Using Music as an Anti-Anxiety Intervention for Outpatients Undergoing Minor Medical Procedures

A Review of the Literature

Numerous patients experience anxiety before minor medical procedures (Roberts, Czakowska, Radiotis, & Korner, 2013). Because patients’ experiences are highly individualized, their distress may range from mild to moderate. For a decade, music-based complementary therapy has received increased attention because of the therapeutic and healing environment it creates for patients undergoing invasive procedures (Zengin et al., 2013). The purpose of this structured literature review is to assess the current evidence regarding the effectiveness of music as an intervention that decreases anxiety for patients undergoing minor medical procedures in outpatient healthcare settings.

Search Methods

The Cochrane Database of Systematic Reviews was searched using the following search terms: music, anxiety, procedure, and outpatient. Inclusion criteria included systematic reviews published between May 2011 and May 2015. Exclusion criteria applied included studies focused on patients with chronic or mental illnesses, obstetrical conditions, and/or children and adolescents. The initial search generated 20 records, two of which addressed the question of interest. The remaining 18 articles were excluded from the review based on exclusion criteria.

A search of the Web of Science database was also conducted. The term music was used with the Boolean operator and with the basic words anxiety, procedure, and outpatient respectively. The search was limited to studies published between May 2011 and May 2015. The initial search generated 94 items. A total of 85 studies that focused on patients with chronic diseases or mental illnesses were excluded. The remaining nine articles were selected for inclusion based on relevance and alignment with the clinical question of interest.

Between the Web of Science and the Cochran Database, 11 studies were selected for inclusion in the review based on specified inclusion and exclusion criteria. The list included two systematic reviews of randomized control trials (RCTs); one systematic review of RCTs that also contained clinical controlled trial (CCTs); six RCTs; one quasi-experimental study; and one literature review.

Appraisal of Evidence

The Johns Hopkins Nursing Evidence-Based Practice (EBP) Model and Guidelines (Dearholt & Dang, 2012) and tools guided the appraisal and synthesis of evidence. The Research and Non-research Evidence Appraisal Tools were used to gauge the strength and quality of each study. The results were summarized using the Individual Evidence Summary Tool and the Synthesis and Recommendation Tool. The Evidence Synthesis and the Selected Translation Pathway tools were used to recommend and select a translation pathway (Dearholt & Dang, 2012).

Two key themes, psychological indicators/impacts and physiological indicators/impacts, emerged during the appraisal phase. The summaries of discussion, which follow, are organized around these themes. Psychological indicators include anxiety levels, pain sensations, and patient satisfaction, which constitute subjective information. The physiological indicators included BP, HR changes, respiratory rate (RR), and stress hormone levels as objective information.

Psychological Findings: Anxiety, Pain, and Discomfort

Of the 11 articles, 10 presented findings related to anxiety levels before, during, or after any medical procedure that involved music intervention. The results of several studies reviewed indicate that listening to music significantly alleviates patients’ anxiety during procedures, such as colposcopy, Mohs surgery, and other surgeries (Bradt, Dielo, & Shim, 2012; Galaal, Bryant, Deane, Al-Khaduri, & Lopes, 2011; Ni, Tsai, Lee, Kao, & Chen, 2012; Thompson, Moe, & Perston Lewis, 2014). Most studies measured anxiety scores by the Spielberger State-Trait Anxiety Inventory (STAI) or the visual analog scale (VAS) (Bradt et al., 2012; DeMarco, Alexander, Nehrenz, & Gallagher, 2012; Galaal et al., 2011; Martindale, Mickocka-Walus, Walus, Keage, & Andrews, 2014; Ni et al., 2012; Thompson et al., 2014; Vachiramon, Sobanko, Rattanaumpawan, & Miller, 2013; Yingel & Gooding, 2015; Zengin et al., 2013).

Bradt et al. (2012) included 26 trials -- a total of 2051 participants in their systematic review -- and specified that listening to music resulted in an anxiety reduction on an average that was 5.72 units greater (95% CI -7.27 to -4.17, p < 0.00001) than in the standard care group as measured by the STAI. Zengin et al. (2013) observed 100 subjects in their research and reported a significant reduction in pain (p < 0.05) and anxiety (p < 0.05) scores in the music intervention group. Nilsson (2012) studied 68 patients in an RTC and found less discomfort (p = 0.044.) compared to the subjects in the control group. Nilsson also noted a substantially higher level of positive experiences in the experimental group.

In an RTC of 34 subjects Martindale et al. (2014) reported that the overall state of anxiety significantly decreased over time, F(1,25) = 30.90, p < .001, but the main effect of music was not significant, F(1,25) = 0.612, p = .441. However, the researchers noticed that the patients expressed a definite preference for music. In the RTC completed by DeMarco et al. (2012) 26 patients were observed; 12 participants listened to music preoperatively, and 12 did not. Patients received the music intervention reported 18% (p = 0.002) less anxiety compared to the control group. Ni et al. (2012) studied 172 RTC subjects in an outpatient surgery setting. In that study both groups showed reduced anxiety and improved vital signs compared with baseline values; however, the intervention group reported significantly lower anxiety [mean change: -5.83(SD 0.75) vs-1.72 (SD 0.65), p < 00001] on the STAI compared with the control group (Ni et al., 2012).

Similarly, in an RTC with 68 patients, Martindale et al. (2014) calculated that the Mann-Whitney U-test of that study showed a significant higher level of positive experience in the music group, 9.0 (1.7) compared to the control group, 7.7 (3.0), (p = 0.013). The subjects in the music group also rated less discomfort associated with lying still, 0.8 (0–10), compared to the women in the control group, 2.0 (0–8), (p = 0.044.) (Nilsson, 2012). Correspondingly, in a RTC with 220 subjects Galaal et al. (2011) noticed that music during colposcopies significantly reduced anxiety levels (MD = -4.80, 95% CI: -7.86 to -1.74) and pain experienced during the procedure (MD = -1.71, 95% CI: -2.37 to -1.05) compared to the group not listening to music.

Vachiramon et al. (2013) -- another RTC with 100 subjects -- found after the music intervention that STAI scores for the experimental group dropped by a statistically significant larger margin (9.9 ± 7.4) than in the control group (3.4 ± 2.6) (p < .001). Alternatively, this study measured anxiety levels by the VAS scores also. The findings were consistent with the STAI results; VAS scores dropped by a statistically significant larger margin in the music group (3.2 ± 1.6) than in the control group (0.66 ± 0.73 (p < .001). Moreover, Thompson et al. (2014) studied 137 subjects in an RTC to find a significant difference in change in the anxiety level between the music and the non-music groups (t [122.35] = 3.56, p < .001). On average, scores in the music group decreased by 1.06 (SD = 1.75), and the scores in the non-music group decreased by 0.17 (SD = 1.75). Finally, Choy (2014) qualitatively reported in a literature review that several clinical trials have found that patients’ anxiety was reduced by music.

Physiological Findings: Vital Sings and Hormone Levels

Of the 11 studies, only five researches had measurements of the patients’ vital signs before and after music intervention. Additionally, one study described adrenocorticotropic hormone (ACTH) levels measuring between 50 experimental and 50 control subjects. The findings indicated a substantial reduction in hormone levels (p < 0.05), HR (p < 0.001), respiratory rate (RR) (p < 0.001), and in diastolic blood pressure (DBP) (p < 0.05) in the music intervention group compared to those in the control group (Zengin et al., 2013).

Bradt et al. (2012) analyzed 26 RTC trials to examine the music’s result on HR, DBP and SBP. They found that listening to music had a small effect on heart rate (MD -2.77, 95% CI -4.76 to -0.78, p = 0.006; I2 = 79%). Additionally, Bradt et al. (2012) calculated a pooled estimate of -2.37 mm Hg (95% CI -4.03 to -0.71; 13 studies) for DBP, and this effect was statistically significant (p = 0.005). For SBP the pool estimate indicated no strong evidence of effect for listening to music (MD -4.82, 95% CI -12.13 to 2.49, p = 0.20; I2 = 98%) (Bradt et al., 2012). Ni et al. (2012) observed slightly improved vital signs of the patients compared with baseline measurements for the experimental and the control group for HR [mean change: -5.01(SD 0.79) vs-3.76 (SD 0.0.63), p < 0.216], SBP [mean change: -7.72(SD 1.16) vs-12.89 (SD 0.16), p < 0.002], and DBP [mean change: -4.26(SD 0.87) vs-4.23 (SD 0.78), p < 0.976].

The study by DeMarco et al. (2012) calculated no significant changes in SBP [mean change: -120.00 (SD 14.7) vs-120.3 (SD 17.0) or HR [mean change: -71.9 (SD 13.5) vs-75.2 (SD 7.1), p < 0.216]. Additionally, the study’s authors qualitatively reported that patients awaiting surgery would emotionally benefit from music therapy, which improves patient experience and outcomes (Yingel & Gooding, 2015). Finally, the literature review conducted by Choy (2014) qualitatively stated that the reviewed observational trials were consistent with heart rate variability.

Limitations

This systematic review may not have found all articles related to the topic because some studies may have been unpublished or reported in different languages that have not been translated to English (Bradt et al., 2012; Galaal et al., 2011; Yingel & Gooding, 2015). Additionally, most of the studies carry a high risk of bias because the nature of the intervention does not permit for blinding staff and patients (Bradt et al., 2012; Galaal et al., 2011; Martindale et al., 2014). Moreover, the inconsistencies of the studies related to the music delivery methods, to the type of music, and to the duration of the intervention further limited the studies. Finally, a high variability was observed among the researchers’ evaluation methods, which made comparing results difficult.

Conclusion

Using the Johns Hopkins Evidence-based Nursing Model and Guidelines, the overall strength of evidence in favor of music as an effective intervention for reducing the physiological and psychological stressors experienced by patients undergoing medical procedures in the outpatient setting falls is consistent with the good and consistent evidence category. These results provide support for the implementation of small scale pilot projects to further examine effectiveness in specific practice settings.

Acknowledgments

The Hazel and Hershel Cole Scholarship supported this literature review at the University of South Florida, Doctor of Nurse Practitioner Program, in Tampa, Florida. Additionally, I acknowledge Dr. Melanie Michael and all staff members in the Department of Nursing at University of South Florida, Doctor of Nurse Practitioner Program for assistance with this literature review.

References

Bradt, J., Dielo, C., & Shim, M. (2012). Music interventions for preoperative anxiety. Cochrane Database of Systematic Reviews, 2012(6), 1-84. doi:10.1002/14651858.CD006908.pub2

Choy, Y. (2014). Treatment of acute procedure anxiety in adults. Retrieved from http://www.uptodate.com/contents/treatment-of-acute-procedure-anxiety-in-adults

DeMarco, J., Alexander, J. L., Nehrenz, G., & Gallagher, L. (2012). The benefit of music for the reduction of stress and anxiety in patients undergoing elective cosmetic surgery. Music and Medicine, 4(1), 44-48. doi:10.1177/1943862111424416

Dearholt, S. L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.

Galaal, K., Bryant, A., Deane, K. H., Al-Khaduri, M., & Lopes, A. D. (2011). Interventions for reducing anxiety in women undergoing colposcopy. The Cochrane Database of Systematic Reviews, 2012(12), 1-34. doi:10.1002/14651858.CD006013.pub3/full

Martindale, F., Mickocka-Walus, A. A., Walus, B. P., Keage, H., & Andrews, J. M. (2014). The effects of a designer music intervention on patients’ anxiety, pain, and experience of colonoscopy. Gastroenterology Nursing, 37(5), 338-42. doi:10.1097/SGA.0000000000000066

Ni, C. H., Tsai, W. H., Lee, L. M., Kao, C. C., & Chen, Y. C. (2012). Minimizing preoperative anxiety with music for day surgery patients – A randomized clinical trial. Journal of Clinical Nursing, 21(5-6), 620-625. doi:10.1111/j.1365-2702.2010.03466.x

Nilsson, U. (2012). Effectiveness of music interventions for women with high anxiety during coronary angiographic procedures: A randomized controlled. European Journal of Cardiovascular Nursing, 11(2), 150-153. doi:10.1016/j.ejcnurse.2010.10.006

Roberts, N., Czakowska, Z., Radiotis, G., & Korner, A. (2013). Distress and coping strategies among patients with skin cancer. Journal of Clinical Psychology in Medical Settings, 20(2), 209-214. doi:10.1007/s10880-012-9319-y

Thompson, M., Moe, K., & Perston Lewis, C. (2014). The effects of music on diminishing anxiety among preoperative patients. Journal of Radiology Nursing, 33(4), 199-202. doi:10.1016/j.jradnu.2014.10.0

Vachiramon, V., Sobanko, F. F., Rattanaumpawan, P., & Miller, C. L. (2013). Music reduces patient anxiety during Mohs surgery: An open-label randomized controlled trial. Dermatologic Surgery, 39(2), 298-305. doi:10.1111/dsu.12047

Yingel, O. S., & Gooding, L. F. (2015). A systematic review of music-based interventions for procedural support. Journal of Music Therapy, 52(1), 1-77. doi:10.1093/jmt/thv004

Zengin, S., Kabul, S., Bechet, A., Sarcan, E., Dogan, M., & Cuma, Y. (2013). Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complementally Therapies in Medicine, 21(6), 689-96. doi:10.1016/j.ctim.2013.08.