Music and Medicine: the Effects of Music on the Human Being 133

Music and medicine: The effects of music on the human being 133

Applied Cardiopulmonary Pathophysiology 16: 133-142, 2012

Music and medicine: The effects of music on the human being Hans-Joachim Trappe Department of Cardiology and Angiology, University of Bochum, Germany

Abstract

Music may not only improve quality of life but also effect changes in heart rate (HR) and heart rate variability (HRV). A greater modulation of HR and HRV was shown during musical performance compared to listening to music. Cerebral flow was significantly lower when listening to “Va pensiero” from Verdi’s “Nabucco” (70.4±3.3 cm/s) compared to “Libiam nei lieti calici” from Verdi’s “La Traviata” (70.2±3.1 cm/s) (p<0,02) or Bach’s Cantata No. 169 „ Gott soll allein mein Herze haben“ (70.9±2.9 cm/s) (p<0,02). There was no significant influence on cerebral flow in Beethoven’s Ninth Symphony during rest (67.6±3.3 cm/s) or music (69.4±3.1 cm/s). Music significantly decreases the level of anxiety for patients in a preoperative setting compared to midazolam (STAI-X-1 score 36) (p<0.001). Listening to music while resting in bed after open-heart surgery leads to significant differences in cortisol levels between the music (484.4 mmol/l) and the non-music group (618.8 mmol/l) (p<0.02).

Key words: music performance, music perception, quality of life, music therapy, cardiovascular system

Introduction cardiovascular and respiratory responses with different styles in most subjects, in Listening to music, whether a Mozart sym- whom responses were related to tempo and phony or to Antonio Vivaldi’s “the four sea- were associated with faster breathing (3,4). sons” may not only help to unwind at the Fast music caused increases in blood pres- end of a stressful day. It could also lower sure, heart rate and breathing rate, and re- blood pressure, heart rate and improve heart duced baroreflex sensitivity. Slow music, on rate variability. The idea that music has an ef- the other hand, caused a significant fall in fect on heart rate, blood pressure and cardio- heart rate and breathing frequency com- vascular system has been reported in 1918 pared with the baseline. The responses were by Hyde and Scalapino (1). They reported qualitatively similar in musicians and nonmu- that minor tones increased heart rate and sicians and apparently were not influenced lowered blood pressure, whereas “stirring” by musical preferences, although musicians music increased both blood pressure and did respond more (5). heart rate. There are several individual reac- In recent years, music has been increas- tions to music that are dependent on individ- ingly used as a therapeutic tool in the treat- ual preferences, mood or emotions (2). It has ment of different diseases (6-8). It has been been reported that music showed consistent shown that music therapy not only reduced 134 H.-J. Trappe

Figure 1: Brain asso- ciation areas. Localiza- left hemisphere right hemisphere tion of different functio- nal areas in the left or right brain hemisphere

abstract thinking emotionality analytic thinking intuition rational thinking spatial reasoning intellect visual reasoning linguistic abilities imagination rhythmic abilities musicality recognition of people analogical thinking

cerebral function

blood pressure, heart rate and patient anxi- baby or even in children born before the reg- ety but had a significant effect on future ular date of birth. This is a well known inter- events, including reinfarction and death, in action between the baby and the mother and acute coronary syndrome patients who un- will help to avoid colic in newborns. In addi- derwent revascularization (Dr. Predrag Mitro- tion, music is also helpful for the mother pri- viv, ESC congress 2009, Barcelona, personal or to delivery. Yang et al (12) studied the ef- communication). Miller et al showed that mu- fect of music on anxiety alleviation in 120 an- sic also affects endothelial function and in tepartal women on bed rest. These women this study brachial artery flow mediated dila- received music therapy for 30 min on 3 con- tion increased 26% during music phase that secutive days. Music was selected according evoked joy compared to baseline to the women’s own preferences. Usual care (p<0,002)(9). The purpose of the present participants had a 30 minute rest on 3 con- manuscript is to summarize the different ef- secutive days. Variables included anxiety fects of music on health, cardiovascular pa- (State-Trait Anxiety Inventory), and physiolog- rameters, anxiety, pain and to describe what ical responses like vital signs and fetal heart kind of music is helpful for whom and what rate. Anxiety levels decreased and physiolog- kind of music is probably dangerous. ical responses improved significantly in the women with music therapy while on bed rest. In another study by Kim et al (13) it was Effects of music on the cardio- suggested to play music for women during vascular pathophysiology in pregnancy, birth and nursing. Increased sym- the pregnant woman pathetic activity during pregnancy has been proposed as a mechanism for increased inci- It is well known that music, as a stimulus, can dence of arrhythmias and, therefore, music be recognized as early as the twentieth week may help to avoid them (14,15). Occurrence of fetal development. The unborn baby will of cardiac tachyarrhythmias may also be re- recognize all sounds and will “learn” music in lated to physiologic changes occurring dur- this way (10,11). This is the first sensory im- ing pregnancy, such as increased heart rate, pression for the child. There is general agree- decreased peripheral resistance and in- ment that soft sounds with regular and low creased stroke volume. Music with slow rhythms (“lullabies”) are ideal for the unborn rhythms, soft sounds and particularly music Music and medicine: The effects of music on the human being 135 from Mozart is beneficial in these circum- tion in blood pressure (p<0.05). Correlations stances and opens new possibilities for un- were significant both in individual and group- born (and born) babies as well as for the averaged signals (p<0.05). Phrases at 10-sec- mother. It seems possible to prevent cardiac ond intervals by Verdi entrained the cardio- arrhythmias for both mother and the unborn vascular autonomic variables. It is important child as well as to prevent sudden infant to note that no qualitative differences were death. In addition to these cardiovascular ef- observed in recorded measurements be- fects, there is a significant improvement in tween musicians and nonmusicians. In this cognitive function (Binet intelligence scale) study cerebral flow was significantly lower when listening to Mozart’s music (score when listening to “Va pensioero“ (70.4±3.3 57.56) compared to relaxation (score 54.61) cm/s) compared to “Libiam nei lieti calici or silence (score 54.00) (p<0.002). In relation (70.2±3.1 cm/s) (p<0,02) or Bach (70.9±2.9 to each other, the relaxation and silence con- cm/s) (p<0,02). There was no significant influ- ditions did not differ (p=0.43) (16). Music ence on cerebral flow in Beethoven’s Ninth can also be helpful in instances of depression Symphony during rest (67.6±3.3 cm/s) or and more specifically postpartum depression music (69.4±3.1 cm/s). The data by Bernardi (17). It seems that Mozart has benefitial ef- et al. (19) also demonstrate that in addition fects on energy expenditure in growing to conscious chills, which typically are expe- preterm infants (18). rienced by a minority of subjects, there is a common pattern of unconscious response when different subjects listen to the same Effects of music on the music. These autonomic responses were pathophysiology and the more apparent with lyrical responses from an cardiovascular system operatic aria or a typical exciting orchestral phrase than with more “intellectual” solo Bernardi et al. (19) studied 24 young, healthy singing from a Bach cantata. The extent of subjects (12 chorists and 12 nonmusician the responses appeared to be dependent on control subjects) who listened in random or- the specific pattern of the musical profile. der to music with vocal (Puccini’s “Turan- When a sudden crescendo was spaced ade- dot”) or orchestral (Beethoven’s Ninth Sym- quately, or the musical profile exhibited a reg- phony adagio) progressive crescendos, more ular or slow change, then the cardiovascular uniform emphasis (Bach’s Cantata BWV 169 system tracked the musical profile, and skin “Gott soll allein mein Herz haben”), 10-sec- vasomotion was evident. When the musical ond period rhythmic phrases (Verdi’s arias profile changed very rapidly, the overall ef- “Va pensiero” and “Libiam nei lieti calci”) or fect was opposite. Skin vasomotion and a re- silence while heart rate, respiration, blood duction in blood pressure by general relax- pressure, middle cerebral artery flow veloci- ation were observed (19). It has been shown ty, and skin vasomotion were recorded. in other studies by Yoshie et al. (20) and Common responses were recognized by av- Nakahara et al. (21) that music will have ben- eraging instantaneous cardio respiratory re- eficial effects on heart rate, heart rate variabil- sponses regressed against changes in musical ity and anxiety levels in not only skilled pi- profiles and by coherence analysis during anists but also nonmusicians during both per- rhythmic phrases. Vocal and orchestral formance of and listening to music. The find- crescendos produced significant correlations ings of these studies suggest, though, that between cardiovascular or respiratory signals musical performance has a greater effect on and musical profile, particularly skin vasocon- emotion-related modulation in cardiac auto- striction and blood pressures, proportional to nomic nerve activity than musical perception crescendo, in contrast to uniform emphasis, (22,23). which induced skin vasodilation and reduc- 136 H.-J. Trappe

It has been shown that the structure of a between the three groups. In addition similar piece of music has a constant dynamic influ- drug regimens were used prior to and after ence on cardiovascular and respiratory re- the procedure. Recently, in the Almut-study sponses, which correlates with musical pro- the effect of different types of music during files (24,25). Specific musical phrases (fre- cardiac catheterization procedures was ana- quently at a rhythm of 6 cycles/min in fa- lyzed by an anxiety score system between mous arias by Verdi) can synchronize inher- patients who had music during the proce- ent cardiovascular rhythms, thus modulating dure compared to those who did not (31). In cardiovascular control. This occurred regard- addition to the anxiety score, heart rate and less of respiratory modulation, which sug- blood pressure were recorded. There were gests the possibility of direct entrainment of patients who listened to classical music, me- such rhythms and led to the speculation that ditation music, Jazz or silence. In patients some of the psychological and somatic ef- who were not able to select their own music, fects of music could be mediated by modula- the most beneficial effect was seen in those tion or entrainment of these rhythms (26). who had classical music. In patients who se- Music as therapy is an option for all since it lected their own music, meditation music has been reported that musicians and non- was most powerful. Although there were sig- musicians alike showed similar qualitative re- nificant differences in the anxiety index be- sponses (cardiovascular and respiratory sys- tween patients with or without music tem). This suggests that “active” playing of (p<0.05), no significant differences among music is not essential to induce synchroniza- the two groups were observed in heart rate tion with music. However, it was pointed out or blood pressure. that musicians appeared to show higher cardiovascular and respiratory modulation induced by music. They also tended to respond Effect of music on the cardio- more than nonmusicians to more “intellectu- pulmonary pathophysiology al” music like that of Bach or Mozart (27-29). prior to and after cardiac surgery Effect of music during cardiac catheterization The influence of music was studied prior to bypass grafting or valve replacement in 372 Argstatter et al. (30) analyzed the role of mu- patients wherein a portion of the group re- sic in 90 patients who underwent cardiac ceived midazolam (0.05-0.1 mg/kg) accord- catheterization. There were three random- ing to the STAI-X-1 anxiety score (32). Of the ized groups: Group I represented patients 372 total patients, there were 177 patients with “music only” during catheterization pro- who had music prior to surgery and 195 pa- cedures, Group II patients had both music tients who received midazolam. There were during catheterization and extended informa- significant differences in the anxiety scores tion prior to the procedure and Group III pa- prior to and after surgery between both tients served as controls. In all groups the groups: in the “music group” prior to and af- anxiety score was evaluated with the cate- ter surgery the score was 34 and 36 respec- gories “minimal anxiety – minimal stress” or tively, whereas the score was 30 and 34 in “severe anxiety – severe stress”. It was be- the midazolam group (p<0.001). Nilsson et coming clear that the behavior during the al. (33) analyzed 40 patients who underwent procedures was significantly better in Group bypass grafting or aortic valve replacement I and Group II patients in contrast to controls and in these patients oxytocin, heart rate,

(p<0.05). However, there were no significant blood pressure, PaO2 and oxygen saturation differences in heart rate and blood pressure SaO2 were studied in two groups: one group Music and medicine: The effects of music on the human being 137 had music, the other group served as con- and in patients with depressive syndromes. trols. As pointed out by the authors there Chan et al. (37) performed a randomized were significantly better values of oxytocin study in 47 people under the age of 65 who

(increased) and PaO2 (increased) in the mu- underwent music therapy compared to 24 sic group compared to controls (p<0.05). No controls. In the music group, there were sta- significant differences were observed regard- tistically significant decreases in depression ing heart rate, blood pressure and SaO2. In scores (p<0.001), blood pressure (p<0.001), another study, Nielsson et al. (34) analyzed and heart rate (p<0.001) after one month the follow-up of 58 patients after cardiac sur- (p<0.001). The implication of this observa- gery. These patients underwent musical ther- tion is that music can be an effective inter- apy (30 min music exposure one day after vention for older and/or patients suffering surgery) compared to controls. Evaluation of from depressive syndromes. Particularly older cortisol, heart rate, ventilation, blood pres- patients with Alzheimer diseases will profit sure, SaO2, pain and anxiety indices was per- from music therapy. We all know that the ter- formed. There were significantly lower corti- minal patient presents a unique situation. It sol levels in the music group (484.4 mmol/l) has been reported that these patients will compared to patients without music (618,8 continue hearing although some other organ mmol/l) (p<0.02). There were no significant functions have been lost. Therefore, music differences in heart rate, blood pressure, res- plays an important role in this situation and piration and oxygen saturation between both music from the patient’s youth has the most groups. Similar effects have been reported by impact. This music might prove to be the last Antonietti in patients who underwent rehabil- source of aesthetic enjoyment and simple itation after surgery (35). happiness for the dying patient (38,39).

Effects of music on intensive What types of music are good care patients, geriatric and for health – which are not? terminally ill patients The most beneficial music for the health of a It is well known that soft and not loud sounds patient is classical music, which holds an im- have beneficial effects on patients while portant role in music therapy (40). It has treated in intensive care medicine and will re- been shown that music composed by Bach, duce pain and stress significantly (36). Soft, Mozart and Italian composers is the most silent or quiet classical or meditation music is powerful in “treating” patients. It is possible associated with the reduced need for seda- to select the “ideal” therapy for cardiovascu- tive drugs and reduced perception of pain. lar disturbances, recreation and refreshment Despite the well known effects of music in in- of the immune system, improvement of con- tensive care medicine this kind of “therapy” centration and help with depression. The is observed rarely in daily practice. In addi- beneficial effects of Bach’s music is possibly tion to this, there are many psychological ef- caused by his “mathematical” compositions fects: music from the youth of the patient will avoiding sudden changes (Fig. 2,3). Patients lead to improved mood, concentration and who would receive the most benefit from motivation, all of which are essential for the classical music include those with anxiety, intensive care patient. There are spectacular depressive syndromes, cardiovascular distur- effects of music in geriatric patients: music bances and those suffering from pain, stress from the youth and music from “better days” or sleep disturbances. Popular music is an will lead to improved mood, motivation, in- “eye-opener”. This music incorporates har- creased vitality and will also encourage social monic melodies that will lead to buoyant spir- contacts (36). This is important in geriatrics it, good mood leading to lift in mood, in- 138 H.-J. Trappe

Figure 2: Johann Sebastian Bach (1685-1750): Fuga in D major (BWV 532) for organ solo. This is a typical example of Bach’s music. The theme is conduced in the same manner four times (“A” – “D”). This explains the typical “Bach effect” avoiding sudden changes in tempo and dynamics (measure 1- 19).

Figure 3: Johann Sebastian Bach (1685-1750): Fuga in D major (BWV 532) for organ solo. This is a typical example of Bach’s music. The theme is conduced in the same manner four times (“A” – “D”). This explains the typical “Bach effect” avoiding sudden changes in tempo and dynamics (measure 20-35). Music and medicine: The effects of music on the human being 139 creased motivation and general stimulation. with psychiatric disorders. It has been used to Meditation music has sedative effects. modify the behavior of children with autism Sounds are slow and rhythms few. This kind and pervasive developmental disorders with of music generates spiritual reflection and, as moderate success. It has been used to re- such, is utilized in Yoga and Tai Chi. Heavy duce agitation in patients with dementia by metal and techno are ineffective or even dan- soothing them and eliminating the social iso- gerous. This music encourages rage, disap- lation of these patients (43,44). Music thera- pointment, and aggressive behavior while py has been used in patients with Parkinson’s causing both heart rate and blood pressure disease to improve motor skills and to deal to increase. Breastfeeding mothers should with emotional problems (45). There is ample avoid this music because there is a negative evidence of the usefulness of music therapy influence on milk flow. In addition, plants in alleviating grief and in combating bouts of have been shown to slow their growth or depression. Music no doubt plays a pivotal even die when exposed to this kind of music role in the lives of human beings. Incorporat- on a permanent basis. Hip Hop and Rap are ing music therapy into regular therapy pro- less frequently effective due to the sounds, grams for psychiatric disorders can help but can often have effect due to their words speed recovery and also help make therapy a – the important element of which is the more positive experience. Music therapy is a rhyme structure. Jazz appeals to all senses, valuable but relatively unexplored asset in but a high degree of concentration is neces- the field of psychiatry and psychotherapy. sary when listening to Jazz. There are few However, the patient may or may not like the studies of the effect of Jazz on health. Latin- music chosen by the therapist and thus is giv- American music like samba, tango, cha-cha- en a choice to include music or not. Careful cha, rumba, reggae or mambo is very rhyth- selection of music that incorporates patient’s mic. This music leads to positive mood and own preferences may yield positive results, buoyant spirit and induces movement. It in- whereas contrary effects may result from use creases motivation and stimulates activity. of the wrong type of music. Selection of Folk is music with a socio-cultural back- “wrong” music can intensify depressive syn- ground. It is enriching for intellectual work, dromes, aggressiveness and anxiety. In addi- leads to confidence and emphasizes protec- tion, feelings toward music may change dur- tion. However, if folklore is “unusual” in char- ing different phases of life and may lead to acter it can have a negative effect. Schlager different effects. music are songs to sing alone with, have simple structures but frequently have “earworm- character”. This kind of music is inappropri- Conclusions ate for influencing health. Music is used more and more as a therapeutic tool, because all subjects, whether musi- When is music not useful? cally trained or not, respond in a similar manner. Music is a combination of frequency, More recently, several reports have indicated beat, density, tone, rhythm, repetition, loud- the usefulness of music therapy in managing ness, and lyrics. Different basic personalities psychiatric disorders (41,42). Music has been tend to be attracted to certain styles of mu- used in the treatment of psychosis and neu- sic. Energy block patterns can intensify, re- rosis and now is being used in addressing or- duce, or change the natural inclinations of a ganic disorders such as dementia. It plays a person’s identity. Music influences our emo- useful role in allaying anxiety and relaxing pa- tions because it takes the place of and ex- tients in critical care. Music therapy has been tends our languages. Research conducted used effectively in both adults and children over the past 10 years has demonstrated that 140 H.-J. Trappe persistent negative emotional experiences or References an obsession and preoccupation with nega- 1. Hyde IM, Scalapino W. The influence of tive emotional states can increase one’s like- music upon electrocardiograms and blood lihood of acquiring the common cold, other pressure. Am J Physiol 1918; 46: 35-38 viral infections, yeast infestations, hypersensi- 2. Koelsch S, Siebel WA. Towards a neural ba- tivities, heart attacks, high blood pressure, sis of music perception. 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Address for correspondence: Prof. Hans-Joachim Trappe, M.D. Department of Cardiology and Angiology University of Bochum Hoelkeskampring 40 44625 Herne Germany [email protected]