music: a double edge sword - european society of...
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Music: A double edge sword
Dr Athanasios Dritsas FESC
Cardiologist
Onassis Cardiac Surgery Center, Athens
Music Composer MA
No conflict of interest
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Pythagoras by dividing the monochord in simple ratios
connected music, mathematics and medicine
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Somatometry in nature follows mathematics of music
and Pythagorean theories
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Structural analogies eg in Dinosaur follow the structure
of a major musical scale!
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Structural principles in nature and music follow
the mathematical sequence of Golden Section
God thinks in musical terms !
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Artists think in terms of music also!
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CLASSICAL PHILOSOPHY ASPECTS
PREDICT MODERN MUSIC
MEDICINE AND MUSIC THERAPY!!
Plato was the first authorized music medicine prescriber in the
history of medicine and he suggested that we need musical rhythm
to overcome our tension as humans to move into a diseased
and non-ordered status. (TIMAIOS)
Plato prescribed the Dorian musical mode as ideal medicine for
body and soul
Aristotle suggested clearly in his works that we can use music to
alter various mood conditions and suggested Mixolydian, Dorian,
Phrygian mode for different mood states
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Tibetan Singing Bowls
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Temple of Asklepios at EpidavrosUsed music as medicine and music therapy
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Hippocratesapplied music medicine
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The Tarantella
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Hypnosis and Music: Mesmer & Mozart
• Mozart’s compositions used the glass harmonica
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Shamans use
Throat Singing
as healing music
for the heart
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Florence Nightingale
She observed the beneficial effects of wind instruments
with continuous sound, also used strings and voice
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A Touch of Modern History in Music
Medicine
Florence Nightingale in mid-1800s observed the beneficial
effects of wind instruments with continuous sound,
Invention of the phonograph in late1800s and Kane (1914)
was the first to provide intra-operative music to distract
patients attention from the “horror” of surgery,
Ilsen (a nurse) in 1926 established the National Association
of Music in Hospitals,
Light et al (1949), Use of magnetic recorder silent music
during operation, Curr Res Anesth Analg 1949
Thaut (1990) proposed biological effects of music stimuli on
human behavior via engaging specific brain functions
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Feel the beat !
tempo heart rate art.pressure
tempo heart rate art.pressure
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Copyright ©2009 American Heart Association
Bernardi, L. et al. Circulation 2009;119:3171-3180
Average cardiovascular and respiratory data obtained in the 24 subjects while listening to "Nessun dorma
Autonomic responses are synchronized with music, so might convey emotions via autonomic
arousal during crescendos or rhythmic phrases
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Copyright ©2009 American Heart Association
Bernardi, L. et al. Circulation 2009;119:3171-3180
Average cardiovascular and respiratory data obtained in the 24 subjects while listening to Bach's cantata
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Copyright ©2009 American Heart Association
Bernardi, L. et al. Circulation 2009;119:3171-3180
Average cardiovascular and respiratory data obtained in the 24 subjects while listening to "Va pensiero
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EFFECTS OF MUSIC LISTENING ON PHYSIOLOGICAL PARAMETERSThe anxiety and pain reducing effects of music interventions:
a systematic review, AORN JOURNAL 2008
Assessed 42 Randomized control trials, 3.936 patients, age 34-76 yrs
Patients in all studies underwent elective surgery, post-op measurements
ANXIETY 12/24 studies (50%) reported reduction in anxiety scores
SEDATIVE in 3 studies sedative requirement was during music listening
PAIN in 13/22 studies (59%) music intervention reduce pain
as assessed by pain Quest-scores
HR music reduced heart rate in 6/22(27%)
BP music reduced BP in 6/22(27%)
Resp-rate music reduced RR in 3/8 (38%)
Cortisol-ACTH music reduced stress hormone levels in few studies
Prolactin, catecholamines non significant evidence
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Medical Music Therapy
Cheryl Dileo & Joke Bradt
Cochrane Systemic Reviews Database, June 2009A Meta-Analysis of all randomized trials
(23 trials and 1461 participants)
Music for stress and anxiety reduction in patients
with CAD
Music listening can exhibit a mild/moderate effect on heart rate,
blood pressure, respiratory rate and pain in patients with CAD.
Most of interventions used pre-recorded music without the
involvement of a trained music therapist in the majority of
studies.
Further studies are needed to assess the effects of long term
active music therapy in CAD.
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ONASSIS CARDIAC SURGERY
CENTER
Athens, Greece
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ONASSIS CARDIAC SURGERY CENTER
Music intervention studies
1997-2011
MUSIC MEDICINE studies
Hospital concerts for patients & personnel
studies performed via portable CD player until 2001,
coronary care unit, cath-lab, cardiac surgery ICU,
exercise testing room
Central multi-CD player system connected to ICU beds
since 2001. Pts listened via good quality headphones.
Needed assistance by nursing personnel.
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ONASSIS CARDIAC SURGERY CENTER
Music intervention studies
1997-2011
Patients were very positive and co-operative with music
medicine projects,
Classical doctors and colleagues were very difficult to co-
operate with and said “We need beds, we do not need
music”
In the beginning some ICU nurses they even disconnected
CD players and cables, they thought they did not have time
to spent in collecting data or switch-on the music for ICU
patients
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Music in CardiologyGeneral relaxation with music
0%
20%
40%
60%
80%
100%94%
6 %
47 YES 3 NO
ICU/Onassis Cardiac Surgery Study, Dritsas et al
Subjective pts opinion
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16%84%
YES n =42
NO n = 8
Music in CardiologyMusic and stress relief in hospital
Onassis Cardiac Surgery Study
Dritsas et al, Heart Surgery Forum 2010 (suppl)
Subjective pts opinion
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0% 20% 40% 60% 80%
78%
22%
50%
39 pts
50%
11 pts
Music in CardiologyStress reduction with music according to VAS
Onassis Cardiac Surgery Study
VAS=
visual analogue scale
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MUSIC, SPORTS AND ATHLETIC PERFORMANCE
Music may improve exercise ability and athletic performance
Suggested mechanisns:
-Distracting attention from effort
-increases positive mood
-improves exercise tolerance by reducing sense of fatigue
-reduces resting heart rate via relaxation
-may prevent fast increases in heart rate and arterial pressure
-synchronizes musical tempo with rate of effort
Karageorgis C & Terry P. The psychopathological effects of
music in sport and exercise. Brunel University, UK
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MUSIC, CARDIOVASCULAR INDICES AND
AEROBIC CAPACITY
Exercise studies
Music Exercise tolerance Hemodynamics VO2 Biochem
Chipman 1966 beat small exercises + - - -
Koschak 1975 beat small exercises + - - -
Leslie 1967 ? negative - - - -
Schwartz1990 various negative - negative negative negative
Copeland 1991 relax positive + favorable - -
Szmedra 1998 relax negative + favorable negative positive
Szabo 1999 upbeat positive + favorable positive -
Pottiger 2000 prefer negative - negative negative negative
Dritsas 2001 relax negative - favorable - -
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0
30
60
90
120
150
music group n=11 Non- music group n=11
Entrance 10 min music
Waiting with music prior to exercise test
P < 0.05
Dritsas et al (2001)
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40
60
80
100
Heart rate changes during recovery
2 min 4 min 6 min
P < 0.05
music group n=11 Non - music group n=11
Dritsas et al (2001)
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40
60
80
100
2 min 4 min 6 min
P < 0.01
P < 0.05
SBP changes during recovery
music group n=11 Non - music group n=11
Dritsas et al (2001)
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EFFECTS OF MUSIC LISTENING ON ANXIETY AND
MOOD PROFILE IN CARDIAC PATIENTS
UNDERGOING EXERCISE TESTING
A Dritsas, *M Pothulaki, *RAR MacDonald,
*P Flowers, DV Cokkinos
Cardiology Department, Onassis Cardiac Surgery Center, Athens,
Greece and *Department of Psychology, University of Glasgow, UK
European Journal Cardiovascular Prevention & Rehabilitation (2006)
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Music-exercise-anxiety-mood profile in cardiac patientsDritsas et al Eur J Cardiovasc Prev Rehab 2006;13:suppl 1
Study Design
30 pts Experimental group
30 pts Control Group
Bruce protocol
Music used classical-pop-jazz
State Anxiety Form Q pre-and post exercise (A+B)
Trait anxiety Form Q pre-exercise
Mood Profile Form Q pre-and post-exercise (A+B)
ECG
Heart Rate
Blood pressure monitoring
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Table 1. EXAMPLES OF MUSICAL PIECES USED:
JS BACH, Air from Suite no 3, D major
GF HANDEL, Largetto, Harp concert, B flat major
C DEBUSSY, Clair de Lune, Suite Bergamasque
WA MOZART, Adagio from piano concerto no.21, K467
WA MOZART, Harp and flute concert K.299
ERIK SATIE, Gymnopaedie no 3
LV BEETHOVEN Adagio, Piano concert no.5
L BOCCHERINI, Minuet
WA MOZART, clarinet quintet in A major K.581
D ELLINGTON (jazz) Tribute by Daniel Barenboim
KARL ZERO (pop) Songs for Cabriolet
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TABLE 2. DESCRIPRIVE DATA
Control group (CG) Experimental Group (EG) (music)
Group of patients n=30 n=30
Gender M/F 26/4 29/1
Age 60.19 5811
Negative Ex-ECG(n) n=22 n=26* *p<0.01
Medication(n) 27 26
Risk factors CAD(n) 1.521 1.581
Exercise time (min) 8.632.74 8.992.45
Systolic BP baseline 14112 14213 (mmHg)
Diastolic BP baseline 812 823
Systolic BP peak 20324 20117
Diastolic BP peak 10212 1009
Values are expressed in mean SD. ANOVA was used for between and within group comparisons.
*Mann-Whitney U/Wilcoxon W/Z used to compare incidence of negative exercise results according to recordings of ECG-ST depression.
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Table 4.
Aspects of Mood Differences from POMS-comparisons between
groups-One way ANOVA
Mean
square
F p value
Mood A-Energetic 0.017 0.019 ns
Mood A-Active 0.267 0.169 ns
Mood B-Energetic 7.350 8.321 *p<0.01
Mood B-Active 3.750 4.279 *p<0.05
*Favouring experimental group (EG), so favouring music listening.
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Table 5.
Correlations between exercise time and scores derived from STAI.
State A phase score vs exercise time r=-0.217, p=ns
State B phase score vs exercise time r=-0.354, *p<0.01
* p derived from Pearson Correlation.
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THE EFFECT OF RELAXING MUSIC ON THE STRESS
DIMENSION AND THE RESPONSE TO TILT-TEST IN VASOVAGAL
PATIENTS
Α. Dritsas1, D. Leftheriotis2, G. Karabela2,
O. Missirliadou3, EG. Livanis2, GN.Theodorakis2,
DT. Kremastinos2, DV. Cokkinos1.
1A΄ Cardiology Department, 2B΄Cardiology Department, 3Transplantation Unit,
Onassis Cardiac Surgery Center, Athens, Greece
Eur Heart J (2004), ESC Congress 2004
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METHODS 3
Positive
CTT1
n = 28
Music
Group
n = 14
Control
Group
n = 14
Rando
mized
CTT2
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RESULTS 2
71%
29%
71%
29%
MUSIC GROUP CONTROL GROUP
*Music Group vs Control p < 0.05 (frequency distribution from Fisher exact & Yates
correct). There was no difference between age, gender distribution or the type of
response to CTT2 between patients in the music compared to the control group.
Positive CTT2 n = 4 (29%)*
Negative CTT2 n = 10 (71%)
Negative CTT2 n = 4 (29%)
Positive CTT2 n = 10 (71%)*
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RESULTS 4
8
7
6
5
4
3
2
1
0
6
5
4
3
2
1
0
Po
sit
ive
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Music Group
Music Group
Control Group
Control Group
P < 0.01 p = ns
P < 0.01 p = ns
CTT 1
CTT 2
CTT 1
CTT 2
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MUSIC LISTENING DURING
HEAD-UP TILT TESTING IN
NEUROCARDIOGENIC
SYNCOPE
Anna Kostopoulou1, Athanasios Dritsas2, George Theodorakis1, Dionyssios Leftheriotis1, Georgia Karabela1, Efthimios Livanis1,
Dimitrios Kremastinos1, Dionyssios Cokkinos2
12nd Cardiology Department, Onassis Cardiac Surgery Center21st Cardiology Department, Onassis Cardiac Surgery Center
European Heart Journal (2006);27 (suppl):186
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Cortisol and prolactin which express serotonergic activation and showed an approximate 2 fold increase during positive HUTs did not rise significantly in negative music tests.
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Music normalized
the
sympathoadrenal
imbalance noticed
during positive
HUTs expressed
through the
increase in
norepinephrine
during negative
HUTs while
listening to music.
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Conclusions
Music seems to modify the neuroendocrine
profile related to NCS and it alters the
response to tilt-testing.
It is also possible that different types of
music (eg stimulative vs relaxing music) and
music preference of the individual patient
may have demonstrated a different effect on
the outcome of tilt testing in NCS.
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MUSIC INTERVENTION IMMEDIATELY POST CABG
Music listening during time up to extubation
Dritsas et al 2010, Heart Surgery Forum
NON-MUSIC MUSIC-GROUP
n=12 n=15
-----------------------------------------------------------------------------------------------------------
AGE 60(11) 61(11)
SBP1 125(25) mmHg 121(15)
SBP2 124(13) 118(10)
HR1 86(17) 80(20)
HR2 104(31) 90(12)
CWP1 10(3)mmHg 10(2)mmHg
GL1 157(56) 140(50)
GL2 181(44) 160(43)
Morphine 6.5(4) mg 5.3(3) mg
Diprivan 15(17) 14(23)
Pethidine 6.25(11) 1.5(10)*
-----------------------------------------------------------------------------------------------------------
*p<0.01 , all values are expressed as means (SD)
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Indication for clinical use of music according to evidence:
For
Stress reduction-anxiety reduction
Improve quality of life
Creating a positive mood
Beneficial modification of hemodynamic parameters
Where To Deliver
CCU patients
Cardiac surgery ICU
Cardiac rehabilitation sessions/psychosocial interventions
Out-patient waiting rooms
Pain clinics
Long term music therapy sessions
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Adverse effects of Music Medicine? The other edge of the sword
____________________________________________
Cardiac patients require relaxing type of music in general
Interventions related to non-preferred music
classical music for all = wrong!
Cultural aspects are important
Individual delivery in hospital ICU (head-phones)
Techno, heavy metal, hip-hop types of music may associated with
stress induction in cardiac patients, (HJ Trappe BMJ 2010)
Up-beat music ideal for treadmill exercise but without very fast changes
There is a need for sufficient relaxation prior to treadmill exercise
to lower resting heart rate
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Future trends in research
Effects of specially composed music for individual patients or
hospital settings
Analysis of results according to cultural group, age, gender etc
How to deliver music in a best way? Loudspeakers, headphones, audio-pillow
Live music therapy sessions for ICU
Improve working conditions for music therapists and extend
indications for music therapy sessions at low cost
Educate doctors on modern aspects of music therapy
Universal rules and regulations for applications of music
therapy within European Union –The next step!
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Music System Channels
• 1. Female Vocal
• 2. Light Piano Pop
• 3. New Age
• 4.Contemporary Rock & Roll
• 5.Classical
• 6. Gospel
• 7. Jazz
• 8. Country
• 9. Soothing Soundtracks
• 10. Classic Rock & Roll
Hospital musical menu of Piedmont Hospital, Atlanta, USA
Fred Schwartz et al
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Piedmont Hospital,
Atlanta, USA
Music Medicine
Cardiac Surgery &
General Surgery
musical menu
Fred Schwartz et al
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Sources Of Hospital Music and Methods of Distribution
SOURCE DISTRIBUTION
• Satellite or cable TV music channels
• CD players as source of music channels
• Hard drive central server
• MP3 player
• Internet radio
• Analog or digital transmission via cable
• Digital sent over ethernet
• Wi-Fi wireless transmission
• Transmission via internet
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Certified Music Practitionersto serve cardiac patients?
Live music more important than pre-recorded music!
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Live music incardiac units?
Include music therapy aspart of cardiac rehabilitation
programs in future
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International Society for Music in Medicine (ISMM)
Dr. Dritsas & Dr. Ralph Spintge
Music by
Dr. Dritsas
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GENERAL CONCLUSIONS
Music medicine can be used easily as a
complementary tool
with a view to reduce stress and anxiety and
improve mood (via a relaxing type of music)
and modify physiological parameters towards
a favorable hemodynamic condition (HR, BP,
neurohormones) in cardiac patients.
So far there are no studies to provide
prognostic information on the effect of music
medicine/music therapy on mortality/morbidity
In cardiovascular disease.
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IDEAL MUSIC FOR CARDIAC PATIENTS?
The flowing river example
Relaxing type mostly (Andante/Adagios)
Full of colours
Progressive changes to maintain a prospect of non-familiarity
Classical music of Mozart, Vivaldi, Bach ideal for Central Europe
Correct for culture where a non-classical original culture
Avoid techno, metal, hip-hop/avoid songs with emotional burden
Active music therapy sessions by a certified therapist
Options via web/www.radioart.gr/antistress web radio
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How music can promote exercise
The importance of a musical game!
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Thank you !
Exercise mind by music and body by physical exercise:
The holistic approach for heart disease
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