Music: A double edge sword

Dr Athanasios Dritsas FESC

Cardiologist

Onassis Cardiac Surgery Center, Athens

Music Composer MA

No conflict of interest

Pythagoras by dividing the monochord in simple ratios

connected music, mathematics and medicine

Somatometry in nature follows mathematics of music

and Pythagorean theories

Structural analogies eg in Dinosaur follow the structure

of a major musical scale!

Structural principles in nature and music follow

the mathematical sequence of Golden Section

God thinks in musical terms !

Artists think in terms of music also!

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

Tibetan Singing Bowls

Temple of Asklepios at EpidavrosUsed music as medicine and music therapy

Hippocratesapplied music medicine

The Tarantella

Hypnosis and Music: Mesmer & Mozart

• Mozart’s compositions used the glass harmonica

Shamans use

Throat Singing

as healing music

for the heart

Florence Nightingale

She observed the beneficial effects of wind instruments

with continuous sound, also used strings and voice

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

Feel the beat !

tempo heart rate art.pressure

tempo heart rate art.pressure

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

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

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

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

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.

ONASSIS CARDIAC SURGERY

CENTER

Athens, Greece

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.

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

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

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

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

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

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 - -

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)

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)

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)

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)

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

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

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.

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.

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.

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

METHODS 3

Positive

CTT1

n = 28

Music

Group

n = 14

Control

Group

n = 14

Rando

mized

CTT2

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%)*

RESULTS 4

8

7

6

5

4

3

2

1

0

6

5

4

3

2

1

0

Po

sit

ive

str

es

s s

co

reP

os

itiv

e a

rou

sa

l s

co

re

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

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

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.

Music normalized

the

sympathoadrenal

imbalance noticed

during positive

HUTs expressed

through the

increase in

norepinephrine

during negative

HUTs while

listening to music.

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.

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)

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

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

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!

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

Piedmont Hospital,

Atlanta, USA

Music Medicine

Cardiac Surgery &

General Surgery

musical menu

Fred Schwartz et al

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

Certified Music Practitionersto serve cardiac patients?

Live music more important than pre-recorded music!

Live music incardiac units?

Include music therapy aspart of cardiac rehabilitation

programs in future

International Society for Music in Medicine (ISMM)

Dr. Dritsas & Dr. Ralph Spintge

Music by

Dr. Dritsas

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.

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

How music can promote exercise

The importance of a musical game!

Thank you !

Exercise mind by music and body by physical exercise:

The holistic approach for heart disease