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Music and Stress in Children Receiving General Anesthesia

January 27th, 2010 · 2 Comments · Music and Surgery

Introduction

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The research I am about to present today has taken three years. Its goal was to reduce physiological and emotional stress in patients undergoing general anesthesia. The research questions were:

Is there audio perception when under anesthesia?
Can we find a parameter that would measure the physiological and biochemical effect of music under anesthesia?
As a resident music therapist in the children’s surgery department of the Medical Center in Jerusalem, I witnessed the positive effects of music on the emotional state of pre- and post-operative children. These encounters gave me the incentive to research the effects music might have during the process of the surgery itself.

I speculated that playing music to children undergoing general anesthesia would help to reduce their psychological and physiological stress levels.

Let us begin with my first question and see what we know about hearing during general anesthesia:

Hearing and Memory Under General Anesthesia

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Lately, research has shown that people are able to hear and report what they heard while under general anesthesia (McCarron and Bonny, 1984).

How would you feel, if you were anesthetized during surgery and heard the following?

Just a moment! I don’t like the patient’s color. Much too blue.
Her lips are very blue. I’m going to give a little more oxygen. . . .
There, that’s better now. You can carry on with the operation.
(Levinson, 1965:544)
Patients are not EXPECTED to be aware of events during anesthesia, and they are not EXPECTED to have any post-surgical memories of events that happened during anesthesia. However, despite these expectations, research (Levinson 1965, Gurman 2000) has shown that in many cases high level auditory processing (as is necessary for music perception) still exists for at least some patients undergoing general anesthesia. In addition, research shows that even if the patients cannot recall exactly what happened in the Operating Room, evidence of their experiences comes up in implicit memory tasks (Gurman 2000).

The implications of such reports are serious indeed. Patients may be at risk of psychological trauma that they not even aware of, or know the source of. In fact, research shows that of those patients who are aware during general anesthesia, 80% show symptoms compatible with Post Traumatic Stress Syndrome (Cundy and Dasey, 1996: 143). So, if nothing else, simply wearing headphones and being exposed to music rather than to stressful comments during the operation could have beneficial results.

However, we hypothesize that the administration of music during anesthesia has much deeper effects. These effects are related to music’s ability to influence physical and psychological states.

Review of Literature

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Discussions about the influence of music on depression and pain have been around since at least the beginning of the 1800’s. Some stories even go back to biblical times. Technological means for measuring results have only come recently. But we still do not know exactly what effect music has on the human body.

So What Do We Know Today?

We know the following effects which music has on the human body:

Physiological and Psychological Aspects:
First of all, we definitely know that music affects the limbic system which regulates deep emotions and many involuntary physical operations and reactions (pulse & blood pressure)
Second, music may alter pain perception and pain sensation.
Third, Music also assists in reducing stress levels:
In the light of the effects mentioned above, it is reasonable to assume that music can provide a significant contribution in reducing stress during anesthesia.

Effects of Music on Patients Under Anesthesia:
A number of studies have shown positive effects of music on patients undergoing general anesthesia. However, there are still many questions unresolved.

Firstly, what are the tests or diagnostics available to measure emotional stress directly?
Secondly, would music have the same positive effects on children undergoing general anesthesia?
Stress caused by Hospitalization
As we know, hospitalization can be a traumatic experience. The experience of being cut off from home, surgery and treatment, creates a stressful reaction (Sekeles, 1996).

As mentioned before, surgery and anesthesia are physically stressful and can be measured scientifically. This contrasts with emotional stress, which is more difficult to define and to measure. In addition, doctors believe that the patients’ emotional state is very important for their recovery.

How to measure emotional stress?
One of the first difficulties I faced was how to measure the emotional stress in children. Since only measurable results are valid, finding a measure for emotional stress was quite important. Such a parameter needs to be standardized, which is not always easy.

We decided to measure the level of Cortisol known as “the stress hormone”.

Although stress isn’t the only reason that cortisol is secreted into the bloodstream, it has been termed “the stress hormone” because it’s also secreted in higher levels during the body’s `fight or flight’ response to stress, and is responsible for several stress-related changes in the body. (Elizabeth Scott)
Since we could not use blood tests for this research because of the Helsinki committee’s limitations on intrusive procedures, we opted for measuring Cortisol levels in saliva.

Research Design

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In order to achieve standardization, my research concentrates on relatively simple eye operations. I investigate the effects of music on patients undergoing general anesthesia, for eye surgery, by comparing both the quality of the post-operative behavior and the biochemical levels of Cortisol – the stress hormone.

I begin by meeting with children ages 6 to18 in the preoperative preparation program. I let them know that they have the option of listening to music during the operation. If the child shows interest, I obtain written permission from the child, their parents and the medical staff. The child then brings their personal choice of music which was pre-selected in an interview before the operation.

During the operation, I supply the child with a set of specially designed earphones that do not interfere with the surgery. The music is turned on and adjusted to a level that does not exceed 65-70 dB (typical for experiments in music cognition).

In order to measure the effects of the music and to measure stress levels before, during and after the time of the operation, the saliva test is taken 3 times:

First, one day before the operation.
Second, immediately before anesthesia
Third, upon awakening from anesthesia after the operation.
Besides the saliva test, we used two additional and complementary scales in order to assess the patient’s state.

The first scale was the 4-point Watcha Agitation Scale, which was applied when the child awoke from the anesthetic by the attending nurse, who reported the child’s agitation level to the researcher.

As you can see on the 4-point Watcha Agitation Scale:

TABLE 1. 4-Point Agitation Scale – Watcha Relaxed
3

Crying but consolable
2

Crying inconsolably
1

Restlessness
0

The second scale was the Oucher Visual Pain Scale, which was also applied on awakening from the anesthesia

FIGURE 1. Oucher Visual Pain-Scale

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Subject Demographics
The research population included children between the ages of 6-18. This age range was selected so as to enable me to communicate with them freely. The children came from 4 different cultural backgrounds:

Secular Jews
Secular Arabs
Religious Jews
Religious Arabs
The patients’ languages included Hebrew, Arabic, English and Russian.

In the case of Arabic speaking children, I invited the parents to assist in translation. In the case of Hebrew, English and Russian speaking children, I personally communicated with the children myself.

How was the music chosen?
My first thought was to choose relaxing music, for example ocean waves or classical pieces. In the end, however, I decided to let the child bring his or her favorite music because it gives them a sense of comfort and security.

By playing the child’s favorite music during the operation, the music served as a “transitional object” (Winnicott, 1971), which helped to overcome unpleasant feelings and loneliness.

What type of music did the children want?
The interesting thing about their choice of music was its intensive tempo and rhythm. I will now play some examples of their choices.

As we have heard, their choice of music is far from “lullaby”, but does contain some common features:

It is familiar
It is music they have at home
There is a singer
Fast rhythm and tempo
Results

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As the next table shows, the results, despite not being statistically conclusive, show that the music group’s awakening was much more pleasant. We compared several categories as we see from the table

The most significant effect, 21 percent, appears in the comparative study of short operations (less than 65 minutes).

TABLE 2. Comparative Results of Quality of Awakening between Control Group and Music Group Description
Results
Conclusion

Study of the effect of music therapy on quality of awakening

The result shows an effect (11.9 %) of provided treatment on patients’ awakeness. (student t-test, 0.1664)

Study of the effect of music therapy on quality of awakening in Jewish patients

The result shows an effect (15.3%) of the therapy on patients’ awakeness for Jewish patients. (student t-test, 0.129). It is also important to note that there is no difference between the awakeness quality values for Jewish and general patients

Study of the effect of music therapy on quality of awakening after operation for Strabismus correction.

The result shows an effect (14.3%) of the therapy on patients’ awakeness after Strabismus correction operation (student t-test, 0.187).

Study of the effect of music therapy on quality of awakening after short time (less 65 min) operations.

The result shows a significant effect (21%) of the therapy on patients’ awakeness after short time operations (student t-test, 0.081).

Study of the effect of music therapy on quality of awakening for both genders

The result shows an effect of the therapy on patients’ awakeness for boys (15.6%) and girls (13.6%) (student t-tests, 0.155 and 0.213, comparatively).

It is also interesting to mention that the studied girls show better post-operative awakeness capability in both, control (17.3%, t-test 0.205) and treated (15.4%, t-test 0.17), groups.

FIGURE 2. Salivary cortisol test

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This table shows the results of the cortisol test. The first time checkpoint was one day before surgery; the second checkpoint was one hour before surgery, and the third checkpoint was one hour after surgery. As we can see, the results are not statistically conclusive, but they do show a clear tendency in favor of the music group.

CONCLUSIONS

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Initially, I thought that measuring the effects of music would be simple. That I would play music to patients, measure their stress levels, and immediately see the benefits that music gave. It turned out that the process was much more complicated. Factors such as the depth of anesthesia, levels of emotional stress, standardizing, and measuring results have all added to the complexity of the experiment. Apart from that, the experiment lacked the optimal infrastructure necessary for a clinical study in the field. And in addition, we discovered during our work that testing for cortisol is a non-routine test and has no acknowledged base line. Nor did we take into account the fact that cortisol levels fluctuate during the day. They can be high in the morning and lower later on, and the cortisol tests we carried out were on children whose surgery was scheduled at different times of the day.

It should be noted that, for technical reasons, the number of subjects tested for cortisol levels was limited, which should be taken into account in future experiments and the number increased. We also felt that objective tests of cortisol and awakening quality should be complemented by subjective psychological tests such as questionnaires. We did not use questionnaires in this study, but in conversations a week after surgery the importance of providing emotional support by means of music for children and their parents was clear.

It is certainly clear from the above that future research should include the use of questionnaires which give insight into subjective experiences and complement the objective use of cortisol.

Finally, I should say that the most important thing my research has shown me is that despite the lack of statistically conclusive results in the physiological and biochemical test I stay convinced more than ever, that music is an effective means for lowering stress in children during general anesthesia and surgery.

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References of this conference paper can be obtained by the author

This article can be cited as:
Bogopolsky, H. (2007) Music and stress in children during general anesthesia and surgery. Music Therapy Today Vol.VIII (3) December. available at http://musictherapyworld.net

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