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Learning Objectives
Authors/Editors disclosure information
Upon completion of this activity, participants will be
able to: Andrew J. Lotery, MD, FRCOphth, has disclosed the
following relevant financial relationships: Served as an
1. Describe the effects of music with and without advisor or consultant for: Bayer HealthCare
embedded binaural beat on subjective measures of Pharmaceuticals; Roche. Served as a speaker or a
anxiety in patients undergoing cataract surgery member of a speakers bureau for: Bayer HealthCare
under local anesthesia, based on a prospective, Pharmaceuticals.
randomized clinical trial. Pornpattana Vichitvejpaisal, MD, has disclosed no
relevant financial relationships.
2. Describe the effects of music with and Lakkana Thaikruea, MD, PhD, has disclosed no
without embedded binaural beat on physiologic relevant financial relationships.
measures of anxiety in patients undergoing cataract
Jakkrit Klaphajone, MD, has disclosed no relevant
surgery under local anesthesia.
financial relationships.
3. Determine the clinical implications of the effects of Anuruk Tantong, MA, has disclosed no relevant
music with and without embedded binaural beat financial relationships.
on subjective and physiologic measures of anxiety Atchareeya Wiwatwongwana, MD, has disclosed no
in patients undergoing cataract surgery under local relevant financial relationships.
anesthesia. Damrong Wiwatwongwana, MD, has disclosed no
relevant financial relationships.
NI
C
AL The effect of music with and without
S
T
binaural beat audio on D Wiwatwongwana1, P Vichitvejpaisal1,
operative anxiety in L Thaikruea2, J Klaphajone3, A Tantong4 and
A Wiwatwongwana1
patients undergoing
cataract surgery: a
randomized controlled trial
Eye
two tones that are close in pitch but not N n
beat group (BB), the plain musical
identical are sent to a different ear, the a d
intervention group (MI) and the
brain creates an interference which is t
control group (earphones with no
called the binaural beat without any u f
music). Patients and researchers were
physical interaction between the r o
blinded to allocation until
waves.7,8 Therefore, to generate binaural a r
administration of interventions.
beats, pure tones must be presented to l e
each ear through earphones. The s
frequency of the tones must be below Subjective assessment of anxiety s t
about 1000 to 1500 hertz (Hz) for the o s
The subjects were asked to complete the
beating to be heard. The binaural beat u o
State-Trait Anxiety Inventory
frequency is equal to the difference n u
questionnaires (STAI). The STAI
between the frequencies applied to each d n
measures anxiety with the state
ear. The difference between the two s d
subscale and the trait subscale. The state
frequencies must be small (below about s
subscale measures temporary anxiety.
30 Hz) for the effect to occur. For s w
The value has variations for individuals
example, if a 400 Hz sine wave is played for subjective feelings of tension, u e
into the right ear and a 410 Hz into the concern, and worries depending on the c r
left ear, the brain is entrained towards situation. The trait subscale is relatively h e
the beat frequency of 10 Hz, in the alpha stable in showing personal differences a
range which is associated with in how individuals differently a l
relaxation. s s
experience anxiety.9 The State-Trait
Inducing brainwave states with o
Anxiety Inventory is a validated 40-
binaural beats has been w i
item self-report measure that contains
used to decrease anxiety in patients. The a n
20 items measuring state anxiety (STAI-
purpose of our study was to determine t s
S) and 20 items measuring trait anxiety
the anxiolytic effect of binaural beat e e
(STAI-T).9–11 Scores for state and trait
embedded music compared with plain r r
components each range from 20 to 80
music without binaural beats and no f t
with a higher score corresponding to
musical intervention in patients a e
higher anxiety levels.
undergoing cataract surgery under local l d
Blood pressure and heart rate was
anesthesia. l .
recorded on admission (baseline), at the
, T
start of the operation, and 20-min after
h
Materials and Methods the initiation of the operation.
b e
The study was approved by the i b
Institutional Review Board of the Faculty Physiologic assessment of anxiety r i
of Medicine, Chiang Mai University, d n
Blood pressure and heart rate were used
Thailand (Research ID 34/ Study Code a
as object measurements of anxiety.
No. OPT-10-01- 28-11-X). c u
Blood pressure and heart rate of each
This prospective, randomized, h r
patient was recorded on admission
controlled study recruited 141 patients i a
(baseline), at the beginning of the
who were diagnosed with senile cataract r l
operation, and 20 min after intervention
and scheduled for phacoemulsification p b
was administered.
with intraocular lens implantation under i e
local anesthesia at the Department of n a
Ophthalmology, Faculty of Medicine, Interventions g t
Chiang Mai University, Thailand, from , e
Binaural beats were synthesized with a
January to m
Self Hypnosis and Relaxation Machine
April 2011 (Figure 1). o b
(S.H.A.R.M., CyberTeam, Ltd.,
Exclusion criteria included previous c e
Informer Technologies Inc., Madrid,
cataract surgery, blood pressure e d
Spain) version 2.4. The carrier tones at
4160/100 mmHg, hearing problems, a d
109 and 209 Hz were utilized to create
infections in the ears and history of n e
binaural beats with a frequency of 20
epilepsy. , d
Hz in the first 5 min. The binaural beat
Patients were randomized in three
frequency was set to decline gradually r a
groups, by using Random Allocation
to the therapeutic frequency of 10 Hz i u
Software (Isfahan, Iran); the binaural
within the following 5 min and v d
sustained for another 50 min. Musical e i
arrangements with relaxing r o
components of melodies, tones and w
rhythms of 60-minute duration were a a
embedded with the binaural beats.
Eye
s exported in MP3 format with beats was very difficult to detect by reco
intra-
high quality for use in the BB experimental listeners. rde operative
group. A plain music audio Before the operation, the eyes were d at complicatio
without binaural beats was dilated with tropicamide 1% the ns were
produced for use in the MI (Mydriacyl, Alcon, Fort Worth, TX, beg recorded.
group. The presence of binaural USA) inni All
The effect ng surg
of binaural of erie
beat on
1
operative
the s
4
anxiety ope wer
1
0
D rati e
Wiwatwong
wana et al on perf
and orm
20 ed
min by
afte thir
r d
the year
star oph
t of thal
the mol
ope ogy
rati resi
on den
tim ts.
e. Sur
Dur geo
atio ns
n of wer
the e
ope not
rati awa
on re
and of
the
pati
ents
’
inte
rve
ntio
n
gro
up.
Afte
r
com
Figure 1 CONSORT flow diagram of the progress through phases of the study. pleti
on
of
& phenylephrine hydrochloride 10% Shanghai, China) were used to play the
(Silom Medical, Bangkok, Thailand) and music for both the BB and MI groups. ope
anesthetized with topical tetracaine Earphones were placed in both ears of rati
hydrochloride 0.5% (Alcon). Lidocaine the patients 10 min before the start of on,
hydrochloride 2% (Xylocaine jelly, the operation. Patients in the control pati
AstraZeneca, London, UK) was applied group wore earphones connected to an ents
on call. A retrobulbar block was iPod without music. An appropriate wer
performed for all patients. Patients were volume level was chosen by the patient, e
assigned to one of the three groups: the which would still allow them to hear tran
BB group, the MI group or the control the surgeon’s communication regarding sfer
group. An iPod shuffle (Apple, Inc., the procedure or requesting their red
Cupertino, CA, USA) MP3 player and cooperation. to
canal-type stereo earphones (Elecom, Blood pressure and heart rate were the
Eye
ward and asked to complete only the two-sided level. Statistical analyses was
c g
STAI-S questionnaire performed using Epi Info for Windows
a g
post-operatively. Version 3.5.1 (CDC, Atlanta, GA, USA)
n e
and STATA version 11 (Stata Corp,
n
College Station, TX, USA). The frequency
Statistical analysis h e
distribution of demographic descriptive
e r
On the basis of the data provided by variables was used to identify the
l a
previous studies,12 a sample size of 47 patients’ demographic profiles. The
p l
patients in each of the three groups was demographic factors were controlled for
a
required to provide 90% power at the 5% by Random Allocation Software
d n
(freeware).
e e
The effect of
binaural beat c s
on operative r t
anxiety 1411
e h
D
Wiwatwongw a e
ana et al s s
e i
a
The results are shown as mean ± Previous studies have reported the benefits of a .
standard deviation. Comparison of music for patients undergoing various types c T
baseline characteristics between groups of surgery.13–16 One such benefit is the relief u o
was performed with Fisher Exact test. of anxiety. Recent studies t t
Univariate analysis of anxiety- suggest that binaural auditory beats can affect e h
associated factors between the three anxiety.17 Padmanabhan et al12 reported that e
groups (difference STAI-scores, blood binaural beat audio p b
pressure, heart rate) was performed r e
with Sidak analysis. P-value ≤ 0.05 was e s
considered statistically significant. - t
o o
p f
Results e o
Of the 143 patients recruited, two refused r u
to participate because of personnel a r
reason. Forty-seven patients were t k
randomly allocated to one of the three i n
intervention groups. Six patients (three v o
patients in the BB and three patients in e w
the MI group) were excluded because the l
duration of the operation was less than a e
n d
20 min (Figure 1).
x g
There were no statistically significant
i e
differences in age, gender, baseline blood
e ,
pressure, heart rate, operating time, and
t t
initial STAI-T and STAI-S scores between
y h
groups (Table 1). Post-operatively, STAI-
i
S score was re- assessed at the ward and
b s
revealed significantly decreased scores in
e i
the MI and BB groups compared with
f s
the control group (Po0.001) (Table 2). The
o t
BB group showed a slightly larger
r h
decrease in STAI-S score although this
e e
difference was not statistically fi
significant. At 20 min into the operation, u r
patients’ heart rate was significantly n s
lower in the BB group compared with d t
the control group (Po0.001) and the MI e s
group (Po0.050) ( T a b l e 3). r t
No adverse events occurred. g u
o d
Discussion i y
n o
Eye
f the effect of binaural beat audio anxiety reduction was not performed.
on operative anxiety patients in Weiland et al18 compared anxiety
patients undergoing ophthalmic reduction effects of different original Table 1 Baseline
surgery under local anesthesia. characteristics of patients in
sound compositions (electroacoustic
different intervention
Furthermore, we compared the music, audio field recordings obtained groups
effect of binaural beat embedded from natural and constructed settings
music with plain music and no Baseline characteristics
and audio field recordings with
musical intervention at all in embedded binaural beat) with Age (years)
order to document any reconstructed ambient noise simulating Sex (Female ratio)
additional effect of binaural an emergency department environment Initial STAI-T score
beats on anxiety reduction. Initial STAI-S score
and headphones only without music in
In our study, anxiety level was emergency department patients. They Blood pressure (mmHg)a
assessed by the Spielberger’s reported that musical interventions Systolic
STAI, which is one of the most including binaural beat embedded Diastolic
commonly used subjective self- compositions significantly reduced Heart rate (beats/min)a
measuring tests. The STAI is now anxiety (assessed subjectively by STAI Operative time (min)
the standard tool for measuring scores) compared with headphones Abbreviations:
preoperative anxiety.10 only or simulated emergency BB, Binaural
Beats and
Le Scouarnec et al17 studied the use of department noise. Musical
binaural beat In our study, we assessed the anxiety Interventions;
tones for treatment of patients Control, No
status of the patients by using both
music; MI,
diagnosed with mild anxiety. subjective and physiological Musical
Their results showed a significant measurement. We also found a Interventions;
STAI-S, State-
reduction in post-treatment STAI statistically significant decrease in Trait Anxiety
scores after 4 weeks of regularly STAI-S score in both the BB group and Inventory-State;
listening to tapes imbedded with MI group compared to the control STAI-T, State-
Trait Anxiety
binaural beat music tones, group. The patients in the Inventory-Trait.
although physiologic measure of a
Values are mean ± SD. Blood
pressure and heart rate on
admission.
T
h
e
1
4 e
f
f
e
c
t
o
f
b
i
n
a
u
r
a
l
b
e
a
t
o
n
o
p
e
r
a
t
i
v
e
a
n
x
i
e
Eye
t Wiwatwong
y wana et al suffi may
D cient have
sam been
ple una
Table 2 Difference in pre and post-intervention STAI-S scores compared between groups by Sidak size war
analysis for e of
Mean (S.D.) the their
stud defic
Control (n = MI (n = 44) BB (n = 44) Control vs y it
47) MI
whic whi
Difference in pre and post STAI-S scores* − 2.9 (4.4) − 7.0 (4.8) − 9.0 (4.2) o0.001 h ch
Abbreviations: BB, Binaural Beats and Musical Interventions; Control, No music; MI, Musical Interventions; STAI-S, may may
State-Trait Anxiety Inventory-State. have have
*Differences in STAI-S scores (Initial STAI-S score minus Post STAI-S score). Subjective measurement of decrease in
anxiety. conf influ
oun ence
ded d
Table 3 Comparison of change in blood pressure and heart rate after intervention between groups (Sidak the the
analysis) resul resu
Vital sign ts. In lts
Mean (S.D.)
P-value addi of
tion, the
Control (n = 47) MI (n = 44) BB (n = 44) Control vs MI defic inter
ienc vent
Control vs BB MI vs BB
y of ions.
Blood pressure
Systolica +5.3 (17.5) − 3.3 (15.5) − 3.2 (16.0) 0.040 hear Oth
Diastolica − 0.1 (9.7) 2.5 (9.4) 0.7 (7.6) 0.505 ing er
Heart ratea +0.4 (11.0) − 1.5 (7.7) − 5.3 (7.8) 0.303 was limit
Abbreviations: BB, Binaural beat embedded musical intervention; Control, No music; MI, Musical self- atio
a
intervention without binaural beat. Difference in vital signs at the beginning of the operation minus vital repo ns of
signs at operative time 20 min. rted our
by stud
the y
BB group had lower post-intervention characteristic binaural beat perception patie incl
STAI scores compared with the MI with a frequency equal to the difference nt ude
group, although the difference was not between the two pure tones presented, and lack
significant (−9.0 vs − 7.0; P = 0.085). Our provided that the original impulses are not of
physiologic outcome measurement of less than 1000 Hz and the difference obje EEG
anxiety included systolic blood pressure between the two tones is between 1 and ctive reco
and heart rate. Systolic blood pressure 30 Hz. If sustained binaural beat ly rdin
in the BB and MI groups were frequencies resonate throughout the teste g
significantly lower than the control brain, it will stimulate the brain and d in facil
group. Patients in the control group alter the levels of arousal via activation ever ities
who were not exposed to any music had of the reticular-thalamic activating y in
increased systolic blood pressure system. This process is called patie the
during surgery. Heart rate in the BB ‘entrainment’ and has been reported in nt, oper
group was significantly lower than the previous researches with EEG ther atin
efor g
MI (P = 0.050) and control groups (P = (electroencephlogram) recording.19
0.004) while there was no difference in e, roo
A weakness of our study was that the
heart rate of patients in the MI group patie m
cataract surgery was performed by
compared with the control group (P = nts and
multiple surgeons in order to obtain a
0.303). Therefore, we suggest that with pati
binaural beats may have an additional mild ents’
anxiolytic hear post
ing -
effect to plain musical
loss inter
interventions without
espe vent
binaural beats.
ciall ion
Theoretically, an audio embedded
y bloo
with binaural beats can induce a
unil d
predictable alteration in brainwave
atera pres
activity. The waxing and waning in
l, sure
amplitude of the resultant tones gives a
Eye
was recorded only once. Furthermore, of 20 Hz (beta frequency range) during
6 C i
patients in the control group could only the first 5 min of the audio file was set to r o
be masked until intervention was be tuned with pre-operative anxiety in u n
administered. Awareness of an which the brainwave pattern was likely i
individual’s intervention group may to be a beta pattern or arousal state. s i
have caused some bias in answering the Therefore, through brain entrainment, a e n
post- intervention STAI. Keeping this in 10 Hz binaural beat would encourage
mind, we also recorded physiologic the brain to produce a 10 Hz beat C e
J
outcomes of anxiety which included corresponding to a relaxed state of l
, d
heart rate and systolic blood pressure in consciousness or alpha pattern.
e
order to confirm the decrease or increase Decreased patient anxiety results
C r
in anxiety state of each patient. in better patient compliance and h l
We explored the potential of the better surgical outcomes. This is u y
binaural beat frequency of 10 Hz (alpha especially important for patients n
frequency range) to decrease acute undergoing cataract surgery which g o
operative anxiety. The initial frequency is usually performed under local u
anesthesia. F t
The effect of
, p
binaural beat a
on operative
Y t
anxiety 1413 i
D o
g e
Wiwatwongw
ana et al e n
n t
d s
r
Conclusion 1 Lee OK, Chung YF, Chan MF, Chan WM.
a u
Music and its effect on the physiological
Our study supports the evidence that n n
responses and anxiety levels
d
music can decrease operative anxiety. of patients receiving mechanical ventilation: a
pilot study. S e
We suggest that binaural beat embedded r
J Clin Nurs 2005; 14: 609–620. ,
musical intervention may have g
2 Cooke M, Chaboyer W, Schluter P, Hiratos Mo.
additional anxiolytic effects over music The effect of music on preoperative anxiety in o
without binaural beats. L i
day surgery.
i n
Further studies on autonomic nervous J Adv Nurs 2005; 52: 47–55.
t g
system alteration in correlation with EEG 3 Lopez-Cepero Andrada JM, Amaya Vidal A,
Castro Aguilar-Tablada T et al. Anxiety t
recordings during exposure to binaural l
during the performance of colonoscopies: c
beats is needed to better understand how modification using music therapy. e
a
and to what extent these special tones can Eur J Gastroenterol Hepatol 2004; 16: 1381–1386. t
effect anxiety state. 4 Yilmaz E, Ozcan S, Basar M, Basar H, Batislam E, D a
Ferhat M et al. Music decreases anxiety and . r
provides sedation in extracorporeal shock wave
a
Summary lithotripsy. Urology 2003; 61: 282–286.
M c
5 Bellan L, Gooi A, Rehsia S. The Misericordia
What was known before u t
Health Centre cataract comfort study. Can J
K Peri-operative anxiety can result in s
Ophthalmol 2002; 37: 155–160.
poor patient compliance and surgical i s
outcome. c u
K Music therapy can help decrease
r
anxiety for patients in some g
i
circumstances.
n e
c r
What this study adds y
r
K Binaural beat embedded musical
e .
intervention has additional
a
anxiolytic effects over music alone
s C
when anxiety was assessed both
subjectively and objectively. e a
s n
s J
Conflict of interest a
The authors declare no conflict of t
i A
interest. n
s
f a
a e
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14 award,
14 content
please
of this
refer to
activity
http://
,
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The effect of music accredi
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with and without provid
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binaural beat audio er,
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ama/a
on operative wards/
ama-
anxiety in patients physici
ans-
undergoing cataract recogni
tion-
surgery: a award.
page.
randomized The
AMA
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determi
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