The Physiology of Rhythm and Entrainment in Music-Thanatology
Kieran Schnabel
October 1
st
, 2011
Academic Research Paper
Music-Thanatology Training
Associated with Lane Community College
Acknowledgements: Thank you to all those authors and scholars whose work
allowed me to study and explore the depths of rhythm and entrainment in music-
thanatology. Thank you Margaret Pasquesi for advising me in this venture. Your
guidance has been much appreciated.
Copyright © 2011 Kieran Schnabel
The Physiology of Rhythm and Entrainment in Music-Thanatology
There are natural rhythms everywhere in the world. The oceans move
rhythmically in and out. The sun moves across the sky and sets to rise again the next day.
Many animate bodies breathe rhythmically and have hearts that beat rhythmically.
Webster’s Third New International Dictionary defines “Rhythm” as harmonious or
orderly movement, fluctuation, or variation with recurrences of action or situation at
fairly regular intervals. The question is, “How does rhythm affect the human body?”
The human body has a heart that beats regularly and sometimes irregularly. It breathes at
regular intervals as well. If external rhythms sound in proximity to the body, do they
affect the heart or breath of the body? When music is playing with regular rhythms, a
person can hardly stop themselves from moving in time to the music. This paper will
seek to explore the ways in which rhythms in music may affect the body at the end of
life.
Rhythm comes from the Latin word rhythmus, meaning “movement in time.” It
also comes from the Greek word rhythmos, which means “measured flow or movement.”
This word is related to rhein, meaning “to flow,” from the Proto-Indo-European base
sreu, also meaning “to flow.”
1
The Elements of Rhythm in Music
Rhythm in music is made up of three fundamental elements. They are pulse,
pace, and pattern. Meter and frequency exist within the fundamental elements and carry
import as well. “Pulse is the ongoing, relentless, steady, evenly spaced, ticking-clock
element of rhythm, referred to in music as ‘the beat’.”
2
Pulse gives music the attribute of
time and organizes or orders musical events through the repetition of strong and weak
beats. Pulse is the primary element of music to which the body entrains and is the
element to which we tap our feet or clap our hands.
3
Pulsating sound vibrations are
processed not only through the ear, but the entire body as well. The tactile system is the
body’s external system that senses sound vibrations as they disturb the air pressure by
using skin receptors including Meissner’s corpuscles, Merkel’s disks, pacinian
corpuscles, hair follicle receptors, tactile disks, and Ruffini endings.
4
The proprioceptive
system is the body’s internal system that senses sound vibrations as the muscular and
joint receptors buzz with the vibrations. It uses muscular and joint receptors including
muscle spindles, Golgi tendon organs, pacinian corpuscles, Ruffini endings, Golgi
endings, and free nerve endings.
5
These sensory systems are evident when a body moves
to music. The muscles of the body are entraining with the strong and weak pulses of the
music as they vibrate through their sensing of sound waves and wish to contract and relax
accordingly. This makes it difficult for the body to follow commands that contradict or
differ in pulsation from those it is already vibrating with.
Another way to imagine the pulse of music is to compare it to the tic toc of a
clock. Pulse could be defined as the tic toc clock that exists in music. Pace could then be
compared to the amount of time between each tic toc. The pace of a piece of music
becomes faster with less time between pulses and slower with more time between pulses.
It is the pace that decides how many pulses take place within a certain amount of time.
The amount of pulses within a minute is called the tempo. For example, if a tempo is set
at 60 pulses per minute, than each pulse will have one second between them. If the
tempo is 120, then the space between each pulse has been halved to one half second. One
way to feel the difference between these two different tempos is to watch a clock with a
second hand and walk in place with each pulse. Walking in place to 60 beats per minute
is quite easy and does not feel rushed. Walking in place to 120 pulses requires the body
to move much quicker and may feel rushed or perhaps energizing. This is a kinesthetic
experience of pace.
Pattern is the most complex element of rhythm. A pulse cannot convey much
information on its own. It is regular repetitive beats that can be fast or slow with pace.
Like the tic toc of a clock, the regularity and unchanging qualities of pulse do not allow it
to tell much of a story. A pulse may be fast or slow, or even have a certain loudness. But
when elements such as pace or loudness of the pulse are changed then it can be called a
pattern.
A prime example of pattern is Morse code. Morse code uses long and short
pulses in combination to create a pattern that can convey a large amount of information
or a “story.” This is exactly what the element of pattern provides for rhythm. The
patterns in music are created through change. The change need not occur in the pulse
itself, but can be a separate rhythmic line that moves around, beside, or on top of the
pulse. It is the rhythmic element of pattern that engages the brain.
“Although the exact mechanisms by which the body entrains
various rhythms are still not clearly understood, rhythmic patterns do
play an important role in maintaining the brain’s attention to acoustic
information, because… the brain does look for, and enjoys the
stimulation of, ever-changing information. It is always in a state of
attention, waiting in anticipation for the next event to occur, expecting
to make sense out of what it is perceiving.”
6
Rhythm without pattern is repetitive and it takes a lot of effort and attention for
the brain to attend to something that repeats without change. The brain seeks change to
interpret, but if rhythm contains ever-changing patterns, the music will maintain the
brain’s interest and attention.
One important concept that is necessary for rhythm to exist is that of
repetition. Repetition is a continuous disturbance. It is the repeated use of pulses that
allows rhythm to affect the body. It gives rhythm its consistent, stable, non-changing,
reliability that a listener or participator entrain to or become mesmerized by. Repetitive
pulses compel the listener to attend to the music. “(It is) the stimulation that keeps the
brain and body connected, and drives a piece of music to its conclusion…”
7
The pulse in music is often organized into a meter. Meter is the grouping of
pulses into a recurring pattern defined by accentuation. It often organizes pulses into
counts of 2s, 3s, 4s, 6s, and more. One or more of each of the pulses in a meter are
accented, giving the listener a clear sense of strong and weak “beats” that organize the
music into the various denominations.
At the foundation of the physical world there is energy and energy vibrates. The
rate at which energy vibrates is called its frequency. These vibrations are characterized
by cyclic or periodic events, which means that they occur at regular intervals. This is
most easily illustrated by imagining a pebble dropped into a still pond. The circles
created once the pebble is dropped are the peaks and valleys of the water as they expand
outward, one behind the other. The unit of measurement for frequency is that of “hertz”
named for the German physicist Heinrich R. Hertz. One hertz designates the passing of
one cycle per second. The human ear can hear sound when energy is vibrating in the 20-
20,000 cycle-per-second range. “In music, the anatomical perception of the frequency at
which sound energy vibrates is called the pitch of the sound, with slower vibrations being
perceived as lower-pitched sounds, and faster vibrations being perceived as higher-
pitched sounds.”
8
Frequency is inherent in sound and rhythm as regular pulsations is
inherent in the peaks and valleys of frequency.
Biorhythms: The Rhythms of the Body
The body is intrinsically an instrument of rhythm. It contains its own rhythms
that operate without thought, intent, or even consciousness. These biorhythms govern the
way we live our daily lives. We eat and sleep at regular intervals while our hearts beat
constantly and our lungs expand and contract in cycles. Our bodies operate in the same
way that all energy operates – with cycles. The human body constantly seeks to maintain
homeostasis in the way that all of energy moves to regain equilibrium after being
disturbed. If we revisit the pebble being dropped into a still pond, we can perceive the
move towards equilibrium. The pebble is dropped into the water – the water is forced
below its previously held state of equilibrium – elastic recoil or rebound causes the water
to move towards and past its equilibrium – each time it moves past the equilibrium it
creates the waves that are visible representations of the cycles.
9
As the disturbance is not
continuous (i.e. the rock was only dropped once and not repeatedly), the energy of the
disturbance becomes less and less each time it is spent on recoil or rebound – and
eventually the water regains its state of equilibrium. The body’s state of equilibrium is
called homeostasis. Homeostasis is constantly disturbed as the body processes food into
energy and then waste. The body does not contain an endless supply of food and so must
intake food at regular intervals. This response to regain homeostasis is the body’s basis
for cyclic or periodic events.
Another aspect of rhythm in the body is the cardiovascular system. The heart and
vessels of the cardiovascular system contract and relax sending blood throughout the
body in rhythmic intervals. The sinoatrial (SA) node is normally the origin of the cardiac
impulse. This impulse travels from the SA node through the atrial conducting fibers,
atrioventricular node, right and left branches of the AV bundle, and finally to the Purkinje
fibers. Each of these cardiac tissues helps to coordinate the pumping activities of the
atria and ventricles. The SA node is also known as the pacemaker of the heart as it fires a
cardiac impulse 60-100 times per minute.
10
The heart is especially unique in that the
cardiac impulse is created by the pacemaker cell without any help from extrinsic nerves.
In other words, the cardiac impulse that stimulates the heart beat comes from the heart
itself. If the SA node ever fails in its role as pacemaker there are other cells in the
ventricular conduction system that can generate the cardiac impulse. The rhythms of the
heartbeat are often referred to as “lubb-dupp, lubb-dupp.” “Lubb-dupp” is the sounds
made by the valves as they close and open between the chambers of the heart. These
heart sounds are made by the vibrations caused by the closure of the valves between the
chambers and vessels of the heart.
11
The main function of the heart is to pump blood through blood vessels to all the
cells in the body. The ventricles pump blood into the arteries an average of 72 times per
minute causing the arteries to expand and recoil with each beat of the heart. “This
alternating expansion and recoil creates a pressure wave (similar to vibration), which
travels through all the arteries. This wave is called the pulse.”
12
In this section that
discusses the heart, I will refer to this pulse as the anatomical pulse and the rhythmic
element of pulse as “rhythmic pulse” for clarity. The anatomical pulse can be felt at
numerous points where an artery is lying close to the surface of the body. In essence the
anatomical pulse conveys the strength, regularity, and pace of the heartbeat. It is a
gateway to the inner rhythm of the cardiovascular system – a rhythm that supports the
functions of the entire body and many of the other rhythms that occur in the body.
The heart has pace, frequency, pattern, and sometimes rhythmic pulse
characteristics in its comprehensive rhythm. The pace of rhythm in the heart is the space
between heart beats. If a heart is beating at 60 beats per minute, then there is exactly one
second between each beat. The frequency of the heart beat is between 1-4 Hz. Recall
that the range of human hearing is between 20-20,000 Hz, so medical staff uses
stethoscopes, which allow them to hear sounds normally outside of the range of human
hearing. The rhythmic pulse in the heart is only present when the heart is beating
regularly; that is to say the duration between beats is relatively unchanging. The heart
beat has a pattern in its regular lubb-dupp beat, as duration between lubb and dupp is
shorter than the duration between dupp and the next lubb. This may be easier to
understand when spelled out as a short-long, short-long pattern. Irregular heart beats may
also produce different patterns or even different paces.
The respiratory system also has rhythms of its own. This system transports
oxygen into the body and expels carbon dioxide from the body in rhythmic intervals. The
basic breathing pattern is mostly determined by the brain stem. Chemoreceptors in the
brain, carotid arteries, and the walls of the aorta sense levels of carbon dioxide, hydrogen
ion, and oxygen. They then stimulate the areas of the brain stem to alter breathing
patterns accordingly. Breathing rates are controlled primarily by the chemoreceptors that
sense carbon dioxide and hydrogen.
13
Respirations are much like the heart beats in that
they change according to the metabolic needs of the body. The body senses its needs to
maintain homeostasis and changes the rhythm of these two systems to fulfill its needs.
The respiratory system contains all three fundamental elements of rhythm. When
respirations are regular, that is they proceed with very similar amounts of space between
each breath, than they can be said to contain the element of pulse. When they are
irregular, they are not evenly spaced anymore and do not meet the definition of pulse.
The respiratory system has a very definitive pattern of inhale-exhale, and these patterns
change in abnormal respiratory models. Some of the more common abnormal respiratory
terms include: Apnea, Dyspnea, Tachypnea, Cheyne-Stokes respirations, and Kussmaul
breathing. Apnea is a temporary lack of breathing. Dyspnea is difficult or labored
breathing. Tachypnea is rapid breathing. Cheyne-Stokes is a cyclical series of shallow
breaths that gradually increase in depth and rate, decrease in depth and rate, and finally
cease altogether for 10-60 seconds before repeating. Kussmaul breathing is an increased
rate and depth of respirations caused by elevated acidity of the blood.
14
Each of these
various respiratory conditions contains elements of rhythm.
The pace of respirations is an extremely important sign of what may be going on
in the body. Respirations may accelerate due to the body’s need to gather oxygen or
exhale carbon dioxide; however it may also increase due to agitation, fear, or other
emotional stimulation. The rhythmic element of pace is present in respirations of all
forms including regular, irregular, and even apnea.
The nervous system is the source of many of the rhythms of the body as sensory
and motor nerves fire in cycles. The nervous system is the communication network of
the body. It gathers information from outside and inside the body through the senses,
brings that information to the Central Nervous System, and sends a plan of action out
through the motor nerves to various parts of the body. It is through the nervous system
that the organ systems receive direction about what the body needs, such as oxygen or
more blood. These messages from the nervous system are the fundamental root of how
the body processes the world and takes action accordingly.
The nervous system is not easily compared to the elements of rhythm as it is not a
single nerve or neuron that fires, but many. According to the neuroscientist Rodolfo
Llinas, the myriad rhythmicities of neurons firing in the brain produce an actual humming
(background signal) of constant electrical impulses which fire rhythmically across
synapses in the brain at about 40 Hz. “Dr. Llinas ascertained that the oscillation in the
gamma range of 40 Hz of neuronal rhythms in the brain, when amplified in his
laboratory, actually emitted hum-drone audible sounds.”
15
In other words, electrical
impulses from neuronal activity in the brain produce an audible drone when amplified. Is
this drone at the basis of how we interact with the sounds around us? Are particular
sounds more acceptable to an individual depending on how harmonious they are with that
individual’s neuronal drone?
The muscular system expresses some of the body’s interior rhythms, and carries
out the body’s reactions to adequate stimuli. For example, the lungs and throat are
muscles that carry the rhythmic aspects of the respirations out of the body through the
mouth. The chest rises as the lungs expand and falls as the lungs contract. The muscular
action of the heart pumping sends a pressure wave through the veins that can be felt or
perceived as the anatomical pulse. Adequate stimuli generating motor nerve impulses
effect change in the actions of the muscular system. This idea will be developed further
in the section on entrainment.
Bipedalism is one of the most explicit expressions of rhythm in the human body.
16
It usually contains two out of three of the primary elements of rhythm including pace and
pulse. At times when it does not contain pulse it may express the element of pattern
instead. “In reality, walking is the process of almost falling, some 80 times per
minute.”
17
The body leans forward and gravity pulls it downwards. This action disturbs
the balance and equilibrium of the body. The labyrinth or vestibular organ, as it is
sometimes called, senses the disturbance and sends a signal to the brain. The brain forms
a motor plan and sends it out, resulting in the body thrusting out a leg to catch itself
before it actual succumbs to falling.
18
The Phenomenon of Entrainment
“In 1665 the Dutch scientist Christian Huygens noticed that two pendulum clocks,
mounted side-by-side on a wall, would swing together in precise rhythm.”
19
Their
synchronicity was much more exact than could be achieved in seeking to match them
mechanically. Huygens conducted experiments to discover how the interaction took
place and found that they were linked through a slight impulse in the wall. This
connection came to be known as the “mutual phase-locking of two oscillators” or more
simply “entrainment.”
“Whenever two or more oscillators in the same field are pulsing at nearly the same time,
they tend to ‘lock in’ so that they are pulsing at exactly the same time. The reason,
simply stated, is that nature seeks the most efficient energy state, and it takes less energy
to pulse in cooperation than in opposition.”
20
This has been observed at all levels as universal. One example occurs in the
documentary The Incredible Machine, which investigates and explores the human heart.
There are two individual muscle cells from the heart seen through a microscope. They
are each beating with their own separate rhythms. They are then moved closer together
and before they touch, there is a sudden change in rhythms, and they are pulsing
together.
21
Entrainment of musical rhythms with biorhythms can be used to affect change in
or support biorhythms. Music-thanatologists deliver music to support the process that is
happening in the moment with the patient. Many people have experienced “that aerobic
exercises are most effective when undertaken in synchrony with the strong beat of loud
and repetitive rock music, which tends to support high-energy exertion, driving the rate
of exercise (we entrain to the beat and, too, to the speed of a tune).”
22
Music-
thanatologists sometimes seek to synchronize the pacing of the music to a patient’s
respiratory pace or pattern or their heartbeat as is sometimes evidenced by a visible
anatomical pulse in the neck. This not only offers a connection to the biorhythms of the
patient, but allows the music to support the existing rhythms of the body by joining the
patient exactly where that patient is. If the music is played at a slightly different pace
than that of the patient, then the patient’s body will seek to entrain with this slightly
different pace.
Physiologic entrainment will only occur if the stimulus (pace, pulse, or pattern) is
consistent and persistent. The persistent application of a certain stimulus will eventually
cause the body to reset its homeostatic set-points. Homeostatic set points are levels for
various systems that the body perceives to be optimum. Many of these set points are
caused by the need to survive and can and will change to suit that ultimate goal.
23
The
body will always try to regain those set-points as they are the body’s understanding of
where it is balanced.
When working with the concept of entrainment in the music vigil, one has to
consider not only the rhythms of the patient, and subsequently, the aspects of rhythm
chosen for the musical prescription, but a third source of rhythm; namely, the body of the
music-thanatologist present at the bedside. The body of the practitioner contains a
multiplicity of rhythms that may affect change in the music or the vigil. The clinician’s
heart rate is a sign of inner rhythms. By being conscious of what is going on in their own
body, the practitioner can add a whole other prescriptive element to the music vigil. For
example, in a situation that generates stress or high emotional levels, a practitioner’s
heart rate may speed up. This may subconsciously cause the practitioner to deliver their
music at a more rapid tempo. If a practitioner is aware of his/her internal rhythms, they
then have an opportunity, knowing that their body is inclined to speed up, to enter into
the vigil setting with a consciousness prepared to focus on the patient’s pace, rather than
their own.
Respiratory rhythms contain the potential for intentional synchronization. The
practitioner may mirror or follow the patient’s respiratory pattern with his/her own
respirations for a few moments. This connection can allow the practitioner a brief
glimpse into one aspect of the patient’s physical state. This also allows the practitioner to
embody the rhythms of the patient, giving the practitioner fundamental directions on how
to match the music to this aspect of the patient.
Entrainment is a tool that can be used by music-thanatologists to connect
intimately with patients, addressing not only physical needs, but emotional and spiritual
needs. Oscillators naturally entrain as it is the most efficient way of working together.
People entrain to each to accomplish bigger tasks than they can alone. Each relationship
contains some entrainment of expression, gesture, or sound that leads to a deeper
understanding, connection, or expression. Think of the sound of thousands of voices
chanting or singing together. How much connection and power do those voices carry?
Dr. William S. Condon of Boston University School of Medicine says, “The more you
move in rhythm with someone, the closer you become with that person.”
24
Rhythm as an Essential Musical Tool for the Music-Thanatologist
In creating a musical prescription for a patient, music-thanatologists draw from a
wide variety of musical elements, including many forms of rhythm. Sometimes the
music is metered and sometimes it is without meter, although not without rhythm. Free
time is music without a particular meter. Metered music requires that certain beats be
stronger while others are weaker, and groups beats or pulses into a certain structure that is
repeated. The repetition of this grouping provides a structure for the perceiver of the
music so that even when the musical notes do not follow this grouping anymore, the
perceiver will often still perceive the grouping. For example, if a music-thanatologist
offers music in a ¾ meter and transitions into music in free time, the perceiver will often
still feel the ¾ meter grouping of stronger and weaker beats for some time after it is gone.
The lack of meter is called free time or free rhythm. In Gregorian chant, free time
allows the language to take control of the rhythmic aspects of the music. The language
has natural accents that give certain notes strength or length depending on the particular
word. Music in free time is often used by music-thanatologists at the bedside of the
dying. As physiological systems begin to slow or even shut-down, their corresponding
external rhythms such as pulse or respirations may become irregular and weak. A music-
thanatologist approaches the bedside with the purpose of supporting a patient’s process.
Music in free time, without the structure of meter, often allows a closer synchronization
or entrainment to the patient’s respirations or pulse. Music in free time is often described
as more lyrical without regularly placed accents that remind us of a structure. The flow
of music in free time is like a river carrying the perceiver along in its current as it moves
along – slows, perhaps – but never truly stops. Rivers usually flow into a larger body of
water such as an ocean or the sea, as one may flow back to the earth or God.
Music in 2/4 time is made up of one strong beat and one weak beat. A march is a
widely known example of this meter. Music in 4/4 time has one strong beat, one less
strong beat, and two weaker beats. This time is also known as common time as it is the
most widely used meter. Both of these meters represent dualism that exists in the world,
and the body itself. Respirations contain the dualism of inhalation and exhalation. The
heart makes the sounds of lubb-dupp. Nerve firings are potential before they become
action. Motion and stillness exist in nature. The dualism of physics can be seen in the
pebble dropped in still water. The water moves below its equilibrium, elastically pulls
back above, below, above, below, until it regains its balance. There are a myriad of
dualisms present in the body and the surrounding world. These two meters can be used
to entrain or respond to these dualisms in patients and the vigil space.
Music in ¾ meter has one strong beat followed by two weak beats. Many people
associate a triple meter with a waltz or a lullaby. The music may feel like it is rocking as
the beats progress One two three, One two three. Lullabies are found in most cultures
around the world and are often used as a soothing song that encourages sleep. These
associations are carried by many and provide preset responses for relaxation and comfort
when a lullaby is played. This is not always the case, as there are many times when
metric music is not soothing for a patient at that particular time.
Whereas in many philosophies dualism represents mind-body, a triad represents
mind-body-spirit. The spiritual needs of a patient are some of the least perceivable at
times, but may be most important as the patient is nearing the end of life. The triad or
trinity is considered sacred in many spiritual or religious groups. The mind-body-spirit
understanding of the triad is the most widely appreciated in the Western world. In
Christianity, for example, the trinity represents the Father, Son, and Holy Spirits. In
Celtic tradition and mythology figures or objects are often grouped in threes, and
creatures have three faces or heads. Some people believe that the third in a triad
represents the in-between of many dualisms. Day and night always has dawn or dusk in
between. The past and the future maintain a connection through the present. The number
three contains unity in the number one and dualism in the number two within it. This is
also the way in which they are typically grouped in a ¾ meter with the first beat strongly
played and the second and third beats played equally less strong.
How Biorhythms may be affected by Heart or Respiratory Failure
Music-thanatologists encounter a variety of disease processes in their work as
medical-musical clinicians. Each disease process acts uniquely in a particular individual
changing their biorhythms as it develops. A couple of the most common disease
processes are Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart
Failure (CHF). Knowing the ways in which these diseases might affect the rhythms of
the body will help to inform the music-thanatologists in their prescriptions.
COPD is the name for a group of lung diseases in which damage to respiratory
airways eventually obstructs the airflow. This impedes the general purpose of the
airways which is to facilitate the exchange of oxygen and carbon dioxide in the lungs.
Emphysema and chronic bronchitis are the most common diseases that are covered under
the title COPD. The two primary biorhythms that music-thanatologists work with are the
respiratory and cardiac rhythms. The respiratory rhythms can be changed by COPD in a
variety of ways in different patients, although many people experience dyspnea and
tachypnea. Dyspnea is shortness of breath or difficulty breathing. It may present with
tachypnea which is rapid breathing at over 20 breaths per minute. When COPD obstructs
airflow, the cardiac system seeks to compensate by accelerating its function of
transporting oxygen out into the blood and carrying as much carbon dioxide out as
possible. The lack of oxygen eventually causes the heart to slow down as well as it needs
oxygen to function.
Heart failure occurs when the heart can no longer pump enough blood to the rest
of the body. It is called systolic heart failure when the heart cannot pump the blood out
of the heart very well. Diastolic heart failure occurs when the heart muscles are stiff and
do not easily fill up with blood. The heart carries oxygen and nutrition in the blood to the
organs of the body. In chronic heart failure, the body is not receiving sufficient amounts
of oxygen and nutrition, which results in damage and a reduction in their ability to
function. Heart failure can often result in a pulmonary edema, which is fluid leakage into
the lungs. Pulmonary edemas lead to shortness of breath which can present as wheezing,
coughing, or gasping. All of these symptoms affect the respiratory rhythms. Wheezing
can affect the pace of respirations. Coughing disrupts the pulse, pace, and pattern of
respirations. Gasping may affect the pulse, pace, and especially the pattern as well. One
of the primary symptoms of heart failure is that of arrhythmias, which are abnormal heart
rhythms. Arrhythmias present as irregular or rapid pulse. All rhythmic aspects of the
pulse will change due to arrhythmias. Many rhythmic aspects of the body in general will
be disrupted as homeostasis breaks down, and each part of the body experiences a lack of
blood flow and thus oxygen and nutrients.
Clinical Examples of Rhythm and Heart and Respiratory Failure
The following is an excerpt from a narrative of a vigil in which rhythmic
entrainment may have caused change in a patient with heart and respiratory failure. The
name has been changed to protect the identity of the patient.
Cecil is lying slightly on his side facing the window and his family. We
greet him and Cecil’s eyes and head move towards us for a moment. The room
settles into an expectant silence as we observe Cecil’s breathing. He has a nasal
cannula and is breathing regularly at 20 breaths per minute. His breathing is easy
but very shallow. Cecil is obese and has an amputation of the lower right leg
below the knee. He has very thin hair on a round head. His face is relaxed with
unfocused eyes gazing out towards the window. An un-metered chant with
regular rhythms begins with soft rolled chords introducing the major tonalities of
a strophic hymn. It is delivered in a regular rhythmic pattern accompanying
Cecil’s regular breathing. As soon as the music begins, Cecil raises his left arm
and waves it slowly up and down. The melody moves up into the middle of the
phrase and down as the phrase winds down. This melodic movement reflects
Cecil’s arm movement and after thirty seconds, the arm movements cease. His
breathing deepens as we continue to synchronize the tempo of the music with it.
Cecil’s wife Patsy looks at us in the silence following the music. “He
hasn’t been breathing that easily for a few days,” she says. We nod in agreement
and a few more seconds of silence pass. She continues, “That sounds just like
meadow music. Isn’t it strange how some music can just create a surrounding
with such detail? This just put me under an apple tree with fields all around me.”
A lullaby in C major takes shape with sung lyrics responding to Patsy’s pastoral
feeling with words portraying twilight and the quality of love in relationship.
Vocal harmonies are offered quietly for emotional support as Cecil begins to
snore quietly. Patsy is watching her husband as he snores and many of the other
family members are sitting quietly. There is a brief ringing of a cell phone or
other device, but it is stifled quickly. The harmonies continue into another verse
moving through a large ambitus offering lower and higher tones for potential
movement or transition. Cecil’s snores end although his breathing does not
return to being shallow.
There is silence for about a minute that is unbroken except for a couple
of family members that join the room. A Macaronic hymn with a small ambitus
of a fifth is introduced. It has phrases that are repeated in a triple meter. The
music moves along with one measure accompanying one of Cecil’s breaths.
Cecil points one finger upwards and his family immediately tells us this means
that he likes the music. The small ambitus, repeated phrases, and almost
exclusive use of two bass harmonies are offering little substance to engage Cecil
allowing for Cecil’s own journey to take place within the spare framework of the
music. Lyrics are brought in with vocal harmonies containing little movement
and continuing the emotional but non-engaging aspects of the offering. A final
blessing carrying many of the same qualities including hypodorian mode, meter,
short repeated phrases, and a small ambitus is offered in response to Cecil’s
approval. Cecil is still breathing at 20 respirations per minute and his unfocused
gaze remains on the window. Cecil’s family is effusive in their thanks as we
stand up from the harps. Cecil’s eyes never stray from the window as we say our
goodbyes to Cecil and his family. The room feels peaceful despite all the
movement and I feel gratitude as we leave.
25
Cecil’s family remarked that his breathing was easier than it had been in days, and
all of his other therapies remained unchanged during the vigil. These observations are
enough to suggest that this change occurred as a result of the work of the music-
thanatologists. One of the observations at the start of the vigil is that Cecil’s respirations
are easy. One may not expect this, as Cecil has both CHF and COPD. Cecil also has a
nasal cannula that is delivering him oxygen, which supplements regular breathing,
allowing his body to receive the amount of oxygen necessary to function in a relatively
sustainable fashion. The incredibly shallow breathing Cecil experiences at the start of the
vigil occurs often in patients with pulmonary edema. A 4/4 meter is offered early in the
vigil with regular pulse, pace, and pattern, to entrain to the regular breathing of the
patient. Each beat accompanies one of Cecil’s exhales. His breathing deepens almost
immediately once the regular rhythms of the music entrain to it. The respiratory system
of the body is supported by the sound waves of the harp as it vibrates in synchrony with
the respirations. Schneck and Berger write that the pulse and pace of rhythm assists in
physical coordination.
26
Perhaps it is the assistance of physical coordination that
supports a deepening of Cecil’s respirations. “It may be that what is sensed as ‘pleasing’
corresponds to the physiological sensation one experiences when the human system
entrains vibrations that resonate synchronously and comfortably with the natural
frequencies of body tissues and organs, a kind of constructive interference pattern, if you
will, between the music and the body.”
27
This is an excerpt of another vigil in which a patient has a sole diagnosis of end-
stage COPD and respiratory failure.
Bruce is a 58 year old man who has end-stage COPD and respiratory
failure. He came into the hospital with shortness of breath and generalized pain.
He has told the nurses and chaplain that he wants to die. He has had two vigils,
with two different music-thanatologists. The first was five minutes before he
asked to stop. Bruce is reported to have a lower level of consciousness at the
time of the second vigil, and falls asleep during it. Bruce has his eyes closed
when we arrive and does not respond as we greet him. Bruce’s medical notes
show that he has family, but so far none has been present during a vigil.
Bruce’s respirations are irregular, very shallow, labored, and quite fast at
34 per/min. His lower chest moves slightly after each breath as if it has its own
separate respiratory rate. The room is quiet amidst Bruce’s labored breathing.
An unmetered chant enters joining the irregular breathing with rhythmically
flexible melodies in fixed Lydian mode. This mode contains the same intervallic
journey as the major scale and mirrors the warm light streaming in from the large
windows. Bruce’s eyebrows rise distinctly for a moment before relaxing again.
The music is offered with blocked and broken fifths as spare accompaniment for
spaciousness. This quality supports restfullness for Bruce who is working so
hard to breathe.
There is silence for a minute or two and Bruce’s breathing sounds loud in
it. I wonder where the obstruction is located in Bruce’s respiratory system. Is it
like a boulder sitting in his stream of air or sand that has narrowed the banks of
his respiration stream. A Hypodorian hymn sounds in the room. It’s text is a
plea for God’s help and it makes me think of Bruce’s wish to die. The music
moves gently in ¾ meter and almost exclusively stepwise movement. The
stepwise movement lends the melody a flow much like the air I was imagining
earlier and the meter offers structure and support to Bruce’s laborious breathing.
Hypodorian mode mirrors his interior state. His mouth pulls down in a grimace
as the music dies away. We sit in the silence counting Bruce’s respirations
which have slowed somewhat.
Music responds to the movements of Bruce’s face with a blessing in
Hypodorian. Short melodic phrases are repeated offering familiarity and an
opportunity to disengage as the music does not continue to offer new material.
The music is in a ¾ meter and moves at a pace of one measure of music to
roughly one of Bruce’s breaths. A small moan escapes Bruce as vocals are
added, and I notice apneic periods in his breathing. The door opens and a young
woman and a man enter quietly. The music progresses as it is repeated, and soft
vocal harmonies are added in thirds above the melody and later below the
melody. The young woman is tearful and vocal harmonies continue to be sung,
alternating between the vocalists, offering emotional support.
We introduce ourselves in the silence following the blessing and find out
that the young woman and man are Bruce’s son and daughter. They move over
to stand by the window and we ask if we should continue. The daughter says the
music is good and that she believes her father would like it. Bruce’s breathing is
still labored and shallow but has slowed to 16/min with apneic periods of seven
seconds. A visionlieder begins with low tones on the harp that resonate quietly
in the room offering grounding and solidarity. The prescription of structure
through meter to support Bruce’s breathing continues. The music also offers
safety through the structure of meter and the familiar major scale to Bruce’s
children. They begin to talk quietly to each other as the music repeats. The last
two phrases are played again in a postlude that becomes quieter and quieter
falling into silence. We ask Bruce’s children if they would like some time alone
with their father and the daughter responds that that would be nice. They are
gracious in thanking us as we leave.
28
The significant change that was observed in Bruce during this vigil is that of the
pace of his respirations. Bruce’s respirations are quite fast at the start of the vigil with 34
per minute. At vigil’s end, Bruce’s respirations have slowed to 16 per minute with up to
seven seconds between each breath. A chant without meter was offered at the beginning
of the vigil to connect with Bruce’s irregular breathing. The lack of meter allows the
music’s flexibility to join the constantly changing rhythms of Bruce’s respirations.
Unlike metered offerings, each pulse, or a regularly numbered pulse (such as the first beat
of every measure) will not land on a breath. Music without meter is generally played so
that a beginning of a melodic line or accented tone synchronizes with a breath. The
music then evolves into a different approach, where the music is very structured
rhythmically through the use of a regular meter. This does not allow the music to
synchronize with the irregular rhythms of Bruce’s respirations, but instead offers a
structure and regularity to which Bruce’s respiratory system can synchronize. Bruce’s
respirations did not become deeper or easier, but they slowed significantly. Why did they
slow down? One distinct possibility is that the music’s pulse was considerably slower
than that of Bruce’s respirations. Bruce’s body may have been pulled into synchrony
with a slower pace, as the body synchronizes to the strong regular pulse of music. One
other consideration is that many studies have shown music in general to lower anxiety
and emotional stress.
29, 30
Both anxiety and emotional stress manifest physiologically,
and if Bruce’s anxiety decreased, this could be the reason his respiratory rate decreased.
“There is no way we can escape it. Rhythmic entrainment, like all
powerful processes, can be used for good or ill, to gain power or to withhold it
from others. Rhythm can be captured or confused or broken. But only for so
long. Ultimately, entrainment stands beyond manipulation, for it is the stuff of
life itself, echoing the essential connectedness that defines existence. Different
cultures speak and move in different specific rhythms, but the process of
rhythmic connectedness is the same for all cultures. The autistic child is beset by
contradictory rhythms, but at the heart of this life, as with all lives, there is the
pulse of perfect rhythm.”
31
Rhythm in the world surrounds us – everything vibrates. If it vibrates in close
proximity and at a similar pace to an oscillator in our bodies than entrainment will occur.
It is through entrainment that rhythm offers us a connection to our patients. We must be
sensitive in joining our patients rhythmically for once entrained, rhythmic changes may
bring about alterations in many of the gross oscillatory systems of the body including the
cardiovascular, respiratory, and muscular systems. Music-thanatology is not an outcome-
based field and yet it is a practice that effects change in its patients. Rhythm is one of the
primary music components that can effect change and must be treated with care. George
Leonard speaks of a perfect rhythm that exists in each individual being. When this
perfect rhythm is disturbed it can lead to disease or dis-ease. Music-thanatologists are
not seeking to resolve a disturbed rhythm, but seek to be aware of and support an
individual’s unique rhythm as they move through their journey at the end of life. It is a
music-thanatologist’s job to be as adept as possible in listening to their patients. They
have much to tell us, so that we may best serve them.
Notes
1
Douglas Harper, “Rhythm” Online Etymology Dictionary, May-June 2011,
.
2
Daniel J. Schneck and Dorita S. Berger, The Music Effect: Music Physiology
and Clinical Applications, (London: Jessica Kingsley, 2006) 144.
3
Schneck and Berger 143.
4
Schneck and Berger 143.
5
Schneck and Berger 143.
6
Schneck and Berger 154.
7
Schneck and Berger 157.
8
Schneck and Berger 47.
9
Schneck and Berger 38-89.
10
Barbara L. Herlihy, The Human Body in Health and Illness, (St. Louis:
Saunders Elsevier, 2007) 293.
11
Herlihy 289.
12
Herlihy 326.
13
Herlihy 390.
14
Herlihy 391.
15
Schneck and Berger 140.
16
Steven J. Mithen, The Singing Neanderthals: the Origins of Music, Language,
Mind, and Body, (Cambridge, MA: Harvard UP, 2006).
17
Schneck and Berger 139-140.
18
Schneck and Berger 139-140.
19
George Leonard, The Silent Pulse: a Search for the Perfect Rhythm That Exists
in Each of Us, (Layton, UT: Gibbs Smith, 2006) 23.
20
Leonard 23.
21
Leonard 24.
22
Schneck and Berger 144.
23
Schneck and Berger 19.
24
Leonard 31.
25
Kieran O. Schnabel, Clinical Assessment #5, (Dec. 2010).
26
Schneck and Berger 158.
27
Schneck and berger 195.
28
Kieran O. Schnabel, Clinical Assessment #17, (March 2011).
29
E. Mok and KY. Wong, “Effects of Music on Patient Anxiety.” PubMed.gov,
Feb. 2003, 01 Oct. 2011 .
30
MJ Winter, S. Paskin, and T. Baker, “Music reduces Stress and Anxiety of
Patients in the Surgical Holding area.” PubMed.gov, Dec. 1994, 01 Oct. 2011,
.
31
Leonard 35.
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