Abstract  Purpose To assessthe effect of music withand without binaural beat audio on the physiological changes, anxiety levelsand motion artifact in medical patients undergoing nuclearmedicine scans.

 Methods Our patients were dividedinto three groups: Group I: patients who listened to the music with binauralbeat (MBB); Group II: patients who listened to the music without binaural beat(MWBB) and Group III: patients who only wore headphones without music calledthe control group. In our study, we evaluated anxiety level andheart rate by DASS questionnaire and heart rate device respectively, and motionartifacts was assessed by nuclear medicine physician as well.  Results After music play, DASS score significantlyindicated lower scores in the groups I and II compared with the group III(P?0.050). After nuclear medicine scan, the heart rate of patientssignificantly decreased in the group I in comparison with the group III(P?0.005). Moreover, groups I and II have significantly decrease in motion artifactrather than control group.

 Conclusion Our study clearly demonstrates that listeningto binauralbeat embedded musical intervention cansignificantly lower anxiety level and heart rate in patients undergoing nuclear medicine scan, so binaural beats can apply as a relief of anxiety and stress.  Keywords: Imaging,music, binaural beat audio, anxietylevels, motion artifact, heart rate  Introduction Anxiety and stress are among the most unpleasant experiences in patients undergoing general surgery and nuclear medicine imaging because ofbeing in an unfamiliar environment, radioactive drugs and their effects,expectation of good imaging test results, separation from family and other possiblecomplications(1). All above mentioned are factorsthat can result in medical patients to be anxious in the waiting room beforenuclear medicine scans and can also induce the motion artifacts on patient’sscans, sofinding some interventions can play significant roles to decrease physiological responses and anxietylevels in patients.

The use of medications for anxiety and stress and recently music are among variousinterventions that can reduce anxiety of patients(2, 3). It is worth mentioning that medications may be accompanied bynumber of side effects and after taking those medications, most patients still feel anxious as well, but music listening is more safe and pleasant(4). The half of reviewed papers have showed that musical interventions have consistentlypositive effects in health care settings to be effectively able to influence onphysiological changessuch as blood pressure and heart rate, and also musical interventions decrease patient pain, stress and anxiety,but the exact mechanism of these therapies still remains unanswered(2).

Some studies have demonstratedthat there is a common theory associated the anxiety and stress-reducing effectof music that it works as distracter and focuses on the patient’s attentionaway from negative stimuli to something pleasant and encouraging(2,5). Binaural beats are auditory illusionperceived when applying head phones, right and left ears are separately exposedto two tones with a little different frequency. In this case, the brainintegrates the two signals and generates a sensation of a third sound calledbinaural beat (6-8).The range of frequency of binaural beats is 30 Hz -1kHz(9). Some studies have reported that binaural beats are able tochange physiological and cognitive processes through synchronization of thebrain hemispheres, which can in turn cause reducing anxiety and increasing pain threshold(10).

Over the past few years, the use of these beats as a therapeutic tool has gained interestamong neurophysiologists and clinicians(2). In 1839, Heinrich Wilhelm Dove showed that listening tocertain tones of sound could induce certain states of mind(11). For instance, if we listen to a tone of 500 Hz in our rightear and 507Hz in our left ear, our brain will make up the difference and hearan imaginary tone of 7Hz. This imaginary tone iscalled a binaural beat that it is in the range of theta, which can berelated to deep meditation, relaxation and non-rapid eyemovement (NREM) sleep. It has been reported that music with and without binaural beat can significantly reduceanxiety levels and lower systolic blood pressure in patients undergoing surgery(12).

In our study, we aimed to assess the effect of music with and without binauralbeat audio on the physiological changes and anxietylevels in medical patients undergoing nuclearmedicine scans.   Materials and Methods The study was approved by the Nuclear Medicine and Molecular Imaging Research Center,Shiraz University of Medical Sciences, shiraz, Iran (Study Code No.1396-01-95-15022).The study comprised 290 patients whovolunteered to participate in our study and were needed to take nuclear medicineimaging at the Department of the Nuclear Medicine, Al-Zahra Hospital, ShirazUniversity of Medical Sciences, Iran, fromApril 2016 to October 2017.In the study, patients were noteligible if they have: (I) heart problems such as atrial fibrillation (AF)etc.; (II) hearing problems; (III) history of epilepsy.Our patients were divided into three groups: Group I: patients who listened tothe music with binaural beat (MBB); Group II: patients who listened to themusic without binaural beat (MWBB) and Group III: patients who only woreheadphones without music called the control group. A Digital Player MP870(Transcend, Taipei, Taiwan) MP3 player and stereo headphones (Sony, Bangkok,Thailand) were applied to play music for both and groups I and II.

2 min beforescanning procedure, headphones were located in both ears of the patients. Weasked all patients for closing their eyes while scanning. Moreover, we allowedto be inserted natural sounds such as waterfall ocean, bird chirping, river andforest sounds. Binaural beats were synthesized with a plain music byNeuro-Programmer version 3. The carrier tones at 200 and 215 Hz were applied togenerate binaural beats with a frequency of 15Hz in the first 3 min. The binaural beat placed-audio withhigh quality was delivered into MP3 format to apply in the group I.

A simplemusic audio without binaural beat was created to use in the group II. It isworth mentioning that listeners could not detect which one is with binauralbeat and which one is without binaural beat.In our study, we evaluated anxiety level andheart rate by DASS questionnaire and heart rate device respectively, and motionartifacts level was assessed by nuclear medicine physician as well. Before and after nuclearmedicine scan, the subjects were requested to fill the Depression AnxietyStress Scales questionnaires (DASS-21). The DASS measures anxiety and stresswith the state subscale and the trait subscale that the state subscale measurestemporary anxiety and stress.  The DASS Inventoryis a validated 21-items self-report measure that includes measuring state ofanxiety, stress and depression. Scores for state and trait components eachrange from zero to 21 with a higher score corresponding to higher anxietylevels. Also, measurement of heart rate was done before scan, in the beginningof scan and after scan.

The results of the study were representedas the mean ± standard deviation (SD) by using SPSS 21 and comparison between three groups wasdone with Fisher Exact test as well. Univariate analysis of anxiety andstress-associated factors between all groups (difference DASS-scores, motionartifact scales, heart rate) were performed with Sidak analysis.    Result Of the 296 volunteer patients, eleven were notwilling to continue during the study because of personnel problem. We randomlyallocated 95 patients to each group and then 6 patients in each group wereexcluded due to AF problems (Table1).Our result showed that there were nosignificant differences in age, gender, heart rate, operating time, and DASSscores between groups (Table 1).

 Aftermusic play, DASS score significantly indicated lower scores in the groups I andII compared with the group III (P?0.050) (Table 2). Furthermore, the group IIshowed a slightly larger reduction in DASS score, but this difference was notstatistically significant. After nuclear medicine scan, the heart rate ofpatients significantly decreased in the group I in comparison with the groupIII (P?0.005) (Table 3). Moreover, groups I and II have a significantlydecrease in motion artifact rather than control group (P?0.005) (Table 4).

 Discussion In our study, anxiety and heart rate inpatients undergoing nuclear medicine scan were assessed by using DASSquestionnaire and heart rate device before and after scan. In our study, therewas a statistically significant decrease in DASS score in both the group I and groupII compared to the group III. The patients in the group I had lowerpost-intervention DASS scores compared with the group II, but the differencewas not significant. After nuclear medicine scan, the heart rate of patientssignificantly decreased in the group I in comparison with the group III. According to the previous studies, it has beenreported that music and binaural beats for patients undergoing different kindsof surgery and general anesthesia have some advantages such as the relief ofanxiety and stress. Wiwatwongwana and co-workers have indicated that music bothwith and without binaural beat can lower anxiety level and decrease systolic BPin patients undergoinggeneral anesthesia and surgery(12).

Also,they have reported that patients who listened to binaural beat audio had adecrease in heart rate and it ispossible that music with binaural beat have more benefit compared with musicalintervention alone in decreasing anxiety. Weiland et al. have also revealed that musicwith binaural beat can significantly decrease anxiety inemergency department patients compared with headphonesonly(13).

Furthermore,Le Scouarnec et al. have demonstrated that patients’ diaries who listened to binaural beat tapes showeda significant decrease in the anxiety level(14). All above mentioned studies nicely confirms the resultof our study. One of the most importantmechanism behind this story is that predictable change in brainwave activitycan be decreased by music with binaural beats. The waxing and waning inamplitude of the resultant tones gives a characteristic binaural beatperception with a frequency equal to the difference between the two pure tonespresented. If sustained binaural beat frequencies resonate in the brain, itwill stimulate the brain and change arousal level through activation of thereticular-thalamic activating system, which called ‘entrainment'(15). Some studies have alsoreported that binaural beats are able to change physiological and cognitiveprocesses through synchronization of the brain hemispheres, which can in turncause reducinganxiety and increasing pain threshold(10). Conclusion Our study clearly demonstrates that listeningto binaural beat embedded musical intervention cansignificantly lower anxiety level and heart rate in patients undergoing nuclear medicine scan, so binaural beats can apply as a reliefof anxiety and stress, and also can be applied for all patients, especiallychildren in different types of imaging centers.

  

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