Listening to calming music before surgery has similar effects as midazolam


Music may offer an alternative to the use of a drug routinely used to calm the nerves before the use of regional anesthesia (peripheral nerve block), suggest the results of a clinical trial, published online in the journal Regional Anesthesia & Pain Medicine.

It seems to have similar effects as the sedative midazolam in reducing anxiety before a peripheral nerve block-a type of anesthetic procedure done under ultrasound guidance and designed to numb a specific region of the body.

Preoperative anxiety is common, and it can raise levels of stress hormones in the body, which in turn can affect recovery after surgery.

It is usually treated with benzodiazepines, such as midazolam. But these drugs have side effects, including affecting breathing, disturbing blood flow, and paradoxically increasing levels of agitation and hostility. Use of these drugs also requires continuous monitoring by a skilled clinician.

Music medicine has been used to lower preoperative anxiety before, but it has not been directly compared with intravenous midazolam.

The researchers wanted to find out if it might offer a suitable alternative to midazolam to calm the nerves before carrying out a peripheral (regional) nerve block.

They randomly assigned 157 adults to receive either 1-2 mg of midazolam (80), injected 3 minutes before the use of a peripheral nerve block, or to listen to Marconi Union’s Weightless series of music via noise-canceling headphones (77) for the same period.

This track is considered to be one of the world’s most relaxing songs:

Song: Marconi Union – Weightless. Video credit: Just Music TV.

Levels of anxiety were scored using a validated measure (State Trait Anxiety Inventory-6, or STAI-6 for short) before and after the use of each anxiety calming method. Satisfaction among patients and doctors were scored on a 10-point scale, with 0 reflecting the lowest level of satisfaction.

Changes in the levels of preoperative anxiety were similar in both groups, although patients in the music group were less satisfied than those given midazolam, possibly because patients were not allowed to choose the music they listened to, suggest the researchers.Music medicine has been used to lower preoperative anxiety before, but it has not been directly compared with intravenous midazolam. The image is in the public domain.

But there was no difference in satisfaction levels among doctors.

Both patients and doctors thought it was harder to communicate when music was used to calm nerves, possibly because of the use of noise-canceling headphones, and not standardizing the volume of the music, suggest the researchers.

They accept that a comparison lasting just 3 minutes may have been too short, but this period was chosen because that is how long it takes for midazolam to reach peak effectiveness. And they acknowledge that the measure used to assess satisfaction wasn’t a validated scale.

Nevertheless, their findings prompt them to conclude that music may be offered as an alternative to midazolam before carrying out a regional nerve block.

“However,” they caution, “further studies are warranted to evaluate whether or not the type of music, as well as how it is delivered, offers advantages over midazolam that outweigh the increase in communication barriers.”

The study period was between May 1, 2017 and June 30, 2018. A total of 221 patients were scheduled to receive a peripheral nerve block at our ambulatory surgical center and were approached to participate in the study.

Fifty-eight individuals declined to participate in the study and three were excluded from the study prior to randomization due to their pre STAI-6 scores being greater than a score of 50. A total of 160 individuals were randomized to the music group or the midazolam group.

Three individuals had incomplete data and were not included in the final dataset. Therefore, 157 subjects were included in the analysis with 77 individuals in the music group and 80 individuals in the midazolam group (figure 1).

Patient demographics were similar between the two groups (table 1).

Figure 1Consort flow diagram.

The change in STAI-6 scores from after to before the procedure was similar in both groups (mean change in music group −1.6 (SD 10.7); mean change in midazolam group −4.2 (SD 11); p=0.14; mean difference between the two groups in the change of STAI-6 scores −2.5 (95% CI −5.9 to 0.9), p=0.1).

Pre-block STAI-6 scores were also similar between both groups (p=0.65). However, the post-block STAI-6 scores were lower in the midazolam group than in the music group (p=0.01) (table 2).

Table 2

Patients’ anxiety scores (before and after block and difference between the post-block and pre-block scores), patient and physician satisfaction scores and their perceptions of difficulty in communication

MusicMidazolamP value
Pre STAI-6 scores33.3 (23.3–41.7)30 (20–40)0.65
Post STAI-6 scores30 (20–40)23.3 (20–33.3)0.01*
Change in STAI-6 scores, mean (SD)−1.6 (10.7)−4.2 (11)0.14
Patient satisfaction8 (5–9)9 (7–10)0.01*
Patient perspective on communication difficulties1 (1–2)1 (1–1)0.005*
Physician satisfaction9 (8–10)10 (8–10)0.07
Physician perspective on communication difficulties1 (1–2)1 (1–1)0.0007*
  • Data are presented as median (IQR), except for the change in STAI-6 scores which is normally distributed and is presented as mean (SD). Patient and physician satisfaction scores are reported on a scale from 0 to 10. Perception of communication difficulty is presented on a Likert scale (from 0 to 5).
  • Wilcoxon rank sum test was used to compare the two groups in all data points except for the change in STAI-6 scores in which a paired t-test was used for this comparison.
  • *Statistical significance is considered when p<0.05.
  • STAI-6, State Trait Anxiety Inventory-6.

Table 2

Patients’ anxiety scores (before and after block and difference between the post-block and pre-block scores), patient and physician satisfaction scores and their perceptions of difficulty in communication

Patient satisfaction was higher in the midazolam group (p=0.01); however, physician satisfaction was similar in the two study groups.

Both patients and physicians perceived communication to be more difficult in the music group than in the midazolam group (p=0.005 and p=0.0007, respectively).

Mean arterial pressure and heart rate trends were similar between the two groups throughout the nerve block administration.

There were no statistically significant differences between the two groups at all time points (figure 2).

Figure 2Mean arterial pressure (MAP) and heart rate (HR) trend throughout nerve block administration between music and midazolam groups.


Several studies in the last few decades have shown the benefits of music medicine perioperatively by reducing preoperative anxiety, reducing sedation while under regional anesthetics and keeping patients calm in the postoperative recovery period.6–8

Prior research has focused primarily on oral anxiolytics, which are not routinely used in the preoperative setting.6 7 

Our study is the first to compare music medicine with an intravenous pharmacologic agent, midazolam, in reducing anxiety scores for patients undergoing a single-injection peripheral nerve block.

We identified better anxiolysis with midazolam compared with music, with the effect of the primary outcome of the change in STAI-6 anxiety scores being insignificant.

Our findings are supported by the findings of a comparable study by Nikolajsen et al.

This study evaluated audiovisual stimulation with music and nature compared with placebo during femoral nerve single-injection blocks and found no statistically significant differences in the change in STAI-6 scores among the groups.17

Secondary outcomes demonstrated better patient satisfaction with their overall experience and less difficulty in communication between patient and provider in the midazolam group; however, we question whether this is clinically meaningful.

These differences may be attributed to the following reasons: (1) Patients were not given a choice to select their own music preference; although patient selection of music could have changed these results, studies demonstrate that research-selected music is effective.8 10 (2)

Patients listened to music via noise-canceling headphones rather than non-noise-canceling headphones, which could have contributed to the communication difficulties.8 10 (3)

We did not standardize the volume level for each patient which also could have affected communication between the provider and the patient. (4)

There was better anxiolysis with midazolam than with music.

There are several limitations to this study: (1) Despite calculating the sample size to detect a clinically meaningful difference in the anxiety scores based on the Cochrane review by Bradt et al,6 it is possible that the current study was still underpowered as evidenced by the wide confidence intervals around the change in the STAI-6 scores from after to before the intervention between both groups. (2)

We allowed only 3 min to lapse after the procedure time out was performed and before the block was started.

It is recommended that music be played for at least 20 min to reap the benefits of anxiolysis,6 which was not possible in this setting due to adherence to operating room efficiency and timely patient readiness.

We instead waited 3 min before starting the nerve block to simulate the length of time it takes for intravenous midazolam to reach peak effect.18 19 (3)

We used noise-canceling headphones instead of non-noise-canceling headphones. (4)

We did not give various music selection options for the patients and only played one track. The use of noise-canceling headphones and limiting the selection of music may have contributed to the perceived difficulty in communication and lower satisfaction rates of the overall experience during the block, respectively. (5)

The 10-point visual analog scale used for patient and physician satisfaction was not a validated instrument.


Music medicine offers an alternative to intravenous midazolam prior to single-injection peripheral nerve block procedures.

The results of the current study have to be cautiously interpreted within the context of the multiple limitations. Further studies should be conducted to evaluate whether or not music genre and techniques of music delivery can offset the trend of improved anxiolysis and fewer communication barriers using midazolam.

Media Contacts: 
Veena Graff – BMJ
Image Source:
The image is in the public domain.

Original Research: Closed access
“Music versus midazolam during preoperative nerve block placements: a prospective randomized controlled study”. Veena Graff, Lu Cai, Ignacio Badiola and Nabil M Elkassabany.
Regional Anesthesia & Pain Medicine. doi:10.1136/rapm-2018-1002515


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