Music Therapy Can Help With Patient Anxiety Levels in the Cath Lab

While angioplasty and angiography procedures are minimally invasive, the prospect of undergoing a procedure on a major organ like the heart often triggers a great deal of patient anxiety, especially when it is the patient’s first time undergoing such a procedure. The experience can be acutely stressful, and factors such as previous traumas from physical pains, an unfamiliar environment, and fear can contribute to varying levels of stress for many patients.¹ Research has shown that music therapy can provide a significant improvement in the anxiety levels of patients in coronary care units², and it has exhibited similar effects on patients undergoing other medical procedures such as hemodialysis, cataract surgery, and Caesarean section. This article will explore the value of music therapy for patients in the cath lab setting.

The effects of stress and anxiety

Stress is physically as well as psychologically taxing. The psycho-physiological stress response involves activation of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. It is characterized by increased heart rate, blood pressure, and cardiac output.¹ These stress responses put an even greater strain on an already compromised cardiovascular system. Anxiety is also a predominant emotion among patients suffering from serious medical conditions. Similarly, it is known to cause increased blood pressure, heart rate and respiration rate, all of which lead to poor circulation, and it can cause fluctuations in body temperature, urinary urgency, enlarged pupils, and loss of appetite.² It has been found that anxiety leads to increased cortisol levels, which inhibit the immune system and blood clotting.² Lastly, conditions that arouse anxiety increase pain. It is clearly to the patient’s advantage to keep anxiety at a minimum.²

The value of music therapy

Music therapy is defined as the use of music by health care professionals to promote healing and enhance quality of life for their patients. Music therapy may be used to encourage emotional expression, promote social interaction, and relieve symptoms.³ While music therapy does not cure disease, there is much in the literature that reviews the capacity of music therapy to reduce some symptoms, aid in healing, improve physical movement, and enrich a patient’s quality of life.³ At our facility, we have witnessed music therapy’s positive results on patient anxiety levels during angiography and angioplasty. Often discomforts or anxieties are due to the anticipation of pain during the process of sheath insertion, immobilization, injection of contrast material, and balloon inflation.¹ While there are medications that are customarily given to patients to reduce their levels of anxiety and a local anesthesia is administered at the sheath site, these medications do not always alleviate the anxiety of patients during the procedure. As such, it is worthwhile to explore unconventional modes of supportive interventions that can help the patient cope during a cath lab procedure. The employment of music therapy is not only an inexpensive recourse, but by appealing to the cognitive, affective and sensory nature of the patient¹, music therapy offers a safe and effective means to improve the overall patient experience of a cardiac catheterization. Because the approach is safe, inexpensive, and well recognized by patients, the employment of music therapy is an acceptable option for medical procedures that necessitate or require a reduction in patient anxiety levels. 

Music was used in ancient times to improve the health and wellness of human beings. The renowned 6th century Greek philosopher Pythagoras said that music, together with proper diet, restores the harmony of the human body and soul.⁴ In the Renaissance era, music was also lauded as a tool to effect changes in heart rate, respiration, digestion, and blood pressure.⁴ Even Florence Nightingale, who laid down the foundations of professional nursing, adhered to the use of music to promote the healing process of injured soldiers in Crimea during the war.⁴

Research

Music therapy can be used as a complementary approach to pharmacological interventions that aim to minimize anxiety and normalize blood pressure levels. A reduction in anxiety will affect how the patient will anticipate and deal with pain and discomfort. Bally et al showed that listening to music can help patients counterbalance feelings of depersonalization in the hospital environment.¹ Patients often perceive themselves as at the mercy of unknown others. The atmosphere music creates can help channel a patient’s fears into positive emotions that can aid in coping. Bally et al looked at the use of music as an effective anxiolytic. In one study, patients showed significantly less “state anxiety” scores if they listened to self-selected tapes during procedures as opposed to those patients who received the standard protocol (the prescribed anxiolytic in the form of medication and other support interventions).¹ Analysis of current literature also indicates that music is a beneficial intervention to alleviate preoperative patient anxiety.1 Pfister noted that the efficacy of music therapy may even reduce cost in providing the usual support interventions (e.g., sedatives) and enhance the subjective perception of the patient on the outcome of the procedure.⁴

The constant pressure to minimize medical expenditures encourages the utilization of therapeutic interventions that effectively alleviate adverse patient states while maintaining fiscal feasibility.⁴ One of these therapeutic interventions may indeed be music therapy. Its safe and convenient administration provides an avenue for health care providers to test efficacy, and explore a wide range of techniques and strategies.  

At our facility, the patient is given the opportunity to choose from a wide range of music (see sidebar). The hope is that the patient, in the midst of the procedure, will sense something that in the presence of strangers and cold instruments will be familiar — something the patient can “lean” on whenever s/he feels uncomfortable or afraid.

Stress can be highest during the preoperative phase, while the patient waits for the unknown to occur. It is at this time that patients often cannot truly process the procedural information given or fully understand the course of the upcoming procedure. It is also at this time when the patient considers the possibility of surgical failure or the threat of discovering a worse illness that has not been detected previously.

Even medications meant to alleviate pain can substantially contribute to anxieties. Fears of anesthetics, the pain of administration, and fear of possible complications can trigger levels of anxiety nearly as strong as the anxiety from anticipation of the medical procedure itself.¹

Levels of anxiety likewise vary according to individual temperament and the patient’s prior experiences with medical procedures. Pfister described the range of emotions that can be found in an anxious or stressed patient, including irritability, worry, and uneasiness.⁴ Those with a personality prone to anxiety required higher amounts of anesthetic and incurred a greater amount of complications associated with anxiety.⁴ Pfister observed how personalities that are often more prone to high-levels of anxiety (i.e., those who are critical, nervous, possessing low self-esteem, and those seeking a high level of control) are soothed by music prior, during, and immediately after being subjected to angiography or angioplasty. The release of adrenaline as these emotions peak can potentially result in cardiac dysrhythmias during surgical procedures. Studies have shown that music minimizes the production of cortisol in the patient’s body prior to conducting surgical procedures.⁴ Cortisol is released by the body in response to a stressful condition, such as the anticipation of the medical procedure. Because cortisol is significantly reduced through the use of music therapy, it would therefore be safe to say that music can be a major factor in the effort to reduce the patient’s anxiety and stress. One study, which sought to evaluate the post-op behaviors of patients, noted that music significantly reduced the cortisol levels among patients during the post-op period as compared to a group of patients who were not subjected to music therapy during the duration of their confinement.⁴

Nonetheless, the employment of music therapy must be done with care. The choices of music, as well as who chooses the music, can contribute to the rising or falling of a patient’s cortisol levels.⁴ Interestingly, a rise in cortisol levels was observed over time in a provider-selected music group, while a patient-selected music group continued to have decreased cortisol levels. Variation between the patient-selected versus the provider-selected music group suggests that the element of patient selection is significant.⁴

Pfister also reviewed the effects of music therapy on minimizing pain, post-op nausea, vomiting, and decreased recovery time, arguing that music has an effect on mu-opiate receptors, associated with the sensation of pain.⁴ A study conducted on 60 patients demonstrated that music had adjuvant analgesic effects for patients suffering from pain and discomfort.⁴ Guzzetta conducted similar tests on 80 patients in a coronary care unit.⁵ The study resulted a lowering in the incidence of cardiac complications, lowering in the apical heart rates, and a rise in the peripheral temperatures of the patients who have been subjected to relaxation and music therapy sessions. Guzzetta concluded that both relaxation and music therapy are effective modalities to reduce stress in these patients.⁵   

Our own observations in dealing patients undergoing angiography and angioplasty seem to indicate that music decreases the stress and anxiety levels of patients undergoing these procedures. The caveat is that the patient must be given the autonomy to choose the music that s/he prefers. In the course of employing music therapy to patients, patient autonomy and the ability to choose are important. Still, it must be kept in mind that significant evidence indicates that the use of classical or new age kind of music has a soothing or relaxing effect, while types of music such as metal or grunge-rock provides the opposite effects, no matter whether the patient prefers such kind of music or not.⁴

Medical personnel should seek a balance between the patient’s autonomy and the perceived effects of the music on the individual. While autonomy is important, the patient must understand that the purpose of employing music therapy over the course of treatment is to reduce levels of anxiety and promote relaxation. The patient should not seek to be entertained by the music, but rather use it as a calming distraction. The medical personnel must likewise be cognizant of the elements of music, and how it can be used to influence relaxation on the part of the patient.

By helping to calm anxiety, music therapy in the course of cardiac catheterization promotes the emotional and psychological well-being of our patients. We are making a breakthrough for wellness in the mainstream employment of music therapy.

The author can be contacted at alexandredz@yahoo.com.

References

1. Bally K, Campbell D, Chesnick K, Tranmer JE. Effects of patient-controlled music therapy during coronary angiography on procedural pain and anxiety distress syndrome. Critical Care Nurse 2003;23:50-57.
2. Metivier L. The effectiveness of music therapy for the reduction of anxiety in women undergoing stereotactic breast biopsies. University Hospitals Health System: Music as Medicine. Available online at  https://musicasmedicine.com/internprojects/upload/lgoodman.pdf. Accessed February 15, 2012.
3. Music therapy. American Cancer Society. Available online at https://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMedicine/MindBodyandSpirit/music-therapy. Accessed February 16, 2012.
4. Pfister M. Harris College of Nursing and Health Sciences, School of Nurse Anesthesia Texas Christian University. Use of music to minimize preoperative patient anxiety. PDF available for download at: https://pdffinder.net/Music-Therapy-for-Preoperative-Anxiety.html. Accessed February 16, 2012. 
5. Guzzetta CE. Effects of relaxation and music therapy on patients in a coronary care unit with presumptive acute myocardial infarction. Heart Lung 1989 Nov;18(6):609-616.