Music Therapy as a Tool for Alleviating Anxiety and Pain in Patients Undergoing Gastrointestinal Endoscopy

Abstract

Objective:

The purpose of this study was to explore how music therapy impacts anxiety and pain levels in patients undergoing gastrointestinal endoscopy.

Methods:

This was a retrospective study conducted from July 2021 to July 2024. A total of 367 patients who underwent gastrointestinal endoscopy at our hospital were selected as subjects. After excluding 67 cases, 300 patients were finally included. Based on whether they received music therapy or not, patients were divided into a music therapy group (n = 165) and a routine nursing group (n = 135). The music therapy included listening to music with headphones while waiting for and undergoing endoscopy. Before and 5 minutes after the endoscopy, the anxiety status [State-Trait Anxiety Inventory (STAI)], pain level [Numerical Rating Scale (NRS)], and hemodynamic characteristics were compared between the two groups.

Results:

Before the endoscopy, there were no significant differences in STAI scores, NRS scores, and hemodynamic characteristics between the two groups (P > 0.05). After the endoscopy, the State Anxiety Inventory score of the STAI (37.88 ± 8.12) and the NRS score (3.95 ± 0.95) in the music therapy group were significantly lower than the STAI score (40.85 ± 8.38) and NRS score (4.55 ± 1.03) in the routine nursing group, with t-values of 3.106 and 5.239, respectively (P < 0.05). No significant differences in hemodynamic characteristics—pulse oxygen saturation, heart rate, and mean arterial pressure—existed between the two groups after the endoscopy (P > 0.05).

Conclusion:

This study showed that music therapy effectively reduced anxiety and pain in patients undergoing gastrointestinal endoscopy, highlighting its significant clinical value.

KEY MESSAGES

• (1)Music therapy effectively reduces anxiety in patients undergoing gastrointestinal endoscopy
• (2)Music therapy effectively reduces pain in patients undergoing gastrointestinal endoscopy, with significant clinical application value
• (3)Music therapy, as a noninvasive and simple auxiliary therapy, can help improve the safety and accuracy of endoscopy.

INTRODUCTION

Gastrointestinal endoscopy is a common and effective medical diagnostic tool that plays a crucial role in disease screening and treatment.[1] However, as an invasive procedure, traditional gastrointestinal endoscopy often causes patients to experience intense discomfort and pain. These consequences can lead to abnormal fluctuations in physiological indicators, such as heart rate (HR) and blood pressure, which may affect the accuracy and safety of the endoscopy.[2,3] Additionally, many patients may experience anxiety and nervousness before and during gastrointestinal endoscopy due to concerns about pain, discomfort, or embarrassment, as well as a lack of knowledge about the endoscopy procedure, which can increase the risk of examination failure.[4,5,6]

In recent years, researchers have extensively explored methods to enhance the experience of patients undergoing gastrointestinal endoscopy,[7] with music therapy emerging as a notable nonpharmacological intervention.[8] Music therapy can modulate the autonomic nervous system and cerebral cortex function through auditory stimulation, with potential sedative and soothing effects.[9,10] Prior research has shown that music therapy can markedly reduce anxiety and pain in procedures such as cesarean sections and dental treatments.[11,12] However, in-depth research on the application and effectiveness of music therapy in gastrointestinal endoscopy remains relatively limited.

As a noninvasive and cost-effective adjuvant treatment, music therapy holds immense potential in alleviating anxiety and pain in patients undergoing gastrointestinal endoscopy, providing a simple and easily implementable form of psychological support.[13] The objective of this study was to assess the possible effects of music therapy on anxiety and pain experienced by patients during gastrointestinal endoscopy, offering evidence to broaden the clinical use of music therapy.

MATERIALS AND METHODS

Subject Selection

The clinical data of patients who underwent gastrointestinal endoscopy at the Endoscopy Center of our hospital from July 2021 to July 2024 were retrospectively analyzed. The sample size was calculated using the following formula: n = (Z_α/2 + Z_β)² × 2 × σ²/d², α = 0.05, β = 0.10, d = 0.5, σ = 1.12, and the resulting sample size was 107 cases for each group.

Considering the possibility of case exclusion and dropout, we selected 367 cases as subjects. After excluding 67 cases, the final sample size was 300. Based on whether they received music therapy, patients were divided into a music therapy group (n = 165) and a routine nursing group (n = 135).

Inclusion Criteria

The inclusion criteria were as follows: (1) patients aged ≥18 years old; (2) underwent gastroscopy or colonoscopy for the first time; (3) no general anesthesia administered during the endoscopy; (4) complete clinical data available; and (5) informed consent provided by the patients and their families.

Exclusion Criteria

The exclusion criteria were as follows: (1) presence of malignant tumors; (2) severe mental illness or cognitive impairment; (3) inability to cooperate with the endoscopy; (4) hearing loss or inability to perceive the effect of music; (5) severe dysfunction of the heart, liver, and other organs; and (6) use of anxiolytics or underwent psychological therapy within the past month.

Endoscopy Methods

Patient Preparation and Medication

(1) Prior to the gastroscopy, patients had to abstain from food for a minimum of 6 hours and from water consumption for at least 4 hours. Thirty minutes before the gastroscopy, patients were instructed to ingest 10 mL of lidocaine hydrochloride jelly (Zhejiang Kangde Pharmaceutical Group Co, Ltd, 10 g/0.2 g, Zhejiang, China), 20,000 units of Streptomyces protease granules (Beijing Taide Pharmaceutical Co, Ltd, Beijing, China), and 30 to 50 mL of 0.5% to 1.0% dimethicone suspension (Zigong Honghe Pharmaceutical Co, Ltd, Sichuan, China).

(2) Colonoscopy Procedure: Before the colonoscopy, patients were instructed to fast and refrain from drinking water for 6 hours. For intestinal cleansing, patients were interested to use polyethylene glycol electrolyte powder for oral solution (IV) (trade name: Shutaiqing, Staidson Biopharmaceutical Co, Ltd, Beijing, China). Six packets were dissolved in 750 mL of warm water and stirred until a homogeneous solution was formed. Patients were asked to consume the solution in divided doses within 45 minutes.

Routine Nursing

Patients in the routine care group received standard care, which included: (1) before the endoscopic examination, patients waited in a quiet and cozy waiting room, where nurses explained the process of endoscopy to patients and assisted with bowel preparation; and (2) during the examination, nurses informed patients on how to cooperate, helped them adjust their body position, closely monitored their physical signs, and ensured their privacy was fully respected.

Music Therapy

Patients in the music therapy group were given music therapy on the basis of routine nursing care. The therapy was divided into two stages. (1) Preparation stage: Nurses actively and effectively communicated with the patients to understand their cultural background, psychological state, personality traits, hobbies, and ability to appreciate music. Appropriate music tracks, including soothing, relaxing, and uplifting music styles, were selected for the patients. (2) Treatment stage: Participants were instructed to listen to music using headphones at a volume of 40 to 50 dB. They were also instructed to do breathing exercises and meditation during endoscopy. Patients continuously listened to the music until the endoscopy was completed.

Observation Indicators

General Information

General information was obtained from the hospital medical record system, including body mass index (BMI), gender, age, education level, payment method, monthly income, family history of cancer, main symptoms, and examination duration.

Hemodynamic Characteristics

Hemodynamic parameters, including mean arterial pressure (MAP), HR, and blood oxygen saturation (SpO₂), were recorded from T₀ (5 minutes before the examination) to T₁ (30 minutes after the examination) using a multiparameter patient monitor (model UMEC10/12; Shenzhen Mindray Bio-Medical Electronics Co, Ltd, Guangdong, China).

Anxiety Level

The State-Trait Anxiety Inventory (STAI)[14] was used to assess patients’ anxiety levels at T₀ and T₁. The scale consists of two dimensions with a total of 40 items. The first 20 items are the State Anxiety Inventory (S-AI), which assesses the patients’ immediate emotional experiences, including tension, fear, and worry. The remaining 20 items make up the Trait Anxiety Inventory (T-AI), which assesses the patients’ stable and chronic anxiety tendencies. A 4-point rating scale was used, with 1 point indicating “almost never” and 4 points indicating “always.” Each dimension has a total score of 80. The Cronbach’s α coefficient for the scale is 0.901.

Pain Level

The Numerical Rating Scale (NRS)[15] was used to evaluate pain at T₀ and T₁. Patients were asked to choose a number that best represented their pain level. A score of 0 indicates no pain, 1 to 3 indicates mild pain, 4 to 6 indicates moderate pain, 7 to 9 indicates severe pain, and 10 indicates the most severe pain. The Cronbach’s coefficient is 0.871.

Statistical Methods

Statistical analysis was performed using SPSS 27.0 (IBM Corp, Armonk, NY, USA). For continuous data, normality was assessed using the Kolmogorov–Smirnov test. Normally distributed continuous data were expressed as (x̄± s) and analyzed using t-tests. Non-normally distributed continuous data were expressed as the median and interquartile range and analyzed using the Mann–Whitney U test. Categorical data were expressed as n (%) and compared using chi-square (χ²) tests, with a P value of <0.05 indicating statistical significance.

RESULTS

General Information

No significant differences were found between the two groups in terms of gender, age, BMI, education level, payment method, monthly income, family cancer history, type of endoscopy, main symptoms, comorbidities, and examination duration (P > 0.05) [Table 1].

Table 1.

General Information of the Two Groups.

Indicator		Routine Nursing Group (n = 135)	Music Therapy Group (n = 165)	t/χ 2	P
Gender	Male	78 (57.78)	90 (54.45)	0.315	0.575
	Female	57 (42.22)	75 (45.45)
Age (year)		41.33 ± 4.15	42.11 ± 4.58	1.530	0.127
Body mass index (kg/m2)		21.25 ± 2.13	21.36 ± 2.05	0.454	0.649
Education level	Junior high school and below	38 (28.15)	48 (29.09)	0.077	0.962
	Senior high school	50 (37.04)	62 (37.58)
	College or above	47 (34.81)	55 (33.33)
Payment method	Self-payment	32 (23.70)	35 (21.21)	1.296	0.523
	Basic medical insurance for urban and rural residents	70 (51.85)	80 (48.48)
	Other	33 (24.44)	50 (30.30)
Monthly income (CNY)	<3000	35 (25.93)	45 (27.27)	0.130	0.937
	3000–5000	50 (37.04)	62 (37.58)
	>5000	50 (37.04)	58 (35.15)
Family cancer history	Yes	108 (80.00)	129 (78.18)	0.147	0.701
	No	27 (20.00)	36 (21.82)
Endoscopy type	Gastroscopy	76 (56.30)	84 (50.91)	0.866	0.352
	Colonoscopy	59 (43.70)	81 (49.09)
Main symptom	Stomachache	6 (4.44%)	8 (4.85%)	0.027	0.869
	Distention	8 (5.93%)	11 (6.67%)	0.069	0.793
	Acid reflux	17 (12.59%)	21 (12.73%)	0.001	0.972
	Nausea	9 (6.67%)	12 (7.27%)	0.042	0.838
	Other	4 (2.96%)	4 (2.42%)	0.000	1.000
Examination duration (minutes)		7.83 ± 2.21	8.11 ± 2.47	1.021	0.308

CNY = Chinese yuan.

Anxiety Level

Before the endoscopy, no significant difference in STAI scores existed between the two groups (P > 0.05). After the endoscopy, the S-AI scores of the music therapy group were significantly lower than those of the routine nursing group (P < 0.05), while the T-AI scores of the two groups showed no significant difference (P > 0.05), as shown in Table 2.

Table 2.

State-Trait Anxiety Inventory Scores of the Two Groups Before and After Endoscopy (Point, x̄± s).

Group	n	S-AI		T-AI
		T0	T1	T0	T1
Music therapy group	165	42.38 ± 10.63	37.88 ± 8.12*	43.78 ± 7.71	43.05 ± 9.85
Routine nursing group	135	41.32 ± 9.60	40.85 ± 8.38*,†	44.80 ± 8.42	44.57 ± 10.02
t		1.145	3.106	1.094	1.316
P		0.158	0.002	0.275	0.188

S-AI = State Anxiety Inventory, T-AI = Trait Anxiety Inventory, T₀ = before the endoscopy, T₁ = 5 minutes after the endoscopy; comparison between groups; ^* P < 0.05;^†P < 0.05; compared with T₀.

Pain Level

After the endoscopy, NRS scores of both groups increased; however, the NRS score of the music therapy group was significantly lower than that in the routine nursing group (P < 0.05), as shown in Table 3.

Table 3.

Numerical Rating Scale Scores of the Two Groups Before and After Endoscopy (Point, x̄± s).

Group	n	T 0	T 1
Music therapy group	165	2.00 (1.00, 3.00)	3.95 ± 0.95
Routine nursing group	135	2.00 (2.00, 3.00)	4.55 ± 1.03*
Z/t		0.073	5.239
P		0.942	<0.001

NRS = Numerical Rating Scale, T₀ = before the endoscopy, T₁ = 5 minutes after the endoscopy; comparison between groups;^* P < 0.05.

Hemodynamic Characteristics

After the endoscopy, HR and MAP levels of both groups increased (P < 0.05), and the SpO₂ levels did not change significantly compared to pretreatment values (P > 0.05). No significant difference in the hemodynamic characteristics existed between the two groups before and after the endoscopy (P > 0.05), as shown in Table 4.

Table 4.

Hemodynamic Characteristics of the Two Groups Before and After Endoscopy (x̄± s).

Group	n	SpO2 (%)		HR (beat/min)		MAP (mm Hg)
		T 0	T 1	T 0	T 1	T 0	T 1
Music therapy group	165	98.34 ± 1.01	98.16 ± 0.93	75.75 ± 11.76	82.01 ± 6.12*	84.17 ± 11.42	92.69 ± 9.95*
Routine nursing group	135	98.21 ± 0.93	98.02 ± 0.98	74.92 ± 12.25	82.69 ± 6.54*	83.92 ± 10.56	94.43 ± 10.12*
t		1.149	1.266	0.597	0.928	0.196	1.495
P		0.251	0.207	0.551	0.354	0.845	0.135

HR = Heart rate, MAP = mean arterial pressure, SpO₂ = blood oxygen saturation, T₀ = before the endoscopy, T₁ = 5 minutes after the endoscopy; compared with T₀; ^* P < 0.05.

DISCUSSION

Endoscopy is a valuable tool used for the clinical diagnosis and treatment of various diseases. Endoscopic technology is being continuously developed and commonly used in more occasions.[16,17] In gastrointestinal endoscopy without sedation, many patients experience anxiety, fear, excessive salivation, and pain, which can affect clinical results.[18,19] These discomfort reactions and emotional changes last for a period of time after the examination, affecting the patient’s overall medical experience.

Foster et al.[20] suggest that music therapy is an easy-to-operate and easily accepted supportive therapy that can alleviate patients’ stress reactions. The S-AI scores of the music therapy group were lower than those of the routine nursing group after endoscopy, indicating that music therapy can reduce the anxiety level of patients during endoscopic examinations. The reason may be that music therapy can lead to an overall reduction in patients’ physical alertness and anxiety, thereby achieving physical and mental relaxation.[21] By immersing themselves in their favorite music, patients can imagine and feel the beautiful scenes in the music, generate emotional resonance, and gain strength. Fleckenstein et al.[22] believe that music can be used as a safe, easily applicable, and noninvasive auxiliary therapy. Patients experienced tachycardia and endocrine abnormalities during endoscopic examinations, leading to an in vivo stress response. The stress response affects the autonomic nervous system, leading to neurological dysfunction and causing patients to feel nervous, anxious, and others. Some studies have shown that music can directly affect the limbic system of the brain, the brainstem reticular formation, human blood circulation, and somatic function. Different types of music can trigger different cortical activation patterns.[23,24] In our study, choosing the appropriate type of music based on the patient’s preferences was found to increase the activity of the parasympathetic nervous system, thereby effectively alleviating patients’ negative emotions—findings that are consistent with other studies.[25]

After the endoscopy, the music therapy group exhibited a lower NRS score compared to the routine nursing group. Cordoba-Silva et al.[26] reported that music therapy reduces pain perception by distracting attention and also increases the pain threshold by increasing the Alpha and Theta brain waves. Through the appropriate sound waves, the patient’s hearing can be stimulated to effectively reduce the patient’s pain level. Other studies have shown that music can enhance the synergy between the amygdala and the prefrontal cortex, reduce cortisol levels, inhibit activity in the pain centers, and thus play an analgesic effect by reducing physiological pain perception in the human body.[27,28,29]Gastrointestinal endoscopy is an invasive procedure, and patients undergoing this examination often experience stress responses due to psychological factors such as discomfort, fear, and anxiety. This stress response leads to the activation of the autonomic nervous system, subsequently causing an increase in HR and arterial pressure. However, our study found no significant differences were in SpO₂, HR, and MAP between the two groups after the endoscopy. The reason may be that hemodynamics is a complex physiological process regulated by a multitude of internal and external factors.[30,31]

LIMITATIONS

This study had several limitations. First, the short duration and relatively small sample size may affect the external validity of the results, and the single-center design may reduce the generalizability of the research results. Second, we did not perform multiple regression analysis to adjust for confounding factors. Potential confounding factors may have affected the study results. Third, this study observed only the indicators before and after endoscopy, conferring difficulty in determining the effect of music therapy during the endoscopy. Furthermore, the use of music therapy in this study focused on pain and anxiety, relying on subjective feedback from patients. The exploration of other objective symptoms such as nausea, vomiting, and headache was limited. Therefore, we will consider conducting multicenter, prospective studies in and adding objective measurement indicators.

CONCLUSION

Music therapy is beneficial for alleviating anxiety and pain in patients undergoing gastrointestinal endoscopy. Therefore, music therapy has clinical application value in patients undergoing endoscopic examination and should be promoted.

Availability of data and materials

The datasets used and/or analyzed during the current study were available from the corresponding authors on reasonable request.

Author contributions

Wei Long and Zhu Yang designed the study; Wei Long, Shengju Lu and Fang Jiang collected and analyzed the data; and Zhu Yang and Huiping Luo participated in drafting the manuscript. All contributors participated in revising the manuscript. All contributors endorsed the final version for publication and each took full responsibility for their respective sections and committed to addressing any inquiries about the accuracy or completeness of the work.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Third Affiliated Hospital of Zunyi Medical University (the First People’s Hospital of Zunyi) with an approval number of (2021)-1-10. All participants have granted their consent to participate.

Conflicts of interest

The authors declare no conflict of interest.

Funding Statement

None.