Complementary Therapies in Clinical Practice 39 (2020) 101162

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Complementary Therapies in Clinical Practice

journal homepage: http://www.elsevier.com/locate/ctcp

Can music influence cardiac autonomic system? A systematic review and

narrative synthesis to evaluate its impact on heart rate variability
Helia Mojtabavi a, b, *, Amene Saghazadeh c, d, Vitor Engra
�cia Valenti e, Nima Rezaei b, c, d, f
a
School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
b
Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
c
Research Center for Immunodeficiencies, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
d
MetaCognition Interest Group (MCIG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
e
Department of Speech-Language and Hearing Therapy, UNESP, Marília, SP, Brazil
f
Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Background: and purpose: The impact of music on the human body extends beyond an emotional response. Music
Autonomic nervous system can bring benefits to the cardiovascular system by influencing heart rate variability (HRV), which is a well-
Heart rate variability accepted method to analyze the oscillations of the intervals between successive heartbeats and investigate the
Music therapy
cardiovascular autonomic nervous system (ANS). This study is a systematic review to examine the effect of
Systematic review
musical interventions on HRV.
Methods: We conducted a systematic search in PubMed, Scopus, Web of Science, and Cochrane and identified
additional studies with hand searching of reference lists of relevant references.
Results: 29 original articles (24 pre-post intervention studies and five randomized controlled trials) with a total of
1368 subjects were available and eligible to be included in the systematic review. Within the whole, only three
studies reveal no significant impact of music on HRV, which might be due to using a small sample size and a
concise duration of music administration. Interestingly, the rest of the studies have suggested a positive impact of
music on HRV with a 0.05 level of significance.
Conclusion: This systematic review confirms music as a stimulus acting to the cardiac ANS that increases para­
sympathetic activity and HRV. The effects are, however, associated with a high risk of bias. Therefore, further
studies are necessary to compare the impact of individualized music therapy to passive listening and preferred
soundtracks.

1. Introduction intervention in medical, educational, and everyday environments with

Music brings more than just an emotional response. It can regulate
arousal [1], improve executive skills and concentration [2,3], boost the
quality of sleep [4], and strengthen social interactions [5]. Music, as a
therapy in medicine, is a debating topic. A growing number of studies
have demonstrated the effect of music on physiological variables [6],
including blood pressure (BP), heart rate (HR), respiration rate (RR),
body temperature, and biochemical parameters in addition to sensitivity
to pain [7]. Recently the possibility of using musical auditory stimula­
tion as a form of non-pharmacological complementary therapy has been
proposed [8,9].
Music therapy (MT) as defined by the World Federation of Music
Therapy (WFMT) is “the professional use of music and its elements as an
individuals, groups, families, or communities who seek to optimize their
quality of life and improve their physical, social, communicative,
emotional, intellectual, and spiritual health and wellbeing” [10]. There
is no doubt that music as a therapeutic intervention, dating back to
antiquity, has reached growing popularity, especially in cardiovascular
medicine. On the one hand, exposure to music enhances positive cardiac
responses [9,11,12]. On the other hand, there are anxiolytic effects of
musical auditory stimulation leading to decreased consumption of
sedative medications [11–13]. The autonomic nervous system (ANS)
function is fundamental to adjust the inherited body functions for
establishing and maintaining homeostasis to adapt to the surrounding
conditions [14]. In the stress setting, to recover the homeostasis balance,
the organism tries to adjust to the novel challenging situation. The two

* Corresponding author. Department of Medicine, Poursina Ave, Tehran, Iran.

E-mail address: heliamojtabavi@gmail.com (H. Mojtabavi).

https://doi.org/10.1016/j.ctcp.2020.101162
Received 23 April 2019; Received in revised form 27 March 2020; Accepted 27 March 2020
Available online 7 April 2020
1744-3881/© 2020 Elsevier Ltd. All rights reserved.
H. Mojtabavi et al.
branches of the ANS, e.g. parasympathetic nervous system (PNS) and
sympathetic nervous system (SNS), work to ensure this adaptation. SNS
mainly mobilizes energy in acute stress to cope with both internal and
external challenges (fight or flight reaction).
Contrary to the SNS, the PNS plays a role as a “Rest and Digest”
system that promotes relaxation and triggers acetylcholine release. The
PNS influences on its target organs, including the heart, through the
vagus nerve. This nerve is known to conduct the relaxation response for
the body leading to a decrease in oxygen consumption, RR, BP, and HR,
with an overall increase in well-being [15]. Also, cardiac vagal tone
contributes to the regulation of cardiac PNS, which correlates many
psychophysiological phenomena, including self-regulation at the
cognitive, emotional, social, and health levels [15].
A healthy heartbeat occurs in a nonlinear manner due to the antag­
onist effects of the PNS and SNS [16]. HRV is a well-accepted indicator
to analyze the oscillations of the intervals between successive heartbeats
(RR intervals) and to investigate cardiac ANS function [17]. HRV de­
creases in acute stress states. Higher vagal activity leads to increased
HRV measures associated with better well-being [15]. Also, decreased
HRV contributes to emotional dysregulation that is a risk factor for
cardiovascular diseases. As expressed by the Porges’s polyvagal theory,
the myelinated vagus fibers are engaged in adaptive, prosocial behavior
and at suppressing automated fear and stress responses. In line with this,
high vagally-mediated (VM)-HRV seems to correlate positively with
resilience, social engagement, well-being, and psychological flexibility
[18]. Taken together, HRV could serve as a reliable biomarker of stress
and relaxation, indicating the interplay between the PNS and SNS
branches of the ANS [16].
Altogether, music appears to influence the cardiac ANS, resulting in
altered HR rhythm [19,20]. Measuring the physiological responses to
MT is crucial to evaluate the actions of the applied methods of imple­
mentation and choose the most suitable one. HRV is a marker of auto­
nomic function in humans [19]. This systematic review aims to evaluate
the effect of immediate and chronic MT on cardiac autonomic regulation
measured using HRV-related parameters.
2. Methods
We prepared present study according to the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) [21].
2.1. Searching for literature
We conducted a systematic search in the Cochrane (https://www.
cochrane.org/), PubMed (http://ncbi.nlm.nih.gov/pubmed), Scopus
(https://www.scopus.com/search/form.uri?display¼basic), and Web of
Science (https://webofknowledge.com) databases. The publication date
was not a restricting factor, and all the studies from inception, at 1968,
up to recent investigations in November 2018, were included in the
present review. We found additional articles with hand searching of
reference lists of relevant references.
2.2. Literature search strategy
We obtained the keywords from the MeSH (Medical Subject Head­
ings), which is the National Library of Medicine (NLM) controlled vo­
cabulary thesaurus used for indexing articles for PubMed (https://www.
ncbi.nlm.nih.gov/mesh). The following search terms were used: (Auto­
nomic Nervous System OR Heart Rate Variability OR Respiratory Rate
OR Blood Pressure) AND Music Therapy.
2.3. Study eligibility criteria
According to the PRISMA guideline, the study selection is a four-step
process. The first step is to identify all the potentially relevant studies.
The second step is the screening of all the studies based on the title/
2
Complementary Therapies in Clinical Practice 39 (2020) 101162
abstract and finding studies related to the topic of interest. In the third
step of the selection process, we reviewed in-detail all the possibly
relevant studies to assess their eligibility. Finally, we included the
eligible studies in the systematic review. We applied the following PICO
principle (patient, intervention, control, and outcomes) for defining the
eligibility of studies.
2.3.1. Patients (subjects)
Subjects needed to be non-pregnant humans aged over 18 years old
and have normal hearing status. Since the autonomic manifestations and
stress-related responses are not similar in children and infants compared
to the adult population, studies involving people younger than 18 years
of age were not included in this paper. Given the effect of musical
experience on brain plasticity, there is a difference between professional
musicians and naïve populations in the neural circuit(s) underlying
music listening. Therefore, we excluded studies including professional
musicians as the study population from the review.
2.3.2. Intervention
There is a substantial difference between MT and passively listening
to recorded music (RM), commonly regarded as music medicine. How­
ever, studies are less likely to adhere to these definitions [22]. In this
review, we distinguished the professional MT from other types of music
applications. We considered no limitations on music genres. However,
studies merely applying audiovisual stimulation and also studies
investigating the effect of performing music, rather than listening to
music, were excluded due to parallel confounding variables. A sub­
stantial number of studies administered self-selected audio tracks.
Genres included soft relaxing melodies with slow to medium tempo, e.g.,
Folkloric Music, Western Classical, Pop, and Natural Sounds, and high
arousal genres included Jazz, Rock, and their subtypes. Methods of
music administration ranged from playing audio from mp3 players
through headphones to playing audio via speakers or with audio pillows.
2.3.3. Control
We included studies using either matched controls or measuring the
effect of the intervention on the same study group over time. Partici­
pants in the control condition received turned off earphones, white noise
application by the headsets, or merely silence.
2.3.4. Outcomes
The primary outcomes were the linear indices of HRV at both the
time and frequency domain:
- The time-domain parameters of HRV: RMSSD (square root of the
mean square of the differences between adjacent regular RR in­
tervals), SDNN (standard deviation of all regular RR intervals), and
pNN50 (percentage of adjacent RR intervals with duration difference
more than 50 ms)
- The frequency-domain parameters of HRV: HF (high frequency), LF
(low frequency), LF/HF ratio (relation between low and high-
frequency components), SD1 (dispersion of points perpendicular to
the identity line, instantaneous record of beat-to-beat variability),
and SD2 (scatter points along the identity line, long-term record).
Secondary outcomes were HR, HRmax (HR peak during exercise),
DBP (diastolic BP), and SBP (systolic BP). Table 1 contains details
regarding the definition of HRV-related metrics of time-domain and
frequency-domain.
2.4. Data extraction
The authors reviewed full-texts of eligible studies and extracted the
following data from each article: study design, sample size, number of
music sessions, duration of each session, music genres, whether music
therapist-assisted or not, assessment protocol, and outcomes of interest.
H. Mojtabavi et al. Complementary Therapies in Clinical Practice 39 (2020) 101162

Table 1
Heart rate variability (HRV)-related parameters.
Heart rate variability (HRV)
Heart rate is the number of heartbeats per minute (BPM). A healthy heart is expected to adapt to variable and changing environmental conditions. For this purpose, it would need to
generate appropriate amounts of variation in the time interval between consecutive heartbeats – which is called heart rate variability (HRV) – related to the stimuli and new
conditions to which the body is exposed.
Analyzing HRV
Parameters that are commonly used for analyzing HRV are of time and frequency domain. As summarized below, they are calculated either from short-term recordings (usually 5 min)
or from 24-h records. Measurements of short-term HRV reflect high-frequency variations rather than low-frequency variations. While analyses during the 24-h period can examine
HRV for both high-frequency and low-frequency bands [58].
Time-domain measures of HRV
Time-domain metrics estimate the amount of variability over the period between two consecutive heartbeats. They are defined in relation to three intervals consisted of IBI (the
interbeat interval), NN intervals (the IBI between normal sinus R-peaks), and RR intervals (the intervals between two successive R-peaks) [57].
� SDNN: Standard deviation of NN intervals (ms)
� SDRR: Standard deviation of RR intervals (ms)
� SDANN: Standard deviation of the average NN intervals for each 5 min segment of a 24 h HRV recording (ms)
� SDNN Index: Mean of the standard deviations of all the NN intervals for each 5 min segment of a 24 h HRV recording (ms)
� pNN50: Percentage of successive RR intervals that differ by more than 50 ms (%)
� HR Max – HR Min: Average difference between the highest and lowest heart rates during each respiratory cycle (bpm)
� RMSSD: Root mean square of successive RR interval differences (ms)
� HRV triangular index (HTI): Integral of the density of the RR interval histogram divided by its height
� Triangular Interpolation of the NN Interval Histogram (TINN): Baseline width of the RR interval histogram (ms)
As defined above, most of the time-domain measurements are calculated from short-term recordings and so correlate with each other. Among these, four measures are thought to be
likely enough for HRV assessment. They include SDNN, HTI, SDANN, and RMSSD. SDNN and HTI reflect overall HRV, whereas SDANN and RMSSD provide estimation of short-term
and long-term components of HRV, respectively [58].
Frequency-domain measures of HRV
Frequency-domain measures indicate the variation of heart oscillatory power. There are four categories to which heart rate oscillations are assigned: ultra-low frequency (ULF), very-
low-frequency (VLF), low-frequency (LF), and high-frequency (HF).
� ULF power: Absolute power of the ultra-low-frequency band (�0.003 Hz) (ms2 )
� VLF power: Absolute power of the very-low-frequency band (0.0033–0.04 Hz) (ms2 )
� LF peak: Peak frequency of the low-frequency band (0.04–0.15 Hz) (Hz)
� LF power: Absolute power of the low-frequency band (0.04–0.15 Hz) (ms2 )
� LF power: Relative power of the low-frequency band (0.04–0.15 Hz) (normal units)
� LF power: Relative power of the low-frequency band (0.04–0.15 Hz) (%)
� HF peak: Peak frequency of the high-frequency band (0.15–0.4 Hz) (Hz)
� HF power: Absolute power of the high-frequency band (0.15–0.4 Hz) (ms2 )
� HF power: Relative power of the high-frequency band (0.15–0.4 Hz) (normal units)
� HF power: Relative power of the high-frequency band (0.15–0.4 Hz) (%)
� LF/HF: Ratio of LF-to-HF power (%)
Measures of HRV in time-domain closely correlate with those in frequency-domain as follows;
1. SDNN, HRVTI, and TINN with total power,
2. RMSSD, SDSD, NN50 count, pNN50, differential index, and logarithmic index with HF,
3 SDNN index with mean of 5 min total power, and
4 SDANN with ULF.
Given this close correspondence between the information from frequency-domain parameters and that from time-domain parameters and given the fact that measuring frequency-
domain parameters is easier than time-domain parameters, it is recommended to evaluate frequency-domain measures if the 24-h recording is planned to be performed.
Non-linear measures of HRV
In addition to the time-domain and frequency-domain metrics, there are non-linear methods that represent the unpredictability of HRV arising from the role different mechanisms play
in the regulation of HRV [57].
� S: Area of the ellipse which represents total HRV ms (ms)
� SD1: Poincar�e plot standard deviation perpendicular the line of identity (ms)
� SD2: Poincar�e plot standard deviation along the line of identity (ms)
� SD1/SD2: Ratio of SD1-to-SD2 (%)
� ApEn: Approximate entropy, which measures the regularity and complexity of a time series
� SampEn: Sample entropy, which measures the regularity and complexity of a time series
� DFA α1: Detrended fluctuation analysis, which describes short-term fluctuations
� DFA α2: Detrended fluctuation analysis, which describes long-term fluctuations
� D2: Correlation dimension, which estimates the minimum number of variables required to construct a model of system dynamics.

2.5. Data synthesis and analysis 2.6. Risk of bias assessment

We classified the included studies based on the health condition of
their recruited samples. Since effect sizes are not recommended for pre-
and post-intervention research studies [23], the plan was to calculate
the pooled effect size if there were three or more randomized controlled
trials (RCTs) that compared the effect of MT on an outcome of interest
with that of control condition. All the outcomes of interest in the present
systematic review were of continuous type. Thus, the effect size was
presumed to be the mean difference (MD) based on means and standard
deviations (SD). If indicated, then the MD and 95% confidence interval
(CI) could be estimated using Review Manager (version 5.3. Copenha­
gen: The Nordic Cochrane Centre, the Cochrane Collaboration, 2014).
We assessed the risk of bias using the Cochrane Collaboration’s tool
for assessing the risk of bias in randomized trials [24].
3. Results
3.1. Literature search result
As outlined in Fig. 1, we screened 286 studies for eligibility, 257 of
which were excluded. Finally, 29 original articles including twenty-four
pre-post intervention studies and five RCTs were included in this sys­
tematic review.

3
H. Mojtabavi et al.
Fig. 1. Flow diagram of the study selection process.
3.2. Characteristics of included studies
The included studies examined the effect of musical interventions on
HRV in seven different target groups: healthy subjects (n ¼ 14), during
exercise in healthy subjects (n ¼ 4), patients with neuropsychiatric
diseases (n ¼ 4), patients undergoing any surgery (n ¼ 4), patients un­
dergoing dental procedures (n ¼ 2), and patients undergoing cardiac
catheterization (n ¼ 1). The sample size ranged from 12 to 167 partic­
ipants per included study. The chronology of musical interventions
ranged from short-term hours to 12 weeks, with the majority (n ¼ 26) of
studies focusing on the efficacy of short-term MT. The duration of MT
ranged from a few minutes to 120 min per session. Table 2 provides an
overview of the characteristics of the studies included in the systematic
review.
3.3. Risk of bias assessment
The designs of studies included pre-post intervention studies (n ¼ 24)
and RCT (n ¼ 5). As summarized in Table 3, all studies had three or more
high risk of bias domains (see Table 4).
3.4. Study results
We were unable to pool the individual effect sizes given the inade­
quate number of RCTs included in each category. Below presents a
narrative synthesis of the evidence.
3.4.1. Healthy population
Lynar et al. [9] investigated the effects of music on physiological
variables and emotional responses among 94 healthy adults. Partici­
pants were exposed to four different stimuli as follows: jazz, classical,
self-selected, and white noise. Classical music was considered as low
arousal and jazz music as high arousal. The panel decided to exclude pop
music due to the assumption that this genre would be a well
4
Complementary Therapies in Clinical Practice 39 (2020) 101162
representative of participants’ (self) selected stimuli. Moreover, among
the self-selected pieces, the tempi ranged from 44 to 192 bpm across the
94 pieces. Candidates listened to 5 min of each music piece to reach a
desirable duration for analysis of HRV. The HRV (HFnu) was higher
when classical music was played compared to when other music genres
and self-selected music were played. The intergroup differences for jazz
music and white noise were non-significant, with p values < 0.01 for
each. Mean HR values increased when listening to self-selected music
compared to each other music, all p < 0.001.
Sixty-four military service members complaining of post-deployment
stress were randomly allocated to either music intervention with
Binaural Beat Technology (BBT) or merely musical intervention [25].
Subjects were asked to listen to an audio player 30 min before bedtime,
three consecutive nights per week, for four weeks. HRV analysis showed
significant results for both LF and HF measurements among the groups.
LF component was significantly lower among the BBT group, with a
p-value of <0.01. HF revealed the opposite pattern with a high level of
significance (p < 0.01). Overall, HRV power increased in the study
population compared to the control (p < 0.01).
In a study by Vanderlei et al. [26], 22 healthy female students
received either musical stimulation or rested for the same period. For the
intervention group, two pieces of music were selected, “Heavy Metal
Universe” by Gamma Ray and “Tra €umerei” by Robert Schumann; each
was played separately for 5 min and 15 s with one week gap between
periods. The research team used three types of non-linear analysis: the
Shannon entropy, symbolic analysis, and the correlation dimension.
Based on the symbolic analysis, a significant decline at the 2LV per­
centage index was observed in Heavy Metal music compared to the
control. Moreover, higher values of 0Vpercentage were notable among
the participants who were exposed to auditory stimulation with Heavy
Metal music compared to the control subjects. The symbolic analysis
method categorized three symbols in four families, 0 V, 1 V, 2LV, and
2UV, where 0Vpercentage can merely reflect sympathetic modulation,
1Vpercentage reflects both para and sympathetic modulations, and
H. Mojtabavi et al. Complementary Therapies in Clinical Practice 39 (2020) 101162

Table 2
Summary of papers that evaluated the effect of heavy metal music on heart-rate variability-related measures.
Reference Sample size Number of Type of Music Result
sessions

[9] 94 1 jazz, classical, self-selected and white noise - HFnu was significantly higher when exposed
to classical music
- HR significantly increased exposed to
self-selected music overall
[26] 22 2 “Heavy Metal Universe” by Gamma Ray and “Tr€
aumerei” - Heavy metal decreased 2LV%
by Robert Schumann
[27] 28 1 “Heavy Metal Universe” by Gamma Ray and “Canon” - Heavy metal decreased SDNN at 80–90 dB
in D Major by Pachelbel and LF at 60–70 dB
- Classical decreased LF at 60–70 dB
[30] 18 1 Heavy Metal versus Classical Baroque Music - Heavy metal decreased SDNN, LF, and HF
- Classical Baroque reduced LF in absolute
units and the LF/HF ratio
[12] 40 1 Heavy Metal versus Classical Baroque Music - RRtri and SD2 were decreased significantly
with heavy metal exposure
[46] 50 1 Traumerei of Kinderszenen by Robert Schumann - Music decreased HR, TINN and increased SDNN,
RMSSD, SD1, and SD2
- Among controls, RR decreased significantly

HFnu, normalized high frequency; HR, heart rate; 2LV%, two like variations; SDNN, the standard deviation of NN intervals; dB, decibel; LF, low-frequency; HF, high-
frequency; RRtri, triangular index; SD, standard deviation; TINN, geometrical parameter of HRV; RMSSD, oot Mean Square of the Successive Differences; RR, res­
piratory rate.

2LVpercentage and 2UVpercentage exclusively reflect vagal
modulation.
Another study conducted in 2014 focused on exploring the effect of
music with different intensities on HRV. Do Amaral et al. [27] included
28 healthy female college students in their study. All participants
received two types of music, Relaxant Baroque by Pachelbel “Canon” in
D Major and excitatory Heavy Metal by Gamma Ray “Heavy Metal
Universe” with 5 min of rest in between. The two styles were played with
three different equivalent sound levels 60–70, 70–80, and 80–90 dB, and
there was a controlled setting in which the volunteers sat in quiet with
no excitatory or relaxant stimulation. Heavy Metal music led to a
decrease in HRV SDNN index (p ¼ 0.01) at 80–90 dB compared with the
control condition. LF domain index was also decreased in its absolute
value at 60–70 dB compared with the control condition, while no
changes were noticed in nLF, HF and LF/HF ratio in the Heavy Metal
group. Baroque music only decreased LF in its absolute value at 60–70
dB.
Thirty-three healthy female volunteers were presented with two
categories of stimuli music-music and sea-wave music in Taiwan [28].
Each category comprised six excerpts, each for 60 s. Three out of six
excerpts of the music-music type included a 30s loud passage followed
by a 30s soft passage, and the other three were loud throughout. The six
mentioned excerpts were extracted from Heavy Metal songs. On the
other hand, for the sea-wave music stimuli type, four manipulated
conditions were created as follows: loud music plus loud music (Loud þ
loud), loud music plus soft music (Loud þ Soft), soft sea sounds plus loud
music (Soft þ Loud), and soft sea sounds plus soft music (Soft þ Soft).
The 12 conducted pieces were presented to the volunteers in random
order preceded by 4s of silence, a warning tone (440 Hz, 100 ms), and
another 1s of silence. Analyzing HRV by t-test revealed that the soft
passages induced higher HF compared to loud passages, whereas
one-way ANOVA did not suggest any significant difference. The shift
from the high-arousal passage to the low-arousal passage (stimulus
Loud þ Soft) led to a decrease in HR in the 30s. The opposite change
from the low-arousal passage to the high-arousal passage led to a
delayed increase of the heart rate at approximately 45s. The two way
ANOVAs for the HR was significant at every time points for all different
stimuli patterns. RR was expressed to be dependent on the arousal level.
However, no correlation analysis was done to investigate the effect of RR
on different HRV patterns.
Twenty-five healthy subjects volunteered to listen to three styles of
relaxing music, considered as relaxing due to their slow to medium
tempo, and a silence period randomly. In this study, Perez-Lloret et al.
[29] tried to address the different effects of relaxant music on cardiac
variables. The three pieces of music selected by the panel were as fol­
lows: Classical piece “The Blue Danube” by Johann Strauss II, New age
music “Only Time” by Enya, and Romantic music “El día que me quieras
(The day you will love me)” by Carlos Gardel, Antonio Le Pera and Luis
Miguel. Each subject was exposed sequentially to the three melodies or
silence in a random pattern. When participants were listening to the
“New Age” melodies, the HF component was significantly higher (p <
0.004) and LF/HF ratio was lower. Compared with the silence duration,
the LF/HF ratio showed an increase (31%) when the New-age music was
being played. In contrast, classical and romantic music decreased the
ratio by 19% and 14%, respectively. Among the nonlinear HRV pa­
rameters, SampEn referring to sample entropy was reduced by listening
to new age music (p < 0.05). Overall, the study showed no positive effect
of music on the HRV parameter.
Da Silva et al. [30] included 18 healthy subjects to explore the effects
of Heavy Metal versus Classical Baroque music, specifically on HRV
measurements. Heavy Metal and Classical Music pieces were randomly
being played, each for a 5-min duration following 10 min of baseline
rest, for every candidate. A significant reduction was observed at the
SDNN when the excitatory Heavy Metal music was played compared to
the control condition (p ¼ 0.023). However, at the RMSSD and PNN50
indices, there were no significant changes for any music styles. Besides,
frequency domain analysis revealed a substantial decrease in the LF
level at both music stimulations compared to the control setting (p ¼
0.01 for Heavy Metal and p ¼ 0.048 for Classical Baroque music). In
addition to LF, the LF/HF ratio revealed a decreasing pattern for the
Classical Baroque Melody (p ¼ 0.019). It is noteworthy that the HF
component showed a reduction pattern in response to the Heavy Metal
stimulation (p ¼ 0.01). It is concluded that acute exposure to excitatory
Heavy Metal music affects both the sympathetic and parasympathetic
components of HRV, whereas Classical Baroque music merely regulates
the sympathetic component of the heart.
Roque et al. [12] assigned 40 healthy women to receive either music
intervention alone or music with additional white noise. The subjects
received both Heavy Metal and Classical Baroque music each for 5 min
after 10 min of rest in a random sequence. To investigate the influence of
the variation in the equivalent sound levels on HRV, the experimental
group was also exposed to white noise auditory stimulation (90 dB).
Although the SD1 index and TINN, which are described as the baseline
width of the RR interval histogram, followed decreasing patterns, the

5
 Table 3
Summary of included papers.
Result þ effect þ effect þ effect þ effect þ effect Not þ effect Neg Not þ effect þ effect þ effect þ effect þ effect þ effect þ effect Not þ effect
of significant effect of significant significant
classical heavy
H. Mojtabavi et al.

metal

Variables HRV,HR HRV HRV HRV HRV HRV HRV HRV HRV HRV, blood HRV HRV BP HRV, HR, BP HRV, HRV HRV HRV HRV
volume HR, BP
pulse
Music jazz, heavy heavy not 3 different heavy heavy classical Chinese, not Bandari’s slow classical, preferred preferred not preferred
selection classical, metal metal specified classical metal metal Japanese, specified Sunny Bay fast classical, music music specified music
self- vs. vs. music vs. vs. Taiwanese, compact dodecaphonic,
selected classical classical classical classical Czech and disc techno, rap,
and white English and raga
noise music
Duration 20 30 5 Missing 6 piece 10 10 10 30 20 15 2 20 15 6 1
per data length
session
Sessions 1 12 2 1 1 1 1 1 1 1 1 1 1 1 4 1 6 1
No.
Chronology short 4 weeks short short short short term short short short term short term short short term short term short 4 days short short term short
term term term term term term term term term term
design 1. single 2 tailed 2 tailed 2 tailed 2 tailed single single 2 tailed 2 tailed 2 tailed RCT single four 2 tailed PPIS 2 tailed 2. single single single single
Healthy group PPIS PPIS PPIS PPIS group group PPIS PPIS group armed PPIS Healthy group group group group
PPIS PPIS PPIS PPIS PPIS exercise PPIS RCT PPIS PPIS
Sample size 94 64 22 28 33 25 18 40 12 34 20 114 24 64 induced 26 30 12 12
No. [9] [25] [26] [27] [28] [29] [30] [12] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40]

Result þ effect Not significant þ effect þ effect þ effect þ effect þ effect þ effect þ effect on þ effect þ effect
HF and LF

6
Variables HRV HRV HRV HRV HRV, HR, BP HRV HR HRV HR HRV HRV HRV HRV
Music Boccherini (Minuet), Grieg (The like music (LM), Traumerei of soft music sedative Tibetan preferred soft Soothing
selection morning), Tchaikovsky entrained Kinderszenen music music music music
(Pathetic—1stmovement), and improvisation, piano pieces by
Mussorgsky (Night on bald disliked music, and Robert Schumann
mountain) white noise
Duration piece length piece length 30 45 during the during the 30 30 25 30 10
per procedure procedure
session
Sessions No. 1 1 3 12 1 1 1 1 2 1 1
Chronology short term short term 3 12 4. Dental short term short term 5. Cardiac short short short term short short
months weeks procedure Catheterization term term term term
design 3. four armed PPIS 2 tailed PPIS 2 tailed 2 tailed PPIS PPIS RCT 7. 2 tailed 2 tailed 2 tailed 3 armed
Neuropsychiatric PPIS PPIS Surgical RCT PPIS PPIS RCT
Sample size 25 41 20 87 50 26 54 60 91 40 167
No. [41] [42] [43] [45] [46] [47] [48] [49] [50] [51] [52]

BP, blood pressure; HR, heart rate; HRV, heart rate variability; RCT, randomized clinical trial; PPIS, pre-post interventional study; NA, not applicable.
Complementary Therapies in Clinical Practice 39 (2020) 101162
H. Mojtabavi et al. Complementary Therapies in Clinical Practice 39 (2020) 101162

Table 4
Risk of bias assessment.
Random sequence Allocation Blinding of participants Blinding of outcome Incomplete Selective Additional Bias: Bias due to
generation (selection concealment and personnel assessment outcome data reporting problems not covered
bias) (selection bias) (performance bias) (detection bias) (attrition bias) (reporting bias) elsewhere in the table
Healthy
Lynar 2017 þ þ þ þ – – –
Gantt 2017 þ – – þ – – –
Vanderlei 2016 þ – þ þ – – –
Do 2016 þ þ þ þ – – –
Amaral
Cheng 2016 þ þ þ þ – – –
Perez- 2014 þ NA þ þ – – –
Lloret
Da silva 2014 þ NA þ þ – – –
Roque 2013 þ þ þ þ – – –
De Castro 2013 þ NA þ þ – – –
Lai 2012 – – – þ – – –
Wang 2010 þ NA þ þ – – –
Peng 2009 þ – þ þ – – –
Bernardi 2015 þ þ þ þ – – –
Lee 2017 þ – þ þ – – –
Exercise
Jia 2016 þ þ þ þ – – –
Archana 2016 – NA þ þ – – –
Wallert 2014 þ NA þ þ – – –
Urakawa 2005 þ þ þ þ – – –
Neuropsychiatry
Riganello 2015 þ þ þ þ – – –
O’Kelly 2013 þ NA þ þ – þ –
Raglio 2010 Full-text unavailable
Okada 2009 þ þ þ þ – – –
Dental procedures
Santana 2017 þ – þ þ – – –
Wang 2016 þ – þ þ – – –
Cardiac catheterization
Chang 2011 – – þ þ – – –
Surgery
Cotoia 2018 – – – – – – –
Hsu 2016 þ – þ þ – – –
Wang 2014 þ – ? – – – –
Lee 2011 – – þ þ – – –

NA, Not available.

data for these indices were not significant. Contrary to the previous
measurements, RRtri and SD2 showed significant reductions during
exposure to relaxing and Baroque music (p ¼ 0.03 and p ¼ 0.04,
respectively). The decrease of RRtri and SD2 resulted in global HRV
decrease.
In a unique study design, de Castro et al. [31] instructed 12 healthy
women to quickly stand up within 3 s after 10 min of being seated and
remain upright for 15 min at the control group. Subjects in the musical
intervention group had ten additional minutes before standing, in which
they were exposed to classical musical auditory stimulation “Pachel­
bel-Canon in D”. The results revealed no significant global HRV differ­
ences induced by music over the Postural Change Maneuver.
A randomized controlled cross-over trial held at the patients’ home
was conducted by Lai et al. [32]. They assigned 34 females from cancer
patients’ caregivers to their study. Diverse music pieces were played live
with Chinese violin (Erhu) including Japanese music (Prayer), Chinese
music (Spring Rural Field, Woman under the Moon), Taiwanese music
(Destiny, Whispering Hope), English music (Amazing Grace), and Czech
music (Going Home). In the music intervention with Nurse Presence,
subjects remained seated for a 30-min duration and were asked to
imagine themselves attending a concert. There was no verbal commu­
nication between the interventionist and the participant. This condition
was compared to the other intervention of listening to the recorded
music for a 30-min duration. All candidates received both interventions
on a random sequence with a one-week interval. HRV was monitored
through the procedure. Data revealed significant therapeutic effects
across different time points at both groups regarding blood volume pulse
(BVP) amplitude and LF/HF ratio (p < 0.001 and p ¼ 0.001
respectively). Moreover, BVP amplitude and arteriole tone waves
changed significantly at every time point of the intervention suggesting
a cumulative effect.
Twenty undergraduate and middle-aged adults were recruited in a
study to investigate the effect of music on HRV [33]. All the subjects
received 20 min of non-specified music after a 10-min rest followed by
another 10-min duration making a total of 40 min monitoring. Data was
suggestive of increased HRV measures post-musical intervention.
To compare the effects of soft music with oil inhalation on cardiac
autonomic balance, Peng et al. [34] carried out a study on 114 healthy
undergraduate students in Taiwan. Volunteers were randomly allocated
to four study groups [1], a music group [2], an aroma group [3], a
combined music and aroma group, and [4] a control group. The music,
preselected by the research panel, was Bandari’s (a new style band
popular in China and Taiwan) Sunny Bay compact disc (Jingo Records,
ISSN: JCD 02030). Each intervention had a 15-min duration, and the
variables of interest were measured before and after that intervention.
Both music/aroma application and control conditions led to a decrease
in SBP and DBP measurements while there were no significant differ­
ences among the groups. For the HRV parameters, no statistically sig­
nificant group differences were observed at the SDNN index. In contrast,
the percent changes in frequency domain indices, specifically normal­
ized LF, normalized HF, and ratio of LF/HF were significantly different
among the four groups (p ¼ 0.003, p ¼ 0.001 and p < 0.001 respec­
tively). Also, significant differences in the percentage change of
normalized LF and HF between the control group and music group were
revealed by post-hoc analysis. Lastly, no changes were observed at HR
values among the four study groups. In conclusion, listening to soft

7
H. Mojtabavi et al.
music may induce parasympathetic activity more than the resting con­
dition does.
Bernardi et al. [35] aimed to shed light on the effect of music stim­
ulation of different styles on cardiac indices among the mixed study
population of 1:1 professional musicians and non-musically trained
subjects. After 20 min of quiet rest, all 24 subjects were presented with
2-min periods of [1] slow classical [2], fast classical [3], dodecaphonic
[4], techno [5], rap, and [6] raga music in random order with no
intervening pause. In conclusion, faster tempi led to a significant in­
crease in variables of interest, HR and LF/HF ratio, of both populations.
Contrary to the fast tempi music, raga induced a significant reduction in
HR at any level of each group (p < 0.001). It is worth mentioning that
there was no significant difference between two groups (professional
musicians and naïve population) for all variables of interest.
In a study conducted in 2015 [36], 64 students received a range of
computer-based stressful tasks for 20-min. Afterward, 33 of them were
scheduled to rest when their preferred music was being played. The
others rested in silence for the same 20-min period. Results support that
music had a significant impact on post-stress HR (p < 0.001), SDNN (p
¼ 0.003), nLF (p < 0 0.001), and nHF (p ¼ 0.010).
3.4.1.1. Comment. Fourteen studies were included in the category of
the healthy population. All were pre-post interventional studies except
for Lai et al. [32], who designed an RCT. 592 healthy participants were
included. All the investigations led to the significant impact of music
intervention on HRV parameters except for the study [31] that included
a small sample size of only 12 subjects.
3.4.2. Post-exercise healthy candidates
To compare the effect of music and exercise on the cardiac para­
sympathetic system, Jia et al. [37] designed a study among 26 healthy
graduate students. On four separate days, participants were asked to
attend a sedentary session, music session, cycling session or combined
music and cycling session. The session’s order was randomized among
the participants and they were asked to bring the selection of their
preferred music. The ANS function was evaluated before and after each
session by measuring HRV. The HR showed a significant decline in the
music sessions (p < 0.01) with an increase in HF in the same courses (p
< 0.01).
A total of 30 healthy volunteers aged between 20 and 25 years were
recruited in a study by Archana et al. [38]. Each participant was asked to
perform a moderate exercise on cycling ergometer without music and
then another 15 min with preferred music. The rest between the two
activities was 30 min. ECG-based HRV analysis showed that music could
minimize the exercise-induced increase in both HF and LF components.
However, only the changes at high-frequency values were statistically
significant (p ¼ 0.0000 for each variable).
Targeting HRV as a representative of cardiac autonomic activity,
Wallert et al. [39] tested whether decreasing or increasing the tempo of
a sound stimulus affects the ANS function following exercise. Twelve
frequently workout subjects were included in the study. They were
asked to join six sessions of cycling ergometer consisting of 6 min of
cycling, followed by 6 min of rest with music intervention. The tempo
was either increased, reaching gradually the double beat of the baseline
or decreased with a similar pattern. The HR analyses for sessions with
increasing and decreasing tempo suggested that HR was slower when
tempo dropped, though this difference was not statistically significant.
Also, HRV analysis was supportive of parasympathetic arousal in the
decreasing tempo sessions.
Observing 12 healthy students’ responses to music while doing
physical activity, Urakawa et al. [40] designed a two-day clinical trial.
On the first day, candidates were asked to rest without music or exercise
and rest without music for 15 min, respectively. Subjects were asked to
bring their preferred music tracks on a compact disc to day two. The
order was similar to the previous day, with music added to the resting
8
Complementary Therapies in Clinical Practice 39 (2020) 101162
parts. LF/HF ratio was significantly increased among the music inter­
vention sessions (p < 0.01).
3.4.2.1. Comment. The category of the post-exercise healthy population
consisted of four studies: three pre-post interventional studies and one
RCT. The survey by Wallert et al. [39] failed to show any effect of music
on HRV-related parameters following exercise, which might be due to a
concise duration of music sessions (<10 min). The other three studies
consistently pointed to the positive effect of MT.
3.4.3. Neuropsychiatric diseases
Sixteen healthy subjects and nine Vegetative State/Unresponsive
Wakefulness Syndrome (VS/UWS) patients listened passively to music.
Riganello et al. [41] selected the following four music types to be played
in a random sequence for the patients: Boccherini (Minuet), Grieg (The
morning), Tchaikovsky (Pathetic—1st movement), and Mussorgsky (Night
on bald mountain). The healthy group was exposed to all four music types
at one stand, while VS/UWS received the intervention in two sets to
avoid overstimulation. Results for normalized LF (nuLF) suggested a
significant difference when Grieg and Mussorgsky were being played (p
¼ 0.001 and p ¼ 0.000 respectively). However, SampEn was found to be
different only for Mussorgsky’s music (p ¼ 0.000). Additionally, among
musical stimuli in VS/UWS, nuLF, and SampEn parameters were sta­
tistically significant (p ¼ 0.009 and p ¼ 0.000 respectively).
O’Kelly et al. [42] evaluated the responses of patients (n ¼ 21)
diagnosed with vegetative (VS) or minimally conscious states (MCS) to
different auditory stimuli and compared that with those of healthy in­
dividuals (n ¼ 20). Both patients and healthy subjects completed a
sequential study of auditory stimuli. Baseline silence (5 min), liked
music (LM), entrained improvisation, disliked music, and white noise,
was administered to the study group, with a 2-min washout silence
between each stimulus. Types of music were defined based on the
comments of participants regarding the music. The music was consid­
ered as disliked if subjects made negative comments about it while the
music was considered as liked if participants made positive comments
regarding that. A peak appeared in the RR interval series, and to a lesser
extent, in HRV with LM for the healthy group. Due to the high level of
heterogeneity among patients, the authors did not report the group-level
data regarding changes in physiological parameters for the patient
group.
In a study conducted by Raglio et al. [43], 20 demented patients were
recruited from five nursing homes to explore the effect of music on
psychological symptoms and HRV. The experimental group received
three cycles of MT; each consisted of three 30-min sessions per week.
There was a one-month washout period between the cycles. Half of the
MT group showed increased pNN50 measurements while this happened
to none of the control participants (p ¼ 0.013). NN50 was first intro­
duced by Ewing et al. [44] as the “mean number of times per hour in
which the change in consecutive normal sinus (NN) intervals exceeds 50
ms”. pNN50 equals NN50 count divided to NN count.
Okada et al. [45] included 87 patients with underlying cerebrovas­
cular diseases who fulfilled the criteria for dementia in a nonrandomized
RCT. Music was administered by an authorized music therapist to the 55
participants in the MT group once per week for 45 min. Meanwhile, the
control group received no additional treatment. The MT group received
an average of 12 � 2.8 sessions overall. Though HRV showed a rising
pattern through the mid sessions and gradually falling to the pre-MT
levels, the differences were not significant.
3.4.3.1. Comment. In general, there were four pre-post intervention
studies that evaluated the effect of music therapy on HRV in patients
with neurological and psychiatric disorders. Three studies reported the
positive effect of music on cardiac autonomic responses in these pa­
tients. The authors of one study avoided reporting any result due to the
high-level heterogeneity among patients [42].
H. Mojtabavi et al.
3.4.4. Dental procedure
Santana et al. [46] applied “Traumerei of Kinderszenen” piano pieces
by Robert Schumann to 50 patients receiving dental root canal pro­
cedure. In this case-control study, the authors measured SBP, DBP, HR,
and HRV at four-time intervals: T1, 10 min before the procedure; T2, the
ten initial minutes after local anesthesia; T3, a total duration of end­
odontic treatment; and T4, 30 min after the endodontic intervention was
completed. Music played via earphones during the T2-4 phases of the
study. Significant increases in the following measurements were
observed in the music group at T3 compared with T1: RR (p ¼ 0.0014),
SDNN (p ¼ 0.0237), RMSSD (p ¼ 0.0240), SD1 (p ¼ 0.0310), and SD2 (p
¼ 0.0336). In contrast, HR (p ¼ 0.0066) and TINN (p ¼ 0.0320)
decreased in response to music.
In a study conducted by Wang et al. [47], 26 subjects who had dental
anxiety based on a modified dental anxiety scale (MDAS) received soft
music, including enhanced nature sounds, while ultrasonic scaling was
being performed or treated as routine. HR and HRV were assessed at
baseline, during the procedure, and three days post-treatment. Among
six features extracted from ECG that are known to be representative of
HRV, four elements were significantly influenced by music: LF/HF (p ¼
0.003), the means of the absolute values of the second differences of the
normalized RR intervals regarded as NmAVISD (p ¼ 0.002), means of the
first differences of RR intervals (p ¼ 0.035), and LF (p ¼ 0.025).
3.4.4.1. Comment. Only two studies investigated the effect of music on
the alleviation of dental anxiety. Both were RCTs, which consistently
noted the positive impact of listening to music during dental procedures.
More studies are needed to make recommendations for using music
during dental procedures.
3.4.5. Cardiac catheterization
Chang et al. [48] assessed physiological responses of 54 participants
to a piece of 30-min sedative music applied before the catheterization
procedure in comparison to resting. The outcomes of interest were HR
and HRV-related indices. The data were statistically significant in both
groups for HR (p < 0.001). HRV parameters were merely significant
among the intervention group (LF p ¼ 0.001 and LF/HF p ¼ 0.001).
3.4.5.1. Comment. The only study that evaluated the effect of music on
patients undergoing cardiac catheterization was an RCT. The authors
found no superior effect for MT in the domain of HRV.
3.4.6. Surgical patients
In a study by Cotoia et al. [49], the aim was to evaluate the effects of
listening to Tibetan music on anxiety, endocrine, autonomic, and
cognitive responses. Sixty patients awaiting urologic surgery were
randomly allocated to either music listening (n ¼ 30) or control group
(n ¼ 30). The musical intervention was listening to the Tibetan sound­
track for 30-min, from a frequency of zero to 1 kHz. HRV-related pa­
rameters, including normalized low (LFnu) and high frequencies (HFnu)
and LF/HF ratio, were analyzed at T0, T10, T20, T30, and T35. The
study showed significantly lower LFnu and higher HFnu at T10 to T30 in
people who received the musical intervention compared to the controls
(p < 0.001).
Hsu et al. [50] assessed the effects of listening to music on anxiety,
HRV, and joint range of motion (ROM). The study involved patients
undergoing continuous passive motion (CPM) therapy after total knee
replacement surgery. Ninety-one subjects scheduled for CPM session
were randomly allocated to experimental (n ¼ 49) and control groups (n
¼ 42). The musical intervention was administered over 25 min, starting
10 min before the rehabilitation, consisted of relaxing slow tempi, low
tone, and soft melodies. The music selection was based on patients’
preference and the genres included pop music (Chinese and Taiwanese),
classical music, and nature sounds. The study revealed no significant
differences in the four time-domain HRV parameters. Contrary to the
9
Complementary Therapies in Clinical Practice 39 (2020) 101162
time domains, frequency-domain endpoints (LF/HF ratio, nLF, and nHF)
showed significant changes between groups (p < 0.05).
Forty candidates were assessed in an RCT by Wang et al. [51]. The
aim was to evaluate the effects of music interventions on HRV and
postoperative anxiety among patients undergoing elective gynecological
or lower limb orthopedic surgery. The intervention group listened to soft
music in quiet surroundings for 30 min before the operation. Comparing
pre and post assessment, the intervention group showed a significant
decrease in the LF/HF ratio (p < 0.05) and an increase in the mean of HF
power (p < 0.01).
Lee et al. [52] aimed at comparing the effects of different methods of
music administration, i.e., headphones and broadcasting, with no music
control group. They assigned 167 patients awaiting surgery to the
mentioned three groups. Ten minutes of soothing music (folk or pop)
was applied to the interventional groups before the operation, while the
other group received no additional care. This study reported no
pretest-posttest comparison. Both HF and LF were shown to be signifi­
cantly different in the broadcasting group compared to the controls (p <
0.01 for both parameters).
3.4.6.1. Comment. Four studies were found that assessed the effect of
music in patients undergoing surgery. There were two RCTs and two pre-
post intervention studies with 358 participants. All studies applied
short-term music, however, of different styles and demonstrated its ef­
fect on the frequency domain parameters of HRV.
4. Discussion
Complementary and alternative medicine (CAM) deals with thera­
peutic and diagnostic approaches other than those provided with stan­
dard or conventional medicine [53]. CAM therapies consist of different
subclasses, e.g., energy medicine, whole medical systems, mind-body
medicine, biologically-based methods, and manipulative and
body-based methods [53]. Music and art are a type of mind-body
medicine that can help to improve the holistic health of the brain,
mind, and body. It offers a means of ‘Neurovisceral Integration’ [54]
meaning that music can act such that not only does affect ANS but also
be engaged with the central nervous system (CNS). As a result, MT is
suggested as an effective intervention for a wide range of medical con­
ditions because its effects can be potentially helpful to coordinate the
whole body. However, the primary target of music is the autonomic
branch of the nervous system, with results ranging from the evoked
responses and the emotional responses in the brain and mind [55] to the
psychoneuroimmunological impact [56].
As its name implies, HRV refers to the beat-to-beat variation. It is a
physiological phenomenon with clinical implications, which can be an
indicator of cardiac autonomic, behavioral and mental state (stress, fa­
tigue, sleepiness, arousal, and emotional strain or time pressure) and of
the body’s capacity for exercise. Indeed, they represent the state of
brain, mind, and body and thus, are eligible to be measured as an
outcome of the music [57,58].
To date, original studies have frequently investigated the effect of
music on HRV-related parameters under different conditions. The pre­
sent study was developed in a systematic manner to 1. Answer whether
and to what extent music therapy can promote HRV-related metrics, 2.
Identify the conditions in which people are most likely to benefit from
music, and 3. Determine which properties of the musical intervention
are the most important in the total effect of music on promoting HRV-
related parameters.
By reviewing more than 1300 subjects with 29 independent studies,
this manuscript is the most comprehensive systematic review of the
topic to date. To assess the outcomes within each subgroup efficiently,
we categorized studies according to the health condition of their
recruited participants, including healthy participants, post-exercise
healthy participants, candidates with neuropsychiatric diseases,
H. Mojtabavi et al.
candidates who underwent a dental procedure, people who underwent
cardiac catheterization, and people who underwent surgery. However,
few studies did not report a positive effect of music on HRV and related
parameters. Those studies included either a small sample size (number
< 50) [31,39,42] or used a concise duration of music administration (�
10 min). Interestingly, regardless of the study population, the majority
of studies provide the same picture that is a positive impact of music on
HRV-related parameters with a 0.05 level of significance.
Contrary to the authors’ assumption, the data supported no differ­
ence between various musical genres unless the tempo and rhythm were
matched. It is noteworthy that less than 1% of total studies had a pro­
fessional music therapist on their team and nearly none have indicated
the individualized therapy protocol. On the one hand, the majority of
studies had no thoughts on music selection leaving the patients with
their preferred soundtracks. On the other hand, studies using the same
music for every candidate failed to show similar effects in people due to
personal differences. In summary, studies published to-date regarding
the topic suffer from poor control of individual differences. Considering
the possibility that the same track can arouse different effects in in­
tensity and nature, at various timelines for a similar participant, the
current evidence is not conclusive enough to identify the most effective
audio stimulation.
HRV is a tool for analyzing the oscillations of the intervals between
successive heartbeats (RR intervals). The effects of music on HRV are not
consistent in literature [18], and different music styles seem to affect
HRV in different ways [20]. Clinical trials reveal significant increases in
HF variation among preoperative patients undergoing a music listening
intervention and in elderly patients with cerebral vascular disease and
dementia exposed to live MT sessions. A pilot study with female cancer
survivors replicated the pattern of decreased HR and increased vagally
mediated (VM)-HRV after 2 h of participating in MT [15]. Another
clinical trial led to the conclusion that MT causes stronger reductions of
vascular sympathetic tone in terminally ill patients [18]. It is not clear
yet to what extent particular types of music are different in affecting the
HRV and also about whether music should be individualized per patient
per disease [59].
More interesting is that even similar types of music promote the SNS
and PNS function differently, under various circumstances. The cardiac
ANS including both SNS and PNS plays a role in the regulation of HRV
[60]. The PNS can contribute to the generation of HRV at low, middle,
and high frequencies while the effects of SNS are confined to low and
middle frequencies. When the body is under stress, the SNS is activated
to elicit the body’s flight or fight response. Otherwise, activating the PNS
leads to a decrease in stress and anxiety. Many techniques have been
shown to activate the PNS, including massage therapy, meditation,
diaphragmatic breathing, and relaxation. As reviewed in the results,
preferred music may be able to further increase the SNS function during
exercise accompanied by an increase in the ratio LH/HF of HRV [40]. On
the other hand, there is evidence that a piece of favorite music seems to
activate the PNS and leads to a reduction of fatigue during low exercise
intensity while HRV-related parameters remained unchanged [61].
Breathing affects HRV, mainly the HF component that naturally oc­
curs in the heartbeat-to-heartbeat time interval. Breathing also de­
termines how much parasympathetic activity is mixed with sympathetic
measures and, therefore, how much noise is caused in parasympathetic
measures. Using training to minimize the effect of breathing on HRV is
still a debating topic [62]. None of the included studies considered the
issue of breathing while measuring the effect of MT on HRV. Therefore,
the current data concerning the effect of MT on HRV suffer from residual
confounding due to ignoring the potential impact of breathing on HRV.
To our knowledge, the present study is likely the most comprehen­
sive study designed in a systematic manner to address whether and to
what extent music therapy can affect cardiac autonomic function, but it
has its limitations. Despite that the initial aim of this study was to
conduct a meta-analysis, we were unable to perform a meta-analysis due
to a two-fold reason. The first was that there was significant
10
Complementary Therapies in Clinical Practice 39 (2020) 101162
heterogeneity across studies in terms of the study design and population
in addition to the different types of musical interventions. More clearly,
there were less than three observations within all subsets of studies that
should be similar in design, condition, and musical intervention. Ac­
cording to the meta-analysis guidelines, it is recommended to calculate
effect sizes when three or more observations are available while we
identified one or two RCTs about each category of studies. Twenty-nine
studies were included in the review, among which only five were RCT.
The remaining twenty-four studies were pre-post intervention studies
and effect sizes must be avoided for pre- and post-intervention research
studies.
5. Conclusion
A systematic review of 29 studies shows the effect of MT on HRV-
related metrics in the majority of studies (about 90% of included
studies). It is promising that both healthy and people suffering from
disease in different conditions can benefit from MT. However, our re­
view leads to the conclusion that with its all advantages, MT is still in its
infancy and recommending it as a treatment in clinical use requires
precise practical guidelines. Our review highlights the need for well-
controlled randomized clinical trials in different medical conditions.
In particular, further studies are required to investigate the effect of
individually composed MT compared to preexisting preferred or random
songs on HRV. Also, the exact therapeutic duration for each condition
still remains unknown. Considering the issue of breathing as a signifi­
cant confounding variable would be of great value as well.
Acknowledgment
We want to express our gratitude to the editor and anonymous re­
viewers for their efforts in assessing the manuscript.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ctcp.2020.101162.
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