Effects of music therapy on the anxiety level and physiological responses of patients undergoing ophthalmic surgery: a systematic review and meta-analysis

来源期刊： Eye Science | 2024年1月第1卷第1期： 62-75 发布时间：2024-01-01 收稿时间：2023/11/13 10:58:39 阅读量：5706

作者：: Qi Fu,

Shuping Li,

Feipeng Wang,

Bishan Tian,

关键词：: Music Therapy Ophthalmic Surgery Anxiety Physiological Responses Meta-analysis; Music Therapy Ophthalmic Surgery Anxiety Physiological Responses Meta-analysis

DOI：: 10.12419/es23111101

Objective: To evaluate the effectiveness of music therapy on the anxiety level and physiological response of patients undergoing ophthalmic surgery.

Methods: Relevant randomized controlled trials that compared the combined effect of music therapy for patients undergoing ophthalmic surgery were included. Four English databases and three Chinese databases were searched from inception to Jan. 2022. Two reviewers independently performed data extraction and risk of bias assessments. The Cochrane Collaboration tool was used to assess the risk of bias. Meta-analysis was performed using Review Manager 5.3. The outcomes were overall anxiety, blood pressure, heart rate and pain.

Results: Atotal of 11 trials with 1 469 participants were included in the meta-analysis. Compared to standard care, music therapy had a good efect on reducing the anxiety levels of patients undergoing ophthalmic surgery (p<0.05). The results also suggested that music therapy produced a signifcant improvement in blood pressure (p<0.05) and heart rate (p<0.05). The visual analogue scale (VAS) showed that music therapy signifcantly reduced pain compared to standard care (p<0.05).

Conclusions: This meta-analysis provided evidence that music therapy has an obvious efect on relieving anxiety levels, while it is also more efective in alleviating pain and improving physiological responses than standard care alone. Our fndings may provide accurate evidence-based guidance for the clinical implementation of music therapy. In the future, more high-quality studies are required for verifying these results.

INTRODUCTION

With the growth of the aging population, the incidence of eye diseases is also increasing.Chronic diseases, such as age-related macular degeneration, glaucoma, diabetic retinopathy and cataract, are particularly common in the elderly.^[1] For individuals with impaired visual function, surgery is the most common treatment that induces patient stress and psychological and physiological responses to stressors. Psychological stress reaction, they might stress the link between psychological stress reaction, immune-inflammatory abnormalities and negative clinical outcomes such as suicidality.^[2] The psychological stress reaction is demonstrated as worrying about the status of the disease and the performance of the operation, which lead to anxiety.^[3] Some of these emotions are accompanied by physiological reactions, such as increasing blood pressure, dizziness or respiratory and heart rate changes.^[4] Previous studies showed that the anxiety level of patients undergoing ophthalmic surgery was higher than that of other surgical patients.^[5] The level of anxiety of patients with ophthalmic surgery increases with the time for surgery approching, especially two hours before surgery.^[6]
Some measures, such as supportive psychotherapy and relaxation trainings, have been proven effective in reducing the anxiety of preoperative ophthalmic patients.^[7] Music therapy is one method of relaxation training. It may be used as a medium to distract attention and considered an escape route from negative stimuli. Therefore, music therapy afects physiological responses, psychological stress, anxiety and other parameters of prefrontal cortex activation.^[8] Some studies also showed that music therapy reduced anxiety levels and pain and afected the physiological indicators of patients, such as blood pressure and heart rate.^[9-11]

Rationale and knowledge gap

However, the following clinically relevant questions were not addressed. What are effective music therapy strategies for the ophthalmic surgery population? Is this intervention good for patients undergoing eye surgery? It has been argued that music therapy offers no significant reduction in the anxiety level, blood pressure or heart rate in patients undergoing ophthalmic surgery.^[12-13]

Objective

The purpose of the present study therefore was to perform a systematic review and meta-analysis of all RCTs, evaluating the effects of music therapy on the anxiety level and physiological response of patients undergoing ophthalmic surgery. To understand whether music therapy really works on the anxiety level and physiological response of patients undergoing ophthalmic surgery.

METHODS

This was a systematic review and meta-analysis of RCTs exploring associations between music therapy and patients undergoing ophthalmic surgery. The protocol for this review has been registered in PROSPERO: CRD42020191724. (https://www.crd.york.ac.uk/PROSPERO/).

Search methods

The literature was extensively searched in English databases (Cochrane Library, PubMed, Embase, Web of Science), and Chinese databases (China National Knowledge Infrastructure, WanFang Data and Chinese Biomedical Database) were searched from inception to Jan. 2022. Acombination of MeSH terms and keywords was used to construct the extensive search strategy. The snowball method was used to trace the included references in the study to prevent literature omission, and we contacted authors for further information when needed. The PubMed search strategy was as follows:
#1“ophthalmic surgery” [Mesh]
#2ophthalmic surgery* [Title/Abstract] OR ocular surgery* [Title/Abstract] OR eyesurgery* [Title/Abstract] glaucoma surgery* [Title/Abstract] ORretinal surgery* [Title/Abstract] OR cataract surgery* [Title/Abstract]
#3 music* [Title/Abstract] OR music therapy* [Title/Abstract] OR music therapies* [Title/Abstract] OR music intervention*
#4 #2AND #3

Inclusion criteria for studies

Types of studies: Randomized controlled clinical trials or clinical trials examining the effectiveness of music interventions were deemed eligible. There were no timing or setting restrictions, and only English and Chinese publications were selected. If the population overlapped between studies, the most recent or most complete study was included.

Type of participants: The population of interest for this systematic review consisted of patients (age > 18 years) undergoing ophthalmic surgery under local anaesthesia who were conscious and able to communicate with researchers by language, body language or other communication channels. There were no restrictions on race or nationality.

Types of interventions: Researchers played any recorded music with melody, harmony and rhythm for the patients in the intervention group. The method of listening to the music and the intervention time were not limited. Standard care was performed with no musical intervention in the control group.

Types of outcome measures: At least one of the following indicators was included as the primary or secondary outcome. Regarding psychological outcomes, the anxiety level was measured with standardized anxiety assessment tools that were published and tested for reliability and validity, such as the Hospital Anxiety and Depression Scale and State Trait Anxiety Inventory and the Hamilton Anxiety Scale. Regarding physiological outcomes, the heart rate, systolic blood pressure, and diastolic blood pressure were measured. Pain was measured using the visual analogue scale (VAS).

Exclusion criteria for studies

a) Repetitive literature
b) Defects in research design and poor quality
c) Incomplete data and unclear outcome efects
d) Wrong statistical methods that could not be corrected; data that could not provide or be converted into the risk ratio, rate difference, or heart rate and the 95% confdence interval; and measurement data that did not include the mean and standard deviation.
e)Animal experiments

Quality appraisal

Assessment on risk bias for each study was performed using the Cochrane Collaboration tool,^[14] which covers sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting and other biases. Every item could be classifed as 'low risk of bias' , 'high risk of bias' or 'unclear risk of bias' . Disagreements were resolved by discussion between the two reviewers and, if necessary, through discussions among the authors.

Data abstraction

Two researchers reviewed the title and abstract of each reference. We scanned the full texts of the relevant studies, applied prespecified inclusion and exclusion criteria and extracted the data. Disagreements were resolved via consensus, and when a disagreement could not be resolved, a senior reviewer acted as the final arbiter. Two trained reviewers independently extracted the following information from each article with a standardized form:
a) basic information of the trial, such as the title, author and source of the literature;
b) the baseline situation of the subjects;
c) intervention measures;
d) measurement indicators: anxiety level, blood pressure, heart rate, etc.

Statistical analysis

We performed statistical analyses in RevMan 5.3 and Stata 12.0. For consecutive variables, the mean values ± standardized mean difference (SMD) and 95% confdence interval (CI) represented the efcacy of treatment. Heterogeneity was tested using the chi-squared test and I2 test. A random-effects model was used when the chi-squared test (p < 0.10) or I2> 50% revealed significant evidence of homogeneity across the studies. Otherwise, a fixed-effects model was used. P values less than 0.05 indicated statistical significance. If the number of included trials was sufficient, sensitivity analysis was used to assess the stability of the results. Funnel plots were constructed to investigate publication bias.

RESULTS

Overview of results

The search strategy retrieved a total of 279 studies. After the removal of duplicate studies, 156 publications remained. Reviewing the title, abstract and full text, 11 studies with a total of 1469 particpantsmet the the inclusion criteria, including the meta-analysis. Nine studies were published in English,^{[12-13, 15-21]} and two studies were published in Chinese.^[22-23] The literature search process is shown in Figure 1.

Characteristics of the literature

The included studies were randomized controlled trials (RCTs), as shown in Table 1. The participants included 748 females and 721 males. There were 734 cases in the music group, with an average age of 64.93 years, and 735 cases in the control group, with an average age of 65.08 years. One study was a four-arm trial,^[12] and one study was a three-arm trial.^[18] We extracted data from the music and control groups. The timing of music therapy in ten studies extended from the beginning of the operation through the whole surgical process, and the intervention in the remaining study was performed before and after the surgery.^[22] The types of music therapy included light music, classical music, and pop music. Three studies allowed the patients to independently select the music, and the methods of listening included earphones and loudspeakers. The details are listed in Table 1.

Table 1 Characteristics of the included studies

Data abstraction

The bias risk assessment for the included studies is shown in Figure 2 and Figure 3. The included eleven studies in this analysis were all RCTs, and seven had detailed descriptions of the methods. The other studies mentioned “random” or “randomization” without describing the detailed randomization information. Six studies that did not report specific methods of allocation concealment were assessed as unclear risk of selection bias, and there was a high risk of performance bias across the studies due to the difficulty of blinding to participants and personnel. Four studies had a single-blind design. We could not confrm any other forms of bias because the available information was insufcient.

Meta-analysis

Anxiety Level
A total of 446 patients, 223 in the music group and 223 in the control group, were recorded in six studies.^{[12, 16, 18, 21-23]} One study was performed using the Self-Rating Anxiety Scale.^[22] Five of these studies were recorded using the State Trait Anxiety Inventory,^{[12, 16, 18, 21, 23]} and the results showed a signifcant diference in the efect of music therapy on the anxiety score of patients with ophthalmic surgery, compared with patients who received standard care [standard mean difference =–0.75, 95% confidence interval (–1.42, –0.07), p=0.03] (I2=91%) (shown in Figure 4).

Physiological responses

Blood Pressure
Eight trials with 1'294 participants reported the effectiveness of music therapy on systolic and diastolic blood pressure.^{[12-13, 15, 18-21, 23]} The pooled result showed a beneficial effect on systolicblood pressure [standard mean difference = –0.82, 95% confidence interval (–1.40, –0.24, p=0.006)] (I2=96%) (shown in Figure 5) and diastolic blood pressure [standard mean difference =–0.93, 95% confidence interval (–1.62, –0.24), p=0.008] (I2=97%) (shown in Figure 6).

Heart Rate
Six studies with 860 participants reported data on heart rate. The pooled result showed a significant improvement in heart rate [standard mean difference = –0.86, 95% confidence interval (–1.55, –0.17, P=0.01] (I2=95%), as shown in Figure 7.

Pain
Four studies with 277 participants reported the efectiveness of music therapy on pain measured using the VAS. The pooled results showed a significant improvement in pain [standard mean difference =–1.16, 95% confidence interval (–2.24, –0.08), P=0.04] (I2=95%), as shown in Figure 8.

Publication bias

According to the trials included in this study, diastolic blood pressure was used to analyze publication bias. Both sides of the funnel plot were basically symmetrical, as shown in Figure 9. Therefore, there was no significant difference in publication bias.

DISCUSSION

The evidence in this review revealed that music therapy has an effective means to reduce the anxiety level in patients with ophthalmic surgery. This result was consistent with the findings of previous relevant studies, which showed that music therapy reduced patient anxiety levels in local anaesthesia surgery^[24-26]. The reason may be that the mechanism of music therapy is to produce pleasant emotions and divert attention, which relieve the patient's emotions and affect their feelings of pain and anxiety. Cooke M^[27] revealed that music was an effective nursing intervention for preoperative anxiety, and they suggested that day surgery units should encourage patients to listen to the music they chosen preoperatively, such as providing portable compact disc players and informing patients about bringing a music compact disc with them. Instead of the patients, it is the researchers who chose the type of music in most studies, which may underlie the differences in results between studies. In the other hand, the type of music and the method or timing of listening to music may influence the effect of the intervention. Current methods, such as comprehensive psychological intervention or video education, are often used to relieve the anxiety of patients,^[28-29] but these methods are difcult to perform and cannot be widely implemented. Music therapy has developed recently tobe a popular method for professional music therapists treating patients. One interesting finding to Wiwatwongwana's study^[18] was that the mode of binaural rhythm was added on the basis of music therapy. The anxiety level of the binaural rhythm music group was also significantly different from that of the control group, with a greater difference. Binaural rhythm refers to the fact that binaural beat technology efectively improves the brain EEG state. An accurate binaural rhythm accurately stimulates the corresponding brain regions, produces biological effects, improves mood or enhances potential^[30]. More studies have shown that binaural rhythm audio may significantly relieve acute anxiety levels preoperatively^[31-32]. Music therapy with binaural beats may be better. Future trials should focus on assessment the efect of music therapy using binaural rhythm on patients undergoing ophthalmic surgeries, to provide a more theoretical basis for clinical practice.

Our findings also revealed that music therapy affected the physiological responses of patients undergoing ophthalmic surgery. Pooled data showed that music therapy had a significant effect on blood pressure and heart rate. These results are as the same as those of Lee and Han^[33-34], and their findings confirmed that short-term therapeutic effects of music listening resulted in a substantial reduction in physiological stress responses. This result suggests that the decrease in blood pressure and heart rate may be due to the effect of background noise reduction/elimination, which may have diminished the infuences of the outside environment.Another systematic review found that music improved systolic blood pressure^[35], which is the main benefit of music for patients with hypertension and is consistent with the results of the present study. Decreases in these physiological variables may indicate a relaxed response. This study aims to analyse the effect of music therapy on diferent types of surgery, but there were few surgical methods to analyse subgroups. There ware few studies on physiological responses. Further research is needed to determine the impact of music therapy on postoperative physiological indicators of patients undergoing ophthalmic surgery.

A limited number of studies (n=4) evaluated the efficacy of music therapy on pain. Significant improvements were detected. This result was consistent with some studies,^[36-37] and music may be a simple, safe, and effective method of reducing harmful pain in patients after surgery. Music relaxes people and reduces the sensitivity of patients to pain, which is an effective and economical method.^[38] A previous meta-analysis also showed that music reduced self-reported chronic pain and depressive symptoms,^[39] and music had a greater efect when the patient, rather than the researcher, chose the music. Most individuals preferred soft and relaxed music, but the effect was not based on a specific type of music. Personalized music was more effective.^[40] Personalized music plays an important role because people like familiar music and dislike unfamiliar music. Although the music was selected according to the preferences for patients, it may not have been what the patients liked. To maximize the efect of music therapy, it is strongly recommended that patients listen to the music they chosen before and during surgery, such as by providing portable compact disc players and informing patients about bringing a music compact disc with them. It is recommended to equip music players in the operating room and prepare diferent types of music, such as light music, pop music, jazz, etc., for patients to choose the music they like. It is also a good idea to allow patients to wear their own music earphones under operating room disinfection conditions.
Preoperative anxiety, vital signs and postoperative pain are clinically relevant issues that may determine morbidity, duration of hospital stay and even mortality. Alleviating these factors may improve clinical outcomes and quality of life, also lead to earlier discharge from hospital, and thus may help to reduce healthcare costs.^[41] This meta-analysis provided evidence that music therapy has an obvious efect on relieving anxiety levels, while it is also more efective in alleviating pain and improving physiological responses than standard care. Based on this, it is suggested to conduct music therapy in the operating room to improve surgical related rehabilitation.

Advantages and limitations

The strength of this review is the explicit and relevant research question to prove the effectiveness of music therapy anxiety and physiological responses of patients undergoing ophthalmic surgery. To our best knowledge, this review is the first to explore music therapy in ophthalmic surgery, and the eleven included studies were RCTs. However, there are some limitations. First, the sample size of the included studies was limited, which reduces the accuracy of the analysis and provides only a small amount of clinical evidence. The population characteristics, the different types of surgery, timing and type of music therapy led to great heterogeneity. The intervention measures in the studies, including the Chinese and English literature, may have led to unstable outcomes. However, the publication bias analysis on all outcomes in this study showed that there was no significant difference, and we made a great effort to search for relevant publications in Chinese and English. Therefore, the conclusion in our study are certainly reliability.

CONCLUSIONS

Compared to standard care, this systematic review indicated that music therapy had a beneficial efect on anxiety, blood pressure, heart rate, and pain in patients undergoing ophthalmic surgery. Music therapy should be promoted in the clinic to comfort patients and help them recover quickly after being interpreted with caution. More high-quality studies are needed on the efects of music interventions ofered by a trained music therapist.

Correction notice

None

Acknowledgement

None

Author Contributions

(I) Conception and design: Qi Fu, Feipeng Wang and Bishan Tian
(II)Administrative support: Bishan Tian
(III) Provision of study materials or patients: Qi Fu and Shuping Li
(IV) Collection and assembly of data: Qi Fu and Shuping Li
(V) Data analysis and interpretation: Qi Fu and Shuping Li
(VI) Manuscript writing:All authors
(VII) Final approval of manuscript:All authors

Funding

None

Confict of Interests

None of the authors has any conflicts of interest to disclose. All authors have declared in the completed the ICMJE uniform disclosure form.

Patient consent for publication

None

Ethical Statement

This study does not contain any studies with human or animal subjects performed by any of the authors

Provenance and Peer Review

This article was a standard submission to our journal. The article has undergone peer review with ouranonymous review system

Data Sharing Statement

None

OpenAccess Statement

This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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