, suffering from or with a history of any psychiatric disorder, deaf or hearing-impaired patients, pregnant, and lactating patients.

Patients were then randomly allocated into two groups. Group I received alprazolam 0.25 mg orally only and Group II received alprazolam 0.25 mg orally and music therapy. Patients arrived in the operation theater on the day of surgery approximately an hour before the scheduled time of surgery. All the patients were kept in the preoperative room with a nurse in attendance. No surgeon was allowed to meet and examine the patient for the next 30 min. Baseline values of HR, blood pressure (systolic, diastolic, and mean), and respiratory rate were recorded on arrival to the preoperative room (T0 vitals). The patients were then randomly allocated to one of the two groups using sealed random allocation cards, which were made using computer-generated random numbers. The sealed envelope was opened by one of the researchers at the time of arrival of the patient in the preoperative room. If the envelope contained an odd-numbered card, the patient was assigned to Group I. Conversely, if an even-numbered card was encountered, the patient was allocated to Group II. The researcher involved in group allocation played no part in the recording of the vitals and was, thus, blinded toward the further proceedings. Likewise, the researcher involved in the recording of the preoperative and intraoperative vitals and VAS scores was blinded regarding the Group a patient belonged to.

Patients allocated to Group I received alprazolam 0.25 mg orally on the night before surgery. On the morning of the surgery, they were shifted to the preanesthetic room 1 h before the scheduled time of surgery. They were then exposed to the environment of the preoperative room for 30 min, following which visual analog scale scoring, HR, blood pressure, and respiratory rate of the patients were recorded (T30 vitals).

Patients allocated to Group II received alprazolam 0.25 mg orally on the night before surgery. On the morning of the surgery, they were shifted to the preanesthetic room 1 h before the scheduled time of surgery. They were then made to listen to prerecorded music (Sufi instrumental music) for approximately 30 min, with the aid of headphones (Panasonic) using an MP3 Player (Sony), with a nurse in attendance throughout this period. The visual analog scale scoring, blood pressure, HR, and respiratory rate of the patients were recorded at the end of this 30 min period (T30 vitals). The music was kept the same for every patient allocated to the music group.

The patients were exposed to a questionnaire consisting of 10 questions and were asked to range responses from 0 to 10, where “0” corresponded to “no anxiety” and “10” coincided with “most severe anxiety.” The questions were divided into three broad categories, as shown in [Table 1]. After collecting all these data, the patients were made to wait for their turn for surgery. Once inside the operation theater, the vitals (HR, systolic and diastolic blood pressure [DBP], mean arterial pressure [MAP], and respiratory rate) of the patient were recorded once more, after shifting the patient on the operation table (T60 vitals). The systolic blood pressure (SBP), DBP, MAP, HR, and respiration rate were noted in each measurement time (T0, T30, and T60).
Table 1: Description of the questions asked to the subjects

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Statistical analysis of the recorded data was performed using the SPSS statistical package (version: 17.0, SPSS Inc., Chicago, USA). Continuous variables, including hemodynamics over time within the groups, were analyzed using repeated-measures analysis of variance (ANOVA) followed by Bonferroni's post hoc testing. Statistical comparisons among the groups were performed using ANOVA. If the F value was significant and variance was homogeneous, Tukey's multiple comparison test was used to assess the differences between the individual groups; otherwise, Tamhane's T2 test was used. Nominal or categorical data between the three groups were analyzed and compared using the Chi-square test. A P < 0.05 was considered statistically significant.


  Results Top


There was no statistically significant difference between the two groups in terms of age, weight, sex, and education [Table 2]. Likewise, there was no statistically significant difference between the T0 vitals of the patients in the two groups [Table 3].
Table 2: Characteristics of the subjects

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Table 3: Observed baseline parameters (T0)

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We found statistically significant changes in all the monitored parameters [Table 4] and [Table 5]. On comparing T30 vitals between the two groups, a statistically significant difference was seen in all the monitored parameters, with vitals in Group II being lower than in Group I [Table 5]. T60 vitals in Group II were found to be lower than Group I in all the monitored parameters, and the decrease was statistically significant in all the parameters except HR (P = 0.051). A statistically significant difference was observed between the mean GA-VAS scores of the two groups, with the mean GA-VAS score of Group II being lower than that of Group I [Table 6].
Table 4: Vital signs measurements at T30 and T60

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Table 5: Comparison of vitals between groups at T30 and T60

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Table 6: General anxiety-visual analog score results (mean±standard deviation)

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  Discussion Top


Music induces relaxation through entertainment and synchronization of body rhythms.[13] This decreases the sympathetic nervous system activity, leading to decreased adrenergic activity, altered state of consciousness, and decreased neuromuscular arousal. All of these changes manifest physiologically in the form of a global decrease in HR, blood pressure, respiratory rate, metabolic rate, oxygen consumption, skeletal muscle tension, epinephrine levels, gastric acidity, and sweat gland activity. These anxiolytic effects of music have been studied in a variety of patients, including surgical, cardiac, and oncological patients.[14] Music is currently used as a treatment modality for conditions such as dementia, stroke, Parkinson's disease, various affective disorders, and pain.

The music intervention given to the patient can be in the form of music medicine or music therapy. Music medicine is an intervention that is administered by medical or healthcare professionals. In this, passive listening to prerecorded music is offered by health-care professionals.[9] Music therapy is an interactive relationship between the therapist and patient that is based on communication through music.[15] Music therapy has been proven to be of value and is well documented.[11],[12] Music intervention is, thus, a beneficial intervention devoid of any side effects, is easy to engage, and is inexpensive as it does not require the use of human or other additional resources such as training or specialized equipment.[16]

Baseline comparison between the two study groups revealed that the groups were comparable for age, weight, sex, and education, with there being no statistically significant variation between them. In addition, there was no statistically significant difference between the T0(baseline) vitals of the patients in the two groups, rendering them comparable.

A statistically significant difference was observed in all the measured parameters on comparing T30 vitals between the two groups. T30 vitals in Group II were less than that in Group I, implying a lower level of anxiety in Group II patients, compared to patients in Group I, after spending 30 min in the preanesthetic room.

On comparing T60 vitals between the two groups, we observed that all the measured parameters were lower in Group II patients than patients in Group I. This difference was statistically significant in all the parameters except HR. This implied that the anxiety level in Group II patients was lower than patients in Group I, inside the operation theater as well.

The mean GA-VAS score of patients in Group II was lower than patients in Group I, and the difference was statistically significant. The GA-VAS scoring is used to objectively measure the anxiety, and thus, lower mean GA-VAS score in Group II patients confirms a lower level of anxiety in Group II patients, compared to patients in Group I.

Lee et al.[17] studied the effect of music on patients undergoing day care procedures and reported a decrease in HR and blood pressure of patients who listened to music during the preprocedure wait time compared to the control group. They also reported a decrease in the anxiety level of patients who listened to music, as measured by the Spielberger State-Trait Anxiety Scale. These results are in agreement with that of the current study.

A study reported significantly less anxiety, HR, and respiratory rate in patients receiving ventilatory assistance after receiving 30 min of music therapy, compared to the control group. These results are, again, similar to the present study.[18]

Yung et al.[19] studied the effect of music on preoperative anxiety in Chinese men undergoing transurethral resection of the prostate. The study was designed as quasi-experimental with three study groups – music intervention, nurse presence, and control. They found that there was a significant decrease in state anxiety levels in the music group, as measured by the Chinese State-STAI. They also reported a statistically significant decrease in the blood pressure (SBP, DBP, and MAP) and an increase in the HR of patients in the music group. The results are similar to that of the current study, with the exception of the HR response. These different variations in blood pressure and HR could be explained based on the studies conducted by DiCara and Miller[20] and Shapiro et al.[21] concluding that changes in blood pressure are not necessarily associated with the corresponding variation in HR. The increase in the HR can also be explained based on conclusions made by Christoph et al.,[22] that HR is related more to the initial attitude toward the experimental procedure than to relaxation response accompanied by the procedure itself.

Yilmaz et al.[23] conducted a study to compare the effect of music and midazolam on sedation and anxiety in patients undergoing extracorporeal shock wave lithotripsy (ESWL) treatment. The STAI score was found to be significantly lower in the music group than the midazolam group, indicating that ESWL can be performed effectively using music for anxiolysis rather than midazolam. In the current study, music was used in conjunction with alprazolam, and the combination of the two was found to be more effective in allaying anxiety than alprazolam alone.


  Conclusion Top


Exposure to music, as an addition to alprazolam 0.25 mg, in the preoperative period for patients who underwent laparoscopic cholecystectomy reduces the patient's anxiety compared to alprazolam alone.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Wang SM, Kulkarni L, Doley JM, Kain ZN. Music and preoperative anxiety – A randomised controlled trial. Anesth Analg 2002;94:1489-94.  Back to cited text no. 16
    
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Lee D, Henderson A, Shum D. The effect of music on preprocedure anxiety in Hong Kong Chinese day patients. J Clin Nurs 2004;13:297-303.  Back to cited text no. 17
    
18.
Chlan L. Effectiveness of a music therapy intervention on relaxation and anxiety for patients receiving ventilatory assistance. Heart Lung 1998;27:169-76.  Back to cited text no. 18
    
19.
Yung PM, Chui-Kam S, French P, Chan TM. A controlled trial of music and pre-operative anxiety in Chinese men undergoing transurethral resection of the prostate. J Adv Nurs 2002;39:352-9.  Back to cited text no. 19
    
20.
DiCara LV, Miller NE. Instrumental learning of systolic blood pressure responses by curarized rats: Dissociation of cardiac and vascular changes. Psychosom Med 1968;30:489-94.  Back to cited text no. 20
    
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Shapiro D, Tursky B, Gershon E, Stern M. Effects of feedback and reinforcement on the control of human systolic blood pressure. Science 1969;163:588-9.  Back to cited text no. 21
    
22.
Christoph P, Luborsky L, Kron R, Fishman H. Blood pressure, heart rate and respiratory responses to a single session of relaxation: A partial replication. J Psychosom Res 1978;22:493-501.  Back to cited text no. 22
    
23.
Yilmaz E, Ozcan S, Basar M, Basar H, Batislam E, Ferhat M. Music decreases anxiety and provides sedation in extracorporeal shock wave lithotripsy. Urology 2003;61:282-6.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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