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ORIGINAL ARTICLE
Year : 2023 | Volume
: 13
| Issue : 1 | Page : 87-93
The effect of music on serum cortisol levels and anxiety in patients undergoing lower segment cesarean section under spinal anesthesia: A randomized controlled interventional study
Harpreet Kaur, Gopal L Bansal, S Sreehari, Veena Shukla, Harsh K Harsh, Ravi Pareek
Department of Anaesthesia, SMS Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
Correspondence Address:
Dr. Veena Shukla
A-342, Officers Campus, Sirsi Road, Khatipura, Jaipur, Rajasthan - 302012
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/JOACC.JOACC_63_22
Background and Aims: Surgical procedures performed using spinal anesthesia techniques present a special challenge to anesthesiologists, because patients are awake and exposed to multiple anxiety-provoking visual and auditory stimuli. Therefore, this study was carried out to define the effect of music on the level of cortisol and anxiety in patients under spinal anesthesia undergoing elective lower-segment cesarean section (LSCS). Methods: The study was conducted on 60 patients undergoing LSCS under spinal anesthesia. The patients were divided into two groups containing 30 patients each. Group A received music through headphones and group B did not receive any music. Blood samples for serum cortisol and visual analog score for anxiety (VASA) were evaluated in both groups in pre-operative and post-operative periods. Results: Student's t-test was used for comparison of serum cortisol levels. The mean cortisol levels in group A were 32.44 ± 14.42 μg/dl in the pre-operative and 33.59 ± 12.74 μg/dl in the post-operative period (P = 0.583). However, in group B, the mean cortisol levels were 25.24 ± 13.54 μg/dl in the pre-operative period and 30.22 ± 17.04 μg/dl in the post-operative period. The difference was highly significant (P = 0.023). The mean VASA 1 score in group A as 5.22 ± 0.73 and in group B was 6.00 ± 0.82. The difference was not significant (P = 0.608). However, VASA 2 in group A was 4.90 ± 0.66 and group B was 5.89 ± 0.99. This difference was highly significant (P = 0.0001). Conclusion: This study's results showed that listening to music during surgery under spinal anesthesia significantly reduces cortisol levels (P = 0.023) as well as anxiety score (P = 0.0001).
Keywords: Anxiety, cortisol, music therapy, spinal anesthesia
Spinal anesthesia is the technique of choice for cesarean sections. Patients undergoing cesarean often feel anxiety which can lead to undesirable effects. Anxiety often causes physiological and psychological complications, as well as delayed post-operative recovery. The adverse physiological events may include an increase in blood pressure (BP) and heart rate (HR) and may even account for effects such as delayed wound healing and increased infections. Psychological negative effects may include postpartum depression and negative feelings about childbirth.[1] The use of pharmacological agents such as opioids and benzodiazepines to alleviate anxiety can impair recovery from anesthesia due to their sedative and emetic effects. So, the need for a non-pharmacological intervention that reduces anxiety and helps in postoperative recovery in women undergoing cesarean section is very well desired.[1] Music therapy is defined as the evidence-based clinical use of music for accomplishing individual goals.[2] Music can be used as a safe and cost-effective adjunct to standard anesthetic care. Music can influence the biochemical production of neurotransmitters and hormones and alleviate anxiety in a patient due to the unfamiliar environment of the operation theater (OT).[2] Music intervention can reduce the secretion of catecholamine and cortisol and also improve physiological responses such as HR, respiratory rate, body temperature, BP, and muscle tension. Many international studies have reported the effect of music intervention in reducing preoperative anxiety and post-operative pain, as well as the reduction in serum and salivary cortisol levels.[3],[4],[5],[6],[7],[8] Serum cortisol level reflects the hypothalamus pituitary adrenal (HPA) axis activity and is an indicator of physiological and psychological stress.[4] Cortisol, a glucocorticoid also known as the stress hormone, causes a rise in blood glucose levels as well as insulin resistance, increases protein levels, and hampers wound healing. In addition, a high glomerular filtration rate due to cortisol leads to dehydration in patients. Cortisol also hikes BP by increasing the tone of arteries as it also impedes the inflammatory process and lowers immunity. The HPA axis and amygdala respond to stress, and a high level of stress leads to a high level of serum cortisol. Listening to music downregulates these stress responses and leads to homeostasis.[5] In this prospective randomized study, our primary aim was to measure the change in serum cortisol levels during pre-operative and post-operative periods, as it is considered as a physiological index for stress. The secondary objective included comparing anxiety score and hemodynamic parameters to test the possible beneficial effects of music in patients undergoing cesarean section under spinal anesthesia.
MethodsThis prospective study was conducted in the obstetrics and gynecology OTs of a tertiary care hospital. The study was conducted after approval from the research reviewer board and institutional ethical committee. It took 12 months to complete the sample size, data processing, analyzing, and writing. The sample size was calculated as per the advice of a statistician.
A sample size of 30 in each of the two groups was found to be adequate at 95% confidence and 80% power to verify the expected difference of 4.82 (±4.3) in mean cortisol variation from the preoperative value to the end of surgery in both groups.[5]
Inclusion criterion: This prospective study was conducted in patients undergoing elective lower-segment cesarean sections (LSCS) of the age group 18 to 35 years who gave written informed consent for study in vernacular language. Patients who were operated on between 8 am and 11 am were included taking into account the diurnal variation in serum cortisol levels.
Exclusion criterion: Patients with the American Society of Anesthesiologist (ASA) grades III and IV, hearing impairment, chronic pain, any known psychiatric and memory disorder, with the intake of drugs influencing hypothalamic hypophyseal system or the sympathetic nervous system, and with history of drug abuse, addictions, or steroids, as well as professional musicians were excluded from the study. Also, patients who had partial and failed spinal block in the first attempt (although included initially), pain during surgery, hypotension requiring vasopressors, laboring patients, nausea, vomiting, patients landing in post-partum hemorrhage who needed multiple uterotonics, and patients with severe shivering were excluded from the study.
Randomization: Simple randomization technique by the sealed envelope method was used to allocate cases into two groups.
Blinding: The anesthesiologist who attached the headphone and plays music was different from the anesthesiologist who recorded the vitals and collected blood samples (Single blinding).
The study was conducted in the following two groups of patients. Each group consisted of 30 patients.
GROUP A (MUSIC GROUP): Patients were made to listen to music during the cesarean section under spinal anesthesia (just after spinal anesthesia up to the end of surgery) through headphones attached to their ears.
GROUP B (NON-MUSIC GROUP): Patients did not receive music during the cesarean section under spinal anesthesia, but headphones were attached to their ears to avoid any bias.
Patients who took part in this study did not receive any pre-anesthetic medication in the pre-operative room. Patients were asked for their willingness to be part of the study. However, patients were not informed before which group they belonged to. Patients were explained in detail about the Visual analogue score for anxiety (VASA), which consists of a 0- to 10-cm horizontal line, where 0 stands for no anxiety and 10 stands for worst anxiety.
After this, the patient was shifted to the OT. Routine monitoring instruments for monitoring BP, HR, and oxygen saturation SP02 were attached and pre-operative vitals such as systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), HR, respiratory rate (RR), electrocardiogram (ECG), and oxygen saturation (SPO2) were recorded. The Intravenous (IV) line was secured using an 18 G IV cannula.
First blood sample (2 ml) was drawn from the cannula to evaluate the pre-operative serum cortisol level. Ringer lactate (RL) infusion was started. At this point, scoring of anxiety was done for the first time using the VASA. This was named VASA 1.
Lumbar puncture was performed with the patient in a sitting position at L2-3 or L3-4 level with 25 G Quincke's spinal needle. On seeing a clear and free flow of cerebrospinal fluid, about 2 ml of 0.5% Bupivacaine Injection (Inj) was injected. The patient was immediately placed in the supine position. Subsequently, occluding headphones which were connected to an MP3 player were attached to the patient's ears.
In group A patients, music of the patient's choice (folk music, Hindi film songs, and religious music) was played while group B patients were not made to listen to any type of music. However, headphones were applied throughout the surgery in group B patients as well. Intraoperative vitals were recorded.
Blinding: The person who applied the headset and played the music or not was different from the person who drew the blood samples and recorded the vitals for blinding (single blinding). After completion of the surgery and closure of the skin incision, the second sample of blood (2 ml) was drawn from the patient to measure the post-operative serum cortisol level. VASA was reassessed for anxiety at this point (VASA 2).
Statistical analysis
It was performed with the SPSS, version 21, for Windows statistical software package (SPSS Inc., Chicago, IL, USA). Qualitative data were expressed in percentage and proportion while quantitative data were in mean ± SD. The significance of the difference in mean of the two different groups was inferred by the student's t-test. The significance of the difference in two means, that is, before and after in the same group, was inferred by paired t-test. The significance of the difference in more than two means was inferred by ANOVA. The significance of the difference in the proportions of the case in both groups was inferred by the chi-square test. The P value of <0.05 was considered significant.
ResultsDemographic characteristics
The mean age of patients in group A was 26.63 ± 4.33 years and in group B was 26.17 ± 3.55 years. No significant difference was noted among the groups on comparing the age-wise distribution (P = 0.649).
The mean weight of patients in group A was 57.33 ± 2.76 kg and the mean weight of patients in group B was 57.50 ± 2.30. No significant difference was noted in comparing the weight-wise distribution of the patients within ± (95% confidence limits) two standard deviations (P = 0.959)).
Serum cortisol
The mean serum cortisol levels before and after surgery in both groups were compared using the student's t-test. The mean serum cortisol levels in group A before the surgery (pre-operative) were 32.44 ± 14.42 ug/dl and in group B were 25.24 ± 13.54 ug/dl, and this difference was found to be non-significant (P = 0.051) [Figure 1].
Figure 1: Mean values of pre-op and post-op cortisol levels in group A and group BThe mean cortisol levels after the surgery (post-operative) in group A was 33.59 ± 12.74 ug/dl and in group B was 30.22 ± 17.04 ug/dl. This difference was found to be non-significant (P = 0.389) [Figure 1].
The mean serum cortisol levels before surgery (pre-operative) and after surgery (post-operative) within each group were also compared using the student's t-test. There was no significant difference between these serum cortisol values in group A which were 32.44 ± 14.42 v/s 33.59 ± 12.74 (P = 0.583) [Table 1].
Table 1: Intra group comparison of serum cortisol; SERUM CORTISOL (ug/dl)In group B, pre-operative mean cortisol levels were found to be 25.24 ± 13.54 ug/dl, whereas these levels in the post-operative period were observed to be 30.22 ± 17.04 ug/dl. This difference in mean cortisol values was significant (P = 0.023).
VASA score
VASA scores before surgery (VASA 1) and after surgery (VASA 2) were compared between both groups using the student's t-test.
The mean VASA 1 score in group A was 5.22 ± 0.73 and in group B was 6.00 ± 0.82, and this difference was not found to be significant (P = 0.256) [Table 2].
Table 2: Comparison of VASA scores between the groups A and B; VASA score (inter group)The mean VASA 2 score in group A was 4.90 ± 0.66 and in group B was 5.89 ± 0.99, and this difference was found to be highly significant (P = 0.0001) [Table 2].
A comparison of VASA scores within the groups was done with the student's t-test. There was a significant difference between values VASA 1 and VASA 2 in group A (5.77 ± 0.73 versus 4.90 ± 0.66 (P < 0.001); [Table 3]).
Table 3: Intra group comparison of VASA 1 and VASA 2; VASA score (Intra group)However, no significant difference was noted between VASA 1 and VASA 2 in group B (P = 0.641) [Table 3].
Hemodynamic parameters: SBP, DBP, MAP, HR, and SPO2 were compared in groups A and B during the pre-operative period as well as at 0, 5, 10, 15, and 30 min. The difference in SBP was noted between both groups with lower SBP in group A at 10 and 15 min after the start of the music, however, the difference was not significant (P ≥ 0.05). Other parameters did not show any significant difference (P > 0.05).
DiscussionMost of the methodologies used to reduce anxiety during and after the operation are based on pharmacological intervention. In this study, we investigated the change in serum cortisol levels during pre-operative and post-operative periods as our primary objective. Secondary objectives included comparing anxiety scores and hemodynamic parameters to test the possible beneficial effects of music in patients undergoing cesarean section under spinal anesthesia.
Influence of music as an inexpensive and non-pharmacological method to reduce the patient's anxiety during and after the operation. Literature has abundant studies showing the effect of music therapy on patient hemodynamic parameters and anxiety scores. However, the number of quantitative studies which have analyzed the influence of music on the level of blood cortisol during surgery and anesthesia is very limited.
Serum cortisol levels
The result of this study indicated that the post-operative levels of serum cortisol in the music group (group A) did not show any significant rise from pre-operative values (32.44 ± 14.42 vs 33.59 ± 12.74) (P = 0.583). Whereas the post-operative levels of serum cortisol in non-music group (group B) showed a significant rise from the pre-operative values (25.24 ± 13.54 v/s 30.22 ± 17.04) (P = 0.023).
This implies that the use of music during surgery could prevent anxiety and in consequence also prevent the rise in the level of blood cortisol. This could be beneficial in limiting the ill effects of raised cortisol levels on the body's physiology.
A study conducted by Mottahedian et al. (2012)[5] on the effect of music on serum cortisol, serum glucose, and hemodynamic variables in a patient undergoing surgery under spinal anesthesia indicated that the level of cortisol after operation in the music group does not reveal any rise as compared to the pre-operative period. Whereas the level of cortisol after the operation in the other two non-music groups showed a significant increase when compared to the time before surgery.[5]
In another study, Koelsch et al. (2011)[3] investigated the effect of music on the level of cortisol as well as propofol used during spinal anesthesia in cases undergoing hip replacement. They demonstrated that music can reduce the level of cortisol as well as the dose of propofol used in the music group compared to the silence group.
Leardi et al (2007)[6] studied the effect of music on the level of stress of patients undergoing a surgical operation. The results of his study displayed that music would decrease blood cortisol but the group in which the patient himself or herself had selected the music displayed a greater decrease in the level of cortisol.
Uedo et al. (2004)[7] inferred from their study that pain and the rise in the salivary cortisol in the music group had been less than that of the control group in patients during colonoscopy. This conclusion agrees with the present study.
Shiva Murthy et al.[8] in 2016 studied the effect of music therapy on serum cortisol in primigravida in active labor. They found out that the music group had significantly lower serum cortisol levels compared to the control group (t = 7.46, P < 0.05).
Syal et al.[9] in 2017 studied the effect of music therapy on anxiety and measured serum epinephrine and norepinephrine levels. They found that there was a significant decrease in serum epinephrine levels (P = 0.039) but norepinephrine levels were not declined significantly in the music group.
Hasanah et al.[10] in 2020 studied the effect of music therapy on salivary cortisol as a stress biomarker in children undergoing intravenous line insertion. However, music therapy did not significantly affect salivary cortisol levels in their study (P = 0.99). This result was in contrast to our study.
Visual analog score for anxiety (VASA)
The present study found that music is effective in reducing patient anxiety as the music group showed a significant reduction in VASA score in the post-operative period when compared to the pre-operative period.
Sarkar et al. (2015)[1] conducted a study to find out the effect of music on anxiety in patients undergoing cesarean sections under spinal anesthesia and found out that music is an effective tool in reducing anxiety and enhancing maternal satisfaction.
Another study conducted by Wang et al. (2014)[11] on the effect of music on anxiety in patients undergoing spinal anesthesia showed that the self-rating anxiety scale (SAS) score of the intervention group was significantly lower (P < 0.05) which is agreeable with our study. Also, the visual analog score for pain was 0.01, significantly lower than that of the control group up to 6 h after surgery (P < 0.01).
The results of our study are also comparable to the study conducted by Pao Yuvan Wu et al.[4] (2017), where the music intervention in patients undergoing awake craniotomy showed a significantly lower State-Trait Anxiety Inventory (STAI) score (P < 0.001).
Similarly, Hepp et al. (2018)[12] observed significantly lower anxiety levels in the music interventional group regarding (STAI) score (31.56 v/s 34.41, P = 0.004) as well as VASA (1.27 v/s 1.76, P = 0.018).
El Hassan et al.[13] in 2009 studied the effect of music on anxiety levels in patients undergoing endoscopy. Music led to a significant reduction in anxiety scores after endoscopy which is similar to our study.
Bechtold et al.[14] also in 2009 studied the effect of music on patients undergoing colonoscopy in a meta-analysis of various randomized controlled trials. They found that patients' overall experience scores were significantly improved with music (P < 0.01).
Ottaviani et al.[15] in 2011 investigated the administration of the effect of music on anxiety and pain during joint lavage for knee osteoarthritis. They observed that as compared to the control group, the music group had lower levels of perioperative anxiety (40.3 ± 31.1 v/s 58.2 ± 26.3 mm; P = 0.046).
Eren et al. in 2018[16] studied the effect of music during multiple cesarean section deliveries. They found that the VASA before and during the procedure showed significantly lower scores for the experimental group as compared to the control group (P < 0.005).
Gökçek et al.[17] in 2019 studied the effects of music therapy in patients undergoing septorhinoplasty surgery under general anesthesia. They concluded that in the music group, sedation agitation scores were lower than those in the control group in the postoperative period (3.76 ± 1.64 v/s 5.11 ± 2.13; P < 0.001). In addition, in patients of the music group, the pain level was lower, requiring less analgesic drugs intake.
A study conducted by Farzaneh M (2019)[18] also showed lower pain severity in patients undergoing cesarean sections who were made to hear nature-based sounds for 20 min using headphones as compared to the silence and control groups (P > 0.05).
Bansal et al. in 2019[19] studied the effect of music on patients undergoing a cesarean section under spinal anesthesia. They also found that the patient satisfaction score was in favor of the music group as compared to the non-music group. The difference was highly significant (P = 0.018). The patients' anxiety in the present cesarean as compared to anxiety in the previous cesarean section was lesser in the music group as compared to the non-music group (P = 0.009). Weingarten SJ et al.[20] conducted a systematic review and meta-analysis on 1296 trials of anxiety in women undergoing LSCS. They concluded that music reduces intraoperative anxiety and opioid use.
Hemodynamic parameters
In this study, music had no significant influence on hemodynamic parameters such as SBP, DBP, MAP, HR, or saturation of oxygen in the blood.
Bansal et al. (2010)[21] investigated the effect of music on physiological variables and the number of tranquilizers used during spinal anesthesia. Their study revealed that music reduced the average level of arterial BP and HR in the patients compared to the control group.
Jaber et al. in 2006[22] studied the effects of music therapy in intensive care unit weaning patients without sedation versus non-ventilated patients and found that music significantly decreased HR, systolic arterial pressure, respiratory rate, bispectral index, and Richmond agitation sedation scale in both intubated as well as non-intubated groups, whereas no significant change was observed during the rest period without music.
Mottahedian et al. (2012)[5] observed the effect of music on serum cortisol, serum glucose, and hemodynamic variables in a patient undergoing surgery under spinal anesthesia and found that the SBP was reduced in the music group.
Sarkar et al. (2015)[1] in their study found that there was a statistically significant effect of music on pulse rate (P = 0.017) and respiratory rate (P = 0.004), whereas no influence was found on SBP, DBP, or SpO2.
Camara et al. in 2008[23] analyzed the effect of live classical piano music on the vital signs of patients undergoing ophthalmic surgery. They concluded that 115 patients who were exposed to live piano music showed a statistically significant decrease in mean arterial BP, HR, and respiratory rate in the operating room compared with their vital signs measured in the pre-operative holding area (P < 0.0001). The control group of 88 patients who were not exposed to live music showed a statistically significant rise in MAP (P < 0.0002), HR, and respiratory rate (P < 0.0001).
Ottaviani et al. in 2011[15] evaluate the music on anxiety and pain during joint lavage for knee osteoarthritis. They observed that as compared to the control group, the music group had a lower mean HR (69.5 ± 11.4 v/s 77.2 ± 13.2; P = 0.043). However, the diastolic and SBP showed no significant change after music intervention which was similar to our study.
Syal et al. in 2017[9] studied the effect of music therapy on anxiety and hemodynamic parameters. They found that there was a statistically significant decrease in HR, MAP, and anxiety scores in the interventional group as compared to the control group (P < 0.001).
Bansal et al. in 2019[19] investigated the effect of music on patients undergoing a cesarean section under spinal anesthesia. They found out that both MAP and HR in the music group started falling after 10 min of spinal anesthesia as compared to the non-music group and the difference was statistically significant (P < 0.005).
Strength And Limitations of study: Our major advantages were the inherent safety of the intervention used for the study as well as the facility of an upgraded laboratory for testing the values of serum cortisol in study patients. Also, music of the patient's choice was used in this study, which helps in lowering the anxiety level. Personal preference, familiarity, and acceptability of type of music are based on cultural and religious background, and this leads to enhanced secretion of beta-endorphin resulting in pleasant emotions and pain reduction.[24] However, the music player and the headphones used by us were not at par with the latest technology due to financial constraints. This may have affected the sound quality being delivered to the patients. In addition, the number of studies showing the effect of music on patient parameters is limited in the literature. Keeping in view the safety offered by music during operative procedures, we recommend that future studies be conducted to check the benefits of music for patients.
ConclusionThe results of the present research revealed that music hinders the increase of blood cortisol; 25.24 ± 13.54 μg/dl in the pre-operative period and 30.22 ± 17.04 μg/dl in post-operative period in the music group (P = 0.023). Also, VASA 2 in group A was 4.90 ± 0.66 and group B was 5.89 ± 0.99 (P = 0.0002. Music can act as a distracting agent and help to refocus the attention from negative stimuli causing stress to something pleasant; it occupies one's mind with something familiar and soothing which allows people to escape to "their own world."
Thus, taking into consideration the advantages of music including its non-aggressive characteristics, availability, and simplicity, it is recommended that music should be used as a complementary treatment.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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