Music Therapy PowerPoint Presentation

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1 An Overview of MUSIC THERAPY Dr Ruvan Ekanayaka MBBS, MD, MRCP(UK), FRCP(Lond), FRCP(Edin), FRCP(Glsg), FCCP, FACC, FESC Consultant Cardiologist

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2 Musicotherapy - Definition “Controlled use of music to influence human physiology and alter physiological and emotional status for the better”

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3 History – Western world The scientific interest in musico therapy commenced during the experience in world war I and II Value recognized for i) Reconditioning of traumatized soldiers ii) Wound healing

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Music therapy as we know it began in the aftermath of World Wars I and II, when, particularly in the United Kingdom, musicians would travel to hospitals and play music for soldiers suffering from war-related emotional and physical trauma. Some neuropsychiatric cases could only be reached via music. 4

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6 History of music therapy Eastern world – Vedic philosophy called this area Nada Vidya * Anahata nada – Sublime sound – Yoga * Ahata nada – audible music It was postulated that the 7 notes affect the 7 primary chakras of the human body Eg:- Muladhara chakra – Sa Swadhistana chakra – Re Sahasrava chakra – Ni Eastern philosophy contains a core of truth. But this is confounded by ‘padding’ of arbitrary theory, un-provable hypotheses and mythology

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8 History – Eastern world Indian musicologists categorized various raga as being therapeutic for specific diseases Miyan ki Malhar Darbari kanada Bhaivari – Asthma, sinusitis, ‘chest’ problems Malhar – Anger, stress Asawari – Impurities of blood Todi – High blood pressure Deepak – Gastric acidity Gunakali – Constipation Hindol Marva Bronchial asthma High fever, malaria

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9 History of music therapy Western world The Greeks introduced the concept of ‘sports and music’ as contributing to good health Apollo – the god of music, gives birth to his son in the form of Aesculipus – the god of healing and medicine Homer believed that music could be used to negate negative feelings

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Music has been used as a healing implement for centuries. Apollo is the ancient Greek god of music and of medicine. Aesculapius was said to cure diseases of the mind by using song and music, and music therapy was used in Egyptian temples. Plato said that music affected the emotions and could influence the character of an individual. Aristotle taught that music affects the soul and described music as a force that purified the emotions. Aulus Cornelius Celsus advocated the sound of cymbals and running water for the treatment of mental disorders. Music therapy was practiced in biblical times, when David played the harp to rid King Saul of a bad spirit. As early as 400 B.C., Hippocrates played music for mental patients. 10

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In the thirteenth century, Arab hospitals contained music-rooms for the benefit of the patients. In the United States, Native American medicine men often employed chants and dances as a method of healing patients. 11

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12 What is Music? “Music is an enigma. Shakespeare asks “Is it not strange that sheep gut should hale souls out of men’s bodies?” - Much ado about nothing” - Prof. Stephen Pinker Prof of Cognitive neuroscience MIT

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13 Physiological aspects of music in humans Music is processed in the Reticular Activating System (RAS) in the brain stem Impulses from various sensory pathways relay via collaterals to the RAS

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14 RAS The RAS contains – Centre for respiration Centre for blood pressure Centre for heart rate Centres for vegetative function

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15 RAS ctd When music is listened to, sensory stimuli travel along ascending sensory fibres to the neurons of the RAS These stimuli are then projected to the thalamus and from there: Upwards to: - Cerebral cortex - Limbic system - Corpus Callosum Downwards to: - Autonomic nervous system - Neuroendocrine system

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16 Processing of music in the brain When music reaches the cerebral cortex the primary processing occurs in the temporal lobe From the temporal lobe impulses go to the Association Cortex (Association Cortex – Highest levels of thinking are done here. Eg:- mathematics, symbolic thought etc)

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17 Music and the limbic system Location: Border between cerebral cortex and brain stem Function: Controls emotions, memory, learning Components of the limbic system: Cingulate gyrus, hippocampus, fornix, hypothalamus, mamillo thalamic tract, anterior thalamus, mamillary body

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18 Music and the limbic system ctd When music is played, all areas of the limbic system are stimulated (PET scan data) Biochemical basis:- When music is played, the levels of Phenyl ethyl amine are increased in the limbic system This neuroamine is responsible for the feeling of ‘love’ (even in animals) (This neuroamine is naturally found in chocolate)

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19 Music and the corpus callosum The corpus callosum interconnects the right and left hemispheres It contains tracts of a fibrous nature Music has been shown to activate biochemical and electrical ‘memory material’ across the corpus callosum, so that the two hemispheres can work better together rather than in opposition

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20 Music and the autonomic nervous system Sympathetic nervous system Parasympathetic nervous system Music tones down the sympathetic nervous system so parasympathetic nervous system overrides the stimulatory effects of the sympathetic system Then it leads to a ‘relaxation response’:- - heart rate - BP - regular deep breathing - muscle relaxation - alpha brain waves

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21 Music and the neuro endocrine system Music effects 3 main pathways of the neuro endocrine system: 1. Endorphins – These are natural opiates, released from the pituitary gland * Relieves pain * Enhances mood 2. Catecholamines – These are reduced by music These cause HR, BP metabolic rate d O2 consumption These also lead to migraine, peptic ulcer, CVA 3. Corticosteroids – These are reduced by music. These are stress related hormones

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22 Stress and the Endothelium Stress causes (1) Unhealthy behavior (2) Rise in stress markers eg:- cortisol, fibrinogen, catecholamines Cortisol – Causes ‘furred’ up arteries Fibrinogen – Causes increased clotting Catecholamines – Causes raised heart rate and blood pressure There are probably a greater number of biochemical changes which have been inadequately studied as yet

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23 With all these physiological data is it safe to conclude that Music therapy is only placebo?? Placebo effect: - Belief and expectancy of patient of benefit - Belief and expectancy of caregiver of benefit Belief and expectancy generated by the relationship between the patient and caregiver of benefit! Nocebo effect also exists!

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24 Scientific studies on music therapy 1. Studies on the cardiac system: Mackel et al – Healthy individual ( Eu J App & occ physiology:1994) Bernadi et al – Healthy individual (BHJ:2006) White et al – Acute MI (Am J Critical care:1999) Siritunge et al – Angina pectoris ( 2008 MD thesis) 2. Studies on the neural system: Pachetti et al – Parkinson’s disease (J. Psychosomatic Med:2000) 3. Studies on cancer patients: Ferrer – Cancer patients (MSc thesis. U of Florida 2001) 4. Studies on mental patients: Hanser et al – Alzheimer's disease (J. Palli. Care 2001) Hanser et al – Depression ( J. Palli. Care 2001)

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25 CVS effects: Healthy volunteers Eu J. Applied & Occup physiology: 1994, Mackel et al Study population: 20 healthy volunteers Study music: Waltz by J Strauss Modern piece by H W Henze Meditative music by R Shankar Listening period: 6 – 6 ½ minutes Study measurement: Doppler study of the mitral valve flow which indicated LV diastolic function HR, BP S. adrenaline, S. noradrenaline, S. cortisol, S. ANP, S. t-PA, S. prolactin Psychological score of Zerssen (0-56)

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26 Mackel et al ctd Results: Music of Strauss – Mental score improved - Atrial filling, ANP Music of Henze – Prolactin level d Music of Ravi Shankar - cortisol adrenaline noradrenaline t-PA

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27 CVS: Bernadi & Sleight: 2006, BHJ Healthy Volunteers: Dept of Cardiology: University of Oxford Study design: * Effect of different types of music – fast classical, slow classical, jazz, metal, techno, rap, country, raga, dodecaphonic * Effect on musicians and non musicians

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28 Bernadi et al ctd Study population: 24 normal volunteers (50% trained in music) Study method: Short tracks of music were listened to in random order, for 4 minutes, followed by a 2 minute pause (= sound of silence) and track replayed for another 4 minutes Results: - Faster the tempo, greater the physical arousal - Complex rhythms caused d Resp R, HR - During the ‘Sound of Silence’, all indicators of physical arousal had fallen below the baselines, in all types of music

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29 Bernadi et al ctd Conclusions: Effects do not depend on the style of music Effects do not depend on the preference of the listener Effects, however, are stronger in musicians than non musicians The tempo and rhythm are the most important therapeutic components of music

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30 CVS; AMI: Am J Critical Care: 1999 White et al Note: This study was done on patients with confirmed myocardial infarction Study population: 45 patients with acute MI Study design: Group I – Relaxing music 20 minutes Group II – Relaxing environment Group III – None of above Study duration: 2 hours Study results: Relaxing music of 20 minutes significantly reduced HR, BP, Resp R, myocardial O2 consumption

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Cardiovascular, cerebrovascular, and respiratory changes induced by different types of music in musicians and non-musicians: the importance of silence L Bernardi, C Porta, P Sleight Heart 2006;92:445–452. doi: 10.1136/hrt.2005.064600 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Presentation was made in random order of six different music styles (first for a two minute, then for a four minute track), with a randomly inserted two minute pause, in either sequence. Main outcome measures: Breathing rate Ventilation Carbon dioxide RR interval Blood pressure Mid cerebral artery flow velocity Baroreflex 31

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*Ventilation, *blood pressure, and *heart rate increased and *Mid-cerebral artery flow velocity and *baroreflex decreased with faster tempi and simpler rhythmic structures compared with baseline. The pause reduced heart rate, blood pressure, and minute ventilation, even below baseline. An order effect was evident for mid-cerebral artery flow velocity, indicating a progressive reduction with exposure to music, independent of style. Musicians had greater respiratory sensitivity to the music tempo than did non-musicians. 32

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After subjects had a 20 minute period of quiet rest, they were continuously monitored for * heart rate (RR interval) from the ECG (chest leads) and *non-invasive beat to beat * blood pressure by applanation tonometry at the radial artery. This method faithfully tracks changes in invasive blood pressure. Mid-cerebral artery blood flow velocity was monitored by a 2 MHz transcranial Doppler (TCD) probe at a depth of 35–55 mm through the temporal window of the non-dominant side . Respiratory movements were continuously evaluated by inductive plethysmography expressed as a percentage of baseline values. In a steady state the amplitude of this signal had excellent intra subject correlation with tidal volume recorded with a facial mask or a mouthpiece and a pneumotachograph. End tidal carbon dioxide was monitored by a nasal cannula and side stream capnography 33

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Responses in breathing frequency, end tidal CO2, minute ventilation, and transcranial mid-cerebral Doppler (TCD) flow velocity for each intervention. L Bernardi et al. Heart 2006;92:445-452 Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

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Responses in blood pressure (BP), interbeat period (RR interval), and baroreflex sensitivity for each intervention. L Bernardi et al. Heart 2006;92:445-452 Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

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Responses in low frequency (LF) to high frequency (HF) ratio to spectral analysis of heart rate variability for each intervention. L Bernardi et al. Heart 2006;92:445-452 Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

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37 Faster tempi induced significant increases in ventilation, breathing rate, TCD, systolic and diastolic blood pressures and heart rate (RR interval), tended to reduce baroreflex sensitivity, and induced a progressive increase in the LF:HF ratio (fig 3). No significant changes were seen in end tidal carbon dioxide. In contrast, slower music had a proportionally smaller effect and raga induced a significantly larger fall in heart rate (increase in RR interval, p , 0.01), even compared with baseline or any other music tracks. These effects appeared to depend on the speed of the music rather than on the style. For example, classical and techno styles induced similar results when similarly fast; raga, classical, and dodecaphonic music, all similarly slow, reduced cardiorespiratory responses.

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38 Effect of music training There were no major differences between musicians and non musicians but the analysis of variance model showed both at baseline and during listening that musicians had a significantly lower respiratory rate (p , 0.05) and increased their breathing rate more than non-musicians in response to increasing tempi (fig 4). During the pause, they had a lower respiratory rate and lower LF:HF ratios than non-musicians (figs 4 and 5).

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39 Conclusions Even short exposure to music can induce measurable and reproducible cardiovascular and respiratory effects, leading to a condition of arousal or focused attention that is proportional to the speed of the music. That may be induced or amplified by respiratory entrainment by the music’s rhythm and speed. This effect is independent (at least under the experimental conditions of the study) of a person’s preference or of repetition and habituation, and is clearer when the rhythmic structure is simpler. A pause in the music induces a condition of relaxation greater than that preceding the exposure to music and leads to the speculation that music may give pleasure (and perhaps a health benefit) as a result of this controlled alternation between arousal and relaxation. It may be viewed as an alternative technique of relaxation or meditation, without involving the active participation of the subject.

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40 Dynamic Interactions Between Musical, Cardiovascular, and Cerebral Rhythms in Humans Luciano Bernardi, MD; Cesare Porta, MD; Gaia Casucci, MD; Rossella Balsamo, MD; Nicolò F. Bernardi, MSc; Roberto Fogari, MD; Peter Sleight, MD Conclusions- Music emphasis and rhythmic phrases are tracked consistently by physiological variables. Autonomic responses are synchronized with music, which might therefore convey emotions through autonomic arousal during crescendos or rhythmic phrases. (Circulation. 2009;119:3171-3180.) DOI: 10.1161/CIRCULATIONAHA.108.806174

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41 There has been considerable recent interest in the cardiovascular, respiratory, and neurophysiological effects of listening to music, including the brain areas involved, which appear to be similar to those involved in arousal. Responses to music appear to be personal, particularly when skin tingling or “chills” occur, which suggests individual reactions to music that are dependent on individual preferences, mood, or emotion. However, our previous study showed consistent cardiovascular and respiratory responses to music with different styles (raga/techno/classical) in most subjects, in whom arousal was related to tempo and was associated with faster breathing. The responses were qualitatively similar in musicians and nonmusicians and apparently were not influenced by music preferences, although musicians responded more.

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The previous study did not investigate the entrainment of spontaneous cardiovascular rhythms, the 6 cycles/min (10-second period, 0.1 Hz) Mayer waves of blood pressure that result from imperfect baroreflex control because of the interaction between a fast (vagal) response in heart rate and a slow (sympathetic) vascular response. 42

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Music is increasingly used in treating cardiovascular, neurological, and respiratory diseases. If music induces similar physiological effects in different subjects, standard therapeutic interventions would be possible. 43

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We examined the dynamic cardiovascular responses to variations in phrasing and emphasis using real compositions, selected for different emotional characteristics, to determine the following: (1) Whether variable musical emphasis (eg, crescendo versus stable emphasis) could produce similar instantaneous cardiovascular/respiratory responses among different subjects; (2) whether phrases at approximately 6 cycles/min could entrain the cardiovascular and respiratory responses; and (3) whether these responses were influenced by music training. 44

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We monitored an ECG (by chest leads); noninvasive beat-to beat blood pressure by radial artery applanation tonometry middle cerebral artery flow velocity by a 2-MHz transcranial Doppler probe at a depth of 35 to 55 mm, through the temporal window of the non dominant side; respiratory movements by an inductive plethysmograph built and validated in our laboratory against a pneumotachograph; skin vasomotion (left index fingertip) by a previously described and validated skin photoplethysmograph; and continuous end-tidal carbon dioxide by a nasal cannula . 45

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46 Figure 2. Average cardiovascular and respiratory data obtained in the 24 subjects while listening to Beethoven’s Ninth Symphony. Note a lesser response to the orchestral crescendo (vertical line) from Beethoven’s Ninth Symphony than to the vocal fortissimo in Figure 1.

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Cardiovascular Responses to Music Consistent dynamic cardiovascular and respiratory responses to music were observed. Almost every music crescendo or emphasis induced progressive skin vasoconstriction (downward deflection), along with increases in blood pressures and heart rate. This consistency would not have been possible if individual subjects had responded differently. Conversely, during the silent pause (and baseline), the changes were minor, with progressive skin vasodilation and reductions in heart rate and blood pressure. The degree of change in the cardiovascular variables paralleled those in the music envelope, with highly significant correlations, the most with skin vasomotion and the least with RR interval. 47

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48 Scattergrams and correlation between music profile and skin vasomotion. In “Nessun dorma,” the crescendo induced a proportional vasoconstriction; in the Bach cantata, the crowded peaks in the music envelope ended by creating a progressive vasodilation.

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Skin Vasomotion Biomed Pharmacother. 2008 Oct;62(8):541-5. doi: Skin vasomotion investigation: a useful tool for clinical evaluation of microvascular endothelial function? Rossi M1, Carpi A, Galetta F, Franzoni F, Santoro G. Skin vasomotion is the rhythmic variation of skin microvessel diameter responsible for skin microcirculatory blood flow oscillation, the so called skin blood flowmotion. It can be easily investigated by means of the spectral analysis of skin laser Doppler flowmetry (LDF) signal. Experimental and clinical findings suggest that vasomotion is partially dependent on microvascular endothelial activity. Based on this, investigation of skin vasomotion, using spectral analysis of skin LDF signal has been recently proposed for the investigation of microvascular endothelial function in clinical setting. Clinical studies have demonstrated that the LDF technique coupled with spectral analysis of skin LDF tracing is a useful and accurate method for the measurement of skin microvascular endothelial-dependent vasomotion in patients with different pathological conditions. 49

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Respiration showed regularization of rhythm and a transitory increase in amplitude with crescendos (Figures 1 through 3), without overall changes in end-tidal carbon dioxide affected by music. When respiratory power was tracked continuously (by use of a time-varying spectral algorithm), there was a clear correlation with the music envelope. During Beethoven’s adagio, the instantaneous power of the respiratory signal closely tracked the amplitude of the music envelope, which also indicates that the depth of respiration could be influenced tightly by music, at least during crescendos (Figure 8), similar to what occurred during “Nessun dorma” and even during Bach. 51

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Cardiovascular and Respiratory Systems Mirror the Music Profile, Particularly During Crescendos Although extreme responses to arousing phrases (goose pimples or chills) are associated with conscious emotional arousal. It was found that there are subconscious reflex autonomic responses, involving respiration and cardiovascular parameters, that are common to all subjects, independent of music preferences or previous training. Musical profile was closely mirrored in the skin microvasculature, which suggests a possible lower (subconscious) connection between auditory sensation and cardiovascular reactions. 52

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These autonomic responses were more apparent with lyrical responses from an operatic aria (“Nessun dorma”) or a typical exciting orchestral phrase (Beethoven’s adagio) than with more “intellectual” solo singing from a Bach cantata, however beautiful. The extent of the response appeared to be dependent on the specific pattern of the music profile. When a sudden crescendo was spaced adequately, or the music profile exhibited a regular or slow change (eg, “Nessun dorma,” Beethoven’s adagio, or Verdi’s arias), then the cardiovascular system tracked the music profile, and skin vasoconstriction was evident. 53

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The sound of silence is music to the heart P D Larsen, D C Galletly Heart 2006;92:433–434. doi: 10.1136/hrt.2005.071902 54 EDITORIAL

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ENTRAINMENT OF RESPIRATION One of the features of biological oscillators is their ability to synchronise to, or be entrained by, external inputs. While the exact nature of the central respiratory pattern generating system remains open to debate, it may broadly be classified as a form of oscillator, and this oscillator may be entrained by a wide range of inputs, including afferent feedback from muscles during rhythmic movement or exercise, by somatic afferent nerve stimulation, vestibular stimulation, or by cardiac afferent inputs. i.e The ability of these ‘‘non-respiratory’’ inputs to alter respiratory timing. 55

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Auditory inputs have also been shown to produce entrainment of respiratory timing, as well as to entrain spinal motor neurones and to produce faster reaction times. 56

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In addition to describing an increase in respiratory frequency, Bernardi and colleagues also noted an increase in heart rate and blood pressure, with the increase again correlated to music tempo. Whether the observed increases in heart rate and blood pressure are the independent consequence of entrainment/stimulation of sympathetic neural oscillators on the brain, or are due to respiratory influences on sympathetic outflow, may be difficult to establish. 57

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58 CVS Angina Pectoris: 2008 Siritunge: MD research: Institute of Cardiology - NHSL Study population: Chronic stable angina. 70 patients with positive stress ECG Study design: Single blind randomized trial. Patients selected for the study group were given a CD with raga music and instructed to listen to it at home – twice a day for one month Study results: Subjective and objective improvement seen

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59 Siritunge ctd Subjective improvement seen (compared to controls) with regard to: Timing of chest pain Early morning angina Chest pain on walking Chest pain on climbing stairs Chest pain during day to day activities GTN consumption Consultation of a doctor for chest pain

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60 Siritunge ctd Objective benefit was seen in “Ischaemia based” effects of music The exercise ECG was analyzed for the following: Exercise duration (minutes) Maximum MET level achieved (METs) Time until 1mm ST segment depression (minutes) Maximum ST segment depression (mm) Duration of maximum ST segment depression (minutes) Before the music intervention, both the study group & control group had NO significant difference in any of these parameters After the music intervention, all changed for the better in the study group without a significant change in the maximal heart rate achieved

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61 Stage of exercise ECG at which the test was terminated before and after the intervention

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62 Music probably does not affect the established atherosclerotic plaque. (But have a beneficial effect on initiating the plaque) Once critical obstruction to the coronary artery has occurred, music therapy alters the autonomic balance of the heart so that myocardial oxygen consumption becomes more efficient Hence it does not cure, but helps alternate the ischaemic condition

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Medical disorders Heart disease According to a 2009 Cochrane review some music may reduce heart rate, respiratory rate, and blood pressure in those with coronary heart disease. 63

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Samitha Siritunga, Kumudu Wijewardena, Ruwan Ekanayaka, Premadasa Mudunkotuwa 64 International Journal of Clinical Medicine, 2015, 6, 307-313 Published Online May 2015 in SciRes. http://www.scirp.org/journal/ijcm http://dx.doi.org/10.4236/ijcm.2015.65039 Effect of Music on Quality of Life in Stable Angina: A Randomized Controlled Trial.

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Conclusion Listening to the music based on Indian classical system twice a day for one month period complementary to usual treatment significantly improved the quality of life of SA patients aged between 45 and 65 years measured by SF-36. A similar improvement did not observe in the control group who were only on prescribed medicines. 65

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67 Total Care concept Prof Herbert Benson of Mind/ Body Medical Institute Harvard Medical School “Medicine’s Spiritual Crisis”

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Mind / Body interaction and interdependence A vital clue to health 68 A professor of medicine at Harvard , Director of the Mind Body Institute at Harvard Med School. ? Dept of Medical Humanities, Colombo could take over this work.

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69 Scientifically, musicotherapy could be accepted as an ancillary therapy for psycho somatic diseases Cardiovascular – high blood pressure, angina, palpitations, VE, AE, SVT, AF Respiratory – asthma, rhinitis Gastrointestinal – ulcers, ulcerative colitis, IBS, vomiting, nausea Skin – itching, psoriasis, eczema Neurological – migraine, tension headache, vertigo, Parkinsonism, weakness of muscles Rheumatological – rheumatoid arthritis, low backache Endocrine – diabetes mellitus, amenorrhea, PMT, impotence Immunological – decreased immunity

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70 These diseases would benefit from Relaxation Techniques Yoga Meditation Musicotherapy Biofeedback Massage therapy Aroma therapy Soothing hobbies – gardening, tropical fish

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71 Comparison of the physiological changes of the fight-or-flight response and the relaxation response

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72 Generic technique I of Dr H Benson for relaxation Step 1: Pick a focus word or short phrase that is firmly rooted in your belief system Step 2: Sit quietly in a comfortable position Step 3: Close your eyes Step 4: Relax your muscles Step 5: Breathe slowly & naturally, & as you do, repeat your focus word, phrase or prayer silently to yourself as you exhale Step 6: Assume a passive attitude. Do not worry about how well you are doing. When other thoughts come to your mind, simply say to yourself, “Oh, well,” and gently return to the repetition Step 7: Continue for 10-20 minutes Step 8: Do not stand immediately. Continue sitting quietly for a minute or so, allowing other thoughts to return. Then open your eyes & sit for another minute before rising Step 9: Practice this technique once or twice a day Nothing of this is enjoyable One needs to expend energy in these activities

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73 Components of music The physiologic effects of music have been studied under several headings: Physical characteristics – tempo pitch volume Musical characteristics – melodic harmonic rhythmic

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74 Tempo This is the speed of music In a study on sick children (Miami Children’s hospital study:2006), a tempo of 60-70 beats/ minute was found to be most soothing ? Tempo of the human heart beat ? Intra uterine acclimatization to maternal heart beat In the Miami study, a faster tempo induced tension, a slower tempo induced feeling of suspense Hence, an ‘ideal’ tempo seems to exist

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75 Pitch This depends on the wave frequency In the Miami Children’s hospital study high pitch – led to tension low pitch – led to relaxation The ‘Do’ – “Sa” – note will have a frequency of 256 Hz 256*2, 256*3 is also ‘Do’, but at different pitch

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76 Volume This depends on the amplitude of the wave High volume – causes tension pain chest heaviness Low volume – causes sooth feeling

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77 Musical characteristics Melodic – Raga, Classical, Dodecaphonic Rythmic – ‘Thala’ in Hindustani music, Jazz, Waltz, Rap, Country, Tango etc. Harmonic – due to overtones

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78 Study at Oxford university suggests that: Melodic idiom is unimportant for physiologic effects. However, it is important in implementation due to its ‘enjoyable’ component Slow tempo is most effective on physiologic variables. Variation of tempo must be avoided whereas a constant tempo had most benefit Rhythmic forms which are ‘sedate’ are best but may change for group therapy and active therapy Words are not important but religious or naturalistic themes are advisable

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Brain Waves: Research has shown that music with a strong beat can stimulate brainwaves to resonate in sync with the beat, with faster beats bringing sharper concentration and more alert thinking, and a slower tempo promoting a calm, meditative state. Also, research has found that the change in brainwave activity levels that music can bring, can also enable the brain to shift speeds more easily on its own as needed, which means that music can bring lasting benefits to a patient’s state of mind, even after the patent has stopped listening. 79

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Breathing and Heart Rate: With alterations in brainwaves comes changes in other bodily functions. Those governed by the autonomic nervous system, such as breathing and heart rate can also be altered by the changes music can bring. This can mean slower breathing, slower heart rate, and an activation of the relaxation response, among other things. This is why music and music therapy can help counteract or prevent the damaging effects of chronic stress, greatly promoting not only relaxation, but health. 81

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State of Mind: Music can also be used to bring a more positive state of mind, helping to keep depression and anxiety at bay. This can help prevent the stress response and can help keep creativity and optimism levels higher. 82

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Other Benefits: Music has also been found to bring many other benefits, such as lowering blood pressure (which can also reduce the risk of stroke and other health problems over time), boost immunity, ease muscle tension, and more. With so many benefits and such profound physical effects, so many are see music as an important tool to help the body in staying (or becoming) healthy. 83

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Music therapy is the use of interventions to accomplish individual goals within a therapeutic relationship by a professional who has completed an approved music therapy program. Music therapy is an allied health profession and one of the expressive therapies, consisting of a process in which a music therapist uses music and all of its facets- (1) physical, (2) emotional, (3) mental, (4) social, (5) aesthetic, and (6) spiritual to help clients improve their physical and mental health. 84

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Music therapists primarily help clients improve their health in several domains, such as, (1) cognitive functioning. (2) motor skills. (3) emotional development. (4) social skills. (5) quality of life. 85

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It has a wide qualitative and quantitative research literature base and incorporates:- (1) Clinical therapy (2) Psychotherapy (3) Biomusicology (4) Musical acoustics (5) Music theory (6) Psychoacoustics (7) Embodied music cognition (8) Aesthetics of music (9) Sensory integration (10) Comparative musicology 86

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Approaches used in music therapy Have emerged from the field of education: Orff-Schulwerk (Orff) Dalcroze Eurhythmics, Kodaly. Neurologic Music Therapy (NMT), Nordoff-Robbins Bonny Method of Guided Imagery and Music. 87 Models that developed directly out of music therapy are

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Different models include * behavioral therapy, *cognitive behavioral therapy, and * psychodynamic therapy. One therapy model based on neuroscience, called “ neurological music therapy" (NMT), is based on a neuroscience model of music perception and production, and the influence of music on functional changes in non-musical brain and behavior functions." In other words, NMT studies how the brain is without music, how the brain is with music, measures the differences, and uses these differences to cause changes in the brain through music that will eventually affect the client non-musically. As one researcher, Dr. Thaut, said: "The brain that engages in music is changed by engaging in music. "NMT trains motor responses (i.e. tapping foot or fingers, head movement, etc.) to better help clients develop motor skills that help "entrain the timing of muscle activation patterns. 88

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Neurological disorders The use of music therapy in treating mental and neurological disorders is on the rise. Music therapy has showed effectiveness in treating symptoms of many disorders, including schizophrenia, amnesia, dementia and Alzheimer’s, Parkinson's disease, mood disorders such as depression, aphasia and similar speech disorders, and Tourette’s syndrome, among others. 89

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Stroke More recent research suggests that music can increase a patient's motivation and positive emotions. Current research also suggests that when music therapy is used in conjunction with traditional therapy it improves success rates significantly. Therefore, it is hypothesized that, music therapy helps a victim of stroke recover faster and with more success by increasing the patient's positive emotions and motivation, allowing him or her to be more successful and feel more driven to participate in traditional therapies. 90

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Recent studies have examined the effect of music therapy on stroke patients when combined with traditional therapy. One study found the incorporation of music with therapeutic upper extremity exercises gave patients more positive emotional effects than exercise alone. In another study, Nayak et al. found that rehabilitation staff rated participants in the music therapy group more actively involved and cooperative in therapy than those in the control group. 91

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Music has proven useful in the recovery of motor skills. Rhythmical auditory stimulation in a musical context in combination with traditional gait therapy improved the ability of stroke patients to walk. The study consisted of two treatment conditions, one which received traditional gait therapy and another which received the gait therapy in combination with the rhythmical auditory stimulation. During the rhythmical auditory stimulation, stimulation was played back measure by measure, and was initiated by the patient's heel-strikes. Each condition received fifteen sessions of therapy. The results revealed that the rhythmical auditory stimulation group showed more improvement in stride length, symmetry deviation, walking speed and rollover path length (all indicators for improved walking gait) than the group that received traditional therapy alone. 92

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Dementia Alzheimer’s disease and other types of dementia are among the disorders most commonly treated with music therapy. Like many of the other disorders mentioned, some of the most common significant effects are seen in social behaviors, leading to improvements in interaction, conversation, and other such skills. A meta-study of over 330 subjects showed music therapy produces highly significant improvements to social behaviors, overt behaviors like wandering and restlessness, reductions in agitated behaviors, and improvements to cognitive defects, measured with reality orientation and face recognition tests. As with many studies of MT’s effectiveness, these positive effects on Alzheimer’s and other dementias are not homogeneous among all studies. The effectiveness of the treatment seems to be strongly dependent on the patient, the quality and length of treatment, and other similar factors. 93

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Aphasia Melodic intonation therapy (MIT) is a commonly used method of treating aphasias, particularly those involving speech deficits (as opposed to reading or writing). MIT is a multi-stage treatment that involves committing words and speech rhythm to memory by incorporating them into song. The musical and rhythmic aspects are then separated from the speech and phased out, until the patient can speak normally. This method has slight variations between adult patients and child patients, but both follow the same basic structure. 94

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95 CNS: Parkinson’s disease: J Psychosomatic medicine: 2000 Pachetti et al Active music therapy in Parkinson’s disease – An integrated method of motor and emotional rehabilitation Study population: 32 patients with PD (all respondent to levodopa) Study intervention: 10 minutes – Listen to relaxing music & visualize peaceful images 10 minutes – Choral singing 15-20 minutes – Rhythmic movement to music 30 minutes – Active music improvisation Study result: Bradykinesia improved (by unified PD rating scale). Happiness measure improved. QOL improved. Conclusion: MT beneficial for motor + emotional components of PD

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96 Cancer: Chemotherapy. MSc thesis. U of Florida State Ferrer Effects of live music in decreasing anxiety in patients undergoing cancer chemotherapy Study population: 50 patients Study intervention: 20 minutes of live familiar music while receiving chemotherapy Results: Significant reduction in anxiety, fear, fatigue, diastolic blood pressure Increase in relaxation Conclusion: Overall results confirmed that music intervention behaved as a powerful independent variable in reducing anxiety

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Depression Music therapy has been found to have numerous significant outcomes for patients with major depressive disorder. A systematic review of five randomized trials found that people with depression generally accepted music therapy and was found to produce improvements in mood when compared to standard therapy. Another study showed that MD patients were better able to express their emotional states while listening to sad music than while listening to no music or to happy, angry, or scary music. The authors found that this therapy helped patients overcome verbal barriers to expressing emotion, which can assist therapists in successfully guiding treatment. 97

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98 Music therapy program for severely regressed persons with Alzheimer’s type of Dementia Study population: 3 male subjects Study intervention: Music therapy weekly. Each session for 30 minutes * Listening * Singing * Interactive with an instrument Study duration: 11 weeks Results: Interaction with others during group therapy with music was more successful than without

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99 Mental State: Depression. J Palliative Care 2001 Hanser et al Study population: 30 patients with depression & anxiety Study intervention: Home based music listening by home visits by music therapist Home based music listening – self implemented, but committed by telephone call of therapist Control group Results: On data from standardized tests for depression, self esteem & mood, music therapy was superior. Benefit seemed to last for 9 months follow up too

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Paul Nordoff, a Juilliard School graduate and Professor of Music, was a gifted pianist and composer who, upon seeing disabled children respond so positively to music, gave up his academic career to further investigate the possibility of music as a means for therapy. Dr. Clive Robbins, a special educator, partnered with Nordoff for over 17 years in the exploration and research of music’s effects on disabled children- first in the United Kingdom, and then in the USA in the 1950s and 60s. 100 Nordoff-Robbins

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Their pilot projects included placements at care units for autistic children and child psychiatry departments, where they put programs in place for children with mental disorders, emotional disturbances, developmental delays, and other handicaps. They were successful in establishing a means of communication and relationship with autistic children at the University of Pennsylvania. 101

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The Nordoff-Robbins approach, based on the belief that everyone is capable of finding meaning in and benefitting from musical experience, is now practiced by hundreds of therapists internationally. It focuses on treatment through the creation of music by both therapist and client together. Various techniques are used to accommodate all capabilities so that even the most low functioning individuals are able to participate actively. 102

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Orff Music Therapy Developed by, Gertrude Orff at the Kindezentrum München. 103

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Is used with children with developmental problems, delays and disabilities. The area of social pediatrics was developed after the Second World War in Germany by Theodor Hellbrügge, who understood that medicine alone could not meet the complex needs of developmentally disabled children. 104

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Gertrude Orff developed a form of therapy (the Orff Schulwerk approach) to support the emotional development of patients. Elements found in both the music therapy and education approaches include the understanding of holistic music presentation as involving word, sound and movement; the use of both music and play improvisation as providing a creative stimulus for the child to investigate and explore; Orff instrumentation, including keyboard instruments and percussion instruments as a means of participation and interaction in a therapeutic setting. 105

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Bonny Method of Guided Imagery in Music (GIM) Music educator and therapist Helen Lindquist Bonny (1921 - May 25, 2010) developed an approach influenced by humanistic and transpersonal psychological views, known as the Bonny Method of Guided Imagery in Music, or GIM. Guided imagery refers to a technique used in natural and alternative medicine that involves using mental imagery to help with the physiological and psychological ailments of patients. The practitioner often suggests a relaxing and focusing image and through the use of imagination and discussion, aims to find constructive solutions to manage their problems. Bonny applied this psychotherapeutic method to the field of music therapy by using music as the means of guiding the patient to a higher state of consciousness where healing and constructive self- awareness can take place. Music is considered a "co-therapist" because of its importance. 106

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The choice of music is carefully selected for the client, based on their musical preferences and the goals of the session. Usually a classical piece, it must reflect the age and attentional abilities of the child in length and genre. 107

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Prenatal music therapy Music Therapy can play an important role during pregnancy. At just 16 weeks, a fetus is able to hear their mother's speech as well as singing. Through technologies, such as ultrasound, health care professionals are able to observe the movements of the unborn child responding to musical stimuli. Through these fetal observations, we see that the baby is capable of expressing its needs, preferences, and interests through movements in the womb. At the beginning of the second trimester, the ear structure is fully matured. By this time, the fetus will begin to hear not only maternal sounds, but also vibrations of instruments. 108

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Prenatal music therapy has three main benefits. 1. Prenatal Stress Relief: Pregnant women may experience high levels of stress which can negatively affect the baby. This will cause the body to release Norepinephrine and Cortisol hormones which will increase blood pressure and weaken the immune system of both mother and child. High levels of cortisol exposure in early development can increase the likelihood of the child later having anxiety, mental retardation, autism, and depression. Music therapists use music to elevate the stress threshold of an expectant mother which helps her to maintain a relaxed state during labor and birthing process. During a music therapy session, the mother is guided to listen to her internal rhythms, as well as listing to the movements and reactions of the fetus in response to her voice and music. This technique is useful in helping reduce the mother's level of stress, and prepare her for the birth of her child. 109

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2. Maternal-Fetal Bonding: Communication between the mother and fetus is essential during pregnancy. One way of strengthening the bond between the two is through music therapy. Music stimulation helps to develop the fetus's nervous system, structurally and functionally. The unborn child especially prefers the voice of their mother. The most effective way to enhance communication is through singing. Lullabies are the most popular songs sung by mothers. Singing lullabies is a wonderful way for mothers to express their love and have the baby become familiarized with their mother's melodies and intonations which will provide them a sense of security when they are born, because it will feel just like how they were in the womb. 110

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3. Prenatal Language Development: Music is said to be the unborn child's beginning of language learning. It can be consider as a pre-linguistic language that prepares the Auditory Sensory System to listen, combine, and produce language sounds. 111

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Music therapy and children with autism Music therapy can be a particularly useful when working with children with autism due to the nonverbal, non-threatening nature of the medium. Studies have shown that children with autism have difficulty with joint attention, symbolic communication and sharing of positive affect. Use of music therapy has demonstrated improvements of socially acceptable behaviors. Wan, Demaine, Zipse, Norton, & Schlaug (2010) found singing and music making may engage areas of the brain related to language abilities, and that music facilitated the language, social, and motor skills. 112

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Successful therapy involves long-term individual intervention tailored to each child’s needs. Passing and sharing instruments, movement games, learning to listen and singing greetings and improvised stories are just a few ways music therapy can improve a child’s social interaction. For example passing a ball back and forth to percussive music or playing sticks and cymbals with another person might help foster the child’s ability to follow directions when passing the ball and learn to share the cymbals and sticks. In addition to improved social behaviors music therapy has been shown to also increase communication attempts, increase focus and attention, reduce anxiety, and improve body awareness and coordination. 113

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Adolescents Mood disorders According to the Mayo Health Clinic, two to three thousand out of every 100,000 adolescents will have mood disorders, and out of those two to three thousand, eight to ten will commit suicide. Two prevalent mood disorders in the adolescent population are clinical depression and bipolar disorder. 114

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On average, American adolescents listen to approximately 4.5 hours of music per day and are responsible for 70% of pop music sales. Now, with the invention of new technologies such as the iPod and digital downloads, access to music has become easier than ever. As children make the transition into adolescence they become less likely to sit and watch TV, an activity associated with family, and spend more of their leisure time listening to music, an activity associated with friends. 115

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Adolescents obtain many benefits from listening to music, including emotional, social, and daily life benefits, along with help in forming their identity. Music can provide a sense of independence and individuality, which in turn contributes to an adolescent's self-discovery and sense of identity. Music also offers adolescents relatable messages that allow them to take comfort in knowing that others feel the same way they do. It can also serve as a creative outlet to release or control emotions and find ways of coping with difficult situations. 116

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Many adolescents go through a period of teenage angst characterized by intense feelings of strife that are caused by the development of their brains and bodies. Some adolescents develop more serious mood disorders such as major clinical depression and bipolar disorder. Adolescents diagnosed with a mood disorder may be referred to a music therapist by a physician, therapist, or school counselor/teacher. 117

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When a music therapist gets a referral, he or she must first assess the patient and then create goals and objectives before beginning the actual therapy. According to the American Music Therapy Association Standards of Clinical Practice, assessments should include the “general categories of (1)psychological, (2)cognitive, (3)communicative, (4)social, and (5)physiological functioning focusing on the client’s needs and strengths and will also determine the client’s response to music, music skills, and musical preferences” The result of the assessment is used to create an individualized music therapy intervention plan. 118

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Treatment techniques There are many different music therapy techniques used with adolescents. The music therapy model is based on various theoretical backgrounds such as (i)psychodynamic, (ii)behavioral, and (iii)humanistic approaches. Techniques can be classified as active vs. receptive and improvisational vs. structured. 119

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The most common techniques in use with adolescents are musical improvisation, the use of precomposed songs or music, receptive listening to music, verbal discussion about the music, and incorporating creative media outlets into the therapy. Research also showed that improvisation and the use of other media were the two techniques most often used by the music therapists. The overall research showed that adolescents in music therapy “change more when discipline-specific music therapy techniques, such as improvisation and verbal reflection of the music, are used”. 120

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Two main methods for music therapy are group meetings and one-one sessions. Group music therapy can include group discussions concerning moods and emotions in or toward music, songwriting, and musical improvisation. Groups emphasizing mood recognition and awareness, group cohesion, and improvement in self-esteem can be effective in working with adolescents. Group therapy, however, is not always the best choice for the client. Ongoing one-on-one music therapy has also been shown to be effective. One-on-one music therapy provides a non-invasive, non-judgmental environment, encouraging clients to show capacities that may be hidden in group situations. 121

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Conclusion 1 In the words of Bernadi Music now has an increasing role in several disparate areas. Music can reduce stress and improve athletic performance, motor function in neurologically impaired patients with stroke or parkinsonism, or milk production in cattle. 122

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Listening to music is a complex phenomenon, involving psychological, emotional, neurological, and cardiovascular changes, with behavioral modifications of breathing. Non-musicians listen by using the non-dominant hemisphere, whereas musicians (who are probably more attentive) use the dominant hemisphere. 123

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These responses may be influenced by musical style (for example, classical versus rock), melody, harmonic structure, rhythm, and tempo but also by verbal content-for example, the brain asymmetry shown for language and melody perception has not been found in rhythm perception. 124

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Cardiorespiratory variables can be modified by rhythmic repetition of a prayer or a yoga mantra or by recitation of poetry. We therefore investigated whether listening to music has similar effects. 125

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Conclusion 2 Summary from the, Oxford handbook of alternative medicine 126

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127 Concept Sensations that accompany music therapy may activate limbic or other areas of the brain related to the reward and motivation circuitry (limbic-cortical circuits). Secondary physiological changes and bodily reactions may follow, i.e., autoregulatory mind/body reactions such as an influence on hemispheric dominance, changes in autonomic nervous system activity, relaxation effects on vital functions such as breath, respiratory rate, blood pressure and cardiac output. Analgesic and anxiolytic properties of music are mainly due to the lowering of stress levels and stress hormone production similar to the relaxation response. There are wide variations in individual music preferences which have a strong impact on the physiological effects of music.

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128 Treatment Since music therapists serve a wide variety of persons with many different types of complaints there is no overall typical session. In pain management, for example, mainly receptive music therapy is used while active music therapy is most common in mental health. The duration of receptive music therapy for pain can be between a single session, for example before, during or after surgery, to a series of sessions over several weeks for chronic pain patients. Active music therapy is used as a form of expression in, for example, mental health or palliative care.

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129 Clinical bottom line - Benefits Beneficial: Anxiety, perioperative and procedural: useful adjunct in reducing anxiety and sedative requirements, decreasing blood pressure, improving physiological parameters. Psychopathology: best results for behavioural and developmental disorders. Stress: reduces anxiety and enhances relaxation response.

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130 Clinical bottom line – Benefits ctd.. Likely to be beneficial: Mood: might improve mood in a range of conditions. Pain, perioperative and procedural: encouraging results for music therapy an as adjunct therapy. Schizophrenia: in addition to standard care, improves global state.

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131 Clinical bottom line – Benefits ctd.. Unknown effectiveness: Anaerobic performance: data are contradictory. Anxiety and stress, after acute MI: data contradictory. Autism spectrum disorder: auditory integration therapy, data contradictory. Back pain: not enough data available. Cancer: clinical music therapy might improve quality of life but not enough data available. Cystic fibrosis: recorded music as an adjunct during routine chest physiotherapy, not enough data available. Dementia: studies are methodologically too limited to draw any useful conclusions. Depression: encouraging results but data scarce.

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132 Clinical bottom line – Benefits ctd.. Unknown effectiveness ctd..: Epilepsy: may reduce seizure frequency yet not enough data available. Fibromyalgia: not enough data available. Insomnia: not enough data available. Multiple sclerosis: strengthening of respiratory muscles through coordination of breath and speech but not enough data available. Nausea & vomiting, chemotherapy-induced: not enough data available. Osteoarthritis: not enough data available. Parkinson’s disease: additional active music therapy might improve motor, affective & behavioural functions but not enough data available. Premature infants: live music therapy might improve heart rate & sleep but not enough data available. Stroke: additional active music therapy supports neurorehabilitation of motor skills.

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133 Clinical bottom line – Benefits ctd.. Unlikely to be beneficial: Labour: no effects on pain reported. Likely to be ineffective or harmful: Nausea/ vomiting, postoperative: no beneficial effects.

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134 Clinical bottom line – Risks Contraindications: none known. Precautions/ warnings : none known. Adverse effects : none known. Interactions : none known.

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135 Conclusions Music therapy as an adjunct therapy has positive effects on anxiety and stress as well as psychopathological disorders; it might improve pain symptoms, schizophrenia and mood in a range of conditions. No risks have been reported. The risk-benefit balance for the above conditions is positive or likely to be positive.

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136 Place of musicotherapy in current therapeutics It is a relaxation technique which is – pleasant & easy to apply – cheap – lacking in side effects 2. Benefit proved by clinical trials in many psychosomatic illnesses 3. Benefit as an ancillary item in lifestyle modification is a reasonable assumption 4. Can be applied in the home setting

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137 Music is universal; seen in all cultures However, most people can mostly enjoy the idiom they grew up with In musicotherapy, select music which is enjoyable to the patient

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Boring physiotherapy can be transformed in to a pleasurable dance ( Same as aerobics with music). 138

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The aesthetics affect the emotive reaction to illness. Musical aspects affects the autonomic nervous system with beneficial physiological results. Physical aspects of music aid neuro- muscular-skeletal mobility. The creative aspects help in personality development 139

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Chance observation (War experience) Generating a hypothesis (Mind-body interaction- Hazy) Literature search (Greek thought, Ayurvedic) Strengthening of hypothesis ( Mind Body interaction likely) Extended Hypothesis (other “mind”therapy effects- Meditation,Yoga) Probability of hypothesis being true increased Controlled laboratory studies with measurable entities Postulate to explain phenomenon (ie: autonomic effect) Neuroscience recruited to explain hypothesis ( A working model) Research for translation in to clinical practice 140

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142 Thank you!