Accepted Manuscript

Title: Music Listening Alleviates Anxiety and Physiological

Responses in Patients Receiving Spinal Anesthesia

Author: <ce:author id="aut0005"

author-id="S0965229916304010-
fb8be26400cee77c953d0f4e8d7d18a7"> Wen-Ping
Lee<ce:author id="aut0010"
author-id="S0965229916304010-
ff306de14107f98866b950121e257cbd"> Pao-Yuan
Wu<ce:author id="aut0015"
author-id="S0965229916304010-
d54cd1125ced89707cea184621c3cbcf"> Meng-Ying
Lee<ce:author id="aut0020"
author-id="S0965229916304010-
79c854b07c24870d9167ae49efdc7e34"> Lun-Hui
Ho<ce:author id="aut0025" author-id="S0965229916304010-
3d70a238dda395dfb225e554ec48b861"> Whei-Mei
Shih

PII: S0965-2299(16)30401-0
DOI: http://dx.doi.org/doi:10.1016/j.ctim.2016.12.006
Reference: YCTIM 1650

To appear in: Complementary Therapies in Medicine

Received date: 3-11-2015

Revised date: 14-6-2016
Accepted date: 19-12-2016

Please cite this article as: Lee Wen-Ping, Wu Pao-Yuan, Lee Meng-Ying, Ho Lun-
Hui, Shih Whei-Mei.Music Listening Alleviates Anxiety and Physiological Responses
in Patients Receiving Spinal Anesthesia.Complementary Therapies in Medicine
http://dx.doi.org/10.1016/j.ctim.2016.12.006

This is a PDF file of an unedited manuscript that has been accepted for publication.
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RUNNING HEAD: MUSIC LISTENING ON PATIENTS OF SPINAL ANESTHESIA

MUSIC LISTENING ALLEVIATES ANXIETY AND PHYSIOLOGICAL RESPONSES

IN PATIENTS RECEIVING SPINAL ANESTHESIA

AUTHOR:

1. Wen-Ping Lee/ Chang Gung Medical Foundation Assistant Head Nurse

2. Pao-Yuan Wu/ Chang Gung Medical Foundation Head Nurse & Hsin Sheng Junior
College of Medical Care and Management, Adjunct Instructor
3. Meng-Ying Lee/ Chang Gung Medical Foundation Supervisor, Department of Nursing
4. Lun-Hui Ho/ Chang Gung Medical Foundation Assistant Director, Department of Nursing
& Chang Gung University of Science and Technology, Adjunct Instructor
5. Whei-Mei Shih/Chang Gung University of Science and Technology, Associate Professor

Corresponding Author: Whei - Mei Shih/Chang Gung University of Science and

Technology, Associate Professor

Corresponding Author e-mail: jeanshih168@frontier.com

1
Summary

Objective: The aim of this study was to explore the effects of listening to music on the

anxiety levels and physiological responses of surgical patients receiving spinal anesthesia.

Methods: An experimental design was used in the study with an experimental group (n=50)

and a control group (n=50). The experimental group received 30 minutes of musical

intervention and routine nursing care in the Post-Anesthesia Care Unit (PACU) while the

control group received only routine nursing care.

Results: The study found significant differences in both anxiety and physiological indices

between the two groups. The mean score of the State-Trait Anxiety Inventory (STAI) in the

study group decreased from a pre-test score of 59.0 to a post-test 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 pre-op values.

Conclusion: Listening to music while in the recovery room may decrease the level of anxiety

in surgical patients receiving spinal anesthesia. The results of this study can serve as a

reference for PACU nurses in utilizing music listening programs to achieve the goal of

holistic care.

Key words: music, listening, anxiety, physiological responses, spinal anesthesia.

INTRODUCTION

In Taiwan, there are over 420,000 patients each year who undergo surgery using anesthesia.1

Most of these operations utilized spinal anesthesia. Anxiety is an emotional human reaction.

It is a vague uneasy feeling of discomfort or dread accompanied by an autonomic response,

or a feeling of apprehension caused by anticipation of danger. It is an alert signal that warns

an individual of impending danger and enables them to take measures to deal with the
2
threat.2,3 Surgery itself causes severe anxiety to the patient and fear of the unknown remains

the major reason for anxiety.4 The fear of surgical failure, the lack of awareness of anesthesia

methodology, the possible risks of anesthesia, and the expected pain during post-operative

recovery all contribute to anxiety.5 Without proper management, these stress responses will

hamper the health and post-operative recovery of patients.6

A review paper on the rate of pre-operative anxiety cites variations from 11% to 80% in adult

patients.7 Spinal anesthesia injects an anesthetic into the spinal fluid through a subarachnoid

injection in order to induce the loss of sensation from waist to toes for anywhere between

four and six hours.8 Throughout the procedure, the patient is fully conscious and breathes on

his/her own. The lack of awareness during the anesthesia procedure, the potential risk, and

the expectation of post-operative pain all contribute to the induction of anxiety and fear.

Research articles revealed that listening to music can effectively reduce both pre-operative

anxiety and post-operative pain.9, 10 Music listen contained delightful beats and melodies to

help individuals who wanted to achieve a peaceful state; the goal being to ease the patient's

discomfort and maintain and promote body and mind health.11

Music consists of pitch, rhythm, and timbre or tone color. It was pointed out that different

types of music had different effects on stress. Listening to classical music was more relaxing

than listening to rock and roll, so it was more suitable for music therapy. However, the effects

of music therapy varied based on one’s personal experience as well as cultural and religious

beliefs.12 Therefore, when nurses provided music therapy, personal preference, familiarity,

and acceptability of patients were considered to avoid eliciting an unpleasant memory or

emotion.10 When individuals listened to their favorite types of music, it increased the

secretion of ß-endorphin, induced pleasant emotions, and resulted in reduced pain.13

High-pitched music elicited stress, while low-pitched, slow-paced, orchestral, harmonious

3
music, and music beats that were similar to a human heartbeat (60 - 80 beat / min) left people

feeling relaxed and had good therapeutic effects when listening for at least 30 minutes.14

Maximum volumes at 60 dB helped to relax and relieve stress.15 Therapeutic environments

were better in quiet and relatively secluded spaces. Music equipment used were mainly

wall-mounted speakers, portable stereos, or mp3 player. The use of headphones enhanced the

focus of a patient on the music and avoided disturbing others nearby.16

A systematic review of 11 research papers concludes that patients receiving musical therapy

show a significantly greater decrease in systolic blood pressure (SBP), diastolic blood

pressure (DBP), and heart rate (HR) compared to those not without musical therapy.17 Studies

show that music can reduce respiration frequency, heart rate, blood pressure, pain, lessen

tension, relieve anxiety, decrease mental perception of horrible thoughts, and increase finger

temperature.9,10,18 Patients left with the sense that overall examination time was shorter.19

Musical therapy is a safe, drug-free treatment that reduces patients' anxiety and pain.20 The

general effectiveness of musical therapy has been supported by many articles, but its effects

on patient anxiety after spinal anesthesia have not yet been addressed. In this study, musical

therapy was found to be effective in reducing tension and guiding the thoughts of a patient

recovering from spinal anesthesia, as well as providing warm feelings.

METHODS

Research design and participants

This is an experimental research design. The sample size was estimated by the G-power

3.010 software with the following selection parameters: power = 0.8; α = 0.05; effect size =

0.3; two-tailed test; estimated total sample size of 84. In considering intention to treat, a total
4
of 100 samples were selected and randomly assigned to either the experimental (n = 50) or

the control (n = 50) group. The inclusion criteria were patients who: (1) were receiving spinal

anesthesia for the first time; (2) were over 20 years of age with no vision or hearing

impairments; (3) were conscious, literate, and able to communicate in Mandarin or Taiwanese;

and (4) had completed and signed the consent form after being thoroughly informed of the

purpose of the study. Patients who could not fill out the inventory themselves were vocally

questioned by the researcher who filled out the inventory on their behalf for consistency. The

exclusion criteria were patients who: (1) received local or general anesthesia; or (2)

experienced changes in condition when they underwent spinal anesthesia or surgery.

Intervention

The purpose of the study was explained and signed consent forms were obtained when

patients arrived in the operating room waiting area. The researcher explained the study

procedure and played 30 seconds of music from six categories of music: nature, piano, harp,

orchestral, jazz, and synthetic. After completion of the pre-operative research questionnaires,

including basic patient information and the STAI, patients were sent to an operating room for

surgery.

After surgery, patients were sent to the PACU for post-operative care. For both groups,

baseline levels of the physiological indices were collected from patients laying down in a

supine position before any potential music intervention. Physiological indices included heart

rate, respiration rate, and blood pressure. For the experimental group, in addition to normal

nursing care, patients listened to soothing music of their choice for 30 minutes, using mp3

player and over-ear headphones to reduce outside interference, at a volume of the patient’s

preference (about 30 dB). Physiological indices were recorded every five minutes, while

STAI was measured again after completion of music listening. For the control group, all the

5
procedures were the same as the experimental group, except they did not receive the music

intervention. Room temperature was controlled at 21-23℃.

Ethical Considerations

This study was approved by the institutional review board (No: 102-2028C) of a medical

center. The researchers disclosed the purpose of the study, the research methods, and other

precautions to the participants and their families prior to their participation. The participants’

rights and privacy were protected throughout the study. Each participant completed a consent

form, and had the right to withdraw from the study at any given time for any given reason.

RESEARCH TOOLS

Demographic data

Demographic data were collected from the patients’ medical records. These included gender,

birth date, marital status, education, religion, and occupation, as well as diagnostics, number

of operations, their surgical site, and their experience with anesthesia.

State-Trait Anxiety Inventory (STAI)

The Chinese version of State-Trait Anxiety Inventory (STAI) was translated from the original

STAI designed by Spielberger.21-22 Each inventory contains 20 questions which are answered

by rating on a scale of one to four. The total score of each inventory ranges from 20 to 80 and

the anxiety level is positively correlated with the score. Scores of 20-39 indicate a low level

of anxiety, 40-59 indicate mid-level anxiety, 60-79 indicate high-level anxiety, and scores of

80 indicate panic status.22 STAI was used in the clinical evaluation and research and is highly

reliable, especially in studying the effects of music intervention on reducing anxiety.4, 11, 23

6
Physiological indices

Physiological indices were recorded using a Philips V26C physiological signal monitor;

indices measured included respiration rate, heart rate, and blood pressure. The Philips V26C

contained four components: processor, monitor, keyboard, and modules. The processor was

the center of this monitoring system. The signals collected from the modules were sent to the

processor for analysis and then presented in the monitor. Heartbeat transmission was in the

range of 30-300 per minute, accuracy was ± 0.5%; respiration range was 1-200 breaths per

minute, systolic blood pressure measuring range was 30-275 mmHg, diastolic blood pressure

measuring range was 10-220 mmHg, and the mean pressure measuring range was between

20-260 mmHg with an accuracy of ± 3 mmHg. Physiological indices were recorded by the

researchers using a self-designed table.

Data analysis

The SPSS 20.0 for Windows software package was used to analyze data. The descriptive

statistical analysis included categorical variable analysis represented as frequency and

percentage, and isometric variable analysis represented as mean and standard deviation. The

inferential statistical analysis included independent t-test and Chi-square test to determine the

presence of significant differences in demographic data among the patients. Paired t-test was

used for evaluating whether there were differences between pre- and post-operation STAI

scores or physiological indices within the experimental group and the control group.

RESULTS

Demographic data

7
Among the 100 participants in this study, there were 51 males and 49 females, with a mean

age of 49.58 ± 14.34 years. There was no significant difference between the two groups in

terms of gender, age, marital status, education, occupation, religion, surgery site, duration of

surgery, or the prior number of general anesthesia use (p > 0.05). Piano music was the

favorite music type amongst participants in both groups with an average of 43%. Ninety one

percent of patients that listened to music found it relaxing (Table 1).

Effects of music listening on anxiety and physiological indices

There was no significant difference when comparing pre-operative anxiety levels between the

experimental group and the control group using the independent sample t-test. The STAI

scores for the experimental group and the control group were 59.00 ± 7.52 and 58.94 ± 5.59

points (t = -0.09, p = .96), and both groups showed moderate anxiety before receiving spinal

anesthesia. Also, there was no significant difference in the physiological indices before

surgery in the experimental group and the control group. Heart rates were 69.02 ± 12.04 beats

/ min and 69.14 ± 12.29 beats / min (t = 0.07, p = .97), respiration rates were 16.18 ± 2.93

breaths / min and 16.12 ± 2.72 breaths / min (t = -0.11, p = .92), systolic blood pressures were

124.42 ± 15.88 mmHg and 130.04 ± 19.94 mmHg (t = 1.56, p = .12), diastolic blood

pressures were 67.48 ± 12.16 mmHg and 69.46 ± 12.62 mmHg (t = 0.80, p = .43) (Table 2).

When applying independent sample t-test to analyze STAI and physiological indices after

music intervention, the STAI scores for the experimental group and the control group were

31.20 ± 4.84 and 58.78 ± 5.49 points (t = 26.65, p <.001), suggesting the music intervention

significantly lowered anxiety when compared to the control group. For physiological indices,

the experimental group and the control group had heart rates that were 66.20 ± 10.67 beats /

min and 68.50 ± 12.88 beats / min (t = 1.97, p = .04), respiration rates that were 15.16 ± 1.17

breaths / min and 16.26 ± 2.56 breaths / min (t = 2.76, p = .01), systolic blood pressures that

8
were 121.96 ± 14.28 mmHg and 129.64 ± 20.14 mmHg (t = 2.20, p = .03), and diastolic

blood pressures that were 63.20 ± 6.78 mmHg and 69.06 ± 12.10 mmHg (t = 2.99, p = .004).

For patients receiving music intervention, all of the variables tested were significantly lower

than those of the control group (Table 3).

Further, paired sample t-test was used to understand the differences between pre-test and

post-test STAI and physiological indices within the same patient group. In the control group,

the difference between pre-test and post-test STAI and physiological indices were: heart rate

0.64 beats / min (t = 1.45, p = .154), respiratory rate -0.14 breaths / min (t = -1.41, p = .164);

systolic blood pressure 0.40 mmHg (t = 1.64, p = .108); diastolic blood pressure 0.40 mmHg

(t = 1.43, p = .159); STAI decline of 0.16 points (t = 1.39, p = .17). These results showed that

without music intervention, but only laying down to rest for 30 minutes the anxiety of

patients receiving spinal anesthesia was not relieved (Table 4).

For the experimental group, the average decline of physiological indices and STAI score were

heart rate 2.82 beats / min (t = 2.61, p = .012); respiration rate 1.02 breaths / min (t = 2.29, p

= .026); systolic blood pressure 2.46 mmHg (t = 2.30, p = .026); diastolic blood pressure 4.28

mmHg (t = 3.02, p = .004); STAI score 27.80 (t = 28.63, p <.001). These results suggest that

music intervention significantly reduced the post-operative anxiety level of patients receiving

spinal anesthesia (Table 4).

DISCUSSION

Music was able to reduce an individual's perception of pain by inducing the release of

endogenous opioid and reducing muscle tension, by interfering with nerve conduction,

thereby reducing the transmission of a pain signal as well as anxiety, helplessness, and

9
powerlessness. 16 Through music listen, anxiety can be alleviated. Therefore, the result of this

study revealed that music intervention reduced anxiety on a patient receiving spinal

anesthesia. This was similar to the study in which music intervention was able to reduce the

anxiety of patients waiting to receive cardiac catheterization. 24 Similar results were also

found in various situations, such as in patients treated with ESWL, 11 patients under

mechanical ventilation, 25 patients with cardiac infarction, 26 and patients receiving spinal

surgery. 27

Music can also reduce physiological responses such as heart rate, respiration rate, and blood

pressure. In this study, the results showed that music intervention could reduce heart rate,

respiration rate, and blood pressure in patients after undergoing surgery with spinal anesthesia.

Similar results were supported by many other references. For examples, music listen was

found to effectively reduce heart rate, respiration, and blood pressure in 60 myocardial

infarction patients. 26 In another study, 213 patients in the PACU were agitated by noise and

had increased post-operative pain and perception of discomfort. Music listen significantly

decreased the post - operative pain, heart rate, and respiration rate. It improved the

satisfaction in the PACU in this same group of patients. 28 In Mok and Wong’s study, there

were significant reduction of heart rate, respiration rate, and blood pressure in 80 patients

with local anesthesia. 29 Buffum et al. analyzed 170 patients undergone angiography with

music listening and found out in reduction of heart rate.30

RESEARCH LIMITATIONS

In this study, heart rate variability (HRV) was not measured due to lack of instrument in

PACU. This will be included in future study to evaluate the autonomous nervous system

modulation as HRV could help to elucidate the reduced heart rate after music listening.
10
Patients only received music intervention after they were moved into the PACU. The study

design did not extend to include music listen during surgery. It is recommended in a future

study to expand the effectiveness of music listen in operating rooms while a patient

undergoes surgery. In addition, it is proposed to include a music listen training course in

on-the-job training and at conferences to expose more clinical nurses to the application of

music therapy and to incorporate it in nursing practices, expanding the roles and functions of

nurses, thereby improving quality of care.

RELEVANCE TO CLINICAL PRACTICE

Spinal anesthesia surgery occurs every day in operating rooms. Nurses taking care of these

patients have to face a patient’s anxiety of surgery. Therefore, it is important to provide good

care such as music listen to sooth a patient’s anxiety and to promote quality of care.

CONCLUSION

In conclusion, patients that had lain down for 30 minutes but did not receive music

intervention after spinal anesthesia showed no difference in physiological and STAI scores,

suggesting that to just lay down was insufficient to relieve anxiety. Instead, receiving music

intervention for 30 minutes was sufficient to reduce the anxiety for patients after spinal

anesthesia as indicated by the reduced heart rate, respiration rate, systolic blood pressure,

diastolic blood pressure, and STAI score.

The source of funding for the study. Special thanks to the head nurse and nurse colleagues
in PACU of Chang Gung Medical Foundation at Linkou branch for their assistance. This
research was supported by 2013 Chang Gung medical research grant (grant number:
CMRPG3C1071).

11
CONFLICT OF INTEREST

The authors declared no potential conflicts of interests with respect to the authorship and/or

publication of this article.

ACKNOWLEDGEMENTS

Special thanks to the head nurse and nurse colleagues in PACU of Chang Gung Medical

Foundation at Linkou branch for their assistance. This research was supported by 2013 Chang

Gung medical research grant (grant number: CMRPG3C1071).

12
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16
 TABLE
Table 1. Demographic data between the two groups (n = 100)

Experimental group (n=50) Control group (n=50)

Variables t /χ2 p
n(%) Mean±SD n(%) Mean±SD
Gender 0.36 0.55
Male 24(48.0%) 27(54.0%)
Female 26(52.0%) 23(46.0%)
Age 47.8±14.55 51.36±14.04 1.25 0.22
Marital status 2.25 0.15
Single 11(22.0%) 6(12.0%)
Married 37(74.0%) 43(86.0%)
Divorced 2(4.0%) 1(2.0%)
Education level 1.49 0.48
Primary 9(18.0%) 12(24.0%)
Junior High 7(14.0%) 6(12.0%)
Senior High 15(30.0%) 17(34.0%)
2 year college 7(14.0%) 4(8.0%)
College 12(24.0%) 11(22.0%)
Occupation 7.03 0.61
Unemployed 21(42.0%) 20(40.0%)
Employed 29(58.0%) 30(60.0%)
Religion 1.96 0.92
Atheist 20(40.0%) 22(44.0%)
Theist 30(60.0%) 28(56.0%)
Surgery type 9.16 0.25
Rectal surgery 7(14.0%) 2(4.0%)
Urological surgery 20(40.0%) 29(58.0%)
Orthopedic surgery 8(16.0%) 12(24.0%)
Trauma surgery 7(14.0%) 5(10.0%)
Gynecological surgery 8(16.0%) 2(4.0%)
Operative time(min) 85.58±36.46 84±36.62 0.35 0.82
Record of general anesthesia 2.01 0.74
0 34(68.0%) 30(60.0%)
1 14(28.0%) 19(38.0%)
2 1(2.0%) 1(2.0%)
≧3 1(2.0%) 0(0%)
Using music for relaxation 0.34 0.56
17
 Experimental group (n=50) Control group (n=50)
Variables t /χ2 p
n(%) Mean±SD n(%) Mean±SD
No 5(10.0%) 4(8.0%)
Yes 45(90.0%) 46(92.0%)
Music genre selected 6.49 0.09
Nature music 17(34.0%) 16(32.0%)
Piano music 24(48.0%) 19(38.0%)
Harp music 0(0.0%) 5(10.0%)
Orchestral music 1(2.0%) 1(2.0%)
Jazz music 4(8.0%) 3(6.0%)
Synthetic Music 4(8.0%) 6(12.0%)

18
Table 2. Comparison of pre-test STAI and physiological indices (n=100)

Experimental Group Control Group

Variables t
(n=50) (n=50)

STAI score 59±7.52 58.94±5.59 -0.09

Heart rate 69.02±12.04 69.14±12.29 0.07

Respiration rate 16.18±2.93 16.12±2.72 -0.11

SBP 124.42±15.88 130.04±19.94 1.56

DBP 67.48±12.16 69.46±12.62 0.80

Note: SBP, systolic blood pressure; DBP, diastolic blood pressure.

* Significant at the p < .05 level

** Significant at the p < .01 level

*** Significant at the p < .001 level

Table 3. The comparison of post-test STAI and physiological indices between experimental

and control group (n=100)

Experimental Group Control Group

Variables t
(n=50) (n=50)

STAI score 31.20±4.84 58.78±5.49 26.65***

Heart rate 66.20±10.67 68.50±12.88 1.97*

Respiration rate 15.16±1.17 16.26±2.56 2.76*

SBP 121.96±14.28 129.64±20.14 2.20*

DBP 63.20±6.78 69.06±12.10 2.99**

Note: SBP, systolic blood pressure; DBP, diastolic blood pressure.

* Significant at the p < .05 level

** Significant at the p < .01 level

*** Significant at the p < .001 level

19
Table 4. The comparison between pre-test and post-test STAI and physiological indices in

experimental group and control group using paired sample t test (n=100)

Variables Experimental Group Control Group within

(n=50) (n=50) ta tb

STAI score 28.63*** 1.39

Pre 59±7.52 58.94±5.59

Post 31.20±4.84 58.78±5.49

Heart rate 2.61 * 1.45

Pre 69.02±12.04 69.14±12.29

Post 66.20±10.67 68.50±12.88

Respiration rate 2.29* -1.41

Pre 16.18±2.93 16.12±2.72

Post 15.16±1.17 16.26±2.56

SBP 2.30* 1.64

Pre 124.42±15.88 130.04±19.94

Post 121.96±14.28 129.64±20.14

DBP 3.02** 1.43

Pre 67.48±12.16 58.94±5.59

Post 63.20±6.78 69.06±12.10

Note: SBP, systolic blood pressure；DBP, diastolic blood pressure

a: paired sample t test for the experimental group.

b: paired sample t test for the control group

* Significant at the p < .05 level

** Significant at the p < .01 level

*** Significant at the p < .001 level

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