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Normalization of Hypertensive Responses During Ambulatory Surgical Stress by Perioperative Music

From the State University of New York at Buffalo and Kaleida Health System, Buffalo, New York.

Address reprint requests to: Karen Allen, PhD, Division of Clinical Pharmacology, Department of Medicine, State University of New York at Buffalo, Millard Fillmore Hospital, 3 Gates Circle, Buffalo, NY 14209. Email: kallen{at}mfhs.edu

	ABSTRACT

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OBJECTIVE: The purpose of this study was to determine whether cognitive appraisals of stress level and hypertensive responses to ambulatory ophthalmic surgery can be ameliorated by patient-selected music.

METHODS: We studied 40 elderly individuals requiring ophthalmic surgery, 20 in an experimental group (mean age, 74 years) and 20 in a control group (mean age, 77 years). All patients had an established resting blood pressure <140/90 mm Hg. In the experimental group self-selected music was provided by headphones throughout the preoperative, surgical, and postoperative periods. In the control group patients had neither headphones nor music. All patients received similar (weight-determined) doses of alfentanil and midazolam during surgery. Heart rate, blood pressure, and patient-reported stress and coping levels were the dependent variables.

RESULTS: In both groups, blood pressure values were normal (approximately 129/82 mm Hg) during screening examinations 1 week before surgery. On the day of surgery both groups displayed increased preoperative blood pressures (approximately 159/92 mm Hg) associated with increases in heart rate (by approximately 17 beats/min). Intraoperative blood pressures in the experimental group returned quickly to screening baseline values, whereas the control group experienced persistent elevations in intraoperative blood pressure similar to preoperative levels. Over the course of the surgical experience, patients with music reported significant reductions in perceived stress and increases in coping abilities (p < .001), whereas those without music did not.

CONCLUSIONS: The perceived stress of ambulatory surgery in geriatric patients is associated with a clinical hypertensive response that is ameliorated by self-selected perioperative music, which also decreases perceived stress and increases patients’ sense of personal control and well-being.

Key Words: blood pressure • surgery • music • cognitive appraisal.

Abbreviations: ANOVA = analysis of variance; BP = blood pressure; DBP = diastolic blood pressure; HR = heart rate; SBP = systolic blood pressure.

	INTRODUCTION

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In recent years researchers interested in the relationship between music and health have produced numerous reports about the anxiolytic effects of music in the literature of music, medicine, and psychology. Unfortunately, however, to date few such studies have included sufficiently rigorous methodologies or adequate sample sizes, and physiological responses to music have been inconsistently demonstrated (1). For example, although some recent investigations have demonstrated the positive role of music in controlling patient-reported pain or anxiety associated with medical and dental procedures (2–9), other studies have reported either no effects or a wide range of findings related to emotional and physiological responses (10–15). In addition, although positive hormonal or cardiovascular effects of music before or during surgery have been found (16–20), other studies have demonstrated positive emotional responses but no physiological influence of music in the pre- and postoperative periods (21, 22).

Although recent investigations have contributed to a greater understanding of the medical environments in which music may play a positive role, there exists a division in these studies regarding the type of music that should be offered to patients. Some researchers focus on demonstrations of how specific types of music will elicit specific responses. These individuals design their studies based on the premise that sedative music, characterized by harmony and predictable rhythm, will consistently evoke lowered autonomic response. Other investigators, rejecting the notion that one piece of music will elicit similar responses across a population, design their research based on the importance of individual cognitive perception of music. A recent study focused on surgeons’ cardiovascular responses to music (23) provides support for the importance of cognitive perception. This study demonstrates that familiarity with and control over selection of music are much better predictors of physiological response than music labeled as sedative.

Our study extends previous findings related to choice and control of music to a specific ambulatory surgery population. In our previous related study (23), participants performed stressful tasks while listening to self-selected music as well as experimenter-selected music. We found that control over choice of music elicited very low reactivity, whereas listening to the experimenter’s choice resulted in large increases in reactivity. Consequently, in the study reported here we focused on the importance of participants’ choice and did not include an experimental condition with music selected by the experimenter. We chose to study elderly patients undergoing ambulatory ophthalmic surgery for a variety of reasons. First, we were interested in designing a practical study with potential for improving health care and patient satisfaction at our institution. Second, we were curious about the degree to which patients would describe ambulatory surgery as stressful. From informal conversations with patients scheduled for ambulatory surgery, we learned that there is a high level of stress and anxiety associated with, as patients called it, "revolving door" surgery. Patients were ambivalent about the safety of such surgery. That is, they liked the idea of going home immediately but suspected that their hasty departure had a great deal to do with health insurance payment limits. In addition, to our knowledge, elderly individuals have never been the focus of research about physiology and music, and we were interested in increasing understanding of the potential benefits of music to a broader patient population. Finally, we were interested in extending our work with music to a nonlaboratory, clinically based setting.

	Hypotheses

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The current study had two major experimental objectives. First, we were concerned with the degree to which patient-selected music could affect BP and HR responses to the moderately stressful experience of ambulatory ophthalmic surgery. We hypothesized that relative to those without music, patients offered music would have lower BP and HR readings. Second, we were interested in the degree to which music could influence a patient’s cognitive appraisal of stress related to surgery, and we hypothesized that patients offered music would perceive surgery as less stressful than would those without music.

	METHODS

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Participants
Participants were 40 ambulatory surgical patients who were sequentially selected from the patient rosters of two ophthalmic surgeons. Office assistants unaware of the study prepared patient rosters. On each day of data collection surgeons were randomly assigned to have their patients in the experimental or control group. Patients were then approached in the waiting room and asked to participate in the study. All patients agreed to be in the study and provided informed consent. With the exception of two patients who had surgery for glaucoma, all participants had surgery for the removal of cataracts. The experimental group included 15 women and 5 men ranging in age from 51 to 87 years with a mean age of 74. In the control group there were also 15 women and five men, and ages ranged from 64 to 88 with a mean age of 77.

Twenty-one study participants had drug-controlled essential hypertension, 10 in the experimental group and 11 in the control group. Drug therapy was not discontinued on the day of surgery and included the following: ß-blocker (two patients in the experimental group and two in the control group), calcium channel blocker (two patients in the experimental group and one in the control group), angiotensin-converting enzyme inhibitor (two patients in the experimental group and two in the control group), angiotensin-converting enzyme inhibitor combined with diuretic (two patients in the experimental group and three in the control group), and diuretic (two patients in the experimental group and three in the control group).

Study Protocol
One week before surgery all participants had a screening presurgical physical examination that included (supine) SBP, DBP, and HR, thus providing a presurgical baseline for our dependent measures. On the morning of surgery patients entered the preoperative room, where a Propaq Monitor (Protocol Systems, Inc., Beaverton, OR) was attached to each participant. Two baseline readings were taken for SBP, DBP, and HR. The monitor was then set to record and store SBP, DBP, and HR every 5 minutes during 1) the preoperative period, 2) surgery, and 3) the postoperative period. Two drugs commonly used in ambulatory ophthalmic surgery, midazolam hydrochloride and alfentanil hydrochloride, were administered to all patients according to standard procedures for corneal surgery. Drug administration, by a nurse anesthetist, was begun in the preoperative phase directly before the patient was taken into surgery. In the preoperative phase the first two authors (K.A., L.H.G.) introduced themselves as a psychologist and a cardiologist, respectively. Special care was taken to give equal amounts of attention to both the experimental and control groups and to engage all participants in similar pleasant conversation. We told patients in both groups that we would meet them again immediately after their surgery. After answering cognitive appraisal questions about perceived stress and coping, participants in the experimental group (N = 20) were provided with stereo headphones, a cassette player, and a choice of 22 types of music. Music tapes were provided by a commercial cable music company, and the range of selections included such types as soft hits, classical guitar, chamber music, folk music, and popular singers from the 1940s and 1950s. After choosing a type of music, participants in the experimental group were left to rest quietly with the music playing. Control group participants (N = 20) also answered questions about stress and coping and then were left to rest quietly with neither music nor headphones.

Cognitive Appraisal
During the preoperative period all participants were asked to respond using a seven-point Likert-type scale to the following questions: "How stressful do you think surgery will be for you?" and "How well do you think you will be able to cope with surgery?" In the postoperative period patients were asked "How stressful did you find surgery?" and "How well do you think you were able to cope with surgery?" This form of assessing perceived stress and coping levels has been used successfully in laboratory studies (24, 25) and provides a way of assessing patterns of threat and challenge responses to psychological stress. In this assessment, if self-reported stress levels are greater than coping resources, people are considered to be "threatened." Conversely, if coping resources equal or exceed stress levels, individuals are considered "challenged." In the surgical setting we considered patients’ cognitive appraisals as reflecting feelings of apprehension or ease rather than patterns of threat or challenge.

Data Analysis
Physiological data.
The major analytical method was a repeated-measures ANOVA over five time periods: 1) 1 week before surgery, 2) entry to the presurgical area, 3) during rest before surgery, 4) during surgery, and 5) immediately after surgery. Between-subjects sources of variation factors were experimental condition (music, no music) and surgeon (two surgeons participated). Within-subject factors were time period (times 1–5 as defined above), time by condition, time by surgeon, and time by condition by surgeon. Averages of the last three recorded measures within each time period were used for comparison in these analyses. Type of music was not included as a factor because no more than three individuals selected the same type of music.

Duration in stages of surgical day data.
Because we had no control over the amount of time patients spent in the preoperative area, surgery, or the postoperative area, we performed an independent samples t test to determine if the music group differed from the nonmusic group in the time spent in each area.

Self-reported data.
Nonparametric one-way ANOVAs (Kruskal-Wallis test) (26) were performed to compare preoperative and postoperative patient assessments of stress and coping by experimental condition.

	RESULTS

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Duration in Stages of Surgical Day Data
No significant differences were found between the groups related to the time they spent in the four stages of the surgical day.

Physiological Data
Table 1 illustrates group means over the five data collection points for HR, SBP, and DBP. At 1 week before surgery and at the beginning of the day of surgery, no significant hemodynamic differences were found between the experimental and control groups. Significant differences between the two groups were found, however, at all subsequent periods of observation. It is interesting to note that when the experimental group was provided with music, the diminished physiological effects occurred within 5 minutes. As an indication of the degree of response in the experimental group, Table 1 shows that during surgery, only the patients who were provided with music had HR and BP values similar to their screening values 1 week before surgery. Table 2 includes results of the repeated-measures ANOVA and illustrates that experimental condition was a main effect but that surgeon was not a significant factor. In addition, although the interaction of time by condition was a significant factor, interaction of time by surgeon and time by surgeon by condition were not.

View larger version (41K): [in this window] [in a new window]   Fig. 1. Main effect of experimental condition by postoperative assessments of stress and coping.

	DISCUSSION

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The findings in this study are consistent with earlier work by Updike and Charles (19), who studied a group of 10 patients in plastic surgery. In Updike and Charles’ investigation, patients served as their own controls, and both SBP and DBP were reduced significantly after listening to the music of their choice. Our study extends these findings through the use of a control group and several data collection points throughout the surgical experience. Although the patients in both our study and that of Updike and Charles experienced significant reductions in BP after exposure to music, the magnitude of change in the two studies differed. Relative to before surgery, after surgery with music the patients in the Updike and Charles investigation had mean reductions of 7 mm Hg in SBP and 5 mm Hg in DBP. Among our patients the mean reductions from surgery day baseline to the postoperative period were much greater, ie, 35 mm Hg in SBP and 24 mm Hg in DBP. In addition to reductions of greater magnitude, however, our patients also had much higher blood pressures at the beginning of the surgery day relative to those in the Updike and Charles study (mean pressures of 158/92 mm Hg in our study compared with 116/80 mm Hg in the Updike and Charles study). We interpret our findings to suggest that especially when individuals have highly elevated BPs related to stress associated with the anticipation of surgery, music can have a highly beneficial effect.

Several findings in this study have potential clinical significance. One week before surgery all patients had BPs in the normotensive range, yet during the preoperative period on the day of surgery BP and HR were significantly elevated (159/92 mm Hg on average) for all participants. This hypertensive response occurred despite the fact that approximately one-third of the patients had drug-controlled essential hypertension.

We believe that patients’ self-reports about stress and coping are especially interesting and have implications for patient care. Before surgery these responses were similar across experimental and control groups and suggest that ambulatory surgery is a stressful experience for elderly patients, as was confirmed during postoperative conversations with the patients. After experiencing surgery, patients spoke at great length about specific surgery-related fears and commented that other medical personnel had not talked to them about their apprehensions. Rather the emphasis had been on how routine and safe the procedure had become. Our findings suggest that elderly people approach any medical procedure with apprehension and that special attention should be paid to alleviating their fears.

The overall response to our music intervention also has clinical implications. In the control group, 19 of 20 participants had sustained BP elevations greater than 140/90 mm Hg before or during surgery, whereas none of the experimental group participants had BP greater than 140/90 after music was provided. This suggests that when the stress of surgery elevates BP to hypertensive levels, perioperative music can normalize these hypertensive stress responses. Especially interesting is that the effect was found regardless of the type of music chosen.

The psychophysiological mechanisms by which music can influence stress-related increases in BP and HR are not fully known, but participants in this and past studies have offered clues. For example, in a recent study involving music as a moderator of task performance and reactivity to stress (23), the participants (surgeons) emphatically suggested that the ability to control the type of music enhanced their abilities at a cognitive task and influenced reactivity. In that study distraction was ruled out as an explanation because participants were actively engaged in a cognitive task. In the current study participants also repeatedly mentioned the word "control" and noted that as surgical patients they felt they had relinquished all personal control on entering the surgical facility. They also commented that being provided with headphones and a choice of music restored a small amount of that personal control. For these patients, however, distraction may have contributed to the favorable effects of music. They reported such things as "the music was wonderful; it made me think of dancing in the 1930s," and "I liked the music, especially because I didn’t have to hear the chatter of the doctors and nurses." Most of the study participants (92%) reported playing music in the background much of the day at home, suggesting that music in surgery may partially replicate an element of a safe, familiar, home environment. If distraction is in fact an important factor in moderating physiological responses of surgical patients, it is possible that other familiar auditory or visual aspects of home life could elicit responses similar to those evoked by music.

The ophthalmic surgeons who participated in this study reported that the presence of the headphones did not interfere with their procedures and that, when necessary, they could communicate easily with their patients. We believe music has potential applications in many types of ambulatory surgery, among many patient age groups. Although our study participants were all healthy enough for ambulatory surgery, we speculate that patients at greater risk could benefit from music as well. In addition, teenagers and others who frequently listen to music through headphones would be especially interesting to study. We acknowledge that the generalizability of our findings is limited by the relatively small sample size and inclusion of patients having only one type of surgery. In addition, because patients were selected sequentially from a roster rather than randomly assigned to experimental groups and surgeons and because investigators were not blinded to the experimental condition, we do not know if subtle biases may have influenced patient outcome. Finally, it is possible that demand characteristics influenced our results. However, although it is possible that individuals wanted to please us by reporting reduced stress and increased coping abilities, it is not likely that the corresponding BP responses were similarly influenced. We conclude, therefore, that music is a safe, enjoyable, inexpensive, noninvasive, nonpharmacologic intervention with no adverse effects. We have demonstrated its efficacy in diminishing stress-induced increases in BP related to surgery.

	ACKNOWLEDGMENTS

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This research was supported in part by a grant from the Food and Drug Administration (FD-T-000889). In addition, we gratefully acknowledge the expertise and assistance of the nursing staff of the Millard Fillmore Ambulatory Surgery Center, without whose cooperation this study could not have been completed. We also appreciate the contribution of Digital Music Express, the provider of music and headphones for the project.

Received for publication June 2, 1999.

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