Colorectal cancer is the third most common cancer diagnosed amongst men, and second amongst women. It is the fourth common cause of cancer deaths[1]. The United Kingdom Flexible Sigmoidoscopy Trial demonstrated that a once only flexible sigmoidoscopy screening between ages 55 and 64[2], significantly reduced the incidence of colorectal cancers and cancer-related mortality from the disease. Following this study, screening using flexible sigmoidoscopy was piloted across six centers in England, inviting anyone aged 55 years to undergo screening. The uptake was 43% (45% in men and 42% in women, 33% in low socioeconomic areas)[3]. A Study on patient attitudes towards screening flexible sigmoidoscopy (FS) showed as possible reasons for poor uptake to be embarrassment and concern regarding pain during the procedure[4]. Anxiety is also thought to be an important factor that may deter patients undergoing screening FS[5].

Given the benefit of FS screening, techniques designed to improve patient tolerance without increasing costs may lead to an increase in uptake. Methods such as distraction have previously been used as cost-effective and noninvasive interventions to alleviate acute and chronic pain[6]. It would therefore be useful to see if distraction techniques such as music can be used to reduce anxiety and pain in patients undergoing flexible sigmoidoscopy.

Music has been shown to modulate activity in parts of the brain that control emotions[7,8], and modulate the dopaminergic systems of the brain[9,10]. The association between music and emotions is complex and can be explained by a series of mechanisms including brain stem reflexes, musical expectancy and contagion[11]. A meta-analysis by Lee found music to be an effective complimentary adjunct, for pain and discomfort in different scenarios like acute or chronic pain, during procedures and cancer[12]. Cepeda et al[13] agreed that music can reduce pain intensity and requirements for analgesia, but suggested that the size of these effects was small.

Music has been shown to reduce anxiety levels in patients who have had acute myocardial infarction[14]. In promoting relaxation and diverting attention from anxiety or painful stimuli[5] music has been utilized as a tool to improve user experience in sectors like hospitality, through a positive perceptual experience. Music as a therapy is regarded as one of the most effective distraction techniques with high level of patient compliance[15], because it introduces a competing sensory stimulus, which alters the cognitive perception of pain.

This article focuses on the role of music on anxiety, pain scores and helpfulness during flexible sigmoidoscopy. Our primary hypothesis was that music results in lower post-procedural anxiety compared to those who do not listen to music in the endoscopy room. Secondary hypotheses were: (1) that there is less pain in the music group; and (2) patients find music helpful during their procedure. Anxiety and pain were assessed using a continuous scale whilst helpfulness was a binary outcome.

Three hundred and six articles were screened for relevance (Figure 1). The electronic databases searched (Medline, Cochrane, EmBase) yielded 177 records and in addition 129 citations were identified through bibliographies and conference proceedings. After removal of duplicates 297 unique records were left. Records were excluded if they were deemed irrelevant or not related to the study. On further scrutiny, 4 studies[5,6,15,22] reported on outcomes after music during flexible sigmoidoscopy in respect to anxiety, pain scores and whether it was deemed helpful. These studies were chosen based on our inclusion criteria (Table 1). There was no data from any unpublished or grey literature.

The characteristics of the 4 studies included are summarised in Table 2. All 4 studies[5,6,15,22] were published in English. Three studies were carried out in the United States[5,6,15] and one[22] in Europe. All studies were comparative, 3 used randomized allocation, but no blinding. None of the patients received sedation. 3 studies offered patients a choice of music from collections of a variety of styles of music like jazz, classical, country-western, blues, gospel music, pop and rock, while in the fourth study[6], patients listened to ocean shore sounds.

A total of 445 patients were included in this review. Of the studies that reported sex there were 208 men (55%) and 173 women (45%). Of the studies that reported age the mean was 53.5 years (range = 20-76 years).

Anxiety was measured using the State-Trait Anxiety Inventory (STAI) and the Stress symptom ratings (SSR). STAI is a widely used tool to measure subject anxiety in two dimensions; State and Trait anxiety. State anxiety is a transitory emotional condition usually as a response to external stimuli, and Trait anxiety is the subject’s baseline emotional status. STAI scoring scales consists of 20 statements to which subjects respond as to how they generally feel (Trait) and how they feel currently (State). Scores range from 1-4 for each statement[23,24]. In our meta-analysis the STAI was used by 2 studies. SSR anxiety scoring includes 12 visual analogue scale ratings based on mood-related adjectives and grouped into 6 sub-scales (arousal, stress, anxiety, anger, fatigue, attention). In our meta-analysis the SSR was used by one study[6].

Patient discomfort was measured using either a numeric rating scale or a visual analog scale, which was quantified using a standardized scale[25,26].

The methodological quality and risk of bias in the trials included is shown in Figure 2.

Three studies reported on anxiety during or after flexible sigmoidoscopy[5,6,15]. Two studies used the STAI[5,15] score and 1 study used the SSR score[6].

In the studies that used STAI scores, there was no significant difference between the baseline pre- procedure STAI scores: Chlan et al[15] , the mean scores were 40.2 ± 11.9 and 36.9 ± 12.5 in the control and music arms, with a P = 0.28; in Palakanis et al[5], the respective scores were 35.68 and 36.92, with no statistically significant difference.

However, both studies showed post-procedure STAI were statistically different and that patients who listened to music had better scores compared to the control group: In Chlan et al[15], the scores were 41.8 ± 13.5 and 34.5 ± 10, with a P = 0.002; in Palakanis et al[5], the scores were 31.48 and 25.24, with a P < 0.002.

In the study by Lembo et al[6], that used SSR scoring system to measure the anxiety, the scores were 4.4 ± 0.6 and 2.8 ± 0.4 in the control and music groups respectively (P < 0.05).

Two studies[5,15] contributed to a summative quantitative outcome and used the STAI anxiety scores. Patients who listened to music during their flexible sigmoidoscopy had less anxiety compared to those who did not [Random effects; SMD: 0.851 (0.467, 1.235), S.E = 0.196, P < 0.001] (Figure 3A). Statistical heterogeneity between studies was not significant (Q = 0.085, df = 1, P = 0.77, I² = 0).

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Figure 3 Comparison of patient. A: Anxiety with or without music; B: Pain with or without music; C: Comparison of whether patients found music helpful.

Three studies reported on pain during or after the flexible sigmoidoscopy[6,15,22]. In study by Chlan et al[15], there was a statistically significant difference between the control and music arms (P = 0.026). Subjects in the control group reported mean discomfort ratings of 5.2 ± 1.7, while those in the music group, reported lower discomfort ratings of 4.3 ± 2.1.

In the study by Lembo et al[6], the subjects in the music group reported a lower discomfort score of 9.5 ± 1.3, when compared to the score in the control group of 10.8 ± 1.6.

In the study by Meeuse et al[22], there was no statistically significant difference between the mean pain intensity scores in the control and intervention groups 40 ± 29 and 36 ± 27, P = 0.27).

Three studies[6,15,22] contributed to a summative quantitative outcome. Patients who listened to music during their flexible sigmoidoscopy had lower mean pain scores than those who did not, however this reduction did not reach statistical significance in the random effects model. [Random effects; SMD: 0.345 (-0.014, 0.705), S.E = 0.183, P = 0.06] (Figure 3B). Statistical heterogeneity between studies was not significant (Q = 3.65, df = 2, P = 0.161, I² = 45).

Two studies reported on whether music was helpful during a flexible sigmoidoscopy[15]. In the study by Chlan et al[15], 25 of the 30 patients (83%) found the intervention helpful. Nineteen of the 34 (56%) subjects in the control group, did not feel music would have been helpful during the procedure.

In the study by Palakanis et al[5], 22 of 25 the subjects (88%) in the music group, deemed the intervention as helpful, while 14 of the 25 subjects (56%) felt music would not have helped or were unsure of its role.

Two studies[5,15] contributed to a summative quantitative outcome. Patients who listened to music during their flexible sigmoidoscopy found it was a useful intervention and this was statistically significant compared with patients who did not listen to music [Random effects; RR = 0.61 (0.46, 0.80), P < 0.001] (Figure 3C). Statistical heterogeneity between studies was not significant (Q = 0.999, df = 1, P = 0.318, I² = 0).

Three[5,6,15] studies selected patients by randomization; in two of these[5,15] it was by the flip of a coin, while in the other the technique of randomization has not been described[6]. The study by Meeuse et al[22], chose control and intervention groups from consecutive patients referred for flexible sigmoidoscopy, during different periods of time. None of the studies describe concealed allocation post randomization. This does lead to an element of selection bias.

Both the subjects and the person carrying out the tests, along with the investigators collecting the data, were not blinded. This theoretically implies a high risk of performance/observer bias, but it is unavoidable considering the nature of the procedure and intervention being studied.

Publication bias was not formally assessed due to low number of studies. This may indicate there is potential for publication bias and therefore conclusions should be taken with caution. In addition, exclusion of unpublished data is a source of publication bias.

Flexible sigmoidoscopy is being increasingly used in the early detection of colorectal pathology, especially as a screening tool in asymptomatic patients. The United Kingdom Flexible Sigmoidoscopy Trial showed a once-only flexible sigmoidoscopy screening between ages 55 and 64, significantly reduced the incidence of and cancer related mortality from colorectal cancer. Despite this, the uptake of flexible sigmoidoscopy remains low, due to patients’ anxiety and concerns about discomfort and embarrassment during the procedure. So this study aims to evaluate the role of music as an adjunct during flexible sigmoidoscopy in improving patient experience.

In this study, the authors have assessed the role of music in reducing patients’ anxiety and discomfort and if this intervention was found by patients to be helpful during the test. They have reviewed comparative studies that used music as an intervention during flexible sigmoidoscopy and have performed both qualitative assessment and quantitative synthesis of outcomes. This is the first such study to systematically review and meta-analyse the use of music during flexible sigmoidoscopy in improving patient satisfaction. This is significant because unlike other endoscopic procedures like colonoscopy and oesophagogastroduodenoscopy, where intravenous sedation is widely used, flexible sigmoidoscopy is mostly performed with no sedation and hence any non-pharmacological relaxation or distraction technique will greatly improve patient experience.

This study appears to conclude that music reduced patient anxiety during the procedure and patients deemed it to be a helpful adjunct. Discomfort was also apparently improved, but a larger study may be needed to confirm this observation.

This study will encourage endoscopists to actively use music as a non-pharmacological, practically cost and risk free adjunct to improve patient experience and this may potentially help increase uptake of this very important screening test. This has helped consolidate a long-held and widely considered speculation that music can act as an effective distraction and relaxation technique during flexible sigmoidoscopy. This study was however limited by the small number of comparative studies addressing this clinical question; hence results should be interpreted with caution. However, as the intervention is completely risk and adverse effects free, this can still be applied in practice, pending further larger, better constructed randomized comparative studies.

This study deals with an innovative, well-speculated clinical question. The study has been well conducted and the paper has been clearly written and is interesting. However the number of studies analysed was small due to a relative paucity in studies involving flexible sigmoidoscopy.