Music in the Wound Care Center: Effects on Anxiety Levels and Blood Pressure Measurements in Patients Receiving Standard Care

BACKGROUND: Chronic wounds require frequent assessment, minor procedures, and dressing changes. Discomfort, anxiety, and stress are commonly reported during treatment procedures. PURPOSE: To examine the effect of music during treatment on post–wound care treatment anxiety levels and blood pressure measurements in patients with chronic wounds. METHODS: This randomized controlled trial was conducted in a wound care center within a nonprofit academic medical center with a before-and-after intervention measurement. A total of 222 consecutive patients were randomly allocated to either an intervention group (n = 112; classical music was played during treatment) or a control group (n = 110; no music was played during treatment) at their scheduled routine outpatient visits. The State-Trait Anxiety Inventory (STAI) was administered and blood pressure measurements were obtained automatically by machine before and after the intervention. Pretreatment and posttreatment scores were compared using the paired t-test in SPSS 25. RESULTS: Patient age and sex did not differ between the intervention and control groups and pretreatment and posttreatment STAI scores; blood pressure measurements were almost identitical in the control group. In the intervention group, statistically significant differences between the pretreatment and posttreatment STAI scores (M = 45.94 and 40.83), systolic blood pressure measurements (M = 141.94 and 135.72), and diastolic blood pressure measurements (M = 70.93 and 66.23) were observed (P < .001). CONCLUSION: In this study, playing classical music in the treatment room during wound care interventions resulted in a significant decrease in patient anxiety scores and blood pressure measurements.

In the United States, chronic wounds (including venous ulcers, diabetic foot ulcers, and pressure ulcers/injuries) affect approximately 8.2 million people as estimated by a 2018 retrospective analysis of Medicare beneficiaries, and treatment costs ranged from $28 billion to $96.8 billion annually.¹ These numbers are expected to increase with the growing aging population and higher prevalence rates of chronic diseases, such as diabetes and peripheral artery disease, in older adults.¹ Patients with chronic wounds are reported as having poor quality of life associated with chronic pain and odorous exudate.² The treatment of chronic wounds in the wound care center (WCC) requires wound assessment, minor procedures, and dressing changes. WCCs provide a specialized level of care using various wound care therapies to promote healing.³ Anxiety has been reported during treatment and may lead to increased pain sensation and stress.⁴ Pharmacological treatment has been a traditional way to alleviate anxiety; however, this can increase the risk of drug dependency and unwanted side effects.⁵ Nonpharmacological approaches are considered to be more desirable because of fewer side effects and greater cost-efficiency.⁶

The use of music to reduce anxiety and promote relaxation has been known for centuries as an adjunct to disease treatment.⁷ Different tempos and modes are used to stimulate social and emotional well-being, which in turn reduce anxiety.⁸ In a randomized controlled trial, Raglio et al⁹ observed 60 people with severe dementia and reported that music had an effect on the autonomic nervous system, plasma cytokine levels, and catecholamine levels. The theoretical basis for reducing anxiety is to promote relaxation through music’s effect on the autonomic nervous system.¹⁰ In a randomized controlled study by Guzzetta,¹¹ 80 patients in a coronary care unit admitted with the presumptive diagnosis of acute myocardial infarction had lower apical heart rates and higher peripheral temperatures after listening to music. In that same study the authors argued that patients’ awareness of time passing became hazy while listening to music because their focus on the music promoted a relaxation response.

For the past decade, the therapeutic effects of music on physical and psychological aspects have been studied in various populations including patients receiving hemodialysis¹² and waiting for a dental procedure¹³ as well as patients who had cancer,¹⁴ postcardiac surgery,¹⁵ a stroke in the post-acute rehabilitation setting,¹⁶ obesity and postoperative pain,¹⁷ and Huntington’s disease.¹⁸ Furthermore, a systematic review by Li et al¹⁹ found a positive correlation between treatments including music interventions and pain alleviation, anxiety relief, and heart rate reduction in patients with burns. Nevertheless, few studies have investigated the effects of music on reducing the level of anxiety in patients undergoing routine wound care treatment in WCCs.

The purpose of this study was to assess the effect of music on anxiety levels and blood pressure among patients with chronic wounds requiring wound treatment. The overarching research question was, “What are the effects of music on posttreatment anxiety levels among patients with chronic wounds?” The literature supports the following hypothesis: listening to music decreases posttreatment anxiety levels among patients with chronic wounds.

Study design and sample. Using convenience sampling methods, consecutive patients from a WCC were randomly assigned to control (no music) and intervention (music) groups. The start date of the study was December 1, 2019. The end date of the study was Feburary 28, 2020. Verbal consent was obtained from all patients while they were in the WCC waiting room. Patients were then randomly assigned to rooms 1 to 6 according to their arrival time and room availability. For patients assigned to rooms 1 to 3 (intervention group), classical music was played in the examination room during treatment. The patients assigned to rooms 4 to 6 (control group) received their treatments but no music was played. Classical music was selected because it was reported to be effective in promoting relaxation.²⁰

Inclusion criteria were patients who 1) had chronic wounds and were seen in the WCC for routine outpatient visits and dressing changes and 2) were alert and oriented with no hearing problems. Exclusion criteria consisted of having cognitive deficits or psychiatric disorders as well as taking pain and/or anti-anxiety medication 8 hours before the wound care clinical visits.

State-Trait Anxiety Inventory (STAI). This scale was developed by Spielberger et al²¹ to measure trait and state anxiety; it can be used in clinical settings to diagnose anxiety and to distinguish anxiety from depressive syndromes.

The STAI is a psychological inventory based on a 4-point Likert scale and consists of 40 questions on a self-report basis. The STAI measures 2 types of anxiety: state anxiety, or anxiety about an event, and trait anxiety, or anxiety as a personal characteristic. The state anxiety items include, “I am tense; I am worried,” and “I feel calm; I feel secure.” All items are rated on a 4-point scale (eg, from “almost never” to “almost always”). Higher scores indicate greater anxiety. The STAI-Y1 is appropriate for those who have at least a sixth-grade reading level. Internal consistency coefficients for the scale range from 0.86 to 0.95; test-retest reliability coefficients range from 0.65 to 0.75 over a 2-month interval.²¹ Test-retest coefficients in this study for this measure ranged from 0.69 to 0.89. In addition, Considerable evidence attests to the strong construct and concurrent validity of the scale.²²

Setting. The study was conducted in a busy WCC of a nonprofit academic medical center in the northeastern United States. A total of 222 patients with chronic wounds were included. The objectives were explained to each participant. After obtaining verbal consent, the pretreatment state anxiety level and blood pressure were measured in the waiting room by one trained registered nurse (RN) working in the WCC. Based on their arrival time and room availability, participants were randomly assigned to either rooms 1 to 3 as the intervention group (n = 112; classical music was played during treatment) or rooms 4 to 6 as the control group (n = 110; no music was played during treatment). After treatment, the state anxiety level and blood pressure were remeasured by the RN.

Ethical considerations. Study approval was obtained from the institutional review board at the medical center before the study began. Only verbal consent was required by the board. All essential components were explained to the participants, including study goals, procedure, sponsorship, potential risks, potential benefits, confidentiality and privacy, data sharing, conflict of interest disclosure, and contact information. The information provided to the patients was consistent with the participants’ comprehensive level to ensure understanding. The STAI is appropriate for those who have a sixth-grade reading level. Participants’ right to privacy and confidentiality were protected throughout the process.

Statistical analysis. To calculate the minimum sample size, the G*Power (Heinrich Heine University, Düsseldorf, Germany) sample size formula was conducted using the t test, difference between 2 dependent means, 2 tails test, moderate effect size, and a desired power of .90 at the alpha level of .05. Once the minimum sample size for each group was established, the researchers ensured enough study participants to strengthen the study. All data were collected using paper instruments and entered for data analysis into the Statistical Package for the Social Sciences (SPSS) 25 software program (IBM). Descriptive statistics were used to analyze patient demographic variables. Pre- and post-test STAI scores as well as systolic and diastolic blood pressure measurements were compared using the paired sample t-test.

The total sample consisted of 222 participants (122 men [55%] and 100 women [45%]) with a mean age of 65.94 years (SD = 10.41) (Table 1). The intervention group consisted of 62 men and 50 women, and the control group consisted of 60 men and 50 women. The mean age of the intervention group was 66.40 years (SD = 11.33). The mean age of the control group was 65.47 years (SD = 9.41). The mean age of the intervention group (n = 112) and the control group (n = 110) was not statistically different (Table 2).

In the intervention group, STAI scores of participants decreased from 45.94 (SD = 6.4) before to 40.83 (SD = 6.5) after treatment (t [111] = 14.406; P = .00); systolic blood pressure decreased from 141.94 (SD = 20.24) to 135.72 (SD = 18.24) (t [111] =6.689; P = .00) and diastolic blood pressure decreased from an average of 70.93 (SD = 11.46) to 66.23 (SD = 10.24) (t [111] = 5.597; P = 0.00) (Table 3). In the control group, before and after treatment STAI scores (42.62 [SD = 5.59] and 42.44 [SD = 5.77]) as well as systolic and diastolic blood pressure scores were virtually identical (Table 4).

Research supports the effectiveness of music in lowering levels of anxiety and depression in a wide variety of health care settings. Jasemi et al¹⁴ conducted a study to examine the effect of music therapy on anxiety and depression in patients with cancer. The study was designed as a quasi-experimental study using a random sampling of 60 individuals divided into 2 groups (control and intervention). The instrument used was the Hospital Anxiety and Depression Scale. The results showed positive effects of music therapy on decreasing the levels of depression and anxiety in patients with cancer. Significant relationships among anxiety, depression, and sex (P < .001; r = 0.42) as well as education (P = .003; r = 0.37) were revealed. Higher mean scores of anxiety and depression were noted among women and college-educated individuals.

A study by Fernandes and D’silva¹² examined the effectiveness of music therapy on depression, anxiety, and stress among patients receiving hemodialysis. The study was a quantitative approach with quasi-experimental design using pretest and posttest methods. Forty (40) people from a hospital hemodialysis unit participated and were divided into 2 groups (control and intervention). The instrument used was the Depression Anxiety Stress Scale. Paired t-test was conducted to obtain the mean scores of the scale before and after the intervention. The results showed a significant difference in mean scores of anxiety, stress, and depression before and after music therapy (P < .001). In addition, there was a difference in systolic blood pressure (P < .05) but no difference in diastolic blood pressure (P > .05) in the control group before and after music therapy.

Music has been utilized widely as an intervention to accomplish individualized goals.²³ It is believed that the auditory stimulation of music occupies the neurotransmitters, thereby diverting feelings of anxiety, fear, and pain and resulting in a more positive perceptual experience.²⁴ Thaut et al²⁵ pointed out that rhythmic entrainment established the first testable motor theory for the role of auditory rhythm and music in therapy. The music stimuli mediate a perceptual response and subsequently determine the patient’s altered feeling states, including the promotion of stress and anxiety reduction.

Although the use of music in patient care has been widely studied, there are few studies focusing on the patient population in WCCs. To the authors’ knowledge, the current study is the first to investigate the effectiveness of music on the anxiety levels of patients undergoing wound care treatment. The current study showed that anxiety levels of patients undergoing treatment in a WCC improve if music is played during treatment. In addition, posttreatment blood pressure measurements also decreased when music was played during treatment. Implementation of music therapy in a WCC may be an easy to implement, noninvasive, nonpharmacologic method to help reduce the anxiety of chronic wound patients requiring wound treatments.

There are several limitations to this study. The first one concerns the generalization of the results because the study was conducted at one WCC only. The results of this study need to be confirmed. In addition, the study assumed that participants in both the control and intervention groups were undergoing similar treatments during the WCC visits. Although the sample size was large and most WCC visits encompass similar interventions, treatment types (eg, dressing change only, nonexcisional debridement, excisional debridement, and biopsy) for each participant were not captured, which could have affected the results.

This randomized controlled trial examined the effect of music therapy on anxiety levels and blood pressure in patients with chronic wounds requiring wound treatments. A sample of 222 consecutive volunteer patients (mean age, 65.94 years) was randomly allocated to either an intervention group (n = 112; classical music was played during treatment) or a control group (n = 110; no music was played during treatment). Following treatment, participants in the intervention group reported less anxiety than participants who underwent routine treatment without music. Additionally, mean blood pressure was decreased after the wound treatment intervention when music was played during treatment. These findings have implications for nurses and other health care professionals who work in WCCs and want to help patients be less anxious about their treatments. The use of music (a nonpharmacological, cost-effective, and safe modality) could be beneficial in decreasing patient anxiety levels and blood pressure.

Ms. Cheng and Ms. Giordano are nurses and Drs. Breitbart, Richmand, and Wong are vascular surgeons, Department of Surgery, JFK University Medical Center, Hackensack Meridian Health, Edison, NJ. Address all correspondence to: Huifang Cheng, APN, Hackensack Meridian Health, 65 James Street, Edison, NJ 08820; tel: 908-848-3300; email: Huifang.cheng@hmhn.org.