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World Journal of
Meta-Analysis

World J Meta-Anal 2019 November 28; 7(9): 406-435

ISSN 2308-3840 (online)

Published by Baishideng Publishing Group Inc

W J M A
World Journal of
Meta-Analysis

Contents Irregular Volume 7 Number 9 November 28, 2019

REVIEW
406 Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice

Kumble LD, Silver E, Oh A, Abrams JA, Sonett JR, Hur C

MINIREVIEWS
418 Mechanisms of action of aqueous extract from the Hunteria umbellata seed and metformin in diabetes

Ejelonu OC

423 Fecal microbiota transplantation: Historical review and current perspective
Leung PC, Cheng KF

META-ANALYSIS
428 Use of music during colonoscopy: An updated meta-analysis of randomized controlled trials

Heath RD, Parsa N, Matteson-Kome ML, Buescher V, Samiullah S, Nguyen DL, Tahan V, Ghouri YA, Puli SR, Bechtold ML

WJMA https://www.wjgnet.com November 28, 2019 Volume 7 Issue 9I

Contents
World Journal of Meta-Analysis

Volume 7 Number 9 November 28, 2019

ABOUT COVER Editorial Board Member of World Journal of Meta-Analysis, Xiangchun Shen,
PhD, Director, Postdoc, Professor, Teacher, School of Pharmaceutical
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Province, China

AIMS AND SCOPE The primary aim of World Journal of Meta-Analysis (WJMA, World J Meta-
Anal) is to provide scholars and readers from various fields of clinical
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systematic review articles and communicate their research findings online.
WJMA mainly publishes articles reporting research results and findings
obtained through meta-analysis and systematic review in a wide range of
areas, including medicine, pharmacy, preventive medicine, stomatology,
nursing, medical imaging, and laboratory medicine.

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Infrastructure (CNKI), China Science and Technology Journal Database (CSTJ), and

Superstar Journals Database

RESPONSIBLE EDITORS FOR
THIS ISSUE

Responsible Electronic Editor: Yan-Xia Xing

Proofing Production Department Director: Yun-Xiaojian Wu

NAME OF JOURNAL
World Journal of Meta-Analysis

ISSN
ISSN 2308-3840 (online)

LAUNCH DATE
May 26, 2013

FREQUENCY
Irregular

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PUBLICATION DATE
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WJMA https://www.wjgnet.com November 28, 2019 Volume 7 Issue 9II

W J M A
World Journal of
Meta-Analysis

Submit a Manuscript: https://www.f6publishing.com World J Meta-Anal 2019 November 28; 7(9): 428-435

DOI: 10.13105/wjma.v7.i9.428 ISSN 2308-3840 (online)

META-ANALYSIS

Use of music during colonoscopy: An updated meta-analysis of
randomized controlled trials

Ryan D Heath, Nasim Parsa, Michelle L Matteson-Kome, Victoria Buescher, Sami Samiullah,
Douglas L Nguyen, Veysel Tahan, Yezaz A Ghouri, Srinivas R Puli, Matthew L Bechtold

ORCID number: Ryan D Heath
(0000-0002-2072-4028); Nasim Parsa
(0000-0003-3882-266X); Michelle L
Matteson-Kome
(0000-0001-8575-1943); Victoria
Buescher (0000-0002-9841-4193);
Sami Samiullah
(0000-0002-1498-0527); Douglas L
Nguyen (0000-0003-3804-0385);
Veysel Tahan (0000-0001-6796-9359);
Yezaz A Ghouri
(0000-0002-8677-1871); Srinivas R
Puli (0000-0001-7650-6938); Matthew
L Bechtold (0000-0002-0205-3400).

Author contributions: Heath RD
and Parsa N contributed equally to
this work; Heath RD, Bechtold ML,
and Parsa N designed research;
Heath RD, Parsa N, Matteson-
Kome ML, Buescher V, and
Bechtold ML performed research;
Matteson-Kome ML, Nguyen DL,
and Puli SR contributed new
reagents/analytic tools; Tahan V,
Ghouri YA, Samiullah S, and
Bechtold ML analyzed data; and
Heath RD, Parsa N, Nguyen DL,
Tahan V, Ghouri YA, Puli SR, and
Bechtold ML wrote the paper.

Conflict-of-interest statement: The
authors deny any conflict of
interest.

Open-Access: This article is an
open-access article which was
selected by an in-house editor and
fully peer-reviewed by external
reviewers. It is distributed in
accordance with the Creative
Commons Attribution Non
Commercial (CC BY-NC 4.0)
license, which permits others to
distribute, remix, adapt, build
upon this work non-commercially,

Ryan D Heath, Nasim Parsa, Michelle L Matteson-Kome, Victoria Buescher, Sami Samiullah,
Veysel Tahan, Yezaz A Ghouri, Matthew L Bechtold, Division of Gastroenterology, University of
Missouri School of Medicine, Columbia, MO 65212, United States

Douglas L Nguyen, Division of Gastroenterology, Heart of the Rockies Regional Medical
Center, Colorado Springs, CO 80907, United States

Srinivas R Puli, Division of Gastroenterology, University of Illinois–Peoria, Peoria, IL 61604,
United States

Corresponding author: Matthew L Bechtold, AGAF, FACG, FACP, FASGE, MD, Professor,
Division of Gastroenterology and Hepatology, Department of Medicine, University Hospital
and Clinics CE405, 5 Hospital Drive, Columbia, MO 65212, United States.
[email protected]
Telephone: +1-573-8821013
Fax: +1-573-8844595

Abstract
BACKGROUND
Music seems to be beneficial in multiple clinical areas. Colonoscopy is a stressful
event for patients, especially with conscious sedation. Music during colonoscopy
has been evaluated in multiple randomized controlled trials (RCTs) with varied
results. Even meta-analyses on the subject over the years have yielded
inconsistent conclusions. Therefore, we conducted an up-to-date meta-analysis
regarding music during colonoscopy.

AIM
To assess the effects of music played during colonoscopy on patients’
perspectives and sedation requirements.

METHODS
Multiple large databases were aggressively searched (November 2018). RCTs
comparing music to without music during colonoscopy on adult patients were
included. Pooled estimates were calculated for sedative medication doses, total
procedure time, and patients’ experience, willingness to repeat procedure, and
pain scores using odds ratio (OR) and mean difference (MD) with random effects
model.

RESULTS
Eleven studies (n = 988) were included. Music during colonoscopy showed a

WJMA https://www.wjgnet.com November 28, 2019 Volume 7 Issue 9428

and license their derivative works
on different terms, provided the
original work is properly cited and
the use is non-commercial. See:
http://creativecommons.org/licen
ses/by-nc/4.0/

Manuscript source: Unsolicited
manuscript

Received: October 2, 2019
Peer-review started: October 2,
2019
First decision: October 23, 2019
Revised: October 26, 2019
Accepted: November 15, 2019
Article in press: November 15, 2019
Published online: November 28,
2019

P-Reviewer: Cremers I
S-Editor: Zhang L
L-Editor: A
E-Editor: Xing YX

statistically significant reduction in procedure times (MD: -2.3 min; 95%CI: -4.13
to -0.47; P = 0.01) and patients’ pain (MD: -1.26; 95%CI: -2.28 to -0.24; P = 0.02)
while improving patients’ experience (MD: -1.11; 95%CI: -1.7 to -0.53; P < 0.01) as
compared to no music. No statistically significant differences were observed
between music and no music during colonoscopy for midazolam (MD: -0.4 mg;
95%CI: -0.9 to 0.09; P = 0.11), meperidine (MD: -3.06 mg; 95%CI: -10.79 to 4.67; P =
0.44), or patients’ willingness to repeat the colonoscopy (OR: 3.89; 95%CI: 0.76 to
19.97; P = 0.1).

CONCLUSION
Music appears to improve overall patient experience while reducing procedure
times and patient pain. Therefore, music, being a non-invasive intervention,
should be strongly considered during colonoscopy.

Key words: Colonoscopy; Music; Relaxation; Meta-analysis

©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.

Core tip: Music during stressful events has been shown to improve patient experience.
Colonoscopy is a stressful event for many patients. Music during colonoscopy has been
studied by many randomized controlled trials and meta-analyses with varying results.
Therefore, given new studies available for analysis, we performed an updated meta-
analysis. This meta-analysis demonstrated that music during colonoscopy reduces
patients’ pain while improving patients’ experience and procedure times. With these
results and extremely limited adverse effects of music, music should be strongly
considered during colonoscopy.

Citation: Heath RD, Parsa N, Matteson-Kome ML, Buescher V, Samiullah S, Nguyen DL,
Tahan V, Ghouri YA, Puli SR, Bechtold ML. Use of music during colonoscopy: An updated
meta-analysis of randomized controlled trials. World J Meta-Anal 2019; 7(9): 428-435
URL: https://www.wjgnet.com/2308-3840/full/v7/i9/428.htm
DOI: https://dx.doi.org/10.13105/wjma.v7.i9.428

INTRODUCTION
Colonoscopy is an important procedure with screening, diagnostic, and therapeutic
indications, but it is associated with significant patient anxiety. Stress and discomfort
encountered both pre- and intra-operatively are associated with delays in proceeding
with screening colonoscopy, increased medication use during the procedure,
decreased patient satisfaction, and increased patient refusal to repeat colonoscopy[1-3].

Utilization of music during gastrointestinal procedures is a common approach to
reduce patient anxiety, as it has been in many fields of medicine, including radiology,
gynecology, urology, and pulmonology[4-11]. Multiple randomized control trials (RCTs)
have attempted to quantify the effects of music on various aspects of undergoing
colonoscopy. A previous meta-analysis of RCTs demonstrated increased patient
willingness to repeat the procedure when music was utilized in the endoscopy suite;
however, no significant differences in levels of dosage of administered sedative,
patient reported pain level, nor procedure time[12]. Other meta-analyses have also
come to differing conclusions regarding the utility of music during colonoscopy[13-15].
Over time, many other RCTs have been undertaken, demonstrating variable findings
in regards to significant differences in these aforementioned parameters. Some studies
demonstrate reduced anxiety scores and improved satisfaction[16-25]. Some studies
showed reduced pain scores[19,26-27] and reduced sedative requirements[18-19,28-30].
Furthermore, some studies demonstrated little significant difference amongst anxiety
levels nor sedation requirements, though variable improvements in patient experience
and willingness to repeat the procedure[31-35]. Given this variation in results and
sedative medication utilized, this meta-analysis sought to include novel data points
by selecting only studies using moderate sedation to ascertain any significant
differences in patient reported pain, satisfaction, procedure time, sedating medication
requirements, and patient willingness to repeat exam when music is utilized in the
endoscopy suite.

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MATERIALS AND METHODS

Data acquisition
Medline, PubMed, Scopus, Cumulative Index for Nursing and Allied Health
Literature, Cochrane Central Register of Controlled trials, and Embase were searched
for articles (search date November 2018) using “music” and “colonoscopy”. Studies
included were RCTs with adult subjects (age ≥ 18 years) comparing music vs no music
during colonoscopy and only moderate sedation. Two independent reviewers
extracted data using standard forms. Pooled estimates were calculated for the effects
of music for dose of sedative medications (midazolam and meperidine), total
procedure time, and patient’s self-reported pain scores, experience, and willingness to
repeat the same procedure using odds ratio (OR) and mean difference (MD) with
random effects model.

Statistics
The impact of music on patients having colonoscopy was analyzed by calculating
pooled estimates of sedative medication doses (meperidine and midazolam), total
procedure time, and patients’ pain scores, experience, and willingness to repeat the
colonoscopy using OR and MD. A random effects model was utilized to calculate the
summary estimate with significance was indicated by P-value < 0.05. I2 measure of
inconsistency was used to assess heterogeneity.

Quality assessment of studies
The Cochrane’s Collaboration Risk of Bias Tool was used to assess the quality of
included studies[36]. In this tool, each outcome was given a GRADE (very low, low,
moderate, or high) based on the quality of evidence. The parameters evaluated in each
study were as follows: Precision, consistency of results, effect magnitude, and
potential bias (publication and other forms)[37].

RESULTS
The initial search identified 177 articles. Figure 1 of these articles, 11 RCTs (n = 988)
met the inclusion criteria[18,19,25,26,28,29,32,33,35,38,39]. Table 1 all RCTs were published from
2002-2016. Studies were global, including many countries (United States, Germany,
Spain, Japan, Italy, China, Turkey, India, Australia, and Sri Lanka). Most of the
studies were deemed high quality studies based on the Cochrane’s Collaboration Risk
of Bias Tool (Table 2).

Procedure times were evaluated in nine studies[19,25,26,28,29,32,35,38,39]. Music during
colonoscopy demonstrated a statistically significant reduction in procedure times
(MD: -2.3 min; 95%CI: -4.13 to -0.47; P = 0.01). Figure 2 Patient pain scores were
evaluated in six studies[18,19,28,29,33,35]. The use of music during colonoscopy showed
statistically significant decrease in patient pain levels as compared to no music (MD: –
1.26; 95%CI: -2.28 to -0.24; P = 0.02). Figure 3 Furthermore, patient experience was
improved using music as compared to no music (MD: -1.11; 95%CI: -1.7 to -0.53; P <
0.01) in four studies[18,28,29,35]. Figure 4 No statistically significant differences were
observed between music and no music during colonoscopy for midazolam (MD: -0.4
mg; 95%CI: -0.9 to 0.09; P = 0.11), meperidine (MD: -3.06 mg; 95%CI: -10.79 to 4.67; P =
0.44), or patients’ willingness to repeat the procedure (OR: 3.89; 95%CI: 0.76 to 19.97; P
= 0.1).

DISCUSSION
Undergoing colonoscopy is a stressful experience for many patients. The ease of
introducing music into the endoscopy suite makes its use an attractive modality to
enhance the patient experience. Multiple studies demonstrate that use of music not
only subjectively improves patient experience during medical procedures, but
improves objective measures of patient stress including heart rate, blood pressure,
and measured levels of salivary cortisol[16,27,39,40]. As noted above, multiple RCTs have
attempted to demonstrate possible benefits of music during colonoscopy with
variable results. Ten years ago, many authors of this study conducted a meta-analysis
yielding the observation that while music does increase patient willingness to repeat
the procedure, it did not necessarily reduce need for sedating medication, reduce
patient reported pain score, nor reduce procedure time[12]. However, many RCTs
conducted over the ensuing decade supplied new data points which suggest the
benefits of music during colonoscopy may be greater than previously observed, with

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Table 1 Description of studies included in the meta-analysis

Ref. Publication year Number of patients Type of study Type of music

De silva et al[26] 2016 118 RCT Variety per patient

Martindale et al[33] 2013 119 RCT Classical

Costa et al[19] 2010 110 RCT Variety per patient

Bechtold et al[35] 2006 29 RCT Watermark by Enya

Ovayolu et al[18] 2006 32 RCT Turkish classical

Harikumar et al[28] 2006 166 RCT Choice of 6 styles (headphones)

Uedo et al[39] 2004 60 RCT Easy-listening

López-Cepero Andrada et al[25] 2004 78 RCT Classical

Smolen et al[32] 2002 34 RCT Variety per patient

Schiemann et al[38] 2002 133 RCT Variety radio station

Lee et al[29] 2002 109 RCT Variety per patient

RCT: Randomized controlled trial.

possible statistically significant reduced procedure times, patient reported pain scores,
and enhanced overall patient experience.

This meta-analysis concludes that music played during colonoscopy improved
patient experience and procedure times while reducing patient pain. This meta-
analysis is unique from the others given the use of the newest RCTs and minimizing
confounding variables by only using moderate sedation rather than moderate and
deep sedation.

This updated meta-analysis has many strengths. This meta-analysis includes only
RCTs to limit selection and observation bias, more patients than prior meta-analyses,
and global studies. This meta-analysis also focused on only one type of sedation.
However, all meta-analyses have limitations as well. First, music was initiated at
different times during the procedure process, in some studies initiated pre-
procedurally while initiated later in others. Second, the delivery method also differed
amongst studies, with some patients receiving music via headphones and others via a
radio in the room. Third, the genre of music varied widely amongst these studies with
some studies utilized classical or easy listening selections, while other studies allowed
patients to select their own music. The inevitable variation of any given individual
patient’s response to different music selections, particularly when considering
cultural and generational preferences as well as response to stressful stimuli, must be
considered when translating these results into one’s own clinical practice. Naturally,
music selection likely also alters the behavior of the performing endoscopist with new
evidence that selection of music can affect adenoma detection rate[41].

In conclusion, given the low cost and relative ease of introducing music during
colonoscopy, these results suggest it is reasonable to include music to both improve
patient pain and experience as well as possibly productivity given reduced procedure
times.

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Table 2 Quality assessment summary of all included studies

Ref.
Study
design

Random
sequence
generation

Allocation
con-
cealment

Blinding
Blinding
outcome
assessment

Incomplete
outcome
data

Selective
reporting

Other bias
Quality
assessment

De silva et
al[26], 2016

RCT Adequate Adequate Double-
blinded

Adequate None None None High

Martindale
et al[33], 2013

RCT Adequate Adequate Double-
blinded

Adequate None None None High

Costa et
al[19], 2010

RCT Adequate Inadequate Single-
blinded

Adequate None None None Moderate

Bechtold et
al[35], 2006

RCT Adequate Not described None Inadequate None None None Low

Ovayolu et
al[18], 2006

RCT Adequate Adequate Double-
blinded

Adequate None None None High

Harikumar
et al[28], 2006

RCT Adequate Adequate Single-
blinded

Adequate None None None Moderate

Uedo et al[39],
2004

RCT Not described Not described Double-
blinded

Adequate None None None Low

López-
Cepero
Andrada et
al[25], 2004

RCT Not described Adequate Double-
blinded

Adequate None None None Moderate

Smolen et
al[32], 2002

RCT Not described Adequate Double-
blinded

Adequate None None None Moderate

Schiemann
et al[38], 2002

RCT Not described Adequate Double-
blinded

Adequate None None None Moderate

Lee et al[29],
2002

RCT Not described Adequate Double-
blinded

Adequate None None None Moderate

RCT: Randomized controlled trial.

Figure 1

Figure 1 Details of search algorithm.

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Figure 2

Figure 2 Forest plot showing comparison between music and no music during colonoscopy for procedure time.

Figure 3

Figure 3 Forest plot showing comparison between music and no music during colonoscopy for patients’ pain.

Figure 4

Figure 4 Forest plot showing comparison between music and no music during colonoscopy for patients’ experience.

ARTICLE HIGHLIGHTS
Research background
Music during colonoscopy has been a controversy subject despite multiple randomized
controlled trials and meta-analyses. Studies vary from music during colonoscopy helping reduce
need for sedative medications and enhancing patient experience to offering little to no benefit.
Given this variability, we conducted this meta-analysis to include all studies to-date and limiting
them to only conscious sedation.

Research motivation
To determine if music is beneficial to patients undergoing colonoscopy. If beneficial, music
would be a very low-cost intervention to improve patients’ experience and pain during a very
stressful procedure.

Research objectives
The objectives of this research were to fully assess the effects of music during colonoscopy
sedative medication doses (meperidine and midazolam), total procedure time, and patients’ pain
scores, experience, and willingness to repeat the colonoscopy.

Research methods

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A meta-analysis was performed by calculating pooled estimates of sedative medication doses
(meperidine and midazolam), total procedure time, and patients’ pain scores, experience, and
willingness to repeat the colonoscopy using odds ratio and mean difference using a random
effects model.

Research results
This research showed that music during colonoscopy improved patient experience and
procedure times while reducing patient pain.

Research conclusions
Music is a benefit to patients undergoing the stressful procedure of colonoscopy. Music during
colonoscopy improves the patient experience while reducing pain. In addition, procedure times
are improved with music playing during colonoscopy. Music is a low-cost intervention that
shows significant benefit and should strongly be considered in endoscopy suites. In the future,
more endoscopy suites should be equipped with music.

Research perspectives
This meta-analysis shows that music has a role in the endoscopy suite. Also, this meta-analysis
demonstrates that with more studies, the results of any meta-analysis may be significantly
altered as these results differ from some prior meta-analyses.

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WJMA https://www.wjgnet.com November 28, 2019 Volume 7 Issue 9

Heath RD et al. Impact of music during colonoscopy

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