Group music performance causes elevated pain thresholds and social bonding in small and large groups of singers

Syncing online: A methodological investigation into movement synchrony, proxemics, and self-other blurring in virtual spaces

A growing body of literature has found that synchronising movements with a group subsequently increases self-other blurring and social closeness with synchronised partners. However, movement synchrony has not been studied in online settings. Our study has a primarily methodological focus to investigate whether synchronous movement leads to changes in self-other blurring and proxemics in an online, desktop-mediated environment. We conducted two experiments to manipulate synchrony with a group of virtual agents and investigate its impact on self-other blurring and comfort distance judgments. In Experiment 1, we compared synchronous movement to a no-movement condition; in Experiment 2, we introduced an unpredictable movement condition. In both experiments, we found that our manipulation of synchronous movement between participants and a virtual group of agents led to an increase in explicit self-other blurring compared to the no and unpredictable movement conditions; however, we did not find reliable effects on comfort distance judgments.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Human musical capacity and products should have been induced by the hominin-specific combination of several biosocial features: A three-phase scheme on socio-ecological, cognitive, and cultural evolution

Various selection pressures have shaped human uniqueness, for instance, music. When and why did musical universality and diversity emerge? Our hypothesis is that "music" initially originated from manipulative calls with limited musical elements. Thereafter, vocalizations became more complex and flexible along with a greater degree of social learning. Finally, constructed musical instruments and the language faculty resulted in diverse and context-specific music. Music precursors correspond to vocal communication among nonhuman primates, songbirds, and cetaceans. To place this scenario in hominin history, a three-phase scheme for music evolution is presented herein. We emphasize (1) the evolution of sociality and life history in australopithecines, (2) the evolution of cognitive and learning abilities in early/middle Homo, and (3) cultural evolution, primarily in Homo sapiens. Human musical capacity and products should be due to the hominin-specific combination of several biosocial features, including bipedalism, stable pair bonding, alloparenting, expanded brain size, and sexual selection.

Music as an Evolved Tool for Socio-Affective Fiction

The question of why music evolved has been contemplated and debated for centuries across multiple disciplines. While many theories have been posited, they still do not fully answer the question of why humans began making music. Adding to the effort to solve this mystery, we propose the socio-affective fiction (SAF) hypothesis. Humans have a unique biological need for emotion regulation strengthening. Simulated emotional situations, like dreams, can help address that need. Immersion is key for such simulations to successfully exercise people's emotions. Therefore, we propose that music evolved as a signal for SAF to increase the immersive potential of storytelling and thereby better exercise people's emotions. In this review, we outline the SAF hypothesis and present cross-disciplinary evidence.

The effects of musical practice on the well-being, mental health and social support of student, amateur, and professional musicians in Canada during the COVID-19 pandemic

This pan-Canadian study investigates the effects of musical practice on the well-being, mental health, and social support of Canadian musicians during the COVID-19 pandemic. Using a survey questionnaire, data was collected from 1,618 participants aged 14 and above during the first wave of the pandemic up to the first half of 2022. The survey included standardized questionnaires to self-assess well-being (WHO-5), mental health (MHC-SF), and social support (SPS-10 measures social support). Results show that increased musical practice frequency correlates with improved well-being and mental health, particularly among amateurs. Professional musicians and those at a post-secondary level exhibit lower well-being scores, likely due to pandemic-related challenges. Factors such as age, gender, sports engagement, and participation in social clubs or volunteer work significantly influenced outcomes. While sports engagement was associated with higher scores on well-being, mental health and social support, no significant differences were found among participants engaged in artistic hobbies. As for involvement in social clubs or volunteer work, benefits were reported on two of the three outcomes. Overall, the findings suggest that regular amateur musical practice, especially in group settings, alongside engagement in sports and social activities, may have promoted well-being, mental health, and social support among musicians during the challenging period of the COVID-19 pandemic.

The psychophysiology of music-based interventions and the experience of pain

In modern times there is increasing acceptance that music-based interventions are useful aids in the clinical treatment of a range of neurological and psychiatric conditions, including helping to reduce the perception of pain. Indeed, the belief that music, whether listening or performing, can alter human pain experiences has a long history, dating back to the ancient Greeks, and its potential healing properties have long been appreciated by indigenous cultures around the world. The subjective experience of acute or chronic pain is complex, influenced by many intersecting physiological and psychological factors, and it is therefore to be expected that the impact of music therapy on the pain experience may vary from one situation to another, and from one person to another. Where pain persists and becomes chronic, aberrant central processing is a key feature associated with the ongoing pain experience. Nonetheless, beneficial effects of exposure to music on pain relief have been reported across a wide range of acute and chronic conditions, and it has been shown to be effective in neonates, children and adults. In this comprehensive review we examine the various neurochemical, physiological and psychological factors that underpin the impact of music on the pain experience, factors that potentially operate at many levels - the periphery, spinal cord, brainstem, limbic system and multiple areas of cerebral cortex. We discuss the extent to which these factors, individually or in combination, influence how music affects both the quality and intensity of pain, noting that there remains controversy about the respective roles that diverse central and peripheral processes play in this experience. Better understanding of the mechanisms that underlie music's impact on pain perception together with insights into central processing of pain should aid in developing more effective synergistic approaches when music therapy is combined with clinical treatments. The ubiquitous nature of music also facilitates application from the therapeutic environment into daily life, for ongoing individual and social benefit.

Love songs and serenades: a theoretical review of music and romantic relationships

In this theoretical review, we examine how the roles of music in mate choice and social bonding are expressed in romantic relationships. Darwin's Descent of Man originally proposed the idea that musicality might have evolved as a sexually selected trait. This proposition, coupled with the portrayal of popular musicians as sex symbols and the prevalence of love-themed lyrics in music, suggests a possible link between music and attraction. However, recent scientific exploration of the evolutionary functions of music has predominantly focused on theories of social bonding and group signaling, with limited research addressing the sexual selection hypothesis. We identify two distinct types of music-making for these different functions: music for attraction, which would be virtuosic in nature to display physical and cognitive fitness to potential mates; and music for connection, which would facilitate synchrony between partners and likely engage the same reward mechanisms seen in the general synchrony-bonding effect, enhancing perceived interpersonal intimacy as a facet of love. Linking these two musical functions to social psychological theories of relationship development and the components of love, we present a model that outlines the potential roles of music in romantic relationships, from initial attraction to ongoing relationship maintenance. In addition to synthesizing the existing literature, our model serves as a roadmap for empirical research aimed at rigorously investigating the possible functions of music for romantic relationships.

The transformative power of music: Insights into neuroplasticity, health, and disease

Music is a universal language that can elicit profound emotional and cognitive responses. In this literature review, we explore the intricate relationship between music and the brain, from how it is decoded by the nervous system to its therapeutic potential in various disorders. Music engages a diverse network of brain regions and circuits, including sensory-motor processing, cognitive, memory, and emotional components. Music-induced brain network oscillations occur in specific frequency bands, and listening to one's preferred music can grant easier access to these brain functions. Moreover, music training can bring about structural and functional changes in the brain, and studies have shown its positive effects on social bonding, cognitive abilities, and language processing. We also discuss how music therapy can be used to retrain impaired brain circuits in different disorders. Understanding how music affects the brain can open up new avenues for music-based interventions in healthcare, education, and wellbeing.

Endogenous Opioids and Volunteering: On the Evolutionary Significance of Helping Others

The human tendency to help others in need has been subject to trans-, inter-, and multidisciplinary studies (e.g., anthropology, neurobiology, evolutionary psychology, economy), within the frame of studying the mechanisms and adaptive significance of human prosocial behavior. Volunteering directed to unrelated and unfamiliar individuals is one common form of such helping behavior. Helping others may be adaptive for a species at a macro-level, which in turn is mediated by neurobiological mechanisms. A key target for analysis of the neurobiological underpinnings of volunteering is the endogenous opioid system (EOS). This chapter discusses EOS activity as a potential mediator of volunteering behavior. Evidence of the congruence between EOS involvement in social group behavior and social bonding and the role of these phenomena in volunteerism is reviewed. Models and empirical evidence of the mechanisms and adaptive value of helping unrelated others are discussed and integrated, including the mammalian caregiving system, the neurobiological model of prosocial behavior, synchrony promoting social bonding, and stress-driven motivation of prosocial action in immediate needs.

Clap, Clap, Clap - Unsystematic Review Essay on Clapping and Applause

The rationale for the following unsystematic review article is to provide a dense description of clapping behavior from an ethological, psychological, anthropological, sociological, ontological, and even physiological perspective. The article delves into its historical uses, possible biological-ethological evolution, and primitive and cultural polysemic-multipurpose social functions. It explores the different distal and immediate messages transmitted by the simple act of clapping, to its more complex attributes like synchronicity, social contagion, as a device of social status signaling, soft biometric data, and its, till now, mysterious subjective experience. The subtle distinction between clapping and applause will be explored. A list of primary social functions will be introduced based on the literature on clapping. In addition, a series of unresolved questions and possible research avenues will be suggested. In contrast, out of the scope of the essay and published as a second article will be the contents of clapping morphological variations and a comprehensive description of purposes achieved through them.

The origins and function of musical performance

Music is widely recognised as a human universal, yet there is no agreed explanation for its function, or why and when it evolved. I summarise experimental evidence that the primary function of musicking lies in social bonding, both at the dyadic and community levels, via the effect that performing any form of music has on the brain's endorphin system (the principal neurohormonal basis for social bonding in primates). The many other functions associated with music-making (mate choice, pleasure, coalition signalling, etc) are all better understood as derivative of this, either as secondary selection pressures or as windows of evolutionary opportunity (exaptations). If music's function is primarily as an adjunct of the social bonding mechanism (a feature it shares with laughter, feasting, storytelling and the rituals of religion), then reverse engineering the problem suggests that the capacity for music-making most likely evolved with the appearance of archaic humans. This agrees well with anatomical evidence for the capacity to sing.

Music production and its role in coalition signaling during foraging contexts in a hunter-gatherer society

Music is a cultural activity universally present in all human societies. Several hypotheses have been formulated to understand the possible origins of music and the reasons for its emergence. Here, we test two hypotheses: (1) the coalition signaling hypothesis which posits that music could have emerged as a tool to signal cooperative intent and signal strength of alliances and (2) music as a strategy to deter potential predators. In addition, we further explore the link between tactile cues and the propensity of mothers to sing toward infants. For this, we investigated the singing behaviors of hunter-gatherer mothers during daily foraging trips among the Mbendjele BaYaka in the Republic of the Congo. Although singing is a significant component of their daily activities, such as when walking in the forest or collecting food sources, studies on human music production in hunter-gatherer societies are mostly conducted during their ritual ceremonies. In this study, we collected foraging and singing behavioral data of mothers by using focal follows of five BaYaka women during their foraging trips in the forest. In accordance with our predictions for the coalition signaling hypothesis, women were more likely to sing when present in large groups, especially when group members were less familiar. However, predictions of the predation deterrence hypothesis were not supported as the interaction between group size and distance from the village did not have a significant effect on the likelihood of singing. The latter may be due to limited variation in predation risk in the foraging areas, because of the intense bush meat trade, and hence, future studies should include foraging areas with higher densities of wild animals. Lastly, we found that mothers were more likely to sing when they were carrying infants compared to when infants were close, but carried by others, supporting the prediction that touch plays an important prerequisite role in musical interaction between the mother and child. Our study provides important insight into the role of music as a tool in displaying the intent between or within groups to strengthen potentially conflict-free alliances during joint foraging activities.

Sex-related communicative functions of voice spectral energy in human chorusing

Music is a human communicative art whose evolutionary origins may lie in capacities that support cooperation and/or competition. A mixed account favouring simultaneous cooperation and competition draws on analogous interactive displays produced by collectively signalling non-human animals (e.g. crickets and frogs). In these displays, rhythmically coordinated calls serve as a beacon whereby groups of males 'cooperatively' attract potential female mates, while the likelihood of each male competitively attracting an actual mate depends on the precedence of his signal. Human behaviour consistent with the mixed account was previously observed in a renowned boys choir, where the basses-the oldest boys with the deepest voices-boosted their acoustic prominence by increasing energy in a high-frequency band of the vocal spectrum when girls were in an otherwise male audience. The current study tested female and male sensitivity and preferences for this subtle vocal modulation in online listening tasks. Results indicate that while female and male listeners are similarly sensitive to enhanced high-spectral energy elicited by the presence of girls in the audience, only female listeners exhibit a reliable preference for it. Findings suggest that human chorusing is a flexible form of social communicative behaviour that allows simultaneous group cohesion and sexually motivated competition.

A Shared Intentionality Account of Uniquely Human Social Bonding

Many mechanisms of social bonding are common to all primates, but humans seemingly have developed some that are unique to the species. These involve various kinds of interactive experiences-from taking a walk together to having a conversation-whose common feature is the triadic sharing of experience. Current theories of social bonding have no explanation for why humans should have these unique bonding mechanisms. Here we propose a shared intentionality account of uniquely human social bonding. Humans evolved to participate with others in unique forms of cooperative and communicative activities that both depend on and create shared experience. Sharing experience in these activities causes partners to feel closer because it allows them to assess their partner's cooperative competence and motivation toward them and because the shared representations created during such interactions make subsequent cooperative interactions easier and more effective.

Help is on its Way: Exploring the Mental Health and Wellbeing Outcomes of a Massed Community Choir Program

BACKGROUND

This paper explores the mental health and wellbeing outcomes of a massed community choir program in Australia.

METHODS

This study employed a mixed methods approach. Data were collected via a survey of choir participants (N = 305), four qualitative interviews and focus groups with facilitators and participants (N = 22), and two workshops with organising staff (N = 5). Questions were derived from a co-designed program logic, and data were triangulated and analysed thematically.

RESULTS

Participants reported feeling a sense of connectedness (psychological), but also experiencing connection (social) with their fellow singers. Psychological outcomes included the sensations of affect, arousal, and affirmation. Social outcomes included experiencing belonging, inclusion, and sharing. These positive psycho-social experiences promoted positive mental health and wellbeing outcomes in the large group of participating singers.

CONCLUSIONS

This paper addresses gaps in our understanding about the mental health and wellbeing outcomes fostered by community choirs at scale.

Feasibility, clinical efficacy, and well-being outcomes of an online singing intervention for postnatal depression in the UK: SHAPER-PNDO, a single-arm clinical trial

BACKGROUND

Postnatal depression (PND) affects over 12% of mothers, with numbers rising during COVID-19. Singing groups can support mothers with PND; however, online delivery has never been evaluated. SHAPER-PNDO, a single-arm clinical trial, evaluated the feasibility, clinical efficacy, and well-being outcomes of a 6-week online version of Breathe Melodies for Mums (M4M) singing intervention developed for mothers with PND during COVID-19 lockdowns.

METHODS

The primary objective of this study was to assess the feasibility of a group online singing intervention for new mothers with postnatal depression. This was ascertained through recruitment rates, study retention rates, attendance rates to the singing sessions, and study completion rates. The secondary objective of the study was to assess the clinical efficacy and well-being outcomes of the singing intervention. Specifically, we measured change in Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI), Perceived Stress Scale (PSS), and Office for National Statistics Wellbeing Scale (ONS) scores from baseline to end-of-intervention (week 6); follow-up assessments were completed at weeks 3, 16, and 32. Mothers were eligible if they scored ≥10 on the baseline EPDS.

RESULTS

Eighty-seven percent of the 37 recruited mothers completed the study, attending, on average, 5 of the 6 group singing sessions. With regard to secondary outcomes, at end-of-treatment, mothers experienced significant reductions in depression (EPDS, 16.6 ± 3.7 to 11.2 ± 5.3, 95% CI [0.79,1.65]), anxiety (STAI-S, 48.4 ± 27.1 to 41.7 ± 26.8, 95% CI [4.96, 17.65]) and stress (PSS, 29.0 ± 5.7 to 19.7 ± 5.3, 95% CI [1.33, 7.07]); and, furthermore, significant improvements in life satisfaction (ONS, 50.5 ± 23.0 to 72.8 ± 11.7, 95% CI [- 39.86, - 4.64]) and feelings of worthwhileness (ONS, 51.7 ± 30.4 to 78.6 ± 15.1, 95% CI [- 52.79, - 0.85]). Reduction on the EPDS correlated with a reduction on the BDI and the STAI-S and maternal childhood maltreatment was predictive of a smaller treatment response.

CONCLUSIONS

M4M online was feasible to mothers who partook in the programme. Furthermore, M4M online supports the mental health and well-being of new mothers experiencing PND, especially when barriers to in-person treatment are present.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04857593 . Registered 22 April 2021, retrospectively registered.

Expectancy Effects Threaten the Inferential Validity of Synchrony-Prosociality Research

Many studies argue that synchronized movement increases prosocial attitudes and behavior. We reviewed meta-analytic evidence that reported effects of synchrony may be driven by experimenter expectancy, leading to experimenter bias; and participant expectancy, otherwise known as placebo effects. We found that a majority of published studies do not adequately control for experimenter bias and that multiple independent replication attempts with added controls have failed to find the original effects. In a preregistered experiment, we measured participant expectancy directly, asking whether participants have a priori expectations about synchrony and prosociality that match the findings in published literature. Expectations about the effects of synchrony on prosocial attitudes directly mirrored previous experimental findings (including both positive and null effects)-despite the participants not actually engaging in synchrony. On the basis of this evidence, we propose an alternative account of the reported bottom-up effects of synchrony on prosociality: the effects of synchrony on prosociality may be explicable as the result of top-down expectations invoked by placebo and experimenter effects.

Social isolation and the brain in the pandemic era

Intense sociality has been a catalyst for human culture and civilization, and our social relationships at a personal level play a pivotal role in our health and well-being. These relationships are, however, sensitive to the time we invest in them. To understand how and why this should be, we first outline the evolutionary background in primate sociality from which our human social world has emerged. We then review defining features of that human sociality, putting forward a framework within which one can understand the consequences of mass social isolation during the COVID-19 pandemic, including mental health deterioration, stress, sleep disturbance and substance misuse. We outline recent research on the neural basis of prolonged social isolation, highlighting especially higher-order neural circuits such as the default mode network. Our survey of studies covers the negative effects of prolonged social deprivation and the multifaceted drivers of day-to-day pandemic experiences.

The Architecture of Happiness

Happiness is an increasingly prominent topic of interest across academia. However, relatively little attention has been paid to how it is created, especially not in a multidimensional sense. By ‘created’ we do not mean its influencing factors, for which there is extensive research, but how it actually forms in the person. The work that has been done in this arena tends to focus on physiological dynamics, which are certainly part of the puzzle. But they are not the whole picture, with psychological, phenomenological, and socio cultural processes also playing their part. As a result, this paper offers a multidimensional overview of scholarship on the ‘architecture’ of happiness, providing a stimulus for further work into this important topic.

Singing for Wellbeing: Formulating a Model for Community Group Singing Interventions

Research into the benefits of community-based group singing, pertaining to positive wellbeing and Quality of Life is lacking. Additionally, no preferred theoretical framework exists for community singing-based interventions. For the present study, six members of a UK community choir were interviewed using a semi-structured interview approach. Interpretative phenomenological analysis (IPA) was employed. Analysis produced superordinate themes of: Social Factors with key elements such as social bonds and group identity; Psychological Factors, highlighting self-efficacy, self-identity and positive emotions and Psychological Motivations for Joining the Group, including autonomy, change of life circumstance and seeking a new challenge. The style/method of the group, teaching, music and group leader, were shown to have an influence on perceived benefits of the singing group. A key product of this study beyond the evidenced benefits of group singing is the development of an intervention model that optimises wellbeing outcomes in community singing groups underpinned by psychological theory, findings from the wider literature and the results of this study.

Cultural transmission of traditional songs in the Ryukyu Archipelago

Geographic patterns of cultural variations are affected by how cultural traits are transmitted within and between populations. It has been argued that cultural traits are transmitted in different manners depending on their characteristics; for example, words for basic concepts are less liable to horizontal transmission between populations (i.e., borrowing) than other words. Here we examine the geographic variation of traditional songs in the Ryukyu Archipelago, southwestern islands of Japan, to explore cultural evolution of music with a focus on different social contexts in which songs are sung. Published scores of 1,342 traditional songs are coded using the CantoCore song classification scheme and distances between the songs are calculated from the codings. Neighbor-Net graphs of regions/islands are generated on the basis of the musical distances, and delta scores are obtained to examine the treelikeness of the networks. We also perform analysis of molecular variance (AMOVA) to evaluate the extent of musical diversification among regions/islands. Our results suggest that horizontal transmission between populations has played a greater role in the formation of musical diversity than that of linguistic diversity in the Ryukyu Archipelago and that the social context in which songs are sung has an effect on how they are transmitted within and between populations. In addition, we compare the observed patterns of song diversity among regions/islands with those of lexical and mitochondrial-DNA (mtDNA) diversity, showing that the variation of songs sung in the "work" context are associated with the linguistic variation, whereas no association is found between the musical and genetic variation.

Singing lessons as a path to well-being in later life

Seventy-two persons, who had begun voice lessons after 40 years of age, were invited to complete an online survey that focused on the singers' experience, motivation, goals, health and well-being, repertoire, practice, and demographic information; 48 respondents (33 females, mean age 60.81 years, range 48.83-82.08, SD = 6.99) completed the questionnaire. Most participants indicated that enjoyment and personal growth motivated their taking lessons. Over 90% commented on benefits of singing to their physical health (e.g., breathing) and mental health (e.g., mood, less depressive episodes). Despite the solitary aspect of singing lessons, 67% reported positive changes in social relations since taking lessons. Benefits to professional relations were also reported (e.g., confidence, listening to others). Repertoire level was generally high, consistent with a high average university educational level. Cost of lessons and time demands may account for the generally high socioeconomic status of respondents. Given that the singing voice is a musical instrument available to almost everyone, results might motivate older adults to consider taking voice lessons, encourage health care professionals to consider voice lessons as interventions to benefit clients, and persuade governments to subsidize voice lessons for older adults in their jurisdictions. The study provides a foundation for future research on the relative impacts on well-being of vocal lessons versus choral singing in the context of relative investments in the two activities.

Endogenous oxytocin, cortisol, and testosterone in response to group singing

Humans have sung together for thousands of years. Today, regular participation in group singing is associated with benefits across psychological and biological dimensions of human health. Here we examine the hypothesis that a portion of these benefits stem from changes in endocrine activity associated with affiliation and social bonding. Working with a young adult choir (n = 71), we measured changes salivary concentrations of oxytocin, cortisol, and testosterone from before and after four experimental conditions crossing two factors: vocal production mode (singing vs. speaking) and social context (together vs. alone). Salivary oxytocin and cortisol decreased from before to after the experimental manipulations. For oxytocin the magnitude of this decrease was significantly smaller after singing compared to speaking, resulting in concentrations that were significantly elevated after singing together compared to speaking together, after controlling for baseline differences. In contrast, the magnitude of the salivary cortisol decreases was the same across experimental manipulations, and although large, could not be separated from diurnal cycling. No significant effects were found in a low-powered exploratory evaluation of testosterone (tested only in males). At a psychological level, we found that singing stimulates greater positive shifts in self-perceived affect compared to speaking-particularly when performed together-and that singing together enhances feelings of social connection more than speaking together. Finally, measurements of heart rate made for a subset of participants provide preliminary evidence regarding physical exertion levels across conditions. These results are discussed in the context of a growing multidisciplinary literature on the endocrinological correlates of musical behavior. We conclude that singing together can have biological and psychological effects associated with affiliation and social bonding, and that these effects extend beyond comparable but non-musical group activities. However, we also note that these effects appear heavily influenced by broader contextual factors that shape social dynamics, such as stress levels, the intimacy of interactions, and the status of existing relationships.

Trauma Healing Club: Utilizing Culturally Responsive Processes in the Implementation of an After-School Group Intervention to Address Trauma Among African Refugees

The State of Tennessee granted appropriations to an urban university in the West Tennessee region to address the needs of at-risk African refugee children and families who have experienced Adverse Childhood Experiences (ACEs). Action oriented research efforts were conducted to address the needs of youth in the local region by developing, implementing, and evaluating a community-based intervention that was not only trauma responsive but culturally competent. The Trauma Healing Club was a treatment package developed and researched for this purpose and offered in an after school support program. This identified intervention utilized an existing evidence-based trauma intervention framework that was adapted to include more culturally responsive processes such as pyramid mentoring and African drumming. This work aimed to evaluate the effectiveness of an integrated trauma-informed practice model for community-based programming and the effectiveness of adapting an existing intervention to better fit the community needs. Results indicated that the adaptation of the trauma-responsive intervention was effective and supportive of the child-participant and his/her family needs -both culturally and as it relates to improved participant functioning post intervention.

Musicality in human vocal communication: an evolutionary perspective

Studies show that specific vocal modulations, akin to those of infant-directed speech (IDS) and perhaps music, play a role in communicating intentions and mental states during human social interaction. Based on this, we propose a model for the evolution of musicality-the capacity to process musical information-in relation to human vocal communication. We suggest that a complex social environment, with strong social bonds, promoted the appearance of musicality-related abilities. These social bonds were not limited to those between offspring and mothers or other carers, although these may have been especially influential in view of altriciality of human infants. The model can be further tested in other species by comparing levels of sociality and complexity of vocal communication. By integrating several theories, our model presents a radically different view of musicality, not limited to specifically musical scenarios, but one in which this capacity originally evolved to aid parent-infant communication and bonding, and even today plays a role not only in music but also in IDS, as well as in some adult-directed speech contexts. This article is part of the theme issue 'Voice modulation: from origin and mechanism to social impact (Part II)'.

Music, Mind, Mood, and Mingling in Alzheimer's Disease and Related Dementias: A Scoping Review

BACKGROUND

Music-based interventions may help to alleviate neuropsychiatric symptoms of dementia and promote prosocial interactions between individuals living with dementia and their caregivers. However, current literature does not combine these evidence bases toward explanation of how music-based interventions may alleviate symptoms and promote prosocial interactions.

OBJECTIVE

We conducted a scoping review to address the following question: what do the evidence bases suggest toward how music therapy or music-based therapeutic interventions might promote prosocial interactions between individuals living with dementia and their caregivers?

METHODS

In this review we focused on: 1) quantitative and qualitative evidence of music-based therapies promoting prosocial behaviors in individuals living with dementia, and 2) potential neurobehavioral mechanisms associated with the processes involved with how music may promote prosocial interactions. Databases included PubMed, EBSCOhost's CINAHL and PsycINFO, Cochrane Library (sub-search conducted using ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group), Web of Science, clinicaltrials.gov, ProQuest's Biological Science Collection, the Journal of Music Therapy, Nordic Journal of Music Therapy, and Google Scholar.

RESULTS

Sixteen original research studies were included for evidence synthesis. This scoping review reveals the need to define and clarify mechanisms of prosocial interactions between individuals living with dementia and their caregivers considering biological and social factors. These mechanisms may include dynamic interactions between preserved brain regions associated with music-evoked autobiographical memory recall and shifts from negative to positive mood states.

CONCLUSION

Defining and clarifying how and to what extent music may promote prosocial behaviors using well-designed and well-controlled mixed-methods studies may positively influence the design of interventions to promote prosocial interactions with caregivers.

An Infant's Question on COVID-19 and Music: Should I Attend My Online Classes?

In the last few months, we all have faced a profound challenge to balance our lives amidst fighting the COVID-19 pandemic. The reactions to this coronavirus pandemic have no doubt affected all aspects of our everyday normalcy as they have called for an extended set of measures that have greatly impacted our social interactions and well-being. During this unprecedented global situation, the pandemic has also taken its toll on education, as schools, universities, and other educational institutions have suspended their programs or moved online to retain educational momentum. Among the programs that tried to adapt to this online model was the early years music education. This mini-review article aims to discuss the framework of online existence for the early years music programs amid the COVID-19 crisis, while considering their benefits and character under these extraordinary circumstances.

How Do Music Activities Affect Health and Well-Being? A Scoping Review of Studies Examining Psychosocial Mechanisms

Background: This scoping review analyzed research about how music activities may affect participants' health and well-being. Primary outcomes were measures of health (including symptoms and health behaviors) and well-being. Secondary measures included a range of psychosocial processes such as arousal, mood, social connection, physical activation or relaxation, cognitive functions, and identity. Diverse music activities were considered: receptive and intentional music listening; sharing music; instrument playing; group singing; lyrics and rapping; movement and dance; and songwriting, composition, and improvisation. Methods: Nine databases were searched with terms related to the eight music activities and the psychosocial variables of interest. Sixty-three papers met selection criteria, representing 6,975 participants of all ages, nationalities, and contexts. Results: Receptive and intentional music listening were found to reduce pain through changes in physiological arousal in some studies but not others. Shared music listening (e.g., concerts or radio programs) enhanced social connections and mood in older adults and in hospital patients. Music listening and carer singing decreased agitation and improved posture, movement, and well-being of people with dementia. Group singing supported cognitive health and well-being of older adults and those with mental health problems, lung disease, stroke, and dementia through its effects on cognitive functions, mood, and social connections. Playing a musical instrument was associated with improved cognitive health and well-being in school students, older adults, and people with mild brain injuries via effects on motor, cognitive and social processes. Dance and movement with music programs were associated with improved health and well-being in people with dementia, women with postnatal depression, and sedentary women with obesity through various cognitive, physical, and social processes. Rapping, songwriting, and composition helped the well-being of marginalized people through effects on social and cultural inclusion and connection, self-esteem and empowerment. Discussion: Music activities offer a rich and underutilized resource for health and well-being to participants of diverse ages, backgrounds, and settings. The review provides preliminary evidence that particular music activities may be recommended for specific psychosocial purposes and for specific health conditions.

Laughter influences social bonding but not prosocial generosity to friends and strangers

Humans deploy a number of specific behaviours for forming social bonds, one of which is laughter. However, two questions have not yet been investigated with respect to laughter: (1) Does laughter increase the sense of bonding to those with whom we laugh? and (2) Does laughter facilitate prosocial generosity? Using changes in pain threshold as a proxy for endorphin upregulation in the brain and a standard economic game (the Dictator Game) as an assay of prosociality, we show that laughter does trigger the endorphin system and, through that, seems to enhance social bonding, but it does not reliably influence donations to others. This suggests that social bonding and prosociality may operate via different mechanisms, or on different time scales, and relate to different functional objectives.

Use of Palliative Care Music Therapy in a Hospital Setting during COVID-19

As many hospitals scaled back integrative therapies during the COVID-19 pandemic, we instead turned to the multifaceted qualities of music to bridge physical and social divides. In this report, we describe palliative care music therapists as frontline providers utilizing evidence-based approaches to support healing and recovery for patients in the intensive care unit, patient and family care at end of life, and staff wellness. We provide examples of music therapy (MT) to promote successful weaning from mechanical ventilation, create bedside rituals and legacy gifts for dying patients and their families, and provide real-time support for overwhelmed staff. Despite barriers brought on by the pandemic, the sensory and emotional immediacy of music bridged social distances at critical moments and addressed "suffering beyond words" among patients, families and health care workers. Our experience reinforced the need for MT as standard of interdisciplinary care during the pandemic and beyond.

Cochlear SGN neurons elevate pain thresholds in response to music

The C-tactile (CLTM) peripheral nervous system is involved in social bonding in primates and humans through its capacity to trigger the brain’s endorphin system. Since the mammalian cochlea has an unusually high density of similar neurons (type-II spiral ganglion neurons, SGNs), we hypothesise that their function may have been exploited for social bonding by co-opting head movements in response to music and other rhythmic movements of the head in social contexts. Music provides one of many cultural behavioural mechanisms for ‘virtual grooming’ in that it is used to trigger the endorphin system with many people simultaneously so as to bond both dyadic relationships and large groups. Changes in pain threshold across an activity are a convenient proxy assay for endorphin uptake in the brain, and we use this, in two experiments, to show that pain thresholds are higher when nodding the head than when sitting still.

Evolutionary origins of music. Classical and recent hypotheses

The aim of this paper is to review recent hypotheses on the evolutionary origins of music in Homo sapiens, taking into account the most influential traditional hypotheses. To date, theories derived from evolution have focused primarily on the importance that music carries in solving detailed adaptive problems. The three most influential theoretical concepts have described the evolution of human music in terms of 1) sexual selection, 2) the formation of social bonds, or treated it 3) as a byproduct. According to recent proposals, traditional hypotheses are flawed or insufficient in fully explaining the complexity of music in Homo sapiens. This paper will critically discuss three traditional hypotheses of music evolution (music as an effect of sexual selection, a mechanism of social bonding, and a byproduct), as well as and two recent concepts of music evolution - music as a credible signal and Music and Social Bonding (MSB) hypothesis.

The Relationship between Neighborhood Deprivation and Perceived Changes for Pain-Related Experiences among U.S. Patients with Chronic Low Back Pain during the COVID-19 Pandemic

OBJECTIVE

Disruptions caused by the COVID-19 pandemic could disproportionately affect the health of vulnerable populations, including patients experiencing persistent health conditions (i.e., chronic pain), along with populations living within deprived, lower socioeconomic areas. The current cross-sectional study characterized relationships between neighborhood deprivation and perceived changes in pain-related experiences during the COVID-19 pandemic (early-September to mid-October 2020) for adult patients (N = 97) with nonspecific chronic low back pain.

METHODS

We collected self-report perceived experiences from participants enrolled in an ongoing pragmatic randomized trial across medical centers within the Salt Lake City, Utah and Baltimore, Maryland metropolitans. The Area Deprivation Index (composite of 17 U.S. Census deprivation metrics) reflected neighborhood deprivation based on participants' zip codes.

RESULTS

Although those living in the neighborhoods with greater deprivation endorsed significantly poorer physical (pain severity, pain interference, physical functioning), mental (depression, anxiety), and social health during the pandemic, there were no significant differences for perceived changes in pain-related experiences (pain severity, pain interference, sleep quality) between levels of neighborhood deprivation since the onset of the pandemic. However, those in neighborhoods with greater deprivation endorsed disproportionately worse perceived changes in pain coping, social support, and mood since the pandemic.

CONCLUSIONS

The current findings offer evidence that changes in pain coping during the pandemic may be disproportionately worse for those living in deprived areas. Considering poorer pain coping may contribute to long-term consequences, the current findings suggest the need for further attention and intervention to reduce the negative affect of the pandemic for such vulnerable populations.

Measurement of Shared Social Identity in Singing Groups for People With Aphasia

Community groups are commonly used as a mode of delivery of interventions for promoting health and well-being. Research has demonstrated that developing a sense of shared social identity with other group members is a key mechanism through which the health benefits of group membership are realized. However, there is little understanding of how shared social identity emerges within these therapeutic settings. Understanding the emergence of shared social identity may help researchers optimize interventions and improve health outcomes. Group-based singing activities encourage coordination and a shared experience, and are a potential platform for the development of shared social identity. We use the "Singing for People with Aphasia" (SPA) group intervention to explore whether group cohesiveness, as a behavioral proxy for shared social identity, can be observed and tracked across the intervention. Video recordings of group sessions from three separate programmes were rated according to the degree of cohesiveness exhibited by the group. For all treatment groups, the final group session evidenced reliably higher levels of cohesiveness than the first session (t values ranged from 4.27 to 7.07; all p values < 0.003). As well as providing confidence in the design and fidelity of this group-based singing intervention in terms of its capacity to build shared social identity, this evaluation highlighted the value of observational methods for the analysis of shared social identity in the context of group-based singing interventions.

Flourishing in Resonance: Joint Resilience Building Through Music and Motion

Worldwide, children face adverse childhood experiences, being exposed to risks ranging from, exposure to political violence and forced migration over the deleterious effects of climate change, to unsafe cultural practices. As a consequence, children that seek refuge or migrate to European countries are extremely vulnerable, often struggling with integration in school, peer community, and their broader social circle. This multifaceted struggle can derive from external factors, such as the adaptation process and contact with other children, or internal factors such as the fears and trauma that every child carries within them since they departed from their homeland. To bounce, grow, connect, and create in both adversity and opportunity, children need to build resilience, i.e., the capacity of an individual to maintain stable psychological functioning throughout the course of adversity. On the one hand, building resilience requires developing a set of individual skills (internal protective factors), such as self-control, emotion regulation, self-esteem, and agency. On the other hand, building resilience involves developing social skills (external protective factors), connection, and close relationships. In this theoretical contribution, we review and map existing research to argue that activities based on the combination of music and movement has a strong potential to intensively build resilience. First, we connect the concepts of resilience and eudaimonia, based on the protective factors and key components of resilience. Then we discuss how music and movement, separately, may contribute to building resilience. Next, drawing on the basic mechanisms of musical sense-making, we argue that through combining music and movement, children engage in empowering musical sense-making processes that support building resilience, and in this way, support them to grow together and deeply experience eudaimonic values such as self-awareness, confidence and self-esteem, personal autonomy, connection, belonging, and bonding. Finally, we connect theory to practice. Based on the presented theoretical elaborations and on the authors’ experience as practitioners, we propose a set of guiding principles for the design of movement-based musical activities that foster the internal and external factors necessary to build resilience.

Musical Training in the Development of Empathy and Prosocial Behaviors

Music not only regulates mood but also promotes the development and maintenance of empathy and social understanding. Since empathy is crucial for well-being and indispensable in social life, it is necessary to develop strategies to improve empathy and prosocial behaviors. To fulfill this aim, researchers have extensively investigated the effect of intensive musical training on the development of empathy. Here, we first summarize evidence showing the powerful influence of musical training on the development of empathy and then discuss psychological mechanisms responsible for those observations. The conclusions drawn from most previous studies were mainly based on behavioral measurements, while the neural basis of musical training in the development of the empathic brain is still unclear. Fortunately, brain imaging research has contributed greatly to our understanding of the neural underpinnings associated with musical training and its possible connection to the development of the empathic brain. One of the most distinctive signatures of musical training is structural and functional changes of multiple brain regions, and such changes might be related to some of the empathic behaviors observed in musically trained children. Therefore, intensive musical training in childhood may increase levels of empathy, and applied research is required to optimize the training strategy before implementing music education in empathy regulation. Moreover, future longitudinal studies are needed to better understand neural mechanisms underlying the causal effect of musical training on empathy development. These findings have important implications for understanding the development of the empathic brain and for improving prosocial behaviors.

Synchronization and Coordination of Art Performances in Highly Competitive Contexts: Battle Scenes of Expert Breakdancers

In the performing arts, such as music and dance performances, people actively interact with each other and show their exciting performances. Some studies have proposed that this interaction is a social origin of the performing arts. Some have further investigated this phenomenon based on the synchronization and coordination theory. Though the majority of these studies have focused on the collaborative context, several genres of the performing arts, such as jazz sessions and breakdance battles, have a competitive context. Several studies have suggested that, in this competitive context, performers actively interact with each other and construct some correspondence. Moreover, a few recent studies focusing on competitive conversations, such as debates, have shown that, compared to people's interactions in collaborative conversations, people in competitive contexts frequently coordinate their behaviors in complicated ways. However, the interaction and coordination among performers in these competitive contexts have not been sufficiently investigated. Therefore, we investigated the coordination of expert breakdancers in battle scenes and measured their rhythmic movements using a motion capture system. We calculated the relative phase of the rhythmic movements between two dancers to investigate their coordination. The results showed that the dancers' rhythmic movements tended to synchronize in an anti-phase fashion, which means that there were similarities as well as differences between the two dancers' rhythmic movements. Furthermore, this pattern of coordination changed dynamically as time elapsed, from an in-phase synchronization or leader-follower relationships to an anti-phase synchronization and then leader-follower relationships.

Group singing improves both physical and psychological wellbeing in people with and without chronic health conditions: A narrative review

The aim of this narrative review was to establish a link between psychological and physical wellbeing in people with and without chronic health conditions who participated in group singing. Four databases were searched (PubMed, WoS, MEDLINE, and Scopus) using a systematic search method. Articles were screened, yielding 19 suitable articles. In most studies that were included group singing led to an increase in both psychological and physiological wellbeing. The major impacts were on affect and depression and anxiety.Group singing positively affects both physical and psychological wellbeing in people with and without chronic health conditions. No direction of causality could be established.

"Like Pieces in a Puzzle": Online Sacred Harp Singing During the COVID-19 Pandemic

Sacred Harp singers the world over gather weekly to sing out of The Sacred Harp, a collection of shape-note songs first published in 1844. Their tradition is highly ritualized, and it plays an important role in the lives of many participants. Following the implementation of lockdown protocols to combat the COVID-19 pandemic, groups of Sacred Harp singers quickly and independently devised a variety of means by which to sing together online using Zoom (“zinging”), Jamulus (“jamzinging”), and Facebook Live (“stringing”). The rapidity and creativity with which Sacred Harp singers developed ways to sustain their activities attests to the strength and significance of this community of practice, and in this article I describe each modality and provide an account of how it came to be developed and widely used. As a participant-observer, I completed extensive fieldwork across these digital sites and conducted semi-structured interviews with 22 other singers. I found that online singing practices have reshaped the Sacred Harp community. Many singers who did not previously have the opportunity to participate now have access, while others have lost access due to technological barriers or lack of interest in online activities. At the same time, geographical barriers have disintegrated, and singing organizers must make an effort to maintain local identity. A stable community of singers has emerged in the digital realm, but it is by no means identical to the community that predated the pandemic. I also identify the ways in which online singing has proven meaningful to participants by providing continuity in their personal and communal practice. Specifically, online singing allows participants to access and celebrate their collective memories of the Sacred Harp community, carry out significant rituals, and continue to grow as singers. While no single modality replicates the complete Sacred Harp singing experience, together they function “like pieces in a puzzle” (as one singer put it), allowing individual participants to access many of the elements of Sacred Harp singing that are most meaningful to them.

Coping with Racism: a Perspective of COVID-19 Church Closures on the Mental Health of African Americans

Academic medical literature and news outlets extensively document how older individuals in communities of color, especially African American communities, are dying disproportionately of COVID-19 due to ongoing societal, racial, and healthcare disparities. Fear of death and suffering are acutely elevated in Black communities; yet, African Americans have been facing, coping with, and overcoming American societal racism and subsequent detriments to our mental health for centuries. Predominately African American churches (hereafter referred to as the "Black Church") have always served a historical, cultural, contextual, and scientifically validated role in the mental health well-being of African American communities coping with American racism. Nonetheless, buildings of worship closed due to the COVID-19 pandemic in mid-March 2020. This article is a first-hand perspective of five Black internists/psychiatrists who are deeply involved in both academic medicine and leadership positions within the Black Church. It will explore how the physical closure of Black Churches during this period of increased mental stress, as caused by healthcare inequities revealed by the COVID-19 epidemic, is likely to be uniquely taxing to the mental health of African Americans, particularly older African Americans, who must cope with American racism without physical access to the Black Church for the first time in history.

Interactional synchrony: signals, mechanisms and benefits

Many group-living animals, humans included, occasionally synchronize their behavior with that of conspecifics. Social psychology and neuroscience have attempted to explain this phenomenon. Here we sought to integrate results around three themes: the stimuli, the mechanisms and the benefits of interactional synchrony. As regards stimuli, we asked what characteristics, apart from temporal regularity, prompt synchronization and found that stimulus modality and complexity are important. The high temporal resolution of the auditory system and the relevance of socio-emotional information endow auditory, multimodal, emotional and somewhat variable and adaptive sequences with particular synchronizing power. Looking at the mechanisms revealed that traditional perspectives emphasizing beat-based representations of others' signals conflict with more recent work investigating the perception of temporal regularity. Timing processes supported by striato-cortical loops represent any kind of repetitive interval sequence fairly automatically. Additionally, socio-emotional processes supported by posterior superior temporal cortex help endow such sequences with value motivating the extent of synchronizing. Synchronizing benefits arise from an increased predictability of incoming signals and include many positive outcomes ranging from basic information processing at the individual level to the bonding of dyads and larger groups.

The Effects of Synchrony on Group Moral Hypocrisy

Humans have evolved various social behaviors such as interpersonal motor synchrony (i.e., matching movements in time), play and sport or religious ritual that bolster group cohesion and facilitate cooperation. While important for small communities, the face-to-face nature of such technologies makes them infeasible in large-scale societies where risky cooperation between anonymous individuals must be enforced through moral judgment and, ultimately, altruistic punishment. However, the unbiased applicability of group norms is often jeopardized by moral hypocrisy, i.e., the application of moral norms in favor of closer subgroup members such as key socioeconomic partners and kin. We investigated whether social behaviors that facilitate close ties between people also promote moral hypocrisy that may hamper large-scale group functioning. We recruited 129 student subjects that either interacted with a confederate in the high synchrony or low synchrony conditions or performed movements alone. Subsequently, participants judged a moral transgression committed by the confederate toward another anonymous student. The results showed that highly synchronized participants judged the confederate’s transgression less harshly than the participants in the other two conditions and that this effect was mediated by the perception of group unity with the confederate. We argue that for synchrony to amplify group identity in large-scale societies, it needs to be properly integrated with morally compelling group symbols that accentuate the group’s overarching identity (such as in religious worship or military parade). Without such contextualization, synchrony may create bonded subgroups that amplify local preferences rather than impartial and wide application of moral norms.

How music may support perinatal mental health: an overview

There is strong evidence that engaging with music can improve our health and well-being. Music-based interventions, approaches and practices, such as group music-making (singing or playing musical instruments), listening to music and music therapy, have all been shown to reduce symptoms of depression and anxiety. Although the existing literature needs expanding, mounting evidence suggests that music-based interventions, approaches and practices may help support maternal mental health prenatally and postnatally. The purpose of this descriptive overview is to provide a broad view of this area by bringing together examples of research across different practices and research disciplines. Selected evidence is examined, showing how music-based interventions, approaches and practices can reduce labour anxiety and pain, anxiety symptoms in pregnancy, postnatal depression symptoms and support maternal-infant bonding. The examined research includes single studies and reviews that use both qualitative and quantitative methods. Drawing on animal and human models, the effect of music on foetal behaviour and various possible biological, psychological and social mechanisms are discussed. The potential preventive effect of music-based interventions, approaches and practices and their possible use across different cultures are also considered. Overall, we highlight how music, employed in a variety of ways, may support perinatal mental health with the aim of stimulating more interest and research in this area.

Heterogeneity in Danish lung choirs and their singing leaders: delivery, approach, and experiences: a survey-based study

OBJECTIVES

Singing is considered a beneficial leisure time intervention for people with respiratory diseases, and lung choirs have gained increasing attention. However, there is no available guideline on preferred methodology, and hence, outcomes, delivery, and benefits are unclear. The present study investigated for the first time ever emerged delivery, approach, and experiences in Danish lung choirs and their singing leaders, hypothesising the array to be heterogeneous, without disease-specific approach, and a challenging field to navigate for the singing leaders.

SETTING

An online survey comprising 25 questions was performed individually, May 2017, in Denmark.

PARTICIPANTS

Current singing leaders of Danish lung choirs, identified by hand searches on the internet. In total, 33 singing leaders in formal and informal settings were identified and 20 (67%) responded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Distribution in content, delivery, and approach; level of disease-specific knowledge and modification; experience of challenges and benefits. Quantitative variables were counted, and an inductive content analysis approach was used for the qualitative study component.

RESULTS

The lung choirs were heterogeneous concerning setting, duration, and content. The approach was traditional without disease-specific content or physical activity. Most singing leaders held various academic degrees in music, but lacked skills in lung diseases. However, they experienced lung choirs as a highly meaningful activity, and reported that participants benefited both musically, psychosocially, and physically. Singing leaders were enthusiastic regarding potentials in the 'arts-and-health' cross-field and experienced an expansion of their role and overall purpose, professionally as well as personally. However, they also experienced insecurity, inadequacy, and isolation, and requested methodological guidelines, formal support, and peer network.

CONCLUSION

Danish lung choirs are led without any disease-specific guideline or methodological approach. Further studies are needed to develop and distribute a preferred methodological approach.

TRIAL REGISTRATION NUMBER

This study is linked to clinical trial number NCT03280355 and was performed prior to data collection and results of the clinical trial.