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Effect of Music Therapy on Hospital Induced Anxiety and Health Related

Quality of Life in Coronary Artery Bypass Graft Patients: A Randomised
Controlled Trial

Article in Journal of Clinical and Diagnostic Research · November 2019

DOI: 10.7860/JCDR/2019/42725.13274

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DOI: 10.7860/JCDR/2019/42725.13274
Original Article

Effect of Music Therapy on Hospital Induced

Physiotherapy Section

Anxiety and Health Related Quality of Life

in Coronary Artery Bypass Graft Patients:
A Randomised Controlled Trial
Abeeshna Ashok1, Sukumar Shanmugam2, Ajith SOmaN3

ABSTRACT by a trained physiotherapist on preoperative day and post

Introduction: Augmented incidence of anxiety is associated operative day 7.
with Coronary Artery Bypass Graft (CABG) compared to other Results: HADS anxiety score showed significant difference
surgeries; it affects the function of vital organ. Preoperative within the intervention as well as control group, with p-value
anxiety may persist after surgery and affects health related <0.05. The p-value of HADS depression component was <0.05
quality of life. Music therapy is found to have an impact on within each group. The values show that there is the reduction
patient’s anxiety. in both anxiety and depression in both groups nevertheless the
Aim: To find the effect of music therapy on hospital induced p-value between the group was >0.05, which showed that there
anxiety and Health Related Quality of Life (HRQoL) in patients is no significant difference in HADS score between groups. The
after CABG. p-value of 6 MWT between the group was >0.05, but showed
significant difference in control group. Physical component of
Materials and Methods: Forty participants were recruited for
SF-36 outcome did not show significant difference between the
the study, (age group 30-80 years) and randomised into two
groups with p-value >0.05. Mental component of SF-36 did not
groups. The intervention group received music therapy along
established significant improvement between the groups. There
with cardiac rehabilitation and control group received cardiac
was significant improvement in Physical component of SF-36
rehabilitation alone once in a day. The primary outcome
within the intervention group.
measure was Hospital Anxiety and Depression Score (HADS)
was measured by a trained physiotherapist on preoperative Conclusion: Both Phase I cardiac rehabilitation and music
day and postoperative day 2 and 7. The secondary outcome therapy has positive impact on anxiety, with music therapy
measures were SF-36 and 6 minute walk distance, measured being the most advisable.

Keywords: Cardiac rehabilitation, Cardiac surgery, Coronary artery disease, Sedative music

INTRODUCTION low ejection fraction, emotional response, and sleep along with
In India, CAD is a major causative factor for death which contributes cardiac symptoms affect the Health Related quality of life [9-11].
more than 25% of death among general population [1]. Elevated Low Cardiac rehabilitation is the standard of care after CABG. Cardiac
Density Lipoproteins (LDL) and other factors such as change the rehabilitation consists of several definitions but all the systems of
permeability of vessel wall and generate inflammatory reactions which definition poses common focus on a multidisciplinary approach and
cause migration of monocytes to the site of inflammation. Monocytes it is mainly directed to patient’s physical, psychological and social
then convert into macrophages, which is rich in cholesterol esters wellbeing. Cardiac rehabilitation is the essential care after CABG
and free fatty acids thus infiltrate the coronary vessels and reduce with level Ia evidence [12].
the coronary blood flow to the cardiac muscles [2]. Music therapy is considered as an alternative intervention to reduce
Preventive measures (diet modification, weight reduction, smoking the anxiety and without any side effects [13-16]. Sedative music has
cessation, cholesterol control, and control of diabetes and high shown better improvement in patients undergone heart surgery [17].
blood pressure) and medications are used in the early stage of the Listening to music arouse activities in nucleus accumbens NAc and
disease [3]. In severe cases, CABG is employed to improve the Ventral Tegmental Area (VTA) and releases dopamine. There is
circulatory compromise. Anxiety caused by fear of death, or level release of endorphins and reduction in catecholamine release which
change in health conditions, stressful setting in the ICU, continuous in turn lowers blood pressure [18]. A systematic review supports
monitoring by nurses, surrounding noise contributes to depression the effect of music therapy on anxiety in hospitalised persons [19].
in post surgery patients. Patients undergo anxiety and depression Listening to music during bed rest after open-heart surgery has some
after surgery due to factors like fear, pain, and lack of sleep can lead effects on the relaxation system as regards s-oxytocin and subjective
to reduced functional mobility and thereby reducing health related relaxations levels [20]. It has found to be cost effective and improves
quality of life [4-8]. quality of life in patients. Music reduces environmental sounds and
provides calm atmosphere thereby enhance psychological well-
Health-Related Quality of Life (HRQOL) is an essential aspect
being [21,22].
in assessing the outcome of any surgical intervention. Various
studies investigated the factors contributing to the reduction In addition, few studies have made known that heart rate and
in quality of life after surgeries and found to have a relationship respiratory rate improve, and oxygen consumption decreases
between psychosocial factors, demographic factors, and patient- after music therapy and found out that music therapy lowers the
related characteristics. Factors such as sex, diabetes mellitus, Heart Rate, Systolic Blood Pressure (SBP), and Mean Arterial
Journal of Clinical and Diagnostic Research. 2019 Nov, Vol-13(11): YC05-YC09 5
 Abeeshna Ashok et al., Effect of Music Therapy on Hospital Induced Anxiety and Health Related Quality of Life in Coronary www.jcdr.net

Pressure (MAP) among patients undergoing CABG. Also, studies according to his/her comfort and cardiac the rehabilitation protocol.
reveal that music therapy reduces the level of anxiety among The sedative music without lyrics (60-80 beats per minute) was
patients undergoing cardiac surgery. Music therapy reduces pain delivered for 20 minutes, once daily from the postoperative day-1
perception and the dosage of analgesics administered during the to postoperative day-7. This method of music therapy was delivered
intensive care unit and surgery unit stays of patients undergoing along with the Phase I cardiac rehabilitation programme [14,17,27].
coronary artery surgery. Few studies showed that music therapy All the patients in control group received Phase I cardiac rehabilitation
did not affect HR, SBP, Diastolic Blood Pressure (DBP), MAP, and from postoperative day 1 to 7 with the help of multidisciplinary
anxiety among patients undergoing cardiac surgery [23-26]. rehabilitation team [28]. Patients received 20 minutes of cardiac
The present authors found that there is a lack of evidence to provide rehabilitation in a day and the protocol was purely individualised.
music therapy as an adjunct in Phase I cardiac rehabilitation. The The progression of the treatment was decided based on patient’s
present authors assumed that music therapy along with the standard condition. Hospital anxiety and depression score was taken on
cardiac rehabilitation may enhance the quality of life and prevent or postoperative day 2 by trained outcome assessor (co-operation of
control anxiety. Therefore, conducted this study to evaluate the role the patient was ensured). All the outcome measures were taken
of music therapy in the standard cardiac rehabilitation protocol for by a trained therapist on postoperative day 7. Hospital anxiety
improving the health-related quality of life and reduce the anxiety. and depression scores were assessed on the postoperative day-2
and day-7 by an independent physiotherapist who was blinded
MATERIALS AND METHODS to group and intervention allocation. All other outcome measures
Ethical clearance was obtained from Institutional Ethics Committee, such as 6 minute walk test and SF-36 questionnaire were taken on
Nitte Institute of Physiotherapy, Deralakatte, Mangalore (Ref:NIPT/ postoperative day 7 by the same therapist [29-31].
IEC/Min//001/2016-2017/dated16-03-2017). Written permission Patients were discharged on postoperative day 6, patients who
to conduct this randomised controlled trial was obtained from the were not shifted from coronary care unit till postoperative day 7,
Head of the Cardiovascular Surgery Department and informed patients who died during the study and who refused to participate
consent was obtained from patients. The study was prospectively after surgery were considered to be drop out from the study. Patients
registered in the clinical trials registry-India with the registration were discharged based on the functional outcome on postoperative
number of CTRI/2017/06/008927. day 7. Intention-to-treat analysis was done after data collection and
To calculate sample size the technique of estimation of sample size drop out patients were also included in the analysis.
for paired t-test was used:
STATISTICAL ANALYSIS
Pre test mean-post test mean The data were analysed using SPSS software version 16.0. The
SD demographic data like age, gender were analysed using descriptive
(Z1-α/2+Z1-β)2 (Z1-α/2) statistics. To compare the outcome measures before and after
N= + interventions paired t-test used and when <2 time measurement
Δ2     2
were there Bonferroni was used. To compare the effectiveness of
Where Δ is technically significant (0.7). α is the confidence level (5%)
interventions between the groups ‘independent sample t-test’ used.
1-α is power of the test (80%). SD is the standard deviation. The
When data did not follow normal distribution Mann-Whitney U test
calculated sample size in each group was 17.
was used to compare between group variables or Wilcoxon sign
A sample size of 40 was considered and 40 sealed envelopes were rank test to compare variables within the group. The p-value less
made. Patients who were willing to participate and who met the than 0.05 was considered significant.
inclusion criteria were randomised and allocated into two groups
based on computer generated randomisation and sequentially RESULTS
numbered opaque sealed envelope method. A total of 55 patients were screened for eligibility during the period
Inclusion and exclusion criteria are listed in [Table/Fig-1]. Based on of August 2017 to March 2018. Out of these, 40 patients were
inclusion-exclusion criteria baseline data of patients were obtained randomly allocated into two groups [Table/Fig-2]. The participants’
prior to intervention (including heart rate, respiratory rate, blood characteristics are summarised in [Table/Fig-3].
pressure, body mass index, rate of perceived exertion, 6 minute walk
test, SF-36, Hospital Anxiety and Depression Scale, history regarding Hospital Anxiety and Depression
any other medical treatment and other health related conditions). Score (HADS) DEPRESSION
[Table/Fig-4] shows that there was a significant difference in POD-7
Inclusion criteria in depression component between groups.
• Subjects 30-80 years of age [Table/Fig-5] shows, within the intervention group at preoperative day
• Both male and female patients
• CABG both on pump and off pump.
and postoperative day 7, and postoperative day 2 and 7 the p-values
• Patients with LVEF <60% were <0.05 and hence there was a difference in depression. In
• Patients with 2 grafts control group at POD 2 and POD7 there was a difference (p<0.05).
Exclusion criteria
• Patients who are having hearing impairments Hospital Anxiety and Depression
• Patients after postoperative day 7, enter into phase II cardiac rehabilitation Score (HADS) ANXIETY
• Patients with multiple procedures (E.g., CABG+ valve replacement)
Comparisons of anxiety component of HADS score showed no
• Patients who do not have interest in music
• Patient contraindicated to 6 minute walk test difference [Table/Fig-6].
[Table/Fig-1]: Inclusion and exclusion criteria. [Table/Fig-7] shows significant difference between preoperative day
and postoperative day 7 and postoperative day 2 and 7 (intervention
Prior to the delivery of music the head-phones were sterilised with group) and postoperative day 2 and 7 (control group) in HADS
steriliser (ALCO SWAB® containing 70% alcohol- Isopropyl alcohol). anxiety component for the same.
Instructions were given prior to the intervention, instructed patient
to inform the therapist whenever he/she felt discomfort in between Six Minute Walk Test (6 MWT)
the treatment session. During the delivery of sedative music the The [Table/Fig-8] shows 6 minute walk test comparison between
volume and pitch were adjusted according to patient’s comfort. groups. The obtained p-values were >0.05 hence there was no
Position of the patient during the music therapy was selected difference in 6 MWT.
6 Journal of Clinical and Diagnostic Research. 2019 Nov, Vol-13(11): YC05-YC09
www.jcdr.net Abeeshna Ashok et al., Effect of Music Therapy on Hospital Induced Anxiety and Health Related Quality of Life in Coronary

Intervention (n=20) Control (n=20)

Median IQR Median IQR Z value p-value
PRE 7.56 5 to 12.75 7.50 7 to 9 1.561 0.49
POD-2 6 4 to 9 6 4 to 9 -0.175 0.92
POD-7 1 0 to 3 1.50 0.00 to 5 -0.859 0.31
[Table/Fig-6]: Between group comparisons of anxiety component of HADS by
using Mann-Whitney U test.

Group Pair Z value p-value

PRE & POD2 -1.201 0.230

Intervention (n=20) PRE & POD7 -3.186 0.001*

POD2 & POD7 -3.304 0.001*

PRE & POD2 -1.057 0.294

Control (n=20) PRE & POD7 -1.724 0.085

POD2 & POD7 -3.221 0.001*

[Table/Fig-7]: Within group comparison of anxiety component of HADS by using
Bonferroni test.
*Indicates significant

Intervention (n=20) Control (n=20)

Mean SD Mean SD “t” value p-value
PRE 276.85 116.670 264.55 85.398 0.380 0.706
POD-7 290.40 71.173 229.57 100.505 1.891 0.069
[Table/Fig-2]: CONSORT flow chart.
[Table/Fig-8]: Between group comparison of 6 MWT by using independent
sample t-test.
Control group Intervention group
Variable Mean SD Mean SD p-value Mean difference p-value

Age (years) 59.85 7.92 60.8 7.75 0.970 Intervention (n=20) PRE & POD7 12.93 0.684

Gender Control (n=20) PRE & POD7 58.999 0.024*

Male 6 6 0.634 [Table/Fig-9]: Within group comparison of 6 MWT by using independent sample t test.
*indicates significant
Female 14 14
BMI (kg/m2) 25.18 5.11 23.11 3.65 0.264 SF-36
HR (beats per minute) 75.65 13.488 75.55 12.194 0.486 Physical component summary: The [Table/Fig-10] shows the
RR (breaths per minute) 21.65 4.998 22.15 5.040 0.754
values of between group comparison of physical component
summary of SF-36 score. It indicates that there was no significant
RPE 7.97 2.377 7.35 2.153 0.396
difference in SF-36 scores.
Systolic BP (mmHg) 122.0 0.396 123.5 11.821 0.421
The [Table/Fig-11] shows significant difference in intervention group
Diastolic BP (mmHg) 78.500 8.750 79.500 8.255 0.522
for the physical component summary of SF-36 score.
6 MWT (distance in metres) 264.55 85.398 276.85 116.670 0.706
[Table/Fig-3]: Participant baseline characteristics by using descriptive statistics. Intervention (n=20) Control (n=20)
Mean SD Mean SD t value p-value
Intervention (n=20) Control (n=20)
PRE 40.69 6.813 40.232 6.867 0.214 0.628
Mean SD Mean SD “t” p-value
POD-7 46.99 6.311 43.372 8.23 1.321 0.355
PRE 5.53 2.722 5.53 2.47 0.046 0.964 [Table/Fig-10]: Between group comparisons of physical component of SF-36 score
POD-2 4.87 2.446 6.29 3.099 -1.44 0.159 by using independent sample t-test.

POD-7 1.80 1.373 3.39 3.025 -2.469 0.020*

Mean difference p-value
[Table/Fig-4]: Between group comparison of depression component of HADS by
using independent sample t-test. Intervention (n=20) PRE & POD7 -5.904 0.006*
*indicates significant
Control (n=20) PRE & POD7 -2.089 0.534
[Table/Fig-11]: Within group comparisons of PCS component of SF36 score by
Group Pairs Mean difference p-value using Bonferroni test.
PRE & POD2 0.667 1 *indicates significant

Intervention (n=20) PRE & POD7 3.73 0.002*

Mental Component Summary
POD2 & POD7 3.067 0.001*
The [Table/Fig-12,13] shows comparison of mental component
PRE & POD2 -0.857 0.985 summary of SF-36 score within group by using Bonferroni test. The
Control (n=20) PRE & POD7 1.5 0.303 obtained p-value was >0.05 within the groups and between the
POD2 & POD7 2.357 0.001* groups, hence there is no significant improvement.
[Table/Fig-5]: Within group comparison of depression component of HADS by The [Table/Fig-14] shows within group comparison of physical
using Bonferroni test.
*indicates significant component score of SF-36 score. The obtained p-value was <0.05
in PF, RP, GH, VT and RE in intervention group and PF component
The [Table/Fig-9] shows a significant difference in 6 MWT in control in control group. It shows that there is a difference in these
group. components.
Journal of Clinical and Diagnostic Research. 2019 Nov, Vol-13(11): YC05-YC09 7
 Abeeshna Ashok et al., Effect of Music Therapy on Hospital Induced Anxiety and Health Related Quality of Life in Coronary www.jcdr.net

Intervention (n=20) Control (n=20) in patients after CABG. There was no obvious clinically significant
t value p-value difference between groups in physical and mental component
Mean SD Mean SD
score. Physical component of SF-36 outcome did not show
PRE 37.65 9.63 39.88 6.270 -0.869 0.123
significant difference between the groups with p-value was >0.05.
POD-7 42.68 9.70 42.71 9.508 -0.009* 0.854 Mental component of SF-36 has been established, no significant
[Table/Fig-12]: Comparison of mental component of SF-36 score between the improvement between the groups and within the group was seen.
group by using independent sample t test.
There was significant improvement in Physical component of SF-36
within the intervention group.
Mean difference p-value
Comparison of cardiovascular indices after treatment showed that
Intervention (n=20) PRE & POD7 -4.273 0.210
there is a significant difference in heart rate and rate of perceived
Control (n=20) PRE & POD7 -2.001 0.550 exertion; there was no significant difference in respiratory rate and
[Table/Fig-13]: Within group comparison by using Bonferroni test. systolic and diastolic BP within each group and between groups.
The results does not correlates with the findings of research done
PRE POST by Heidari S et al., which state that there is no significant difference
Mean SD Mean SD “t” p-value among cardiovascular indices after music therapy in patients
Intervention 46.667 23.503 65.332 22.635 -2.441 0.029* following surgery [32].
PF
Control 45.000 25.343 57.885 20.726 -1.419 0.179 Effect of music on health-related quality of life along with Phase I
Intervention 37.083 31.112 51.666 26.142 -3.205 0.006* cardiac rehabilitation has not been evaluated in any of the studies to
RP date to the best of authors’ knowledge. Kurfirst V et al., demonstrated
Control 44.196 16.710 46.875 18.467 -0.442 0.666
that there is an improvement in health-related quality of life after one
Intervention 47.066 26.477 65.000 32.958 -1.757 0.101
BP year by using the SF-36 score in cardiac surgery patients, our study
Control 45.500 26.258 53.214 26.873 -0.652 0.526 showed that there is an improvement in HRQOL in CABG patients
Intervention 54.466 18.360 66.066 14.404 -2.054 0.059* till discharge from hospital (Phase I cardiac rehabilitation) [9]. The
GH
Control 60.500 17.986 65.000 17.119 -0.706 0.493 prolonged effect is out of scope of the present study. Future studies
Intervention 51.250 15.345 59.166 16.781 -2.588 0.021*
can be done to find out the prolonged-effect on the quality of life in
VT CABG patients after music therapy. This is the first study evaluating
Control 53.571 20.904 59.375 19.107 -0.756 0.463
the effect of music therapy on health related quality of life.
Intervention 54.166 23.464 48.333 23.081 0.959 0.354
SF
Control 55.357 26.726 43.750 21.230 1.247 0.234 LIMITATION
Intervention 33.889 27.180 57.778 28.948 -3.170 0.007* Patient received sedative music which is not of patient’s choice. The
RE
Control 51.190 23.763 52.975 25.235 -0.225 0.825 follow-up treatment outcomes has not been considered in the study,
Intervention 61.000 19.838 66.666 23.196 -0.732 0.476 the effect of music therapy on functional outcomes after discharge
PF is not known. The sample strength is not sufficient to provide an
Control 55.357 19.361 71.428 20.232 -2.337 0.036*
accurate result.
[Table/Fig-14]: Within group comparison of eight components of SF-36 score by
using paired t-test.
CONCLUSION
DISCUSSION In conclusion, the present authors demonstrate that music therapy
This study primarily aimed at finding the effect of music therapy on during Stage-I cardiac rehabilitation is found to be effective to reduce
postoperative anxiety. HADS score showed significant difference postoperative anxiety and improve quality of life in CABG patients.
within each groups nevertheless there was no significant difference The present authors also suggest that it’s an effective and harmless
in the outcome between the groups. This result correlates with the means for the management of hospital induced anxiety.
study by Heidari S et al., which showed music therapy reduces
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PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of Physiotherapy, Nitte Institute of Physiotherapy, NITTE (Deemed to be University), Mangalore, Karnataka, India.
2. Assistant Professor, Department of Physiotherapy, Nitte Institute of Physiotherapy, NITTE (Deemed to be University), Mangalore, Karnataka, India.
3. Assistant Professor, Department of Physical Therapy, College of Applied Medical Sciences, Shaqra University, Kingdom of Saudi Arabia.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: PLAGIARISM CHECKING METHODS: [Jain H et al.] Etymology: Author Origin
Abeeshna Ashok, • Plagiarism X-checker: Aug 27, 2019
Nitte Institute of Physiotherapy, NITTE (Deemed to be University), • Manual Googling: Sep 23, 2019
Mangalore, Karnataka, India. • iThenticate Software: Oct 10, 2019 (10%)
E-mail: [email protected]

Author declaration:
• Financial or Other Competing Interests: No Date of Submission: Aug 27, 2019
• Was Ethics Committee Approval obtained for this study? Yes Date of Peer Review: Sep 03, 2019
• Was informed consent obtained from the subjects involved in the study? Yes Date of Acceptance: Sep 24, 2019
• For any images presented appropriate consent has been obtained from the subjects. Yes Date of Publishing: Nov 01, 2019

Journal of Clinical and Diagnostic Research. 2019 Nov, Vol-13(11): YC05-YC09 9

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