Role of Music in the Perioperative SettingBy Veena Graff, MD, MS Jun 21, 2017
Veena Graff, MD, MS
Section Editor: Melanie Donnelly, MD
Patients often feel anxious during their planned surgical procedure and anesthetic with apprehensions about their overall outcome and postoperative pain control.1,2 These feelings can adversely affect their perioperative experience, elevate their stress markers, cause various fluctuations in their hemodynamics, and could negatively impact their postoperative recovery.3 Pharmacologic agents such as short-acting benzodiazepines and opioids are commonly used to ease patients’ anxiety and pain perioperatively. However, patients can have significant side effects, which may limit the use of these medications and, in some instances, prevent their use. Therefore, music can be a very desirable non-pharmacologic alternative that is relatively cheap, with virtually no side effects.
Music Medicine vs Music Therapy
There is a distinction between two terms that are commonly misused: “music medicine” and “music therapy.” Music medicine is defined as the passive listening of prerecorded music which may be offered by medical personnel. Headphones are commonly used when listening to music, and it may involve patient choice when selecting the type of music. In contrast, music therapy involves the “clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.”4,5 Therefore, when referring to patients listening to music via headphones in the perioperative period, music medicine is the correct terminology to be used. It is also important to clarify that when referring to music medicine in the perioperative setting, this does not refer to music being played out loud in the operating room theater.
What role can music play in the perioperative setting?
Music is a safe, non-invasive adjuvant that can positively complement the overall perioperative experience for a patient during one of the most important, sometimes life-changing, stressful periods in his or her life. In the last few decades, numerous studies have been conducted to show that passively listening to music via headphones can be beneficial throughout each phase of the perioperative setting.
In the preoperative setting, it can be used either as an adjuvant or replace anxiolytics.3,6-8 This can be beneficial especially in patients who may be very sensitive to intravenous anxiolytics and for patients who do not report a significant amount of anxiety.
In the intraoperative setting, it can be highly desirable while undergoing conscious sedation and/or regional anesthesia by reducing a patient’s overall medication consumption for sedation and/or analgesia and improving a patient’s comfort and satisfaction.9-14 For example, a common reason that patients may refuse regional anesthetics is simply because they do not want to “hear” their surroundings.15,16 Therefore, the anesthesia provider may administer deep sedation in conjunction with the regional anesthetic or the patient may refuse regional anesthetics entirely, which is listed as one of the absolute contraindications. As a result, these decisions may unfortunately lead to unnecessary use of deep sedation or general anesthetics when regional anesthetics are suitable or safer to conduct. In scenarios like this, a simple solution to minimize a patient’s fear of hearing their surroundings would be to place a pair of headphones and allow the patient to listen to music during the intraoperative setting.
During general anesthesia, limited studies have shown any reduction or changes in inhalational or IV anesthetics when listening to music.17-20 Both explicit and implicit memory of auditory stimuli is highly unlikely especially when minimum alveolar concentration levels exceed 0.5, which could explain why the anesthetic depth may not change. However, auditory signals are quite resistant to both intravenous and inhalational anesthetics; therefore, there is a potential that auditory stimuli can alter the neurocognitive responses to surgery.20 Nevertheless, music can still be beneficial during the induction and emergence periods by keeping the patient relaxed and preventing him or her from listening to ambient noise and conversations that may be recalled due to these lighter states of anesthetic periods.
Finally, listening to music in the postoperative period can reduce acute medication consumption, help relax patients, and improve overall satisfaction. It can be beneficial in the immediate postoperative period and in subsequent days (Figure 1). 21-24
Figure 1. Listening to music in the postoperative period can reduce acute medication consumption, help relax patients, and improve overall satisfaction.
What type of music should patients listen to?
Patients can choose their musical preference when music medicine is involved. However, there are certain genres of music and characteristics within music that are known to be relaxing. These genres include classical, smooth jazz, and music with soothing sounds. The characteristics that are common to relaxing music are non-lyrical, tempo ranges of 60-80 beats per minute, and non-percussive sounds without too many fluctuations in the melody. Binaural beat infused music is another recommended style of music that is known to be soothing and relaxing.4,25
What are binaural beats?
Binaural beats are developed when two different tones are played at the same time through both ears. The difference in the frequencies from these tones form a rhythm produced within the brain and can produce a particular electroencephalography (EEG)-associated state.25 For example, if there is a tone playing at 410 Hz in the right ear and another tone playing at 400 Hz in the left ear, the difference of the two tones are 10 Hz and can simulate an alpha-wave EEG pattern, a waveform known to occur in the relaxed state. There are numerous styles of binaural beat infused music options that can simulate the alpha, theta, and delta EEG waveforms and can be found on common music applications.
How can you incorporate music into your perioperative practice?
With the advancement in technology today, an individual can easily listen to music and access a variety of musical genres. As of 2015, approximately 89% of adult users in the U.S. use the internet at least occasionally and 72% report owning a smartphone.26 Of those who own smartphones, approximately 67% report listening to an online radio or music service; 87% of these individuals are 18-29 years of age, 74% are 30-49 years of age, and 41% are 50+ years of age.27 Therefore, the implementation of allowing patients to listen to music throughout the perioperative period could potentially be easier to adopt in a hospital setting by allowing patients to bring in their own media devices and headphones to listen to music. This project was implemented at the University of Vermont Medical Center in 2015. To learn more about this project, see an interview conducted by Vermont’s WCAX TV here: http://www.wcax.com/story/30719516/using-songs-to-help-surgery-patients-relax.
A news article from the University of Vermont Robert Larner College of Medicine is posted here: http://www.uvm.edu/medicine/?Page=news&storyID=21920&category=spot1
Another alternative is to offer Wi-Fi capable media player devices with headphones during the perioperative period. This can be an option for patients who do not own smartphone devices, media players, or headphones and for institutions that have strict policies that do not allow patients to bring in their personal belongings into the perioperative area.
Music is a safe, non-pharmacologic option to enhance a patient’s perioperative experience. It can be used as an adjunct to minimize or replace medications in certain points of the perioperative period. Allowing patients to listen to music via headphones throughout the perioperative setting gives them a sense of autonomy in a vulnerable period in their life and can be a simple, relatively cheap solution to incorporate in a perioperative practice.
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- American Music Therapy Association. Definitions and quotes about music therapy. Available at: http://www.musictherapy.org/about/quotes. Accessed January 3, 2017.
- Bringman H, Giesecke K, Thorne A, Bringman S. Relaxing music as pre-medication before surgery: A randomised controlled trial. Acta anaesthesiol Scand. 2009;53:759-64.
- Lee KC, Chao YH, Yiin JJ, Hsieh HY, Dai WJ, Chao YF. Evidence that music listening reduces preoperative patients' anxiety. Biol Res Nurs.2012;14:78-84.
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- Ayoub CM, Rizk LB, Yaacoub CI, Gaal D, Kain ZN. Music and ambient operating room noise in patients undergoing spinal anesthesia. Anesth Analg. 2005;100:1316-9, table of contents.
- Koelsch S, Fuermetz J, Sack U et al. Effects of music listening on cortisol levels and propofol consumption during spinal anesthesia. Front Psychol. 2011;2:58.
- Lepage C, Drolet P, Girard M, Grenier Y, DeGagne R. Music decreases sedative requirements during spinal anesthesia. Anesth Analg. 2001;93:912-6.
- Newman A, Boyd C, Meyers D, Bonanno L. Implementation of music as an anesthetic adjunct during monitored anesthesia care. J Perianesth Nurs.2010;25:387-91.
- Nilsson U, Unosson M, Rawal N. Stress reduction and analgesia in patients exposed to calming music postoperatively: A randomized controlled trial. Eur J Anaesthesiol.2005;22:96-102.
- Ottaviani S, Bernard JL, Bardin T, Richette P. Effect of music on anxiety and pain during joint lavage for knee osteoarthritis. Clin Rheumatol. 2012;31:531-4.
- Gajraj NM, Sharma SK, Souter AJ, Pole Y, Sidawi JE. A survey of obstetric patients who refuse regional anaesthesia. Anaesthesia. 1995;50:740-1.
- Rhee WJ, Chung CJ, Lim YH, Lee KH, Lee SC. Factors in patient dissatisfaction and refusal regarding spinal anesthesia. Korean J Anesthesiol. 2010;59:260-4.
- Nilsson U, Rawal N, Unestahl LE, Zetterberg C, Unosson M. Improved recovery after music and therapeutic suggestions during general anaesthesia: A double-blind randomised controlled trial. Acta anaesthesiol Scand. 2001;45:812-7.
- Nilsson U, Rawal N, Unosson M. A comparison of intra-operative or postoperative exposure to music--a controlled trial of the effects on postoperative pain. Anaesthesia. 2003;58:699-703.
- Tsuchiya M, Asada A, Ryo K et al. Relaxing intraoperative natural sound blunts haemodynamic change at the emergence from propofol general anaesthesia and increases the acceptability of anaesthesia to the patient. Acta anaesthesiol Scand. 2003;47:939-43.
- Szmuk P, Aroyo N, Ezri T, Muzikant G, Weisenberg M, Sessler DI. Listening to music during anesthesia does not reduce the sevoflurane concentration needed to maintain a constant bispectral index. Anesth Analg. 2008;107:77-80.
- Ebneshahidi A, Mohseni M. The effect of patient-selected music on early postoperative pain, anxiety, and hemodynamic profile in cesarean section surgery. J Altern Complement Med. 2008;14:827-31.
- Nilsson U, Rawal N, Enqvist B, Unosson M. Analgesia following music and therapeutic suggestions in the pacu in ambulatory surgery; a randomized controlled trial. Acta anaesthesiol Scand. 2003;47:278-83.
- Vaajoki A, Pietila AM, Kankkunen P, Vehvilainen-Julkunen K. Effects of listening to music on pain intensity and pain distress after surgery: An intervention. J Clin Nurs. 2012;21:708-17.
- Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: A systematic review and meta-analysis. Lancet. 2015;386:1659-71.
- Padmanabhan R, Hildreth AJ, Laws D. A prospective, randomised, controlled study examining binaural beat audio and pre-operative anxiety in patients undergoing general anaesthesia for day case surgery. Anaesthesia. 2005;60:874-7.
- Pew Research Center. Smartphone ownership and internet usage continues to climb in emerging economies. Available at: http://www.pewglobal.org/2016/02/22/smartphone-ownership-and-internet-usage-continues-to-climb-in-emerging-economies/. Accessed October 5, 2016.
- Pew Research Center. More Americans using smartphones for getting directions, streaming tv. Available at: http://www.pewresearch.org/fact-tank/2016/01/29/us-smartphone-use/. Accessed October 5, 2016.
Veena Graff, MD, MS, is an assistant professor of Anesthesiology and Critical Care in the Department of Anesthesiology and Critical Care at the University of Pennsylvania Perelman School of Medicine, University of Pennsylvania Health System, in Philadelphia, PA.
Note: This article originally appeared in the ASRA News, Volume 17, Issue 2, pp. 27-29 (May 2017).