Feature Article
The Effect of Music on Dyspnea Severity, Anxiety, and Hemodynamic Parameters in Patients With Dyspnea Eda Ergin, MSc, RN
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Tulay Sagkal Midilli, PhD, RN
This randomized controlled study (pretest, posttest, test control group) was conducted with the aim of determining the effect of music on the severity of dyspnea, anxiety, and hemodynamic parameters in patients with dyspnea. The research was conducted in the Chest Diseases Service of a public hospital in the western region of Turkey. The number of patients included in the sample was determined by power analysis, and as a result, 60 patients were accepted, 30 in the music group and 30 in the control group. Sixty percent of the patients who took part in the study were male, their mean age was 61.21 T 1.13 years, and their mean dyspnea severity before the intervention was 62.68 T 22.28. The difference between the mean dyspnea severity and anxiety scores of the music group patients before and after the application of music was found to be statistically significant (P G .05), but no statistically significant difference was found in hemodynamic parameters (P 9 .05). In light of the research findings, it was concluded that music had an effect on anxiety and the severity of dyspnea in patients with dyspnea but that it had no effect on hemodynamic parameters.
KEY WORDS anxiety, dyspnea severity, hemodynamic parameters, music yspnea is an unpleasant subjective experience of shortness of breath.1,2 The American Thoracic Society defines dyspnea as a multifaceted subjective experience arising from physiological, sociologi-
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Eda Ergin, Msc, RN, is research assistant, Faculty of Health Science, Department of Fundamentals Nursing, Celal Bayar University, Manisa, Turkey. Tulay Sagkal Midilli, PhD, RN, is assistant professor, Faculty of Health Science, Department of Fundamentals Nursing, Celal Bayar University, Manisa, Turkey. Ebru Baysal, MSc, RN, is research asistant, Faculty of Nursing, Department of Fundamentals Nursing, Ege University, Izmir, Turkey. Address correspondence to Eda Ergin, MSc, RN, Faculty of Health Science, Department of Fundamentals Nursing, Celal Bayar University, 45000 Manisa, Turkey (
[email protected]). This article has been presented as a poster presentation in Tamamlayıcı ve Destekleyici Bakım Uygulamaları Kongresi, May 27-29 2015, in Kayseri, Turkey. The authors have no conflicts of interest to disclose. Copyright B 2018 by The Hospice and Palliative Nurses Association. All rights reserved. DOI: 10.1097/NJH.0000000000000403
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Ebru Baysal, MSc, RN
cal, psychological, and environmental factors and the physiological and behavioral interactions that may accompany them.3 The effectiveness of music as a noninvasive and nonpharmacological intervention to reduce dyspnea is well known.4,5 Music affects anxiety, which is a person"s natural reaction to stressors in life or when they feel under physical or physiological threat.6 The effect of music therapy in the recovery of patients was emphasized by Florence Nightingale in the early 19th century when she described it as a nursing intervention that reduced both pain and anxiety.6,7 Interventions to manage dyspnea and anxiety are necessary to help in the development of physical functioning.2 Music therapy is used as a nonpharmacological method in the management of dyspnea and the anxiety and hemodynamic changes that develop in connection with it.8 Turkish classical music is a national and traditional type of music that is enjoyed by Turkish people,9 and therefore, individuals are more affected by music they have chosen themselves and the music of their own culture10 because they can form a firmer bond. The appreciation of music of individuals varies according to the social and cultural makeup of the society in which they live and the education that they have received. Some people accept or reject only certain kinds of music because of their own prejudices or those of society. Knowledge of these factors helps music therapists in their work.10 Music therapy is a natural and inexpensive treatment, without adverse effects and with an effective role in physical, psychological, social, emotional, and spiritual recovery.7 Music therapy has been successfully applied in various clinical environments to help reduce anxiety levels. Music has improved mood, has reduced the anxiety and pain connected with medical procedures and chronic illnesses, and has helped to improve the quality of life.11 For this reason, music should be combined with pharmacological methods in patients with dyspnea. Studies have evaluated the effect of music, a complementary treatment that can be directly applied by nurses, on chronic obstructive pulmonary disease (COPD) patients2,4 and patients on mechanical ventilation,12-14 in intensive care,13,15 during colonoscopy16 and endoscopy,17 with pain,6,7,15,18,19 in reducing blood pressure,9,12,13,18,19 www.jhpn.com
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Feature Article and in the treatment of symptoms such as anxiety.12-14,16,18,19 However, no study was identified in Turkey examining the effects of music on the severity of dyspnea, anxiety, and hemodynamic parameters in patients hospitalized with dyspnea. Therefore, the objective of this study was to determine the effect of music on the severity of dyspnea, anxiety, blood pressure, breathing rate, pulse rate, and blood oxygen levels in patients with dyspnea.
METHODS Design A randomized controlled trial design was used to determine the effects of music intervention on dyspnea severity, anxiety, and hemodynamic parameters in patients with dyspnea. Subjects were randomly assigned to either the music or control groups by having patients draw lots. Patients draw cards with labels of either A (control group) or B (music group) prepared in a bag.
Sample The study was conducted between June 2015 and February 2016 in the Chest Diseases Service of Manisa Public Hospitals Association Government Hospital. The research sample consisted of patients who were being followed up with a complaint of dyspnea between these dates, who fit the selection criteria of the study, and who agreed to participate in the research. Subjects who were considered for participation were those who accepted to take part in the research and who were literate, were hospitalized in the chest service, could speak Turkish, had no problems with vision or hearing, and had no cognitiveaffective disorders or oral communication problems. The number of patients included in the sample was determined by power analysis, and as a result of this, 60 patients were accepted, 30 in the experimental group and 30 in the control group. This sample size has an 81% power to detect an effect size of 0.519, with a 0.05 1-side significance level.
Data Collection Three different forms, a Patient Identification Form, a Form for the Effect of Music on Hemodynamic Data, and the State-Trait Anxiety Inventory (STAI), were used to collect research data. The forms were completed by the researchers in face-to-face interviews with the patients. Patient Assessment Form This form was prepared by the researchers and consisted of six questions covering patients" sociodemographic characteristics and information about their illness. These were questions on information such as age, sex, educational level, current diagnosis, the existence of chronic illness, and the presence of a chest tube. 82
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Hemodynamic Parameters Hemodynamic parameters, including respiratory rate (RR), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and O2 saturation (SO2), were measured before and after the 30-minute intervention period for both groups. Dyspnea Severity In establishing the cause of dyspnea, which is a subjective complaint, it is of great importance to measure the degree of dyspnea during treatment. For this, a visual analog scale (VAS) is frequently used. The VAS is a 100-mm vertical or horizontal line that is marked with a pen. On this line, the 0-mm point represents no dyspnea, whereas the 100-mm point represents the most severe dyspnea. The patient marks the scale for the severity of breathing difficulty at that moment. Scoring is accomplished by measuring the marked point along the line. In most studies, the VAS has been found to be a reliable measure for use in assessing dyspnea severity.20 In a study with COPD patients, Gu¨nes¸ et al21 (2012) compared the effectiveness of various scales in measuring the severity of dyspnea and found the VAS to be suitable for this purpose. Therefore, dyspnea severity in this study was measured by VAS before and after the 30-minute intervention period for both groups. Anxiety Level Validity and reliability testing of the Turkish adaptation ¨ ner and Le Compte22 (1977) of the STAI was performed by O (1983). State and trait anxiety scores are calculated separately. Later, the scores of all 20 items are totaled to provide a score of between 20 and 80. A high score denotes a high level of anxiety, whereas a low score indicates a low level of anxiety. Spielberger et al stated that a score of 0 to 19 on the index indicated no anxiety, 20 to 39 indicated slight anxiety, 40 to 59 indicated medium anxiety, and 60 to 79 indicated severe anxiety. A score of 60 or more meant that the individual had a need of professional help.22 The state of anxiety of the subjects in this study was measured at baseline and after the 30-minute intervention period to evaluate preintervention and postintervention differences between the groups. The subjects indicated how they felt by responding to each of the six phases on a 4-point Likert scale from ‘‘not at all’’ to ‘‘very much.’’ Because the subjects could not read the questionnaire easily because of their serious illness, the researcher read each of the six items to the subjects. The subjects then responded to the questions by holding up the corresponding number of fingers from one to four or choosing from the four answers that had been printed on large signs.22 Patient Satisfaction Patient satisfaction was measured by asking the subjects in the music group to rate the music after the intervention. Volume 20 & Number 1 & February 2018
Feature Article Procedures After the subjects agreed to participate in the study, the patients drew lots to assign subjects to either the music intervention group or the add group. The researcher entered the patient"s room and collected the data. Data collection was carried out at times that did not interfere with the patient"s care. During the data collection period, the subjects stayed in their own rooms. The researcher stayed with the subject during the data collection period. The patients who fit the criteria of the study were placed in a supine position, and while resting in this position for 5 minutes, their hemodynamic parameters (pulse rate, blood pressure, breathing rate, and SPO2), their dyspnea severity, and STAI were evaluated and the patient assessment form was applied. In the preparation of the music for the music therapy in this study, the expert views of the Fine Arts Faculty of Ege University in Turkey were sought. In line with their suggestions, a program of music was prepared in a maqam (mode), which was used in medicine and which is used today in music therapy applications. The Hu¨seyni maqam imparts beauty, wellness, quiet, and comfort and has a refreshing effect; it was chosen because the sound of the flute creates a feeling of comfort and relaxation. In the literature,4,12 music therapy is recommended as a nursing approach supporting holistic care for patients with dyspnea. In addition, a 25- to 30-minute session was reported to be sufficient for patients with dyspnea,4,12 and therefore, a 30-minute CD was prepared, so that all patients listened to the same music. To exclude sounds from outside, the music was listened to on earphones, and a new set of earphones was used for each patient. The subjects were instructed to close their eyes and concentrate on the sound of the music. The use of headphones helped subjects to receive and focus on the music played. The volume of the music was adjusted to a satisfactory level according to the subject"s facial expressions. At the end of 30 minutes of listening to music, the patients" hemodynamic parameters, dyspnea severity, and STAI were assessed. In the control group, no intervention took place and the patients were allowed to rest on their beds for 30 minutes in a supine position. Subjects in the control group were instructed to close their eyes and rest with their headphones switched on and connected to a CD player but without a CD playing. Headphones were used in the control group to build up an absolutely silent environment to foster the comparison between the music and no-music conditions. After 30 minutes of rest, patients" hemodynamic parameters, dyspnea severity, and STAI were assessed.
Data Analysis A descriptive statistical analysis of the quantitative data was conducted using SPSS 16.0. Descriptive statistics were used to analyze background variables (sex, age, educational level, the presence of chronic illness, and dyspnea severity) Journal of Hospice & Palliative Nursing
to ensure that there was no significant difference between the music and control groups. In addition, mean values and standard deviations were calculated and compared between groups and within times for 7 outcome measures: RR, HR, SBP, DBP, SO2, dyspnea severity, and STAI. The Mann-Whitney U test on abnormal distribution of data (RR and SO2) and the independent sample t test on normal distribution of data were used in the study to examine whether the differences were significant for all outcome measures between groups in the pretest and posttest. The paired sample t test on normal distribution of data and the Wilcoxon signed rank test on abnormal distribution of data (RR and SO2) were used to determine whether there were any differences between pretest and posttest for each group.
Ethical Considerations The study was carried out after written permission was obtained from the management of the Manisa Public Hospitals Association and the ethics committee of Celal Bayar University Medical Faculty (approval no. 85,252,386-15). Information about the process of the study was given to all participants before they took part, and an informed voluntary consent form was given. The patients who agreed to voluntarily participate completed the questionnaires with the help of the researchers.
RESULTS Demographic Data and Clinical Characteristics The mean age of the patients participating in the study was 61.21 T 1.13 years, 60% were male, 55% were educated to primary school level, 53.3% had a diagnosis of COPD, and 41.7% had a chronic illness, of which the most frequent at 48% was hypertension (Table 1). None of the patients had a chest tube attached, and their mean dyspnea severity was 62.68 T 22.28. It was determined that 73.3% of the patients in the music group enjoyed the music they listened to. In the comparison of demographic and clinical characteristics between groups, no differences were found in this study between the groups on patients" sex (# 2 = 2.500, P = .114), age (F = 1.479, P = .412), educational level (# 2 = 2.228, P = .328), having a chronic illness (# 2 = 1.714, P = .190), or dyspnea severity (F = 0.675, P = .165) (Table 1). These findings give more homogeneity to the groups.
Measuring Hemodynamic Parameters As shown in Table 2, no differences were found between the groups before the test on SBP (P = .241), DBP (P = .106), HR (P = .592), RR (P = .706), and SO2 (P = .731). For the posttest, no differences were found between the groups on any of the five hemodynamic outcomes. There were no significant changes in any of the 5 outcome measures for the music group in the posttest period: www.jhpn.com
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Feature Article TABLE 1 Comparison of Demographic and Clinical Characteristics Between Groups Group Demographic and Clinical Characteristics
Total N
Control %
n
Music %
n
%
# 2, P
Sex Male
36
60
15
50
21
70
# 2 = 2.500
Female
24
40
15
50
9
30
P = .114 F = 1.479a
Age, y Mean (SD)
61.21 (1.13)
62.43 (10.65)
60.00 (12.12)
P = .412
5
16.7
5
16.7
# 2 = 2.228
63.3
P = .328
Educational level Only know reading and writing
10
16.7
Primary and secondary schools
33
55
14
46.7
19
College
17
28.3
11
36.7
6
Yes
25
41.7
15
50
10
33.3
# 2 = 1.714
No
35
58.3
15
50
20
66.7
P = .190
20
Other chronic illness
F = 0.675a
Dyspnea severity Mean (SD)
62.68 (22.28)
66.70 (23.58)
58.66 (20.50)
P = .165
Abbreviation: # , # test. a Independent t test. 2
2
SBP (P = .358), DBP (P = .545), HR (P = .136), RR (P = .142), and SO2 (P = 1.000). For the control group, there was no significant reduction in any of the 5 hemodynamic outcome measures in the posttest period (Table 2).
Measuring Dyspnea Severity and Anxiety Level As shown in Table 2, no differences were found between the groups before the test on dyspnea severity (P = .479) or the STAI (P = .506). For the posttest, no difference was found between the groups on dyspnea severity. However, significant differences were found between the groups" posttest on the STAI (P = .010). There were significant changes in dyspnea severity (P = .001) and the STAI (P = .001) measures for the music group in the posttest period. For the control group, there was no significant reduction in dyspnea severity (P = .094) measures in the posttest period. However, there were significant decreases in the STAI (P = .003) in the posttest period (Table 2).
DISCUSSION Hemodynamic Parameters Dyspnea is a condition of inadequacy of breathing and is a subjective symptom perceived by the patient.2,21 There 84
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are many studies that demonstrate that musical sensations and rhythms affect physiological activities and physiological studies of music.6,7,19 In this study, it was found that, when the hemodynamic parameters of the patients in the music and control groups were examined before and after the music application, there was no significant difference between the two groups (P 9 .05). It was found that there was no effect on hemodynamic parameters before or after the music played to the music group, and in addition, there was no effect on the hemodynamic parameters of the control group before or after the bed rest that was given to them. The results of our study are similar to the study in the literature12,19 but differ from others.9,11,13,15,17 The hemodynamic values of all patients before and after the application were at physiologically normal values, and therefore, there was no difference between them. It is thought that music gave the patients homeostatic balance.
Dyspnea Severity and Anxiety Level It was established in our study that the music applied to the patients in the music group had the effect of reducing mean dyspnea severity scores (P G .05). In a 6-week study Volume 20 & Number 1 & February 2018
Feature Article TABLE 2 Comparison of Outcome Measures Between Groups and the Pretest and
Posttest Control (n = 30)
Music (n = 30)
Outcome Measures
Test
Mean (SD)
Mean (SD)
Testa
Systolic blood pressure
Pre
129.00 (16.58)
123.77 (17.63)
F = 0.413 P = .241
Post
129.03 (17.87)
121.77 (19.09)
F = 0.019 P = .133
Testb
t = j0.017 P = .987
t = 0.934 P = .358
Pre
75.30 (9.75)
71.26 (9.28)
F = 0.002 P = .106
Post
75.46 (8.98)
70.13 (11.39)
F = 2.247 P = .050
Testb
t = j0.109 P = .914
t = 0.612 P = .545
Pre
88.73 (16.65)
90.66 (10.38)
F = 3.017 P = .592
Post
89.33 (14.74)
89.03 (9.28)
F = 3.169 P = .925
Testb
t = j0.449 P = .657
t = 1.535 P = .136
Pre
24.73 (5.24)
24.53 (4.13)
z = j0.378c P = .706
Post
24.03 (5.41)
23.33 (4.99)
z = 0.008c P = .994
Test
z = j1.194d P = .233
Pre
94.70 (5.54)
95.23 (4.25)
z = j0.344c P = .731
Post
94.36 (4.69)
95.23 (3.77)
z = j0.614c P = .539
Test
z = j0.368d P = .713
z = j0.511d P = .609
Pre
48.83 (34.50)
43.00 (28.69)
F = 1.491 P = .479
Post
44.00 (34.97)
32.00 (31.88)
F = 0.559 P = .170
Testb
t = 1.732 P = .094
Diastolic blood pressure
Heart rate
Respiratory rate
O2 saturation
Dyspnea severity
z = j1.621d P = .105
t = 3.792 P = .001e (continues)
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Feature Article TABLE 2 Comparison of Outcome Measures Between Groups and the Pretest and
Posttest, Continued Outcome Measures State anxiety scores
Control (n = 30)
Music (n = 30)
Test
Mean (SD)
Mean (SD)
Testa
Pre
43.43 (11.02)
45.23 (9.76)
F = 0.001 P = .506
Post
38.16 (9.54)
31.73 (9.28)
F = 0.004 P = .010f
Testb
t = 3.203 P = .003e
t = 6.001 P = .001e
a
Independent sample t test. Paired sample t test. Mann-Whitney U test. d Wilcoxon signed rank test. e P G .01. f P G .05. b c
by Canga et al4 (2015) examining the effects of pulmonary rehabilitation and music therapy or pulmonary rehabilitation alone on the breathing symptoms, psychology, and quality of life of patients with other pulmonary diseases such as COPD, it was found that the dyspnea VAS showed an extremely significant effect in the music group between the fifth and sixth weeks (P G .001). The findings of this study suggest that music therapy, together with pulmonary rehabilitation, can be an effective method in the treatment of pulmonary disease. Fear of not being able to breathe and of breathlessness increases the anxiety of individuals.2 In music therapy, different musical modes and instruments are beneficial depending on the type of illness.23 The Hu¨seyni maqam of classical Turkish music used in this study is one of the oldest maqams and creates a feeling of calm and relaxation with the sound of the flute.24 The low pitch and slow tempo of the music relieve feelings of discomfort by reducing the transmission capacity of the nerves, and the music stimulates the pituitary gland, which is the center of emotion and excitement, to increase the secretion of endorphin. As a result of endorphin secretion, this natural painkiller and mood stabilizer reduces anxiety and has a positive effect on perception.7 In this study, the mean STAI score of the patients in the control group with dyspnea was 43.43 T 11.02, and this fell to 38.16 T 9.54 after 30 minutes of rest. This difference was found to be statistically significant (t = 3.203, P = .003) and represents a 12.14% reduction. The mean STAI scores of the music group fell from 45.23 T 9.76 to 31.73 T 9.28 after the music intervention. This difference was found to be statistically significant (t = 6.001, P = .001) and represents a reduction of 29.85% (Table 2). The 30% reduction in the music group relative to the control group shows that music is an effective intervention in reducing anxiety. Similarly, Lee et al13 (2017) found that 86
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a single 30-minute session of music reduced anxiety for patients undergoing mechanical ventilation in an intensive care unit. Saadatmand et al14 (2013) investigated the effect of 30 to 90 minutes of listening to nature-based sounds on agitation, anxiety level, and physiological stress responses in patients under mechanical ventilation support. The intervention group had significantly lower SBP, DBP, anxiety, and agitation levels than the control group. Ko et al16 (2017) found that listening to music reduced the level of anxiety in patients undergoing colonoscopy examination without sedation. Wang et al18 (2014) investigated the effect of listening to soft music on older patients the night before an operation under spinal anesthesia and found that it reduced ¨ ztun015 (2015) anxiety and pain. In a study by /ift0i and O examining the effect of music on anxiety in patients hospitalized with a diagnosis of cerebrovascular event (n = 72), patients listened to soft instrumental music (Rast maqam) for 25 to 30 minutes on earphones. It was found that the music reduced the level of anxiety in cerebrovascular event patients (P G .05). It was seen that, despite differences in methods and sampling between this study and other studies in the literature, different kinds of music were effective in reducing anxiety levels in different sample groups.
CONCLUSION In light of the findings of the study, it was concluded that music has an effect on anxiety and the severity of dyspnea in patients with dyspnea but that it does not have an effect on hemodynamic parameters. It is recommended that randomized controlled studies be planned and conducted on a larger sample group, providing alternatives of different kinds of music and allowing subjects to listen to the music of their choice. Volume 20 & Number 1 & February 2018
Feature Article Acknowledgment The authors thank all the patients who participated in this study.
References 1. Upadhyay G, Thakker RM. Subjective assessment of dyspnoea in patients with chronic obstructive pulmonary disease and its relation with associated depression. Int J Med Sci Public Health. 2014;3(11):1347-1350. ¨ z0elik H. Management of the frequently observed 2. Kılı0 Z, O symptoms in advance stage chronic obstructive pulmonary disease patients. J Chest Dis Crit Care. 2014;1(2):85-89. 3. Akıncı /A, Pınar R. Dyspnea rehabilitation in patients with chronic obstructive pulmonary disease. Cumhuriyet Nurs J. 2012; 1(1):2429. http://dergi.cumhuriyet.edu.tr/cumunuj/article/view/ 1008001168/1008001402. 4. Canga B, Azoulay R, Raskin J, Loewy J. AIR: advances in respirationVmusic therapy in the treatment of chronic pulmonary disease. Respir Med. 2015;109(12):1532-1539. 5. Bausewein C, Booth S, Gysels M, Higginson IJ. Nonpharmacological interventions for breathlessness in advanced stages of malignant and nonmalignant diseases. Cochrane Database Syst Rev. 2013;22(11):CD005623. 6. Onieva-Zafra MD, Castro-Sa´nchez AM, Matara´n-Pen˜arrocha GA, Moreno-Lorenzo C. Effect of music as nursing intervention for people diagnosed with fibromyalgia. Pain Manag Nurs. 2013;14(2):e39-e46. 7. Korhan EA, Uyar M, EyigPr C, YPnt GH, /elik S, Khorshıd L. The effects of music therapy on pain in patients with neuropathic pain. Pain Manag Nurs. 2014;15(1):306-314. 8. Brooks D, Sidani S, Graydon J, McBride S, Hall L, Weinacht K. Evaluating the effects of music on dyspnea during exercise in individuals with chronic obstructive pulmonary disease: a pilot study. Rehabil Nurs. 2003;28(6):192-196. 9. Bekiro?lu T, Ovayolu N, Ergu¨n Y, Ekerbi0er H/. Effect of Turkish classical music on blood pressure: a randomized controlled trial in hypertensive elderly patients. Complement Ther Med. 2013;21(3):147-154. ¨ . Music therapy [in Turkish]. Kastamonu Educ J. 10. Gen0el O 2006;14(2):697-706. 11. Chen LC, Wang TF, Shih YN, Wu LJ. Fifteen-minute music intervention reduces pre-radiotherapy anxiety in oncology patients. Eur J Oncol Nurs. 2013;17(4):436-441.
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12. Yaman Aktas¸ Y, Karabulut N. The effects of music therapy in endotracheal suctioning of mechanically ventilated patients. Nurs Crit Care. 2016;21(1):44-52. 13. Lee CH, Lee CY, Hsu MY, et al. Effects of music intervention on state anxiety and physiological indices in patients undergoing mechanical ventilation in the intensive care unit: a randomized controlled trial. Biol Res Nurs. 2017;19(2):137-144. 14. Saadatmand V, Rejeh N, Heravi-Karimooi M, et al. Effect of nature-based sounds" intervention on agitation, anxiety, and stress in patients under mechanical ventilator support: a randomised controlled trial. Int J Nurs Stud. 2013;50(7):895-904. ¨ ztun0 G. The effect of music on comfort, anxiety and 15. /ift0i H, O pain in the intensive care unit: a case in Turkey. Int J Caring Sci. 2015;8(3):594-602. 16. Ko CH, Chen YY, Wu KT, et al. Effect of music on level of anxiety in patients undergoing colonoscopy without sedation. J Chin Med Assoc. 2017;80(3):154-160. 17. Wang MC, Zhang LY, Zhang YL, Zhang YW, Xu XD, Zhang YC. Effect of music in endoscopy procedures: systematic review and meta-analysis of randomized controlled trials. Pain Med. 2014;15(10):1786-1794. 18. Wang Y, Dong Y, Li Y. Perioperative psychological and music interventions in elderly patients undergoing spinal anesthesia: effect on anxiety,heart rate variability, and postoperative pain. Yonsei Med J. 2014;55(4):1101-1105. 19. Liu Y, Petrini MA. Effects of music therapy on pain, anxiety, and vital signs in patients after thoracic surgery. Complement Ther Med. 2015;23(5):714-718. 20. Kara D, Yıldız H. Effectiveness and frequencies of dyspnea scales in evaluating symptom of dyspnea [in Turkish]. Gu ¨ mu ¨ ¸shane Univ J Health Sci. 2013;2(1):137-144. 21. Gu¨nes¸ YU, Kara D, Erba?cı A. Comparison of the different dyspnea scales in patients with complaints of dyspnea [in Turkish]. Deuhyo Ed. 2012;5(2):65-71. ¨ ner N, Le Compte AW. Durumluk Su 22. O ¨ reklilik Kaygı Envanteri el Kitabı, 1. Vol. 333. Baskı, Istanbul: Bo?azi0i Zniversitesi Yayınları; 1985:1-26. 23. Somakcı P. Tu¨rklerde mu¨zikle tedavi [in Turkish]. Sosyal Bilimler Enstitu ¨ su ¨ Dergisi. 2003;2(15):131-140. 24. The Group for the Research and Promotion of Turkish Music (TZMATA). Turkish music tonalities (maqam) and their effects on human beings. 2017. http://www.tumata.com/ContentDetail. aspx?cid=5&SM=2.
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