Music to Alleviate Symptoms & Anxiety in Cancer Patients Receiving Radiation and/or Chemotherapy

The Louis Armstrong Center for Music and Medicine

Music to Alleviate Symptoms & Anxiety in Cancer Patients Receiving Radiation and/or Chemotherapy

Andrew Rossetti MMT, MT-BC September 7 2012

Disclosure Information • Nothing to Disclose

• Identifying, encouraging, and addressing opportunities to recruit and retain employees through a transparent, uniform and consistent process. • Identifying and addressing opportunities to cultivate a work environment where all hospital community members feel

respected, appreciated, and in turn are able to fully contribute to our mission.

Learning Objectives • Participants will gain an understanding of the causal relationship between anxiety, emotion and pain perception • Paticipants will recognize aspects of the use of music to modulate the perception of pain • Paticipants will be able to explain the impact that music therapy can provide on anxiety in newly diagnosed patients undergoing simulation for radiation therapy

Overview • Music Therapy to modulate oncology patients’ perception of pain severity • Overview of treatment symptomatology in cancer patients • Emotion, traumatic response, and anxiety’s role in pain perception • Music’s role in altering pain response through modulation of affect states and anxiety • Music Therapy program development in Radiation Oncology

Preamble “Patients with progressive medical illnesses, including those with cancer, experience numerous symptoms, impairments in physical and psychosocial functioning, and other problems that can undermine the quality of life.

For more than a decade, pain has been recognized as a major quality of life concern for the cancer population.”

“In epidemiologic surveys, relationships have been discerned between pain and various adverse phenomena, such a mood disturbance” Portenoy, R.K. Contemporary Diagnosis and Management of Pain in Oncologic and AIDS Patients 1997

Mechanisms of Sensory Based Pain Modulation • A variety of pain modulatory mechanisms exist in the nervous system, and these modulatory systems can be accessed through contextual and/or cognitive manipulation [1].

• Variables such as attentional state, emotional context, hypnotic suggestions, attitudes, expectations or changes in consciousness now have been shown to alter both pain perception and forebrain pain transmission in humans.

[2]

1. Fields HL. Pain modulation: expectation, opioid analgesia and virtual pain. Prog Brain Res 2000;122:245–253.

2. Villemure, C, Bushnell, M. Cognitive modulation of pain:how do attention and emotion influence pain processing? Pain 95 (2002) 195–199

Mechanisms of Sensory Based Pain Modulation (cont.)

• These techniques alter sensory and/or affective aspects of pain perception, and the associated modulation of pain-evoked neural activity occurring in limbic and/or sensory brain regions. [1] • Principal cognitive variables: attention and emotion 1. Villemure, C, Bushnell, M. Cognitive modulation of pain:how do attention and emotion influence pain processing? Pain 95 (2002) 195–199

Cognitive Variables • Attentional: Integration in music experience directionality through guided visualization with music. Less anxiety and pain when focused on physical sensations. [1] • Emotional: Modulation of mood state through metaphoric content in music and reduction of treatment related state anxiety.

1. Hadjistavropoulos HD, Hadjistavropoulos T, Quine A. Health anxiety moderates the effects of distraction versus attention to pain. Behav Res Ther 2000;38:425–438.

Mood State / Emotion • Emotion: a temporary state usually the result of some external event – present, remembered, or anticipated • A mental state that arises spontaneously rather than through conscious effort and is often accompanied by physiological changes; a feeling: the emotions of joy, sorrow, reverence, hate, and love. a conscious mental reaction (as anger or fear) subjectively experienced as strong feeling usually directed toward a specific object and typically accompanied by physiological and behavioral changes in the body (Merriam Webster 2011)

Emotion’s relation to Pain Perception • Psychological factors other than attention, such as mood and emotional state, also alter pain perception. Clinical studies show that emotional states and attitudes of patients have an effect on pain associated with chronic diseases [1, 2] • The effect of emotions on pain perception is generally recognized but the underlying mechanisms remain unclear, negative emotions produced robust increases in pain - pain-related emotions influence pain perception and pain-related physiological responses [3] 1.Haythornthwaite JA, Benrud-Larson LM. Psychological aspects of neuro- pathic pain. Clin J Pain 2000;16:S101–S105.

2. Schanberg LE, Sandstrom MJ, Starr K, Gil KM, Lefebvre JC, Keefe FJ, Affleck G, Tennen H. The relationship of daily mood and stressful events to symptoms in juvenile rheumatic disease. Arthritis Care Res 2000;13:33–41.

3. Pierre Rainville, P., Viet Huynh Bao, Q., Chrétien, P., Pain-related emotions modulate experimental pain perception and autonomic responses. Pain (2005) Volume: 118, Issue: 3, Publisher: Elsevier,

Emotion’s relation to Pain Perception (cont.)

• The multiplicity of mechanisms underlying the emotional modulation of pain is reflective of the strong interrelations between pain and emotions, and emphasizes the powerful effects that emotions can have on pain. [1] • It is thought that anxiety states are caused by activation of the sympathetic nervous system, potentiated by adrenaline and noradrenaline from the adrenal medulla, stimulated by the hypothalamus. This is similar to the mechanisms that produce pain Thus, anxiety may have a role in potentiating pain by enhancing physical symptoms. [2] 1. Roy, M.,Piché, M., Chen, J., Peretz, I,. Rainville, P. Cerebral and spinal modulation of pain by emotions Retrieved http://www.pnas.org/content/early/2009/11/18/0904706106 2. O’Leary, U., Psychosocial influences on pain perceptions in cancer 22 October, 2002 VOL: 98, ISSUE: 43, PAGE NO: 36 retrieved from http://www.nursingtimes.net/nursing-practice-clinicalresearch/psychosocial-influences-on-pain-perceptions-in-cancer/205904.article

Emotion’s relation to Pain Perception (cont.)

• Pain is defined as a sensory and affective experience.

• “Pain affect” encompasses the negative emotions brought about by the cognitive processes underlying the elaboration of meaning and the evaluation of the significance and future implications of pain.

• Catastrophizing and fear of pain have been shown to contribute to pain severity, distress, and disability.

Pierre Rainville, P., Viet Huynh Bao, Q., Chrétien, P., Pain-related emotions modulate experimental pain perception and autonomic responses. Pain (2005) Volume: 118, Issue: 3, Publisher: Elsevier,

Emotion’s relation to Pain Perception (cont.)

• Perception of pain intensity has been shown to be directly modulated by anxiety through strong reciprocal connections between amygdala and entorhinal cortex

Ploghaus A, Narain C, Beckmann CF, Clare S, Bantick S, Wise R, Matthews PM, Rawlins JN, Tracey I. Exacerbation of pain by anxiety is associated with activity in a hippocampal network. J Neurosci 2001;21:9896–9903.

Pitkanen A, Pikkarainen M, Nurminen N, Ylinen A. Reciprocal connec- tions between the amygdala and the hippocampal formation, perirhinal cortex, and postrhinal cortex in rat. A review. Ann NY Acad Sci 2000;911:369–391.

Affect Positive affect is associated with increased brain dopamine levels, notably in frontal cortical areas The concept that positive affect results in the release of dopamine and in turn influences cognitive functioning could well be extended to pain, since animal behavioral and neurophysio-logical studies provide considerable evidence for a role of forebrain dopaminergic systems in pain and analgesia Ashby FG, Isen AM, Turken AU. A neuropsychological theory of positive affect and its influence on cognition. Psychol Rev 1999;106:529–550.

Magnusson JE, Fisher K. The involvement of dopamine in nociception: the role of D(1) and D(2) receptors in the dorsolateral striatum. Brain Res 2000;855:260–266.

Oncology Units Served by the Music Therapy Department • • •

• •

St. Luke’s Roosevelt Hospital – Chemotherapy Suite Beth Israel Hospital – Inpatient oncology unit Pre/post surgery and palliative care

Phillips Ambulatory Care Center – Radiation Oncology Unit, Chemotherapy suite Comprehensive Cancer Care Center West Campus - Radiation Oncology Unit, Chemotherapy suite, Breast Cancer Unit

Radiation Therapy External Beam Radiation Brachytherapy (radioactive implants) The majority of patients receive a combination or sequence of treatments including: surgery, hormone therapy, immunotherapy, chemotherapy and radiation therapy Variant True Beam Cyclotron

Radiation Oncology • In the US, 2/3 of patients diagnosed with cancer receive radiation therapy [1]

•

Few therapeutic modalities in medicine cause more confusion, fear, and anxiety as does the use of radiation in the treatment of cancer” [2]

• The treatment of breast and head & neck cancer frequently includes radiation therapy, which, given its severe side effects, leads to a strongly significant decline in quality of life [3] • The literature shows that patients with head & neck cancer in particular suffer from high levels of anxiety. [4]

1. Benchmark Survey 2004 2. Weintraub 2001 3. Clover 2011 4. Weintraub 2001, Hamen 2008, Ledeboer 2003

Symptomatology related to Radiation Therapy

Depression Anxiety disorders Insomnia Situational trauma Feelings of Loss– physical, psychosocial, existential Psychosocial dysfunction Confusion / Disorientation Pain

Pain Perception • Pain is always subjective.

• Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience.

• Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain.

Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited

by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994 2011

Pain Experienced During Treatment for Cancer Joint pain from taxotere chemo therapy Post surgical, neuropathic, or nociceptive pain Changes in anatomy - tissue variation from radiation, resection, Cancer or Malignant Pain Needle sticks – trypanophobia may lead to a generalized fear of medical procedures and agliophobia (fear of pain). Can create a cycle of distress leading to increased levels of pain perception.

• Affects an estimated 10% of Americans recognized as a specific phobia in DSM IV 1994 characterized by feelings of panic and heightened sensitivity to painful stimulii, lead to and rise in RR HR and blood pressure, it may also be accompanied by sudden drops in blood pressure and heart rate • • • • •

Hamilton, James G. “Needle phobia: a neglected diagnosis.” Journal of Family Practice. August, 1995. June 28, 2008.

Acute Cancer Pain Syndromes •

Acute pain associated with diagnostic procedures Lumbar puncture, Venipuncture, Paracentesis (belly tap), Thoracentesis (chest tap)

• Acute Post-operative pain • Acute pain associated with chemotherapy infusion techniques Intervenous infusion pain (venous spasm, extravasation, phlebitis) Hepatic artery infusion pain, Headache caused by intrathecal chemotherapy • Acute pain associated with chemotherapy toxicity Mucositis, painful peripheral neuropathy, diffuse bone or muscle pain • Acute pain associated with radiation therapy Mucositis, radiation enteritis and protocolitis • Acute tumor-related pain

Music as Therapeutic Tool Music - a complex phenomena • Music perception involves acoustic analysis, auditory memory, auditory scene analysis, processing of interval relations, of musical syntax and semantics, and activation of (pre)motor representations of actions. Moreover, music perception potentially elicits emotions, thus giving rise to the modulation of emotional effector systems such as the subjective feeling system, the autonomic nervous system, the hormonal, and the immune system.

The Pros and Cons of Live Music? + Shift composition according to mood and preference of patient + Change tempo of music according to HR, RR of patiententrain + Ability to control volume, regulate dynamic shifts + Enhance a feeling of reciprocity otherwise unavailable. + Provide clinical conditions and on-going updates to medical team.

• + More expensive to implement a music therapy program-certified music therapist • + Generalizing Results: Difficult to quantify the effectiveness of individual music therapy treatment plan.

Basis for use on Music in Clinical Contexts • Five factors which contribute to the effects of music therapy. These modulating factors are: attention, emotion, cognition, behavior, and communication.

• Music can automatically capture attention integrating one in the experience • Music can modulate activity of all major limbic and paralimbic brain structures, that is, structures crucially involved in the initiation, generation, maintenance, termination, and modulation of emotions.

• Music is in essence an associative experience.

• Music can be employed as a situmulus to influence behavior • Music can be used to convey important information to patients

Clinical Properties of Music “Entrainment” – A physiological phenomenum of syncronization of diverse functions of the organism with the elements of music – rhythm, melodic contour, and anticipation/resolution Music is by nature metaphoric. Metaphors create images.

We “think” in words and images. Images can be created and directed through music, thus directing the person.

Music affects and modulates emotion. Emotions produce physiological changes in the organism.

Areas a Intervention with Music Therapy

• Simulation • Oncology Waiting Areas • Radiation Therapy Treatment Rooms • Chemotherapy Infusion Suite • Music Psychotherapy Pre/Post Radiation/Chemo • Procedural Support (hydration, venipunctures, blood draws)

Simulation and the Impact of Situational Trauma Simulation: The first intervention a patient experiences in radiation therapy, is physically un-painful. Yet, it is often described by patients as being one of the moments of greatest anxiety of their entire treatment trajectory.

Simulation and the Impact of Situational Trauma ( Cont.)

Important to look at past hospitalization and trauma (especially medical trauma) and the patients who fair well through traumatic experiences will fair better in treatment El trauma and its effects may influence a person’s capacity to heal and find/maintain homestatic states.

“Patients that acknowledge the emotional severity of a stressor fare better than those that deny it. Therefore, clearly labeling the treatment experience as emotionally traumatic can be therapeutic”

Peebles-Kleiger MJ. Pediatric and neonatal intensive care hospitalization as traumatic stressor: implications for intervention. PMID: 10842450 [PubMed - indexed for MEDLINE]

Placement of Positional Device

“Mask” in place

Associations

Trauma Theory 

EtimoIogy - "Trauma” from the Greek for "a wound” and, importantly for " ”



DSM IV-TR-2000 DEFINITION:



The person has been exposed to a traumatic event in which both of the following have been present:  experienced, witnessed, confronted with an event involving actual or threatened death or serious injury, threat to physical integrity of self or others.  response involved intense fear, helplessness, or horror.

Trauma Theory

ď ł Dyadic Regulation of Affective States The dyadic regulation of affective states through fluctuations in voice, gaze, rhythm, touch, and timing is a fundamental aspect of interpersonal interaction throughout the lifespan. [1] Trauma therapy in essence involves undoing the individual's aloneness in the face of overwhelming emotions.

The process of moment-to-moment mutual coordination and affect regulation is considered to be the fundamental mechanism by which attachment is established [2] 1. Fosha, D The Dyadic Regulation Of Affect Journal of Clinical Psychology/In Session, 2001, 57 (2) 2. Schore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Hillsdale, NJ: Lawrence Erlbaum.

Trauma Theory

• Overwhelming life experience Shock, Developmental, Mass trauma • Physiological and biological in nature • Can be stored as sense memory in the body • Continuity between neuro-physiological and psychological processing

Current Trauma Theory

 Polyvagal Theory 

Music has been used to calm, to enable feelings of safety, to build a sense of community and to reduce the social distance between people.



Music is intertwined with emotions, affect regulation, interpersonal social behavior, and other psychological processes related to personal responses to environmental, interpersonal, and intrapersonal challenges



Provides a strategy to understand the mechanisms and processes that enable music and music therapy to improve social engagement behaviors and to facilitate the regulation of bodily and behavioral states.

Stephen Porges

Polyvagal Theory (cont.)

• 

Differentiation of Reptilian / Mamalian Vagus - Vagal control of Autonomic Nervous System (Sympathetic / Parasympathetic) Hierarchal Response to stress -Social Engagement System (Homeostatic) – Defensive Fight or Flight Response – Overwhelm, Shut-down, “Freezing”

“Trauma can turn off the Social Engagement System. Attempts to engage a person with a trauma history, rather that eliciting spontaneous social behavior, may trigger defensive and aggressive behaviors. “ 

Music can be used to regulate vagal response

 Modulation of middle ear muscles (listening to specific frequencies)  Modulation of the laryngeal and pharyngeal muscles (singing)  Modulation of the facial and oral muscles supporting an embouchure Leading to pro-social behavior Stephen Porges Porges SW. The polyvagal theory: new insights into adaptive reactions of the autonomic nervous system. Cleve Clin J Med. 2009 Apr;76 Suppl 2:S86-90. Review.

PMID: 19376991 [PubMed - indexed for MEDLINE]

Polyvagal Theory (cont.)

•

Social Engagement System

•

Involves pathways that travel through cranial nerves (V, VII, IX, XI)

 Modulation of middle ear muscles  Modulation of the laryngeal and pharyngeal muscles  Modulation of the facial and oral muscles supporting an embouchure

“Music triggers neural mechanisms that regulate the entire Social Engagement System with the resultant changes in facial affect and autonomic state. “ Leading to avoidance of fight/flight response, promotes feelings of safety, and facilitates spontaneous social behavior Stephen Porges Porges SW. The Polyvagal Theory: phylogenetic contributions to social behavior.

Physiol Behav. 2003 Aug;79(3):503-13. Review.

PMID: 12954445 [PubMed - indexed for MEDLINE]

Music Psychotherapy Intervention Prior to Simulation • Assessment: Level of state anxiety, exisitance of previous trauma related to medical intervention, history of claustrophobic events, personality profile, reading of patients’ transference / countertransference, psychosocial history • Two part Intervention: 1.

2.

Relaxation – altered state induction with music – incorporation (body awareness) “to unite” psyche & soma. Psychoeducation on techniques for focus and comfort to be used during simulation Guided Visualization – Music/ verbal induction into a deeper trance state to enhance relaxation. Suggestion. Visualization may be used by patient during treatment.

Music Therapy Intervention During Simulation and Radiation Therapy • Pre-recorded prescribed music program • Music organizes time in such a way that the passage of time is perceived thus avoiding temporal distortion • Music therapy assessment: Determine patient’s “significant music”.

• Construction of prescribed music program based on patient’s “profile” and assessment of state anxiety following the parameters of a “music elements charactarization guide”

Music Psychotherapy • Individual sessions to address: • • • • •

Anxiety Pain managment techniques Process trauma Provide perspective on psychosocial concerns Enhance resillience

The Waiting Area • Distortion of temporal perception • Long waits, being ill, surrounded by others who are also ill : a petrie dish for anxiety Anxiety: a multi-systemic response to a perceived threat or stressor.The anticipation of impending danger and dread accompanied by restlessness, tension, rapid heartbeat, and rapid breathing that may or may not be associated with a certain event or situation. (Mosby´s Medical Dictionary 2011)

• May lead to the breakdown of the therapeutic relationship between patient and medical staff

Procedural Support

Environmental Music Therapy Definition • Environmental Music Therapy is the intentional use of live music and sound to modulate the soundscape of an area or space. • EMT has the capacity to transform an environment into one more conducive to healing and wellbeing by means of an interactive process between the person(s) actively providing EMT and those actively receiving it.

Environmental Music Therapy • Relationship of individuals in an environment is not passive, but transactional and integrative.

• Environments are perceived as an integrated experience: a time & space.

• A “whole” constructed of physical, cultural and social elements.

• Music used is incorporative of these elements and also merge emotional and aesthetic elements.

• Music is an evocative and directive means of communication, and through its metaphoric properties stimulates images.

• Stimulation of images is a means to referential ideation.

Mazer SE. Assessing and resolving hospital noise issues. Health Facil Manage. 2005;18:24-29.

Available at: http://www.healinghealth.com/d-resources/documents/Mazer_HearHear.pdf.

Accessed March 30, 2008.

EMT

• Designed to address “environmental sounds” perceived as noise [1] • Use of music by a trained music therapist who uses music to meld and soften the constantly occurring barrage of noise • Music therapist can “play with” as opposed to “play to” the environment [1] • Purposeful, Intentional • Modulate of staff’s, personal caregivers’, and patients’ perception in fragile environments • modulating external ambient stressors to form a non-noxious soundscape • provides a means for more positive mood states • Does not mask sounds but incorporates them 1. Stewart, K. & Schneider, S. (2000) Environmental Music Therapy. In Loewy J. V. (Ed) Music therapy in the NICU. NY, NY : Satchnote Armstrong Press.

EMT Construct

•Interactivity and correlation between stress, emotion, pain •Emotion affects the perception of pain (biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient’s physiological state, thoughts, emotions, behaviors, and sociocultural influences.) [1] •The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

1. Rodit, D., Robinson, ME., The role of psychological interventions in the management of patients with chronic pain Psychol Res Behav Manag. 2011; 4: 41–49.

EMT: Working Hypothesis

•

Stress affects the perception of pain

•

Music impacts and can modulate both emotion and stress and through this process can affect the perception of pain. [1]

•

Music powerfully stimulates socio-emotional processes, which, in turn, positively affect mood [1]

•

“The environment of care is so integrated into the human experience that it is inseparable from the effects of medication diagnoses, stress, anxiety, pain, and similarly, noise and music” [2] 1. Dileo, S. International Handbook of Occupational Therapy Interventions Springer, Jun 23, 2009, 2. Koelsch, S., Investigating emotion with music: An fMRI study Human Brain Mapping Volume 27, Issue 3, pages 239–250, March 2006

Experiential These are actual ambient sounds recorded on an treatment area. We invite you to focus on these sounds and perhaps imagine what it would like to be a patient in this treatment area, seriously ill and perhaps suffering through acute pain while hearing these sounds‌..

Research Projects • •

• • •

Effects of an Integrative Music Therapy Program on the Perception Noise in the SICU: A Patient, Caregiver, and Physician/Nurse Environmental Study n=120 Clinical Music Improvisation and Infusion Study at St Luke's Roosevelt. Music therapists are investigating the impact of clinical music improvisation on resiliency of patients receiving infusion therapy. n=75 The Impact of Music Therapy on State Anxiety in Cancer Patients Undergoing Simulation (Radiation Therapy) n=60 The Effect of EMT on Anxiety Levels and Perception of Waiting Time in the Radiation Oncology Waiting Room n= 80 The Effects of Music Therapy in the Recovery of Patients Undergoing Spine Surgery.

Music therapists are measuring the effects of live music applications in pain and recovery of SPINE patients. n=75 + Completed

+ EEG Sedation Study: Chloral Hydrate vs. Entrained Lullabies n=60 +

Heather-on Earth Multi-site Music Therapy Study: n=270 10 NICU’s (Heather on Earth)-TRAINING-International Summit-Remo

+ AIP (Asthma Initiative Program): n=200+/Clinic/3 schools-Bronx, Brooklyn, Lower East Side + Music for AIR (Advances in Respiration) n=200 Clinic, CCR, Nursing Homes

Music & Health Clinic Musicians and performing artists have specific medical and health needs related to the unique physical, mental and emotional demands of their profession.

Performance can be stifled by  Overuse injuries  Scar tissue from surgical procedures  Side effects from medication  Anxiety, chronic fatigue, focusing difficulties  Performers report a high incidence of depression and chemical dependency Interventions include:  Tonal intervallic synthesis  Vibration and  Clinical music improvisation  Music-assisted relaxation, guided visualization and stress management

Submit manuscript through the Music and Medicine online submission and review system at

http://mc.manuscriptcentral.com/mmd

MUSIC AND MEDICINE Editors Joanne V. Loewy, DA, LCAT, MT-BC The Louis Armstrong Center for Music and Medicine Beth Israel Medical Center, New York, NY, U.S.A. Ralph Spintge, MD Sportkrankenhaus Hellersen, Luedenscheid, Germany, and the University for Music and Drama HfMT, Hamburg, Germany Music and Medicine is a new international journal that offers an integrative forum for clinical practice & research of applied music in medical settings & allied institutions. Empirical research studies, clinical case reports, and applied models explicating theory and practice across the health, behavioral and neurosciences. Emphasis is placed on research practices that integrate music, music psychology, music cognition, music neurology, music therapy, and infant & early child development applied medical practice and knowledge. Research and clinical practices related to music psychotherapy and wellness practices is inclusive of the health of musicians Methodology favor quantitative and qualitative research outcomes.

Topics include: Analgesia and Music Sedation Cancer Care: Active and Receptive Music Approaches Cardiology and Rhythm Clinical Improvisation in Health and Disease Dementia, Stroke and Music Memory TO SUBMIT: Environmental ICU Music http://mc.manuscriptcentral.com/mmd Infant Stimulation Medical Conditions and Treatment of Musicians Mood Disorders and Music Psychology Music in Transition: NICU, Hospice to End of Life Music in Surgery: Pre-op to post-op Music in Traumatic Response and Injury Neurologic Music Approaches Pain and Palliative Medical Music Strategies Psychosocial Music Interventions Respiratory Music Advances: Asthma, CF, COPD

Contact Info & Training Andrew Rossetti MMT, MT-BC arossetti@chpnet.org Telephone: 1.212.420-2710 Mailing Address:

Beth Israel Medical Center Louis Armstrong Ctr Music & Medicine 6 Silver 21- 1st Ave & 16th St NY, NY 10003 Website: www.musicandmedicine.org We offer trainings for MDs, RNs and others. 2 day, weekly and monthly orientations and observations-hands on experiences.

To join: International Association for Music & Medicine www.iammonline.com