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The effect of music on patients undergoing general anesthesia
Bogopolsky, Helena
Introduction
For the last two years I have been researching the effect of music on patients undergoing general anesthesia. While we are still in the process of collecting results and therefore cannot report conclusively on them, we have discovered some intriguing and important data in the process. My personal interest in researching the effect of music on patients undergoing general anesthesia is motivated by the facts that :
I spent many months searching for an anesthesiologist who would agree to collaborate with me in this research. I encountered a lot of skepticism. The idea of a music therapist donning mask and robe and entering the operating room was unusual. The emotional well-being of the child undergoing surgery - was not something most of the surgeons tended to deal with, due to their emphasis on the clients' physical being. I was fortunate to find Dr. Kadari from Hadassah Medical Center in Jerusalem, who was the first anesthesiologist to allow parents to enter the operating room with the child, and stay up to the point when the child falls asleep. This simple and natural way of helping both parents and child to cope more easily with the trauma of an operation (even a simple one) is now an accepted practice in Israeli hospitals. I would also like to add a point of clarification regarding the presentation itself. The presentation will focus on physiological, bio-chemical and behavioral aspects of music therapy during anesthesia. Unfortunately, and despite earlier references, we are not yet able to report on neurological aspects.
Hearing and Memory Under General Anesthesia
In the last few years, research has shown that people are able to hear and, afterwards, report what they heard while they were subjected to general anesthesia (McCarron and Bonny, 1984). How would you feel if you were a patient undergoing surgery and heard the following words while lying anesthetized in the operating room? Just a moment! I don't like the patient's color. Much too blue.
FIGURE 1.
Surgical patients who have been administered general anesthesia are not EXPECTED to be aware of events during anesthesia, and they are not EXPECTED to have any post-surgical memories of events that occurred 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 occurred 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 may not even be aware, or know the source of. In fact, research shows 80 % that of those patients who are aware during general anesthesia 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
Discussions about the influence of music on depression and pain have been around since at least the beginning of the 1800s. Some stories even go back to biblical times. In those days, there were no technological means to measure or standardize experimental results. Over the years we have witnessed vast improvements in science and technology, but we still do not know exactly what effect music has on the human body. So What Do We Know Today? We do know the following effects which music has on the human body: Physiological and Psychological Aspects:
FIGURE 2.
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 (music can change the rhythm of our body, such as our heartbeat and breath rate). Second, music may alter pain perception and pain sensation.
Music also assists in reducing stress levels:
Hypothesis: In light of the factors and influences mentioned above, it is reasonable to assume that music can provide a major contribution to reduce stress levels. Effects of Music on Patients Under Anesthesia:It is therefore not surprising that a number of studies have shown positive effects of music on patients under general anesthesia (Lehmann, 1985; Furlong, 1990; Aldridge, 1995; Spintge, 1985; Gozal & Gozal, 1998; Nilsson, 2001). Although some research has been done to better understand the effect of music on patients undergoing general anesthesia, there are still many questions left unresolved. Firstly, what are the tests or diagnostics available to measure emotional stress directly? Secondly, would music provide the same beneficial effects on children undergoing general anesthesia? Stress from HospitalizationAs we know, hospitalization can be a traumatic experience. Robertson and Bowlby (1952) researched the effects of hospitalization on children under the age of four. Observations revealed that even those who were hospitalized for short periods underwent the following stages:
It appears that even after the 1950s, when parents were permitted to remain in the hospital at the child's bedside, the same stages could be observed. The very experience of being cut off from home, and the traumas of hospitalization, surgery and treatment, sufficed to create such reactions. (Sekeles, 1996). As we mentioned before, surgery and anesthesia, as intrusive medical procedures, are physically stressful and can be measured scientifically. However, emotional stress due to hospitalization is more difficult to define and to measure. Nonetheless, doctors will admit that reducing levels of emotional stress is also an important factor in helping to guide the patient to a healthy recovery. According to Dr. Kadari's personal experience, children's emotional states, whether stressed or relaxed, are the same when they enter the operating room as when they leave. The child's initial emotional state will strongly influence his pain perception and recovery after operation. It is well known that entering the operating room can be a very difficult task for a child. Children are often afraid and sometimes even cannot cooperate with the surgeon or the anesthesiologist. Surrounded by unfamiliar faces and objects, children often enter the room scared and nervous. It is therefore important to intervene in this process. One of the better methods of intervention is music therapy. As a resident music therapist in the children's surgery department of Hadassah Medical Center in Jerusalem, I have often witnessed the positive effects music has on the emotional state of post-operative children. I can tell you about one nine-year-old girl who underwent music therapy in the pre-medication process. Instead of entering the operating room shy and reserved, she leaped in singing and full of joy. These encounters with the children before and after surgery gave me the incentive to research the effects music might have during the process of the surgery itself. Hypothesis: Given all of the above I hypothesized that the use of music therapy for anesthetized patients undergoing surgery can help to reduce levels of emotional stress. How to measure emotional stressOne of the first major difficulties I faced was how to measure the emotional stress in children. Since in the world of medicine only measurable results are valid, finding a measure for emotional stress can be quite a challenge. In addition, once the measure is defined, it has to be standardized which leads to additional problems. We decided upon measuring the level of Cortisol known as "the stress hormone". 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 ( Vining RF, McGinley RA 1987).
Research Design
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:
In addition to the saliva test, we used two additional scales in order to determine the patient's state. As you can see on the 4-point Watcha Agitation Scale:
FIGURE 3.
Subject DemographicsThe 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:
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 initial thoughts were to choose relaxing music. This can range from the soothing sounds of the ocean waves to the rhythmic echoes of dolphins and whales, to a particularly mellow jazz or classical piece. After listening to the many possibilities of sounds (waves, dolphins etc.), I realized using "natural sounds" may be problematic.
So, I came to the conclusion that "natural sounds" may not be suitable for this specific situation. Given that hospital settings can be very stressful and filled with tension, I believe it is important for each patient to find music that gives him comfort and support . So, when choosing what music to bring, I believe that it is important to take into account the cultural and personal background of the patient. The type of music a patient might choose can vary significantly depending on the patient's background and personal tastes; it is important to let the patient choose what music best suits them and makes them feel most comfortable. Therefore, rather than applying the principle of an "International Language of Music" I emphasized the patients' own personal preferences. I suggested that each child bring music they love, music that I assumed would evoke feelings of comfort and security. Before I began my project, the nurses would tell children to bring a favorite toy or stuffed animal that would greet them after their operation. However, music could both greet them when they woke up and accompany them through the entire procedure of pre-, intra- and post-operation; just like Tamino who played upon the flute while braving the dangers of fire and water in Mozart's "The Magic Flute". In this way, music serves as a "transitional object" (Winnicott, 1971), a tool used to help overcome unpleasant feelings and loneliness. So what type of music was chosen?
Boys - Rap Download excerpt of the song (Rap_Subliminal.mp3; 1.8 MB)
Girls - Pop Download excerpt of the song (Pop_Dana.mp3; 1.5 MB)
Download excerpt of the song (ReligiousJewish.mp3; 1.3 MB)
Download excerpt of the song (ArabicPop_Fairuz.mp3; 1.6 MB)
As we have just witnessed, some of the common factors in the musical selection were:
Children selected music that was listened to at home Children looked for something to hold onto and find comfort in when in an unfamiliar and scary situation. Most children listened to either Rap, Pop or Religious "Rock": it is important to note that these are all far from being classical lullabies and often have a fast tempo and loud vocal and instrumental parts. In almost all cases, music had a human voice. It is possible that the human voice has a special capacity to connect. Religious children would often find comfort when listening to religious texts Indeed, the choice of fast tempo reminds us of ecstatic healing rituals in which the healer is using music with a characteristic acceleration in order to overcome pain and anxiety. (Sekeles, 1996). Ralph Spintage (Professor of Music Medicine and Doctor of Anesthesiology) emphasizes that rhythm is the main factor of stimulation in music. When he asks his patients what they feel when they are listening to music during an operation, they say that they escape from the current situation to the "discothèque".
Conclusion
To conclude, today we have talked about some of the many helpful psychological and physiological effects of music. These aspects convinced me that music could play an important role in helping patients at risk of emotional stress. Initially, I thought that measuring the effects of music would be simple. I would provide patients with music, measure levels of stress, and we could immediately measure the benefits. It turns out the process was much more complicated than that. Factors such as the depth of the anesthesia, levels of emotional stress, standardizing and measuring results have all added to the complexity of the experiment. However, I feel that, as in music, the process of discovery itself is important, and not just the results. What we have seen, based on our other measures, has been very positive. When measured on the 4 point agitation scale, patients have consistently measured at either the "Relaxed" or the "Crying but Consolable" levels. However, these results still need to be validated due to the absence of a control group. As I have previously mentioned, due to technical challenges in measuring levels of emotional stress, we are still in the phase of testing saliva and are eagerly looking forward to the results. We are continuing with our research and look forward to advancing to the next stages. Acknowledgement
This research was made under the supervision of Dr. Roni Granot, Department of Musicology, The Hebrew University, Jerusalem, and Dr. Avishag Kedari from the Department of Anesthesia and Intensive Care, Hadassah Medical Centre, Jerusalem, The Medical School of the Hebrew University, Jerusalem I would like to extend a warm thank you to my teacher, my advisor, and a person that has given me much support during my research, Dr. Chava Sekeles. Thank you all for your time...
References
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This article can be cited as
Bogopolsky, H. (2005) The effect of music on patients undergoing general anesthesia. Music Therapy Today Vol. 6, Issue 4 (November), p.776-791. available at MusicTherapyWorld.net
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