Music: A double edge sword Dr Athanasios Dritsas FESC Cardiologist Onassis Cardiac Surgery Center, Athens Music Composer MA

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1 Music: A double edge sword Dr Athanasios Dritsas FESC Cardiologist Onassis Cardiac Surgery Center, Athens Music Composer MA No conflict of interest

2 Pythagoras by dividing the monochord in simple ratios connected music, mathematics and medicine

3 Somatometry in nature follows mathematics of music and Pythagorean theories

4 Structural analogies eg in Dinosaur follow the structure of a major musical scale!

5 Structural principles in nature and music follow the mathematical sequence of Golden Section God thinks in musical terms!

6 Artists think in terms of music also!

7 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

8 Tibetan Singing Bowls

9 Temple of Asklepios at Epidavros Used music as medicine and music therapy

10 Hippocrates applied music medicine

11 The Tarantella

12 Hypnosis and Music: Mesmer & Mozart Mozart s compositions used the glass harmonica

13 Shamans use Throat Singing as healing music for the heart

14 Florence Nightingale She observed the beneficial effects of wind instruments with continuous sound, also used strings and voice

15 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


17 Feel the beat! tempo heart rate art.pressure tempo heart rate art.pressure

18 Autonomic responses are synchronized with music, so might convey emotions via autonomic arousal during crescendos or rhythmic phrases Average cardiovascular and respiratory data obtained in the 24 subjects while listening to "Nessun dorma Bernardi, L. et al. Circulation 2009;119: Copyright 2009 American Heart Association

19 Average cardiovascular and respiratory data obtained in the 24 subjects while listening to Bach's cantata Bernardi, L. et al. Circulation 2009;119: Copyright 2009 American Heart Association

20 Average cardiovascular and respiratory data obtained in the 24 subjects while listening to "Va pensiero Bernardi, L. et al. Circulation 2009;119: Copyright 2009 American Heart Association

21 EFFECTS OF MUSIC LISTENING ON PHYSIOLOGICAL PARAMETERS The anxiety and pain reducing effects of music interventions: a systematic review, AORN JOURNAL 2008 Assessed 42 Randomized control trials, patients, age yrs Patients in all studies underwent elective surgery, post-op measurements ANXIETY SEDATIVE PAIN 12/24 studies (50%) reported reduction in anxiety scores in 3 studies sedative requirement was during music listening 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

22 Medical Music Therapy Cheryl Dileo & Joke Bradt Cochrane Systemic Reviews Database, June 2009 A 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.


24 ONASSIS CARDIAC SURGERY CENTER Music intervention studies 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 Pts listened via good quality headphones. Needed assistance by nursing personnel.

25 ONASSIS CARDIAC SURGERY CENTER Music intervention studies Patients were very positive and co-operative with music medicine projects, Classical doctors and colleagues were very difficult to cooperate 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

26 Music in Cardiology General relaxation with music ICU/Onassis Cardiac Surgery Study, Dritsas et al 100% 94% 80% 60% 40% 20% 0% 6 % 47 YES 3 NO Subjective pts opinion

27 Music in Cardiology Music and stress relief in hospital Onassis Cardiac Surgery Study 16% 84% YES n =42 NO n = 8 Subjective pts opinion Dritsas et al, Heart Surgery Forum 2010 (suppl)

28 Music in Cardiology Stress reduction with music according to VAS Onassis Cardiac Surgery Study VAS= visual analogue scale 50% 39 pts 50% 11 pts 78% 22% 0% 20% 40% 60% 80%

29 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

30 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 - -

31 Waiting with music prior to exercise test 150 Dritsas et al (2001) 120 P < Entrance 10 min music music group n=11 Non- music group n=11

32 Heart rate changes during recovery 100 P < 0.05 Dritsas et al (2001) min 4 min 6 min music group n=11 Non - music group n=11

33 SBP changes during recovery 100 P < 0.01 Dritsas et al (2001) P < min 4 min 6 min music group n=11 Non - music group n=11

34 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)

35 Music-exercise-anxiety-mood profile in cardiac patients Dritsas 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

36 Table 1. EXAMPLES OF MUSICAL PIECES USED: JS BACH, GF HANDEL, C DEBUSSY, WA MOZART, Air from Suite no 3, D major Largetto, Harp concert, B flat major Clair de Lune, Suite Bergamasque 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 KARL ZERO (jazz) Tribute by Daniel Barenboim (pop) Songs for Cabriolet

37 TABLE 2. Control group (CG) DESCRIPRIVE DATA Experimental Group (EG) (music) Group of patients n=30 n=30 Gender M/F 26/4 29/1 Age Negative Ex-ECG(n) n=22 n=26* *p<0.01 Medication(n) Risk factors CAD(n) Exercise time (min) Systolic BP baseline (mmhg) Diastolic BP baseline Systolic BP peak Diastolic BP peak 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.

38 Table 4. Aspects of Mood Differences from POMS-comparisons between groups-one way ANOVA Mean square F p value Mood A-Energetic ns Mood A-Active ns Mood B-Energetic *p<0.01 Mood B-Active *p<0.05 *Favouring experimental group (EG), so favouring music listening.

39 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.

40 THE EFFECT OF RELAXING MUSIC ON THE STRESS DIMENSION AND THE RESPONSE TO TILT-TEST IN VASOVAGAL PATIENTS Α. Dritsas 1, D. Leftheriotis 2, G. Karabela 2, O. Missirliadou 3, EG. Livanis 2, GN.Theodorakis 2, DT. Kremastinos 2, DV. Cokkinos 1. 1 A Cardiology Department, 2 B Cardiology Department, 3 Transplantation Unit, Onassis Cardiac Surgery Center, Athens, Greece Eur Heart J (2004), ESC Congress 2004

41 METHODS 3 Positive CTT1 n = 28 Music Group n = 14 Rando mized CTT2 Control Group n = 14

42 RESULTS 2 MUSIC GROUP CONTROL GROUP 29% 71% 71% 29% Positive CTT2 n = 4 (29%)* Negative CTT2 n = 10 (71%) Negative CTT2 n = 4 (29%) Positive CTT2 n = 10 (71%)* *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.

43 Positive arousal score Positive stress score RESULTS P < 0.01 p = ns CTT 1 CTT Music Group Control Group 6 P < 0.01 p = ns 5 4 CTT CTT Music Group Control Group

44 MUSIC LISTENING DURING HEAD-UP TILT TESTING IN NEUROCARDIOGENIC SYNCOPE Anna Kostopoulou 1, Athanasios Dritsas 2, George Theodorakis 1, Dionyssios Leftheriotis 1, Georgia Karabela 1, Efthimios Livanis 1, Dimitrios Kremastinos 1, Dionyssios Cokkinos nd Cardiology Department, Onassis Cardiac Surgery Center 2 1 st Cardiology Department, Onassis Cardiac Surgery Center European Heart Journal (2006);27 (suppl):186

45 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.

46 Music normalized the sympathoadrenal imbalance noticed during positive HUTs expressed through the increase in norepinephrine during negative HUTs while listening to music.

47 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.

48 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= 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)

49 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

50 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

51 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!

52 Music System Channels Hospital musical menu of Piedmont Hospital, Atlanta, USA Fred Schwartz et al 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

53 Piedmont Hospital, Atlanta, USA Music Medicine Cardiac Surgery & General Surgery musical menu Fred Schwartz et al

54 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

55 Certified Music Practitioners to serve cardiac patients? Live music more important than pre-recorded music!

56 Live music in cardiac units? Include music therapy as part of cardiac rehabilitation programs in future


58 International Society for Music in Medicine (ISMM) Music by Dr. Dritsas Dr. Dritsas & Dr. Ralph Spintge

59 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.

60 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/ web radio

61 How music can promote exercise The importance of a musical game!

62 Exercise mind by music and body by physical exercise: The holistic approach for heart disease Thank you!