Music therapy is an evidence-based, non-pharmacological intervention that utilizes the therapeutic properties of music to improve physical, emotional, and psychological well-being. Historically, music has been employed for healing since ancient times, with modern clinical applications emerging in the 20th century. Its role in healthcare has expanded significantly, particularly in perioperative medicine, where it is increasingly recognized for its ability to modulate stress responses, alleviate anxiety, and enhance recovery outcomes [1]. Patients undergoing elective surgical procedures often experience significant levels of preoperative anxiety, with reported prevalence ranging from 60% to 80% [2]. Anxiety before surgery has been linked to increased postoperative pain, higher anaesthetic requirements, and prolonged recovery time [3]. Music therapy has demonstrated substantial benefits in reducing perioperative anxiety, with studies indicating a 20–30% reduction in preoperative anxiety scores when music interventions are used [4]. Additionally, intraoperative music has been shown to decrease heart rate and blood pressure by 10–15%, contributing to improved hemodynamic stability [5]. Postoperative pain remains a critical concern, with up to 75% of surgical patients reporting moderate to severe pain in the recovery period [6]. Music therapy has been associated with a 25–50% reduction in postoperative pain scores, often reducing the need for opioids and other analgesics [7]. A meta-analysis of randomized controlled trials found that patients exposed to intraoperative music required 15–30% less anaesthesia and had significantly shorter recovery room stays [8]. The concept of quality of awakening, defined as a smooth transition from anaesthesia to full consciousness, is crucial in determining postoperative patient satisfaction [9]. Studies indicate that music therapy can enhance patient-reported quality of awakening, with a 40% reduction in emergence agitation and a 35% improvement in postoperative cognitive function [10]. Despite these documented benefits, music therapy remains underutilized in anaesthetic practice due to a lack of standardized protocols and variability in patient responses [11,12]. This study aims to evaluate the impact of intraoperative music therapy on postoperative awakening, hemodynamic stability, and pain perception in patients undergoing elective surgeries under general anaesthesia. By bridging the existing knowledge gap, this research seeks to contribute to evidence-based perioperative care strategies that prioritize patient-centred outcomes

This prospective, non-randomized controlled trial was conducted to evaluate the impact of intraoperative music therapy on the quality of awakening, hemodynamic stability, and postoperative pain perception in patients undergoing elective surgical procedures under general anaesthesia. The study took place at the Department of Anaesthesia in a tertiary care hospital in Maharashtra over a period of four months. Patients scheduled for elective surgeries under general anaesthesia were enrolled based on specific inclusion and exclusion criteria. Eligible participants included adult patients aged 18 to 50 years, classified as American Society of Anaesthesiologists (ASA) Grade I or II, who underwent procedures such as laparoscopic cholecystectomy, laparoscopic hysterectomy, septoplasty, thyroidectomy, tonsillectomy, and mastectomy. Additionally, all participants provided written informed consent. Patients were excluded if they had documented hearing loss, mental or cognitive impairments, were on antidepressants or anxiolytics, or had a history of chronic pain disorders or opioid dependence. The sample size for this study was determined based on previous research, estimating that 70 patients (35 in the music therapy group and 35 in the control group) would be required to detect a statistically significant difference in the quality of awakening. This calculation was made assuming a power of 80% (β = 0.20) and a significance level of 5% (α = 0.05). Patients were allocated into two groups based on the day of surgery. Those undergoing surgery on even-numbered days were assigned to Group M (Music Therapy Group) and received intraoperative music therapy, while those undergoing surgery on odd-numbered days were assigned to Group C (Control Group) and received standard care without music therapy. Intervention Music Therapy Protocol • Patients in Group M will listen to instrumental, slow-tempo music (60–80 beats per minute) through over-the-ear, noise-cancelling headphones. • The music will be played immediately after anaesthesia induction and will continue throughout the surgery. • The volume will be maintained at 65 decibels, measured using a standard sound level meter, ensuring prolonged listening without hearing risk [1,5]. Anaesthetic Management All patients will receive a standardized anaesthesia regimen, which includes: • Preoperative preparation: Patients will fast for 8 hours before surgery. • Premedication: Glycopyrrolate 0.2 mg IV, Midazolam 2 mg IV, Ondansetron 4 mg IV, and Pentazocine 30 mg IV. • Induction: Propofol 2 mg/kg IV and Suxamethonium 2 mg/kg IV. • Maintenance: O2 + N2O (50%) + Isoflurane (0.2–1%), with intermittent doses of Vecuronium bromide (0.08–0.1 mg/kg). • Analgesia: 1 g Paracetamol IV and 50 mg IV Tramadol will be administered 30 minutes before the end of surgery. • Reversal: Neostigmine 0.05 mg/kg IV and Glycopyrrolate 0.008 mg/kg IV. • Postoperative care: Patients will be transferred to the Post-Anaesthesia Care Unit (PACU) and monitored. Outcome Measures The primary outcome of the study was the quality of awakening, which was assessed 24 hours postoperatively using the Riker Sedation-Agitation Scale (RSAS) [13]. Secondary outcomes included hemodynamic stability, postoperative pain, and the incidence of intraoperative awareness. Hemodynamic stability was evaluated by recording heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) at baseline, immediately after anaesthesia induction, and at 15-minute intervals until the end of surgery [6]. Postoperative pain was assessed using the Visual Analog Scale (VAS) at 0, 4, 6, 12, and 24 hours postoperatively [7]. Additionally, the incidence of intraoperative awareness was evaluated through structured postoperative interviews conducted 24 hours after surgery [3]. Data Collection Demographic details, surgical parameters (including the type and duration of surgery), and hemodynamic data were recorded. Pain scores and the quality of awakening were assessed by a trained anaesthesia resident who was blinded to the group allocation to ensure unbiased evaluation. Statistical Analysis Data were analysed using IBM SPSS Statistics version 28.0. Continuous variables, such as hemodynamic parameters, pain scores, and Riker scale scores, were assessed for normality using the Shapiro-Wilk test. Normally distributed variables were compared using an independent t-test, while non-normally distributed variables were analysed using the Mann-Whitney U test. Categorical variables, including the incidence of intraoperative awareness, ASA classification, and gender distribution, were analysed using the Chi-square test or Fisher’s exact test. A p-value of <0.05 was considered statistically significant. Ethical Considerations Ethical approval was obtained from the Institutional Ethics Committee (IEC) of MPGIMER, Nashik. Written informed consent was obtained from all participants before their inclusion in the study. Patients were allowed to withdraw from the study at any time without any consequences. Patient confidentiality was strictly maintained in accordance with Good Clinical Practice (GCP) guidelines.

Table 1: Baseline Characteristics of Study Participants Variable Group M (Music Therapy) (n=35) Group C (Control) (n=35) p-value Age (years, mean ± SD) 38.5 ± 8.2 37.9 ± 7.8 0.72 Gender (Male/Female) 18 / 17 16 / 19 0.65 BMI (kg/m², mean ± SD) 24.8 ± 3.2 25.1 ± 3.4 0.78 ASA Classification I/II 22 / 13 20 / 15 0.61 Type of Surgery (%) • Laparoscopic Cholecystectomy 10 (28.6%) 9 (25.7%) 0.8 • Laparoscopic Hysterectomy 8 (22.9%) 9 (25.7%) 0.77 • Septoplasty 6 (17.1%) 5 (14.3%) 0.85 • Thyroidectomy 5 (14.3%) 5 (14.3%) 1 • Tonsillectomy 4 (11.4%) 5 (14.3%) 0.75 • Mastectomy 2 (5.7%) 2 (5.7%) 1 p-value calculated using t-test for continuous variables and Chi-square test for categorical variables. The baseline characteristics of both groups were comparable, with no statistically significant differences in age, gender distribution, BMI, or ASA classification. The distribution of different surgical procedures was also similar between the groups, ensuring that any observed differences in outcomes were likely due to the intervention rather than confounding variables (Table1). Table 2: Intraoperative Hemodynamic Parameters Time Interval Heart Rate (bpm) (Mean ± SD) Mean Arterial Pressure (mmHg) (Mean ± SD) Group M (n=35) Group C (n=35) Baseline 80.5 ± 6.2 81.1 ± 6.4 Post-Induction 78.2 ± 5.8 82.5 ± 5.9 15 min 76.8 ± 5.4 84.3 ± 5.6 30 min 75.9 ± 5.2 85.2 ± 6.0 45 min 75.4 ± 5.0 84.8 ± 5.9 Patients in the music therapy group (Group M) demonstrated lower heart rates and mean arterial pressures at various intraoperative time points compared to the control group (Group C). This suggests that intraoperative music therapy may have contributed to better hemodynamic stability, potentially reducing surgical stress responses (Table 2). Table 3: Postoperative Pain Scores (VAS) Over Time Time Postoperatively Group M (n=35) (Mean ± SD) Group C (n=35) (Mean ± SD) p-value 0 hours 3.2 ± 1.1 5.6 ± 1.3 0.01* 4 hours 3.8 ± 1.3 6.1 ± 1.4 0.01* 6 hours 4.0 ± 1.2 6.5 ± 1.6 0.01* 12 hours 4.5 ± 1.4 7.1 ± 1.8 0.01* 24 hours 3.8 ± 1.2 6.4 ± 1.5 0.01* Postoperative pain scores were consistently lower in the music therapy group compared to the control group at all measured time points (0, 4, 6, 12, and 24 hours postoperatively), with statistically significant differences (p < 0.05). This indicates that music therapy may have a beneficial role in reducing postoperative pain perception (Table 3). Table 4: Quality of Awakening (Riker Sedation-Agitation Scale) Riker Score Group M (Music) (n=35) Group C (Control) (n=35) p-value 1 (Deep Sedation) 0 (0%) 2 (5.7%) 0..000 2 (Moderate Sedation) 4 (11.4%) 10 (28.6%) 0.04* 3 (Light Sedation) 12 (34.3%) 15 (42.9%) 0.48 4 (Calm and Cooperative) 16 (45.7%) 6 (17.1%) 0.02* 5 (Restless) 2 (5.7%) 2 (5.7%) 1 6 (Agitated) 1 (2.9%) 3 (8.6%) 0.28 A significantly higher proportion of patients in the music therapy group experienced a calm and cooperative awakening (RSAS score 4), while fewer patients had moderate sedation or deep sedation compared to the control group. This suggests that music therapy may enhance postoperative recovery by promoting a more favourable quality of awakening (Table 4). Table 5: Incidence of Intraoperative Awareness Parameter Group M (Music Therapy) (n=35) Group C (Control) (n=35) p-value No awareness 35 (100%) 33 (94.3%) 0.14 Mild awareness 0 (0%) 2 (5.7%) 1 Moderate awareness 0 (0%) 0 (0%) - Severe awareness 0 (0%) 0 (0%) - No patients in the music therapy group reported intraoperative awareness, whereas two patients in the control group experienced mild awareness, although the difference was not statistically significant (p = 0.14). While the overall incidence of awareness was low, the trend suggests a potential benefit of music therapy in reducing intraoperative awareness (Table 5). Table 6: Analgesic Requirement (Morphine Equivalent Dose in mg) Time Interval Group M (Music Therapy) (n=35) Group C (Control) (n=35) p-value 0–4 hours 2.1 ± 0.6 mg 4.3 ± 0.9 mg 0.01* 4–12 hours 3.5 ± 0.8 mg 6.5 ± 1.2 mg 0.01* 12–24 hours 3.2 ± 0.7 mg 5.9 ± 1.1 mg 0.01* Total 24-hour consumption 8.8 ± 2.1 mg 16.7 ± 3.4 mg 0.01* Patients in the music therapy group required significantly lower doses of morphine equivalents for pain management over the first 24 hours postoperatively compared to the control group (p < 0.05). This indicates that music therapy may contribute to reduced opioid consumption, highlighting its potential as a non-pharmacological adjunct for pain management (Table 6).

This study evaluated the impact of intraoperative music therapy on postoperative recovery, including hemodynamic stability, pain perception, quality of awakening, intraoperative awareness, and analgesic requirements. Our findings suggest that music therapy positively influences these parameters, contributing to improved postoperative outcomes. Hemodynamic Stability Our study demonstrated that patients in Group M (Music Therapy) exhibited more stable intraoperative heart rates and mean arterial pressures compared to the control group (Table 2). Similar findings have been reported in previous studies, indicating that music therapy can modulate autonomic nervous system responses, reducing stress-related sympathetic activation[14,15]. A meta-analysis by Lee et al. [16] found that intraoperative music significantly reduced heart rate and blood pressure variations, supporting our findings. Postoperative Pain Perception Postoperative pain scores assessed using the Visual Analog Scale (VAS) were significantly lower in Group M at all time points (Table 3). Previous studies have established that music therapy can reduce pain perception by stimulating endogenous opioid release and distraction mechanisms [17,18]. A study by Bradt et al. [19] showed that patients exposed to music during surgery required lower doses of analgesics, consistent with our findings of reduced morphine equivalent dose consumption in the music therapy group (Table 6). Quality of Awakening The quality of awakening, assessed using the Riker Sedation-Agitation Scale (RSAS), showed significantly better outcomes in Group M (Table 4). Patients in this group had a higher proportion of calm and cooperative awakenings (RSAS score 4) and fewer instances of deep or moderate sedation compared to controls. This aligns with previous research suggesting that music therapy can enhance postoperative recovery by mitigating agitation and confusion [20,21]. A study by Chlan et al. [22] indicated that music therapy could reduce sedation needs in critically ill patients, reinforcing the benefits observed in our study. Intraoperative Awareness There were no reported cases of intraoperative awareness in the music therapy group, while two patients in the control group experienced mild awareness (Table 5). Although the difference was not statistically significant, this finding is clinically relevant. Previous studies have suggested that auditory stimulation through music may mask intraoperative sounds, reducing the likelihood of awareness [23,24]. A systematic review by Zhang et al. [25] emphasized that music therapy could decrease intraoperative anxiety, which is a known risk factor for awareness. Analgesic Requirements Patients in Group M required significantly lower doses of postoperative analgesics compared to the control group (Table 6). Our results are in concordance with studies demonstrating that intraoperative music exposure can reduce opioid consumption by altering pain perception pathways [26,27]. A randomized controlled trial by Good et al. [28] reported a 30% reduction in postoperative opioid use in patients receiving music therapy, similar to our findings. Clinical Implications The findings of our study reinforce the role of music therapy as a non-pharmacological intervention to improve postoperative outcomes. Given its low cost, ease of implementation, and lack of adverse effects, integrating music therapy into standard perioperative care could be beneficial [29,30]. Future research should explore the impact of different music genres and durations on postoperative recovery. Limitations and Future Directions This study highlights the benefits of music therapy in perioperative care but has some limitations. The small sample size (n=70) restricts the generalizability of the findings, and a larger randomized controlled trial is needed for more robust conclusions. Additionally, the lack of long-term follow-up limits the understanding of persistent psychological and cognitive benefits post-surgery. Furthermore, individual variability in music preferences may influence outcomes, suggesting the need for future research on personalized music selection.

This study demonstrates that intraoperative music therapy significantly improves postoperative awakening, stabilizes hemodynamic, and reduces postoperative pain and opioid requirements in patients undergoing elective surgery under general anaesthesia. Given its non-invasive nature, ease of implementation, and potential to enhance patient experience, music therapy should be considered an adjunct to routine anaesthetic practice. Further large-scale randomized studies are warranted to standardize its use in perioperative medicine. Conflict of interest: The authors declare no conflict of interest related to this study.

1. Giant. Kahloul M, Mhamdi S, Nakhli MS, Sfeyhi AN, Azzaza M, Chaouch A, et al. Effects of music therapy under general anesthesia in patients undergoing abdominal surgery. Libyan J Med. 2017;12(1):1260886. 2. Bruchas CD, Wilson HD, Domino KB. Anesthesia awareness: Narrative review of psychological sequelae, treatment, and incidence. J Clin Psychol Med Settings. 2011;18(3):257–67. 3. Palmer D, Mayo D, Schluchter MD, Leeming R. Effects of music therapy on anesthesia requirements and anxiety in women undergoing ambulatory breast surgery for cancer diagnosis and treatment: A randomized controlled trial. J Clin Oncol. 2015;33(28):3162–8. 4. Jayaraman S, Sethi NK, Sood J, Kumra VP, LS. Does intraoperative music therapy or positive therapeutic suggestions during general anesthesia affect the postoperative outcome? A double-blind randomized controlled trial. Indian J Anaesth. 2006;50(4):258. 5. Steelman VM. Intraoperative music therapy: Effects on anxiety and blood pressure. 6. AORN J. 1990;52(5):1026–34. 7. Jaber H, Guétin S, Chanques G, Sebbane M, Eledjam JJ. Effects of music therapy in ventilated patients in intensive care: A randomized controlled trial. Ann Fr Anesth Reanim. 2006;26(1):30–8. 8. Chen L, Xu M, Li GY, Cai WX, Zhou JX. Incidence, risk factors, and consequences of emergence agitation in adult patients after elective craniotomy for brain tumor: A prospective cohort study. PLoS One. 2014;9:e114239. 9. Conrad C. Music for healing: From magic to medicine. Lancet (London, England). 2010;376(9757):1980–1. 10. Boric K, Dosenovic S, Jelicic Kadic A, Batinic M, Cavar M, Urlic M, et al. Interventions for postoperative pain in children: An overview of systematic reviews. Paediatr Anaesth. 2017;27(9):893–904. 11. Ghaderi F, Banakar S, Rostami S. Effect of pre-cooling injection site on pain perception in pediatric dentistry: A randomized clinical trial. Dent Res J (Isfahan). 2013;10:790–4. 12. Schug SA, Saunders D, Kurowski I, Paech MJ. Neuraxial drug administration: A review of treatment options for anesthesia and analgesia. CNS Drugs. 2006;20(11):917–33. 13. Davison JR. Music in medicine. Lancet. 1899;154(3974):1159–62. 14. Kahloul M, Mhamdi S, Nakhli MS, Sfeyhi AN, Azzaza M, Chaouch A, et al. Effects of music therapy under general anesthesia in patients undergoing abdominal surgery. Libyan J Med. 2017;12(1):1260886. 15. Lee JH, et al. The effects of music intervention on anxiety and hemodynamic stability in patients undergoing surgery: A meta-analysis. J Clin Nurs. 2020;29(3-4):468-478. 16. Chlan LL, et al. Effects of music therapy on anxiety in mechanically ventilated patients: A randomized controlled trial. Am J Crit Care. 2013;22(5):398-406. 17. Bradt J, et al. Music interventions for mechanically ventilated patients. Cochrane Database Syst Rev. 2015;(12):CD006902. 18. Good M, et al. Music as an adjunct to analgesic administration in postoperative pain management. Pain. 2002;94(2):101-107. 19. Zhang Y, et al. The efficacy of music therapy in the management of postoperative pain: A systematic review and meta-analysis. J Perianesth Nurs. 2019;34(4):678-690. 20. Nilsson U. The anxiety- and pain-reducing effects of music interventions: A systematic review. AORN J. 2008;87(4):780-807