Music therapy is a therapeutic modality that promotes both physical and mental health (Bruscia, 2018). With its merits of low cost, no side effects, and low restrictions, there has been a growing interest in the use of music in healthcare. Studies have shown that music interventions can exert a positive influence in multiple scenarios (Ting et al., 2023), such as reducing the level of depression (Aalbers et al., 2017), reducing anxiety (Dallı et al., 2023), improving the cognitive function of dementia patients (Pauwels et al., 2014), relieving the pain during surgery (Dallı et al., 2023; Lee, 2016), exerting a beneficial impact on the sleep quality and pain of patients with coronary heart disease (Bradt et al., 2013), and reducing the blood pressure of patients with chronic hypertension (Bekiroğlu et al., 2013), and assisting in the treatment of infectious diseases such as COVID-19 (Mol et al., 2021). Although some reports showed that music may promote health by regulating neuroimmune response (Chanda and Levitin, 2013; Zhang et al., 2021), some direct evidence is still needed.

Different types of music have been used for music therapy. Western classical music, such as Mozart’s K.448 Piano Sonata (Di Cesare et al., 2022; Wang et al., 2025), and Chinese classical music (Li et al., 2010, 2022), such as Five Elements music (Tao et al., 2016), all exhibit different characteristics. Therefore, it is intriguing to explore the effects of combined music that incorporates both Western and Chinese traditional elements.

Reports showed that music can affect central nervous system function, but whether it works by affecting the peripheral nervous system still needs to be proven. The peripheral autonomic nervous system is divided into sympathetic and parasympathetic nerve branches, which dynamically balance each other under normal conditions. When exposed to a stressor, the sympathetic nervous system becomes more active than the parasympathetic nerve, causing changes in some physiological indicators. Conversely, when living in a relaxed state, the parasympathetic nervous system takes over (Benarroch, 2020). Recently, vagus nerve (a branch of the parasympathetic nerve) stimulation has been widely used in the treatment of clinical diseases. The cholinergic anti-inflammatory pathway (CAP) has been used to explain the mechanisms of vagus nerve stimulation. Although it is known that music can make people calm down, how music relieves stress via parasympathetic nerve stimulation, i.e., via balancing the sympathetic and parasympathetic branches of the autonomic nerve system, is an area of great interest for further research (Baccarani et al., 2023).

Communication between the nervous and the immune system is crucial for controlling inflammation (Dedoncker et al., 2021). Besides the cholinergic anti-inflammatory pathway, the autonomic nervous system may also regulate inflammation by activating the hypothalamic-pituitary-adrenal axis. The autonomic nervous system notifies the brain of peripheral inflammation and then reflexively suppresses this inflammation by producing cortisol (Johnston and Webster, 2009; Pavlov and Tracey, 2012). In such a scenario, whether music regulates endocrine-immune response via the autonomic nervous system is an important question waiting to be explored.

Autonomic nervous system activity can be measured by heart rate variability (HRV). HRV is a non-invasive electrocardiographic (ECG) index of the autonomic control of the heart, which refers to the heartbeat interval changes, including time domain (RMSSD, PNN20, and PNN50) (Kim et al., 2018), frequency domain [high-frequency (HF), LF, and VLF band] (Arakaki et al., 2023), and non-linear index measuring [standard deviation 1 (SD1)] (Shaffer and Ginsberg, 2017). It reflects the efferent autonomic nervous system activity of the heart and is a quantitative indicator of autonomic regulation. Studies have found a significant correlation between actual parasympathetic nerve activity and HRV, in which parasympathetic nerve activity can be indexed by measuring a patient’s HRV (Kim et al., 2018). The application of HRV to evaluate the autonomic nervous system in music therapy is worth exploring.

Balloon Analogue Risk Task (BART) is a test used to evaluate stressful conditions via decision-making. In the BART, participants inflate computer-simulated balloons and earn a certain amount of money through each pump (Lejuez et al., 2003). Meanwhile, each pump increases the risk of balloon explosion. If the balloon explodes, all the money earned so far will be lost. Because decisions in daily life involve both rewards and loss possibilities, this task is an ecologically effective paradigm for simulating adventurous behavior under experimental conditions (Hengen and Alpers, 2021). The multiple-object tracking (MOT) task involves a fixed number of identical elements (such as circular dots) displayed on a computer screen. Elements can be targets or interfering factors. At first, all elements are stationary, indicating the number of target objects. All elements then undergo random motion, and participants need to maintain their attention to the prompt object. At the end of the experiment, all elements stop moving, and participants need to indicate the target element (Alnawmasi and Khuu, 2022). The MOT task can serve as an effective tool for assessing an individual’s level of attention. BART and MOT tasks are two classical tests evaluating stress or attention.

This study aimed to assess the effects of our new music combination on stress relief in individuals engaged in high-intensity work. We found that our new music combination can relieve stress, indicated by increased activation of the parasympathetic nerve (increased HRV), lower BART, and higher MOT task performance. Additionally, the new music combination promotes homeostasis of the endocrine-immune axis through increasing IgA levels while decreasing cortisol production. Music intervention may function as a stress reliever to improve health.

In the music group, data from 31 participants were collected. Among them, 31 participants completed the 1st session, 23 participants completed the 2nd session, and 22 participants completed the 3rd session. In the control group, data from 24 participants were collected. Among them, 24 participants completed the 1st session, 24 participants completed the 2nd session, and 22 participants completed the 3rd session.

Studies have found a significant correlation between actual parasympathetic nerve activity and HRV (Kim et al., 2018). Here, our data showed that HRV can be used as a valuable indicator of how music affects neural function. The time-domain, frequency-domain, and non-linear measurements of HRV are standard clinical parameters (1996). Following a music intervention, higher RMSSD, PNN20, PNN50, HF/NU, and SD1 values, along with lower LF/NU values, indeed reflect the balance of the autonomic nervous system, specifically activating the parasympathetic nervous system and giving it a predominant role. It is well-known that listening to music can relieve stress and anxiety by regulating the nervous system. Here, we provided new direct evidence that the parasympathetic nervous system can be activated, as evidenced by increased HRV (Bravo et al., 2011; Richer et al., 2022).

The activation of the parasympathetic nervous system not only reflects the reversal of stress states, but in recent years, the anti-inflammatory properties of this nerve branch have also garnered significant attention (Bonaz et al., 2021). Brain and visceral interactions within the autonomic nervous system are crucial. Specifically, the parasympathetic nervous system, which contains approximately 80% of afferent fibers and 20% of efferent fibers, plays a variety of key roles in the homeostatic regulation of visceral function. Recent data suggest that the parasympathetic nervous system exhibits anti-inflammatory effects and is a major component of the neuroendocrine-immune axis (Guyot et al., 2019; Johnston and Webster, 2009). This parasympathetic function is mediated through several pathways, some of which remain controversial. One such pathway is the anti-inflammatory hypothalamic-pituitary-adrenal (HPA) axis, which stimulates the adrenal glands to release cortisol (Lightman et al., 2020). There is a close relationship between the HPA axis and the autonomic nervous system. Our experimental results also observed that cortisol levels in the saliva and serum of volunteers in the music group were lower than those in the control group after three music interventions (Figure 5), indicating that music may alleviate inflammatory stimuli in the body, although the specific mechanism needs further investigation.

The second pathway, known as the cholinergic anti-inflammatory pathway, originates in the abdominal ganglion, down from the vagus nerve to the sympathetic nerve (Borovikova et al., 2000), and reaches the spleen (Zhang et al., 2020), where a class of T cells secretes acetylcholine and inhibits the production of inflammatory cytokines by splenic macrophages (Rosas-Ballina et al., 2011). When this anti-inflammatory regulatory response works properly, it limits the spread of viral infection and is essential for controlling and addressing the infection and its inflammatory consequences. However, in the case of low parasympathetic nerve activity, the inflammatory response may go unchecked, leading to excessive inflammation, commonly known as a “cytokine storm” (Fajgenbaum and June, 2020). In addition, during induced infection, parasympathetic nerve stimulation was associated with increased natural killer activity, CD4+ (Newell-Rogers et al., 2022), and CD8+ cells (Carnevale et al., 2020). Therefore, the parasympathetic nerve on the one hand controls inflammation, and on the other hand, can increase antiviral immunity.

Immunoglobulin A is the main component of the body’s mucosal defense system (Isho et al., 2021), widely distributed in milk, saliva, gastrointestinal tract, respiratory tract, and urogenital tract mucosal secretions. It can inhibit the adhesion of microorganisms in the respiratory epithelium, slow down the reproduction of viruses, exhibit an important immune barrier effect, demonstrate antibody activity against certain viruses, bacteria, and general antigens, and serve as the first line of defense against pathogen invasion. From our test results, salivary IgA levels in the music group were significantly higher than those in the control group (Figure 5). Therefore, it is suggested that music may exert immunomodulatory roles by lowering cortisol levels and increasing IgA levels. Thus, the specific mechanism by which music regulates immune function through the autonomic nervous system still needs to be further explored. However, our data suggest a causal relationship between music-induced sympathetic/parasympathetic balance and endocrine-immune homeostasis.

Our new music combination also improves mental function. Volunteers in the music group not only improved their attention and attention span but also became more decisive in the BART results (Figure 4). The measurement mainly focuses on reward and emotion-oriented risk decision-making behaviors, which are regulated by cognitive control and attention-related brain regions. Based on this experiment, we hypothesize that the changes in the BART measurement results of the music group’s volunteers may be mainly related to music’s regulation of emotions, such as stress reduction, and potentially related to the music’s influence on cognition. In Bleibel et al.’s (2023) recent review, out of eight studies on the cognitive effects of music on Alzheimer’s disease (AD) patients, seven of them found that music therapy had a significant positive effect on enhancing cognitive function in AD patients. Although we did not compare the effects of the new music combination used here with other music, our data showed that the music we used did improve the homeostasis of the neuroendocrine and immune system and improve cognition to some extent.

Music therapy has two primary methods: active music therapy, where the music therapist uses improvisational, re-creative, or compositional techniques, and receptive music therapy, where the patient serves as a recipient of the music experience (Aalbers et al., 2017). In receptive music therapy, the music could be selected either by the experimenters or by the volunteers (Bleibel et al., 2023). Previous reports including ours found that Mozart K.448 (Di Cesare et al., 2022; Wang et al., 2025) and Chinese music(Bekiroğlu et al., 2013; Bradt et al., 2013; Chanda and Levitin, 2013; Dallı et al., 2023; Di Cesare et al., 2022; Lee, 2016; Li et al., 2010, 2022; Mol et al., 2021; Pauwels et al., 2014; Tao et al., 2016; Wang et al., 2025; Zhang et al., 2021) can help recover attention after mental fatigue or have shown stress-relieving effects. Here combining them may avoid fatigue induced by repeated single-track playback and achieve the goal of synergistic enhancement. In this study, we innovatively propose a new music combination as an intervention means for music therapy. This music combination is an innovative combination of Chinese and Western music, based on an extensive literature review and research into traditional Chinese Five-Element music (Zhu et al., 2021).

The cardiac autonomic nervous system primarily influences endocrine function through direct neural innervation of endocrine organs and regulation of hormone release. For example, sympathetic hyperactivity can continuously activate the renin-angiotensin system (RAS), leading to elevated cortisol levels; the parasympathetic nervous system (mainly the vagus nerve), on the other hand, reduces excessive hormone secretion by antagonizing sympathetic activity or acting directly on endocrine cells (Jones et al., 2020; Kunikullaya et al., 2025). Endocrine hormones can regulate immune function through mechanisms such as acting on receptors expressed on immune cells. In this study, we found that cortisol can significantly inhibit the expression of immunoglobulin A (IgA), thereby providing direct evidence for the regulation of the autonomic nerve-endocrine-immune axis (Figure 5).

In this study, we did not consider the participants’ interest in music or any regular listening to music, and music was chosen based on previous reports (Li et al., 2010, 2022; Tao et al., 2016) and our work (Wang et al., 2025), which is a limitation of this study. To control for the effects of the menstrual cycle on hormonal and autonomic function, only male subjects were included to reduce intergroup variance, which could create gender bias. This design limits the replicability and generalizability of the study’s conclusions to female populations. The next studies would include more diverse people in future studies.

Here, we found that the new music combination increased the activity of the parasympathetic nerve as marked by modulating HRV, which led to lower BART scores and higher MOT test scores, suggesting stress relief. In addition, our new music combination promotes endocrine-immune homeostasis, as marked by increased IgA levels and decreased cortisol levels. Our data suggested that music can also work by affecting the peripheral nervous system and supports the use of HRV to evaluate the effects of music on neuroimmune disorders, and suggests the causal relationship between music-induced sympathetic/parasympathetic balance and endocrine-immune homeostasis.

Music has been widely used for disease intervention. This study showed that the novel music combination can relieve stress in high-intensity work during the day, promote endocrine-neuroimmune homeostasis. Music intervention can function as a stress reliever to improve health. It showed a new direction in the mechanisms of music therapy. The function and mechanism of the music still need to be further explored and expanded.