Annals vol5 iss 2 jun dec2016

ISSN 2395 - 1982

SRI BALAJI VIDYAPEETH ACADEMY OF HEALTH PROFESSIONS EDUCATION AND ACADEMIC DEVELOPMENT

ANNALS OF SBV VOLUME 5 - ISSUE 2 JULY - DEC 2016

THEME

YOGA AND MUSIC FOR SALUTOGENESIS

A Publication of

SRI BALAJI VIDYAPEETH

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Sri Balaji Vidyapeeth EDITORIAL CORRESPONDENCE TO MANAGING EDITOR ANNALS OF SBV

SRI BALAJI VIDYAPEETH

(DEEMED UNIVERSITY, ACCREDITED BY NAAC WITH 'A' GRADE) MAHATMA GANDHI MEDICAL COLLEGE & RESEARCH INSTITUTE CAMPUS PILLAIYARKUPAM, PUDUCHERY - 605 403 INDIA E.mail:annals@sbvu.ac.in | Phone : +91 413 2615449 to 58 | Fax : +91 413 2615457 Visit Annals of SBV Online at http://www.annals.sbvu.ac.in

INDEX Foreword - KR Sethuraman

4

From the Editor's desk of CYTER - Madanmohan

5

From the Editor's desk of CMTER - Sumathy Sundar

6

1. Enhancing Quality of Life in Cancer Survivors through Yoga

- Lee Majewski, Ananda Balayogi Bhavanani 7

2. Finding Peace on a Psychiatric Ward with Yoga: Report on a Pilot Anthropological Study in Pondicherry, India.

- Krzysztof Bierski, Ananda Balayogi Bhavanani, Eswaran S, Madanmohan

14

3. Stress and its management by Yoga - Madanmohan

20

4. Yoga for Palliative Care Nurses - Renuka K, Anbu M

23

5. Yoga Therapy: An Overview - Ananda Balayogi Bhavanani

28

6. Musicogenetics: A new specialty on horizon?

-Sumathy Sundar , Parin N Parmar

31

7. Music therapy: Bridging traditional healing system and modern science - Sumathy Sundar , Parin N Parmar

33

8. Music therapy and biomarkers of depression treatment - JörgFachner

37

9. Indian Classical Music : An objective sluice in the realms of Mind - Body Medicine - Vellore A.R.Srinivasan

42

10. Music therapy and anxiety in preoperative stress - Maria Montserrat Gimeno

47

Annals of SBV

FOREWORD SALUTOGENESIS, THE FOCUS OF MUSIC AND YOGA THERAPIES Mother Teresa had stated that “anti-war” posturing is not the same as “pro-peace” initiatives. Similarly, the WHO has clearly stated that “mere absence of disease is not Health”. With so much of stress on learning pathogenesis and pathology during their studies, the healthcare professionals are often unaware of the concept of Salutogenesis, which deals with promoting wellness.

Salutogenesis was first described by Aaron Antonovsky, a Medical Sociologist. He coined this term in 1968 to capture the concept of wellness, which he demonstrated among some of his subjects even under extremely adverse circumstances.

Medical science based on Pathogenesis looks at the following: causation of diseases; avoiding problems, such as disease and illness, which are abnormal states; reactive in nature with its focus on prevention and management of diseases; mitigation of pain and adverse squeal; works to keep the population alive.

Salutogenesis, on the other hand, looks at the following: what causes health and wellness; how to reach one's full potential for 'joy of Life' despite human-life that is inherently flawed and prone to illness and disease; be proactive to promote wellness for personal gain and growth; discover ways and means of living one's life fully, despite illness and disease.

Aaron Antonovsky showed that relatively unstressed people had much more resistance to illness than those who were highly stressed. Similarly, by de-stressing the individual, Yoga therapy and Music therapy operate through mind-body connections to promote wellness. Currently, research is ongoing to study the various epigenetic mechanisms initiated by these complementary and alternate therapies (CAM), which promote wellness and resistance to Life's adversities. Such evidence from cell biology could provide us the rationale for incorporate CAM along with modern medical management to create "optimal healing environment".

The twenty first Century will witness major evidence-informed adoption of integrative therapies that promote optimal healing and wellness.

– Prof KR Sethuraman, VC, SBVU.

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Ann. SBV, July-Dec 2016;5(2)

Annals of SBV

FROM THE EDITOR’S DESK OF CYTER ADVANCES IN YOGA HEALTH SCIENCES It is a matter of great satisfaction, a pride that Sri Balaji Vidyapeeth has embarked on a number of innovative courses in allied health sciences under the visionary patronage of our honorable Chairman, Shri M K Rajagoplan and inspiring encouragement of Chancellor, Prof. P Rajaram, Centre for Yoga Therapy Education and Research (CYTER) is a unique centre manned by qualified and dedicated staff and has undergone rapid expansion with the professional guidance of our VC, Prof. KR Sethuraman and Dean Research and Allied Health Sciences, Professor N Ananthakrishnan. Sri Balaji Vidyapeeth is the first university to introduce yoga in medical and nursing curricula.

Modern man is victim of everyday stress. Best lifestyle ever designated, holistic science yoga is the means to prevent as well as manage stress and stress disorders that are bane of modern society. Yogic attitude, yogic lifestyle and yogic practices strengthen our body and mind and develop positive health, enabling one to withstand stress by normalizing perception of stress, optimising reaction to it and effectively releasing pent-up stress through various yogic practices.

Scientific studies have shown that yoga has beneficial effects on our physiological functions and yoga has sound scientific basis. CYTER is actively involved in research and teaching in yoga in addition to providing yoga therapy to hospital patients.

CYTER conducts yoga therapy courses which are innovative since they are being offered by a modern medical university. Three batches of students have already completed Postgraduate Diploma in Yoga Therapy. We have also started certificate and M Phil courses based on credit based choice system (CBCS). We also conduct CMEs/ workshops on a regular basis. CYTER is the first university based yoga therapy center in India to become member of International Association of Yoga Therapeutists (USA).

With the support and guidance of our superiors, we will do our best to raise CYTER to higher levels of academic excellence and one such example is the five articles published in this journal, 'Annals of SBV' with the theme - 'Yoga and Music for Salutogenesis' Dr Madanmohan, Professor and Head, Department of Physiology and Director, Centre for Yoga Therapy, Education and Research (CYTER) Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkuppam, Puducherry-607403, INDIA

Ann. SBV, July-Dec 2016;5(2)

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Annals of SBV

FROM THE EDITOR’S DESK OF CMTER CAN INTERDISCIPLINARY COLLABORATIVE RESEARCH RESULT IN NEW UNDERSTANDINGS TOWARDS THERAPEUTIC EFFECTS OF MUSIC? In recent times, we have witnessed in SBV, a lot of interest in introducing music therapy as an innovative method into medical care with a focus towards salutogenesis in medical sciences. This is supported by a steady surge in empirical knowledge to understand the mechanisms underlying the therapeutic aspects of music. On one side, music neuroscience and music therapy fields have started to merge and integrate providing information on not only the therapeutic outcome but also to develop more effective music based clinical applications in medical care1.

There are also mounting evidences of the beneficial effects of music by Cochrane reviews in psychiatric disorders, autism, and in acquired brain injury. On the other side, music psychologists and cognitive neuroscientists have discovered the neural mechanisms related to music processing and the effects of music training on processes such as cognition, emotion, self-regulation, learning and neuroendocrine functions2. Psycho-neuro-endocrinoimmunological researches also have recorded the beneficial effects of music in treating stress related disorders and diseases.

Pharmacogenetic testing is an important advancement towards personalized medical treatments and similarly in this issue, one of the articles explores the possibility of applying the knowledge of genetics in personalized music therapy. Some of the interesting research questions that emerged are 1) Are there genes that predict a therapeutic response or failure to music therapy? If yes, 2) Are genes associated with music therapy response are the same or different from those associated with music traits? It remains to be seen how these questions would be answered. Though medical researches always focus on group interventions that are targeted to work the same way across a large group of patients, music therapists are always driven towards customizing the therapeutic approach3 and outcome oriented studies impacting the genes as ways of effecting the change due to music therapy orient towards a personalized music therapy approach. Further, current neuro-anthropological understandings of engaging in research with the idea of not considering the patients as objects of study but rather as human subjects taking into account the patient’s culture and including it in their therapeutic considerations and interpreting the research results with ethnographic insights and interdisciplinary dialogues with the other care givers and family members present new understandings on how musical experiences are therapeutic as objective research methods may indicate the positive change but not the humanistic processes4.

To conclude, to understand the therapeutic effects of music, novel methods integrating interdisciplinary ideas and collaborations with multi-disciplinary team comprising of music psychologists, health care professionals, anthropologists, neuroscientists and music therapists better inform the complex processes involved in comprehending the health benefits of music therapy services.

REFERENCES 1. Sarkamo T, Altenmuller E, Fornells AR, Peretz I. Editorial: Music, Brain, and Rehabilitation: Emerging therapeutic applications and potential neural mechanisms. Front.

Hum. Neurosci. 10:103. doi: 10.3389/fmhum.2016.00103 2. Hunt AM. Boundaries and potentials of traditional and alternative neuroscience research methods in music therapy research. Front. Hum. Neurosci. 9:342. doi:10.3389/ fmhum.2015.00342 3. Magee WL, Stewart L. The challenges and benefits of a genuine partnership between music therapy and neuroscience: a dialogue between scientist and therapist.

Front. Hum. Neurosci. 9:223. doi: 10.3389/fmhum.2015.00223 4. Vogl J, Heine AM, Steinhoff N, Weiss K, Tucek G. Neuroscientific and neuroanthropological perspectives in music therapy research and practice with patients with disorders of consciousness. Front. Neurosci. 9:273. Doi:10.3389/fnins.2015.00273

Dr Sumathy Sundar, Director Centre for Music Therapy Education and Research (CMTER), Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkuppam, Puducherry-607403, INDIA

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Ann. SBV, July-Dec 2016;5(2)

ENHANCING QUALITY OF LIFE IN CANCER SURVIVORS THROUGH YOGA Lee Majewski, Senior Yoga Therapist Kaivalyadhama Yoga Institute, Lonavla, Maharastra, INDIA. Email: litka24@gmail.com

Ananda Balayogi Bhavanani, Deputy Director, CYTER, Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, INDIA Email: yoga @mgmcri.ac.in

INTRODUCTION The media worldwide is reporting the rise of the cases of cancer and the 5-year global cancer prevalence was estimated to be 28.8 million in 2008 with half the burden in areas of very high human development comprising only one-sixth of the world’s population1.

Typically patients of cancer undergo extensive chemotherapy with or without surgery, followed often by radiation.2 After such intensive treatment schedules provided by modern medicine patients are physically exhausted2,3. Their bodies have been subjected to a wide array of chemical poisons, which indiscriminately attack all generative cells resulting in physical exhaustion. However, the toll on the physical body is only one side of the coin as many enter various degree of depression after completion of intensive treatments. 4 Long term chemotherapy results in chemotherapyinduced cognitive dysfunction or “chemo brain” that may be due to restriction in blood supply to the brain, manifesting as depression, mental confusion, inability to focus and loss of short-term memory2,5,6 .

Yoga is the original mind-body medicine and is regarded as being beneficial in various psychosomatic, stress related, lifestyle disorders7-11. The practice of yoga is therapeutically unique in that it conjointly emphasizes body, mind, and spirit, which may be particularly useful for enhancing patients’ social and spiritual well-being12. Some studies have reported the effectiveness of Yoga, meditation and mindfulness as a rehabilitative and palliative therapy in various types of cancer13-21.

Ann. SBV, July-Dec 2016;5(2)

Banerjee and colleagues studied effects of an integrated yoga program in modulating perceived stress levels, anxiety, as well as depression levels and radiation-induced DNA damage in 68 breast cancer patients undergoing radiotherapy. They concluded that an integrated approach of yoga intervention modulates the stress and DNA damage levels in breast cancer patients during radiotherapy. There was significant decrease in the HADS scores in the yoga intervention group, whereas the control group displayed an increase in these scores. Mean PSS was decreased in the yoga group, whereas the control group did not show any change. Post radiotherapy DNA damage was less in the yoga group when compared to the control group22.

Cancer survivors often report cognitive problems and it has been seen that decreases in physical activity over the course of cancer treatment contribute further to this loss. Cognitive function comprises intellectual processes, including perception, thinking, reasoning, and memory and studies examining the effects of yoga for patients with breast cancer often evaluate cognitive function before and after treatment12.

This recent review also concluded that yoga benefits women’s emotional functioning during and after breast cancer treatment, including decreases in anxiety and depression and enhanced cognitive functioning12. They noted that patients cite physical activity, breathing, meditation, and group support as particularly helpful components of yoga. Practitioners of Yoga vouch for its efficacy and relative safety in a multitude of conditions. Derry et al reported that at 3-month followup, yoga participants’ Breast Cancer Prevention Trial Cognitive Problems Scale scores were an average of 23% lower than wait list participants’ scores. These Page 7

Annals of SBV

group differences in cognitive complaints remained after controlling for psychological distress, fatigue, and sleep quality. Those who practiced yoga more frequently were found to report significantly fewer cognitive problems at 3-month follow-up than those who practiced less frequently. They concluded that yoga can effectively reduce breast cancer survivors’ cognitive complaints and suggested further research on mindbody and physical activity interventions for improving cancer-related cognitive problems23. Similarly notable cognitive improvements were reported by Vadiraja and colleges in their study that covered 6 weeks of daily yoga during radiotherapy treatment24. Another randomized controlled trial by Culos-Reed etal found similar trends, with cognitive disorganization and confusion decreasing in participants who participated in a yoga program18. Another case series by Galantino and colleagues reported positive impact of yoga on various aspects of cognition during and after chemotherapy administration. They suggested that yoga as a mindbody intervention may stave off chemotherapy-related cognitive impact (CRCI) 25.

The physical benefits of Yoga are merely the “tip of the iceberg” while there are an immense amount of psychosomatic, psychic and spiritual benefits of it as an integrative therapy. If disease is viewed as a disassociation of the body-mind-spirit complex (duhkham), Yoga may be understood as a re-integrator of this complex, inducing a state of dynamic wellbeing, a state of health26.

With this in mind, we created a 3 week residential program for cancer patients to empower them in their journey, “back to health”. The curriculum was geared specifically for those who had undergone chemotherapy and/or radiation, and the program utilized the lifesciences of Yoga with a healthy dose of self-education to assist patients in their recovery from the devastation of cancer and its modern treatment. The first of these programs was held in 2013 at Kaivalyadhama Yoga Institute in Lonavla, India (www.kdham.com/cancer).

MODES OF REINTEGRATION The modes of reintegration used in this program were designed to specifically address the physical, mental and psychic (spiritual) needs of the participants post allopathic treatments. Many studies have reported the effectiveness of yogic techniques while technique of silent meditation and chanting may enhance natural, inherent body, mind and emotional healing processes9,12,14,15,17, 20.

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Everyone loves to be loved, valued and feel respected as an individual. This support from friends, family and society creates a positive sense of self esteem that enables one to heal oneself in a natural manner. Patients of cancer and survivors of breast cancer are no different and have identified social support as a crucial element for coping with illness and for achieving adequate QOL2729 . The presence of social support has been positively associated with promotion of survival in both early and late stages of disease30. Group yoga sessions create a sense of positive social support that in turn facilitates self healing through stress reduction and a feeling of being valued. This has been well brought out in a study by Vadiraja and colleagues that reported effects of a 6-week daily yoga program for 88 patients with Stage II or Stage III breast cancer undergoing adjuvant radiotherapy. The yoga group participants reported improved social support following intervention relative to controls31.

It has been previously noted that group Yoga classes provide patients with a community and a forum in which to share their experience12 and hence we consciously adopted primarily the group classes pattern to facilitate such social and interpersonal empowerment throughout the programme.

Daily schedule – Monday to Saturday 06:45-8:15

Yoga – asana/pranayama

08:30

Breakfast

10:00-11:30

Group Activity - Education

11:30-12:30

Yoga – Pranayama and Silent Meditation

12:30

Lunch

3:00-4:30

Therapeutic Group Activity

5:00-6:15

Yoga Nidra

06:30

Dinner Yoga – Chanting and silent meditation

08:15-9:00

1. Asana-pranayama-mudra-bandha: We used simple stretching asanas often modifying them to specific patients’ needs. These psychophysical practices of Yoga enable participants to get to “know their bodies” better and create a positive sense of oneness between breath and body movements. It has been suggested that Yoga may have a role in managing psychological stress and modulating circadian patterns of Ann. SBV, July-Dec 2016;5(2)

Enhancing Quality of Life in Cancer Survivors through Yoga

stress hormones in patients with breast cancer and Vadiraja et al reported marked decreases in anxiety and morning salivary cortisol in those receiving yoga instruction compared with controls31. It has been suggested that yoga practices could reduce pro-inflammatory cytokine and increase anti-inflammatory cytokine and this beneficial effect has been primarily attributed to reductions in the stress levels. 32, 33 A randomized controlled 3-month trial with 200 breast cancer survivors by KiecoltGlaser and colleagues studied the effects of yoga on lipopolysaccharide-stimulated production of pro inflammatory cytokines interleukin-6 (IL-6), tumor necrosis factor alpha TNF-α, and interleukin-1β IL-1β, and scores on the Multidimensional Fatigue Symptom InventoryShort Form MFSI-SF, the vitality scale from the Medical Outcomes Study 36-item Short Form SF-36, and the Center for Epidemiological Studies-Depression (CES-D) scale34. They reported that Yoga practice substantially reduced fatigue and inflammation. Immediately post-treatment, vitality was higher in the yoga group compared with the control group. At 3 months post-treatment, the yoga group’s fatigue was lower, vitality was higher, and IL-6, TNF-α, and IL-1β were lower for yoga participants compared with controls. More frequent practice produced greater benefits in fatigue, vitality, and inflammation. Their findings are very important as cancer survivors have a greater risk for secondary cancers as well as several chronic diseases, including cardiovascular disease, diabetes, and osteoporosis compared to individuals without a cancer history. They suggested that by dampening or limiting fatigue and inflammation, the regular practice of Yoga could have substantial health benefits. This practical conscious body work may enhance a feeling of health through release of ‘feel good’ hormones and other chemical transmitters such as GABA while circulation is also improved throughout the body by such practices 35. Pranayamas used in our program were ujjayi, sitali, bhramari, nadi shuddhi as they all induce a sense of calm and serenity that enables healing. Kapalabhati was used in select participants to create a sense of energy to combat the feeling of depression. Basic introductory practice of bandhas with ashwini mudra and brahma mudra were also given to tone up the energy flows.

Ann. SBV, July-Dec 2016;5(2)

2. Chanting : Chanting is widely used in the Yoga tradition as it creates a sense of inner peace that is conducive to healing. When we chant, we are in the “now” and this induces empowerment as we begin to take charge of our thoughts, feelings and actions36. A novel study by Kalyani et al studied the hemodynamic correlates of ‘OM’ chanting and reported that it produced limbic deactivation37. They observed significant deactivation bilaterally during ‘OM’ chanting in comparison to the resting brain state in orbitofrontal, anterior cingulate, parahippocampalgyri thalami and hippocampi. In addition the right amygdala demonstrated significant deactivation.

We used healing mantras culled from different traditions. In the first week, the Ra Ma Da Sa from Kundalini Yoga tradition was used. It was noticed that, even those who do not usually like chanting, enjoyed the beautiful music and mantra intonations. In the second week we switched to chanting 108 rounds of the Maha Mrityunjaya (Om trayambakam) mantra as this is traditionally believed to reduce the fear of death and create a sense of life and living in the individual. In the third week we used 108 rounds of Omkara as the Pranava AUM has been documented to be useful in stress management and in creating an inner sense of relaxation manifesting as reduced heart rate and blood pressure38.

3. Education: The goal of educational component of the program was to inform patients of potential carcinogenic factors in their life and to change their mindset and attitudes from victimhood to self-empowerment. As the IAYT definition of Yoga therapy includes the empowerment of the individual, 39 we considered this a vital component of our program and every afternoon, patients spent 90 minutes learning about yogic values, environmental toxicity, diet and healthy lifestyle and impact of yoga on the body, emotions and thought process. Change must come from within, and this was the goal, to educe such a positive change in our participants.

4. Therapy: Throughout the program, patients had access to naturopathic and allopathic doctors for any consultations if needed. Yogic therapy was also available upon request and generally the participants were eager to discuss their issues with chosen specialists. In addition, towards the end of the program, they worked on creating personal mandalas to help them find a new sense and direction in life.

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Annals of SBV

CASE STUDIES In order to scientifically validate the program, we tested the following parameters on the first and last days of the program and also repeated them as follow up three months later. Given that a majority of patients end up depressed after completing modern anti-cancer therapy, we used standard tools such as WHO Quality of Life, Hospital Anxiety and Depression Score (HADS) and Profile of Mood States (POMS). These are standardized tools that enable us to document the state of mind, levels of anxiety and depression and understand the subjective feelings of our participants both before and after the program12, 15,16,18,19. Such tools are used regularly in both in-patient and out-patient scenarios to understand psychological affect of different treatment modalities and hence their application gives us a hard core scientific understanding of the subjective changes in our participants.

Case Study 1 The first of the above programs was run in April 2013 at Kaivalyadhama Yoga Institute in Lonavla, India and we present the case of participant A who is a Caucasian female, age 58 from Poland who is a soft-spoken schoolteacher by profession. She was diagnosed with colon cancer in June 2012 and after a hemicolectomy, had eight chemotherapy sessions (Folfox4), which ended in January 2013. She required no radiation therapy. She was on regular thyroxin medication after a previous strumectomy in July 2000.

In the pre-program case record, which we sent to participants before they arrive she noted the following side effects of her therapy: nausea, neuropathy, anemia, hot flashes, weakness, fatigue, chemobrain: struggle for right word, difficulty in focusing on one task and feeling mentally slower then before. She had difficulties sleeping and often she would suffer states of feelings, which she described as highly uncomfortable and agitated, based on unspecified pains in the body.

Although she described herself as having positive attitude, the Hospital Anxiety and Depression Score HADS indicated severe anxiety [15] and mild depression[8]. Her total HADS score was 23. The Profile of Mood States POMS had high values in tension [35], depression [24] and lesser in anger [13], fatigue (15) and confusion (16). Her total POMS score was 96.

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She was very quiet at the beginning of the program and when she spoke it was so quietly that we could hardly hear her. Face rather serious, it took about a week before the first smile came on her face. She had strong self-discipline and attended the program full heartedly.

The group found silent meditations and chanting very powerful. On a third day during meditation after chanting mantra for 30 min she, an avid atheist, shared her vivid vision of Christ and light entering through top of her head. She was shaken, moved to tears and deeply feeling the truth of the experience.

She asked for counseling session during which she became aware of her life long struggle. Her mother became pregnant at 45 and was crying through pregnancy fearing to be too old to bring her daughter up. Since her birth, our participant was trying to make as little trouble to her parents as possible. Denying her own truth since childhood for the sake of pleasing others seemed to be her life long struggle. She found this discovery to be very helpful and freeing, and after that she started to participate more openly in the group sessions and speak louder.

Her first incident of anxiety attack happened 6 days into the program. The group planned to go shopping to a city that is 2 hrs drive from here on a Sunday. On that day, she came to facilitator’s room at 5:30 in the morning – complaining about fainting with some strong discomfort in abdomen (where the cancer had been). She was shaking and it was apparent that she had a strong anxiety. We started with a long deep yogic breathing for 10 min, followed by nadi shuddhi for another 15 min. Then we chanted Omkar for quite a while. As we proceeded, her anxiety level decreased and her discomfort and fainting spells lost intensity. However – she was convinced that her state is purely physical.

The medical officer came and checked her BP and pulse and as they were normal he suggested that she attend class instead of being alone in her room to avoid it worsening. However she found it very difficult to believe that her reaction was purely psychosomatic.

She went to morning yoga and the rest of the day went relatively well. The group decided to postpone the shopping trip to the next week.

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Enhancing Quality of Life in Cancer Survivors through Yoga

The following Sunday (end of second week), facilitator met our participant early in the morning by the tea spot. She said that she had an anxiety attack again and that she didn’t sleep the whole night.

However, this time she didn’t seek help of facilitator.

Throughout the night she sat on her bed and used pranayama (nadi shuddhi, sitali) and chanted omkar and was able to manage her level of anxiety on her own. “And we are going shopping!!” she exclaimed with triumphant smile.

As the time went on, she was found more often in peaceful and even cheerful states of mind. By then the group had bonded strongly and she felt an integral part of it. The spark in her eye was igniting and she often reminded us of a little mischievous girl initiating fun in the group.

At the end of the program we repeated the tests and the psychological test results [TABLE-1] showed the following dramatic changes: TABLE -1 POMS Profile of Mood States Tension Depression Anger Vigour Fatigue Confusion TTL Mood Dist

D1 D20 3M 35 24 13 7 15 16 96

3 2 0 22 4 6 -7

4 5 2 23 5 5 -2

HADS Anxiety Depression

15 8

8 5

9 7

Total

23

13

16

Sub Normal 0-7 Mild 8-10 Moder 11-14 Severe 15-21 TTL 0-42

Post-program self-evaluation: 2 months later in telephone interview she said: “I no longer suffer nausea, anemia, fatigue and difficulty in focusing on one task and I don’t feel mentally slower then before anymore.

I have no anxiety attacks like before and my sleep is great. My colon is clean as a whistle! Looking back the main benefit of the program for me is twofold.

First – it empowered me, gave me self-confidence and belief in myself. It gave me tools to deal with my life and health. Second – it gave me focus and discipline of my daily program I follow, which makes me feel good and healthy.

Ann. SBV, July-Dec 2016;5(2)

Case Study 2 The second case we will consider is a 50-year-old female Indian entrepreneur, who came to us two months after finishing her last chemotherapy. Bladder cancer resulted in removal of one kidney and mouth of bladder followed by 12 sessions of chemotherapy and no radiation. Her physical state was fairly good but her mind was very erratic and she often seemed to have bouts of mild anxiety. She was certified yoga instructor and her yogic practices were performed very quickly and energetically perhaps reflecting her lack of inner peace and attitude of ‘go-n-getter’. Her breath was very erratic and very shallow and she constantly had a forced smile on her face as if to say “I am OK!”.

The first week we worked on slowing down her asana practices, deepening and slowing down her breathing patterns, which she found very difficult to follow. But by nature she was motivated and determined so at the end of first week she started to follow the instructions very well and her anxiety seemed to quiet down. With a lot of one-on-one attention her breath became much longer and deeper. By the beginning of second week she had a moment of crisis – the forced smile was gone from her face and she broke in tears admitting to a great fear of cancer coming back again…

It was wonderful to watch her during the third week when the smile on her face became more and more authentic, her yoga practices became centered and deliberate and her emotions stable and filled with inner peace. Her tests scores have confirmed this at the end of the three weeks (D20, see the table below). The follow up three months later TABLE-2 POMS Profile of Mood States Tension Depression Anger Vigour Fatigue Confusion TTL Mood Dist

D1 D20 3M 19 1 24 1 9 0 12 23 20 0 23 3 83 -18

3 1 0 26 0 7 -15

HADS Anxiety Depression

13 15

3 3

3 1

Sub Normal 0-7 Mild 8-10 Moder 11-14 Severe 15-21

Total

28

6

4

TTL 0-42 Page 11

Annals of SBV

showed no changes – the scores stayed low due to her maintaining disciplined yogic practices. The increase of energy after 3 months she attributed to finding her life purpose – educating cancer patients and spreading the Rejuvenation program to as many places as possible. See Table -2: Case Study 3 A 55-year-old French female, chartered accountant, arrived at Kaivalyadhama Yoga Institute, Rejuvenation for Cancer Patients program a year after finishing her treatments. Breast cancer was treated with mastectomy, 12 sessions of chemotherapy and 28 sessions of radiation and hormonal therapy. She reported mid range muscle and joint pain as a side effect of hormonal therapy.

She felt physically disabled comparing to her ability before cancer - she used to be very active physically with mountain hiking and jogging. She also started to do yoga about a year before being diagnosed with cancer. Additional challenge was created by language barrier – she didn’t speak English very well. During the program our interaction was limited to simple physical corrections because of difficulties in communication.

Overall she was a very conscientious and very motivated participant. We could observe easily her physical improvement and her mood Her initial POMS score showed fairly high level of tension, depression and anger (see table below). In initial interview during which we discuss the first test results, it became apparent that she was completely unaware of her emotional states. In POMS test there is a direct question about the level of “Anger” to which she gave 0 value.

During the first week she came for counseling session during which we discussed ways to work with her anger. At the beginning of second week she had an outburst of anger when the group was watching video about the healthy diet and lifestyle. It became apparent that she felt cheated by “life” – she did all the right things and yet she still had cancer!

In the last week of the program patients work with life mandala. It is a wonderful meditative exercise during which patients answer 16 core-value questions and map out the way to life they desire to have. She found this process very transformative during which she reported to have made many key decisions in her

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life. Her scores three months later show even more improvement perhaps confirming the value of her transformation[Table-3].

TABLE 3 POMS Profile of Mood States Tension Depression Anger Vigour Fatigue Confusion TTL Mood Dist HADS Anxiety Depression Total

D1 D20 3M

20 18 27 13 22 17 91

9 7 19 18 18 10 45

10 3 13 26 5 6 11

6 7

3 6

5 1

Sub Normal 0-7 Mild 8-10 Moder 11-14 Severe 15-21

13

9

6

TTL 0-42

CONCLUSION This is a small introduction to our program and through these three case studies we can see that yoga surely has beneficial effects for those recovering from the aftermath of anti-cancer therapies. Although not all the cases show such dramatic changes, in our opinion the biggest benefit of the program lies in the empowerment of the participants. They are given the yogic tools, which make them feel in control of their health and wellbeing. They arrive with long drawn faces, often with a lot of pain and suffering. In the 3 weeks of the program their faces slowly light up, the moods change and their outlook on life becomes optimistic. They leave as different people with new, health enhancing attitudes and often new values.

The advantage of such program is that in most cases it is very effective and with proper training of yoga teachers it can be conducted in any medical facility, which has an in-patients department. The program is completely transferable and adaptable to any setting providing the patients stay at the facility continuously for 3 weeks, have common space in which the group can perform group activities 4 – 6 hrs per day. It is our hope that soon such healing programs will be available at every facility dealing with cancer patients.

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Enhancing Quality of Life in Cancer Survivors through Yoga

REFERENCES

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

Bray F, Ren JS, Masuyer E, Ferlay J. Global estimates of cancer prevalence for 27 sites in the adult population in 2008. Int J Cancer 2013; 132: 1133-45.

The National Comprehensive Cancer Network NCCN. www.nccn.com/life-after-cancer. Accessed on 25.11.2016 Gina Shaw. Breast cancer survivors: life after the treatments end. www.webmd.com/breast-cancer/guide/life-after-breast-cancer-treatment. Accessed on 25.11.2016 Feuerstein M. Handbook of Cancer Survivorship. New York: Springer; 2007: 287.

Asher A. Cognitive dysfunction among cancer survivors. American Journal of Physical Medicine and Rehabilitation. 2011;90 suppl: S16.

Phillips KM, et al. Cognitive functioning after cancer treatment. Cancer 2012;118: 1925.

Funderburk J. Science Studies Yoga: A Review of Physiological Data. Honesdale, Pennsylvania, USA: Himalayan International Institute of Yoga Science & Philosophy; 1977.

Innes KE, Bourguignon C, Taylor AG. Risk indices associated with the insulin resistance syndrome, cardiovascular disease, and possible protection with yoga: a systematic review. J Am Board Fam Pract 2005;18: 491-519.

Khalsa SBS. Yoga as a therapeutic intervention: a bibliometric analysis of published research studies. Indian J Physiol Pharmacol 2004; 48: 269-85.

Yang K.A Review of yoga programs for four leading risk factors of chronic diseases. Evid Based Complement Alternat Med 2007; 4 : 487-91.

Sharma R, Gupta N, Bijlani RL. Effect of yoga based lifestyle intervention on subjective well-being. Indian J Physiol Pharmacol 2008; 52: 123-31.

Levine AS, Balk JL. Yoga and quality-of-life improvement in patients with breast cancer: A literature review. International Journal of Yoga Therapy 2012; 22: 95-99.

Bower JE, Woolery A, Sternlieb B, Garet D. Yoga for cancer patients and survivors. Cancer control 2005; 12: 165-71.

Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate DHEAS and melatonin in breast and prostate cancer outpatients. Psychoneuroendocrinology 2004; 29: 448-74.

Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med 2003; 65: 571-81.

Cohen L, Warneke C, Fouladi RT, Rodriguez MA, Chaoul-Reich A. Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma. Cancer 2004; 100 :2253-60.

Coker KH. Meditation and prostate cancer: integrating a mind/body intervention with traditional therapies. Semin Urol Oncol 1999; 17: 111-18.

Culos-Reed SN, Carlson LE, Daroux LM, Hately-Aldous S. A pilot study of yoga for breast cancer survivors: physical and psychological benefits. Psychooncology 2006; 15 :891-97.

Harder H, Parlour L, Jenkins V. Randomized controlled trials of yoga interventions for women with breast cancer: a systematic literature review. Support Care Cancer 2012; 20: 3055-64.

Wolsko PM, Eisenberg DM, Davis RB, Phillips RS. Use of mind-body medical therapies. J Gen Intern Med 2004 ; 19 : 43-50.

Zhang J, Yang KH, Tian JH, Wang CM. Effects of yoga on psychologic function and quality of life in women with breast cancer: a meta-analysis of randomized controlled trials. J Altern Complement Med 2012; 18 : 994-1002.

Banerjee B, Vadiraja HS, Ram A, et al. Effects of an integrated yoga program in modulating psychological stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherapy. Integr Cancer Ther 2007 Sep;63:242-50.

Derry HM, Jaremka LM, Bennett JM, et al. Yoga and self-reported cognitive problems in breast cancer survivors: a randomized controlled trial. Psychooncology 2015; 24 8:958-66 Vadiraja HS, Rao MR, Nagarathna R, et al. Effects of yoga program on quality of life and affect in early breast cancer patients undergoing adjuvant radiotherapy: a randomized controlled trial. Complement Ther Med 2009; 175-6:274-80 Galantino ML, Greene L, Daniels L, Dooley B, Muscatello L, O'Donnell L. Longitudinal impact of yoga on chemotherapy-related cognitive impairment and quality of life in women with early stage breast cancer: a case series. Explore NY 2012; 82:127-35.

Bhavanani AB. Are we practicing Yoga therapy or Yogopathy? Yoga Therapy Today 2011; 7 2: 26-28.

Al-Azri M, Al-Awisi H, Al-Moundhri M. Coping with a diagnosis of breast cancer-literature review and implications for developing countries. Breast J 2009; 156:615622.

Landmark BT, et al. Women with newly diagnosed breast cancer and their perceptions of needs in a health-care context. J Clin Nurs 2008;177B:192-200 Nosarti C, et al. Early psychological adjustment in breast cancer patients: a prospective study. J Psychosom Res 2002;536:1123-1130 Reynolds P, et al. Use of coping strategies and breast cancer survival: results from the Black/White Cancer Survival Study. Am J Epidemiol2000;15210:940-949 Vadiraja HS, et al. Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: a randomized controlled trial. Integr Cancer Ther 2009;81:37-46 Kiecolt-Glaser JK, et al. Stress, Inflammation, and Yoga Practice. Psychosomatic medicine 2010;722:113.

Rajbhoj PH, Shete SU, Verma A, Bhogal RS. Effect of Yoga Module on Pro-Inflammatory and Anti-Inflammatory Cytokines in Industrial Workers of Lonavla: A Randomized Controlled Trial. JCDR 2015;92:CC01-CC05.

Kiecolt-Glaser JK, et al. Yoga’s Impact on Inflammation, Mood, and Fatigue in Breast Cancer Survivors: A Randomized Controlled Trial. Journal of Clinical Oncology 2014;3210:1040-49.

Streeter CC, et al. Yoga asana sessions increase brain GABA levels: a pilot study. J Altern Complement Med 2007; 13: 419-26.

Bhavanani AB. Understanding the Yoga Darshan. Pondicherry: Dhivyananda Creations; 2011 Kalyani BG, et al. Neurohemodynamic correlates of “OM” chanting: A pilot functional magnetic resonance imaging study. International Journal of Yoga 2011;41:3-6 Bhavanani AB, Madanmohan, Sanjay Z, Vithiyalakshmi L. Immediate cardiovascular effects of pranava relaxation in patients of hypertension and diabetes. Biomedical Human Kinetics 2012; 4:66-69.

Taylor MJ. What is Yoga Therapy? An IAYT definition. Yoga Therapy in Practice 2007; 33: 3.

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FINDING PEACE ON A PSYCHIATRIC WARD WITH YOGA: REPORT ON A PILOT ANTHROPOLOGICAL STUDY IN PONDICHERRY, INDIA Krzysztof Bierski, Postdoctoral Fellow, Centre for Area Studies, FreieUniversitaet, Fabeckstrasse 23-25, 14195 Berlin, Germany.

Email: k.bierski@gmail.com

Ananda Balayogi Bhavanani, Deputy Director, Centre for Yoga Therapy, Education and Research Email: yoga@mgmcri.ac.in

Eswaran S, Professor and Head Department of Psychiatry, Email: psychiatry@mgmcri.ac.in

Madanmohan, Director, CYTER and Head, Department of Physiology, Email: drmadanmohan999@rediffmail.com Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, INDIA

ABSTRACT 

his article explores how patients and their families engage with yoga practice offeredat T a psychiatric ward of MGMC&RI in the Sri Balaji Vidyapeeth in Pondicherry, India. The material collected during participant observation-based research in form of detailed field notes, photography and video focused on patients’ experiences, hopes and limitations as well clinical staff’s expectations and opinions on providing yoga as a therapeutic activity.

Participants in the study found yoga to be a beneficial practice through which they could release tensions, relax and care for themselves. However, patients also felt that they would not be able to continue with their practice once discharged from the hospital. In addition to therapeutic interventions, then, there is a burning need to introduce yoga in patients as a long-term skilled practice. Yoga could be brought out of the psychiatric ward into the patients’ day-to-day lives by encouraging families to practice together. Furthermore, we suggest that using personalised videos could support patients in maintaining regular practice and to enhance adherence.

Key Words: Yoga, Psychiatry, Mental Health, Anthropology.

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Ann. SBV, July-Dec 2016;5(2)

Finding Peace on a Psychiatric ward with Yoga: Report on a pilot Anthropological Study in Pondicherry, India

INTRODUCTION Research on remedial applications of yoga in mental health problems has focused, among other issues, on exploring yoga’s efficacy in the treatment of depressive symptoms1,2 or improving cognitive functions among the elderly 3-4. Researchers have also investigated yoga’s therapeutic potential in functional disorders such as schizophrenia 5-6, cognitive functions in geriatric patients 7, treatment of children 8 or distress relief among victims of natural disasters 9-10.

While the existing research tends to focus on assessing the outcomes of yoga “interventions” in targeting particular conditions or symptoms, very little attention has been paid to the subjective perspectives of patients, their families as well as therapists and medical professionals involved in yoga training. Quantitative data might verify the effectiveness of yoga but it fails to account for how people engage with its practices and philosophy. Current research in the field can, thus, be enhanced by attending to personal motivations, meanings given to and struggles in personal practice as well as the particularities of the context in whichyoga is introduced. This current account makes an initial step in this direction by discussing a pilot research conducted at the Psychiatry departmentof MGMC&RI in Tamil Nadu, South India where inpatients have been introduced to yoga practices.

For a period of twenty-five days an exploratory participant observation was conducted with psychiatric patients and their families, yoga therapists, clinicians, nurses as well as postgraduate college students. Drawing on their subjective accounts, and in anticipation of the forthcoming period of the research, we discuss existing opportunities and limitations in introducing yoga to the local population in rural India. Concurrently, this report hopes to open up a discussion regarding the relevance of anthropological approaches in the field of yoga therapeutics and research and calls for a closer cooperation between specialists working in the field of psychiatry, yoga and anthropology.

METHODS AND THERAPEUTIC MODEL This research evaluated patient care in anticipation of extending the yoga training to rural health centres.

Patients in the study were informed about this goal and asked whether they are willing to share their accounts. Verbal informed consent was collected and no identifiable information is presented here.

Ann. SBV, July-Dec 2016;5(2)

The material collected during the pilot in form of detailed field notes, photography and video focused on patients’ experiences, hopes and limitations as well clinical staff’s expectations and opinions on providing yoga as a therapeutic activity on the ward. The pilot anticipated a more extensive anthropological research by contemplating feasible research questions and methodology that would be suited to the specificities of the context. The study was conducted as part of an inquiry into applications of yoga in mental health problems in a variety of settings including hospitals that offer yoga therapy as well as yoga ashrams and schools that run yoga therapy courses. The material collected in these locations is not discussed here but provided the necessary background for understanding the therapeutic uses of yoga in contemporary India on one hand and the scope of as well as challenges in psychiatric services in the country on the other.

Although yoga lessons are available to both patients and staff at the hospital through its Centre for Yoga Therapy, Education and Research (CYTER), it was proposed, bearing patients’ safety in mind that classes would also be provided directly at the psychiatry ward.

The treatment model was devised at CYTER under the guidance of the second author and introduced by the centre’s therapists alternatively in the female and the male ward. On most days, patients of both genders practiced alongside each other. Yoga sessions would last forty-five minutes during which patients practiced a number of techniques drawn from the Gitānanda Yoga tradition (www.icyer.com). These included, among others, kayakriya (moving of legs, arms, and neck combined with attentive breathing), jattis (loosening and shaking of body parts) or śavāsana(relaxing supine pose) lying on the hospital bed. Patients were also introduced to nasargamukabastrika, a practice that entails nasal inhalation and forceful exhalation through the mouth combined with dynamic movements of limbs all of which aims at a release of bodily and mental tensions. Participants also gave attention to their breathing by learning various pranayama techniques including relaxing chandranādī (left nostril breathing), bhrāmarī(bee-like humming exhalation with closed mouth) as well as PranavaA-U-M chanting in both sitting and supine positions. Vyagaragage (observing inhalation and exhalation) as well as mudra(actions) such as bhramamudrā(chanting A-U-I-M with head movements) were also taught.11-12 While each of the two therapists took a slightly different approach to sequencing the class, introducing particular techniques as per patients’ requirements and Page 15

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space availability, an upbeat and accepting approach was always required in building a trusting relationship with patients. By being kind and approachable, therapists encouraged patients to commit to their practice with confidence. Bearing this in mind, only minor postural corrections were given, for example, when participants would show little interest in the practice or low bodyparts awareness. Individual assistance was provided upon request.

FINDINGS Patients at the ward where this research took place suffered from a wide range of conditions ranging from schizophrenia and bipolar spectrum disorder to depression. Instead of focusing on these criteria we asked the patients to describe how they felt. They usually answered “nervous”, “stressed”, “uncertain about the future”, “overworked” or ‘”tired”. Understandably, the sessions would start slowly and sometimes patients needed a lot of encouraging standing up from their bed. As a practice would progress, smiles and laughs indicated that the patients found it enjoyable and worthwhile.Certain patients, but also relatives, would join only after some minutes or even on the next day having watched others practice first.A handful of patients, however, were not able to practice due to lethargy or inertia, which clinical staff interpreted as side effects of medication.

While female patients and family members would be less keen to engage in the more vigorous parts of the class, male participants found the dynamic āsana and kriya to be their favourite. A gendered difference was also noted in terms of attitudes towards relaxation techniques. Female patients, in general, enjoyed the repose more easily, whereas male patients pulled out of the experience quickly and, for example, found lying down with their eyes closed and stilling their body much more difficult than females. Even in relaxing poses, male patients would tighten their muscles, especially in their extremities. In spite of these difficulties, participants of the same gender encouraged each other and several staff members made positive remarks about bonding well as a sense of comradeship that yoga practice brought to the ward.

Throughout the research, participants reported that practicing yoga had brought them a sense of “joy”, “peace”, “satisfaction”, “relaxation”, “lightness” or “feeling of ease”. For many, becoming aware of their breath and movement was unfamiliar yet it appeared to free them, at least temporarily, from tensions and Page 16

worry. One young male patient called yoga sessions an “important social service” while patients who had practiced yoga in the past were happy to see it introduced in a hospital. Junior medical practitioners at the ward recounted that their patients spoke highly of the yoga classes.All in all, participants in this research reported that yoga provided a lively alternative to the otherwise mundane flow of life at the ward.

As a methodological experiment for future work, photographs and short films were taken during the practice. These were used in the ensuing discussions with patients to encourage them to reflect on their participation. Upon seeing himself in a film, a male patient in his thirties opened up about his experiences; he told of his life struggles and history of substance abuse but also about being reluctant to join the class. At first, he thought yoga was too energy consuming but, “by doing it”, he actually felt “calmed” and “relaxed”.

Notably, it was found that the patients whom we asked to reflect on their practice engaged with more vigour and enthusiasm during the following session. Film and video recordings, in particular, made participants realise that both yoga classes and the research project had their best interest in mind.

Participating in yoga classes also provided a space for thinking about some more fundamental live issues: “would yoga make me more outgoing?”, “can I improve my communication skills with yoga?”, “can yoga help me relax” were some of the questions patients asked the researcher. Subsequently, it emerged that in their day-to-day lives, participants rarely engaged in sports or unwinding practices. Furthermore, the patients who worked as farmers or labourers considered partaking in physically demanding or sporting activities as neither desirable nor feasible. While most patients chose to socialise as their preferred way for relaxing, some also attended either Hindu or Muslim shrines.

Notably, a number of male patients claimed to have recently stopped participating in religious activities.

When asked to explain his reasons for doing so, one participant, who also recently shifted from working in agriculture to driving, responded: “I felt that I could rely on myself more”. He then added that he enjoyed having a disposable income that his new employment generated. In similar vein, another male participant whose financial situation had also recently improved asserted: “I became stronger, so I did not need someone to tell me what to do anymore.”

Regardless of how patients approached matters of belief, from ambivalent to downright rejection, there Ann. SBV, July-Dec 2016;5(2)

Finding Peace on a Psychiatric ward with Yoga: Report on a pilot Anthropological Study in Pondicherry, India

were no explicitly negative attitudes towards yoga.

When asked whether he finds yoga to be compatible with Islam, one elderly Muslim patient claimed that on Friday evening he first went to a mosque and then a yoga class: “Prayer and yoga are the same”, he explained, pointing out that both are a form of “surrender to a higher force” and “both are (concerned with) Manidhaneyam”, the notion that is best translated as a sense of or platonic love for humanity. “Islam is asking (you) to do yoga, by doing yoga I care for myself, I become myself”, he continued.

In the context of the research, relatives would often motivate patients to participate in yoga.Some relatives refused to join explaining that only their sick relatives needed to practice. They were also keen to rest from their daily duties: an elderly female explained that since her daily job was farming, she preferred to rest and avoid exertion while taking care of her hospitalised son. In cases when relatives would pressurise a patient to join in, they were encouraged to practice together.

While family members often appeared shy to become involved, whenever they overcame their inhibitions they found joy and contentment in the class.

On several occasions during the research, consultants at the ward would ask therapists to suggest individual patients with techniques to alleviate some particular symptoms. Since there was a concern that patients might not be able to remember how to practice, we reached out to their families or fellow patients. A mother of a severely anxious female patient in her twenties was taught brahmaripranayama and encouraged to practice together with her daughter. Another female patient, also in her twenties, complained about insomnia. On a Saturday morning, she was introduced to some relaxing breathing techniques such as chandranadi. During a follow up after the weekend, the patient reported that her sleep only improved on Sunday night even though she practiced on Saturday only.

This incident clearly highlighted the need to pay more careful attention to how patients adhere to and evolve in their yoga practice. Clinical staff at the Department of Psychiatry shared this concern with practice continuity as they explained that patients often wanted a quick fix such as a tablet or an injection and, even though they rested during their hospital stay, they were also keen to return to their everyday lives.

Crucially, in the course of the pilot project only one patient said that, once discharged, he would be able to attend regular yoga classes provided free of cost at the hospital centre. Other patients saw the distance Ann. SBV, July-Dec 2016;5(2)

between the hospital and their places of residence, lack of funds or time, work and family obligations as preventative.

LOOKING AHEAD Patients hospitalised at the psychiatry clinic where this research took place experience considerable stress in their day-to-day lives and expressed concerns about their future. This is in response to work- or educationrelated pressures, family expectations as well as changes in employment especially moving away from sustenance agriculture towards wage labour or, in case of female patients, carrying a double burden of agricultural work and family care. For some patients, their decreasing interest in religious matters preceded their loss of hope. Furthermore, some saw personal income as a chance for both personal growth and family prosperity.

Participants, in general, enjoyed few opportunities to talk about their mental health problems to others as mental illness continues to remain a taboo subject.

Most patients come to the hospital as a last resort, when their ill-health had already advanced.

Following yoga classes, patients reported to be more “comfortable”, “relaxed” and “at ease”, feelings they experienced all too rarely. Even though some participants were initially reluctant to join, through practicing they could loosen up without getting fatigued. Arguably, participants found yoga practice useful because, through “doing it’” they developed awareness of self in the world, removed tensions through sequencing of movements and breath and found a sense of freedom as well as satisfaction in simplicity but also repetition of practice. Patients also appreciated that therapists were positive and accommodating and did not force them into practice. By spelling out what yoga meant to them during interviews, patients gained further motivation toparticipate. They were considerably more willing to discuss difficulties they experienced, both in their life and yoga practice, once they had realised that the therapists and the researcher had a genuine interest in their accounts.

Using stills and film as a feedback mechanism was particular useful in this as, rather than trying to meet the researcher’s expectations or patients’ subjective perceptions thereof, participants were able to focus on their own feelings and experiences. This speaks to the observation made across the extensive literature on illness accounts, namely, that control of narratives is crucial in recovery processes 13-16 or even a form of recovery in itself 17-18. Yoga practice, as the next Page 17

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stage of the research hopes to explore, might provide psychiatric patients with new ways of telling their stories: not only verbally but physically, mentally and communally too. In particular there is a great potential in employing visual methods to collaboratively generate personal accounts and stories of yoga practice and using personalised videos or online communication tools to support patients in maintaining regular practice 19-20 and to enhance adherence.

Stigma against mentally ill perpetuates a sense of vulnerability and social inadequacy 21 and, as such, prevents healing. This is also why mental health movements, organisations and campaigns around the world have focused on eradicating discriminatory and stigmatising attitudes22-23. One method of removing stigma is to engage a broad spectrum of social actors in the recovery. The role of family in this process cannot be overstated, especially in India where patients are admitted to psychiatric wards only with an accompanying relative. We found that families played a crucial role in encouraging patients to practice and suggest that yoga could be brought out of the psychiatric ward into the patients’ day-to-day lives by encouraging families to practice together. This would prevent relatives from putting pressure on the patient to recover faster, usually because engaging in care duties at the hospital leads to a loss of income.

Providing training to patients and relatives could give them a sense that the time spent at the hospital was useful. First, however, a number of perceptions needs overcoming such as that yoga is only for the patient, that it is physically demanding, that illness requires a “quick fix”, and that responsibility for healing rests on the shoulders of medical professionals.

While recording and publicly displaying patients’ accounts in the form of posters and leaflets but also films could be helpful in providing more accurate information about yoga and its aims, this research identified a need for a systematic model of yoga education for patients and their families. Nurses who maintain extensive contact with patients are in the position to effectively guide and support them during practice. The existing yoga training that nursing students receive as part of their undergraduate degree at the medical college where the research took place

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provides such important educational opportunities.

However, staff at the psychiatric clinic explained to require further training in yoga in order to bring a closer understanding between staff and patients.

YOGA AS A SKILL The pilot study presented here breaks with the tendency to employ multiple regression analysis to understand therapeutic value of yoga practice by offering what, in this field, is an innovative anthropological approach. As a conclusion, limitations of this study and an outline of the intended plans for the next phase of the research are discussed. One major drawback of this pilot was its relatively short time frame. More extensive interviews with the patients and clinical staff and longer period of participant observation, also in local villages, would provide a more comprehensive picture of mental health needs and practices in the population. Translation posed another concern and, in the future, interviews with patients will be conducted in Tamil only.

While the research revealed no particular issues with implementing the yoga module itself, it exposed a concern with how patients could benefit from yoga on a long-term basis. This aim could be achieved by brining yoga training, and with it, this research, out of the clinic and to patients’ everyday milieu. In their report on the scope of mental health problems in rural West Bengal, Chowdhury et al24 explained that the significant disparities in access to health care between urban and rural populations of India necessitate the development of localised mental health services. More than a decade later, their call pertains to the situation in the southern state of Tamil Nadu. The authors proposed “cultural epidemiology” as an opportune tool for understanding the conditions in which localised health care could be provided. This on-going research, meanwhile, draws on Ingold’s25 suggestion that cultural difference is, essentially, a variation of skills or adaptations to the broadly defined environment that includes social life (26). Presented with yoga as a skill, patients could develop proficiency within the realm of their own possibilities while approaching their wellbeing as an ontogenetic development27 or an ongoing process of self-transformation.

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Finding Peace on a Psychiatric ward with Yoga: Report on a pilot Anthropological Study in Pondicherry, India

REFERENCES 1. Gangadhar BN, Naveen GH, Rao MG, Thirthalli J, Varambally S. Positive antidepressant effects of generic yoga in depressive out-patients: A comparative study. Indian journal of psychiatry2013; 55(7): 369.

2. Naveen GH, Rao MG, VishalV,Thirthalli J, Varambally S,Gangadhar BN. Development and feasibility of yoga therapy module for out-patients with depression in India. Indian J Psychiatry 2013; 55 (Suppl 3):S350-56.

3. Hariprasad VR, Varambally S, Varambally PT, et al. Designing, validation and feasibility of a yoga-based intervention for elderly. Indian J Psychiatry2013 Jul;55 (Suppl 3):S344-49.

4. Hariprasad VR, Koparde V, Sivakumar PT, et al. Randomized clinical trial of yoga-based intervention in residents from elderly homes: Effects on cognitive function. Indian Journal of Psychiatry. 2013;55(Suppl 3): S357-S363.

5. Manjunath RB, Varambally S, Thirthalli J, Basavaraddi IV,Gangadhar BN. Efficacy of yoga as an add-on treatment for in-patients with functional psychotic disorder. Indian J Psychiatry2013; 55 (Suppl. 3): 374-78.

6. Bhargav H, Nagendra HR, Gangadhar BN, Nagarathna R. Frontal Hemodynamic Responses to High Frequency Yoga Breathing in Schizophrenia: A Functional Near-Infrared Spectroscopy Study. Frontiers in Psychiatry 2014; 5:29.

7. Umadevi P, Ramachandra S, Varambally S, Philip M, Gangadhar BN. Effect of yoga therapy on anxiety and depressive symptoms and quality-of-life among caregivers of in-patients with neurological disorders at a tertiary care center in India: A randomized controlled trial. Indian journal of psychiatry 2013; 55 (Suppl 3):S385-9 8. Uma K, Nagendra HR, NagarathnaR, Vaidehi S, Seethalakshmi R. The integrated approach of yoga: a therapeutic tool for mentally retarded children: a oneyear controlled study. J MentDefic Res 1989; 33 (Pt 5): 415-21.

9. Telles S, Naveen KV, Dash M. Yoga reduces symptoms of distress in tsunami survivors in the Andaman Islands. Evid Based Complement Alternat Med 2007;4:503-09.

10. TellesS, Singh N, Joshi M. Risk of posttraumatic stress disorder and depression in survivors of the floods in Bihar, India. Indian Journal of Medical Sciences2009; 63(8): 330-34.

11. Giri Swami G. Yoga: Step-by-step. Pondicherry, India: Satya Press;1976.

12. Bhavanani AB,Yoga Chikitsa: Application of Yoga as a therapy. Pondicherry, India: Dhivyananda Creations; 2013.

13. Kleinman A. The illness narratives: Suffering, healing and the human condition.New York: Basic Books; 1988.

14. CharmazK. Good Days, Bad Days: the Self in Chronic Illness and Time. Sociology of Health & Illness1992; 14(3):420-422.

15. FrankAW. The wounded storyteller: body, illness and ethics.Chicago& London: University of Chicago Press; 1995 16. SkultansV. Authority, Dialogue and Polyphony in Psychiatric Consultations: A Latvian Case Study. Transcultural Psychiatry 2004; 41(3): 337-359.

17. Rosen Sidney. My voice will go with you: the teaching tales of Milton H. Erickson.New York& London: Norton; 1982.

18. AntzeP, Michael L. Tense past: cultural essays in trauma and memory. Abingdon: Routledge; 1996.

19. Cheung C, Wyman JF, Savik K. Adherence to a yoga program in older women with knee osteoarthritis. Journal of Aging and Physical Activity 2016;24(2): 181-188.

20. Guo SH, Lee CW, Tsao CM, Hsing HC. A social media-based mindful yoga program for pregnant women in Taiwan. Studies in Health Technology and Informatics2016; 225:621.

21. Goffman E. Asylums. Harmondsworth: Penguin;1961 22. Crossley N. Contesting Psychiatry: Social movements in mental health. Abingdon: Routledge; 2006.

23. Bierski K. ‘Something We All Have’ – Mental health, activism and media in the United Kingdom. Special Issue Arts, Media and Cultural Mental Health.

World Cultural Psychiatry Research Review 2015; 10(3-4):138-148.

24. Chowdhury AN, Chakraborty AK, Weiss MG. Community mental health and concepts of mental illness in the Sundarban Delta of West Bengal, India.

Anthropology & Medicine 2001; 8(1):109–129.

25. Ingold T. The Perception of the Environment: Essays on Livelihood, Dwelling and Skill.Abingdon: Routledge; 2000.

26. Bierski K. Recovering mental health across outdoor places in Richmond, London: Tuning, skill and narrative. Health & Place 2016; 40: 137-144.

27. Ingold T. Prospect: death of a paradigm. In:Ingold T, Palsson G, editors.Biosocial becomings: integrating social and biological anthropology. Cambridge:Cambridge University Press;2013.

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STRESS AND ITS MANAGEMENT BY YOGA Madanmohan, Professor and Head, Department of Physiology and Director, Centre for Yoga Therapy, Education and Research Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India Email: drmadanmohan999@rediffmail.com

INTRODUCTION Stress is an emotionally disruptive and psychologically challenging condition that is mentally and physically demanding. Fast life, negative emotions and outer, material development without a parallel development of our inner, spiritual resources results in imbalanced personality that is easily stressed when faced with demands of daily life. When there is demand and our ability to meet the demand is inadequate, we feel stressed. Hans Selye defined stress as “Non-specific response of the body to a demand”. Stress challenges homeostasis and leads to tension, distress and increase in rate of wear and tear.

Stress is an unavoidable fact of life and all of us experience it. But why make it a way of life when yoga, the best lifestyle ever designed is the perfect answer to stress and stress disorders? A change can be positive (beneficial) or negative (harmful). Similarly, stress also can be beneficial or harmful. Yogic attitude helps us to transform harmful stress (distress) into beneficial stress (eustress). Eustress is beneficial and productive as it stimulates us and we feel energised with heightened awareness and concentration. When we manage stress, we feel better and relaxed, look better and can manage our work and relationships in a better way. A stress-free day leads to restful night and the result is psychosomatic health and happiness.

CAUSES OF STRESS: A YOGIC PERSPECTIVE The basic cause of mental stress is that “modern man” is out of balance due to materialistic lifestyle and lack of development of inner, spiritual resources.

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Setting reasonable goals and striving to achieve them is desirable; being over-ambitious is not. Inflated needs in face of limited resources results in frustration and stress. Rajasik mind is always in hyperdrive and restless mode. Rajasik mode of aggressive competition results in waste of energy, disturbed mind and mental stress.

Satvik lifestyle is key to prevent stress and promote holistic health.

Our body is a sensitive electrochemical complex that responds to our thoughts, emotions and actions. Lower, animal emotions like anger and fear are associated with limbic system (primitive brain). Higher, desirable emotions like compassion are a function of prefrontal brain which is highly evolved in humans. Negative emotions create stress, waste our time and energy and it is quite unwise to let them affect us. Yogeshwar Krishn says that “Lust, anger and greed are gates to hell and destruction and must, therefore, be eschewed” (Bhagavadgita, 16:21). Over-indulgence disturbs and weakens the mind making it easy for stressors to prey on it. From the yogic point of view, we should promote positive, desirable emotions and thoughts to counter negative ones (pratipaksh-bhavanam).

Home and job environment can be highly stressful.

Lack of love and affection, cruel husband, nagging wife, irresponsible parents and problematic children can be a source of much stress. Exposure to occupational hazards like chemicals, noise and heat, problematic co-workers and exploiting employer are common causes of jobrelated stress.

Hormonal changes have psychophysiological consequences and women are prone to stress due to such changes at the time of puberty, pregnancy and Ann. SBV, July-Dec 2016;5(2)

Stress and its management by Yoga

menopause. Chronic disease, pain, deformities, some psychiatric conditions and some drugs can produce mental stress, especially in the elderly. Caffeine, nicotine and diet pills stimulate nervous system and can produce mental stress. Hence, drugs should be taken only under expert medical guidance.

PSYCHOLOGICAL AND PHYSIOLOGICAL RESPONSE TO STRESS Effects of acute stress are adaptive changes for maintaining homeostasis. Stress affects the whole person -body, mind and behavior. Many psychological and physiological responses/adaptations enable one to deal with the stressful situation. They are called ”Fight or flight response” because they help an animal to fight or run away. The immediate physiological responses to acute stress are neuroendocrine changes for mobilizing forces that help in combating and overcoming the stressful situation. Stress response involves many parts of nervous system including prefrontal cortex, limbic system, hypothalamus, reticular formation as well as autonomic division of the nervous system. Pituitary-adrenal axis and adrenal medulla also play an important role in the stress response as a defence reaction. Stress also increases the secretion of antidiuretic hormone, thyroxine, glucagon and renin. These hormonal changes increase blood glucose and fatty acids which are important sources of energy. Increase in cardiac output and vascular tone raises blood pressure. Blood flow to muscles and heart increases while blood flow to abdominal viscera decreases. Muscle tone, body temperature and oxygen consumption increase. These physiological responses aim at supplying sufficient nutrients and oxygen to skeletal muscle, heart and brain and maintain homeostasis in face of the stress. Release of endogenous opoids results in stress analgesia. Stress increases arousal of cerebral cortex enabling a person to react more efficiently to the stressful event. These adaptive physiological responses help in dealing with the stressful situation and restoration of normalcy and homeostasis.

If the stress is severe/prolonged/repetitive and a person is unable to overcome it, undesirable consequences and health problems follow. Constant “red alert” taxes the neuro-endocrine system and physiological regulatory mechanisms disturbing homeostasis. The result is mental and physical sickness.

Stress can drive a person into unhealthy behaviors like abnormal eating behaviors, drinking, smoking Ann. SBV, July-Dec 2016;5(2)

and drug addiction. Excess cortisol secretion impairs immune mechanism resulting in poor defence against diseases like common infections, AIDS and cancer. A large proportion of patients seen in general practice have stress-related physical problems and majority of backaches and headaches are due to stress. Stress is the underlying, aggravating and/or precipitating cause of a number of diseases including psychiatric problems, insomnia, muscle pains, tension headache, backache, migraine, hypertension, ischemic heart disease, bronchial asthma, peptic ulcer, irritable bowel, impotency, menstrual disorders, rheumatoid arthritis and substance abuse.

YOGIC MANAGEMENT OF STRESS Stress can not be avoided. Hence, it needs to be properly managed. The best way to manage stress is to strengthen our psychosomatic health so that we can efficiently resolve and overcome the stress. Management of stress by drugs has a number of drawbacks. Drugs have undesirable side effects, weaken the patient and at the time of acute stress, a person is likely to overuse/ abuse the drug. In many cases, drugs do not work. And the question is: “Will today’s drugs be used tomorrow also”? Conventional psychotherapy and instrumental biofeedback are expensive, time consuming and not always effective. Fundamental cause of mental stress is loss of inner harmony and peace. Hence, holistic yoga is the best way to prevent as well as manage stress and stress disorders.

Yoga is a wonderful tool for calming the mind and promoting psychosomatic health. By improving physiological functions and mental health, it enhances our ability to face a stressful situation. Yogic techniques influence our body as well as mind. Yogic philosophy and practice inculcates discipline, moral- ethical values and faith in Higher Power and improves our psychosomatic health. Relaxation is the fundamental and distinguishing feature of yoga. When practiced with awareness and breath-body coordination, every technique of yoga induces inner peace and relaxation.

Shavasan, yoga nidra and meditation are special yogic techniques that have been proved to induce deep psychosomatic relaxation. They also increase energy level and improve thinking and decision making.

Relaxation training improves autonomic balance and is effective in treatment of hypertension. Satvik diet promotes satvik state of mind. It may also affect gut microbiome. Gut-brain and gut-microbiome-brain relationship is an exciting field of study.

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Slow stretch is an antidote for stress. Easy asans performed slowly and with breath-body coordination and meditative awareness are very effective in producing relaxation. Slow, rhythmic pranayams produce a significant decrease in oxygen consumption and promote psychosomatic relaxation. Through holistic combination of movement, breathing, stretch and meditative awareness, yoga encompasses several modalities that are capable of reducing the effects of stress.

CONCLUSION In conclusion, yoga is very effective in prevention as well as management of stress and stress disorders.

Living a yoga life results in strengthening and relaxing our body and mind, inner joy and resolution of mental stress. Yoga is a holistic science and one should adopt a judicious combination of simple asans, slow rhythmic pranayams and meditation.

SOME TIPS TO COPE WITH STRESS:

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Avoid stressors/stressful situations. If you cannot, be realistic and adjust.

Practice acceptance. Jnan yoga and belief in Higher Power develops a positive attitude and helps us let go.

Learn to relax. Rhythmic pranayam breathing and mini-shavasan can be done any time and anywhere. Meditation keeps the mind calm and alert.

Eat sensibly. Avoid over/under eating and junk food. Nutritionaly balanced and pure diet is called as satvik ahar that promotes healthy body and calm mind.

Be active in good deeds (satkarm). Then negative, stress-generating thoughts will not disturb your mind.

Have healthy hobbies. Gardening, music and social service are uplifting and relaxing hobbies.

Have your “Me time” when you will be only with the higher Divine Power and practice your daily yoga. That will make your mind and body strong, calm and relaxed that can easily face any stressful situation.

Get organised and avoid time urgency. Plan your work schedule well in advance and use your time and energy efficiently. Slow down a bit.

Talk to a supportive friend/relative. Healthy social engagements are good for mental health.

Watch your thoughts and habits and avoid substance abuse. Promote positive thoughts.

Laugh often and smile always. Smile relaxes facial muscles and sets a “feel good” chain reaction.

Adaptogens are healing herbs that improve physical and mental performance. Tulasi is a commonly cultivated anti- stress tonic.

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YOGA FOR PALLIATIVE CARE NURSES Renuka K, Dean, Nursing Faculty, Principal of KGNC, Anbu M, Lecturer, Dept. of Medical Surgical Nursing.

Kasturba Gandhi Nursing College - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India

ABSTRACT 

alliative care is an approach of specialized medical care for people with serious illnesses. It P focuses on caring patients with relief from the symptoms, pain, physical stress, and mental stress of a serious illness. The philosophy of palliative care nursing includes providing care to patients using medical science combined with compassion and caring. Palliative care Nursing is always associated with stress in both professional and personal levels.

Palliative care nurses are even more at risk of work stress as their role involves exposure to frequent deaths and family grieving. Palliative care nurses are frequently exposed to stressful situations related to death and dying.

Key Words: Burnout, Coping, Palliative care, Psychological stress

INTRODUCTION Palliative care is unique in its holistic approach to care. It involves treating not only pain and physical symptoms but also the psychological, social, and spiritual needs of patients. Given the characteristics of their profession, nursing staff are more heavily involved in the direct care of these patients, both in residential and hospital settings.1-3 When a patient dies in a hospital or residential center, the emotional burden that comes with exposure to death that had previously fallen primarily on families is now also assumed by health care staff.4 When one is exposed to such events repeatedly, the phenomenon generates stress, anxiety, depression, and emotional fatigue among nursing professionals and changes in personality variables.5-6. These stimuli may also trigger the burnout syndrome, which is defined as “a syndrome of emotional exhaustion, depersonalization, and reduced personal achievement that can develop in individuals who carry out activities oriented toward Ann. SBV, July-Dec 2016;5(2)

working with other people.”7 Burnout syndrome is associated with, increased risk of employee absenteeism and increased intention to quit their employment the syndrome results in reduced efficacy and efficiency among nursing staff in work-related settings.8,9 This can affect workplace environment by increasing levels of dissatisfaction and rates of absenteeism and low productivity, conflict between co-workers, and higher turnover rates.10 Wilkes and Beale13 conducted a qualitative study on Exploration of perceived stressors for urban and rural palliative care nurses working Australia. The study concluded that major stressors for both group of nurses were impact of family relationships and role conflict in the community. Furthermore the study also identified 24-hour service over great distances and lack of financial resources for rural nurses, were the additional stressors and urban nurses reported stressful situations arising when families had coping problems or personality issues, families with whom communication was Page 23

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difficult, families who were physically and emotionally distressed in caring for a family member at home, and where identification with the family or the patient was difficult.13 Grau-Arberola et al14 conducted a study to determine burnout levels among palliative nursing staff of a particular hospital at a particular time and conducted the same test 1 year later. The study revealed that a significant increase in emotional fatigue levels and depersonalization had occurred over time among the palliative care nursing staff. Working experience, communication process and environmental factors are contributing to the stress experienced by the palliative care nurses14 As palliative care nurses, are very good at taking care of others, often they fall short of taking care of themselves. Physical activity is a huge piece of self-care, not just for its physical benefits but for emotional and mental benefits, as well.11 The aim of this article is not removing the stress completely, because stress is part of the life, but response to stress can be in an unhealthy way, and the role of the nurse at this time is helping herself in health promotion strategies for reduction and management of the stress. These strategies include physiologic, behavioral, and experimental responses, which can result in a different outcome in physical and mental health15. Stress coping strategies are the efforts that individuals make to enhance their adaptation with the environment, and to prevent negative outcomes of overload.12 Various techniques are employed to control or lower stress, and to amend stress coping strategies and behavior16 . It is imperative for the palliative care nurses to manage the stress level for themselves to promote good professional and personal development.

The practice of Yoga has proved to revert back the nurses to a state of healthy state of body and mind and to prevent stress disorders17.

Yoga, has been studied and emphasized by scientists as a technique to relax the mental state and control stress through internal and external sources. These techniques are used as both preventive and recovery methods.18 Yoga is the most ancient action-discipline system known in the world whose exercises help people to cope with stress.

YOGA - A STRESS BUSTER FOR PALLIATIVE CARE NURSES. Yoga, developed thousands of years ago, is recognized as a form of mind-body exercises improve muscle Page 24

strength, flexibility, blood circulation and oxygen uptake as well as hormone function. In addition, the relaxation induced by meditation helps to stabilize the autonomic nervous system with a tendency towards parasympathetic dominance.

In a study in 2007 to investigate the effect of Tai Chi Yoga and meditation and promotion of nurses’ health and their problem-solving ability, it was revealed that Yoga promoted nurses’ health, their decisionmaking ability, and their concentration on giving care in critical conditions.19 Another study conducted on 17 nonprofessional caretakers showed that there was a noticeable increase in their stress coping strategies after 8 weeks of Yogic exercises.20 Since the main goal of nursing is to promote the level of public health, and as inappropriate responses and application of nonefficient coping strategies can jeopardize individuals’ health, taking actions toward promotion of stress coping strategies and reduction of stress side effects are considered among nurses’ duties.21 Yoga and meditation are part of a holistic approach to self-healing that brings about harmony between body, mind and soul and helps in relieving numerous aliments.

• Brings about harmony between body, mind and soul • Promotes the process of self-healing • Controls blood pressure • Slows down the process of aging • Relieves stress and anxiety • Improves functioning of the nervous system • Increases concentration and focus • Weight gain • Improves flexibility and posture • Boosts energy

YOGA STEPS FOR PALLIATIVE CARE NURSES Instead of reaching out for antidepressant pills, bring out yoga mat and try these poses when you feel low and depressed and see your mood perk up instantly.

Child Pose (Balasana) The child pose or balasana is undoubtedly the most relaxing yoga pose that helps in calming the mind and Ann. SBV, July-Dec 2016;5(2)

Yoga for Palliative Care Nurses

Down Dog (Adho Mukha Savasana) The down dog or the downward facing dog pose is an amazing stress-relieving yoga pose that helps in waking up the senses and reduces fatigue and tiredness. It helps

rejuvenating the body with energy. It is also an effective yoga pose for relieving lower back pain, hip strain and shoulder and neck stiffness. It has a healing and restorative power that helps in providing mental and emotional relief. Sit on the yoga mat kneeling while bringing your knees together and resting your buttocks on your feet. Now, slowly lower your torso over your thighs exhaling so that your forehead touches the mat and your hand rest on the floor. Hold the position for 30 seconds to 1 minutes breathing regularly and come back to the starting position. This makes one repetition. Repeat it 3 to 4 times. 22 Standing Forward Bend (Uttanasana) The standing forward bend is the ideal yoga pose to reduce stress. It helps in preserving proper functioning of the nervous system by improving blood supply throughout the body. It also helps in stretching and relaxing the spine and increasing flexibility. It tones the abdominal muscles and organs, and is the perfect yoga pose for weight loss. Stand with your feet closed and arms resting on the side. Raise your hand above your head while inhaling and bend your torso forward while exhaling. Touch the ground with both your hands, keeping your legs straight. Hold the pose for 30 seconds with normal breathing rhythm. Come back to the starting position. This makes 1 repetition. Repeat it 5 to 10 times.22

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in improving bone density and preventing bone diseases such as osteoporosis in women. It rejuvenates the body by improving blood circulation, and this yoga pose can also help in relieving neck pain by reducing stiffness of the upper body. Get down on your knees and hands so that your back remains straight and parallel with the floor. Now, push up your hips by straightening the knees and elbows so that your body forms an inverted V shape, Hold the pose for 30 seconds to 1 minute while breathing normally. Return to the starting position exhaling slowly. This makes 1 repetition. Repeat it 5 to 6 times. .22 Bridge Pose (Setu Bandha Sarvangasana) The bridge pose (Setu Bandha Sarvangasana) is the best yoga pose for stress and anxiety. It helps in stretching the muscles of the back and the leg and is an effective exercise for toning the thighs and hips. In addition, it also helps in controlling high blood pressure and reduces backaches, headaches, sleep disorders and fatigue. Lie flat on the yoga mat and bend your knees to rest your feet close to the buttocks. Your feet should be placed

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hip width apart. Now, lift your hips upward by pressing the arms on the floor and lift your breastbone as well while keeping your head fixed facing to the ceiling.

Remain in the position for 30 seconds to 1 minute and come back to the starting position. This makes 1 repetition. Repeat it 5 to 6 times.22 Extended Triangle Pose (Utthita Trikonasana) The extended triangle pose is the ideal yoga pose for stress management that helps in full-body stretching.

It helps in increasing flexibility, improving digestion and relieves the problems of anxiety, depression and fatigue. It addition, it also increases bone density and reduces the risk of developing osteoporosis. It also helps in toning the oblique muscles and is effective to reduce fat. Stand straight with your feet approximately 4 feet apart, raise your arms on both sides and keep them parallel to the floor,. Now turn your right foot out by 90 degrees and bend your torso to the right side while

Cat Pose (Marjaryasana) The cat pose is the best pose for stress relief that helps in stretching the spine and toning the muscles and organs of the abdomen. It helps in improving overall health by relieving digestive problems . Get on all fours with your wrists directly under your shoulders and your knees directly under your hips. Now, exhale and pull your spine inward to form a curve pointing towards the

ceiling. Bend your head toward the floor, but make sure your chin should not touch the breast. Hold the pose for 30 seconds and come back to the starting position.

In most cases, the cat pose is combined with cow pose which you can do by inhaling and dropping your belly towards the mat while pointing your head upward.

These 2 poses are to be repeated 5 to 6 times holding each pose for 30 seconds alternatively.22 Extended Puppy Pose (Uttana Shishosana) The extended puppy pose is one of the most simple yoga exercises that helps in relaxing the body by stretching the spine and shoulder, thus reducing stiffness. It is useful for correcting body posture, increasing flexibility and rejuvenating the mind and the body. This pose helps in toning the hips and back and is one of the best yoga poses to lose weight after pregnancy. Begin on all fours and slowly lower your chest towards the floor by sliding your arms forward but make sure that your elbows don’t touch the ground. Drop your head so that exhaling, and hold your right calf with your right hand while pointing your face and left hand towards the ceiling. Hold the position for 30 seconds and come back to the starting position while inhaling. This is 1 repetition. Now repeat the entire movement on the left side. Repeat it 5 to 6 times on both sides. 22 Page 26

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Yoga for Palliative Care Nurses

it touches the floor. Keep your neck relaxed and hold the pose for 30 seconds to 1 minute while breathing normally. Now, come back to the starting position while exhaling. This makes one repetition. Repeat it 5 to 6 times.22 Corpse Pose (Savasana) Last but not the least comes the corpse pose or Savasana, the ultimate yoga pose for stress relief. No yoga session is complete without the corpse pose which is the most calming and relaxing of all poses. It transports the body to a state of deep rest and relaxation. This yoga pose helps in promoting sleep, lowering high blood pressure and calming the nervous system. Lie down on

the yoga mat with any cushion or pillow for support.

Keep your feet slightly apart and relax your knees and toes. Place your arms on the side of your body, your palms open and facing the ceiling. Close your eyes and breathe slowly and deeply to relax your body and mind.

Stay in this posture for 10 minutes and end your yoga session in a relaxed and rejuvenated way.22

CONCLUSION This article identifies the value of support of yoga to improve palliative care nurses’ self-care and overcome burnout. Palliative care nurses experience work-related stress which emphasizes the need for weekly regular yoga practice. It would significantly decrease workrelated stress and increases the stress adaptation of palliative care nursing professionals which will help them to give a quality care.

REFERENCES 1. Higginson IJ, Finlay IG, Goodwin DM, Hood K, Edwards AG, Cook A, Douglas HR, Normand CE. Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? Journal of pain and symptom management 2003; 25 (2): 150–168.

2. Lim J, Bogassian F, Ahern K. Stress and coping in Australian nurses: a systematic review. Int Nurs Rev 2010; 57(1): 22–31 3. Donovan RO, Doody O, Lyons R. The effect of stress on health and its implications for nursing. Br J Nurs 2013; 22: 969-70.

4. John OP, Donahue EM, Kentle RL. The Big Five Inventory. Berkeley, CA: University of California (Institute of Personality and Social Research); 1991.

5. Borritz M, Rugulies R, Bjorner JB, Villadsen E, Mikkelsen OA, Kirstensen TS. Burnout among employees in human service work: design and baseline findings of the PUMA study. Scandinavian Journal of Public Health 2006; 3481:49-58.

6. Edwards D, Burnard P, Owen M, Hannigan B, Fothergill A, Coyle D. A systematic review of the effectiveness of stress management interventions for mental health professionals. J Psychiatr Ment Health Nurs 2003;10:370-71.

7. Warshawsky NE, Havens DS. Nurse manager job satisfaction and intent to leave. Nurs Econ 2014; 32: 32-39.

8. Westermann C, Kozak A, Harling M, Nienhaus A. Burnout intervention studies for inpatient elderly care nursing staff: systematic literature review. Int J Nurs Stud 2014; 51:63-71.

9. Garrosa E, Moreno-Jime´nez B, Liang Y, Gonza´lez JL. The relationship between socio-demographic variables, job stressors, burnout, and hardy personality in nurses: an exploratory study. Int J Nurs Stud 2008;45:418-27 10. Go´mez C, GandoyM, PugaA, ClementeM, Maya´n JM. Factores depersonalidad del personal de enfermerı´a de unidades de cuidados paliativos. (Personality traits of palliative care unit nursing staff). Gerokomos 2012;23:110-13.

11. Vachon ML. Caring for the caregiver in oncology and palliative care. Semin Oncol Nurs 1998;14(2): 152–57 12. Wakefield A Nurses’ responses to death and dying: a need for relentless self-care. Int J Palliat Nurs :2000, 6(5): 245–51 13. Wilkes LM, Beale B : Palliative care at home: stress for nurses in urban and rural New South Wales, Australia. Int J Nurs Pract 2001 ; 7(5): 306–13 14. Grau-Alberola E,Gil-Monte PR,Garcı´a-Juesas JA, Figueirido-FerrazH.Incidence of burnout among Spanish nursing professionals: a longitudinal study. Int J Nurs Stud.

2010;47:1013-20 15. Weinstein N, Brown KW, Ryan R. A multi-method examination of the effects of mindfulness on stress attribution, coping, and emotional well-being. J Res Pers 2009; 43:374–85.

16. Forozandeh N, Delaram M. Effect of cognitive behavioral therapy on coping methods non-medical student university of medical sciences. Shahre Kord Univ Med Sci J 2003; 5: 26–34.

17. Akochekian SH, Rohafza HR, Hasanzadeh A, Mohammad Shrifi H. Associated with social support and coping strategies in a psychiatric ward nurses. J Med Sci Gilan 2008; 18: 41–6.

18. Rizzolo D, Zipp GV, Stiskal D, Simpkins S. Stress management strategies for students: The immediate effects of yoga, humor, and reading on stress. J Coll Teach Learn 2009; 6: 79–88.

19. Raingruber B, Robinson C. The effectiveness of Tai Chi, yoga, meditation, and Reiki healing sessions in promoting health and enhancing problem solving abilities of registered nurses. Issues Ment Health Nurs 2007; 28:1141–55 20. Van Puymbroeck M, Payne L, Hsieh PC. A phase I feasibility study of yoga on the physical health and coping of informal caregivers. Evid Based Complement Alternat Med 2007;75:11–17.

21. Ramezani S. Effect of humor education on mental health and coping styles of nurses in emergency departments in hospitals affiliated to medical sciences university of shiraz, MS Thesis. Shiraz, Iran: Shiraz University of Medical Sciences; 2006.

22. Yoga Journals for Healthy Minds and Healthy Body. Cruz bay publishers:2014

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YOGA THERAPY: AN OVERVIEW Yogacharya Dr Ananda Balayogi Bhavanani, Deputy Director, CYTER, Centre for Yoga Therapy, Education and Research Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India Email: yoga@mgmcri.ac.in

“Yoga Chikitsa is virtually as old as Yoga itself, indeed, the ‘return of mind that feels separated from the Universe in which it exists’ represents the first Yoga therapy. Yoga Chikitsa could be termed as “man’s first attempt at unitive understanding of mind-emotions-physical distress and is the oldest wholistic concept and therapy in the world.”

- Yogamaharishi Dr. Swami Gitananda Giri, ICYER at Ananda Ashram, Pondicherry.

Yoga may be said to be as ancient as the universe itself, since it is said to have been originated by Hiranyagarba, the causal germ plasm itself. This timeless art and science of humanity sprouted from the fertile soil of Sanathana Dharma, the traditional pan-Indian culture that continues to flourish into modern times. 1,2,3,4 Today, Yoga has become popular as a therapy, and most people come to it seeking to alleviate their physical, mental and emotional imbalances. We must understand, however, that the use of Yoga as a therapy is a much more recent happening in the wonderful long history of Yoga–which has historically served to promote spiritual evolution. Yoga helps unify all aspects of our very being: the physical body, in which we live our daily life; the energy body, without which we will not have the capacity to do what we do; the mind body, which enables us to do our tasks with mindfulness; the higher intellect, which gives us clarity; and, finally, the universal body, which gives us limitless bliss. 5,6 All aspects of our life--physical, energetic, mental, intellectual and universal--are unified through the practice of Yoga, which may also be described as the science of right-use-ness, that is, of using our body, Page 28

emotions, and mind responsibly and in the most appropriate manner. One of the best definitions of Yoga given by Swami Gitananda Giri is that it is a ‘way of life’.7,8 It is not something you do for 5 minutes a day or 20 minutes a day. It is indeed a 24 × 7 × 365. lifestyle.

Illness, disease and disorders are so common in this world,and people everywhere are desperately seeking relief from their suffering. Yoga helps us to think better and to live better; indeed, it helps us improve ourselves in everything we do. Hence it holds out the promise of health, well-being and harmony. According to the Bhagavad Gita, an ancient text which can be said to be a Yoga Shastra (seminal textual source of Yoga), Lord Krishna the Master of Yoga (Yogeshwar) defines Yoga as “dukkhasamyogaviyogam yoga samjnitham” meaning thereby that Yoga is the disassociation from the union with suffering. Pain, suffering, disease - Yoga offers a way out of all of these. 5,6,9,10 One of the foremost concepts of Yoga therapy is that the mind, which is called adhi, influences the body, thus creating vyadhi, the disease. (Fig 1) This is known as the adhi vyadhi or adhija vyadhi, where the mind brings about the production of disease in the physical body. In modern language, this is called psychosomatic illness. 6 Virtually every health problem that we face today either has its origin in psychosomatics or is worsened by the psychosomatic aspect of the disease. The mind and the body seem to be continuously fighting each other.

What the mind wants, the body won’t do, and what the body wants, the mind won’t do. This creates a dichotomy, a disharmony, in other words, a disease.

Yoga helps restore balance and equilibriumby virtue Ann. SBV, July-Dec 2016;5(2)

Yoga Therapy: An Overview MODALITIES OF YOGA AS A THERAPY(6)

ADHI

PHYSICAL THERAPIES ∙ Asanas, Kriyas, Mudras and Bandhas EMOTIONAL THERAPIES ∙ Swadhyaya, Pranayama, Pratyahara, Dharana, Dhyana and Bhajans

MENTAL AGITATIONS

HAPAZARD FLOW OR PRANA

AJIRANATVAM (under digestion)

UNSTABLE NADIS

ATIJIRANATVAM (over-digestion)

KUJIRANATVAM (wrong digestion)

PHYSICAL AILMENTS (VYADHI)

Fig 1. Causation of disease, the Yogic perspective of the internal process of unifying mind, body and emotions. The psychosomatic stress disorders that are so prevalent in today’s world can be prevented, controlled and possibly even cured via the sincere and dedicated application of Yoga as a therapy.

Psychosomatic disorders go through four major phases. The first is the psychic phase, in which the stress is located essentially in the mind. There is jitteriness, a sense of unnatural tension, a sense of not being ‘at ease’.

If the stress continues, the psychic stage then evolves into the psychosomatic stage. At this point,the mind and body are troubling each other and fluctuations, such as a dramatic rise in blood pressure, blood sugar or heart rate, begin to manifest intermittently. If this is allowed to continue, one reaches the somatic stage, where the disease settles down in the body and manifests permanently. At this stage, it has become a condition that requires treatment and therapy. In the fourth, organic stage, the disease settles permanently into the target organs. This represents the end stage of the disease.

Yoga as a therapy works very well at both the psychic and psychosomatic stages. Once the disease enters the somatic stage, Yoga therapy as an adjunct to other therapies may improve the condition. In the organic stage, Yoga therapy’s role is more of a palliative, pain relieving and rehabilitative nature. Of course the major role of Yoga is as a preventive therapy, preventing that which is to come. Maharishi Patanjali tells us in Ann. SBV, July-Dec 2016;5(2)

∙ Development of +ve attitudes

– Vairagya – Chitta Prasadan – Maitri, Karuna, Mudita, Upekshanam

MENTAL THERAPIES ∙ Relaxation & visualization, Trataka, Pranayama, Pratyahara, Dharana & Dhyana SPIRITUAL THERAPIES ∙ Swadhyaya, Satsangha, Bhajans and Yogic counseling PREVENTIVE THERAPIES ∙ Start early in childhood ∙ Prevention of accidents ∙ Improved immunity ∙ Knows the technique so that can do it if needed REHABILITATIVE THERAPIES ∙ Prevention of disability & improving QOL PAIN RELIEF THERAPIES ∙ Increases pain tolerance - improved quality of life

his Yoga Darshan, “heyamdukkhamanagatham”-prevent those miseries that are yet to come”. 1,11 If the practice of Yoga is taken up during childhood, we can prevent so many conditions from occurring later on in life. This is primary prevention. Once the condition occurs, once the disease has set in, we have secondary prevention, which is more in the nature of controlling the condition to whatever extent we can. Tertiary prevention is done once the condition has occurred, as we try to prevent the complications, those that affect the quality, and even the quantity, of a patient’s life. 7 When we use Yoga as a therapy, we need to consider both the nature of the person–his or her age, gender and physical condition–and the nature and stage of the disorder. A step-by-step approach must include a detailed look at all aspects of diet, necessary lifestyle modifications, attitude reconditioning through Yogic counseling, as well as the appropriate practices. All of these are integral components of holistic, or rather, wholesome Yoga therapy. When such an approach is Page 29

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adopted, tremendous changes will manifest in the lives of the patients and their families. The quality of life improves drastically and, in many cases, so does th quantity.

As human beings, we fulfill ourselves best when we help others. Yoga is the best way for us to consciously evolve out of our lower, sub-human nature, into our elevated human and humane nature. Ultimately, this life giving, life enhancing and life sustaining science of humanity allows us to achieve in full measure the Divinity that resides within each of us.

I would like to conclude this overview of Yoga therapy with a word of caution. Yoga therapy is not a magic therapy! It is not a ‘one pill for all ills’. There should be no false claims or unsubstantiated tall claims made in this field. Yoga therapy is also a science and must therefore be approached in a scientific, step-bystep manner. It should be administered primarily as a ‘one on one’ therapy that allows the therapist to modify the practices to meet the needs of the individual. It is not a “one size fits all” or “one therapy fits all” approach!

REFERENCES 1. Feuerstein G. The Yoga Tradition : Its history, literature, philosophy, and practice. 3rd ed. Prescott, Ariz: Hohm Press; 2001.

2. Bhatt GP. The Forceful Yoga: Being the Translation of HathaYoga-pradipika, Gheranda-samhita and Siva-samhita. 2nd ed. New Delhi, India: Motilal Banarsidass Publishers; 2016.

3. Bhavanani MD. The history of yoga from ancient to modern times. 1st ed. Pondicherry, India: Satya Press; 2010.

4. Sovik R, Bhavanani AB. History, Philosophy, and Practice of Yoga. In: Khalsa SB, Cohen L, McCall T, Telles S, editors. The Principles and Practice of Yoga in Health Care.

1st ed. East Lothian, UK: Handspring, 2016.

5. Feuerstein G. The Deeper Dimension of Yoga Theory and Practice. 1st ed. Boston Massachusetts, USA: Shambala Publications Inc; 2003.

6. Bhavanani AB. Yoga Chikitsa: Application of Yoga as a therapy. 1st ed. Pondicherry, India: Dhivyananda Creations; 2013.

7. Giri G S. Yoga: Step-by-step. 1st ed. Pondicherry, India: Satya Press; 1976.

8. Giri G S. Ashtanga Yoga of Patanjali. 1st ed. Pondicherry, India: Satya Press; 1999.

9. Ramanathan M. Applied Yoga-Application of Yoga in Various Fields of human Activity. 1st ed. Puducherry, India: Aarogya Yogalayam; 2007.

10. Bhavanani AB. A primer of yoga theory. 4th ed. Pondicherry, India: Dhivyananda Creations;2014.

11. Bhavanani AB. Understanding the yoga darshan. 1st ed. Pondicherry, India: Dhivyananda Creations;2011.

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MUSICOGENETICS: A NEW SPECIALTY ON HORIZON? Sumathy Sundar, Director Parin N Parmar, Visiting Faculty Centre for Music Therapy Education and Research (CMTER), Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India Email: musictherapy@mgmcri.ac.in

Advances in fields of genetics and molecular biology have changed approach to health and diseases in human beings. Genes are known to affect the health directly by being in causation/predisposing relationship with specific medical condition(s). In addition to direct gene-disease relationship, gene also affect overall medical management of a patient by increasing one’s susceptibility for or resistance to certain drugs and drug interactions, and by increasing or decreasing probabilities of drug tolerance or intolerance – pharmacogenetics has wide applications in practice of medicine. Beyond drugs and diseases, genes start play their role right from formation of an embryo – from synthesis of organ systems, to functioning of organs, to altering thoughts and emotions, to affecting healthrelated behavior, etc. Concept of medical treatment guided by genetic constitution of a patient seems promising and rational. 1.

Over last a few decades, interest in music therapy has grown globally. Music therapy has found its applications in areas of psychiatry, psychology, neurology, oncology, anesthesiology, intensive care, obstetrics, pediatrics, geriatrics, palliative care, etc 2. On one side, reciprocal relationship between effects of music on brain and effects of music behavior on brain function seems to hold a strong potential to see music therapy as an important treatment modality in therapeutics in future 3, researches in psycho-neuro-endocrino-immunology also point towards irrefutable importance of stress regulation and healthy behaviors in management of many common diseases 4. As human physiology and pathology are influenced by genes parallelly, we Ann. SBV, July-Dec 2016;5(2)

believe that there is a wide scope for research in field of “musicogenetics” – a term coined by us to describe a specialized field of bioscience to study interactions between human genes, music traits, music behavior, and music therapy responses.

Till date, we have studied that roots of musicality is an expression of musical self and that neuroscience and psychobiology have identified the potential of musical expressions to bring about therapeutic change in music therapy5. Also studies have indicated a link between the felt quality in musical expression with the psychosomatic aspects, emotions and thought patterns and the deeper needs of the clients/patients 6.

Researchers have also studied relationship between genes and music traits. Based on research so far, it is rational to think of genetic basis of individual differences in musicality – music perception, music memory, music listening, music production, singing, and music creativity. Genes AVPR1A on chromosome 12q and SLC6A4 on chromosome 17q have been associated with music memory; AVPR1A and SLC6A4 have been also implicated in music perception-music listening and choir perception respectively. Several loci on chromosome 4 are associated with music perception and singing, while certain loci on chromosome 8q have been implicated in music perception and absolute pitch.

7, 8 . Recently, a study by Kanduri C et al has shown up-regulation and down-regulation of several genes following listening to music 9. However, much more research is needed in “musicogenetics” and there is no study in this field that would help to apply knowledge of genetics in field of music therapy.

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As music therapists and researchers, we have tried to identify several unanswered questions and we would like to briefly summarize them as follows: a. Are there genes that predict a therapeutic response or failure to music therapy? If yes, are genes associated with music therapy response same as or different from those associated with music traits? b. Is congenital amusia 8, 10 related to ineffectiveness of music therapy? c. In patients with multi-gene disorders, are there specific genes that would predict high probability of effectiveness of music therapy? d. Can music therapy affect gene expression via epigenetic mechanisms?

Of course, these are very basic questions, and further questions are likely to arise when these questions would be answered.

Answers to these questions are likely to reveal links between genetic constitution, a “personal map” of every individual, determinants of musicality and of music therapy; such discoveries would definitely help health care providers and therapists to provide music therapy in a more personalized way and more effectively.

Musicogenetics appears to be an emerging specialized field that should discover some interesting truths. It is apparent that research in this field requires dedicated and integrated efforts from geneticists, music therapists, psychologists, physicians, and allied health care professionals. Of course, such efforts have a great potential to understand gene-mind-body interactions better, to alter management of several medical conditions, and to influence clinical practice.

REFERENCES:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Chang KL, Weitzel K, Schmidt S. Pharmacogenetics: Using Genetic Information to Guide Drug Therapy. Am Fam Physician 2015; 92(7): 588-94.

Kemper KJ, Danhauer SC. Music as Therapy. South Med J 2005; 98(3): 282-8.

Thaut MH. The Future of Music in Therapy and Medicine. Annals of the New York Academy of Sciences 2005; 1060(1): 303-8.

Lutgendorf SK, Costanzo EF. Psychoneuroimmunology and health psychology: An integrative model. Brain, Behavior, and Immunity 2003; 17(4): 225-32.

Perret D. Roots of Musicality: Music Therapy and Personal Development. Jessica Kingsley 2005; 16-22 Perret D. Roots of musicality: On neuro-musical thresholds and new evidence for bridges between musical expression and ‘inner growth’. Music Education Research 2004; 6(3): 327-342. doi: 10.1080/1461380042000281767.

Gingras B, Honing H, Peretz I, Trainor LJ, Fisher SE. Defining the biological bases of individual differences in musicality. Philosophical Transactions of the Royal Society B 2015; 370: 20140092. doi: 10.1098/rstb.2014.0092.

Tan TY, McPherson GE, Peretz I, Berkovic SF, Wilson SJ. The genetic basis of music ability. Frontiers in Psychology 2014; 5: 658. doi: 10.3389/fpsyg.2014.00658.

Kanduri C, Raijas P, Ahvenainen M, Philips AK, Ukkola-Vuoti L, Lahdesmaki H, Jarvela I. The effect of listening to music on human transcriptome. Peer J 2015; 3: e380. doi: 10.7717/peerj.830.

Peretz I, Hyde KL. What is specific to music processing? Insights from congenital amusia. Trends in cognitive sciences 2003; 7(8): 362-7.

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MUSIC THERAPY: BRIDGING TRADITIONAL HEALING SYSTEM AND MODERN SCIENCE Sumathy Sundar, Director Parin N Parmar, Visiting Faculty Centre for Music Therapy Education and Research (CMTER), Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India.

Email: musictherapy@mgmcri.ac.in

ABSTRACT 

The aim of this paper is to introduce and discuss about how music therapy clinical practice and research initiatives in India serve as a bridge between the experiences of traditional music healing practices and scientific validations. The current status of these healing applications in the global framework of music therapy is highlighted. The multimodal approach by which aspiring music therapists engage in clinical practice and research with an individualized approach to bring about the therapeutic outcome are presented.

Traditional healing resources like Vedic chanting, raga cikitsa, garbhasanskara ( Learning in the Womb) time theory of ragas integrating the ancient Ayurvedic perspectives, ancient raga visual imagery and cakra activation (music and breathing technique using ragas) are enumerated. The clinical outcomes are reviewed as a way to impact biological, physiological, psychological, chrono-biological and spiritual dimensions.

INTRODUCTION Although profession of music therapy started developing in 1940s in USA and scientific research in field of music therapy has grown significantly during last 4 decades, influence of sound on music on healthy and diseases states of mind and body seems to have been known since ancient times. With advances in integrative medicine, psychoneuroimmunology, and psychoneuroendocrinology, it has been easier for researchers to see a big, holistic picture of health which is affected both positively and negatively by multiple factors such as genetic constitution, diet & lifestyle, environment, etc. Till date, there is convincing scientific evidence showing detrimental effects of noise and positive effects of music and music therapy on human health [1, 2]. However, still there are many questions to be answered, many why’s to be explained, and many how’s to be demonstrated.

Ann. SBV, July-Dec 2016;5(2)

Scriptures and documents suggest that ancient civilizations such as Indians and Greeks were aware of healing properties of music and had been using music therapeutically3. The Vedas, the earliest Indian scriptures dating back to 1500 to 1700 B.C., contain many verses related to musicology and health.

Gandharvatattva, literature on science of music in India, dates back to fourth century B.C.4 Brhaddesi, a 6th century a landmark work in Indian musicology

by Sri Matanga Muni, and Sangitaratnakara, a 13th century treatise by Sarangadeva, are not only important for musicological aspects but also for psychological, physiological, and metaphysical aspects.

In this article, we aim to discuss important Indian traditional healing systems in context of music therapy. We also have tried to connect the traditions with modern science by gathering latest scientific evidence that is directly or indirectly related to the ancient concepts.

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INDIAN TRADITIONAL MUSIC HEALING TECHNIQUES Musicologically, Indian classical music can be broadly divided into Karnatik music and Hindustani music systems. Both the systems are rich in numerous ragas (a raga is a specific and melodious structure of selected notes and microtones). ragacikitsa is a very popular term in Indian traditional music therapy, which literally means “treatment by raga”. In context of modern music therapy, raga cikitsa can be considered as a form of receptive music therapy in which a patient is made to listen to one or more specific raga/s to experience its/their therapeutic effects. Ragas can be used in form of instrumental improvisations, vocal improvisations and/or pre-recorded music/performances.

There is accumulating evidence showing effectiveness of specific ragas on specific medical conditions, including a few randomized controlled trials 5, 6, however, it has been difficult to explain how listening to a particular raga is beneficial in a particular medical condition, considering multiple aspects of musical sound, complexity of human hearing and listening process, musical profile of patients and multifactorial nature of health and illnesses. All the more difficult it is to prove that the other ragas are ineffective in each case and a specific raga only is effective.

One possible explanation for beneficial effects of specific ragas on specific diseases could involve ability of specific ragas to evoke specific emotions in the listeners. It has been shown various ragas can elicit distinct emotions in the listeners, with tonic intervals, tonality, rhythm, and tempo as additional factors modulating overall emotional responses7. In face of increasing evidence suggesting role of emotional factors in diseases, beneficial effects of different ragas can be, at least, partly explained by eliciting positive emotions in the listeners and these emotional responses to music could be explained by several mechanisms like (a) brain stem reflexes, (b) rhythmic entrainment (c) evaluative conditioning (d) contagion (e) visual imagery (f ) episodic memory or (g) musical expectancy8. Of course, music being a sociocultural phenomenon, it is difficult to presume that a particular raga would evoke same emotional response in listeners with different cultural backgrounds.

Time Theory of Raga is another interesting concept in Indian Classical music. As per this theory, a 24-hourday is divided into eight praharas (3-hour-time periods) and each of the ragas is assigned a specific prahara.

It is believed that effects of a raga are best produced when it is performed or listened to during the specific time period assigned to it. Scholars have explained Page 34

this unique concept in context of Indian philosophy9, however, its significance in relation to therapeutic use of ragas needs to be evaluated. Recently, we reported a case study of a pregnant woman with major depression who was successfully treated with receptive music therapy using Indian Classical music, integrating concepts of Time Theory of Raga and Ayurveda, the ancient Indian medicine system10. However, there is no other evidence investigating relevance of Time Theory of Raga in clinical settings till date.

GarbhaSanskara (literally meaning “education in womb”) is another Indian traditional practice where in low frequency chants are used as auditory stimulation to pregnant women from second trimester onwards. The pregnant women chant with the therapists. The ritual is an auditory stimulation provided to manipulate the micro environment in-utero during the prenatal period of pregnancy which aims to provide health benefits to both the woman and the developing fetus11. Effects of sounds on fetuses have been well recognized and exposure to prenatal music has shown to be associated with favorable neurobehavioral outcomes12, 13, 14 and help the fine tuning of hair cells in the ear and their neuron connection to spiral ganglion and cochlear nuclei15, 16. It is worth noting that GarbhaSanskara is a concept described in Ayurveda includes many other interventions in addition to music-based interventions.

Eastern literature, including ancient Indian texts about Ayurveda and Yoga, has described concepts of human energy (or subtle) body, cakras (energy wheels), and kundalini (dormant energy). Many traditional healing systems such as Yoga therapy, reiki, qi-gong, meditation, acupuncture, etc are believed to work on human energy body. Seven major cakras have been described, which regulate flow of energy in the energy body. Imbalances in the energy body or imbalances between cakras are believed to produce diseased states.

Various cakra activating and cakra balancing techniques are described in Indian texts, which aim to restore the balance in human energy body, and therefore to restore health. In Indian music therapy context, there are seven notes in Indian Classical music (“S”, “R”, “G”, “M”, “P”, “D”, “N”) and each one corresponds to each of the seven major cakras. Thus, cakras can be influenced by appropriate use of musical notes. Recently, concepts of energy/subtle body, cakras, and kundalini have been explored by many researchers and interesting results have been observed17-19. Attempts have also been made to cross-refer human energy system with meridians (described in traditional Chinese literature) and modern central nervous system20, 21. However, it Ann. SBV, July-Dec 2016;5(2)

Music therapy: Bridging traditional healing system and modern science

must be realized that as far as these esoteric concepts are concerned, modern science has more questions than has satisfactory answers. To worsen the scenario for music therapists, little scientific work has been done integrating music therapy and cakrasystem/ energy body. Recently, we reported an exploratory study that showed elevation of body temperature after a single session of musical (vocal) technique of cakra activation in the raga mayamalavagowla in all the subjects22. Hopefully, future research in areas of mindbody medicine and advanced physics would make the picture clearer. One more important Indian traditional healing practice is mantra (single or a group of sacred sound/s, utterance/s, syllable/s, or word/s) chanting.

Reciting mantras had been an essential part of ancient Indian traditional life and numerous mantras, meant to be chanted for different purposes, are described in Vedas. From musicology perspective, mantras are usually not raga based or to say melodious, but chanting them with correct intonations, rhythm and inflection of voice is given immense importance to produce their desirable effects. Many of these mantras are also

part of meditation techniques. In Indian traditions, “Om” is considered a cosmic sound with harmonizing effects23. Om chanting has shown to produce significant neurohemodynamic effects in different areas of brain24.

Therapeutic importance of Om mantra and other mantras needs further research.

MUSIC THERAPY IN INDIA: FROM TRADITIONS TO CLINICAL PRACTICE Music Therapy is in infancy in India and it is a huge task and challengeto integrate all musicological healing traditions into clinical practice of music therapy. This, however, is very much desirable as music therapy is strongly influenced by culture and traditions and India is rich in cultures and traditions. Many of the contemporary researchers have validated and supported ancient Indian traditions, hence it also appears highly reasonable to explore, evaluate, understand, apply, and integrate concepts of Indian music healing traditions into music therapy practice.

REFERENCES 1. Basner M, Brink M, Bristow A, de Kluizenaar Y, Finegold L, Hong J, Janssen SA, et al. ICBEN review of research on the biological effects of noise 2011-2014. Noise Health 2015; 17(75): 57-82. doi: 10.4103/1463-1741.153373.

2. Kamioka H, Tsutani K, Yamada M, Park H, Okuizumi H, Tsuruoka K, et al. Effectiveness of music therapy: a summary of systematic reviews based on randomized controlled trials of music interventions. Patient Preference and Adherence 3. Sanivarapu SL. India’s rich musical heritage has a lot to offer to modern psychiatry. Indian Journal of Psychiatry 2015; 57(2): 210-3. doi: 10.4103/0019-5545.158201.

4. Sambamurthy P. South Indian Music. Book 1 16th edition. Chennai: The Indian Music Publishing House; 1999.

5. Deshmukh AD, Sarvaiya AA, Seethalakshmi R, Nayak AS. Effect of Indian classical music on quality of sleep in depressed patients: a randomized controlled trial. Nord J Music Ther. 70-8.

6. Kumar TS, Muthuraman M, Krishnakumar R. Effect of the Raga AnandaBhairavi in Post Operative Pain Relief Management. Indian Journal of Surgery 2014; 76(5): 36370. doi: 10.1007/s12262-012-0705-3.

7. Mathur A, Vijayakumar SH, Chakrabarti B, Singh NC. Emotional responses to Hindustani raga music: the role of musical structure. Forntiers in Psychology 2015; 6: 513. doi: 10.3389/fpsyg.2015.00513.

8. Juslin PN, Liljestrom S, Vastfjall D, Lundqvist LO. How does music evokes emotions? Exploring underlying mechanisms. In: Juslin PN, Sloboda JA (eds.) Handbook of music and emotion: Theory, research, applications. 2010; Oxford: Oxford University Press. 605-42 9. Westbrook P. Ayurveda, Samkhya, and the time theory of performance in Hindustani Classical music. Journal of Indian Philosophy and Religion 1998. http://www. sacredscience.com/archive/Westbrook1.htm as on 12 February 2016.

10. Sundar S, Durai P, Parmar PN. Indian classical music as receptive music therapy improves tridoshic balance and major depression in a pregnant woman. International Journal of Ayurveda and Pharma Research 2016; 4(9): 8-11.

11. Sundar S. Integrating cultural music therapy approaches with pregnant women in antenatal wards in a south Indian hospital. Proceedings of the 4th International conference of the International Association for music and medicine: Where music and medicine meet. Beijing. June 11-13, 2016 12. Gerhardt KJ, Abrams RM. Fetal exposures to sound and vibroacoustic stimulation. Journal of Perinatology 2000; 20(8Pt2): S21-30.

13. Arya R, Chansoria M, Konanki R, Tiwari DK. Maternal Music Exposure during Pregnancy Influences Neonatal Behaviour: An Open-Label Randomized Controlled Trial.

International Journal of Pediatrics 2012: 901812. doi: 10.1155/2012/901812.

14. Partanen E, Kujala T, Tervaniemi M, Huotilainen M. Prenatal Music Exposure Induces Long-Term Neural Effects. PLoS ONE 2013; 8(10): e78946. doi: 10.1371/journal. pone.0078946.

15. Hall J. Development of the ear and hearing. Journal of Perinatology 2000; S11-19.

16. Shoemark H. Frameworks for using music as a therapeutic agent for hospitalised newborn infants. In:Rickard N, McFerran K. (eds.). Lifelong engagement in music: Benefits for mental health and well-being. New York: Nova Science Press. 2012; 1-20.

17. McMurray S. Chakra talk: Exploring human energy systems. Holistic Nursing Practice 2005 Mar/Apr; 19(2): 94.

18. Rubik B. Scientific analysis of the human aura. Measuring Energy Fields State of the Science. Fair Lawn, NJ, Backbone (2004): 157-170.

19. Prakash S, Chowdhury AR, Gupta A. Monitoring the Human Health by Measuring the Biofield" Aura": An Overview. International Journal of Applied Engineering Research 2015; 10(35): 27654-8.

20. Greenwood M. Acupuncture And The Chakras. Medical Acupuncture. 2006; 17(3): 27-32.

21. Loizzo JJ. The subtle body: an interceptive map of central nervous system function and meditative mind-brain-body integration. Annals of the New York Academy of Sciences 2016: 1-18. doi: 10.1111/nyas.13065.

22. Sundar S, Parmar P. Effect of a single musical cakraactivation manoeuvre on body temperature: An exploratory study (Accepted) Ancient Science of Life 2016; 35(5) 23. Kumar S, Nagendra HR, Manjunath NK, Naveen KV, Telles S. Meditation on Om: Relevance from ancient texts and contemporary science. International Journal of Yoga 2010; 3: 2-5.

24. Kalyani BG, Venkatasubramanian G, Arasappa R, Rao NP, Kalmady SV, Behere RV, et al. Neurohemodynamic correlates of ‘OM’ chanting: a pilot functional magnetic resonance imaging study. International Journal of Yoga 2011; 4: 3-6.

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MUSIC THERAPY AND BIOMARKERS OF DEPRESSION TREATMENT Dr. JörgFachner, Professor, Anglia Ruskin University Cambridge, UK,

ABSTRACT 

ow can we document change as a function of doing music in a therapeutic setting and H how does it work? Biomarkers representing the effectiveness and those representing the music therapy process are related to an accumulation of and a focus on important moments in therapy time. Analysing resting state EEG may inform about group effects, while moments of interest in the improvisational process may reveal synchronization of brain processes. In music therapy it may be an important key to understand where and why change in therapy occurs. We will discuss the promises of biomarkers and neurometrics for music therapy, will draw on results of depression research, on recent work with wireless EEGs and improvisation, music performance, neurofeedback and game applications in psychiatric and neurorehabilitation.

ANTIDEPRESSANT REDUCTION OR INTERACTION? Activating brain circuits inducing pleasure gives rise to the hope that the right music therapy intervention stirring up the emotions of the individual client at the right time, may reduce medication prescribed for mental health issues, as music can replace the drug’s desired effects. For example, in a study with depressed clients comparing treatment with Indian ‘relaxation’ music or hypnotics, the authors discussed that “the effects of music could be equivalent to 10 mg of Chlordiazepoxide or 7 mg of Diazepam” 1.

Reductions of medication have been demonstrated in medicine employing music, for example, as an adjunct to anaesthetic medication 2, 3. For instance, sedatives are regularly administered before surgery to reduce a patient’s anxiety. However, sedatives often have negative side effects (drowsiness, respiratory depression, etc.), and may interact with anaesthetic agents, prolonging patient recovery and preventing discharge. Therefore, increased attention is being paid to the introduction of music to reduce medication during 4 and reducing anxiety before 5 surgery. These Page 36

few examples may indicate that there is hope that we can use music as a decrement of medication.

The word ‘complementary’ means ‘in addition to’ or ‘allied to’ and is seen as an addition to standard care.

For example, research into treating chronic pain with music therapy indicates that “music therapy is an effective adjuvant intervention for patients suffering from chronic non-malignant pain, doubling the effects of pharmacological treatment”6.

Our own research into the treatment of depression with music therapy indicates that a complementary interaction between improvisational music therapy and antidepressant medication may facilitate standard care7. Clients receiving music therapy and standard care showed significantly decreased depression and anxiety symptoms compared to those receiving only standard care.

PERSONALISED MEDICINE On one hand we may strive for a reduction of medication but on the other hand the right medication may support psycho- or music therapy. This is desirable from the stance of personalized medicine 8. Prescriptions are Ann. SBV, July-Dec 2016;5(2)

Music therapy and biomarkers of depression treatment

ideally based on the bio-psycho-social identity of a particular person and not solely on a diagnostic classification. Personalized medicine hopes to address the right medication based on genotypes and biomarkers reflecting the client’s biological condition 9, aiming to administer an individualized combination. While an antidepressant may be adequate for moderate or severe depression, it may not be the right choice for a first episode of mild depression. However, antidepressant prescriptions are on the rise 10 and once the proposed ‘chemical imbalances’ are treated with antidepressants, they “may reduce sense of self and soul into dopamine, serotonin, neurons, milligrams”11.

A striking example of the dominance of medication in depression treatment is a Finnish study 12 that explored the treatments offered to people who were retired prematurely because of depression. The study revealed that 89% of the retired individuals during 1993 to 2004 never received any form of psychosocial treatment. Without a doubt, a better balance between the treatment choices could be achieved. There is convincing evidence that a combination of psychosocial support (such as psychotherapy) and medication is the best treatment, with psychotherapy acting as the initial treatment 13.

BIOMARKING MUSIC THERAPY TREATMENT A distinction among outcome types in clinical trials is between clinical endpoints and surrogate endpoints or biomarkers. A clinical endpoint may reflect “how a patient feels or functions, or how long a patient survives” 14. In contrast, a biomarker is an objectively measured indicator of normal or pathological processes.

Nevertheless, the process of selecting a measure remains subjective. A biomarker is objective only in the sense that it is not easily influenced by social expectancy bias and similar biases that may be encountered in clinical assessments. That is, “a measure can only be objective once it is decided which measure to use” 15.

How well this indicator reflects a clinical endpoint may vary . One of the biomarkers aiming to be a surrogate for predicting and estimating the effectiveness of a pharmacological intervention in depression treatment 16,17 are EEG measures, as for example Frontal Alpha Asymmetries 18. This article reflects on its use in an RCT on music therapy and depression.

In a randomised controlled trial (RCT), an outcome research method of proving treatment effectiveness, researchers were interested in whether music therapy Ann. SBV, July-Dec 2016;5(2)

added to standard care of depression treatment produced different outcomes from standard care only 19. Here it was important to develop a balance between a flexible and spontaneous practice of responding to the client and a standardisation of a treatment practice. Standardisation meant, for example, using the same musical instruments and a shared reference system created by all therapists taking part in the study, in terms of understanding depression, research and treatment practice and its philosophy 20. By constructing treatment fidelity, i.e. a consensus of understanding limitations of aims and common techniques employed, for example to be clear that this is a model of a normal treatment and not a normal treatment as such, a baseline to start from was developed and supervised on the way 21. The results indicated a significant effect of music therapy added to standard care compared to standard care only.

Three of the outcome measures indicated a substantial improvement, i.e. a reduction of depression and anxiety scores and an increase of overall global function - and most clients were not happy that the treatment ended after 20 sessions 7.

EMOTION, DEPRESSION AND FRONTAL BRAIN ACTIVITY Clients with depression have difficulties in expressing and processing emotion 22, and, given the frequent comorbidity with anxiety 23, are more likely to act in a withdrawn and anxious manner in social interaction 24. A heuristic concept explaining affective disorders links the withdrawal behaviour of depressed clients to increased right frontal activity, i.e., pathological asymmetric frontal processing of emotion 25.

Depressed clients tend to use rumination and expressive suppression as strategies to regulate their emotions instead of actively approaching them 26.

A few studies have demonstrated an immediate effect of pleasurable music listening on frontal processing in depression, i.e., during and after music listening a relatively right-sided frontal activity of depressed adolescents 27,28 and depressed mothers 29 shifted towards relatively left-sided activity. These results indicate an immediate influence of music listening on frontal processing in depression. Fachner et al’s aim was to find out whether these effects are lasting, and can be observed in an additional resting EEG recording, i.e., one not taken during or directly after listening, as in the study with depressed mothers from Field et al (1998), but after a course of active music therapy 30. Correlations between anterior EEG, Montgomery-Åsberg Depression Rating Scale Page 37

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(MADRS) and the Hospital Anxiety and Depression Scale - Anxiety Subscale (HADS-A), power spectral analysis (topography, means, and asymmetry) and normative EEG database comparisons were explored.

NEUROMETRICS Normative EEG comparisons allow to distinct excessive or abnormal EEG patterns against a database of age, gender, and condition-matched controls 31 in order to estimate z-scored deviation from normality on measures at baseline and after treatment. The z-transformation is a nonlinear transformation in which each measured value is translated to a deviation from the typical value of a healthy person of the same age.

In Case study designs normative EEG databases may help to provide an objectivist measure to estimate a client’s brain process before and after a therapy session or sequence 32 or guide neuro-feedback goal setting in music therapy 33. Ideally a client returns to normal processing. Neurologists have used EEG tools for decades, but research asks for generalizability of these biomarkers in the music therapy realm 15,30.

BRAIN PLASTICITY, MUSIC AND LANGUAGE PROCESSING IN MUSIC THERAPY The results of the EEG study were quite interesting and may shed another light on Felicity’s work on vocalisations. Many functions of the brain are bilaterally processed. For example, the left frontal operculum (Broca’s area) organizes motor processes of speech production, while the contralateral site may influence the tone of the voice 34, a function reduced in aprosodic clients after cerebral damage 35. F. North’s three examples show how vocalisation changed and became a tool for musical communication in therapy. In the depression study outlined above, the EEG resting state measures employed, a simple and easy to apply indicator of neuroplasticity, as utilised in PharmacoEEG studies36, pointed to fronto-temporal changes as a signature of difference between both groups and between the pre and post music therapy treatment [30].

Fronto-temporal areas have broadly been investigated in research on common areas of music and language processing 37. Emotional modulation of limbic structures, activation of the perception-action mediation in premotor areas, and intentional processes of social cognition in frontal and temporal areas are discussed as possible neuroscientific concomitants of music-therapeutic action 38. A study on frontoPage 38

temporal lobar degeneration in 26 patients indicated the importance of fronto-temporal areas for the recognition and processing of emotion in music 39.

Further, increases in the density of grey matter of Broca’s area have been found in orchestral musicians [40], indicating the relevance of musical training for fronto-temporal brain plasticity.

At intake the depressed clients perceived emotions in film music excerpts representing sadness and anger differently from normal controls. That is, they detected anger and fear more often than normal controls 22.

Non-verbal expression of emotional content through music creation, and subsequent verbal reflection of its personal meaning, is part of the therapeutic relationship established during music therapy 20. Considering that about 70% of the therapy sessions were used for verbal reflection and 30% for improvising, fronto-temporal changes may prove that doing music therapy initialised neural reorganisation in areas which were busy with processing music and language in manifold ways, while offering the client a context to experience and embody a playful means of emotional expression supporting reduction of anxiety among and depressive withdrawal from others. Felicity’s work shares this offer to the clients: ‘an invitation to change’.

Prosody and emotion in music therapy treatment Previous music therapy research has encouraged a closer enquiry into music therapy and the enhancement of preverbal skills in expressing and communicating emotions 41 . In her three musical excerpts F. North exemplifies how vocalisation and communication link to music and language processing, and how the emotional colour of the voice can change in a musical dialogue. In the depression study, right-hemispheric activity increased after music therapy 30. Panksepp and Trevarthen42 discussed the importance of right hemispheric prosody in its connection to emotion processing and communicative musicality and already Patel et al 43 X-Ray Computed</keyword><keyword>Wechsler Scales</keyword></keywords><dates><year>1998</ year><pub-dates><date>Jan</date></pub-dates></ dates><isbn>0093-934X (Print had suggested a shared neural resource for prosody and music. In psychotherapy research speech prosody measures indicated emotional involvement during an interview on childhood memories 44. Koelsch et al 45 has stressed the close connection of semantic and syntactic functions in music and speech processing. Processing of melody is connected to pre-motor speech process activation at a laryngeal level, initiating pre-motoric level movement Ann. SBV, July-Dec 2016;5(2)

Music therapy and biomarkers of depression treatment

processes, especially when meaningful and rewarding emotional processes trigger perception-action mediation 38. Examining patients with lesions in Broca’s area, Sammler et al 46 discussed the left Inferior Frontal Gyrus as a functional prerequisite for processing musical syntax. Results with aphasic patients undergoing melodic intonation therapy showed plasticity changes in the fibre tract connecting the superior temporal and inferior frontal lobes and the motor cortex in the right anterior hemisphere 47,48. Right hemispheric activity at fronto-lateral sites is also linked to prosodic processing 35 . Williamsen et al. correlated reduced alpha, theta and delta power at F8 demonstrating that aprosodic expressive deficits of a client were “caused by cerebral damage to the right hemisphere region homologous to Broca's area” 35. Taking the fronto-lateral asymmetry changes in Fachner et al’s study and the findings on prosodic processing in these regions together, we may look at traces of emotional processing that occurred in music therapy with depressed clients.

OUTLOOK Music therapy is increasingly recognized as an area full of applied potential in the field of neuroscientific research 49 . Music therapists are attracted by brain research as some principles applied in therapy, such as the social aspects of music making 50, seem to be confirmed in neuroscientific research. However, music therapists and neuroscientists recognize the limitations of the tools and

paradigms of neuroscientific heuristics, but also their potential to visualize components of a music therapy action mechanism 51-53. Furthermore, outcome research aims to detect biomarkers and predictors of treatment response 15,30. Biomarkers like neurotransmitters (see below), hormones, cytokines, lymphocytes, vital signs, and immunoglobulins indicating music–related changes of psychoneuroimmunological status are seen as promising tools to study stress reduction and wellbeing from a music psychology perspective, that is to say, to use music more systematically, 54. Brain imaging methods are becoming more sophisticated and provide insights into formerly hidden cerebral processes related to human functioning and pathologies. Studies of the brain aim to show how music plasticizes fibers 48, sparks neurotransmitter cascades 55, and synchronizes body movement 56 and biological rhythms 57.

Interest is growing in the area of flow states, for instance, training musicians to enter a relaxed but highly concentrated state in preparation for an artistic performance in the orchestra. In jazz and rock bands neurofeedback (NFB) methods have been successfully applied in this area58,59 and aim to train the participant to control brainwaves that represent certain brain states, moods and emotions. However, engaging in NFB and bio–guided music therapy means that people learn to perform according to rules that put the music and the body into a harmonic relationship 33.

REFERENCES 1. Deshmukh AD, Sarvaiya AA, Seethalakshmi R, Nayak AS. Effect of Indian classical music on quality of sleep in depressed patients: A randomized controlled trial. Nordic Journal of Music Therapy. 2009;18(1):70-8.

2. Spintge R. Die therapeutisch-funktionalen Wirkungen von Musik aus medizinischer und neurphysiologischer Sicht - Musik als therapeutische Droge. In: Rösing H, editor.

Musik als Droge? Zu Theorie und Praxis bewußtseinsverändernder Wirkungen von Musik. Parlando - Schriften aus der Villa Musica. 1. Mainz: Villa Musica; 1991. p. 13-22.

3. Spintge R. Clinical Use of Music in Operating Theaters. In: MacDonald R, Kreutz G, Mitchell L, editors. Music, Health, and Wellbeing. Oxford - New York: Oxford University Press; 2012. p. 277 - 86.

4. Harikumar R, Raj M, Paul A, Harish K, Sunil Kumar K, Sandesh K, et al. Listening to music decreases need for sedative medication during colonoscopy: a randomized, controlled trail. Indian Journal of Gastroenterology. 2006;25(1):3.

5. Bringman H, Giesecke K, Thörne A, Bringman S. Relaxing music as pre-medication before surgery: a randomised controlled trial. Acta Anaesthesiologica Scandinavica.

2009;53(6):759-64.

6. Nickel AK, Hillecke T, Argstatter H, Bolay HV. Outcome research in music therapy: a step on the long road to an evidence-based treatment. Ann NY Acad Sci. 2005;1060:283-93.

7. Erkkilä J, Punkanen M, Fachner J, Ala-Ruona E, Pöntiö I, Tervaniemi M, et al. Individual music therapy for depression - Randomised Controlled Trial. Br J Psychiatry.

2011;199(2):132–9.

8. Fachner J, Erkkila J, Brabant O. On musical identities, social pharmacology and timing in music therapy. In: Hargreaves D, MacDonald R, Miell D, editors. Musical Identities. Oxford: Oxford University Press; 2016 in press.

9. Holsboer F. How can we realize the promise of personalized antidepressant medicines? Nature Reviews Neuroscience. 2008;9(8):638-46.

10. Lönnqvist J. Stressi ja depressio (Stress and depression) Helsinki: Kustannus Oy Duodecim; 2009 [Available from: http://www.terveyskirjasto.fi/terveyskirjasto/ tk.koti?p_artikkeli=seh00020.

11. Norris C. The medicated me [Essay]. NYC: http://chrisnorriswordsandmusic.com/; 2011 [updated 2011. Weblog]. Available from: http://chrisnorriswordsandmusic.com/ pages/stories/medicated.php.

12. Honkonen TI, Aro TA, Isometsa ET, Virtanen EM, Katila HO. Quality of treatment and disability compensation in depression: comparison of 2 nationally representative samples with a 10-year interval in Finland. J Clin Psychiatry. 2007;68(12):1886-93.

13. Greenberg RP, Goldman ED. Antidepressants, psychotherapy or their combination: Weighing Options for depression treatments. J Contemp Psychother. 2009;39, :83-91.

Ann. SBV, July-Dec 2016;5(2)

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Annals of SBV 14. De Gruttola VG, Clax P, DeMets DL, Downing GJ, Ellenberg SS, Friedman L, et al. Considerations in the evaluation of surrogate endpoints in clinical trials. summary of a National Institutes of Health workshop. Controlled Clinical Trials. 2001;22(5):485-502.

15. Gold C, Fachner J, Erkkilä J. Validity and reliability of electroencephalographic frontal alpha asymmetry and frontal midline theta as biomarkers for depression. Scand J Psychol. 2013;54(2):118-26.

16. Leiser SC, Dunlop J, Bowlby MR, Devilbiss DM. Aligning strategies for using EEG as a surrogate biomarker: A review of preclinical and clinical research. Biochemical Pharmacology. 2011;81(12):1408-21.

17. Baskaran A, Milev R, McIntyre RS. The neurobiology of the EEG biomarker as a predictor of treatment response in depression. Neuropharmacology. 2012;63(4):507-13.

18. Alhaj H, Wisniewski G, McAllister-Williams RH. The use of the EEG in measuring therapeutic drug action: focus on depression and antidepressants. Journal of Psychopharmacology. 2011;25(9):1175-91.

19. Erkkila J, Gold C, Fachner J, Ala-Ruona E, Punkanen M, Vanhala M. The effect of improvisational music therapy on the treatment of depression: protocol for a randomised controlled trial. BioMedCentral Psychiatry. 2008;8:50.

20. Erkkilä J, Ala-Ruona E, Punkanen M, Fachner J. Perspectives on creativity in improvisational, psychodynamic music therapy. In: Hargreaves D, Miell D, MacDonald R, editors. Musical Imaginations: multidisciplinary perspectives on creativity, performance and perception. Oxford: Oxford University Press; 2012. p. 414-28.

21. Fachner J, Erkkilä J. The Finnish research model of a music therapy practice treating depression. Musiktherapeutische Umschau. 2013;34(1):35–45.

22. Punkanen M, Eerola T, Erkkila J. Biased emotional recognition in depression: perception of emotions in music by depressed patients. J Affect Disord. 2011;130(1-2):118-26.

23. Aina Y, Susman JL. Understanding comorbidity with depression and anxiety disorders. J Am Osteopath Assoc. 2006;106(5 Suppl 2):S9-14.

24. Davidson RJ, Marshall JR, Tomarken AJ, Henriques JB. While a phobic waits: regional brain electrical and autonomic activity in social phobics during anticipation of public speaking. Biol Psychiatry. 2000;47(2):85-95.

25. Henriques JB, Davidson RJ. Left frontal hypoactivation in depression. Journal of Abnormal Psychology. 1991;100(4):535-45.

26. Joormann J, Gotlib IH. Emotion regulation in depression: relation to cognitive inhibition. Cognition & Emotion. 2010;24(2):281-98.

27. Field T, Martinez A, Nawrocki T, Pickens J, Fox NA, Schanberg S. Music shifts frontal EEG in depressed adolescents. Adolescence. 1998;33(129):109-16.

28. Jones NA, Field T. Massage and music therapies attenuate frontal EEG asymmetry in depressed adolescents. Adolescence. 1999;34(135):529-34.

29. Tornek A, Field T, Hernandez-Reif M, Diego M, Jones N. Music effects on EEG in intrusive and withdrawn mothers with depressive symptoms. Psychiatry : Interpersonal and Biological Processes. 2003;66(3):234-43.

30. Fachner J, Gold C, Erkkilä J. Music therapy modulates fronto-temporal activity in the rest-EEG in depressed clients. Brain Topography. 2013;26(2):338-54.

31. Thatcher RW. Validity and Reliability of Quantitative Electroencephalography. Journal of Neurotherapy. 2010;14(2):122 - 52.

32. Fachner J, Gold C, Ala-Ruona E, Punkanen M, Erkkilä J. Depression and music therapy treatment - clinical validity and reliability of EEG alpha asymmetry and frontal midline theta: three case studies. In: Demorest SM, Morrison SJ, Campbell PS, editors. Proceedings of the 11th International Conference on Music Perception and Cognition (CD-ROM). ICMPC. Seattle: University of Washington - School of Music; 2010. p. 11-8.

33. Miller EB. Bio-Guided Music Therapy. London: Jessica Kingsley Publishers; 2011.

34. Kolb B, Whishaw IQ. Fundamentals of human neuropsychology. 5th ed. New York, NY: Worth Publishers; 2003. 1 v. (various pagings) p.

35. Williamson JB, Harrison DW, Shenal BV, Rhodes R, Demaree HA. Quantitative EEG diagnostic confirmation of expressive aprosodia. Applied Neuropsychology.

2003;10(3):176-81.

36. Saletu B, Anderer P, Saletu-Zyhlarz GM. EEG topography and tomography (LORETA) in diagnosis and pharmacotherapy of depression. Clin EEG Neurosci. 2010;41(4):203-10.

37. Koelsch S. Brain and music. Oxford Wiley-Blackwell; 2012.

38. Koelsch S. A neuroscientific perspective on music therapy. Ann N Y Acad Sci. 2009;1169:374-84.

39. Omar R, Henley SM, Bartlett JW, Hailstone JC, Gordon E, Sauter DA, et al. The structural neuroanatomy of music emotion recognition: evidence from frontotemporal lobar degeneration. Neuroimage. 2011;56(3):1814-21.

40. Sluming V, Barrick T, Howard M, Cezayirli E, Mayes A, Roberts N. Voxel-based morphometry reveals increased gray matter density in Broca's area in male symphony orchestra musicians. Neuroimage. 2002;17(3):1613-22.

41. Aldridge D. Music therapy and research in medicine - from out of the silence. London: Jessica Kingsley Publishers; 1996.

42. Panksepp J, Trevarthen C. The neuroscience of emotion in music. In: Malloch S, Trevarthen C, editors. Communicative Musicality - Exploring the basis of human companionship. Oxford: Oxford University Press; 2009. p. 105-46.

43. Patel AD, Peretz I, Tramo M, Labreque R. Processing prosodic and musical patterns: a neuropsychological investigation. Brain and language. 1998;61(1):123-44.

44. Moneta M, Penna M, Loyola H, Buchheim A, Kächele H. Measuring emotion in the voice during psychotherapy interventions: Apilot study. Biological Research.

2008;41:389-95.

45. Koelsch S, Kasper E, Sammler D, Schulze K, Gunter T, Friederici AD. Music, language and meaning: brain signatures of semantic processing. Nat Neurosci. 2004;7(3):302-7.

46. Sammler D, Koelsch S, Friederici AD. Are left fronto-temporal brain areas a prerequisite for normal music-syntactic processing? Cortex. 2011;47(6):659-73.

47. Schlaug G. Part VI introduction: listening to and making music facilitates brain recovery processes. Ann N Y Acad Sci. 2009;1169:372-3.

48. Schlaug G, Marchina S, Norton A. Evidence for plasticity in white-matter tracts of patients with chronic Broca's aphasia undergoing intense intonation-based speech therapy. Ann N Y Acad Sci. 2009;1169:385-94.

49. Dalla Bella S, Kraus N, Overy K, Pantev C, Snyder JS, Tervaniemi M, et al. The Neurosciences and Music III : disorders and plasticity. Braaten D, Abrajano J, editors.

Boston, Mass.: Published by Blackwell Pub. on behalf of the New York Academy of Sciences; 2009. xi, 569 p. p.

50. Koelsch S, Stegemann T. The brain and positive biological effects in healthy and clinical populations. In: MacDonald R, Kreutz G, Mitchell L, editors. Music, Health and Well-Being. Oxford: OUP; 2012. p. (pp. 436-56).

51. Fachner J. Communicating change – meaningful moments, situated cognition and music therapy – a reply to North (2014). Psychology of Music. 2014;42(6):791-9.

52. Hunt A. Boundaries and potentials of traditional and alternative neuroscience research methods in music therapy research. . Front Hum Neurosci 2015;9(342).

53. Magee W, Stewart L. The challenges and benefits of a genuine partnership between Music Therapy and Neuroscience: a dialog between scientist and therapist. . Front Hum Neurosci. 2015; 9(:223).

54. Fancourt D, Ockelford A, Belai A. The psychoneuroimmunological effects of music: A systematic review and a new model. Brain, Behavior, and Immunity.

2014;36(February):15-26.

55. Menon V, Levitin DJ. The rewards of music listening: Response and physiological connectivity of the mesolimbic system. Neuroimage. 2005;28(1):175-84.

56. Toiviainen P, Luck G, Thompson M. Embodied metre: hierarchical eigenmodes in spontaneous movement to music. Cognitive Processing. 2009;10 Suppl 2:S325-7.

57. Balzer H-U. Chronobiology - as a foundation for and an approach to a new understanding of the influence of music. In: Haas R, Brandes V, editors. Music that works. Berlin: Springer; 2011. p. 25-83.

58. Egner T, Gruzelier JH. Ecological validity of neurofeedback: modulation of slow wave EEG enhances musical performance. Neuroreport. 2003;14(9):1221-4.

59. Gruzelier J. A theory of alpha/theta neurofeedback, creative performance enhancement, long distance functional connectivity and psychological integration. Cogn Process.

2009;10 Suppl 1:S101-9.

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INDIAN CLASSICAL MUSIC : AN OBJECTIVE SLUICE IN THE REALMS OF MIND- BODY MEDICINE Dr. VelloreA.R.Srinivasan, Professor, Department of Biochemistry and adjunct faculty, Centre for Music Therapy Education and Research (CMTER), Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India

HISTORICAL PERSPECTIVES Mind -body medicine employs the unique power of thoughts and emotions. This enables us to influence physical health that eventually leads to holistic health, wherein both physical and mental health acquire optimal attributes1.

It must be mentioned that several healing practices of the past including our Ayurvedic medicine had convincingly demonstrated the linkbetween the mind and the body2.In the West, the prevalent notion was that mind and body were separate entities and this concept essentially surfaced during the Renaissance and Enlightenment eras. A plethora of scientific and technological discoveries laid emphasis on diseasebased models, gross pathological changes, and curative modalities. But, in the twentieth century, mind and body in health and disease made an objective and evidence based reappearance. Several cardinal discoveries,with reference to pain perception, control and effects of stress on health opened newer vistas in the domains of complementary and alternative medicine 3.

Herbert Benson assigned the term relaxation response, while studying how meditation could influence blood pressure. In 1975, the well-knownpsychologist Robert Ader showed that mental and emotional cues could affect the immune system, which in turn largely regulates holistic health 4.

One of the earliest known documented references in the realms of music therapy dates back to 1789.

Incidentally, it appeared in a Columbian Magazine Ann. SBV, July-Dec 2016;5(2)

titled "Music Physically Considered." However, the medical fraternity had to wait till 1804, when the therapeutic value of music made its great appearance in medical dissertation, the first published one by Edwin Atlee . Soon, one more dissertation compiled by Samuel Mathews in the year 1806 came into the scene.

The credit must however go to Dr. Benjamin Rush, a physician and psychiatrist who was a strong votary of using music to treat medical diseases. Atlee and Mathews were his students. Thus, music therapy saw its genesis in the realms of mind body medicine. However, mention must be made of the fact that the moorings in mind-body medicine, as related to music therapy dates back to the Ayurveda era in Indian history. In the present context, the equivalent is salutogenesis.

Music medicine and therapy of our sub continent is synonymous with Ayurveda5.

AYU and VEDA which literally meanthe knowledge of long life is constituted by the single wordAyurveda . This represents the oldest existing medical system of India and has flourished over 5000years, because of its fundamental principles which acquire relevance in the modern era. Ayurveda has a holistic preventive and curative approach where the goal is not only to curtail the disease but also to maintain the Physical, mental and spiritual health of a healthy person. In the present context, the equivalent is salutogenesis.

Music medicine and therapy of our sub continent is synonymous with Ayurveda 6.

Techniques in mind body medicine: To train the mind so as to focus on the body without distraction is an essential tenet . In this state of focused concentration, the client/patient mayenvisage improvement in health.

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Of a variety of techniques employed in mind body medicine, mention must be made of the following:Biofeedbacktrains one to regulate processes that normally occur involuntarily. These processes can be measured and depicted on a monitor whichprovides feedback about the internal environs of the body 7. Based on these, it is possible to use CAM .Biofeedback has been received wellin a number of conditions including migraine, headache and chronic pain.Cognitive behavioral therapy is one more modalitythat helps enable people to recognize and attenuate harmful thoughts. Of all these, music therapy holds much promise and in recent years has been promulgated on a large scale the world over.

The mindâ&#x20AC;&#x201C;body nexus and Relaxation techniques:Hippocrates, the Greek physician of the Age of Pericles eulogized mind body medicine. He made the profound statementâ&#x20AC;? The natural healing force within each one of us is the greatest force in getting well." This forms the essential nucleus of mind body medicine, which in recent years has been creating a lot of interest and impetus in the world of medicine7.

When a person is physically or emotionally stressed, the body releases stress hormones that can affect several organs and systems. Depression, anxiety and emotional distress/turmoil may diminish the body's natural capacity to heal and precisely for this reason, emotions have been linked to diseases. The goal of mind-body techniques is to get the body and mind to relax and to reduce the levels of stress hormones in the body, so that the immune system is in a vantage position to combat illness. Mind-body techniques may help treat many different diseases, including several psychosomatic conditions. Some of the medical conditions include hypertension, ischaemic heart diseases, insomnia, irritable bowel disease etc. In recent years, such techniques have found use in palliative care too. However, it is to be noted that Mind-body medicine yields optimal results when combined with the conventional medical care.

There are 3 major types of relaxation techniques that have been recognized in mind body medicine, viz. autogenic training, which uses both visual imagery and body awareness to create a deep state of relaxation. Guided imagery and music (GIM) is presently acquiring enhanced significance in music therapy. GIMis considered as a psychodynamic and multimodal unique therapy that incorporates listening to music,while the client is in a deeply relaxed state.

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Thisprovokes imagery, memories and feelings that eventually help the client comprehend several facets of life, but from a holistic perspective. Western classical music has been used widely in GIM 8,9. However, Indian Classical music which boasts of a rich past, present and future should be considered as a rightful candidate for use in GIM. Progressive muscle relaxation and meditation are two other modes of relaxation techniques and music therapy/medicine has quite a lot of inputs in this arena.

Spiritual healing and mind body medicine :Providing compassionate care to the patient essentially means that the care provider should alleviate suffering, be it physical, emotional or spiritual. Spiritual healing is yet another mode that has been assuming greater relevance in recent years and it is in this context that music acquires the dimension of a healer and more so, in the light of the fact that Indian Classical Music has got a major spiritual component that is inherent 10.

Though a host of Mind-body techniques are presently available and are principally aimed at relaxation, stress attenuation, endurance, alleviation of tension and pain, and more importantly decreasing the requirements of pharmacological preparations, music therapy is objective and alleviates symptoms of anxiety and depression .

THE UNIQUENESS OF INDIAN CLASSICAL MUSIC Indian classical music is characterized by its elaborate, expressive and emphatic nature. Each of the Indian Classical mode is referred to as a rag or raga. The word 'raga' in Sanskrit means 'to please'. Each raga is typified by the presence of an ascending scale designated as arohana and a descending scale referred to as the avarohana. Akin to the Western classical music, the classical music of India segregates the octave into 12 semitones. Of these, Sa, RiGa Ma Pa DhaNi denote the basic notes. These notes are similar to Western music's Do Re MiFa So La Ti[11 Basically, Indian Classical music has two idioms, namely Carnatic or karnatik and Hindustani. The Karnatikmusic has 72 main or parent ragas designated as melakarta and hundreds of ragas ( musical modes) that are born out of these parent ragas-the janyaragas.

Hindustani music which is prevalent in the relatively northern areas of India follows a unique system, known as thaat. There are basically only 10 thaats12 Ann. SBV, July-Dec 2016;5(2)

Indian Classical Music : An objective sluice in the realms of Mind- Body Medicine

Indian music uses intonation tuning, unlike most modern Western classical music, thereby lending itself to greater improvisation. Indian classical music is monophonic .

Each of the ragas has select phrases known as jeevaswar(a).

Subtle oscillations of select notes in a musical mode, synonymous with the term gamaka or gamakendear Indian Classical music to experimentation that could effectively be used in music therapy13. In other words, Indian classical music depends upon melodic movement, that is, the occurrence of tones or musical notes to create a single line of tune, rather than upon harmony, which uses several lines of melody in pleasing contrast with each other, as is common in Western music. This facet of Indian classical music comes in handy while extending its services to the cause and practice of adjuvant music therapy.

INDIAN CLASSICAL MUSIC AND ITS EVOLUTION WITH RESPECT TO THERAPY Indian classical music therapy is an excellent complementary therapeutic modality that works on the principle of Mind- Body medicine. It not only rediscovers, but also enhances the inbuilt natural healing process. The proven benefits of classical Indian music rests largely on its ability to create beneficial effects. Classical music is more than an entertainment.

It is physically, psychologically, emotionally and even spiritually uplifting. Indian classical music forms an adjuvant therapy and has been inherited from our ancestors . The Vedas or holy scriptures of the Hindus have had reference to music. Of the four Vedas, music is believed to have evolved from Sama Veda.

GandharvaVeda, which is a constituent of SamaVeda, is regarded as the Veda of Music14.

Evidences are available to cite that the 72 ragascan influence the cardinal 72 nerves in the human body.

Singing or performing a raga or even listening to it can influence mind and body . However, it is imperative that the performer or the therapist applies principles in compliance withthe purity in pitch and effective use of intonations/ gamaks etc.15 The concept of Music Therapy in India is unique and is absolutely dependent on the use of correct/ appropriate intonation and the right mix of music. The Classical ragas are based on select notes . Since there are several musical modes or ragas in the Indian classical music, each having its inherent mood and texture , the possibility of using a particular raga as a therapeutic modality for a particular disease becomes an objective reality. Different types ofragas are applied in each of Ann. SBV, July-Dec 2016;5(2)

the different disorders/ diseases , a pronounced feature that needs to be taken cognizance of16.

THE ROLE OF AUTONOMIC NERVOUS SYSTEM IN MUSIC THERAPY The autonomic nervous system (ANS) acts as a bridge between the central nervous system (CNS; brain and spinal cord) and the major peripheral organs and organ systems. The organ systems of cardinal significance include circulatory, digestive, endocrine,integumentary, reproductive, respiratory etc. The ANS has two major branchesâ&#x20AC;&#x201D;a sympathetic branch, associated with energy mobilization, and a parasympathetic branch concerned with vegetative and restorative functions17.

Humanbeings interact with music, both consciously and subconsciously, at behavioral, emotional, and physiological levels. Pertaining to experimental studies, it is important to explore how specific features of Indian classical music (e.g., itsraga, beat, tempo, or pitch level) trigger neurophysiological, psychophysiological, emotional, and behavioral responses18. On the contrary, with respect to interventions with physiological targets, it is important to consider that ANS dysfunction is mediated by the CNS, and that treatment of the former should be sensitive to the state of the latter.

This concept needs to be effectively capitalized upon, while considering music therapy.

The use of ragas or musical modes is linked to the daily cyclical changes that occur in our own body and mind which are constantly undergoing subtle physiological changes. This could be capitalized in view of the fact that the Indian Classical Music modes are available to reflect the cyclical changes and perceptions

THE CAKRA SYSTEM AND INDIAN CLASSICAL MUSIC IN THERAPY: AN INSTANCE OF MIND â&#x20AC;&#x201C;BODY MEDICINE In the Indian scenario, music therapy has been allowed to evolve right from the Ayurveda age by facilitating its proximity to mind body medicine. There are seven chakras or centers in our body through which energy flows-the harbinger of mind body medicine 19.

The Omkar Therapy is regarded as a component of the Indian music that envisages the improvement of holistic health through music. It is interesting to note that a combination of specific notes or melodic scales can act on a specific chakra and bring typical effect.

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The RootCakra is synonymous withour feeling of being grounded. Sacralcakra enables us to endear with others and acquire new experiences. The Solar Plexus cakraenables us to be in control of our lives. The heart cakradenotes ability to like /love. Whereas, the throat cakra defines our ability to communicate, the third eye cakracentres around our ability to envisage the bigger picture, Thecrown cakra is the ultimate as it signifies the spiritual component. Thus, the cakra system of healing can very well explain the role of using classical Indian music as healing adjuvants 19 The variegated potentials of Indian music therapy: It is believed that the chakras enjoy nexus with different organs. As a result, any aberration in the functioning of an organcreatesan imbalance in the person. Different effects are perceived that vary with physiological psychological and emotional factors. Each effect is an attribute of the flux in mind body medicine. Furthermore, it is a matter of revelation that Indian classical music produces different physical, physiological and emotional contours in the listener 20.

or sacralcakra.This raga promotes internal meditation and stabilizes the vagal tone.

One of the most popular ragas that are in vogue in bothKarnatik and Hindustani idioms of Indian classical music is Abhogi. This raga enables the activation of the cakra in the navel region and thus stimulates the digestion process.

RagaShyamKalyan belonging to the Kalyanthaatin the Hindustani idiom helps to activate Mooladharacakra, thereby allowing the primal energy- theKundalini to rise gently and naturally, for conferring optimal benefits.

RagaBhairav and raga Durga in the Hindustani idiom of Classical Indian Music activate the heart cakra, thereby conferring equipoise and optimization of heart rate variability (HRV), by taking into due consideration the sympathetic and parasympathetic nervous inputs of the autonomic nervous system for optimization.

It has to be reiterated that more of experimental/ interventional studies on volunteers/ clients need to When the energy, typical vibrations and frequency be documented in PUBMED and other established of Indian classical music match with those of the databases, although there are isolated reports of such chakras, they get activated. This facilitates Kundalinior studies cited in the literature. primal energy that is located in the base of the spine to rise upward. While rising, the Kundalini nourishes INDIAN CLASSICAL MUSIC the chakras and provides proper energy to them. In AND EMOTIONS view of the fact that organs are connected with the chakras, they also acquire the appropriate and adequate The musical notes are shadja, rishaba, gandhara, energy required. Once the Kundalini finds its path to madhyama, panchama, dhaivata and nishada, while the rise, it rises and pierces through the fontanelle bone moods are shringar (love), hasya (laughter), karuna area facilitating connection with the cosmic energy. (compassion), vira (heroism), raudra (wrath), bhayanaka This activation process is synonymous with the use of (fear), bibhatsa (disgust) and adbhuta (wonder). Hence, music as an adjuvant therapeutic agent, though it is the classical music of India endears itself with the categorically stated that more of evidence based and emotions themselves, that are eventually regulated objectivised research inputs need to be acceded to the by the limbic component of the human brain. The armamentarium of adjuvant medicine 21. madhyama and panchama notes are used to create a feeling of love or laughter. Gandhara and nishadaare The use of ragas or musical modes is linked to evocative of compassion, while fear and disgust are aptly the daily cyclical changes that occur in our own body conveyed by resorting to the use of dhaivata. Shadja and mind which are constantly undergoing subtle and rishabacreate a mood of anger, courage or wonder23 physiological changes. This could be capitalized in view of the fact that the Indian Classical Music modes are The reaction to the music one listens to is both available to reflect the cyclical changes and perceptions the primary effect of the notes and their systematic arrangement, and a secondary effect of the thoughts Putative effects of some ragas as therapeutic agents 22: and moods evoked by the primary reaction. The brain processes music in a complex and yet subtle way, using The ragaYamanin the Hindustani idiom that resembles several different modes, such as perceptual, emotional, the 65thmelakartaraga Mechakalyani of Karnatik music cognitive, motor and autonomic. The sound waves has a power of sustenance by activating the Swadisthan impinge on the cochlea of the ear to produce effective signals, which reach the brainstem and finally the Page 44

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Indian Classical Music : An objective sluice in the realms of Mind- Body Medicine

auditory cortex of the brain.There are also additional areas involved in music perception, which help to define the pitch, the timbre or quality, the rhythm, the roughness and the loudness or intensity of the music24 Other areas, such as the amygdala and cingulate gyrusmay be responsible for the emotional reaction to music. Music which produces pleasure activates the frontal cortex, while the temporal lobe is active when listening to unpleasant music. Ironically, sadness in music is sometimes a source of defined pleasure as well as pain. This assumes relevance in music therapy25.

CONCLUSION • Raga based Indian music therapy is set to meet individual needs.Generalisation is not possible • Unlike other forms of music used in adjuvant therapy, Indian classical music has the spiritual component adhered to itself

• Raga based approach produces characteristic and nodal changes in the body which go a long way in alleviating stress and anxiety • Indian music therapy is believed to enhance concentration and attention span • Raga based music can be tailor made for the client, in view of the several choices that are made available . Typical musical modes are available such as those based on pentatonic, hexatonic scales etc.

• More evidence based research has to be summoned, if a few subjective aspects in Indian Classical Music Therapy need to essentially metamorphose into an objective sluice in the realms of Mind-body medicine.

REFERENCES 1. Barrows KA , Jacobs BP. Mind-body medicine. An introduction and review of the literature.MedClin North Am. 2002 Jan;86(1):11-31 2. Mukherjee PK , Harwansh RK , Bahadur S , Banerjee S , Kar A , Chanda J , Biswas S , Ahmmed SM , Katiyar CK. Development of Ayurveda - Tradition to trend.J Ethnopharmacol.2016 Sep 12.pii: S0378-8741(16)30782-6 3. Cheung CK, Wyman JF, HalconLL.Use of complementary and alternative therapies in community-dwelling older adults.JAltern Complement Med. 2007 Nov; 13(9):997-1006 4. Stahl JE, Dossett ML, LaJoie AS, Denninger JW, Mehta DH, Goldman R, Fricchione GL, Benson H.Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization.PLoS One. 2015 Oct 13;10(10):e0140212. doi: 10.1371/journal.pone.0140212. eCollection 2015 5. Nagarajan K, Srinivasan TM, Nagendra HR. Music therapy based on individual’s ‘biological humor’ –With reference to medical astrology: a review. http://iamj.in/posts/images/upload/528_543.pdf 6. Mind-body medicine.http://umm.edu/health/medical/altmed/treatment/mindbody-edicine 7. Rausa M ,PalombaD, Cevoli S, Lazzerini L, Sancisi E, CortelliP,PierangeliG.Biofeedback in the prophylactic treatment of medication overuse headache: a pilot randomized controlled trial.J Headache Pain. 2016 Dec;17(1):87. Epub 2016 Sep 22 8. Fasting and purification. http://www.greekmedicine.net/hygiene/Fasting_and_Purification.html 9. Beebe LH, Wyatt TH. Guided imagery and music: using the Bonny method to evoke emotion and access the unconscious. J PsychosocNursMent Health Serv. 2009 Jan;47(1):29-33 10. Music Therapy for Meditation. http://www.sahajayogaportal.org/en/music-therapy.html 11. Ludwig Pesch. The Oxford Illustrated Companion to South Indian Classical Music, Oxford University Press 12. Bor, Joep. The Rāga Guide, Charlottesville,Virginia: Nimbus Records ( 1999) 13. Sambamoorthy P. South Indian Music - Vol I, Chennai, India: The Indian Music Publishing House, p. 18.2005 14. Guy Beck . Sonic Theology: Hinduism and Sacred Sound, University of South Carolina Press, ISBN 978-0872498556, pages 107-108. 1993 15. Indian music : a therapeutic heritage-1. http://ayurveda-foryou.com/music/therapeutic-music1.html 16. Raga music therapy. http://www.pilu.in/raga-therapy.html 17. Okada K, Kurita A, Takase B, Otsuka T, Kodani E, Kusama Y, Atarashi H, Mizuno K. Effects of music therapy on autonomic nervous system activity, incidence of heart failure events, and plasma cytokine and catecholamine levels in elderly patients with cerebrovascular disease and dementia.Int Heart J. 2009 Jan;50(1):95-110 18. Banerjee A, Sanyal S, Sengupta R, Ghosh D. Music and its Effect on Body, Brain/Mind:A Study on Indian Perspective by Neurophysical Approach. http://blood-pressure.imedpub.com/ 19. Shang C. Emerging paradigms in mind-body medicine.J Altern Complement Med. 2001 Feb;7(1):83-91 20. Moore MM. Comparison of the Strength of Harmony, Melodic Line, Rhythmic Variation, and Expressive Elements in Influencing Emotional Judgment in Music. http://scholarworks.wmich.edu/cgi/viewcontent.cgi?article=1454&context=masters_theses 21. de Castro JM. Meditation has stronger relationships with mindfulness, kundalini, and mystical experiences than yoga or prayer.Conscious Cogn. 2015 Sep;35:115-27. doi: 10.1016/j.concog.2015.04.022. Epub 2015 May 22 22. Sanivarapu SL.India's rich musical heritage has a lot to offer to modern psychiatry.Indian J Psychiatry. 2015 Apr-Jun;57(2):210-3. doi: 10.4103/0019-5545.158201 23. Mathur A, Vijayakumar SH, Chakrabarti B, Singh NC. Emotional responses to Hindustani raga music: the role of musical structure. Front Psychol. 2015 Apr 30;6:513. doi: 10.3389/fpsyg.2015.00513. eCollection 2015.

24. Thomas L. Indian Music Therapy.http://www.news- medical.net/health/Indian-Music-Therapy.aspx 25. Nizamie SH, Tikka SK. Psychiatry and music. Indian J Psychiatry. 2014 Apr-Jun; 56(2): 128–140. doi: 10.4103/0019-5545.130482

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MUSIC THERAPY AND ANXIETY IN PREOPERATIVE STRESS Maria Montserrat Gimeno, Fellow Association for Music and Imagery Associate Professor at State University of New York at New Paltz

Numerous authors indicate that music therapy can alleviate the stressors from a hospital environment as well as the stressors from illness. It has been documented that for over 50 years, creative arts therapies have improved the quality of life for patients by facilitating relaxation, decreasing anxiety, and providing a distraction from the hospital environment.

Furthermore, O’Callaghan, suggests that music therapy can calm, relieve distress, promote supportive relationships, and encourage creativity.1,2More literature has shown that the anticipation of surgery produces a prominent amount of stress for patients.3,4 The anticipatory anxiety, may even impede the patient’s postoperative recovery process. In Oncological surgery, patients who experience preoperative anxiety have an increased likelihood of having post-operative anxiety.5It is well documented that this stressful experiences carries on as the patient is transported to the surgical holding area.6 The body reacts physiologically to anxiety by activating the hypothalamic-pituitary-adrenal axis and engaging the sympathetic nervous system to release hormones and catecholamines.7These physiological reactions manifest as high blood pressure, heart palpitations, sweating, and rapid breathing. Anxiety can affect a patient postoperatively as well; cortisol and catecholamines can negatively impacting the immune system and deter the healing process.State anxiety and trait anxiety are two subdivisions to note when understanding anxiety and stress. State anxiety refers to an emotional response to a stressful event, and is temporary. Trait anxiety refers to a personality trait of anxiety that persists consistently throughout one’s life.7 Anxiety can be alleviated by anxiolytic medications, but their negative side effects often render them undesirable prompting health care professionals to search for nonpharmacological means of relieving stress.8 The benefits of music therapy contribute to a sense of “normalcy” in an environment where one can become overstressed amidst hospital qualities such as chaos, coercion, and neglect.9Yung et al., reported in his study that patients who listened to slow music via earphones for 29 minutes before their surgery had a significant reduction in heart rate Page 46

respiratory rate and state of anxiety. In this study the authors select a panel of experts to decide which music will be used that had sedative characteristics.10 They defined music for sedation as having slow tempo and selected tree slow music types to use in the study. No more information was given in regards to the music elements on the pieces selected or the titles. Another study done by Alam et al., looked at the effects of recorded guided imagery, and relaxing music in reducing patient pain and anxiety during cutaneous surgical procedures. There was no significant difference between groups, but a reduction in anxiety.11 Considerable medical music therapy literature demonstrates the use of adapted music experiences to decrease the use of sedatives, analgesics, and anxiolytics. Presenting problems such as pain and anxiety are addressed in individualized music therapy treatment of patients in Oncology, Trauma, Burn, Psychiatric, and Toxicology units as well as in the waiting room of the emergency department. Music therapy has been studied with patients being weaned off mechanical ventilation, who are often administered sedatives that put the patient at risk for respiratory depression.11 Madsen and Silverman,13 found that playing live patient-preferred music could decrease patients’ anxiety, pain level, and nausea after receiving organ transplants, ultimately leading to an increased in their relaxation. Li and colleagues14 found that listening to patient-preferred music twice a day following a radical mastectomy helped to reduce anxiety. Each of these studies used music as a tool for promoting relaxation; however, they are missing the element of imagery. One technique in music therapy, called the Bonny Method of Guided Imagery and Music, has been proven to be very successful in reducing anxiety levels through the addition of guided imagery.15 The Bonny Method of Guided Imagery (BMGIM) was developed by Helen Bonny in 1970 at the Maryland Psychiatric Research Center.16 Goldberg,17 stated that this technique is considered unique in music therapy because it uses music to create an altered state of consciousness to further one’s own understanding of the self as cited by Beebe & Wyatt.16 Through this process, clients are given Ann. SBV, July-Dec 2016;5(2)

Music therapy and anxiety in preoperative stress

the opportunity to get an introspective look into their own imagery, helping them to explore problems, issues, and strengths. Through this inner-personal exploration, clients can confront and conquer the root of their anxiety, resulting in a higher state of relaxation.18 The Bonny Method has a history of being used in the medical field due to its ability to help with patients’ pain, confusion, anxiety, and depression that sometimes result from the physical impact of medical procedures.19 Adaptations of the Bonny Method were reported recently in a study done by Gimeno.20 In her study, she uses a music and imagery technique that she developed called Music Imagery Relaxation (MIR), to decrease anxiety and pain levels on post operatory patients. MIR generally takes between 2030 minutes, and the primary goal is to relax the body and the mind. It uses the concept of music and imagery to give patients the tools to reflect inwardly and conjure up positive images, promoting relaxation and decreasing anxiety. It does not dive

deep into the psyche of the patient as the Bonny Method does, but uses patient´s preferred music and on imagery to provide a relaxing experience. MIR showed statically significance in decreasing levels of anxiety and pain.20,21 Indeed, music therapy researchers identify music therapy uses in the alleviation of pain and anxiety as perhaps the most effective use of music therapy in the field. This research on pain management and stress reduction through music therapy is supported by further exploration in emotional foundations of music as a non-pharmacological treatment modality for pain management.22 Much research needs to be done on the use of music and imagery paired together to decrease pain and anxiety and as Gimeno20,21 states, MIR, the abbreviated version of the Bonny Method of guided imagery reinforce the well-known psychological effects of the mind over patient´s physiological responses showing that music and imagery can promote relaxation in the hospital environment.

REFERENCES 1. Haussmann NT. The role of the creative arts therapies in the treatment of pediatrichematology and oncology patients.Primary Psychiatry.2016. Retrieved from http://primarypsychiatry.com/the-role-of-the-creative-arts-therapies-in-the-treatment-of-pediatric-hematology-and-oncology-patients/ 2. O'Callaghan C. Music's relevance for children with cancer: Music therapists' qualitative clinical data-mining research. Social Work In Health Care. 2013;52(2/3), 125. doi: 10.1080/00981389.2012.737904 3. Garbee DD. Coping with stress of surgery [Case commentary].Association of Operating Room Nurses Journal.2001; 73, 946, 949–951.

4. Jelicic M, Bonke B. Preoperative anxiety and motives for surgery.Psychological Reports.1990; 68, 849–850.

5. Bilberg R, Nørgaard B, Overgaard S, Roessler K. Patient anxiety and concern as predictors for the perceived quality of treatment and patient reported outcome (PRO) in orthopaedic surgery. BMC Health Services Research.2012;12244.doi:10.1186/1472-6963-12-244.

6. Welsh J. (2000). Reducing patient stress in theatre.British Journal of Perioperative Nursing.2000;16, 321–322.

7. Pittman S, Kridli S. Music intervention and preoperative anxiety: An integrative review. International Nursing Revie.2011; 58, 157-163. Retrieved from http://eds. a.ebscohost.com.libdatabase.newpaltz.edu/ehost/pdfviewer/pdfviewer?sid=e4e71a9e-33ce-4fdf-8a42-2772bfa02126%40sessionmgr4004&vid=17&hid=4113 8. Binns-Turner PG, Wilson LL, Pryor ER, Boyd GL, Prickett CA. (2011). Perioperative music and its effects on anxiety, hemodynamics, and pain in women undergoing mastectomy.American Association of Nurse Anesthetists Journal.2011; 79, 21-27. Retrieved from http://eds.a.ebscohost.com.libdatabase.newpaltz.edu/ehost/pdfviewer/ pdfviewer?sid=e4e71a9e-33ce-4fdf-8a42-2772bfa02126%40sessionmgr4004&vid=21&hid=41 9. Robb SL, Clair AA, Watanabe M, Monahan PO, Azzouz F, Stouffer JW &Hannan A. (2008). Randomized controlled trial of the active music engagement (AME) intervention on children with cancer.Psycho-Oncology, 17(7), 699-708. doi:10.1002/pon.1301 10. Yung PMB, Kam SC, Lau BWK, Chan TMF. (2003). The effect of music in managing preoperative stress for chinese surgical patients in the operating room holding area: A controlled trial. International Journal of Stress Management, 10, 64-74. doi: 10.1037/1072-5245.10.1.64 11. Alam, M., Roongpisuthipong, W., Kim, N. A., Goyal, A., Swary, J. H., Brindise, R. T., Do, S. I., Pace, N., West, D. P.,Polavarapu, M. &Yoo, S. (2016). Utility of recorded guided imagery and relaxing music in reducing patient pain and anxiety, and surgeon anxiety, during cutaneous surgical procedures: A single-blinded randomized controlled trial. Journal MA Academy Dermatology. 1-4. Retrieve from: DOI: http://dx.doi.org/10.1016/j.jaad.2016.02.1143.

12. Hunter, B.C., Oliva, R., Sahler, O.J.Z., Gaisser, D., Salipante, D.M. &Arezina, C. (2010). Music therapy as an adjunctive treatment in the management of stress for patients being weaned from mechanical ventilation.Journal of Music Therapy, 47(3).198-219.

13. Madsen, A., & Silverman, M. (2010). The effect of music therapy on relaxation, anxiety, pain perception, and nausea in adult solid organ transplant patients.Journal Of Music Therapy, 47(3), 220-232.

14. Li, X., Yan, H., Zhou, K., Dang, S., Wang, D., & Zhang, Y. (2012). Effects of music therapy on pain among female breast cancer patients after radical mastectomy: Results from a randomized controlled trial. Breast Cancer Research and Treatment, 128, 411-419. doi: 10.1007/s10549-011-1533-z 15. Beebe, L. H. & Wyatt, T. H. (2009). Guided imagery & music: Using the bonny method to evoke emotion & access the unconscious. Journal of Psychosocial Nursing & Mental Health Services, 47(1), 29-33. Retrieved from http://search.proquest.com/docview/225534887?accountid=12761 16. Bonny, H. L., &Savary, L. M. (1973). Music and your mind: listening with a new consciousness. New York, NY: Harper & Row. 17. Goldberg, F. S. (1994). The Bonny method of guided imagery and music as individual and group treatment in short-term acute psychiatric hospice.Journal of the Association for Music and Imagery, 3, 19-33.

18. Ventre, M. (2002). The individual form of the Bonny Method of Guided Imagery and Music (BMGIM). In K. E. Bruscia& D. E. Grocke (Eds.), Guided imagery and music: the Bonny Method and beyond (pp. 29-35). Gilsum, NH: Barcelona Publishers.

19. Short, A. (2002). Guided imagery and music (GIM) in medical care. In K. E. Bruscia& D. E. Grocke (Eds.), Guided imagery and music: the Bonny Method and beyond (pp. 29-35). Gilsum, NH: Barcelona Publishers.

20. Gimeno, M. M. (2015a). The effects of music imagery relaxation technique (MIR) in medical setting.International Journal of Pharma and Bio Sciences.

21. Gimeno, M. M. (2015b). MED-GIM Adaptations of the Bonny method for medical patients: individual sessions. In Moe, T. & Grocke, D. E. (Eds).The Music Imagery - Guided Imagery and Music (GIM) Spectrum: A Continuum of Practice. Gilsum, NH: Barcelona Publishers.

22. Bernatzky, G., Presch, M., Anderson, M., Panksepp, J. (2011). Review: Emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neuroscience and Biobehavioral Reviews, 35. doi:10.1016/j.neubiorev.2011.06.005

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