Introduction
The rapid development of technology has led to the creation of an abundance of material goods, which on the one hand has led to progress and on the other hand to increased stress, anxiety, and dissatisfaction. People who suffer from accumulated stress are more susceptible to diseases, especially psychosomatic and cardiovascular diseases. Due to the complete interdependence of physical, emotional, and mental processes, stress affects every phase of a person’s life. Processes related to psychological stress contribute to the multifactorial risk of disease onset and development. (1) The high incidence of acute heart disease worldwide as well as the high costs associated with their treatment have set professionals to task of developing affordable, efficient, and cost-effective prevention strategies. (2,3)
Anxiety is often observed in patients with coronary heart disease. This stress stimulates the sympathetic system, which manifests as increased heart rate, respiratory difficulties, high blood pressure, and anxiety symptoms. These adverse effects pose a higher risk for cardiovascular (CV) patients, including sudden cardiac death. It is, therefore, crucial to provide and organize stress management programs for patients with CV diseases. (4,5) The interdisciplinary and transdisciplinary approach by health professionals who work as a team in specialized hospitals or outpatient centers conducts CV rehabilitation as a part of secondary prevention. A holistic approach is the foundation of CV rehabilitation, which includes individual risk assessment, recommended physical activity, control of CV risk factors, therapeutic education and counseling, interventions focused on the mental functioning and behavior of patients, and assessment of work ability. (6) Music therapy, as a planned intervention that is an integral part of the CV rehabilitation program, can help reduce anxiety and improve mood. In the future, care should be taken to include and cooperate with experts in addition to cardiologist and to establish cooperation with citizen associations and other stakeholders whose activities are complementary to the goals of the Working Group for Prevention and Rehabilitation of CV Diseases. (7)
Receptive music therapy
Among the various types of therapies in the category of complementary therapies, music therapy seems to be one of the most popular and acceptable interventions. (8-15) The reason for this is that it is easily accessible and that it can be understood and accepted by healthy people as well as patients. (16) As a young discipline, music therapy could be considered an interdisciplinary or even a transdisciplinary professional field, because it contains elements from several fields and disciplines connected in new ways. (17) According to the definition of the American Association for Music Therapy, music therapy as a complementary therapy is the professional use of music and its elements as an intervention in the medical, educational, and everyday environment, working with individuals, groups, families, or communities seeking to achieve optimal quality of life and improve physical, social, emotional, cognitive, and spiritual health. (18) Research, education, and clinical practice in music therapy are based on professional standards set with regard to the cultural, social, and political environment. Music therapy can be performed as an active form of music therapy, in which music is created together with the client, or as receptive music therapy, in which, depending on the client’s preferences, relaxation music is carefully chosen to help reduce stress and anxiety and facilitate acceptance of new living conditions. (19)
Contemporary research on the effects of music on psycho-emotional behavior emphasizes the importance of discovering the interconnections between compositions and stimulated physiological effects, as well as the connection between aesthetic pleasure and feelings of comfort. (20) Music can be listened to for recreational purposes as background music in order for clients to connect with the community or with the members from the group. It can also be listened to provide stimulation or to produce a calming or relaxing effect. Bruscia states that these reasons are also potential clinical goals that, given the type of receptive musical experience, can be set for the client. (21) It is important to consider the function of the music, the musical form, and the volume at which the music should be listened to in order to elicit the optimal responses and to capture the attention and interest of clients. Recorded music used for receptive music therapy experiences has a special value and can be used in music therapy to facilitate relaxation and attention and to achieve awareness of each client or group of clients. The recorded music repertoire can be included in therapy sessions for a wide range of clients in group and individual sessions. Different styles and genres of music, ranging from early classical to twentieth-century music, folk traditional music to popular music, from opera to musicals, provide a rich source of experience in therapeutic work. (22) Receptive music therapy encompasses techniques in which the client receives a musical experience by listening, as opposed to actively making music. Most adult clients have previously had the experience of listening to different music genres and styles according to their preferences and remember the feelings that arose due to listening to a particular music piece, (23) so the choice of music is extremely important. Research on music therapy has found that the most effective music includes the music style and genre that are known and preferred by the client himself. A music program refers to a list of compositions that are consistent with the client’s preferences, and in particular with their previous musical experiences and emotional attributes that they attach to a particular composition, artist, or instrument. From this predefined list of compositions, the music therapist only includes music in the music therapy intervention which, according to its elements (tempo, rhythm, dynamics, harmony etc.), can have a positive effect on the goals that have been set. (23) Sometimes, however, the therapist has to choose without knowing the client’s preferences, which is when one has to rely on assumptions about musical choices that are effective. A systematic review on the effects of music on stress and anxiety showed that listening to music can most effectively reduce the anxiety level in people if they are offered a choice of music content according to their preferences. The most effective relaxation music has a stable pulse and is calming and predictable. There are slight changes in dynamics, as the purpose of music is to enhance the deep relaxation of the body. (22)
Only a trained music therapist as a part of a multidisciplinary team can conduct music therapy treatment to achieve the therapeutic goal: to restore, maintain and/or improve the mental and physical health of the patient. According to the guidelines of the music therapist, the application of music in the therapeutic environment is systematic and aims to achieve desirable changes in behavior. (16)
A review of research on music therapy interventions in cardiology
Contemporary medicine defines health as a state of complete physical, mental, and social well-being of a person. This holistic approach explains health as a balance of a person’s physical, mental, emotional, and spiritual state, and the goal is to stimulate processes within the body to fight disease. (24)
The shift from the functioning and mode of chronic stress to the mode of relaxed alertness can affect several reactions in the body such as increased production of cells to activate the defense system and hormonal and psychological changes. (25) Therapies aimed at a relaxed state share the same features, the most important being muscle relaxation, lowering blood pressure, and regulating breathing. According to Nilsson, and as stated by Katušić et al. (5,23) receptive music therapy should certainly be one of the components of the CV rehabilitation program, as an intervention that can help patients to relax by raising awareness of the music they listen to. Receptive music therapy is associated with improvement in the psychological state of patients, decreased psychophysiological and vascular reactivity, and a smaller increase of beta-endorphins under emotional stress. (26)
The possible effects of receptive music therapy in rehabilitation are related to stress reduction and achievement of general well-being. The application of music therapy during rehabilitation in CV patients is primarily aimed at improving mood as well as alleviating and reducing fear and anxiety. (3,27)
The benefit of using receptive music therapy as a form of complementary therapy in the process of rehabilitation of CV patients has been described in several papers. Mandel et al., in studies conducted by Murrock, 2002, and Emery, Hsiao, Hill, and Frid, 2003, describes the effect of a good combination of listening to music and a physiotherapy exercise program on improving cognitive performance and improved mood in patients involved in a CV rehabilitation program, (3) and in 2009 Okada et al. described that the relaxing effect of music is associated with increased plasma release of oxytocin and decreased plasma levels of cytokines and catecholamines. (28) In 2013, Bradt et al. reported that listening to music can also have a beneficial effect on people with CV diseases because listening to music reduces anxiety, systolic and diastolic pressure, and frequency of myocardial infarction after hospitalization. (29)
In 2016, Clark et al. reported on the characteristics of musical preference and music perception during a physiotherapy exercise program. The study was conducted on 27 elderly adults. (30) The aim was to discover the basic, common characteristics of selected music using the Structural Model of Music Analysis and to analyze the subjective experience of music. The predominant characteristics of the music selected by the participants included a duple meter (two beats per measure), consistent rhythm, major scale, rounded melodic lines, legato articulation, predictable harmonies, variable volume, and episodes of tension with a delayed solution. There was no prevailing tempo, and the selection of music pieces ranged from slow to medium-fast and fast. Four topics emerged from the thematic analysis of the interviews with the participants: psycho-emotional responses, physical responses, influence on behavior during exercises, and negative experience. The findings were consistent with theory and research explaining the effects of listening to music on physiological arousal and subjective experiences during exercise. Additionally, a holistic approach to music selection in elderly adults with heart disease that takes into account general well-being and adjustment issues, rather than simply performing exercises, can improve long-term lifestyle changes and align with guidelines for physical activity.
Unlike Clark, who examined the characteristics of musical preference and perception of music during a physiotherapy exercise program, Van Dyck et al. were interested in the influence that tempo, as an element of music, has on the heart rate. The 32 subjects who participated in the study had their resting heart rate measured and later listened to ambient, instrumental music with a tempo matching their heart rate. After listening to the same music several times with the tempo being faster or slower from the tempo during the first instance, no connection was found between the change in tempo with regard to the change in heart rate. Research showed a significant increase in heart rate while listening to music compared with silence. It can be concluded that excitement is created during listening to music, which is reflected in the heart rate. These results are an important contribution to the methods of music application in everyday activities. (31)
Ivanuša et al. reported that they applied receptive music therapy in the period from June 2017 to October 2018 in outpatient CV rehabilitation for 17 patients at the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb. The results of the health self-assessment on the Hospital Anxiety and Depression Scale at the end of the program indicated that treatment with receptive music therapy contributed to the reduction of anxiety and depression symptoms in patients. (32)
A year later in 2019, Bando et al. described the effects of music therapy as a complementary therapy at the Shikoku Division of Integrative Medicine in Japan. They reported on the benefits of music therapy during a physiotherapy exercise program. Music has a double effect, stimulating relaxation and reducing tension, which directly affects the activity of the parasympathetic nervous system. They monitored heart rate before, during, and after exercise. They concluded that subjects who listened to music during exercise, selected in consultation with a music therapist, had increased parasympathetic activity that was reactivated even after exercise. A connection between music and the activity of the autonomic system after exercise was observed. (16)
Conclusion
The contemporary approach to health is multidisciplinary and transdisciplinary, and it is implemented by trained professionals from various fields to achieve the well-being of the individual and the entire community. A music therapist should be a team member of a multidisciplinary team in the CV rehabilitation program, with the role of carefully and professionally selecting music for relaxation that helps the patient in reducing stress and anxiety as well as acceptance of new living conditions, monitoring the patient’s recovery, and recording changes. The regulated emotional state that manifests in the activity of the autonomic nervous system affects the overall recovery during rehabilitation and creates a better self-image in CV patients. Receptive music therapy as a planned intervention with precisely set rehabilitation goals can shorten the recovery period and permanently influence the improvement of patient moods. As part of the CV rehabilitation program, it is necessary to conduct further research with a larger number of CV patients to investigate the optimal frequency of music therapy treatment and its duration, and to develop and determine scales for personal musical preference and personal perception of music.