Listening to motivational music while walking elicits more positive affective response in patients with cystic fibrosis

Complementary Therapies in Clinical Practice 23 (2016) 52e58

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Listening to motivational music while walking elicits more positive affective response in patients with cystic fibrosis Ebru Calik-Kutukcu a, *, Melda Saglam a, Naciye Vardar-Yagli a, Aslihan Cakmak a, Deniz Inal-Ince a, Cemile Bozdemir-Ozel a, Hazal Sonbahar-Ulu a, Hulya Arikan a, Ebru Yalcin b, Jale Karakaya c a b c

Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, 06100, Samanpazari, Ankara, Turkey Hacettepe University, Faculty of Medicine, Department of Child Health and Diseases, Unit of Chest Diseases, 06230, Sihhiye, Ankara, Turkey Hacettepe University, Faculty of Medicine, Department of Biostatistics, 06230, Sihhiye, Ankara, Turkey

a r t i c l e i n f o

a b s t r a c t

Article history: Received 10 February 2016 Received in revised form 29 February 2016 Accepted 14 March 2016

Objective: The purpose of this study was to investigate the effects of motivational and relaxation music on affective responses during exercise in patients with cystic fibrosis (CF). Methods: Thirty-seven patients with CF performed the 6-min walk test (6MWT) under three experimental conditions: listening to no music, relaxation music, and motivational music. 6min distance
body weight product (6MWORK) was calculated for each trial. Patients' affective responses during exercise was evaluated with Feeling Scale (FS). The motivational qualities of music were evaluated with the Brunel Music Rating Inventory-2 (BMRI-2). Results: 6MWORK was significantly lower while listening to relaxation music compared to 6MWORK without music (p < 0.05). FS and BMRI-2 scores were significantly higher during 6MWT with motivational music than 6MWT with relaxation music (p < 0.05). Conclusions: Carefully selected motivational music can lead to positive affective response during exercise and increase the enjoyment of patients from exercises in CF. © 2016 Elsevier Ltd. All rights reserved.

Keywords: Cystic fibrosis Motivational music RPE Affect Exercise

1. Introduction Cystic fibrosis (CF) is an inherited autosomal recessive multisystem disorder characterized by obstructive lung disease, pancreatic insufficiency, malnutrition and high electrolyte levels in sweat [34]. CF occurs due to mutation in the Cystic Fibrosis Transmembrane Conductance Regulator gene located on the long arm of chromosome 7 [6] and the prevalence of CF is one in every 2500 live births [46]. It is expected that newborns with CF will survive to the age of 50 in the twenty-first century [36]. The exercise capacity of patients with CF has been shown to be lower than in healthy controls [2,11]. Pulmonary, cardiac and

* Corresponding author. E-mail addresses: [email protected] (E. Calik-Kutukcu), ptmeldaozturk@ yahoo.com (M. Saglam), [email protected] (N. Vardar-Yagli), [email protected] (A. Cakmak), [email protected] (D. Inal-Ince), [email protected] (C. Bozdemir-Ozel), [email protected] (H. Sonbahar-Ulu), [email protected] (H. Arikan), [email protected]. tr (E. Yalcin), [email protected] (J. Karakaya). http://dx.doi.org/10.1016/j.ctcp.2016.03.002 1744-3881/© 2016 Elsevier Ltd. All rights reserved.

peripheral skeletal muscle function, along with physical activity, all contribute to exercise limitation in CF [1]. Exercise capacity, which is an objective measure of exercise tolerance, predicts the risk of mortality and hospitalization in patients with CF [31,32]. Although the value of physical activity and exercise training in the therapeutic intervention for patients with CF is well recognized by clinicians [30,43], it has not yet been established how best to implement physical activity and exercise to ensure a positive behavioral change, and clinicians are not aware of the beneficial effects of listening to music during exercise. It has been shown that music therapy could affect oxygen saturation (SpO2), heart rate (HR), respiratory rate, anxiety, depression, and quality of life in the medical environment [35]. Sliwka et al. showed in their study that patients with mild asthma benefit from music therapy; their pulmonary function improves and dyspnea perception decreases [38]. Music leads to improvements in the psychological outcomes such as quality of life, dyspnea and anxiety and physiological outcomes such as pulmonary functions among individuals living with COPD [29]. Rating of perceived exertion (RPE) was found to be lower during low-

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intensity exercise in the presence of music compared to exercise performed without music in healthy people [45]. Evidence suggests certain musical experiences can positively affect mood during exercise [5,24]. Although studies have shown that music can have a positive effect on exercise participants [13,24] and increase physical performance [9,40], the findings in the literature are not consistent. In addition, the studies were often done on healthy subjects and cardiac patients. There is only one study that evaluates the benefits of music therapy as an adjunct to chest physiotherapy in patients with cystic fibrosis [15]. Considering the lack of literature on this subject and of any study regarding the effects of music during exercise on patients with CF, we planned this clinical trial. The present study is the first to examine the effects of music during walking on patients with CF. In this study we aimed to investigate the effects of motivational and relaxation music on functional exercise capacity, vital signs, RPE and affective responses during exercise in patients with CF. Because the findings regarding the effects of music have been controversial, no specific hypotheses were advanced and the investigation was exploratory in nature.

2. Methods 2.1. Participants Thirty-seven stable CF patients between the ages of 8e18 who were diagnosed by Hacettepe University, Faculty of Medicine, Department of Child Health and Diseases, Unit of Chest Diseases according to CF-compliant clinical manifestations and sweat chloride above 60 mEq/L in both measurements; who were ambulant and cooperative; and who volunteered to participate in the study were enrolled. Patients who were in acute exacerbation period or had severe pulmonary dysfunction, hearing impairments, neurological disease, severe orthopedic disease or any systemic disease that would interfere with the tests performed were not included in the study. The study was approved by the Ethics Committee of Hacettepe University and subjects and their families signed an informed consent form.

2.2. Procedure Each patients' exercise capacities were assessed by 6MWT with motivational music, relaxation music and without music in a random order determined by draw. The three 6MWT trials were conducted with 30 min intervals between each test. During the 30 min resting period after each exercise test, patients provided feedback by marking scales related to affective responses and the motivating level of the music during exercise.

2.3. Music selection Songs were played with a portable MP4 device (GOLDSMART Digital MP4 Player, Model No: MP4-224, China) and patients listened the music via earphones (Sony MDRZX100W White Headband Headphones). The volume of the music was increased individually for each participant to a level that was easily audible and comfortable. A song with a tempo of 120 beats/min (‘Survivor’Eye of the Tiger, 1982) was selected as motivational music and a song with a tempo of 60 beats/min (relaxing music-slow instrumental music for meditation and more-rdN 019) was selected as relaxation music [17,21]. The selected musics were the songs which can appeal to these age group.

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2.4. Assessments The physical and sociodemographic characteristics of all subjects were recorded. Body mass index (BMI) was calculated from the formula (body weight/height2, kg/m2). Subjects were classified as thin (<18.5 kg/m2), normal (18.5e24.9 kg/m2), overweight (25e29.9 kg/m2) and obese (30e39.9 kg/m2) [44]. Patients provided information regarding the numbers of emergency department visits, hospitalizations, and doctor visits they had during the previous year, their symptoms, and physiotherapy techniques they had used. The drugs they used and laboratory test results were recorded from their hospital file. 2.4.1. Pulmonary functions The pulmonary function test was performed with a spirometer (Zan100USB, nSpire Health Inc, USA). The test was performed in the sitting position. The best of three technically acceptable maneuvers with 95% compliance was selected for analysis [12]. Pulmonary function test results were expressed as percentages of the expected values adjusted for age, height, body weight and sex [39]. 2.4.2. Dyspnea perception Patients' dyspnea levels were determined with the Modified Medical Research Council (MMRC) Dyspnea Scale. The MMRC Dyspnea Scale is a five-level rating scale to describe breathlessness in daily activities. Level 0 represents the lowest level of dyspnea impairment perceived, level 4 the greatest dyspnea perception [4]. 2.4.3. Functional exercise capacity In the 6-min walk test (6MWT), subjects were requested to walk along a 30-m level corridor as fast as they could at their walking speed for 6 min. The test was administered three times (with motivational music, with relaxation music and without music in a randomized order) in the same day with half-hour intervals. Preand post-test HR and SpO2 with a pulse oximeter (Nonin Model 2500C, Nonin Medical, Inc., Plymouth, MN, USA) were recorded. Dyspnea, general fatigue and quadriceps fatigue perceptions were assessed with the Modified Borg Scale and pre- and post-test scores were recorded. RPE during the test was assessed with Modified Borg Scale and recorded after each test. Distance results of the three tests were used in the statistical analysis for each patient [3]. The 6MWT distance was expressed as a percentage of the expected values from age and sex (%6MWT distance) [27,37]. The 6MWORK (kg.m) was calculated as 6MWT distance (in m)
body weight (in kg) for each test [37]. 2.4.4. Motivational qualities of music during exercise The motivational qualities of music during exercise were evaluated with the Brunel Music Rating Inventory-2 (BMRI-2). In this study, The second part of BMRI-2 was only used for assessing motivational qualities of motivational and relaxation musics. The first part of BMRI-2 that contains 13 items for selecting music was not used. The BMRI-2 is comprised of six items, each concerning a musical component (rhythm, style, melody, tempo, instrumentation and beat). After participants listened to motivational and relaxation music during the 6MWT, they indicated the extent of their agreement with each item (e.g. ‘The rhythm of the music would motivate me during exercise’) on a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree). The total score is summed to give a value ranging from 6 to 42 which represents the motivational quotient for that piece of music [19]. The motivational quotients of music are described as high (36e42), moderate (24e35), and oudeterous (24) [20]. The BMRI-2 can be used both by exercise instructors and participants. It is easy to use and provides a valid and internally consistent tool for selecting music to

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Table 1 Characteristics of patients with CF (n ¼ 37). X ± SD 12.8 ± 3.1 19/18 148.9 ± 16.3 42.1 ± 16.0 18.3 ± 3.5 83.6 ± 17.9 80.3 ± 14.8 10.7 ± 4.2 Median (min-max) 89.5 (64.9e101) 85 (56e112) 92.5 (26e139) 4 (0e15) 0 (0e4) 0 (0e6) 0 (0e3)

Age (years) Sex (male/female) Height (cm) Body weight (kg) BMI (kg/m2) FEV1 (%) FVC (%) Disease duration (years) FEV1/FVC PEF (%) FEF%25e75 (%) Doctor control visits in last year (n) Hospitalizations in last year (n) Emergency visits in last year (n) MMRC score (0e4)

Abbreviations: BMI, body mass index; FEV1, Forced expiratory volume in 1 s; FVC, Forced vital capacity; FEF25e75%, Forced expiratory flow between 25% and 75% of FVC; PEF, Peak expiratory flow; MMRC, Modified Medical Research Council Research Council Dyspnea Scale.

distribution. One-way repeated measures ANOVA was used to assess the significance of the three experimental conditions in the variables assessed. A post-hoc LSD test was used to examine for multiple comparisons. Non-parametric Friedman's test was performed to compare differences of non-normal quantitative variables. If there were significance differences between the trials, Conover's multiple comparison test was performed as a post hoc test. Paired sample t-test was used to determine whether there was a significant difference between the dependent values. The Wilcoxon Test was applied for the dependent group comparisons when the data were not normally distributed. Dependent measures for ordinal categorical variables were compared by using a marginal homogeneity test. Observed power of the study was 83% considering comparison of mean BMRI-2 values with alpha ¼ 0.05 and a sample size of 37. A p < 0.05 was accepted as statistically significant. All statistical analyses were performed using SPSS Statistics software (SPSS Statistics for Windows version 21.0, IBM, Armonk, NY, USA). Graphics was created using the Windows-based Graphpad Prism 5.04 (Graphpad Software Inc., California, USA) software. 3. Results

accompany exercise or a training session [19]. 2.4.5. Affective responses during exercise The Feeling Scale (FS) was used to evaluate affective responses during exercise. It is common to experience changes in mood during exercise. Some individuals consider exercise pleasurable, whereas others find it unpleasant. The FS measures emotional responses during exercise as a score ranging from þ5 to 5 (þ5 ¼ very good, þ3 ¼ good, þ1 ¼ fairly good, 0 ¼ neutral, 1 ¼ fairly bad, 3 ¼ bad, and 5 ¼ very bad) [8]. 2.4.6. Participant's satisfaction level with and without music Patients' satisfaction level during tests with and without music was assessed with the Visual Analogue Scale (VAS). After completing all three 6MWT trials, subjects rated their satisfaction level on a horizontal, 100-mm line bounded by ‘not satisfied at all’ on the left and ‘very satisfied’ on the right [26]. In addition, patients indicated their music preference (motivational or relaxation). 2.5. Statistical analysis Numerical variables were evaluated for normality of data distribution using the Kolmogorov-Smirnov test. Descriptive statistics were expressed as mean ± standard deviation (SD) or median (minimum-maximum) according to the assumption of normal

Patient demographic characteristics, dyspnea levels and pulmonary functions are presented in Table 1. According to BMI classification, 54.1% of patients were thin, 43.2% were normal, and 2.7% were overweight. Twenty-one patients (56.8%) had cough, 25 patients (67.6%) had sputum, 4 patients (10.8%) had resting dyspnea and 24 (64.9%) had exertion dyspnea symptoms. Regarding physiotherapy techniques, 21.6% (n ¼ 8) were using active cycle of breathing technique, 24.3% (n ¼ 9) were using breathing exercises, 16.2% (n ¼ 6) were using postural drainage, 8.1% (n ¼ 3) were using a shaker, 2.7% (n ¼ 1) were using a flutter and 13.5% (n ¼ 5) were using a Threshold PEP. The patients were using comparable drugs. Table 2 presents differences in 6MWT distance, HR, SpO2, dyspnea/fatigue perceptions, and RPE responses between 6MWT trials with motivational music, with relaxation music and without music. There were no significant differences in 6MWT distance, %6MWT distance, change in HR, SpO2, dyspnea, quadriceps fatigue and general fatigue perceptions, RPE responses or percentage of maximum HR between the three 6MWT trials (Table 2, p > 0.05). There was a statistically significant difference in 6MWORK between the three trials (Table 2, p < 0.05, Fig. 1). The 6MWORK of patients during 6MWT without music was significantly higher than during 6MWT with relaxation music (p ¼ 0.024). Table 3 shows comparisons of the motivational qualities of music, patients' satisfaction levels and affective responses during the 6MWT with motivational music, with relaxation music and

Table 2 Comparison of parameters of the 6-min walk test with motivational music, with relaxation music and without music. X ± SS

6MWT distance (m) %6MWT distance 6MWORK (kg.m) DHR (beats/min) %Maximum HR

DSpO2 (%) DDyspnea perception DQuadriceps fatigue perception DGeneral fatigue perception RPE

F/c2

p

6MWT with motivational music

6MWT with relaxation music

6MWT without music

618.6 ± 72.2 87.0 ± 10.9 26171.2 ± 11598.6 27.1 ± 16.1 60.8 ± 9.4 Median (minimum-maximum) 0 (-4 to 4) 0.5 (-1 to 5) 1 (0e4) 1 (-1 to 6) 3 (0e10)

612.2 ± 63.6 86.9 ± 10.4 25683.3 ± 10923.7 22.6 ± 17.5 60.1 ± 10.4

630.0 ± 68.1 88.7 ± 10.0 26724.7 ± 12149.1 27.4 ± 24.6 61.8 ± 11.7

1.946 1.146 3.254 1.186 0.498

0.150 0.324 0.045* 0.311 0.610

0 1 1 1 3

0 1 1 1 3

0.262 2.155 1.357 0.831 1.086

0.877 0.340 0.507 0.660 0.581

(-3 to 11) (-3 to 7) (0e7) (-4 to 7) (0e10)

(-3 to 5) (0e10) (-0.5 to 8) (-2 to 9.5) (0e10)

Abbreviations: 6MWT, 6-min walk test; 6MWORK, 6-min walk work; HR, Heart rate; SpO2, Oxygen saturation; RPE, Rating of perceived exertion. *One-way repeated measures ANOVA, p < 0.05.

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Fig. 1. Comparison of 6 min walk test work between motivational music, relaxation music and no music.

without music. There was no statistically significant difference in patients' satisfaction level between the 6MWT trials with motivational music, with relaxation music and without music (Table 3, p > 0.05). The majority (75%) of patients preferred motivational music, while 25% of patients preferred relaxation music. FS scores of the three trials were significantly different (Table 3, p < 0.05, Fig. 2). FS scores of patients during 6MWT with motivational music were significantly higher than during 6MWT with relaxation music (p ¼ 0.012). There was a statistically significant difference in BMRI2 between motivational and relaxation music (Table 3, p < 0.05). BMRI-2 scores of motivational music during 6MWT were significantly higher than those of relaxation music during 6MWT (Table 3, p < 0.05). Table 4 represents the motivational quotients of the motivational music and relaxation music played during the 6MWT. There was no statistically significant difference between the motivational quotients of the motivational and relaxation music during the 6MWT (Table 4, p > 0.05). 4. Discussion The main findings of our study were that listening to motivational or relaxation music during a walking test does not change functional exercise capacity, vital signs, dyspnea/fatigue perceptions or RPE during exercise. We have shown that more work was required to perform the 6MWT without music than while listening to relaxation music. Listening to motivational music during walking elicits a more positive affective response in patients with CF and the motivational qualities of motivational music are higher than those of relaxation music. There is controversy in the literature about the effects of music on RPE [7,10,14,42,45]. In a study with 18 (10 males, 8 females) untrained student volunteers, Elliott et al. found that both motivational and oudeterous music types elicited similar responses in terms of distance traveled and RPE during a 20 min cycle trial [10]. Ghaderi et al. showed that the aerobic performance of 30 male college students was significantly higher while listening to

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Fig. 2. Comparison of affective responses during exercise between motivational music, relaxation music and no music.

motivational music than to relaxation music or no music. They also showed that RPE was significantly reduced while listening to relaxation music in contrast to motivational music and no music conditions [14]. RPE was found to be lower during cycling exercises at 40% of maximal oxygen consumption (VO2) in the presence of relaxation music in eight healthy adult males but the influence of music on HR was not significant [45]. In a laboratory study with eleven elite triathletes, RPE was lowest for neutral music and highest for the no-music control [42]. Hutchinson and Karageorghis showed that RPE was higher among dissociators when compared to associators in the two (motivational and oudeterous) music conditions during treadmill runs at three intensities [16]. Cognitive styles have been shown to affect the perception of an external stimulus like music by focusing attention on the different features and aspects of the stimulus [25]. In our study, the similar results in functional exercise capacity and responses given to exercise observed with the three test conditions may be attributable to the fact that the musical experience is highly individual and the dominant attentional style of a person contributes significantly to the variability of the effects of music during exercise [16]. In addition, while listening to music, the participants were unable to hear the standardized encouragement normally given during the 6MWT, which may have prevented them from continuing at the same tempo and motivation level during exercise and lead to similar exercise capacity results. Furthermore, because our patients know that the 6MWT is a test, they may have felt stressed and benefited less from the music stimulus. Attentional focus is dynamic in nature and thus varies in accordance with situational demands [28]. According to Rejeski's parallel processing model, the amount of information that can be processed at a given time is limited and attending to one stimulus may prevent processing of other stimuli outside of the attention span [33]. Because the tests were performed in a hospital setting, hospital and university staff sometimes passed through the test corridor. Therefore, although the patients did not hear sounds from outside, this situation could have

Table 3 Comparison of motivational qualities of music, patients' satisfaction level and affective responses during the 6-min walk test with motivational music, with relaxation music and without music. Median (minimum-maximum)

Satisfaction level (VAS) FS BMRI-2

6MWT with motivational music

6MWT with relaxation music

6MWT without music

8.3 (0e10) 4 (-2 to 5) 36 (14e42)

8.3 (0e10) 3 (-4 to 5) 32 (7e42)

7.1 (0e10) 3 (-5 to 5)

Abbreviations: VAS, Visual analogue scale; FS, Feeling Scale; BMRI-2, The Brunel Music Rating Inventory-2. *Friedman's test, p < 0.05; &Paired sample t-test, p < 0.05.

F/c2/t

p

1.044 11.938 3.003

0.344 0.003* 0.005&

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Table 4 Comparison of the motivational quotients of music during the 6-min walk test with motivational music and with relaxation music.

High (36e42) Moderate (24e35) Oudeterous (24)

6MWT with motivational music n (%)

6MWT with relaxation music n (%)

z

p

19 (51.4) 14 (37.8) 4 (10.8)

17 (45.9) 8 (21.6) 12 (32.4)

1.826

0.068*

*Marginal homogeneity test, p > 0.05.

had a negative impact on their attention and may have affected their enjoyment of the music and their 6MWT performance. When performing two separate tests of the same exercise intensity, participants reported lower RPE when music was being played, especially preferred music, and that their work rate had become easier [22]. We selected one motivational and one relaxation song for our participants without questioning their music preferences and each participant listened to the same song throughout the test. This may affect change in the vital signs, dyspnea/fatigue perceptions and perceived effort of the patients and the nature of this effect may vary between patients. Terry et al. showed that time-to-exhaustion was also longer when running with motivational and neutral music compared to no music, and that both music conditions were associated with lower VO2 and better running economy than the no-music control in eleven elite triathletes [42]. Higher values for hemodynamics and lactate were observed with no music but oxygen consumption was not different with and without music during exercise in a clinical trial with 10 well trained men during treadmill running [41]. 6MWORK correlates more strongly with VO2 peak than 6MWT distance alone [37]. In our study, patients' 6MWORK without music was significantly higher than with relaxation music, suggesting a greater metabolic demand without music. The relaxation music may have allowed individuals to relax and reduce muscle tension, thereby increasing blood flow and lactate clearance while decreasing lactate production in working muscle. Therefore, less energy was required to perform the 6MWT. Motivational music appears to improve affective states during sub-maximal exercise [18,23,42]. Elliott et al. showed that participants reported significantly higher FS scores listening to motivational music compared to no music in eighteen untrained student volunteers (10 males, 8 females). In addition, when compared to the oudeterous music condition, the motivational music condition elicited a higher level of positive affect during a 20-min submaximal cycle task [10]. Although affective measures during exercise showed no overall training group differences in 8 trained and 8 untrained runners, untrained subjects reported more positive affect compared to trained subjects while listening to fast music during low- and high-intensity exercise [7]. In a study with infants and toddlers with cystic fibrosis and their parents, both composed and familiar musics increased the enjoyment of children and parents during usual chest physiotherapy [15]. Consistent with the literature [5,7,10,18,23,24,42], our study showed that CF patients exhibited a significantly positive affective state with motivational music, the motivational qualities of motivational music were higher than relaxation music and most patients (75%) preferred motivational music during the walking test. Patients' satisfaction levels were similar during all three of the trials, possibly because the 6MWT is a test and they may have felt the same stress during each trial. The similar motivational quotients of motivational music and relaxation music can be attributed to differences in the music preferences of the participants. Our study has several limitations that should be considered. We selected the motivational and relaxation music according to their tempo; we did not consider rhythm response, musicality, cultural impact, participants' preferences or associations when selecting

songs. Individual preferences and familiarity might enhance attentive listening to music. This clinical trial was not performed in an exercise training situation. In addition, we were not able to give standardized encouragement to the participants when they were listening music. Patients with very severe CF were not included in the study in order to see differences in response patterns to music in patients with mild disease. The study did not include assessment of dominant attentional style, which can influence psychological and psychophysical responses to music during exercise. 5. Conclusion This is the first study to show that listening to motivational music while walking elicits a more positive affective response in children and adolescent patients with CF, and that the motivational qualities of motivational music are greater than relaxation music. Metabolic demands of walking are reduced by listening to relaxation music compared to without music. Listening to motivational or relaxation music during the 6MWT results in similar responses in vital signs, dyspnea/fatigue perceptions and RPE. In practice, the results of this study indicate that carefully selected motivational music can lead to positive affective response during exercise and increase CF patients' enjoyment of exercise. Relaxation music also decreases the metabolic demands of exercise and could allow patients to do exercise without fatigue perception. The results of this study promote the use of music within the exercise environment during pulmonary rehabilitation programmes for patients with CF. Further studies are needed to determine the effects of music selected according to individual preferences during exercise on CF patients with different disease severities. Disclosure statement No potential conflict of interest was reported by the authors. References [1] A. Almajed, L.C. Lands, The evolution of exercise capacity and its limiting factors in cystic fibrosis, Paediatr. Respir. Rev. 13 (4) (2012) 195e199, http:// dx.doi.org/10.1016/j.prrv.2012.01.001. [2] H. Arikan, I. Yatar, E. Calik-Kutukcu, Z. Aribas, M. Saglam, N. Vardar-Yagli, S. Savci, D. Inal-Ince, U. Ozcelik, N. Kiper, A comparison of respiratory and peripheral muscle strength, functional exercise capacity, activities of daily living and physical fitness in patients with cystic fibrosis and healthy subjects, Res. Dev. Disabil. 45e46 (2015) 147e156, http://dx.doi.org/10.1016/ j.ridd.2015.07.020. [3] ATS Committee on Proficiency Standarts for Clinical Pulmonary Function Laboratories, ATS statement: guidelines for the six-minute walk test, Am. J. Respir. Crit. Care Med. 166 (1) (2002) 111e117, http://dx.doi.org/10.1164/ ajrccm.166.1.at1102. [4] J.C. Bestall, E.A. Paul, R. Garrod, R. Garnham, P.W. Jones, J.A. Wedzicha, Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease, Thorax 54 (7) (1999) 581e586. Retrieved from, http://www.ncbi.nlm.nih.gov/pubmed/ 10377201. [5] S.H. Boutcher, M. Trenske, The effects of sensory depravation and music on perceived exertion and affect during exercise, J. Sport Exerc. Psychol. 12 (1990) 167e176. [6] M.L. Brennan, I. Schrijver, Cystic fibrosis: a review of associated phenotypes, use of molecular diagnostic approaches, genetic characteristics, progress, and dilemmas, J. Mol. Diagn. (2015), http://dx.doi.org/10.1016/

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Ebru Calik-Kutukcu, PhD, PT. She was graduated from Hacettepe University School of Physical Therapy and Rehabilitation in 2007. She was appointed in 2009 as a research assistant in Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation. She received Master of Science degree in 2010 and Doctorate degree in 2014 from Cardiopulmonary Rehabilitation Program, Department of Physiotherapy and Rehabilitation in the Institute of Health Sciences. She has worked as a researcher at the Katholieke Universiteit Leuven in Belgium from September 2012 to January 2013 for a period of 4 months. She has been working in the Cardiopulmonary Rehabilitation clinical units of both Hacettepe University Hospitals and Faculty of Health Sciences Physiotherapy and Rehabilitation Department since 2009. Fields of Study: Cardiopulmonary Rehabilitation, Exercise Physiology, COPD, CF.

 lam, PhD, PT, Assistant Professor. She was Melda Sag graduated from Hacettepe University School of Physical Therapy and Rehabilitation in 2002. She was appointed in 2003 as a research assistant. She received Master of Science degree in 2005 and Doctorate degree in 2012 from Hacettepe University Institute of Health Sciences. She has worked as a researcher at the Katholieke Universiteit Leuven in Belgium from February 2008 to June 2008. She became an assistant professor in 2015. She has still been working in the Cardiopulmonary Rehabilitation Unit of Hacettepe University Faculty of Health Sciences Department of Physiotherapy and Rehabilitation. Fields of Study: Cardiopulmonary Rehabilitation, Exercise Physiology, CF.

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E. Calik-Kutukcu et al. / Complementary Therapies in Clinical Practice 23 (2016) 52e58 lı, PhD, PT, Assistant Professor. She Naciye Vardar Yag was graduated from Hacettepe University School of Physical Therapy and Rehabilitation in 2003. She was appointed as a research assistant in 2004. She received Master of Science degree in 2007 and Doctorate degree in 2012 from Hacettepe University Institute of Health Sciences. She became an assistant professor in 2015. Currently, she has been working in the Cardiopulmonary Rehabilitation unit of Hacettepe University Faculty of Health Sciences. Fields of Study: Cardiopulmonary Rehabilitation, yoga, body awareness, CF.

Aslihan Cakmak, PT. She was graduated from Suleyman Demirel University, Isparta Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation in 2013. She was appointed in 2014 as a research assistant in Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation. Currently, she is going on with her master of science studies in Cardiopulmonary Rehabilitation Program, Department of Physiotherapy and Rehabilitation in the Institute of Health Sciences. She has been working in the Cardiopulmonary Rehabilitation clinical units of both Hacettepe University Hospitals and Faculty of Health Sciences Physiotherapy and Rehabilitation Department since 2014. Fields of Study: Cardiopulmonary Rehabilitation, Exercise Physiology, COPD, CF.

Deniz Inal-Ince, PT, PhD, Professor. She graduated from Hacettepe University University School of Physical Therapy and Rehabilitation in 1991. She had MSc degree in Exercise Physiology from METU Institute of Social Sciences in 1995 and in Physical Therapy and Rehabilitation from Hacettepe University Institute of Health Sciences in 1997. In 2002, she got her PhD degree from Hacettepe University Institute of Health Sciences with the dissertation entitled “Effects of respiratory physiotherapy in patients with acute respiratory failure undergoing noninvasive ventilation”. She worked as a fellow at King’s College Hospital, St Thomas Hospital and Royal Brompton Heart and Lung Hospital in United Kingdom in 2000, and Maine Medical Center and Medical Center of Georgia in the USA in 2001. She got the American Association for Respiratory Care “International Fellowship” award in 2001. She worked as a full time faculty member at Ohio State University, Department of Respiratory Therapy, in USA in 2003e2004. In 2007, she worked as a faculty at the Netherlands Saxion University, Physiotherapy Department for as a part of the ERASMUS program. She became an associated professor in 2006. Currently, she is working as a professor in faculty in Cardiopulmonary Rehabilitation Unit of Hacettepe University Department of Physiotherapy and Rehabilitation since 2012.

Cemile Bozdemir Ozel, MSc, PT. She was graduated from Dumlupinar University, Kutahya School of Health, Department of Physiotherapy and Rehabilitation in 2009. She was appointed in 2014 as a research assistant in Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation. She received Master of Science degree in 2014 from Cardiopulmonary Rehabilitation Program, Department of Physiotherapy and Rehabilitation in the Institute of Health Sciences. Currently, she is going on with doctorate studies in Cardiopulmonary Rehabilitation Program, Department of Physiotherapy and Rehabilitation in the Institute of Health Sciences. She has been working in the Cardiopulmonary Rehabilitation clinical units of both Hacettepe University Hospitals and Faculty of Health Sciences Physiotherapy and Rehabilitation Department since 2014. Fields of Study: Cardiopulmonary Rehabilitation, Exercise Physiology, COPD, CF.

Hazal Sonbahar Ulu, MSc, PT. She was graduated from Baskent University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation in 2012. She was appointed in 2014 as a research assistant in Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation. She received Master of Science degree in 2015 from Cardiopulmonary Rehabilitation Program, Department of Physiotherapy and Rehabilitation in the Institute of Health Sciences. Currently, she is going on with doctorate studies in Cardiopulmonary Rehabilitation Program, Department of Physiotherapy and Rehabilitation in the Institute of Health Sciences. She has been working in the Cardiopulmonary Rehabilitation clinical units of both Hacettepe University Hospitals and Faculty of Health Sciences Physiotherapy and Rehabilitation Department since 2014. Fields of Study: Cardiopulmonary Rehabilitation, Exercise Physiology, COPD, CF.

Hulya Arikan, PhD, PT, Professor. After graduating from Hacettepe University School of Physical Therapy and Rehabilitation in 1973, she completed her Master of Science in 1973 and doctoral studies in 1978 at Hacettepe University Institute of Health Sciences. She received the title of Associated Professor in in 1983 and the title of Professor in 1988. She still continues the job of faculty member in Hacettepe University Faculty of Health Sciences Department of Physiotherapy and Rehabilitation and she is responsible for Cardiopulmonary Rehabilitation Unit. She has attended numerous courses about Cardiopulmonary Rehabilitation. Fields of Study: Cardiopulmonary Rehabilitation, COPD, CF.

Ebru Yalcin, MD, Professor. She graduated from Ankara University, Faculty of Medicine in 1994. She had a specialist pediatrician degree in Hacettepe University Faculty of Medicine, Department of Pediatrics in 2000. She was assigned as a clinical fellow in the same department since then. Subject of her thesis was in pediatric chest diseases: Features of apoptosis in lung and liver tissue in cystic fibrosis patients. She worked as a pediatrician between 2000-2006 in Hacettepe University Faculty of Medicine, Department of Pediatrics. She worked at Amsterdam Medical Center on pulmonary function tests in children for 4 months (November 2004-April 2005) by ERS scholarship. She became an assistant professor in 2006. At the same year, she became an associated professor and worked as an associated professor between 2006e2013 in Hacettepe University Faculty of Medicine, Department of Pediatrics. She became a professor in 2013. Her general experiences are pulmonary function tests, follow-up and management of patients in ICU with respiratory problems, follow-up and management of patients with cystic fibrosis, cyst hydatid, tuberculosis, bronchiectasis, fiberoptic bronchoscopic procedures in infants and children. Currently, she is working as a professor in Hacettepe University, Faculty of Medicine, Department of Child Health and Diseases, Unit of Chest Diseases.

Jale Karakaya, PhD. She was graduated from Ankara University, Faculty of Science, Department of Statistics in 1999. She was appointed in 2002 as a research assistant in Hacettepe University, Faculty of Medicine, Department of Biostatistics. She received Master of Science degree in 2002 from Ankara University, Department of Statistics and Master of Science degree in 2005 from Hacettepe University, Faculty of Medicine, Department of Biostatistics and Doctorate degree in 2012 from Hacettepe University, Faculty of Medicine, Department of Biostatistics. Her recent research interests are evaluation of diagnostic test performance, missing value analysis, multivariate analysis and decision tree methods.