The Efficacy of Music Therapy

Judith H. Wakim, EdD, RN, CNE, Stephanie Smith, MSN, CRNA, Cherry Guinn, EdD, RN

Undergoing a procedure that requires anesthesia can be anxiety provok-

ing. Anxiety is associated with increases in heart rate and blood pressure
and other changes that can have a negative impact preoperatively;
during the induction, maintenance, and emergence phases of anesthesia;
and postoperatively. Music therapy is a nonpharmalogical intervention
that has the ability to reduce anxiety levels in some patients. This review
presents research studies that have been conducted on the effects of music
therapy for patients in different clinical settings. In general, the majority
of the published articles reviewed revealed that listening to music was
beneficial to the patient no matter the setting. Offering a music selection
to patients before anesthesia could enhance its positive effect. Peri-
anesthesia nurses could easily develop a protocol for different situations
where patients will be exposed to interventions where the use of general
or local anesthesia is expected.
Keywords: Perianesthesia anxiety, music therapy, nonpharmacological
anxiolytic.
Ó 2010 by American Society of PeriAnesthesia Nurses

ANXIETY IS DIRECTLY RELATED to an uncer-
tainty about a medical or surgical procedure that
will include the use of anesthesia. Information con-
veyed by friends and family, previous negative expe-
riences with anesthesia and surgery, uneasiness in an
unknown environment, and the fear of loss of con-
trol all play a role in increasing anxiety. Anxiety
may also be related to the symptoms of an underlying
disease, the lack of knowledge regarding a diagnosis,
uncertainty of the chain of events to occur, and fear
of unknown or unexpected findings.1 Feelings of
anxiety are unpleasant for the patient. Furthermore,
anxiety may complicate the induction, mainte-
nance, and emergence from anesthesia, placing the
Judith H. Wakim, EdD, RN, CNE, is Professor Emerita, School
of Nursing, The University of Tennessee at Chattanooga,
Chattanooga, TN; Stephanie Smith, MSN, CRNA, is a staff nurse
anesthetist, Anesthesiology Associates, Chattanooga, TN; and
Cherry Guinn, EdD, RN, is Associate Professor, School of Nurs-
ing, The University of Tennessee at Chattanooga, Chattanooga,
TN.
Address correspondence to Judith H. Wakim, The University
of Tennessee at Chattanooga, School of Nursing, Dept. 1051,
615 McCallie Avenue, Chattanooga, TN 37403; e-mail ad-
dress: Judith-Wakim@utc.edu.
Ó 2010 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
doi:10.1016/j.jopan.2010.05.009
patient’s life at risk, especially in more vulnerable
populations. Anesthesia is used not only for surgery,
but also for procedures such as bronchoscopy,
endoscopy, colonoscopy, cystoscopy, lithotripsy,
cardiac catheterization, pacemaker placement,
cesarean section, and vasectomy. When patients en-
ter an OR or procedure room, they rarely ask what
kind of music will be playing while they go to sleep,
have moderate sedation, or try to relax. However,
recent studies have shown that music can actually
calm patients, improve vital signs, and increase pa-
tients’ overall levels of comfort.2-11 Music therapy
is a noninvasive intervention that can be used to
reduce anxiety levels in the patient undergoing
anesthesia.
Anxiety Associated with Anesthesia for
Surgery or Medically Invasive Procedures
Health care professionals are beginning to treat not
only the patient’s medical condition or diagnosis,
but the patient’s state of mind as well. This is very
important in any setting where anesthesia is admin-
istered because most surgical or medically invasive
procedures tend to promote anxiety, worsen the
person’s state of mind, change a patient’s hemody-
namics, and potentially affect outcomes.

226 Journal of PeriAnesthesia Nursing, Vol 25, No 4 (August), 2010: pp 226-232

THE EFFICACY OF MUSIC THERAPY
Anxiety consists of feelings of apprehension and
fear in anticipation of an unknown and unfamiliar
situation. It is more specifically characterized by
subjective, consciously perceived feelings of
threat, nervousness, and tension accompanied by
autonomic nervous system arousal. Behaviors asso-
ciated with anxiety include restlessness, trembling,
shortness of breath, fearful facial expressions, mus-
cular tension, and fatigue.12 Anxiety is not always
transient; it often affects the patient psychologi-
cally and physiologically well into the post-
anesthesia period.13
State-Trait Anxiety Inventory (STAI) scores are fre-
quently used to measure anxiety levels in surgical
patients. State scores measure how the person
feels “right now” and trait scores measure how
the person “generally feels.” In one study, 42 adult
ambulatory surgery patients were alternately
assigned to either a treatment group or a control
group.10 Initial vital signs were recorded and pa-
tients were left alone to complete the STAI. All
patients received routine preoperative teaching.
Each member of the treatment group was given
a choice from 20 tapes (new age, classical, environ-
mental, country-western, or easy-listening) and
a set of headphones. Ten minutes before surgery,
vital signs and STAI tests were repeated. The ex-
perimental group had significant decreases in sys-
tolic and diastolic blood pressure, heart rate,
respiratory rate, and STAI state scores (P , .025
to P , .0005), whereas the control group had sig-
nificant decreases only in systolic blood pressure
(P , .05) and in respiratory rate (P , .025).10 In
another study, a group of 30 patients awaiting gen-
eral anesthesia for a transurethral resection of the
prostate demonstrated lower state and trait scores
(P , .05) after listening to 20 minutes of self-
selected slow, rhythmic music (either Chinese or
Western). The music intervention also significantly
reduced blood pressures (P , .05).14
Seventy-eight healthy undergraduates were ran-
domly divided into four groups that received four
different conditions over a 2-hour period: (1) music
imaging, (2) silent imaging, (3) music listening, and
(4) controls. Groups 1 and 2 received tape-recorded
instructions on relaxation, and were then encour-
aged to picture themselves in a meadow. Music
heard by Group 1 and the music-only Group 3 was
Ravel’s “Introduction and Allegro.” Group 4 read,
studied, or talked quietly for the 2 hours. All
227
participants donated 15 mL of blood before and
after the intervention period for the purpose of
measuring plasma b-endorphin, a neurohormone
released during stressful situations. Those in Group
1 experienced a significant pre-post decrease in
b-endorphin as opposed to the findings from the
other three groups.15 In another study by the same
researchers, 28 adults were randomized into a con-
trol group and a group that participated in a guided
imagery and music experiment for a 13-week inter-
vention period and a 6-week follow-up period.
Blood (15 mL) was drawn before the intervention
and at follow-up to determine cortisol levels. Depres-
sion, fatigue, and mood disturbance were assessed
by paper and pencil scales. The experimental group
had significant decreases in cortisol and in the
measures indicating depression, fatigue, and mood
disturbance.16
Stress response was measured during and after
hernia repair surgery. Seventy-five patients were
randomly assigned to three groups: (1) intraopera-
tive music, (2) postoperative music, and (3)
silence. The same surgeon performed all repairs.
Anesthesia and analgesia followed a standard pro-
tocol. Stress response was measured during and
after surgery using cortisol levels, blood glucose
levels, immunoglobulin A levels (IgA), pain levels,
anxiety, blood pressure (BP), heart rate (HR), and
oxygen saturation. There was a significant differ-
ence in cortisol levels between Group 2 and the
control group. Group 2 also had less anxiety, less
pain, and required significantly less morphine
than the control group. Group 1 reported less
pain than controls. There was no significant differ-
ence among groups in IgA, blood glucose, BP, HR,
and oxygen saturation.17
Studies of neurophysiology and neurobiology of
the musical experience were reviewed in 2006.
The review reported the ability of musical stimuli
to activate specific pathways in several brain areas.
It also addressed several neurochemical studies
that indicated that biochemical mediators may be
active in the musical experience.18
Anesthesia for Different Types of Surgery
or Medically Invasive Procedures
A study conducted on 247 patients who were un-
dergoing routine dental extractions under general
anesthesia confirmed that the majority of patients
228
experienced anxiety preoperatively.19 The re-
searchers developed a patient questionnaire that
addressed the fear of postoperative pain and
sickness, problems waking from anesthesia, intra-
operative awareness, inexperience, embarrassing
moments, anesthesia, and other critical points
that exacerbate patients’ anxiety. Pain associated
with a surgical procedure was found to be the
most common fear among preoperative patients,
whereas waiting to go to the OR was the second
most common concern. The researchers con-
cluded that some of these fears and anxieties could
be alleviated with proper preoperative teaching
and reassurance about anxiolytic premedication
or intervention.19
In a study on the effects of music preoperatively,
Winter and associates found that music decreased
STAI in 31 patients awaiting gynecological proce-
dures from admission to the surgical holding area
until the time of surgery (P , .05). The results of
the study led the researchers to introduce the
music option in conjunction with preoperative
teaching when patients came in for their preadmis-
sion laboratory work.11
Thirty patients who were scheduled to undergo ce-
rebral angiography were randomly assigned to ei-
ther a music or a control group. Their cortisol and
catecholamines, blood pressure, heart rate, and
STAI were measured. The music group chose one
of nine tapes the evening before the angiogram
(international pop, German pop, oldies, medita-
tion, rock, techno, instrumental, classic, and tradi-
tional). State anxiety fell during the angiography
in the music group but was stable in the control
group. The difference, however, was not signifi-
cant. Patients in the music group had a significant
decrease in blood pressure, whereas the control
group showed no change. Cortisol in the music
group remained stable during the procedure, but
it increased in the control group (P 5 .015).
Patients who showed the most anxiety before
surgery seemed to profit the most from music.20
A 2009 study evaluated the responses of four
groups of patients while they were undergoing
coronary angiography and percutaneous coronary
intervention. Sixty females and 61 males listened
to relaxing music and 59 females and 58 males re-
ceived standard care without music. All were eval-
uated before and after their procedures on a 1 to
WAKIM, SMITH, AND GUINN
10 scale for angina, anxiety, and feeling relaxed.
Measures recorded after the procedures included
discomfort from arterial puncture, perception of
environment sound, discomfort from lying still,
dose of anxiolytic, and dose of analgesic. No signif-
icant differences were found between the music
and the control groups or between the genders. In-
vestigators had no trouble providing the music for
both patients and staff. They all liked the music,
but its effectiveness proved questionable.21
A musical therapy program was developed for im-
plementation before a child’s surgery. The program
involved music therapists (MTs), children, and their
families. Its purpose was to decrease the opportu-
nity for anxiety to develop while waiting for sur-
gery. The program not only helped the child and
the family, but also helped the staff carry out its pre-
operative preparation. The children were admitted
to the hospital on the morning of surgery, and 1
hour before surgery they were invited by the MT
to interact in music activities. If the parents agreed,
the MT accompanied the child to the holding area
and continued the music activities. Patients, family,
and staff all reacted positively to the program, but
formal measurement was not attempted.22
A Hong Kong study randomly assigned 64 patients
receiving mechanical ventilation into two groups:
one that had 30 minutes of music intervention and
one that had a 30-minute rest period. Both groups
wore headphones. The music group could select
from Chinese classical, Buddhist or Christian reli-
gious, Western classical, or natural sounds with
slow beats. Six questions from the state scale of
the Chinese STAI were asked of patients before
and after the 30-minute periods. Heart rate, respi-
ratory rate, blood pressure, restlessness, facial dis-
tortion, restfulness, and sleep were also collected
before and after the 30-minute sessions. Patients
who listened to music appeared to be significantly
more relaxed when pretest measurements were
compared with posttest measurements, whereas
the control group showed no significant differ-
ences between pre- and posttest results except
in the C-STAI (P 5 .048).23
Support for Listening to Music, Especially
if Self-Selected, as an Intervention
In a patient with no serious underlying medical
problems, physiological signs such as increased
THE EFFICACY OF MUSIC THERAPY
heart rate, blood pressure, and respiratory rate can
indicate anxiety.3 Awaiting surgery in the preoper-
ative area is anxiety provoking and may be wors-
ened if the patient has to wait longer than
originally planned. One study, conducted with
100 nonorthopedic patients (varicotomy or lar-
yngological) waiting in the preoperative area,
used an individually designed 60-minute music
program for half of the patients. The addition of
music was associated with a decreased heart
rate, blood pressure, and respiratory rate in the
music-listening group as opposed to the group
that was left alone (P , .001).9 Individually com-
posed music plans are of great benefit to the pa-
tient because music preferences vary among
patients.
Fifty-four participants were recruited through ad-
vertisements within a university and paid for their
participation in an experiment to determine
whether there was a difference in their (1) toler-
ance (in seconds) to cold pressor trials; (2) percep-
tion of pain intensity using a visual analog scale
(VAS) and the McGill Pain Questionnaire; and (3)
perceived control over pain using a VAS when
they were alternately exposed to white noise, spe-
cially designed relaxation music, and their own
choice of music. Preferred music resulted in signif-
icantly longer tolerance time than white noise or
designed music. For females, preferred music pro-
duced significantly lower VAS pain intensity scores
than for the other two conditions, whereas there
was no significant difference for male participants.
McGill pain intensity scores produced similar re-
sults. Significantly higher ratings of perceived con-
trol occurred with preferred music compared with
white noise and music designed for relaxing.24
Sixty patients undergoing same-day surgery were
randomly assigned to three groups. Before and dur-
ing surgery one group listened to new age music,
a second listened to a choice of music from four
styles, and the third heard the normal OR sounds.
Plasma levels of cortisol and lymphocytes were
measured before, during, and after surgery. Plasma
levels of cortisol and levels of natural killer lym-
phocytes decreased during operation in both of
the music-listening groups but increased in the
control group. Interestingly, cortisol levels in the
group given new age music were significantly
higher than in those who had a choice of music
(P , .05).25
229
Patients’ reports of anxiety and actual physiologi-
cal signs do not always correlate. One study of
93 patients, 48 who listened to self-selected music
and 45 who did not listen, showed that changes in
physiological signs such as blood pressure, heart
rate, and respiratory rate were not significant af-
ter 30 minutes of music intervention (P 5 0.19).
However, the experimental group of patients con-
tinued to report that anxiety and stress were less-
ened.3 Three groups of 20 patients each were
studied in the PACU, one group with headphones
and no music, one group with headphones listen-
ing to music, and one group with no headphones.
There were no significant differences in pain levels
using the VAS, morphine requests, hemodynamics,
respirations or length of stay in the PACU, but
those who listened to music perceived their
PACU experience as being more pleasant and com-
fortable than did those in the other two groups.13
This difference persisted both one day and one
month later. Other patients in a similar study state-
d that music helped them relax and acted as
a distracter.8 Again, physiological signs were un-
changed but the patients’ perceptions reflected
benefits from listening to music.
Some studies examined the effects of music
throughout the perianesthesia period. One group
of investigators observed an immediate decrease
in physiological signs back to the patient’s baseline
in 20 ambulatory ophthalmic patients who listened
to music played via headphones as compared with
a randomized control group of 20 (P , .01).5
Twenty-nine gynecologic laparoscopy patients
had lower respiratory rates (P , .01), heart rates
(P , .05), blood pressures (P , .05), and a de-
creased need for opioid analgesia (P , .05) before,
during, and after anesthesia was administered
when music therapy was used. The same patients
reported an improved sense of well-being upon
waking in the PACU than did the 26 members of
the control group (P , .05).2
Investigators examined how music affects propofol
and opioid requirements in 34 patients undergoing
urologic procedures and 43 patients undergoing
lithotripsy. Spinal anesthesia allowed the patients
to be awake, so other medication could be given
through a patient-controlled system.7 Approxi-
mately half of each group of patients listened to mu-
sic intraoperatively, whereas the remainder listened
to regular OR noises. Results showed that there
230
was a significant decrease in opioid (P , .001) and
propofol (P , .01) use in the group of patients who
listened to music.7 A separate study analyzed mida-
zolam requirements and music therapy in 50 unpre-
medicated spinal anesthesia patients. The 25
patients who listened to music of their choice intra-
operatively required much less patient-controlled
midazolam than did the patients who did not listen
to music (P , .05).4 However, neither VAS nor STAI
showed significant differences. Because it is most
often patients who cannot tolerate general anesthe-
sia who undergo spinal anesthesia, the authors
hypothesized that using music as an intervention
could prove to be highly beneficial to those patients
who are not stable enough to receive increased
doses of anxiolytics.4
Another investigator analyzed the use of music
through headphones in addition to relaxation tech-
niques in patients undergoing gastroenterological
procedures. Those who listened to music and
practiced relaxation techniques had lower blood
pressures and heart rates throughout the proce-
dure (P , .05).6 It was evident that music com-
bined with relaxation techniques using imagery
and distraction was a beneficial nonpharmacologic
method of reducing anxiety.
One randomized controlled trial of 60 bronchos-
copy patients used pretests and posttests. Baseline
state anxiety scores from the STAI were similar to
those previously reported in other surgical pa-
tients. Trait anxiety scores, flexible fiberoptic
bronchoscopy scores, and other characteristics
were similar in both the treatment and control
groups. Within 1 hour, postprocedure anxiety
was measured by the STAI. Trait anxiety scores de-
creased significantly (P , .001) in both groups, but
state scores showed no statistical or clinical de-
crease in either group, except in six patients
who received intravenous midazolam.1 It should
be noted that patients in the study were not able
to choose their music selection, physiological
signs were not included as part of the study, and
patients were asked to fill out the STAI before
results of the bronchoscopy were shared with
them, ie, when they were still apprehensive about
the outcome of the procedure.
In another randomized controlled trial of 58 pa-
tients who had undergone coronary artery bypass
grafting or aortic valve replacement surgery, on
WAKIM, SMITH, AND GUINN
postoperative day one they were assigned to re-
ceive either 30 minutes of music followed by 30
minutes of uninterrupted bed rest (experimental)
or 60 minutes of bed rest (control). All patients
were tested before, during, and after the 60-minute
interval, determining serum cortisol, heart rate, re-
spiratory rate, mean arterial pressure, arterial oxy-
gen tension, arterial oxygen saturation, and
subjective pain and anxiety levels. After 30 min-
utes, there was a significant difference in cortisol
levels between the music and the control group
(P , .02). However, after 60 minutes, there was
no significant difference between the two groups.
No significant differences were found in the other
measures.26
A 1984 study compared the frequency of use of mu-
sic during childbirth in 54 women who had prac-
ticed labor with music prenatally and others who
knew of the music option but had not rehearsed
with music. Of the 54 patients, only 8 actually
used musicdsome who had rehearsed with music
and others who had not. Many who intended to
use music stated that equipment was not available
and staff did not seem accommodating. When all
54 subjects were questioned, 61% said that they
would consider using music in a subsequent deliv-
ery, but 30% said that they would not and 9%
were neutral.27
A study in 2000 found that music enhanced other
coping strategies used during labor such as imag-
ery, breathing exercises, and distraction.28 How-
ever, in 2001, researchers asked 46 parturients to
rate the effectiveness of 10 nonpharmacological
methods of pain relief. Listed in order, the first
four were breathing techniques, relaxation, acu-
pressure, and massage. Although 96% of the
mothers had been taught prenatally about listen-
ing to music, only six (13%) used it during labor,
whereas a minimum of 23 (50%) used one or
more of the other four techniques.29
Perianesthesia nurses are rarely present for normal
labor and delivery, but they are often there during
cesarean births when regional anesthesia is used
and patient anxiety is high. The effects of listening
to music were studied in 64 married women be-
tween the ages of 20 and 40 whose singleton
pregnancies were at term and who were to have spi-
nal or epidural anesthesia for a cesarean section.
The women were randomly divided into an
THE EFFICACY OF MUSIC THERAPY 231

experimental and a control group. Anxiety was

measured using the VAS. Physiological indices in-
cluded oxygen saturation (SpO2), temperature of
the finger, respiratory rate, pulse rate, and blood
pressure. The experimental group listened to their
individual choices of music for at least 30 minutes
from the start of anesthesia until the end of surgery.
The control group received standard nursing care.
Differences in physiological measures were nonsig-
nificant, but differences in anxiety were significant
(P , .05). The music-listening group reported
greater satisfaction with the cesarean experience
(P , .01).30

Summary
The majority of studies reviewed for this report
demonstrated that music had a positive impact on
both psychological and physical patient outcomes.
No differences were noted in the results obtained
in different clinical settings or in different coun-
tries. In most studies, the treatment groups that
listened to music responded with lower blood pres-
sures, lower respiratory rates, and lower heart
rates. The results from the state and trait portions
of the STAI were lower with the music interven-
tion, indicating that the anxiety patients perceived
was less after listening to music. There were some
studies that did not show significant differences
between the treatment groups and control groups.
In concert, a systematic review of 42 randomized
controlled trials using music interventions in perio-
perative settings led its author to recommend that
Figure 1. Algorithm for initiating music listening
music therapy be used in light of its potential to
as an anxiety-lowering intervention before anesthesia
reduce patient distress.31 for surgery or invasive procedures.

Music should be offered to the patient as a noninva-

sive intervention in a preanesthesia setting in hopes
of reducing the anxiety the patient may be experi-
encing. Allowing the patient to choose his or her
preference for the type of music or even bringing
a portable music device from home will foster a feel-
ing of familiarity and enable the patient to become
part of the treatment plan. Because music does not
appear to have detrimental effects on the patient,
outcomes will either be positive or unchanged.
Music as an intervention is simple and does not re-
quire much time. Practitioners administering this
technique are more likely to establish rapport with
the patient during the initial meeting. Patients appre-
ciate the time and effort that is spent in helping them
deal with threatening procedures. Each phase of an-
esthesia could proceed more smoothly if the overall
anxiety level of the patient was decreased. Peri-
anesthesia nurses might consider initiating a music
protocol (such as is suggested in Fig 1) as a safe
and inexpensive nonpharmacological means of as-
sisting patients to perceive a lower level of anxiety.
232
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