Web app-based music intervention before cataract surgery lowers anxiety levels and hypertension: JAMA
Cataract surgery is the most frequently performed operation in high-resource countries. In most cases, the phacoemulsification procedure is performed under local anesthesia in an outpatient unit. Overall, up to 80% of patients experience anxiety before surgery, including cataract surgery. Anxiety causes stress that in turn drives the cardiovascular system to respond by activating the sympathetic nervous system, resulting in elevated heart rate and blood pressure (BP) levels. These mechanisms can complicate the surgical procedure owing to increased intraocular pressure. Hypertension and tachycardia above 85 beats per minute represent an increased risk of orbital hemorrhage during the injection of a local anesthetic and of potential perioperative suprachoroidal expulsive hemorrhage. Therefore, special arrangements are suggested for patients with severe anxiety.
The provision of information on the safety of cataract surgery and the informed consent process can contribute to reducing patient anxiety. However, high-quality individual preoperative patient counseling remains challenging in view of the busy clinical environment. In addition, some patients prefer distraction to ease anxiety rather than information on the procedure. One effective nonpharmacologic approach to anxiety before surgery is music intervention. Music augments positive reward pathways in the brain and functions to reinforce a healthy engagement with disease states.
Music interventions in perioperative and postoperative settings in general surgery can have positive effects on reducing patient anxiety. Paying attention to personal musical preferences and cultural background is considered to be one of the main characteristics of a successful musical intervention.
According to the literature, music sessions should last between 20 and 60 minutes (at approximately 60 to 80 beats per minute), be instrumental (nonlyrical), and consist principally of harmonic variations.
Based on recent scientific recommendations, a web app–based personalized music intervention has been developed: the U sequence based on a musical composition algorithm. The music sequence can last from 20 to 60 minutes and is divided into several phases that gradually enable the patient to lower pain and anxiety levels in line with the U sequence technique.
Little is known about nonpharmacologic approaches to anxiety during cataract surgery performed while the patient is awake. They could offer an inexpensive method to reduce anxiety in these patients. Furthermore, music may theoretically reduce anxiety in the surgeon and even improve surgical performance.
The principal objective of the study done by Gilles Guerrier and team was to describe the effects of a web app–based music intervention on the incidence of hypertension in patients during cataract surgery performed under local anesthesia.
This randomized, single masked, controlled clinical trial was composed of 2 arms and took place at a single center at Cochin Hospital in Paris, France. A total of 313 participants were screened between February 2017 and July 2018. Among these, 311 participants undergoing a phacoemulsification procedure for elective surgery for their first eye cataract under local anesthesia were enrolled. Analysis was intention to treat and began in September 2018 and ended November 2018. Interventions included participants requiring cataract surgery were assigned randomly to either the experimental arm (web app–based music listening intervention delivered via headphones) or control arm (noise-canceling headphones without music) for 20 minutes before surgery.
The primary end point was the occurrence of at least 1 hypertensive event during cataract surgery, defined in the protocol as systolic BP level more than 160 mm Hg and/or diastolic BP level more than 100 mm Hg combined with tachycardia level more than 85 bpm. Secondary end points concerned the evolution of anxiety at the end of the music intervention, the mean quantities of anxiolytic drugs injected during the surgical procedure, and the duration of the surgical procedure. Anxiety levels determined using a visual analog scale (VAS rated from 0 to 10), BP level, and heart rate were all recorded before and after the music intervention, preoperatively, and postoperatively in the recovery room.
RESULTS:
- A total of 310 participants were randomized in the study (155 to each arm) and 309 were analyzed.
- The mean (SD) age of the participants was 68.9 (10.8) years, and there were 176 female individuals (57%).
- On the primary end point, the incidence of hypertension was significantly lower in the music arm (21 [13.6%]) than in the control arm (82 [52.9%]), with a difference between the 2 arms of 39.3% (P < .001).
- Regarding the secondary end points, the mean (SD) visual measure of anxiety was lower in the music arm (1.4 [2.0]) than in the control arm (3.1 [2.4]), with a difference of 1.5 (P = .005).
- The mean (SD) number of sedative drug injections required during surgery was 0.04 (0.24) vs 0.54 (0.74) in the music vs control arms, respectively, with a difference of 0.50 (P < .001).
This single-masked, prospective, randomized, controlled assessment of a web app–based music intervention before cataract surgery demonstrated a significant reduction in hypertensive events during phacoemulsification. An improvement in anxiety levels was also demonstrated.
In addition, a reduction in the number of drugs injected to reduce anxiety or hypertension during the procedure was reported. This could be of particular interest in outpatient settings in that it avoids adverse effects such as drowsiness and shortens the hospital stay. Interestingly, despite some music sessions being halted prematurely in a few participants, music still had beneficial effect in terms of reducing anxiety.
BP and heart rate levels were lower during surgery in participants receiving the music intervention than in the control arm. Because the music session lasted only 20 minutes, a noticeable remnant relaxing and anxiolytic effect was observed.
Neuroscience findings have indicated that music is processed differently in the brain depending on an individual's musical background and skills. The present study was able to demonstrate that a web app–based music intervention offers a simple and cost-effective method to deliver the U sequence algorithm as treatment for anxiety. It is now necessary to explore the effects of music intervention on preoperative anxiety by comparing patients who listen to researcher selected or predetermined music vs patients who listen to no music at all.
The authors concluded, "This study offers empirical evidence that a patient controlled music intervention, specifically using a web app– based music intervention, can improve the overall effect and consequences of anxiety on cataract surgery. By reducing hypertension, levels of anxiety, and the need for sedative drugs during the procedure, a 20-minute music intervention before cataract surgery based on the U sequence algorithm appears to offer an effective treatment for anxiety, thus highlighting the importance of listening to music in decreasing its debilitating effects. Furthermore, this treatment is easily accessible and distributable via its computer- and smartphone-based application. Overall, we would like to stress the positive effects of using a web app–based music intervention as potential large-scale treatment for those who experience anxiety and possibly in the context of other types of surgical procedures."
Source: JAMA Ophthalmology
doi:10.1001/jamaophthalmol.2021.2767
