The Effect of Music Listening During Pulmonary or Cardiac Rehabilitation on Clinical Outcomes: A Systematic Review and Meta-analysis : Cardiopulmonary Physical Therapy Journal

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The Effect of Music Listening During Pulmonary or Cardiac Rehabilitation on Clinical Outcomes: A Systematic Review and Meta-analysis

Frank, Hannah E. BPhysio1; Munro, Prue E. BPhysio1; Clark, Imogen PhD2; Lee, Annemarie L. PhD1,3,4

Author Information
Cardiopulmonary Physical Therapy Journal 34(1):p 13-29, January 2023. | DOI: 10.1097/CPT.0000000000000204

Abstract

INTRODUCTION

Pulmonary rehabilitation (PR) is defined as a comprehensive intervention based on patient assessment and patient tailored therapies inclusive of exercise training, education, and behavior change, designed to improve the physical and psychological conditions of those with chronic respiratory disease.1 Cardiac rehabilitation (CR) is a coordinated physical, social, and psychological intervention which influences underlying risk factors to stabilise, slow or reverse cardiac disease progression and facilitates the preservation or resumption of activity and function of an individual.2 Pulmonary rehabilitation and CR are part of standard care for people with chronic respiratory conditions1 and cardiac disease.2,3 Improvements in exercise tolerance, reduction in symptoms of dyspnea, fatigue, anxiety and depression, and enhanced quality of life are notable with PR.4 Increased endurance capacity, physical activity and improved cardiovascular health through measures of blood pressure and heart rate (HR) have been observed with CR.2,3 To sustain the benefits of these interventions, individuals are often referred to PR or CR maintenance programs.5,6 Maintenance PR or CR have been defined as ongoing supervised exercise at a lower frequency than the initial PR or CR program,4,6 which aim to sustain lifestyle changes and physical activity initiated during rehabilitation. However, not all individuals engaged with PR or CR or their corresponding maintenance programs achieve these clinical benefits.7,8 A proportion of participants experience symptoms of breathlessness or fatigue, accompanied by anxiety,7 or reduced levels of compliance and motivation,9 which may reduce the effectiveness of the prescribed exercise interventions over the short-term and long-term.

Possible modulating impacts of music listening on exercise and physical activity are explained through effects on physiological arousal and subjective experience.10 Physiological arousal during music listening may be facilitated through entrainment or synchronisation with rhythmic stimuli (walking cadence, HR, respiratory rate) and neurophysiological responses (autonomic nervous system and neuroendocrine system). Subjective experiences as a result of positive personal associations with the music and diversion from other negative stimuli include emotion and mood enhancement.10 For example, in healthy individuals, listening to music during exercise has been reported to moderate the perception of fatigue.11-14 This switch in focus from an internal concentration on fatigue to an external concentration on music has been associated with decreased symptom perception and achievement of a greater intensity of exercise.15,16 Together, these physiological responses and subjective experiences may positively affect behavior resulting in increased exercise participation and adherence.

Music listening has been applied as part of CR or PR programs or maintenance programs following CR or PR,9,17-19 with the intention of optimizing exercise training by distracting participants from exercise-limiting symptoms of dyspnea and fatigue. For those with respiratory disease, music listening during exercise training may desensitise or distract individuals to dyspnea and fatigue, which may increase the tolerance to exercise.17,20 A similar rationale of attenuating individual's perceptions of effort during exercise has been proposed for individuals undertaking CR.21 Although some studies suggest this adjunct enhances PR and CR programs or their corresponding maintenance program outcomes, the overall effects of applying music listening during these interventions require further clarification.

This review aimed to determine the effects of music listening during single or multiple sessions of exercise training within PR or CR programs or corresponding maintenance programs on clinical outcomes in people with chronic respiratory or cardiac conditions. This review was registered with PROSPERO (Number: CRD42020178457).

METHODS

Search Strategies

The following electronic databases were searched: Ovid MEDLINE, EMBASE and CINAHL and Physiotherapy Evidence Database (PEDro) from inception to April 2019. An update was conducted in November 2020 and June 2021. The search strategy applied in MEDLINE was adapted for other databases (see Appendix 1, Supplemental Digital Content, https://links.lww.com/CPTJ/A12).

Inclusion Criteria

Only randomized controlled or cross-over trials were included. Participants included were of any age, with a cardiorespiratory or cardiovascular condition who were undertaking a CR or PR program or maintenance program following CR or PR. Diagnoses included chronic respiratory conditions, cardiac failure, and coronary heart disease (including those postsurgery) (Table 1). These diagnoses are consistent with national and international guidelines for patient inclusion in PR or CR.1,4 The music listening intervention was applied during a single session, series of sessions within PR or CR, or an entire program, and inclusive of supervised and unsupervised exercise sessions. The rehabilitation programs could be within the inpatient or outpatient hospital setting, community, or home-based. Music listening was self-selected, therapist-selected, or ambient background music. Comparators included sham treatment or absence of any type of music listening. Studies were included if they reported data on clinical outcomes, including physical and psychological symptoms, exercise capacity, health-related quality of life, cardiorespiratory physiological factors including blood pressure, HR, oxygen saturation and respiratory rate, and physical activity. Data reported at baseline, immediately postintervention, and any follow-up period were extracted. Only trials published in English were included, because of a lack of access to translation resources. The inclusion criteria are outlined in Table 1.

TABLE 1 - Eligibility Criteria
Inclusion
Participants Any patients with chronic cardiac or respiratory conditions enrolled in CR or PR respectively
Any age
Music intervention Music listening or DAS in conjunction with PR or CR. This excluded music which incorporated rhythmic sonic enhancements or beat accentuation.
Comparators No music
Sham intervention
Outcome measures Exercise capacity measured by validated tests (i.e. 6-minute walk test, incremental shuttle walk test, endurance shuttle walk test, step test, cardiopulmonary stress test)
Health-related quality of life (disease-specific and generic measures)
Psychological symptoms (both validated and non-validated measures will be considered)
Symptoms of dyspnea/breathlessness or fatigue (both validated and non-validated measures will be considered)
Cardiorespiratory physiological factors including heart rate, blood pressure, respiratory rate, oxygen saturation
Levels of physical activity (steps, proportion of time spent in light, moderate and high intensity physical activity)
CR, cardiac rehabilitation; DAS, distractive auditory stimuli; PR, pulmonary rehabilitation.

Study Selection

Two reviewers independently screened all titles and abstracts against the inclusion criteria. Potentially relevant articles were identified and retrieved in full text for independent assessment. Any disagreements were resolved in consultation with a third reviewer.

Assessment of Risk of Bias

Two authors independently assessed risk of bias of the included studies using the Risk of Bias tool from the Cochrane Collaboration (Appendix 2).22 Items included random sequence generation, allocation concealment, blinding of all participants, personnel, and outcome assessment, incomplete outcome data, selective reporting, and other biases. Each criterion was rated as low risk of bias, high risk of bias, or unclear risk (lack of information or uncertainty over the potential for bias).

Data Extraction

A data extraction form was developed to guide identification of relevant information, with one reviewer extracting data and a second reviewer checking for accuracy. For each included study, the following were extracted: author and year published, trial characteristics (including design and sample size), participant characteristics (including age, sex and diagnosis), intervention characteristics for each treatment group, outcomes reported, including measurement instrument used and timing of data collection and results. Where required, data were extracted from graphs using WebPlot digitizer.

Data Analysis

Meta-analysis was planned for ≥2 studies that were clinically homeogeneous (similar model of intervention and outcome tool).23 Data were analyzed using Review Manager 5.3 (Cochrane Collaboration Information Management System), with outcomes treated as continuous variables. Data reported as mean ± SD or mean ± SE were pooled; data reported as median and interquartile range were not able to be pooled. Mean difference or standardized mean using a random-effects model was selected when estimating the total effect of a pooled follow-up period. To ensure health-related quality-of-life scales pointed in the same direction, means were subtracted from the maximal possible value for the scale where required. Forest plots were generated from Review Manager software 5.3 to depict results. Heterogeneity was tested according to the overlap in confidence intervals (CIs), interpretation of the χ2 test, and the I2 statistic, with substantial heterogeneity represented by I2 > 50%.22 Where studies could not be combined in meta-analysis because of clinical heterogeneity, a narrative format was used to report individual study results.

RESULTS

Study Selection

The PRISMA flow diagram of study selection is shown in Figure 1. The search yielded a total of 115 studies. After removal of duplicates, there were 86 studies. Independent review of titles and abstracts excluded 72 studies. Fourteen studies underwent full text review. A further 5 were excluded with reasons outlined in Figure 1. A total of 9 studies met the inclusion criteria, 6 being randomized controlled trials9,17,19-21,24 and 3 randomized cross-over trials.25-27

F1
Fig. 1.:
Flow of studies.

Study Characteristics

There was a total of 334 participants; of these, 230 were men and 66 were women. All participants were older than 18 years.

Pulmonary Rehabilitation (Single or Multiple Sessions and Maintenance)

Four studies reported on PR (total of 132 participants)20,24,27 or PR maintenance programs (total of 24 participants)17 in conjunction with music listening. Of these studies, all included participants with a diagnosis of COPD.17,20,24,27 One study reported on a single session of PR,26 2 studies reported on a PR program ranging from 12 to 52 weeks,20,24 and one study reported on a PR maintenance program.17 The music listening activities included researcher selected music (ambient)27 and participant-selected music, which was or was not synchronized to a walking pace.17,20,24 The control condition for all studies of PR was no music listening; there was no use of sham music.

Cardiac Rehabilitation (Single or Multiple Sessions and Maintenance)

Five studies reported on CR (total of 108 participants)9,21,25,26 or a maintenance program following CR (total of 56 participants)19 in conjunction with music listening. Of the studies of CR, 3 included participants with mixed cardiac pathology21,25,26 and one reported on participants postcoronary artery bypass graft surgery.9 In the one study of a CR maintenance program, all participants had a mixed cardiac pathology.19 One study reported on a single session of CR,26 2 studies reported on a series of CR sessions (ranging from 1 week to 13 session),9,25 one study reported on a 12-week CR program,21 and one reported on a CR maintenance program.19 The music listening activities ranged from participant-selected music, with or without the assistance of a music therapist,19,21,26 or researcher-selected music.9,25 One study included 2 music-listening conditions21; only the findings of those listening to music without rhythmic auditory stimulation were extracted. Similar to PR, the control condition for all studies of CR was no music listening. Full details of the interventions are outlined in Table 2.

TABLE 2 - Characteristics of Included Studies
Study Design Sample Size (Intervention/Control) Participant Characteristics Male/Female; Diagnosis; Mean Age (SD) Intervention
Control Experimental
Pulmonary rehabilitation (single and multiple sessions)
 Reychler et al 27 Randomized cross-over 43 38/3; COPD; 71 (8) yrs A single session of outpatient PR (an individualized session consisting of aerobic exercise on a cycle ergometer (30 minutes of interval training), a rower (10 minutes of endurance training), and a treadmill and strengthening of upper arm and lower legs muscles). A single session of outpatient PR with the addition of ambient DAS (A mix of music pieces selected by the researcher, at a tempo of 120bpm). Music was played by 2 speakers in the room.
 Lui et al 20 Randomized controlled 48 (24/24) 48/0; moderate-severe COPD; mean NS 12 months of at-home PR (encouraged to do daily endurance exercise training with telephone reinforcement every 2 weeks within the first 3 months). 12 months of at-home PR with the addition of music with an individualized tempo played via software uploaded onto mobile phones (with use of earphones). It is unclear who selected the music.
 Ho et al 24 Randomized controlled 41 (20/21) 39/2; mild-severe COPD; 74 (10) yrs Encouraged to do their usual PR exercises 5 times a week for 12 weeks (home-based). Encouraged to do their PR usual exercises 5 times a week for 12 weeks (home-based) with the addition of an individualized exercise program accompanied by music (individualized to pace tempo) provided on an mp4 player. Participants selected own music.
Pulmonary rehabilitation maintenance
 Bauldoff et al 17 Randomized, controlled 24 (12/12) 4/20; moderate-severe COPD; 68 (8) yrs 8-week PR maintenance program (walk at own pace for 20–45 minutes, 2–5 times a week, home-based). 8-week PR maintenance program (home-based) with music (tempo of 90–110 bpm), delivered by portable audiocassette. Music included country/western, classical, pop/Motown and big band) with self-selection by participant.
Cardiac rehabilitation (single and multiple sessions)
 Murrock et al 9 Randomized controlled 30 (15/15) Control: 12/3; post CABG surgery, 70 yrs
Intervention: 5/10; post CABG surgery; 71 yrs
13 sessions of outpatient CR (including a warm-up, 30 minutes of continuous aerobic exercise and cool down). 13 sessions of outpatient CR with the addition of music in the last 10 sessions (ambient music recordings of researcher-selected classical composers, with tempo ranging from 128 to 160bpm). Music was delivered by cassette desk and speakers.
 Alter et al 21 Randomized, controlled 20 (9/11) Not stated; cardiac disease; 63 yrs 12 weeks of an outpatient CR program (12-week CR program, attending once weekly, aerobic and resistance exercises, with recommendations for home exercise 4 times/week). 12 weeks of an outpatient CR program with the addition of participant preference-based music audio playlists individually synchronized to approximate walking pace uploaded onto portable iPod.
 Cheng et al 25 Randomized cross-over 36 Not stated; cardiac pathology (including angina, coronary artery disease, cardiomyopathy, post myocardial infarction, valve disease); 63 (10) yrs 1 week of outpatient CR classes (15-minute warm-up, 24-minute conditioning component (6 exercise stations that alternated between AR exercises and CV exercises), and 10-minute cool-down). 1 week of outpatient CR classes with the addition of predetermined classical music playlist, selected by researcher (tempo ranging from 120 to 200 bpm). Interface used was not stated.
 Miller et al 26 Randomized cross-over 22 17/5; established cardiac disease; 64 (8) yrs A single exercise session within outpatient CR including 10 minutes of treadmill exercise at 3mph. A single exercise session within outpatient CR including 10 minutes of treadmill exercise at 3mph with the addition of listening to stimulating music (fast-pace and uplifting music with tempo of approximately 130–140bpm (tempo applied ranged from 128 to 148bpm).
1 single exercise sessions within CR including 10 minutes of treadmill exercise at 3mph with the addition to listening to sedative music (75–94bpm). Music selected by participants, delivered via iPod touch with stereo headphones.
Cardiac rehabilitation maintenance
 Clark et al 19 Randomized controlled 56 (28/28) 44/1; cardiac pathology (cardiac disease, conduction disorder, myocardial infarction, heart failure and valve disease), 68 (7) yrs 26-week home-based CR maintenance program (participants were encouraged to follow the physical activity guidelines using walking as the recommended mode of moderate level PA). 26-week home-based CR maintenance program with the addition of a single-session assessment, with a music therapist, to select an unlimited and preferred music playlist for walking-based exercise which was then provided on an mp3 player.
AR, active recovery; bpm, beats per minute; CABG, coronary artery bypass graft; CR, cardiac rehabilitation; CV, cardiovascular; COPD, chronic obstructive pulmonary disease; DAS, distractive auditory stimuli; mp, moving picture; mph, miles per hour; NS, not stated; PA, physical activity; PR, pulmonary rehabilitation; yrs, years.

Risk of Bias

The results of the risk of bias assessment are summarized in Table 3. Five studies adequately generated a random sequence,19-21,24,27 whereas 2 described allocation concealment.19,21 Four studies did not report their randomization method and had an unclear risk of selection bias.9,17,25,26 There was an unclear risk of bias with participants and therapists in 5 studies9,17,19-21 and high risk in 4 studies.24-27 Three studies19,24,25 adequately blinded outcome assessors whereas 6 studies were unclear.9,17,20,21,26,27 Six studies9,19-21,24,27 had complete outcome data whereas 3 studies17,25,26 were unclear on attrition. All studies included a complete reporting of results.

TABLE 3 - Risk of Bias Summary
Reference Random Sequence Generation (Selection Bias) Allocation Concealment (Selection Bias) Blinding of Participants and Personnel (Performance Bias) Blinding of Outcome Assessment (Detection Bias) Incomplete Outcome Data (Attrition Bias) Selective Reporting (Reporting Bias) Other Bias
Pulmonary rehabilitation (single or multiple sessions)
 Reychler et al 27 ? ?
 Lui et al 20 ? ? ?
 Ho et al 24 ?
Pulmonary rehabilitation maintenance
 Bauldoff et al 17 ? ? ? ? ?
Cardiac rehabilitation (single or multiple sessions)
 Murrock et al 9 ? ? ? ?
 Alter et al 21 ? ?
 Cheng et al 25 ? ? ?
 Miller et al 26 ? ? ? ?
Cardiac rehabilitation maintenance
 Clark et al 19 ?
Key: ✓, low risk of bias; ✗, high risk of bias; ?, unclear.

Exercise Capacity

Pulmonary Rehabilitation (Single or Multiple Session or Maintenance)

Meta-analysis of 2 studies20,24 showed that music listening during PR was associated with improvement in the incremental shuttle walking distance (ISWD) after 12 weeks, with a mean difference of 73 m (95% CI 26–120 m) (Fig. 2) compared with no music listening. In a study that included a long-term self-management period, this benefit was maintained at 1 year.20

F2
Fig. 2.:
Effect of music listening on exercise capacity over a 12-week pulmonary rehabilitation program

Similarly, music listening during an 8-week PR maintenance program improved the end 6-minute walk distance (6MWD) by 155 metres greater compared with no music,17 with a large effect size of 1.64 (95% CI 0.67–2.5).

Cardiac Rehabilitation (Single or Multiple Session or Maintenance)

In contrast, music listening during a 26-week CR maintenance program was not associated with any difference in 6MWD19 (Table 4).

TABLE 4 - Results of Included Studies
Study Follow-up Period Outcome Measures Findings a
Pulmonary rehabilitation (single or multiple sessions)
 Reychler et al 27 Beginning and end of session Perceived exertion Modified Borg RPE
Dyspnea: VAS
Anxiety: HADS-A
Physiological factors: HR and SpO2 (via pulse oximeter)
Listening to music during a session of PR significantly decreased anxiety compared with the control (P = .02). However, there was no significant differences between groups for perceived exertion (P = .33) or dyspnea [5 (2) vs 5 (2) points, P = .46; ES 0.0 (95% CI −0.42 to 0.42)]. Similarly, there was no significant difference groups for HR [101 (19) vs 100(8) bpm, P = .9; ES 0.07 (95% CI −0.35 to 0.49)] or SpO2% [92 (5) vs 93(5), P = .9; ES −0.20 (95% CI −0.62 to 0.23)].
 Lui et al 20 Baseline, 12 and 52 weeks Exercise tolerance: ISWT
Perceived breathlessness at the end of ISWT: Borg
QOL: SF-12
Music listening significantly increased exercise tolerance compared with control [324.2 (77.9) vs. 248 (48.5) m, P < .01, ES 1.17 (95% CI 0.54–1.77)] after 12 weeks. This was maintained at 1 year (P < .01). Perceived breathlessness at the end of the ISWT was significantly decreased in the intervention group [3.0 (0.3) vs 4.3 (0.3), P < .01, ES −4.33 (95% CI −5.29 to −3.24)] at 12 weeks and at 52 weeks [3.2 (0.7) vs 3.9 (0.7), P < .05, ES −1 (95% CI −1.58 to −0.38)]. QoL was significantly increased with music intervention compared with control at 12 weeks [45.4 (3.8) vs 34.3 (5.2) points, P < .001, ES 2.44 (95% CI 1.66–3.14)] and at 52 weeks [47.9 (3.8) vs. 30.9 (7.6) points, P < .001, ES 2.83 (95% CI 1.99–3.58)].
 Ho et al 24 Baseline and 16 weeks Exercise tolerance: ISWT
Physiological factors: SpO2 and mean resting HR
Dyspnea: Borg RPE
Leg fatigue: Borg RPE
HRQoL: SGRQ total score
Exercise tolerance increased significantly with the music intervention compared with control [306 (107) vs 219 (119) m, P < .001, ES 0.77 (95% CI 0.12 to 1.39)] after 16 weeks of training. Similarly, dyspnea decreased by 1.4 points with the intervention group compared with an increase of 0.1 points in the control group [P < .0001, ES −0.51 (95% CI −1.12 to 0.12)]. Leg fatigue reduced by 0.9 points in the intervention groups compared with 0.1 points for the control group (P < .05). There was no difference in mean resting HR or SpO2 between groups (P > .05). The music intervention significantly increased HRQoL compared with control [18.3 (12.7) vs 31.6 (16.3) points, P < .001, ES −0.16 (95% CI −0.77 to 0.46)].
Pulmonary rehabilitation maintenance
 Bauldoff et al 17 0 and 8 weeks Perceived dyspnea: UCSD-SOBQ
Exercise tolerance: 6MWD
Anxiety: Spielberger STAI
Depressive symptoms: CES-D
HRQoL: SGRQ total score
Breathlessness/perceived exertion at end of 6MWT (Modified Borg scale)
Perception of dyspnea decreased with DAS compared with control after 8 weeks [44.2 (4.2) units vs 53.3 (3.1) units, P < .001; ES −2.47 (95% CI −3.43 to −1.33)]. The 6MWD was greater after 8 weeks with DAS [447 (111) m vs 292 (75) m, P < .001; ES 1.64 (95% CI 0.67–2.5)]. Depression reduced in both groups, with no significant difference between groups [ES −0.08 (95% CI −0.88 to 0.72)]. There was no difference in HRQoL [ES 0.09 (95% CI −0.71 to 0.89)], anxiety [ES −0.63 (95% CI −1.43 to 0.21)], level of breathlessness [ES −0.03 (95% CI −0.83 to 0.77)] or level of fatigue [ES −0.69 (95% CI −1.48 to 0.16)] at end 6MWT between groups.
Cardiac rehabilitation (single or multiple sessions)
 Murrock et al 9 Collected at session 3 (baseline) and session 10 (end intervention) Mood: FS
Perceived exertion: Modified Borg RPE
There was no significant difference in perceived exertion between sessions with music and control [P = .16, ES −0.19 (95% CI −0.91 to 0.53)] during the last 5 minutes of treadmill walking. Listening to music significantly improved general mood compared with control [change score of 2.67 vs −0.80 units, P < .01; ES 1.74 (95% CI 0.86–2.53)].
 Alter et al 21 0 weeks and 12 weeks Weekly volume of PA, measured using an accelerometer
Level of high-intensity, moderate-intensity, or low-intensity PA, measured using an accelerometer
There was no difference in the average weekly volume of PA between the intervention and control groups [320 (355.2) vs 370.2 (332.5) mins, ES −0.15 (95% CI −0.98 to 0.70)].
There was no difference in the volume of high [5.7 (15.1) vs 2.22 (4.3), ES 0.31 (95% CI −0.54 to 1.14)], moderate [99.6 (120.4) vs. 123.3 (130.9), ES −0.19 (95% CI −1.02 to 0.66)] or low (214.6 (254.7) vs. 244.7 (230.7), ES −0.12 (95% CI −0.96 to 0.72)] intensity physical activity between groups.
 Cheng et al 25 Recorded mean for each outcome over the 1 week per intervention Physiological factors: HR (average and peak)
Borg RPE
There was no difference in the mean Borg RPE scores between the music intervention compared with control [12.1 (1.4) units vs 11.4 (1.4) units, P = .997, ES 0.50 (95% CI 0.03 to 0.96)]. Similarly, there was no difference in average HR between music listening and control [88.1 (12.5) vs 87.8 (12.4) bpm, P = .582; ES 0.02 (95% CI −0.44 to 0.49)]. However, peak HR was higher with music compared with control (median difference 7 bpm, P = .009).
 Miller et al 26 Baseline, 5 and 10 minutes Physiological factors: HR
Perceived exertion: Borg RPE
Mood: NRS
Although there was a lower RPE with sedative music compared with control at both 5 minutes [mean (SD) 9.5 (1.9) vs 10.6 (2.2), P < .0015] and 10 minutes [9.9 (2.0) vs 11.3 (2.5), P = .0002], there was no difference in RPE between stimulating music and control [mean (SD) 10.2 (2.0) vs 10.6 (2.2)] at 5 minutes or 10 minutes [10.5 (1.9) vs 11.3 (2.5)]. Mood was improved with sedative music compared with control after 5 minutes [4.0 (1.0) vs 3.5 (1.2), P = .015], but there was no difference between stimulating music and control.
HR was higher with stimulating music versus control [101.7 (13.1) vs 95.1 (13.2) b/min, P = .0005, ES 0.50 (95% CI −0.11 to 1.09)] at 5 minutes and at 10 minutes [102.5 (12.5) vs 96.6 (14.1) bpm, P < .0001, ES 0.44 (95% CI −0.16 to 1.03)]. There was no difference between sedative music and control.
Cardiac rehabilitation maintenance
 Clark et al 19 Baseline and end intervention at 26 weeks Physical activity: accelerometer, minutes of moderate to vigorous physical activity (cadence >100 steps/min), number of steps n); daily hours spent lying or sitting (hrs/day)
Exercise tolerance: 6MWD
No between group differences in daily minutes walking at cadence >100 steps [mean difference (MD) −1.76 (95% CI −10.3 to 6.8) minutes, ES 0.18 (95% CI −0.36 to 0.72)]. No difference in number of steps [MD −149.3 (95% CI −1667 to 1369) steps, ES 0.35 (95% CI −0.20 to 0.89)]. No difference in hrs/day sitting/lying [MD 0 (95% CI −0.7 to 0.8) hrs, ES −0.05 (95% CI −0.59 to 0.49)].
There was no significant difference between groups for 6MWD (MD 25 m [95% CI −5 to 55) m; ES 0.68 (95% CI 0.12–1.23)].
aData are mean (SD) unless otherwise stated.
bpm, beats per minute; CES-D, Centre of epidemiological studies depression questionnaire; CI, confidence interval; Con, control; DAS, distractive auditory stimuli; ES, effect size; Exp -experimental; FS, Rejeski Feeling Scale; HADS-A, Hospital anxiety and depression scale, Anxiety subscale; HR, heart rate; HRQoL, health related quality of life; ISWT, incremental shuttle walk test; kgm2, kilograms per metre squared; m, metres; MD, mean difference; NRS, numerical rating scale; NS, not stated; OR, odds ration; PA, physical activity; PR, pulmonary rehabilitation; QoL, quality of life; RPE, rating of perceived exertion; SF-12, Short form-12; SGRQ, St. George's Respiratory Questionnaire; SpO2, percutaneous oxygen saturation; STAI, state-trait anxiety intervention; UCSD-SOBQ, The University of California, San Diego Shortness of Breath Questionnaire; VAS, visual analogue scale; vs, versus; yrs, years; 6MWD, 6-minute walk distance; 6MWT, 6-minute walk test.

Health-Related Quality of Life

Pulmonary Rehabilitation (Single or Multiple Session or Maintenance)

Meta-analysis of 2 studies20,24 showed that music listening during PR was associated with a trend toward improvement in quality of life measures after 12 weeks, with a standardized mean difference of −4.6 points (95% CI −11.8 to 2.6 points) (Fig. 3). This improvement persisted at 52 weeks in one study.20 In contrast, after an 8-week PR maintenance program, there was no difference in health-related quality of life according to the St George's Respiratory Questionnaire17 (Table 4).

F3
Fig. 3.:
Effect of music listening on health-related quality of life over a 12-week pulmonary rehabilitation program

Psychological Symptoms

Pulmonary Rehabilitation (Single or Multiple Session or Maintenance)

During a single session of PR, anxiety was reduced with ambient music compared with control (P = .02).27 However, during a PR maintenance program, music listening did not reduce anxiety or depression levels.17

Cardiac Rehabilitation (Single or Multiple Session or Maintenance)

Although listening to sedative music improved mood during a single CR session, there was no effect with stimulating music.26 Ambient music applied during the last 10 sessions of CR improved general mood compared with control (P < .01).9

Symptoms of Dyspnea and Fatigue

Pulmonary Rehabilitation (Single or Multiple Session or Maintenance)

After a single session of PR, music listening did not alter dyspnea or perceived exertion.27 However, at the conclusion of a home-based PR compared with control, music listening reduced dyspnea at end incremental shuttle walk test with effects sizes ranging from moderate to large.20,24 This symptomatic improvement was still maintained at 12 months in one study.20 Similarly, leg fatigue reduced with music listening following 16 weeks of PR.24 Although music listening reduced overall dyspnea perception following PR maintenance program (44.2 points vs 53.3 points, P < .001), there was no change in end 6MWD dyspnea or fatigue.17

Cardiac Rehabilitation (Single or Multiple Session or Maintenance)

For CR, there was a lower perceived exertion listening to sedative music following 5 or 10 minutes of exercise during a single session.26

Physiological Factors

Pulmonary Rehabilitation (Single or Multiple Session or Maintenance)

Music listening during a single session of PR did not alter HR or percutaneous oxygen saturation (SpO2).27 Similarly, there was no difference in these physiological measures with music listening compared with control following 12 weeks of PR.24

Cardiac Rehabilitation (Single or Multiple Session or Maintenance)

During a single session of CR, HR was higher with stimulating music (defined by the study authors as fast-pace and uplifting music with a tempo of approximately 130–140 bpm) compared with control at 5 and 10 minutes, with effect sizes ranging from 0.44 to 0.50.26 During a week of CR classes, whereas peak HR was higher with music listening (median difference 7bpm, P = .009), there was no difference in mean HR between interventions25 (Table 4).

Physical Activity

Cardiac Rehabilitation (Single or Multiple Session or Maintenance)

Physical activity was measured in 2 studies of CR.19,21 Synchronized participant-preference music listening did not affect weekly volume of physical activity compared with control21 and there was no difference in daily minutes spent walking at a cadence greater than 100 steps, number of steps or number of hours spent sitting or lying in a CR maintenance program.19

DISCUSSION

This systematic review with meta-analysis assessed the effect of music listening during exercise training undertaken within CR or PR programs, including maintenance programs. Compared with control, listening to music during a PR program enhanced exercise capacity, but this effect was not evident during a maintenance program following CR. The effect of music listening during a single or series of sessions of a PR or CR programs on psychological and physical symptoms were variable, but there was no effect on physical activity during CR.

The improved exercise tolerance when listening to music during PR mirrors the findings in healthy populations,28-30 with reduction in perceived exertion and delayed onset of fatigue.29,30 The intensity of exercise undertaken may determine the extent to which music inhibits the processing of symptoms of dyspnea or fatigue during moderate-intensity exercise.13 With 2 studies in PR prescribing exercise at 80% of maximal capacity,20,24 the enhanced exercise capacity, with a moderate effect size supports this concept. The magnitude of change for ISWD was clinically significant, greater than the minimally important difference of 35 to 36.1 metres defined for COPD,31,32 although these findings only apply to those with moderate-to-severe disease.33 With only 2 studies in this meta-analysis, the results should be interpreted with caution. As this improvement is usually achieved over the course of a rehabilitation program, it is not surprising there was negligible effect of music listening on exercise capacity or symptoms during a single exercise session in PR or CR.9,26,27 It highlights the general conditioning process that occurs over longer period in PR or CR programs.

The influence of music listening on maintenance programs were contrary. An eight-week program with music listening during PR maintenance achieved a clinically significant improvement in 6MWD, despite a negligible effect on dyspnea or fatigue.17 By comparison, music listening throughout a 26-week CR maintenance program did not offer a greater level of improvement in exercise capacity.19 As these studies apply a dissimilar intervention to different populations over variable time periods, it is unsuitable to directly compare these results. However, the varying approaches taken to applying music listening may account for these findings. One study applied upbeat tempos between 90 and 110 beats per minute17; given the positive association between music tempo and exercise performance,10 this may partially account for contrasting findings between studies. The lack of effect on dyspnea and fatigue measures highlight that the mechanisms of symptom desensitization targeted by music listening may be partially dependent on exercise intensity. Clark et al19 selected music based on participants' personally motivating elements, with the range of music tempo applied across participants not reported. In addition, the low levels of adherence to physical activity recommendations may account for the lack of effect during a CR maintenance program.19

The magnitude of change in health-related quality of life in COPD was clinically significant.34 However, the pooled effect demonstrated only a trend toward improvement, and this may be attributed to the high level of heterogeneity (I2 = 98%) between the studies.20,24 Benefits were noted in all domains of the St George's Respiratory Questionnaire and total score after 8, 12, and 16 weeks of training,24 whereas the physical component summary score of the SF-36 was increased at 12 weeks and persisted for 1 year.20 Additional studies with similar interventions and outcome measures may further clarify the effects. The lack of effect on quality of life with music listening during a PR maintenance program may be partially attributed to the intensity of exercise.17 Participants were instructed to maintain pace walking to a subjective sensation of dyspnea equivalent to a modified Borg rating of 2 to 3;17 the extent to which this was adhered to is unknown.

A strong association between dyspnea and anxiety in people with COPD has been previously reported.35 It is hypothesized that music listening during exercise may invoke desensitization to or distraction from dyspnea in individuals with COPD,13,17,20 which may assist in reducing anxiety levels. However, the effectiveness of this distraction may be dependent on the baseline levels of anxiety. Participants with borderline anxiety had a reduction in symptoms after a single session of ambient music listening in PR applied at a tempo of 120bpm.27 Those with low levels of anxiety after completion of PR and before an 8 week maintenance program remained unaffected by music listening, which was applied at a tempo of 90 to 110bpm.17 Music tempo is an important moderator of music-related arousal and relaxation, with slow tempo music linked to greater relaxation and reduced anxiety.36 Further studies of music listening over the course of a PR program in individuals with COPD and concurrent anxiety are required to enable meaningful conclusions to be drawn regarding the effects of this adjunct on anxiety.

Enhanced mood was achieved with music listening over both series of sessions9 and a single session of CR.26 Positive effects on mood have been previously documented in healthy populations,37 but the genre of music may be significant. Although high tempo music (128–141 b/min) seemed to be less effective,26 improvements were noted with therapist-selected classical music9 or participant-selected sedative music,26 which seemed to initiate positive emotional states and provoked enjoyable memories.9 It is possible that the melodic and harmonic elements in classical music, which are believed to influence subjective experience, may have facilitated these positive emotional states.38 Furthermore, qualitiative research suggests that melodic and harmonic elements in music helped CR participants to feel more confident while exercising.38 Given the high prevalence of depression among CR participants,9 these potential influences from music listening during CR in not only enhancing mood but reducing depression require further evaluation.

The minimal effect on selected physiological markers during a single or short series of CR or PR sessions is likely to be influenced by the lack of opportunity to elicit a training effect, irrespective of the program.25-27 Furthermore, the mechanisms behind the corresponding reduction in dyspnea and fatigue with music listening during a 12-week PR program incorporate a mix of physiological, sensory, and emotional factors that are unable to be captured through HR and SpO2 measurements.24 Although a single session of CR was associated with HR elevation with music delivered at a high cadence,26 this may be because of the high music tempo (cadence of 130–140 bpm), particularly as the intensity of exercise was similar during listening to sedative music.26 Sychronization between HR and musical tempo has been previously reported, with listening to fast tempo music leading to an increase in HR.36

The absence of effect on physical activity for participants engaged in a CR maintenance program may be related to the lack of behavioral change strategies recommended to enhance compliance with physical activity,19,40 and the low adherence to physical activity recommendations.19 In addition, matching music tempo to walking cadence may affect achievement of activity levels. Although Alter et al21 selected music whose tempos were within ± 10 beats per minute of a participant's exercise step pace, this demonstrated minimal impact on the weekly volume of physical activity or engagement in low-intensity, moderate-intensity, or high-intensity physical activity during a CR program. Further exploration of the potential influence of the subjective and psycho-emotional response to music listening on physical activity is required.

The review was limited by minimal mention related to adherence of music listening and for long-term studies, adherence to the exercise intervention. Greater consistencies in reporting prescription adherence among future studies will enhance interpretation of these clinical effects. The lack of clinically homogenous studies limited the extent of meta-analysis. Although most studies9,17,19-21,24 excluded participants who were hard of hearing and/or used hearing aids, 3 studies25-27 did not specify this criteria. No studies stated whether potential participants were excluded based on a lack of enjoyment of listening to music or a preference for conversation or a quiet environment while exercising. Furthermore, the conditions of applying music were mixed across studies, with participant and researcher selection of music, and interfaces for delivering music ranged from ambient music via audiocassette to individual mp3/4 players or iPods with earphones or headphones. These conditions may result in less engagement with music listening or an inability to hear ambient music adequately, both of which are considered less than favourable circumstance for listening to music for some individuals41 and may influence some findings. Finally, for those studies related to PR or maintenance programs, the included studies only examined those diagnosed with COPD. The extent to which these results apply to other respiratory populations engaged in PR is unclear. Consistency in the use of random sequence generation and allocation across studies was variable and the inclusion of blinding of participants, personnel and of outcome measure assessment was minimal, which increases the risk of bias within studies.

CONCLUSIONS

Music listening during a course of long-term PR program improved exercise capacity, with variable effects on symptoms of dyspnea and perceived exertion and a trend toward improvement in quality of life. During single or a series of sessions of CR, music listening had limited impact on physiological markers and an absence of effect on physical activity. Further studies examining the effects of therapist-directed and participant-selected music listening during PR or CR exercise training, including the impact on psychological symptoms of anxiety and depression and on adherence and completion of training is warranted.

APPENDIX 2. Risk of bias

-
Bias domain Source of bias Support for judgment
Selection bias Random sequence generation Describe the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.
Allocation concealment Describe the method used to conceal the allocation sequence in sufficient detail to determine whether intervention allocations could have been foreseen before or during enrolment.
Performance bias Blinding of participants and personnel* Describe all measures used, if any, to blind trial participants and researchers from knowledge of which intervention a participant received. Provide any information relating to whether the intended blinding was effective.
Detection bias Blinding of outcome assessment* Describe all measures used, if any, to blind outcome assessment from knowledge of which intervention a participant received. Provide any information relating to whether the intended blinding was effective.
Attrition bias Incomplete outcome data* Describe the completeness of outcome data for each main outcome, including attrition and exclusions from the analysis. State whether attrition and exclusions were reported, the numbers in each intervention group (compared with total randomized participants), reasons for attrition or exclusions where reported, and any re-inclusions in analyses for the review.
Reporting bias Selective reporting State how selective outcome reporting was examined and what was found.
Other bias Anything else, ideally prespecified State any important concerns about bias not covered in the other domains in the tool.
*Assessments should be made for each main outcome or class of outcomes.

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Keywords:

cardiac rehabilitation; pulmonary rehabilitation; music listening; quality of life; exercise capacity

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