The stress of surgery

Surgery and the “surgical experience,” from pre-op to post-op, is stressful and elicits anxiety in humans. Anxiety has been described as having two components, the emotional and the physiological (1,2). Anxious individuals may complain of shortness of breath, restlessness, trembling, muscle tension, loss of appetite, and fatigue. Surgeons and anesthesiologists witness this in their patients as elevations in heart rate, blood pressure, breathing rate and metabolism. Why is anxiety bad? First, it doesn't feel good. Who likes to walk around with muscles tensed, heart beating out of the chest, sweat dripping down the back, and breathing so fast the limbs become numb? Second, the stressed individual may require a multitude of medications in order to help regulate the pulse, blood pressure, and respiratory rate before, during, and after surgery. How then can someone better prepare the mind and body for the stressors of an operation?

Can music be used to help the surgical patient?

The ideal medicine to help anxiety would be completely safe to take. It would have no side effects, would be inexpensive, non-invasive, and readily available. As an experienced emergency physician, I cannot think of a single drug in any of the medical specialties that would fit this profile. Music and music therapy have been effectively used in many patients to treat anxiety (see anxiety chapter of this website). It is not a drug in the true sense of the word, but if it were, its safety and psycho-physiologic efficacy would be outstanding. Music has been studied as a method to reduce the pain and anxiety associated with surgery, and there are data to support its use before, during, and after surgery.

What studies have been conducted with music and surgery?

Sheri Robb, et al., conducted a study involving 20 pediatric burn patients from the Shriners Burns Institute in Texas who needed surgery. Half of them were given Music Assisted Relaxation (MAR) interventions prior to surgery. The MAR consisted of music listening, deep diaphragmatic breathing, progressive muscle relaxation, and imagery to facilitate relaxation. Dr. Robb scored their anxiety levels using the state portion of the State-Trait Anxiety Index for Children and found that children receiving MAR experienced a significant decrease in anxiety when compared with the children who had not received MAR (3).

The interest in music as an adjunctive therapy in the surgical arena is not limited to healthcare providers in the United States. Dr. Barbara Miluk-Kolasa and colleagues in Warsaw, Poland, published an article in the Journal of Music Therapy studying the effects of music on 100 patients awaiting non-orthopedic surgery. The day before their surgery, half of the patients listened to music while they were told about their upcoming procedure, and half had no music. The patients had their blood tested and their vital signs taken three times in the course of the experimental hour. The examiners found that the stress level in all patients was significantly elevated at the beginning of the hour. However, those who had listened to "individually composed music programs from Walkman-type tape players recovered from the initial stress at the end of the hour, while those who had no music had no reduction in their stress level (4).”

Nursing staff and anesthesiologists have also explored the use of medicine in an effort to help reduce the stress levels of their patients. In the Spring, 1999, issue of Plastic Surgical Nursing, Dr. Maureen Reilly, a nurse-anesthetist, reviewed research studies from 1984-1997 exploring "Music as a Cognitive Therapy in the Operative Experience." She concluded that in those studies, which addressed music as a method of pain or stress control, "The overall results indicate clinically significant improvement in patient outcomes either by subject report or physiologic parameter or both." These studies, although small, measured a parameter such as muscle relaxation or a patient's subjective reporting of his or her pain (5).

In Sweden, as reported in Anaesthesia, researchers conducted a study involving 151 patients undergoing hernia and varicose vein surgery. They wanted to know if patients who listened to music experienced a reduction in pain during their procedure or in the first couple of hours immediately after. The music the group received "played via headphones was soft instrumental with a slow, flowing rhythm and included seven different melodies for 43 minutes of new-age synthesizer using a compact disk player...Diskman, Model No. D-181, Sony Corp." The control group had the same CD player but listened to a blank CD. The researchers concluded that the patients who were exposed to music during and after surgery reported significantly lower pain scores at one and two hours post-surgery than the control group. The patients who received music after surgery were also found to require half as much morphine for their post-op pain compared with the other two groups (6).

What are the most recent published studies?

Two research studies were recently published evaluating the effects of music therapy on surgical patients. In the first study, physicians wanted to know if they could measure any differences in stress hormone levels in women who were exposed to music while undergoing gynecological surgery. Thirty women were randomly assigned to either a music or non-music group. The women were asked to choose to listen to music from four compact discs (classical, jazz, new-age, and popular piano) for the purpose of the study. The levels of stress hormones (epinephirine, norepinephrine, cortisol and ACTH), and the amount of pain medicine dispensed was recorded for all the women. In this study, the researchers found no significant differences in the blood levels of stress hormones in the music versus the non-music group (7).

The second study, conducted by researchers at Yale, suggested that music and music therapy were somewhat ineffective at relieving pediatric pre-anesthesia anxiety as compared to Midazolam (a sedative related to Valium) (8). To any physician who has used Midazolam, this comes as no surprise and it may seem like a ‘no contest’ between the two therapies. Midazolam is a very powerful sedative-hypnotic and, in the right dose relaxes the body to a point where thoughts and memories about one’s surgery melt away. The body becomes limp, and the patient generally falls asleep. It would be quite a challenge to compete with Midazolam.

E.R.'s bottom line on music and surgery:

Perhaps the most difficult and challenging task for a researcher is to study something which is difficult to quantify. Music, as with all art, is so complex that its beauty, meaning, and value truly lie in the ears of the beholder. It is far easier to conduct research on whether a new antibiotic can eradicate bacteria than it is to figure out how a particular tune can survive, be enjoyed by generations without developing any signs of resistance, and make people feel good. The studies conducted on the effects of music on the surgical patient were small, and many of the results were inconclusive. However, if you were one of the patients having surgery, and music or music therapy did help you through the experience, wouldn't it have been worth it? There seems to be very little to lose. To those pioneers who are studying the effects of music on the surgical patient, the answers may not lie in the hands of surgeons, anesthesiologists, and statisticians, but in the hands of the musicians.

We at E.R. Music are grateful to readers who inform us about new research being published involving music and the surgical patient. We will review the studies and incorporate them into this chapter. Please join our mailing list if you would like to be informed of the latest developments.

Copyright 2008, E.R. Music, LLC

1. Speilberger, C.D., et al, "Stait trait Anxiety Inventory for Children," 1973, Palo Alto, CA: Consulting Psychologists Press, Inc.

2. Lazarus, R.S., "Psychological Stress and the Coping Process," 1966, New York:Spring-Verlag

3. Robb, et al, "The Effects of Music-Assisted Relaxation on Preoperative Anxiety," Journal of Music Therapy, XXXII(1), 1995, 2-21

4. Miluk-Kolasa, Matejek, "The Effects of Music Listening on Changes in Selected Physiological Parameters in Adult Pre-Surgical Patients," Journal of Music Therapy, XXXIII(3), 1996, 208-218

5. Reilly, "Incorporating Music into the Surgical Environment," Plastic Surgical Nursing, Spring 1999,19:1

6. Nilsson, Rawal, Unosson, "A comparison of intra-operative or postoperative exposure to music - a controlled trial of the effects on postoperative pain," Anaesthesia, 2003, 58, 684-711

7. Migneault, et al, "The Effect of Music on the Neurohormonal Stress Response to Surgery Under General Anesthesia," Anesthesia/Analgesia, 2004;98:527-32

8. Kain Z, et al, “Interactive Music Therapy as a Treatment for Preoperative Anxiety in Children: A Randomized Controlled Trial,” Anesthesia & Analagesia 2004;98:1260-1266