08. Music as an Alternative

Musical notes
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These simple notes can effect us in great ways

Music is a powerful tool. It is capable of regulating emotion, able to calm, excite and relax a person, but more importantly it can be utilized in medicine. Music can be used as an alternative to anesthetic and anxiety medication. Music, unlike medication, does not contain any harmful side effects. It is also capable of reducing the levels of stress and anxiety of a patient. How this specifically works, has yet to be determined, though there are several theories that have tried to explain this. Different styles of music would also elicit varying degrees of effectiveness[2]. Classical music is far more effective at reducing stress level than heavy metal. Research has been done to identify how effective music is on pre-surgery, during surgery and post-surgery.

Background

Stress is not something rare. It occurs all the time. It effects people's daily lives, due to the many symptoms that are associated to stress. Some of the symptoms include rapid heart rate, depression, and anxiety[1]. Music has always had an effect on people. Be it exhilarating people before a big event, setting the mood for a romantic night, or calming oneself before an important test. There has been research done to show which type of music elicit certain effects. Classical music has been shown to strongly induce a calming effect, while pieces of heavy metal would induce a more aggressive state[2]. Since music has calming capabilities, it lead researchers to study the effectiveness of music on surgical patients. This field of research is far from new, research has been done on this since the late 1980s. Sandra L.Curtis was one of the researchers in the 1980s looking into music's pain relief capabilities, on the terminally ill. Her paper found that indeed, music is effective on patient's perception of pain[3]. This type of research, set the ground work for subsequent studies, that not only looked at terminally ill patients, but also patients that are going into surgery and patients who are in the process of being discharged.

Musical Effects

Physiological Effects

Music causes several physiological changes to occur in patients. Most physiological effect includes reduction in heart rate, lower diastolic and systolic blood pressure, and a overall decrease in activity of the sympathetic nervous system[4]. Music enters through the auditory system and stimulates the limbic system which causes the physiological changes. The auditory system may hold an important component for this process to occur. Nitric oxide (NO) is important in the development of the auditory system, making it a candidate for how music evoke physiological changes[5]. This theory is based on NO being used a both a neurotransmitter and a hormone, that acts on the sympathetic nervous system and relaxes the body.

Psychological Effects

Along side with the physiological changes that music causes, only one major psychological change occurs. Reduction of anxiety is the major effect that is shown when music is used as a treatment. However other changes have also been documented, such as the reduction in depression in breast cancer patients after radical mastectomy[6]. How these changes occur could be accounted to the distraction capability that music has. By being distracted, people tend to perceive anxiety, stress, and pain in a less intense manner[7].

Music as a Treatment

Pretreatment

Music used prior to surgery, aims to reduce the overall anxiety a patient feels before undergoing something that is unknown to them. This allows for a much safer surgery to be performed. State trait anxiety inventory (STAI), heart rate, and blood pressure are the usually measurements taken to determine how stressed a patient is prior to an operation. Through clinical trails, only STAI shows a significant difference when exposed to music. Blood pressure and heart rate stay the same[8]. On the contrary, other studies were able to produce results that included reduction of blood pressure and heart rate in addition to the anti anxiety effects music displays[9]. These differences in results show that music may not work in a simple cause and effect fashion. Some of the effects may only occur in certain patients or they type of operation that is at hand. This really shows that this field needs to be dived into deeper to obtain a more concise and better understanding. Some clinical trails have also included bio-marker such as cortisol, epinephrine, and norepinephrine into their findings. These bio-markers are up-regulated when under stressful conditions. Musical trails aimed to show that music is capable in reducing these bio-markers levels, however results have shown that the bio-marker levels in those who listen to music prior to an operation are no different from the levels from the control group. [10].

During Treatment

Anxiety Test
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Typical visual analogue scale test anxiety (VASA)
source:annals.org/data/Journals/AIM/19936/9FF1.jpeg

Not only has music been used as a pretreatment, it has also been applied to patients under general or localized anesthesia that are undergoing operations, such as cardiovascular surgery and caesarian section. The aim for this type of music intervention is same as for pretreatment, to reduce stress and anxiety of the patients. Females that undergo cesarean sections have shown to have typical anxiety that most patients exhibit. Visual analogue scale for anxiety (VASA) is used to measure their perceived anxiety. At the time of the operation, an average scale value of 6 is perceived by most pregnant females. During the operation, some females were given the option to listen to music of their choice. Shortly after the operation, another VASA test is done, yielding results that strengthens the music capabilities in reducing anxiety. Females who listen to music average a 2 on the VASA test while the control averaged a 3. Other test were done along side this, but showed no significant results[11]. Music has been shown to be effective when patients are under localized anesthesia, but when under general anesthesia, its effectiveness becomes non-existent. This could be contributed to the patients not being able to consciously listen to the music. Most patients under these conditions do not recall hearing music during the operation[12]. Since music does not seem to have an effect on unconscious patients, it does not mean that music is entirely useless in this regard. Some clinical trails have shown that by listening to music before surgery, the amount of anesthesia required can be reduced[13]. This decreases some of the side effects that come along with anesthesia and this could also help those that cannot tolerate standard levels of anesthetic.

Post-treatment

Post-treatment follows what both pretreatment and during treatment accomplishes, which is to reduce anxiety, but in addition to this, post-treatment also aims to reduce patients pain levels and the duration of their stay. After most surgeries, most patients would require morphine to reduce the pain they feel. Since music is capable of distracting people, it could be used to divert patients attention away from their pains. When exposed to music immediately after an operation, perceived pain is significantly lower than compared to those who are not exposed to music. More importantly the amount of opioid, in this case morphine, is considerably lower. Patients in the music group only requires an average of 1.0mg while the control patients require 2.9mg of morphine[14]. This finding benefits females that have undergone cesarean section. These females are not exposed to opioid during the operation due to the side effects it may cause the new born. Music in this case acts similar to pain killers during and shortly after the operation to alleviate the pain. In addition, after the operation, when the female can have opioid, the amount required is lower due to the extended exposure to music[15].

As a Drug

Music has already shown to relieve stress, reduce anxiety, and is an effective pain killer. So how effective would music be as a kind of pseudo drug? In terms of effectiveness as an anti anxiety drug, it could be comparable to the drug midazolam, if not more effective[9]. However when looked in terms of a pain killer, this question won't be answered through any normal clinical trial, since it would be unethical to omit painkiller during surgery. Instead music is tested along side with normal medication. It has already been stated that music reduces the amount of painkillers required after surgery, but prior to surgery music is capable to reduce the amount of anesthetic required to go under. 2.7mg/kg/h of propofol is required to cause ansethesia. When music is applied the amount required is lowered to about 2.2mg/kg/h to achieve the same effect[13]. Even though music cannot be tested by itself, the effects it has on reducing drug consumption is highly important. Since less drugs consumed would lead to lower adverse side effects.

Other

Music can also be utilized in other aspects other than just for surgical use. An example of this would be the use of music in people who suffer from Alzheimer. When music is applied, both a reduction in anxiety and depression is seen[16]. Another use for music that has been put into practice is mood regulation of adolescents. Music down regulates negative emotions and up regulates positive emotion[17]. Finally music has been shown to improve cognition after stroke[18].

Bibliography
1. Smith M., Segal R., Segal J. (2013). Stress Symptoms, Signs and Causes. Retrieved from www.helpguide.org/mental/stress_signs.htm
2. Labbe E., Schmidt N., Babin J., Pharr M. (2007). Coping with Stress: The Effectiveness of Different Types of Music. Appl Psychophysiol Biofeedback, 32:163-168.
3. Sandra L. Curtis. (1986). The Effects of Music on Pain Relief and Relaxation of the Terminally ill. Journal of Music Therapy, 10-24
4. Triller N. et. al. (2006). Music during Bronchoscopic Examination: the Physiological Effects. Respiration, 73:" 95-99
5. Salamon E. et. al. (2003). Sound therapy induced relaxation: down regulating stress processes and pathologies. Med Sci Monit, 9(5): RA116-121
6. Kai-na Z., Xiao-mei L., Hong Y., Shao-nong D., Duo-lao W. (2011). Effects of music therapy on depression and duration of hospital stay of brest cancer patients after radical mastectomy. Chinese Medical Journal, 124(15): 2321-2327
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11. Chang S. C. and Chen C. H. (2005). Effects of Music Therapy on Women;s Physiologic Measures, Anxiety, and Satisfaction During Cesarean Delivery. Research in Nursing & Health, 28, 453-461
12. Migneault B., Girard F., Albert C., Chouinard P., Boudreault D., Provencher D., Todorov A., Ruel M., Girard D. C. (2004). The Effects of Music on the Neurohormonal Stress Response to Surgery Under General Anesthesia. Anesth Analg, 98:527-32
13. Koelsch S., Fuermetz J., Sack., Bauer K., Hohenadel M., Wiegel M., Kaisers U. X., Heinke. (2011). Effects of music listening on cortisol levels and propofol consumption during spinal anesthesia. Frontiers in Psychology, doi: 10.3389/fpsyg.2011.00058
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15. Sen H., Yanarates O., Sizlan A., Kilic E., Ozkan S., Dagli G. (2010). The efficiency and duration of the analgesic effects of musical therapy on postoperative pain. AGRI, 22(4):145-450
16. Guetin S., Portet F., Picot M. C., Pommie C., Messaoudi M., Djabelkir L., Olsen A. L., Cano M. M., Lecourt E., Touchon J. (2009). Effects of Music Therapy on Anxiety and Depression in Patients with Alzheimer's Type Dementia: Randomised, Controlled Study. Dement Geriatr Cogn Disord, 28:36-46
17. Saarikallio S. and Erkkila J. (2007). The role of music in adolescents' mood regulation. Psychology of Music, 35(1): 88-109
18. Sarkamo T., Tervaniemi M., Laitinen S., forsblom A., Soinila S., Mikkonen M., Autti T., Silvennoinen H. M., Erkkila J., Laine M., Peretz I., Hietanen M. (2008). Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain, 131, 866-876

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