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Original Research: COPD |

Distractive Auditory Stimuli in the Form of Music in Individuals With COPDDistractive Auditory Stimuli in COPD: A Systematic Review FREE TO VIEW

Annemarie L. Lee, PhD; Laura Desveaux, MScPT; Roger S. Goldstein, MD, FCCP; Dina Brooks, PhD
Author and Funding Information

From the Respiratory Medicine Service (Drs Lee, Goldstein, and Brooks and Ms Desveaux), West Park Healthcare Centre, the Department of Physical Therapy (Drs Lee, Goldstein, and Brooks and Ms Desveaux), and the Department of Medicine (Dr Goldstein), University of Toronto, Toronto, ON, Canada.

CORRESPONDENCE TO: Dina Brooks, PhD, Department of Physical Therapy, University of Toronto, 160-500 University Ave, Toronto, ON, M5G 1V7, Canada; e-mail: dina.brooks@utoronto.ca


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(2):417-429. doi:10.1378/chest.14-2168
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BACKGROUND:  Music has been used as a distractive auditory stimulus (DAS) in patients with COPD, but its effects are unclear. This systematic review aimed to establish the effect of DAS on exercise capacity, symptoms, and health-related quality of life (HRQOL) under three conditions: (1) during exercise training, (2) during exercise testing, and (3) for symptom management at rest.

METHODS:  Randomized controlled or crossover trials as well as cohort studies of DAS during exercise training, during formal exercise testing, and for symptom management among individuals with COPD were identified from a search of seven databases. Two reviewers independently assessed study quality. Weighted mean differences (WMDs) with 95% CIs were calculated using a random-effects model.

RESULTS:  Thirteen studies (12 of which were randomized controlled or crossover trials) in 415 participants were included. DAS increased exercise capacity when applied over at least 2 months of exercise training (WMD, 98 m; 95% CI, 47-150 m). HRQOL improved only after a training duration of 3 months. Less dyspnea was noted with DAS during exercise training, but this was not consistently observed in short-term exercise testing or as a symptom management strategy at rest.

CONCLUSIONS:  DAS appears to reduce symptoms of dyspnea and fatigue when used during exercise training, with benefits observed in exercise capacity and HRQOL. When applied during exercise testing, the effects on exercise capacity and symptoms and as a strategy for symptom management at rest are inconsistent.

Figures in this Article

Although dyspnea and fatigue are common symptoms in COPD,1 concomitant anxiety has also been described, with a prevalence of 2% to 96%.24 Anxiety accompanying dyspnea on exertion59 has been linked to reduced physical activity in COPD,10 a strong predictor of survival in stable COPD.11 Identifying treatment approaches that will maximize physical activity is, therefore, important.

The current international guidelines for COPD management recommend pulmonary rehabilitation (PR),1,12 which results in reduced dyspnea, improved exercise tolerance and health-related quality of life (HRQOL),13 and diminished anxiety.14,15 These improvements are partially achieved by altering the perception of breathlessness through the repetition of exercise in a safe and supervised environment,16,17 which may assist in alleviating the fear of dyspnea.18,19

One approach by which desensitization to symptoms during exercise may be further facilitated is through attentional distraction, such as distractive auditory stimulus (DAS) therapy. Modes of distracters may include background auditory noise, irrelevant dialogue, or listening to music.2022 Attending to DAS (music) during exercise reduces the ability to simultaneously attend to the sensation of fatigue.23 This change from a narrow internal focus on fatigue to an external focus on DAS decreases or delays the perception of exercise-induced fatigue, resulting in a higher workload in healthy individuals, particularly during high-intensity or prolonged training.21,2427 When applied in patients with cardiac disease or cancer, this form of DAS has also been associated with reduced anxiety and improved HRQOL.28,29 The musical distraction should be sufficiently arousing to compete with the mental processing of the fatigue stimulus to alter symptom perception.20,30,31 In addition, the beneficial effects of DAS may depend on the type of music, with both tempo and rhythm being important factors, the option to self-select music and the association between the type of music and mode and intensity of exercise.32 The effects of DAS on individuals with COPD has been explored during exercise training,3336 during exercise testing,37,38 and for alleviating symptoms of dyspnea and anxiety at rest.39 Despite this research, the overall effects of DAS are unclear, and the role of this adjunct therapy in COPD requires clarification.

The primary aim of this review was to determine the effects of DAS in the form of music applied under three conditions—(1) during exercise training, (2) during exercise testing, and (3) at rest—on the outcomes of exercise capacity, symptoms, HRQOL, functional performance, and psychologic symptoms in individuals with COPD. This review was registered with PROSPERO (No. 42012002950) and is reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.40

Search Strategy

The primary search strategy used the MEDLINE, CINAHL, Embase, PubMed, CAIRSS (Computer-Assisted Information Retrieval Service System) for Music, Cochrane Database of Systematic Reviews, and Physiotherapy Evidence Database (PEDro) electronic databases from inception to June 2014. The key terms were “COPD/chronic obstructive pulmonary disease, pulmonary obstructive lung disease,” “music therapy, distractive stimuli, auditory stimuli,” “pulmonary rehabilitation/exercise therapy/exercise testing,” and “symptoms/dyspnea/anxiety/depression.” These terms were applied for each of the three conditions investigated: exercise training, exercise testing, and symptom management at rest.

The search strategy used for MEDLINE is shown in e-Appendix 1 and was adapted for use in the other databases. Secondary searches involved hand searching reference lists from identified articles, citation tracking of included articles, and use of the PubMed related articles option.

Inclusion Criteria

Two investigators (A. L. L. and L. D.) reviewed titles and abstracts independently, and potentially relevant articles were identified and retrieved in full text for independent assessment using the inclusion criteria. Any disagreements were resolved by consensus or in consultation with a third reviewer (D. B.) when necessary. Abstracts were included if sufficient data could be obtained. The inclusion criteria are outlined in Table 1.

Table Graphic Jump Location
TABLE 1 ]  Inclusion Criteria for Studies

6MWT = 6-min walk test; CPET = cardiopulmonary exercise test; DAS = distractive auditory stimulus; ESWT = endurance shuttle walk test; HRQOL = health-related quality of life; ISWT = incremental shuttle walk test.

a 

Outcome measures included instruments or formal tests that may or may not have established reliability and validity in the COPD population.

Data Extraction and Quality Assessment

Two investigators (A. L. L. and D. B.) independently assessed the internal validity of the randomized controlled and crossover studies using the PEDro scale.41,42 Two investigators (A. L. L. and L. D.) applied the Downs and Black43 tool for observational studies. This tool comprises 27 questions relating to study description and external and internal validity, with a maximum score of 27.43,44 GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria, which included assessment of risk of bias, inconsistency, indirectness, imprecision, and publication bias, were used to determine an overall quality grading for each outcome measure within the three studied conditions.45 Data extraction was performed by one investigator (A. L. L.) using a standardized template,46 with data checked by a second author. Authors of included studies were contacted when necessary to obtain additional information.

Data Analysis

Meta-analysis was planned for two or more studies considered clinically homogenous (similar model of intervention and outcome tools).47 Data were entered using the Review Manager 5.3 computer program (Cochrane Collaboration Information Management System), with outcomes treated as continuous variables. Weighted mean difference (WMD) (same metric scale) using a random-effects model was selected when estimating the total effect of pooled data for a given follow-up period. Forest plots were generated to depict results, and heterogeneity was tested according to the overlap in CIs, interpretation of the χ2 test, and the I2 statistic, with substantial heterogeneity represented by I2 > 50%.48 For meta-analyses, authors of included studies were contacted for additional information where necessary. In the event that information was not provided, relevant figures were imported into xyExtract Graph Digitizer (SOFTLAND SRL) software to allow data extraction. When study findings could not be combined, a narrative format was used to report results.

Of the possible 29 studies, 13 were included, with reasons for study exclusion outlined in Figure 1, and strong agreement (k = 0.82) was achieved between reviewers for study selection.49 Five studies explored the role of DAS during exercise training, five explored the role of DAS during formal exercise testing, and three examined the effect of DAS on symptom management at rest. Table 2 illustrates the characteristics of included studies.

Figure Jump LinkFigure 1 –  Study flow from identification to inclusion of final studies.Grahic Jump Location
Table Graphic Jump Location
TABLE 2 ]  Characteristic of Studies Including DAS

6MTT = 6-min treadmill test; Con = control; Exp = experimental; ISWD = incremental shuttle walk distance; mph = miles per hour; NA = not applicable; NR = not reported; PEDro = Physiotherapy Evidence Database; RCT = randomized controlled trial; RXT = randomized crossover trial. See Table 1 legend for expansion of other abbreviations.

The two reviewers consistently agreed on study quality. The median PEDro score was 5 for exercise training studies, 5 for exercise testing studies, and 6.5 for symptom management studies (e-Table 1). Most studies reported random allocation3337,5055 and similarities between groups at baseline,3338,50,5355 but only one reported randomization sequence concealment.54 There was a consistent lack of participant, therapist, and assessor blinding in all studies. All studies included between-group analysis and points variability, but one did not provide adequate follow-up.35

For the observational study of symptom management, the overall score was 17 of 27.39 The study scored high for the quality of reporting. With little description of the representative population from which participants were recruited, the external validity of the study was limited. It is unclear whether sufficient participants were recruited because the sample size was not calculated.

Overall, the grading of the quality of evidence for outcome measures was low to very low (Table 3). Predominant reasons for these ratings were: serious limitations related to risk of bias for most studies; limitations around inconsistency,45 with heterogeneity between studies influencing the overall effect size; limitations around imprecision secondary to small sample sizes and wide CIs; and some publication bias.45

Table Graphic Jump Location
TABLE 3 ]  GRADE Evidence Profile of Outcome Measures

6MWD = 6-min walk distance; ADL = activity of daily living; GRADE = Grading of Recommendations Assessment, Development and Evaluation. See Table 1 and 2 legends for expansion of other abbreviations.

a 

High: We are very confident that the true effect lies close to the estimate of the effect. Moderate: We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low: Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low: We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of the effect. (From the GRADE Working Group grading [Balshem et al45].)

b 

One study compared both fast- and moderate-tempo DAS with control.

c 

(−1 risk of bias) Some significant risk of bias (lack of allocation concealment, lack of blinding, selective reporting of results) across included studies.

d 

(−1 imprecision) Small sample sizes of included studies, with or without wide CIs.

e 

(−1 inconsistency) Significant heterogeneity between studies.

f 

(−1 publication bias) Limited information available in the current form.

g 

Involved noncomparison with control group.

Description of Studies

A description of the exercise programs is outlined in Table 2. Three studies undertook exercise training in the home environment,33,35,36 whereas two completed hospital-based training.34,52 Four studies applied aerobic- and walking-based training,33,35,36,52 and a single study focused on upper limb (UL) training.34 One study explored effects during a single exercise session,52 and one study applied training for 1 month34; one for 2 months33; and two for 3 months,5,36 of which one incorporated longer-term training.36

The details of the exercise testing are included in Table 2. Two studies38,51 applied a ground-based 6-min walk test (6MWT), one applied a 6MWT on a treadmill,55 and one used a ground-based 10-min walk test.50 One study used a treadmill stress test.37

The use of DAS for symptom management at rest is outlined in Table 2. One study compared DAS to relaxation,54 whereas another tested one condition only.39 Two studies applied the DAS over a single session,53,54 and one examined the effects after a single session and over 5 weeks.39

Exercise Capacity

The findings between groups for all studies are outlined on e-Table 2. For studies exploring exercise training, exercise capacity was measured using the incremental shuttle walk test in two35,36 and the 6MWT in one.33 Data were pooled for three studies.33,35,36 Information from one study36 was included after extraction of data from a graphical representation of results, with further information not available from the authors. At 2 months, the WMD for exercise capacity (n = 65) was 98 m (95% CI, 47-150 m) in favor of DAS (Fig 2). However, 2 months of walking with DAS did not change the overall distance walked.33 Delivering DAS through a cell phone increased the incremental shuttle walk distance by 38 m after 3 months, which was maintained for 12 months.36

Figure Jump LinkFigure 2 –  The effect of DAS vs control on exercise capacity at 2 mo follow-up. = point estimate; = pooled effect estimate. DAS = distractive auditory stimulus; df = degrees of freedom; IV = independent variable.Grahic Jump Location

Of the three studies applying DAS during a 6MWT (ground-based or treadmill), data could not be pooled for meta-analysis due to information not available through the authors50 or lack of further information from authors.38,55 DAS was not associated with either a greater 6-min walk distance8,51,55 (e-Table 2) or an increased distance during a 10-min walk test.50 A symptom-limited stress test yielded higher total exercise time and external work with DAS than with gray noise or silence.37

Symptoms

Less dyspnea35,36 and exertion35 at the end of the incremental shuttle walk test was evident after 3 or 4 months of walking training with DAS, with this effect maintained at 12 months.36 Two months of DAS with walking training reduced dyspnea during activities of daily living.33 In contrast, moderate- or slow-tempo DAS during UL training did not reduce dyspnea during activities of daily living.34 No benefit was evident with DAS on symptoms during a single exercise session.52

For a treadmill-based 6MWT, DAS was associated with less intense and unpleasant dyspnea,38 and comparable benefits to fatigue were achieved with moderate-tempo DAS during an exercise stress test.37 In contrast, there was no difference in dyspnea or exertion at the conclusion of ground-based walking tests with DAS.50,51,55

Dyspnea reduced with DAS compared with relaxation techniques.54 In contrast, compared with control condition, DAS did not change dyspnea when applied in a single treatment session.53 One study found improvement in dyspnea after a single session, but no difference over 5 weeks.39

Health-Related Quality of Life

Disease-specific HRQOL was measured with the St. George’s Respiratory Questionnaire in three studies of exercise training.3335 After 1 month of training, neither a change in total St. George’s Respiratory Questionnaire score (WMD, −1.73 (95% CI, −8.43 to 4.98) nor any change in symptoms, activity, or impact scores (Fig 3) was found; similar findings were evident after 2 months of training.33 Moderate heterogeneity was found for the symptom domain (I2 = 58%), suggesting a variation in intervention between studies. However, after 4 months of walking training, HRQOL improved in all domains of DAS compared with control.35 Liu et al36 also found an improvement in generic measures of physical quality of life after 3 months, which was maintained at 12 months.

Figure Jump LinkFigure 3 –  Effect of DAS during exercise training vs control on measures of health-related quality of life according to the St. George’s Respiratory Questionnaire after 1 mo of training. = point estimate; = pooled effect estimate. See Figure 2 legend for expansion of abbreviations.Grahic Jump Location
Functional Status

Significant improvement in UL function was achieved with 1 month of UL training with moderate- and slow-tempo DAS compared with control (both P < .001), although there was no difference between tempos (P = .67).34

Psychologic Symptoms

The addition of DAS to exercise training for a 2-month duration had no effect on anxiety or depression.33 General anxiety decreased with DAS compared with relaxation techniques (P = .003).54 However, when applied in a single treatment session, levels of anxiety did not change with DAS compared with control.53 Although less anxiety was observed after a single session (P < .05), this difference was not evident at 5 weeks.39

To our knowledge, this review is the first to examine the effects of DAS during various interventional stages in patients with COPD. It suggests that DAS may play a role in enhancing exercise capacity when applied during walking-based exercise training. However, there appears to be minimal short-term effects on exercise testing. Similarly, a positive impact is only evident on dyspnea, fatigue, and HRQOL when DAS is an adjunct to longer-term exercise training. As a method to reduce anxiety and dyspnea at rest, DAS appears to have an inconsistent, positive, medium effect size.

The improvement in exercise capacity with exercise training with DAS supports the positive findings of endurance exercise with DAS in healthy individuals, where higher workloads were achieved with fewer symptoms.24,27,56,57 Although the magnitude of change in walking distance in COPD was large (98 m) and clinically significant beyond the minimal important difference of these outcomes in COPD,58,59 this result should be interpreted with caution because only three studies were in the meta-analysis. Despite this, the parallel reduction in dyspnea and fatigue33,35,36 implies that this distraction shifted the focus away from an internal, attention-demanding sensation (dyspnea) toward an external one (listening to music), resulting in reduced cognitive processing of the former.37,60 This change in focus was achieved through high-intensity training of a prescribed frequency and duration for patients with COPD.12 Similar results have been achieved with DAS during resistance training in healthy control subjects.61 Further work is required to determine the effects of DAS during resistance training in COPD.

Both physiologic and psychologic advantages may be attained with DAS in COPD. The lower perception of dyspnea unpleasantness during a 6MWT suggests that the affective dimension of dyspnea may be modified by DAS.62,63 Reducing the fear associated with uncomfortable symptoms may facilitate the enjoyment of exercise,64 which may explain the effects of DAS over longer-term exercise training. Exploring patient perception of the effects of DAS through qualitative studies will provide further insight into the underlying psychologic mechanisms and patient response to exercise with DAS. In healthy individuals undertaking maximal exercise testing with DAS, reduced muscle tension has been observed27 accompanied by reduced lactate production.56 Similar physiologic benefits of DAS in individuals with COPD may be evident but are yet to be explored.

Although improvement in functional UL tasks was evident with moderate- and slow-tempo DAS,34 this change was not accompanied by reduced dyspnea during activities of daily living, which is consistent with a lack of improvement in dyspnea following supported or unsupported UL training without DAS.65 The attentional distraction of music may be insufficient to overcome the dual role of the UL musculature for moving the ULs and for respiration.66

Achieving an improvement in HRQOL with DAS after only 3 months35,36 beyond the minimal important difference measured by both disease-specific and generic instruments67 is unsurprising. Although traditional 6-week PR programs have been associated with greater HRQOL,13 these programs have a greater level of supervision than the home-based programs included in the current review.33,35,36 In addition, the exercise prescriptions were maintained rather than progressed, which may explain the slower rate of improvement in HRQOL and the lack of change in anxiety or depression.33

The lack of benefit for symptoms with the addition of classical music to a single exercise session52 supports the hypothesis that a longer duration of training may be necessary to achieve a sufficient attentional distraction effect. It may also reflect that the genre of music to achieve successful distraction is important. With aversive dyspnea and fatigue during exercise observed, especially at the commencement of PR in some patients,38 determining the effect of this easy-to-implement adjunct to exercise training is important. Some individuals with COPD are reluctant to commence PR or discontinue a program secondary to fear of these symptoms during exercise,68 which may influence physical activity following PR. Exploring the effect of DAS during PR on both rates of PR uptake and physical activity levels after PR will provide further insight into the effectiveness of this approach on patient tolerance and symptom intensity.

The lack of a beneficial effect of DAS during timed walking tests of a short duration38,50,51,55 is likely to be related to the tests beginning at a submaximal level as well as the instructions to the individual to slow down as part of symptom management.69 In addition, although the 6MWT learning effect is well documented,70,71 the studies included in this review performed only one test per condition,38,51,55 which may have inhibited the ability to identify the true effect of DAS. This contrasts the findings of Thornby et al37 where greater exercise time, greater external work, and less fatigue during a symptom-limited graded exercise test suggested that DAS has a greater effect at high exercise testing intensities. Although DAS has been reported to alleviate symptoms of dyspnea and anxiety at rest in populations with chronic heart disease, cancer, and organ transplantation,28,29,7274 the findings in COPD were inconsistent,39,53,54 and the reasons are unclear.

Positive results for exercise training were achieved with music of a faster tempo (90-120 beats/min),3338 which may be necessary to achieve sufficient arousal to compete with fatigue and dyspnea.30 Most studies used self-selection of at least two types of music, which included options of country/western, classical, pop/Motown, and big band.3335,3739,50,5355 Both tempo and type of music may have influenced the findings in this review. Having a choice of music may be important for increasing enjoyment, with individual preference likely to influence motivation to exercise. The influence of this factor should be explored in future studies.35,75

This review was limited by the small number of trials in each key area of intervention, the heterogeneity of training programs and the influence of this on outcomes, and incomplete study data in some reports. For this reason, interpreting the clinical significance of these outcomes is difficult. The quality gradings for outcome measures ranged from low to very low, suggesting that these findings should be interpreted with caution. The randomized trial scores were moderate on the PEDro scale because of the lack of concealed allocation as well as the lack of blinding of therapists and assessors. The observational study may have limited application to a broader population. In addition, although the authors of all included studies were contacted to provide additional information and results, some information was not supplied, and this limited the data included in some meta-analyses.

In conclusion, this review suggests that DAS may reduce symptoms of dyspnea and fatigue when applied during exercise training, with subsequent benefits in exercise capacity and HRQOL. The observations reported would not support the application of DAS for exercise testing or for overall dyspnea management. Further exploration is required to determine the relevance of the music selected as well as the role of DAS during other forms of exercise in patients with COPD.

Author contributions: A. L. L. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. A. L. L. contributed to the research design and concept, data analysis, and preparation and review of the manuscript; L. D. contributed to the research design, data analysis, and drafting and review of the manuscript; and R. S. G. and D. B. contributed to the research design and concept, data analysis, and review of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Additional information: The e-Appendix and e-Tables can be found in the Supplemental Materials section of the online article.

6MWT

6-min walk test

DAS

distractive auditory stimulus

HRQOL

health-related quality of life

PEDro

Physiotherapy Evidence Database

PR

pulmonary rehabilitation

UL

upper limb

WMD

weighted mean difference

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Bauldoff GS, Rittinger M, Nelson T, Doehrel J, Diaz PT. Feasibility of distractive auditory stimuli on upper extremity training in persons with chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 2005;25(1):50-55. [CrossRef] [PubMed]
 
Ho CF, Maa SH, Shyu YI, Lai YT, Hung TC, Chen HC. Effectiveness of paced walking to music at home for patients with COPD. COPD. 2012;9(5):447-457. [CrossRef] [PubMed]
 
Liu WT, Wang CH, Lin HC, et al. Efficacy of a cell phone-based exercise programme for COPD. Eur Respir J. 2008;32(3):651-659. [CrossRef] [PubMed]
 
Thornby MA, Haas F, Axen K. Effect of distractive auditory stimuli on exercise tolerance in patients with COPD. Chest. 1995;107(5):1213-1217. [CrossRef] [PubMed]
 
von Leupoldt A, Taube K, Schubert-Heukeshoven S, Magnussen H, Dahme B. Distractive auditory stimuli reduce the unpleasantness of dyspnea during exercise in patients with COPD. Chest. 2007;132(5):1506-1512. [CrossRef] [PubMed]
 
McBride S, Graydon J, Sidani S, Hall L. The therapeutic use of music for dyspnea and anxiety in patients with COPD who live at home. J Holist Nurs. 1999;17(3):229-250. [CrossRef] [PubMed]
 
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. [CrossRef] [PubMed]
 
de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother. 2009;55(2):129-133. [CrossRef] [PubMed]
 
Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713-721. [PubMed]
 
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-384. [CrossRef] [PubMed]
 
Ng LWC, Mackney J, Jenkins S, Hill K. Does exercise training change physical activity in people with COPD? A systematic review and meta-analysis. Chron Respir Dis. 2012;9(1):17-26. [CrossRef] [PubMed]
 
Balshem H, Helfand M, Schünemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-406. [CrossRef] [PubMed]
 
Cochrane Consumers and Communication Review Group. Data extraction template for Cochrane reviews. Cochrane Consumers and Communication Review Group website. http://cccrg.cochrane.org/author-resources. Accessed July 2, 2014.
 
Ryan R; Cochrane Consumers and Communication Review Group. Data extraction template for Cochrane reviews: meta-analysis, 2013. Cochrane Consumers and Communication Review Group website. http://chmg.cochrane.org/sites/chmg.cochrane.org/files/uploads/Template-Data%20Extraction-CHMG.pdf. Accessed August 1, 2014.
 
Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-560. [CrossRef] [PubMed]
 
Portney L, Watkins M. Foundations of Clinical Research: Applications to Practice.3rd ed. Upper Saddle River, NJ: Pearson/ Prentice Hall Health; 2009:254-267.
 
Brooks D, Sidani S, Graydon J, McBride S, Hall L, Weinacht K. Evaluating the effects of music on dyspnea during exercise in individuals with chronic obstructive pulmonary disease: a pilot study. Rehabil Nurs. 2003;28(6):192-196. [CrossRef] [PubMed]
 
Caty G, Pieters T, Liistro G, Reychler G. Influence of music with a fast tempo on the 6-minute walk test in COPD patients. Ann Phys Rehabil Med. 2013;56(S1):e327.
 
Caty G, Mottart F, Boland M, et al. Influence of music on the dyspnea during a session of pulmonary rehabilitation. Ann Phys Rehabil Med. 2013;56(S1):e328. [CrossRef]
 
Sidani S, Brooks D, Graydon J, Hall L. Evaluating the effects of music on dyspnea and anxiety in patients with COPD: a process-outcome analysis. Int Nurs Perspect. 2004;4:5-13.
 
Singh VP, Rao V, Prem V, Sahoo RC, Keshav PK. Comparison of the effectiveness of music and progressive muscle relaxation for anxiety in COPD—a randomized controlled pilot study. Chron Respir Dis. 2009;6(4):209-216. [PubMed]
 
Pfister T, Berrol C, Caplan C. Effects of music on exercise and perceived symptoms in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 1998;18(3):228-232. [CrossRef] [PubMed]
 
Szmedra L, Bacharach DW. Effect of music on perceived exertion, plasma lactate, norepinephrine and cardiovascular hemodynamics during treadmill running. Int J Sports Med. 1998;19(1):32-37. [CrossRef] [PubMed]
 
Nethery VM. Competition between internal and external sources of information during exercise: influence on RPE and the impact of the exercise load. J Sports Med Phys Fitness. 2002;42(2):172-178. [PubMed]
 
Holland AE, Hill CJ, Rasekaba T, Lee A, Naughton MT, McDonald CF. Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil. 2010;91(2):221-225. [CrossRef] [PubMed]
 
Singh SJ, Jones PW, Evans R, Morgan MD. Minimum clinically important improvement for the incremental shuttle walking test. Thorax. 2008;63(9):775-777. [CrossRef] [PubMed]
 
Levanthal H, Everhart D. Emotion, pain and physical illness.. In:Izard C., ed. Emotions in Personality and Psychopathology. New York, NY: Plenum; 1979:263-298.
 
Crust L. Carry-over effects of music in an isometric muscular endurance task. Percept Mot Skills. 2004;98(3):985-991. [CrossRef] [PubMed]
 
von Leupoldt A, Dahme B. Psychological aspects in the perception of dyspnea in obstructive pulmonary diseases. Respir Med. 2007;101(3):411-422. [CrossRef] [PubMed]
 
von Leupoldt A, Seemann N, Gugleva T, Dahme B. Attentional distraction reduces the affective but not the sensory dimension of perceived dyspnea. Respir Med. 2007;101(4):839-844. [CrossRef] [PubMed]
 
Murrock CJ. The effects of music on the rate of perceived exertion and general mood among coronary artery bypass graft patients enrolled in cardiac rehabilitation phase II. Rehabil Nurs. 2002;27(6):227-231. [CrossRef] [PubMed]
 
Janaudis-Ferreira T, Hill K, Goldstein R, Wadell K, Brooks D. Arm exercise training in patients with chronic obstructive pulmonary disease: a systematic review. J Cardiopulm Rehabil Prev. 2009;29(5):277-283. [CrossRef] [PubMed]
 
Velloso M, Stella SG, Cendon S, Silva AC, Jardim JR. Metabolic and ventilatory parameters of four activities of daily living accomplished with arms in COPD patients. Chest. 2003;123(4):1047-1053. [CrossRef] [PubMed]
 
Schünemann HJ, Griffith L, Jaeschke R, Goldstein R, Stubbing D, Guyatt GH. Evaluation of the minimal important difference for the feeling thermometer and the St. George’s Respiratory Questionnaire in patients with chronic airflow obstruction. J Clin Epidemiol. 2003;56(12):1170-1176. [CrossRef] [PubMed]
 
Harris D, Hayter M, Allender S. Improving the uptake of pulmonary rehabilitation in patients with COPD: qualitative study of experiences and attitudes. Br J Gen Pract. 2008;58(555):703-710. [CrossRef] [PubMed]
 
ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-117. [CrossRef] [PubMed]
 
Hernandes NA, Wouters EF, Meijer K, Annegarn J, Pitta F, Spruit MA. Reproducibility of 6-minute walking test in patients with COPD. Eur Respir J. 2011;38(2):261-267. [CrossRef] [PubMed]
 
Spencer LM, Alison JA, McKeough ZJ. Six-minute walk test as an outcome measure: are two six-minute walk tests necessary immediately after pulmonary rehabilitation and at three-month follow-up? Am J Phys Med Rehabil. 2008;87(3):224-228. [CrossRef] [PubMed]
 
Madson AT, Silverman MJ. The effect of music therapy on relaxation, anxiety, pain perception, and nausea in adult solid organ transplant patients. J Music Ther. 2010;47(3):220-232. [CrossRef] [PubMed]
 
Barnason S, Zimmerman L, Nieveen J. The effects of music interventions on anxiety in the patient after coronary artery bypass grafting. Heart Lung. 1995;24(2):124-132. [CrossRef] [PubMed]
 
Sabo CE, Michael SR. The influence of personal message with music on anxiety and side effects associated with chemotherapy. Cancer Nurs. 1996;19(4):283-289. [CrossRef] [PubMed]
 
Karageorghis CI, Priest DL, Terry PC, Chatzisarantis NL, Lane AM. Redesign and initial validation of an instrument to assess the motivational qualities of music in exercise: the Brunel Music Rating Inventory-2. J Sports Sci. 2006;24(8):899-909. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Study flow from identification to inclusion of final studies.Grahic Jump Location
Figure Jump LinkFigure 2 –  The effect of DAS vs control on exercise capacity at 2 mo follow-up. = point estimate; = pooled effect estimate. DAS = distractive auditory stimulus; df = degrees of freedom; IV = independent variable.Grahic Jump Location
Figure Jump LinkFigure 3 –  Effect of DAS during exercise training vs control on measures of health-related quality of life according to the St. George’s Respiratory Questionnaire after 1 mo of training. = point estimate; = pooled effect estimate. See Figure 2 legend for expansion of abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Inclusion Criteria for Studies

6MWT = 6-min walk test; CPET = cardiopulmonary exercise test; DAS = distractive auditory stimulus; ESWT = endurance shuttle walk test; HRQOL = health-related quality of life; ISWT = incremental shuttle walk test.

a 

Outcome measures included instruments or formal tests that may or may not have established reliability and validity in the COPD population.

Table Graphic Jump Location
TABLE 2 ]  Characteristic of Studies Including DAS

6MTT = 6-min treadmill test; Con = control; Exp = experimental; ISWD = incremental shuttle walk distance; mph = miles per hour; NA = not applicable; NR = not reported; PEDro = Physiotherapy Evidence Database; RCT = randomized controlled trial; RXT = randomized crossover trial. See Table 1 legend for expansion of other abbreviations.

Table Graphic Jump Location
TABLE 3 ]  GRADE Evidence Profile of Outcome Measures

6MWD = 6-min walk distance; ADL = activity of daily living; GRADE = Grading of Recommendations Assessment, Development and Evaluation. See Table 1 and 2 legends for expansion of other abbreviations.

a 

High: We are very confident that the true effect lies close to the estimate of the effect. Moderate: We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low: Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low: We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of the effect. (From the GRADE Working Group grading [Balshem et al45].)

b 

One study compared both fast- and moderate-tempo DAS with control.

c 

(−1 risk of bias) Some significant risk of bias (lack of allocation concealment, lack of blinding, selective reporting of results) across included studies.

d 

(−1 imprecision) Small sample sizes of included studies, with or without wide CIs.

e 

(−1 inconsistency) Significant heterogeneity between studies.

f 

(−1 publication bias) Limited information available in the current form.

g 

Involved noncomparison with control group.

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Boutcher S, Trenske M. The effects of sensory deprivation and music on perceived exertion and affect during exercise. J Sport Exerc Psychol. 1990;12(2):167-176.
 
Dorney L, Goh E, Lee C. The impact of music and imagery on physical performance and arousal: studies of coordination and endurance. J Sport Behav. 1992;15(1):21-33.
 
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Bradt J, Dileo C, Potvin N. Music for stress and anxiety reduction in coronary heart disease patients. Cochrane Database Syst Rev. 2013;12:CD006577. [PubMed]
 
Bradt J, Dileo C, Grocke D, Magill L. Music interventions for improving psychological and physical outcomes in cancer patients. Cochrane Database Syst Rev. 2011;;(8):CD006911.
 
Szabo A, Péronnet F, Gauvin L, Furedy JJ. Mental challenge elicits “additional” increases in heart rate during low and moderate intensity cycling. Int J Psychophysiol. 1994;17(3):197-204. [CrossRef] [PubMed]
 
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Karageorghis CI, Priest D-L. Music in the exercise domain: a review and synthesis (part I). Int Rev Sport Exerc Psychol. 2012;5(1):44-66. [CrossRef] [PubMed]
 
Bauldoff GS, Hoffman LA, Zullo TG, Sciurba FC. Exercise maintenance following pulmonary rehabilitation: effect of distractive stimuli. Chest. 2002;122(3):948-954. [CrossRef] [PubMed]
 
Bauldoff GS, Rittinger M, Nelson T, Doehrel J, Diaz PT. Feasibility of distractive auditory stimuli on upper extremity training in persons with chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 2005;25(1):50-55. [CrossRef] [PubMed]
 
Ho CF, Maa SH, Shyu YI, Lai YT, Hung TC, Chen HC. Effectiveness of paced walking to music at home for patients with COPD. COPD. 2012;9(5):447-457. [CrossRef] [PubMed]
 
Liu WT, Wang CH, Lin HC, et al. Efficacy of a cell phone-based exercise programme for COPD. Eur Respir J. 2008;32(3):651-659. [CrossRef] [PubMed]
 
Thornby MA, Haas F, Axen K. Effect of distractive auditory stimuli on exercise tolerance in patients with COPD. Chest. 1995;107(5):1213-1217. [CrossRef] [PubMed]
 
von Leupoldt A, Taube K, Schubert-Heukeshoven S, Magnussen H, Dahme B. Distractive auditory stimuli reduce the unpleasantness of dyspnea during exercise in patients with COPD. Chest. 2007;132(5):1506-1512. [CrossRef] [PubMed]
 
McBride S, Graydon J, Sidani S, Hall L. The therapeutic use of music for dyspnea and anxiety in patients with COPD who live at home. J Holist Nurs. 1999;17(3):229-250. [CrossRef] [PubMed]
 
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. [CrossRef] [PubMed]
 
de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother. 2009;55(2):129-133. [CrossRef] [PubMed]
 
Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713-721. [PubMed]
 
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-384. [CrossRef] [PubMed]
 
Ng LWC, Mackney J, Jenkins S, Hill K. Does exercise training change physical activity in people with COPD? A systematic review and meta-analysis. Chron Respir Dis. 2012;9(1):17-26. [CrossRef] [PubMed]
 
Balshem H, Helfand M, Schünemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-406. [CrossRef] [PubMed]
 
Cochrane Consumers and Communication Review Group. Data extraction template for Cochrane reviews. Cochrane Consumers and Communication Review Group website. http://cccrg.cochrane.org/author-resources. Accessed July 2, 2014.
 
Ryan R; Cochrane Consumers and Communication Review Group. Data extraction template for Cochrane reviews: meta-analysis, 2013. Cochrane Consumers and Communication Review Group website. http://chmg.cochrane.org/sites/chmg.cochrane.org/files/uploads/Template-Data%20Extraction-CHMG.pdf. Accessed August 1, 2014.
 
Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-560. [CrossRef] [PubMed]
 
Portney L, Watkins M. Foundations of Clinical Research: Applications to Practice.3rd ed. Upper Saddle River, NJ: Pearson/ Prentice Hall Health; 2009:254-267.
 
Brooks D, Sidani S, Graydon J, McBride S, Hall L, Weinacht K. Evaluating the effects of music on dyspnea during exercise in individuals with chronic obstructive pulmonary disease: a pilot study. Rehabil Nurs. 2003;28(6):192-196. [CrossRef] [PubMed]
 
Caty G, Pieters T, Liistro G, Reychler G. Influence of music with a fast tempo on the 6-minute walk test in COPD patients. Ann Phys Rehabil Med. 2013;56(S1):e327.
 
Caty G, Mottart F, Boland M, et al. Influence of music on the dyspnea during a session of pulmonary rehabilitation. Ann Phys Rehabil Med. 2013;56(S1):e328. [CrossRef]
 
Sidani S, Brooks D, Graydon J, Hall L. Evaluating the effects of music on dyspnea and anxiety in patients with COPD: a process-outcome analysis. Int Nurs Perspect. 2004;4:5-13.
 
Singh VP, Rao V, Prem V, Sahoo RC, Keshav PK. Comparison of the effectiveness of music and progressive muscle relaxation for anxiety in COPD—a randomized controlled pilot study. Chron Respir Dis. 2009;6(4):209-216. [PubMed]
 
Pfister T, Berrol C, Caplan C. Effects of music on exercise and perceived symptoms in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 1998;18(3):228-232. [CrossRef] [PubMed]
 
Szmedra L, Bacharach DW. Effect of music on perceived exertion, plasma lactate, norepinephrine and cardiovascular hemodynamics during treadmill running. Int J Sports Med. 1998;19(1):32-37. [CrossRef] [PubMed]
 
Nethery VM. Competition between internal and external sources of information during exercise: influence on RPE and the impact of the exercise load. J Sports Med Phys Fitness. 2002;42(2):172-178. [PubMed]
 
Holland AE, Hill CJ, Rasekaba T, Lee A, Naughton MT, McDonald CF. Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil. 2010;91(2):221-225. [CrossRef] [PubMed]
 
Singh SJ, Jones PW, Evans R, Morgan MD. Minimum clinically important improvement for the incremental shuttle walking test. Thorax. 2008;63(9):775-777. [CrossRef] [PubMed]
 
Levanthal H, Everhart D. Emotion, pain and physical illness.. In:Izard C., ed. Emotions in Personality and Psychopathology. New York, NY: Plenum; 1979:263-298.
 
Crust L. Carry-over effects of music in an isometric muscular endurance task. Percept Mot Skills. 2004;98(3):985-991. [CrossRef] [PubMed]
 
von Leupoldt A, Dahme B. Psychological aspects in the perception of dyspnea in obstructive pulmonary diseases. Respir Med. 2007;101(3):411-422. [CrossRef] [PubMed]
 
von Leupoldt A, Seemann N, Gugleva T, Dahme B. Attentional distraction reduces the affective but not the sensory dimension of perceived dyspnea. Respir Med. 2007;101(4):839-844. [CrossRef] [PubMed]
 
Murrock CJ. The effects of music on the rate of perceived exertion and general mood among coronary artery bypass graft patients enrolled in cardiac rehabilitation phase II. Rehabil Nurs. 2002;27(6):227-231. [CrossRef] [PubMed]
 
Janaudis-Ferreira T, Hill K, Goldstein R, Wadell K, Brooks D. Arm exercise training in patients with chronic obstructive pulmonary disease: a systematic review. J Cardiopulm Rehabil Prev. 2009;29(5):277-283. [CrossRef] [PubMed]
 
Velloso M, Stella SG, Cendon S, Silva AC, Jardim JR. Metabolic and ventilatory parameters of four activities of daily living accomplished with arms in COPD patients. Chest. 2003;123(4):1047-1053. [CrossRef] [PubMed]
 
Schünemann HJ, Griffith L, Jaeschke R, Goldstein R, Stubbing D, Guyatt GH. Evaluation of the minimal important difference for the feeling thermometer and the St. George’s Respiratory Questionnaire in patients with chronic airflow obstruction. J Clin Epidemiol. 2003;56(12):1170-1176. [CrossRef] [PubMed]
 
Harris D, Hayter M, Allender S. Improving the uptake of pulmonary rehabilitation in patients with COPD: qualitative study of experiences and attitudes. Br J Gen Pract. 2008;58(555):703-710. [CrossRef] [PubMed]
 
ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-117. [CrossRef] [PubMed]
 
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Madson AT, Silverman MJ. The effect of music therapy on relaxation, anxiety, pain perception, and nausea in adult solid organ transplant patients. J Music Ther. 2010;47(3):220-232. [CrossRef] [PubMed]
 
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NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
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