An investigation
into the use of music
as adjunct analgesia
with particular reference to the relationship between the
effectiveness of music as analgesia and levels of musical training.
Carole B. Miller
July 2002
Submitted in partial fulfilment of the MA in Psychology for Musicians,
Department of Music, University of Sheffield
Table of Contents
Discussion of Previous Research
Empirical Pain Research and Treatment
So what are the present treatments for pain?
So why try to help pain with music?
Appendix
Appendix A: Pain Survey
Appendix B: Short-Form McGill Pain Questionnaire
Appendix C: SF-MPQ Results
Appendix D: Paired t-Test Results
Appendix E: Independent t-Test Results
Appendix F: Two-Factor Analysis of Variance
Abstract
Research within the medical profession has shown that Music may be useful as a source of distraction, relaxation and reduction of anxiety in the treatment of chronic pain (as opposed to acute pain which music may also help relieve), therefore reducing the pain experience. Most studies have dealt with music as the sole pain reliever and although these studies had a positive outcome, they have concluded that music was only of limited use. This study questions this and starts with the assumption that music would be more efficiently used alongside other treatments to reduce the pain experience.
This research was done in the form of questionnaires and diaries with participants being asked to keep a diary over the period of a month. The sample was divided into three groups: Group one relaxed only for a given time (ten (10) minutes per day for the duration of the study), group two listened to music of their own choice and relaxed for the given time and group three, listened to a variety of music pre-selected by the researcher. Pre and post diary testing using the Short Form McGill Pain Questionnaire (SF-MPQ) was used to measure changes in the circumstances of the pain sufferer and the pain experience. Using the data from the SF-MPQ, the improvements in the pain experience were compared between the three groups and also between the musicians and non-musicians to see if levels of musical training influence the use of music as an adjunct analgesia.
Investigated from a music psychology perspective (as opposed to a medical perspective), this study extends previous research by also investigating whether there is a relationship between the effectiveness of music as analgesia and levels of musical training. Findings from this study confirm the outcomes of previous research in finding a positive effect to the use of music as analgesia (although the effect was not statistically significant). This study also found that the greater the involvement with music and music making, the greater analgesic effect music has on pain, although again, the effect was not statistically significant.
How I came upon this topic.
I became
interested in using music as a distraction because I suffer from
pelvic pain. I was quite determined that pain would not be allowed to
take over my life and was curious as to what coping strategies I might
use.
Health
professionals had commented on the fact that I was more able than some
of the other pain patients my consultants saw to maintain a fairly
normal life style. (Although appearances can be deceiving!) My
Consultants had also commented (and I noticed too) that I appeared to
suffer less post-op pain than the majority of the other patients
having the same procedures and operations performed. One consultant,
after talking with me at great length, gave me some articles, which
suggested that the music listened to by surgeons while operating on
patients in theatre had some effect on the recovery. He thought that
because I was a musician perhaps his playing music in theatre (he was
a Mozart lover!) was helping me in some manner that wouldn't help the
average patient. This sparked my imagination and I began to dig around
and ask some questions of the health care professionals that were
personally known to me.
I was at the
end of my first year of this course by that time and looking for a
dissertation topic that would be interesting to research and would be
fairly novel with practical applications also. After some searching
and reading various articles, I realised that the one thing I did that
the other patients didn't (on my ward at any rate), was listen to
music! I always had my tapes and my Walkman and happily listened all
day long to the radio or the tapes. �Mmmm,� I thought. Is this why
I appear to recover quicker and appear to suffer less pain than the
others who have had the same procedures? If so, I wonder why and how
music might help? Would music as a pain killer work better for myself
as a musician, or better for non-musicians?
And so this project was born.
Some initial thoughts
Most people intuitively believe music has the power to heal. Even the ancients believed that music could heal. In the Old Testament, there is the story of Saul, an old king, who was suffering and was given the following advice:
�Seek out a man, who is a wise player on the harp and it shall come to pass�that he shall play with his hand and thou shall be well.� (1 Samuel 16:16)
The King sent for David with the following results:
�David took a harp and played with his hand and Saul was refreshed and was well, and the evil spirit departed from him.� (1 Samuel 16:23)
It is apparent from this and other stories that the ancients understood the healing power of music and used it in their lives, even if they did not know how it worked. Specific techniques are barely mentioned and when they are, they are often so obscure that it is difficult for us in the Twenty First Century to relate to them.
Nonetheless it is clear that everyone responds to rhythm and sound, but this is not surprising given that we experience these stimuli even before we are born. In our mother�s womb, the first sound we hear is that of her heart beating (Hoffman 1995, Sloboda 1985, 1995). This early experience almost certainly creates an intimate connection between musical rhythm and body rhythms. When young, we are rocked as babies when we need to be comforted thereby creating a strong association between relaxation and rhythm. From rocking horses used as children, we move onto rocking chairs as adults, illustrating that rhythm for soothing purposes does not have anything to do with chronological age (Hoffman 1995).
This relationship between musical rhythms and internal body rhythms is extremely significant. Internal body rhythms play an important part in how relaxed or tense one feels (Bonny & McCarron 1984). Relaxation has been shown to produce striking physiological changes such as decreased metabolism and lower blood pressure and respiration rate (Bonny 1983, Melzack and Wall 1996). Cox et al (1975 cited in Melzack and Wall 1996) found that relaxation is more effective than a placebo for the relief of tension headaches and other researchers (e.g. Philips 1987 cited in Melzack and Wall 1996) have shown relaxation therapy produces significant decreases in a wide range of clinical pains � including back pain.
Additionally, music's influence extends to everyday life. Most people experience music every day somehow, somewhere. Today, more people listen to music than ever before (Storr 1997, Cook 1998). Recordings, radio and television have made music far more accessible and responses like nostalgic recognition are fairly common E.g. �They�re playing our tune� (Sloboda and Juslin 2001b).
With this increased access to music and information, people are seeking non-invasive and �natural� cures and aids for their illnesses and pains. As a result, how music affects us emotionally and physically, and the application of such knowledge, is the subject of much research. And it is this research that I am most interested in.
Discussion of Previous Research
Before considering research into music and the mechanisms of pain, it is first necessary to consider why we feel pain.
What's
the Point of Pain?
Evolution has found two complementary means to defend the body against damage. First there are reflexes. Reflexes are fast and organised and they move a part of the body away from something that is potentially harmful. These reflexes are determined by genetics, meaning they are largely fixed when we arrive in this world. They consist of interneurons and nociceptive neurons[1], which trigger activity in appropriate motor neurons so as to distance the body from the harm. This reaction precedes the conscious perception of pain (Eysenck 1998).
([1] A Neuron is a nerve cell, found within the central nervous system. An Interneuron is a connecting Neuron that lies between sensory and motor neurons. A Nociceptive Neuron detects tissue damage (Eysenck 1998).)
The second line of defence is the Pain System. Any living thing that has a brain can feel pain (Aldridge 2001). The sensation of pain is an essential survival technique, yet we dread it, because of the fear of losing control. But in functional terms, pain is of crucial value as it helps result in behaviour that will assist recovery from injury. Normally we hurt when our body is damaged and this has a clear significance for survival. However life is rarely so simple and there are many examples of pain that do not fit this picture (Eysenck 1998). Pain is not always perceived after an injury and there are enormous individual variations in sensitivity to pain (Brown et al. 1989).
Why are there enormous variations in pain perception? Early work in psychology looked at the 'flight-or-fight' response to danger and generally took a biological approach but there has recently been more interest in the psychological judgements we make that affect our experiences of stress. The same event may be exhilarating to one person and stressful to another because of the different ways in which they interpret what is going on (Banyard 1996). Perhaps this is why some people can have the same injury/illness and have very different pain experiences.
Moving on, Wall (2000), rather than defining pain as purely a sensory experience, recognised the phenomenon of pain as a need state which promotes recovery from injury. The Model of Fear and Pain developed by Bolles and Fanselow (as cited in Davis 1992) supports this theory. Bolles and Fanselow stated that a threatening stimulus triggers endorphins and related peptides that lessen the degree of perceived pain so that fight or flight behaviour, and therefore survival, may occur.
Looking at other models, the Biomedical Model of Pain takes the view that there are known and knowable physical causes for disorders (Curtis 2000), specifically germs, genes and chemicals. These may all contribute in different ways to the causes of disorders and pain and subsequent treatments are usually based on physical interventions (e.g. medicines, surgery etc.)
The roots of this approach date back to the seventeenth century when philosophers like Descartes, proposed that the mind and body were separate entities (Horn & Munafo 1997). However, historically philosophers have fluctuated between the view that the mind and the body are part of the same system and the view that they are separate (Banyard 1996, Curtis 2000). As stated previously, Descartes and other early philosophers had a dualistic conception of mind and body (the mind and body were separate entities), in which the mind had no physical basis (Glassman 2000). With this kind of framework, it becomes difficult to imagine how mental states could affect specific body functions, but a growing body of research suggests that our mind influences our body and vice versa, although the mechanisms linking mind and body are not well understood (Harari & Legge 2001).
Nonetheless, one criticism of the Biomedical Model is that it places too much emphasis on 'body' at the expense of 'mind' (Curtis 2000). Another criticism of this model is that it assumes there is a physical cause for the disorder. As stated previously, pain is not always perceived after an injury � often there is pain and no obvious injury and even injury without pain. Also bear in mind that there is a great deal of variation in an individual�s sensitivity to pain (Brown et al. 1989). So you can see that it is essential to acknowledge that humans are not simply machines that operate in a social and economic vacuum and that we are individuals with many thoughts, feelings and emotions � something that the Biomedical Model fails to do.
So if pain is indeed mediated by the mind, we can conclude that such mediation has contact with the memory storage of the brain, including musical memories (Eagle & Harsh 1988). And since memory differs from person to person, everyone has different associations for music and pain. Indeed, different interpretations of the same sensations will lead to a different experience of pain (Banyard 1996) and peoples' perceptions of pain will be very different.
As you can see, pain is a common but little understood experience, with quite a few conflicting models expressing how and why pain is felt (Hardcastle 1999). However what we do understand is that pain has emotional and motivational aspects and these aspects are organised centrally in the brain (Eysenck 1998, Pitts & Phillips 1998).
Pain is definitely a complex phenomenon that has interacting physiological, psychological, social, cultural and spiritual components. According to Zimmerman et al. (1989), and in common with other researchers, the factors that influence the pain experience are cultural, social and personal. The pain process involves emotion, previous experience, expectation and environmental effects. Yet another factor that might influence the perception of pain is the duration of the pain episode. If the pain lasts for a longer period of time, then tolerance is lowered and perception of pain is increased, therefore leading the sufferer to believe that the experience has become more painful (Wall 2000).
The pain process itself (as opposed to the pain experience), involves emotion, previous experience, expectation and environmental effects. Research suggests that pain perception is also influenced by attention, suggestion, prior experience, the duration of the pain episode and other psychological variables as well as anxiety (Melzack 1987a, 2001). The latter of these influences, anxiety, is thought to be a highly related and contributory phenomenon where perceived apprehension and tension cause sympathetic physiological arousal. Research has also found that there is a marked correlation between pain and anxiety (Wall 2000) and studies have shown that a high level of anxiety increases the perceived degree of pain (Curtis 1986, Davis 1992, Melzack 1987a, 2001).
So it is generally assumed that when there is pain, there is also anxiety (Davis 1992). The research on pain and anxiety does not make it clear what the nature of the involvement of anxiety is, whether it is �state� (situation provoking anxiety) or �trait� anxiety (predisposition to anxiety).
The process through which pain produces or increases psychological components, which in turn increase pain or sensitivity to pain, is frequently described as the 'Pain Circle'. Psychological components common to all pain types include cultural and social factors, age, sex, race, marital status, religious beliefs and emotional states (Curtis 1986).
These are the factors that can influence the pain experience, but how do we actually perceive pain?
The
Perception of Pain
There are a number of distinct theories about the perception of pain.
Pain research has been long dominated by Specificity Theory (Baum et al 1983, Horn & Munafo 1997). The Specificity Theory of Pain describes the traditional understanding of pain. This theory proposed that a specific system of nerves carry messages from pain receptors in the skin to a pain centre in the brain and that the intensity of the pain is correlated to the amount of tissue damage (Banyard 1996, Melzack & Wall 1996, Curtis 2000, Melzack 2001). However examples of injury without pain, and pain without injury, show that there is not a direct connection between stimulation and pain, therefore showing weaknesses in the specificity theory.
Pattern Theories, in contrast to Specificity Theories, suggest there are no separate systems for perceiving pain but instead the nerves are shared with other senses - such as touch. According to Pattern Theories, the most important feature of pain is the amount of stimulation. But again, there are examples of pain without injury (stimulation) and so this theory is also weak.
Psychologists have been interested in the study of Pain since the realisation that it has a psychological dimension as well as a physical dimension (Curtis 2000). But as yet, there seems no way to differentiate between the pain experienced due to tissue damage and pain without tissue damage. So, it appears sensible not to tie pain to a particular stimulus as in the Specificity Theory or Pattern Theory.
The most renowned Pain theory is the Gate Control Theory (GCT), first proposed in 1965 by Ronald Melzack and Patrick Wall in their now famous paper, 'Pain Mechanisms: a new theory' (Wolfe 1978, Maslar 1986, Brown et al. 1989, Zimmerman et al 1989, Whipple & Glynn 1992, Horn & Munafo 1997). This theory combined the medical approach of previous theories with the more recent bio-psychosocial model of health. Their approach considered biological, psychological and social factors in pain and not simply the medical factors alone (Horn & Munafo 1997).
The Gate Control Theory model is biologically complex and the description of the nervous system pathways involved is beyond the scope of this dissertation. At its simplest, the theory suggests that there is a 'gate' or 'gating mechanism' in the nervous system that opens and closes in response to various factors. Opening the 'gate' allows pain messages to travel to the brain, whereas closing it stops messages travelling to the brain (Melzack & Wall 1965).
Activity in these pain fibres causes Transmission Cells (T-Cells) to send pain signals to the brain and open the 'gate'. Activity in sensory nerves not directly linked to pain causes larger diameter nerves to carry information (e.g. touching, rubbing or scratching). These activities close the 'gate' and reduce the likelihood of experiencing pain.
The Gate Control Theory differs from earlier models in a number of fundamental ways (Ogden 2001): According to the Gate Control Theory, pain is a perception and an experience rather than a sensation. (This change in terminology reflects the role of the individual in the degree of pain perceived.) Also the Gate Control Theory sees pain as an active process where the individual no longer responds passively to stimuli but actively interprets and appraises painful stimuli (Ogden 2001).
As
stated, the Gate Control Theory Model (see Figure 1) suggests
that pain is a two-way flow of information to and from the brain, and
that the brain not only processes the information but also directly
affects the 'gating mechanism' (Melzack & Wall 1965).
|
Conditions
that open the 'Gate' |
Conditions
that close the 'Gate' |
|
Physical
Emotional
Mental
|
Physical
Emotional
Mental
|
Figure1
As well as proposing there is a 'gate' for pain in the spinal cord, Melzack and Wall (1965, also cited in Brown et al. 1989, Zimmerman et al. 1989, Hekmat and Hertel 1993) also suggest that the experience of pain is made up of three components, or in other words, three major psychological dimensions:
(1) Sensory-discriminative: location and type of pain and intensity of the sensation
(2) Motivational-affective: focuses on the emotional properties of pain and ability to escape pain or tackle it
(3) Cognitive-evaluative: evaluation of pain information leading to a decision on how to tackle it
Although the Gate Control Theory represented an important advancement on previous theories, it cannot be the whole picture for many reasons. Firstly, there is no complete theory that explains exactly what pain is and why/how it is felt, nor is there any undisputable evidence to substantiate the Gate Control Theory, nor indeed any particular theory. Even Melzack and Wall only point to a possible gating mechanism but as yet it has not been clearly identified (Hardcastle 1999). There is still no direct evidence of either the 'gating mechanism' or the transmission cells although it is assumed that they exist in some form within the nervous system. Secondly, even if we could get details on some sort of gating system, this would not mean that pain was not subjective (Ogden 2001).
Nevertheless the Gate Control Theory still remains the best theory available (and most influential) for explaining many of the puzzling characteristics of pain by recognizing the need to include psychological factors like cognition and emotion and not simply looking at the physical factors (Curtis 2000).
Empirical
Pain Research and Treatment
Since the publication of the Gate Control Theory in 1965 pain research has grown rapidly and incorporates developments from other disciplines such as Psychology, Sociology and Anthropology as well as from the more obvious field of Physiology and Clinical Medicine (Brown et al. 1989). But although psychologists have discovered many things about Pain, this knowledge is rarely put into practise in medical treatment (Banyard 1996). The theoretical foundations of pain may be progressing but, excepting the advent of morphine, our methods of treating pain (especially chronic pain) have not advanced much over the centuries (Hardcastle 1999). This may be because there are enormous problems present for those who study and treat pain due to the fact that pain is both subjective and a personal experience (Brown et al 1989).
So
what are the present treatments for pain?
For centuries doctors and other health practitioners have used a number of means for alleviating pain. Mostly these have been of a medical nature (i.e. drugs) but it is now recognised that the most effective treatments are those that are supplemented with psychological and behavioural techniques (McCaffery & Pasero 1999). E.g. TENS Machine, Acupuncture and Surgery are frequently used.
On the other hand, there are also a number of Psychological Treatments:
- Hypnotherapy: Any psychotherapy that uses hypnosis, (the process which 'transports' the subject into a 'separate state of mind') is considered to be hypnotherapy (Reber 1995).
- Relaxation Training: Relaxation is an essential component of many forms of pain therapy and it has been shown by many studies that relaxation does alleviate the pain experience and increases the Pain Threshold (Reilly 1996).
- Biofeedback: With the help of sensitive electronic equipment, which monitors a person's brain waves, blood pressure and heart rate, it has become possible to 'feedback' the measurements. This �entrainment� can be used to influence anxiety, pulse, blood pressure and promote well being, therefore reducing the pain experience.
- Operant techniques: This technique uses the principles of operant conditioning to encourage behaviours that reduce pain and discourages behaviours that increase pain. However this approach only deals with behavioural responses to pain and is most useful if someone has developed inappropriate behaviours for dealing with their pain e.g. excessive alcohol consumption.
- Behaviour Modification: Behaviour Modification works on the principles of operant techniques and aims to shape or change behaviour rather than the feelings associated with it (Curtis 2000).
- Cognitive Therapy (coping skills): Cognitive Therapy trains the patient to reinterpret the pain experience, avoiding negative and catastrophic thinking and encourages the use of distraction at key times. Cognitive Therapy holds that psychological dysfunction is at least partially responsible for chronic pain (Hardcastle 1999, McCaffrey & Pasero 1999). Of course the difficulty with this approach is that the pain processing is not treated at all. It isn't a cure but perhaps of help in alleviating the pain experience. Cognitive Therapy uses imagery, self-statements and attention-diversion. Distraction and diversion are sometimes referred to as cognitive refocusing and the mechanisms underlying the effectiveness of distraction as a method of pain relief remain unclear (McCaffery & Pasero 1999). Similar to the Gate Control Theory, the belief is that if the patient focuses on something other than the pain, less attention is available for focusing on the pain (McCaffrey & Pasero 1999).
- Mental Imagery: This technique uses the imagination of the patient to visualise more positive outcomes/pictures to enhance mood and perception (Reber 1995).
- Self-efficacy: Researchers (like Bandura) have suggested in the past that low self-esteem is stressful to the body and therefore contributes to the pain experience (Banyard 1996). Of course, conversely there is the possibility that those with high self-efficacy beliefs are ready to do something about their situation and so appear to suffer less pain.
- Counselling: A Generic term that is used to cover the several processes of interviewing, testing, guiding, advising that are designed to help an individual solve problems and plan for the future (Reber 1995).
- Multi Modal Approaches: Multi Modal Approaches combine different treatments and also use different modes of delivery (Curtis 2000).
- Placebo Response: If you strongly expect the pain to disappear, it may disappear. This is called the Placebo Response (Wall 2000, Ogden 2001) and it relies on psychological expectations. This seems so unlikely that it is not a popular therapy but this may be why listening to music, with positive suggestion that it will relieve pain, may be helpful. (It is important to note however, that a placebo is not the same as no treatment whatsoever.)
The power of suggestion on pain is demonstrated by studies on placebos (Melzack & Wall 1996). These studies illustrate the powerful contribution of suggestion to the perception of pain. It is generally assumed that the suggestion itself is sufficient to produce a placebo effect. Giving a placebo tablet also reduces anxiety because the patient feels that something is being done to relieve their pain. The combination of both suggestion and prescribing a placebo can have a powerful influence on the cognitive processes (Melzack & Wall 1996, Murphy 1963).
Placebo studies have compared the placebo effect with drugs and have shown that the placebo is equal to approximately half of the actual drug. For example, if the drug is aspirin then the placebo has around half the pain relief of an aspirin - if the drug is Morphine, then the placebo has around half the pain relief of Morphine. This clearly shows that the psychological context contains powerful therapeutic value in its own right, in addition to the effects of the drugs themselves (Melzack & Wall 1996).
But unfortunately, there are large differences in susceptibility to placebos. It would seem that placebos are more effective for severe pain and are more effective when the sufferer is under great stress and anxiety or indeed suffers from 'state anxiety' (Melzack & Wall 1996). In short, the greater the implicit and explicit suggestion that pain will be relieved, the greater the relief obtained by the patient (Melzack & Wall 1996).
The Placebo Response is the fulfilment of an expectation (Melzack & Wall 1996). Individuals learn expectations and if enough individuals share the same expectation it is called a culture (Wall 2000). As stated earlier, Brown et al. (1989) felt that cultural influences were an important part of pain perception and according to Melzack and Wall (1996), and Gouk (2000), cultural values are known to play an important role in the way a person perceives and responds to pain.
Research has discovered that sensation threshold is reasonably �even� amongst most cultures. It has also been discovered that the more different the cultures, the more noticeable the difference in pain perception threshold and pain tolerance threshold, with the most noticeable differences being in the pain tolerance threshold (Horden 2000). This is something future studies could investigate to decide which pain control method would be most suitable for each individual patient.
The preceding discussion shows unequivocally that psychological factors play an important role in pain perception and response (Melzack & Wall 1996). According to Pincus (1998) the main components that form the psychological factors include cognitions and affect. According to her research,
"depression, beliefs about control over pain, catastrophizing and somatization have all been described by researchers in relation to developing disability and poor outcome after treatment."
(Pincus 1998)
But where does music fit into the picture?
Music and Pain Research
There has been a huge body of research on music and its effect on our emotions. Sloboda and Juslin (2001a) suggest that there are two kinds of musical emotion. Firstly, there are the emotions that concern the artistic value of music and secondly, there are those emotions that are induced or expressed by the music. Clearly more understanding of music and the role it has to play in evoking emotions would be helpful to those who use music as medicine.
Leslie Bunt and Mercedes Pavlicevic (2001, also Bunt 1997) suggested several sources of emotion in music therapy that may contribute towards music�s success as an adjunct analgesia. For instance, associative connections play a part. (�Darling, they�re playing our tune� can be a powerful trigger for a range of associations with specific events, places and memories of people.) They also suggested Iconic Connections (where a particular sound can link musical characteristics to an external musical event) and Intrinsic Connections (where connections are made between the emotional experiences of the �client� and the structural aspects of the music).
Dowling and Harwood (1986) also identify three types of expressive meaning for music: indexical (association with an event), iconic (resemblance) and symbolic (knowledge of musical structure). These connections may explain the differences in people�s responses to music as analgesia, since the implication is that the music chosen to listen to must be totally suitable for the patient. It goes without saying that our preferences for certain pieces of music and composers will reflect our personal tastes and individual differences (Kemp 1997, Campbell 1997). A growing body of research is looking into the nature of musical preference and again this research will be relevant, and of use, to those in Music Medicine.
Additionally, there have been studies that advocate the use of music as a therapy to relieve pain, but why would music help? It would appear from a survey of the literature that music might help by distraction, suggestion of pain relief (Placebo Response), enforced relaxation or by masking pain. You may recall that Melzack and Wall (1996) stated suggestion, distraction, the meaning of the situation and the feeling of control, are each capable of exerting a powerful influence on pain.
Zimmerman et al. (1989) also think that diversion of attention from pain decreases the adverse nature of the stimulus and used music as a diversional stimulus that refocused the attention of their patients from pain onto something more pleasant. Maslar (1986) also concluded, after reviewing the use of music to reduce pain, that music can reduce pain through distraction and emotional change. Moreover, Mcgill-Levreault (1993) also suggested that the use of music by distraction, change in mood, increased control, use of prior skills and relaxation might reduce pain perception. This presents a strong case for the use of music as a diversion. The general consensus is that music might serve as a distraction from pain for a variety of reasons. Whipple and Glynn (1992) also felt that this non-invasive method of pain distraction gave patients a sense of control because they became more actively involved in the management of their pain.
Looking
further at the literature involved with music and pain research,
Maranto (1993) suggests that we already know a lot about music�s
effect on the body. For instance:
1) Music elicits physiological responses. It influences heart rate, blood pressure temperature, muscular responses, reduces stress hormones, etc. (Bonny 1983, Maranto 1993).
2) Music elicits psychological responses. Music can and does influence mood, decreases anxiety (Brown et al 1989, Maranto 1993).
3) Music evokes imagery and associations.
4) Music elicits cognitive responses that are unique to the individual (Colwell 1997).
5) Music does have an effect on physical, psychological and emotional boundaries (Wolfe 1978, Halpern 1978 cited in Zimmerman et al. 1989, Bailey 1985).
Bailey (1985), in line with other researchers, also suggests that music alleviates pain through relaxation, emotional change and encouragement of sense of control and self-expression as does Mucci (2000) and Lingerman (1995). And according to Bailey (1985) patients had fewer overt pain reactions and required less pain medication, when music was used in post-operative care than when no music was used. Brown et al (1989) also believe that actively listening to music in a structured fashion may provide a means for altering the perception of pain. Deep breathing and imagery techniques are often used in conjunction with progressive music relaxation to alter anxiety and pain (Colwell 1997).
The purpose of Colwell's (1997) study was to determine the use of music as a cue for relaxation (to reduce anxiety levels and the severity of the pain) and as a distracter to redirect focus from the pain to pleasurable activities. Her aims for her patient were to improve self-perception of pain, to improve pain coping skills, to decrease frequency of pain episodes, to decrease severity of pain episodes and to decrease the ingestion of narcotics. Her results indicated that the patient perceived less severe pain during the post-test than she did during her pre-test. Positive results indicated that the patient became more successful at coping with pain. Although Colwell (1997) only used one particular patient in a case study format, she had sufficient success to suggest that more detailed study would be beneficial.
Furthermore, Bailey (1985, 1986) suggested that during pain management, the therapist should assess the level of pain and general mood of the patient to consider the most appropriate music to use. It is considered generally that music, which initially matches the mood, is more successful (Bush 1995, Schorr 1993).
Musical works specifically mentioned in the literature for the relief of pain were Albinoni's Adagio in G Minor, Pachelbel's Canon, Vivaldi's Adagio from Concerto Grosso in F Op.320, Marcello's Adagio from Concerto in C Minor for Oboe, Vivaldi's Adagio from Concerto in D for Guitar and Enya. There is no justification for the use of this music other than the research implied that it would be helpful. Perhaps baroque and folk music are forms of music which most people are familiar with and therefore comfortable with for the use of passive music therapy.
So
why try to help pain with music?
It is now widely
recognized that pain presents a major problem in terms of quality of
life for individual pain sufferers and social and economic costs for
both the individual and the community. Pain can have a dramatic effect
on the lives of the individuals in both their work and home
environments (Colwell 1997) and the management, and subsequent
treatment of pain patients presents a challenge to health care
providers (Zimmerman et al. 1989, Brown et al. 1989). A significant
proportion of the population suffer pain of varying severity and since
pain is multidimensional, this represents a major problem in terms of
potential distress and dysfunction in the physical, psychological and
social areas of people�s lives. It is in everyone�s interest to
reduce pain as the reduction of pain influences the course of recovery
and influences the quality of life for the individual (Maranto 1993).
Melzack and Wall (1996) have repeatedly pointed out the significant effect that distraction has on altering pain perception and many researchers have already found that music can relieve the cycles of anxiety and fear that can intensify pain experiences while refocusing attention onto pleasing sensations (Oritz 1997). Listeners can therefore use the emotions aroused by music to influence the pain experience rather than the emotions merely being a reaction to it (Colwell 1997, Pincus 1998).
Additionally, as mentioned earlier, threatening stimuli can release the body's own painkillers - our own endogenous opiates (Davis 1992). Listening to music has also been shown to trigger the release of these endorphins (Spintge & Droh 1992, Oritz 1997, Horn & Munafo 1997), which helps lessen the pain.
Yet another added benefit is that Music Therapy is a non-pharmacological method (Bailey 1986). Music is a non-invasive treatment and should not add to the pain experience. By taking responsibility for their pain treatment with the use of music, the patient gains a sense of control and is actively involved in the management of their pain. Moreover, music can also be used to reach patients who feel isolated during pain and illness (Bunt 1994) by encouraging the patient to take part in more active music therapy. Music Therapy came about to serve this purpose. As a result of Music Therapy, communication can be re-established between patients and their surroundings and among patients, families and staff (Bailey 1985, Bunt 1994). Moreover, discussing musical choices with others gives an added interest that may also distract from the pain experience.
As stated already, pain is associated with several physiological reactions (Bonny 1968, Curtis, 1986; Davis 1992). These reactions include increased blood pressure, heart rate, respiratory rate, and muscle tension. It appears that these responses are also influenced by musical styles and elements as well as by the listener's preference and past experience (Curtis 1986). As already seen in the Gate Control Theory Model, mood is an important factor in the psychological control of pain. Furthermore research by Hekmat and Hertel 1993 found musical passages are more frequently conducive to the induction of physiological reactions that any other stimuli, and according to Clark et al (1981) music may be used as attention focusing, distraction, stimulus for pleasure response, conditioned stimulus for relaxation and a structural aid for breathing.
The findings of many studies support the use of music as an independent intervention to relieve pain (Beck 1991) and indeed, most of the music and pain studies reviewed by this researcher, have examined the effect of music alone, on the reduction of perceived pain, heart rate and behavioural characteristics of pain (Bonny 1983, Tame 1984, Bailey 1985, Beck 1991, Brown et al 1989). The majority have found that music and relaxation had a positive effect on the patients' heart rate and behavioural characteristics of pain. However, there is very little research available that measures the effects of administering medications in combination with a non-invasive method for reducing pain (Zimmerman et al. 1989, Reilly 1996). In other words, there is little or no research looking at music as adjunct analgesia.
And yet, there is only one study (Wagner & Menzel 1977) that has measured whether for musicians, as opposed to non-musicians, music might be a more successful strategy for pain relief. This study suggested that musicians (as opposed to non-musicians) would be more attentive in their listening and therefore gain the most from using music listening as a distraction from the pain experience.
In addition, comparison between studies is difficult because of the different methodologies: some look at acute pain and others have investigated chronic pain and others investigate the fact that chronic and acute pain may have different patterns of response (Wall 2000). Also, previously mentioned studies used different instruments or tools to measure pain.
How
can Pain be measured?
The measurement of pain is a difficult issue due to the subjective nature of the pain experience. Nonetheless it is important to be able to measure pain so as to assess whether a particular intervention has been successful. Over the years, many tests and procedures have been tried, including observation of behaviour. However self-reporting still remains one of the more reliable (Curtis 2000).
One technique is to ask the sufferer to gauge their pain from a Pain Intensity Scale (PIS). One PIS method asks patients to rate their pain on a scale e.g. from 1-100 with 1 being the least amount of pain detectable and 100 being the most excruciating pain imaginable.
A similar PIS technique uses the Visual Analogue Scale (VAS), which simply involves anchoring a line on the left with a phrase like 'no pain' and on the right with a phrase like 'worst pain imaginable'. The patient merely makes a mark along the line to indicate the intensity of their pain. Because this scale has no marked units, it is considered more sensitive, allowing more effective comparisons to be made.
Both
the numerical scale and the VAS have been shown to be reliable (Curtis
2000). However, Melzack (of 'Gate Control Theory' fame) was highly
critical of the PIS and he accused the PIS of not taking into
consideration the many dimensions of pain. He therefore developed the
McGill Pain Questionnaire (MPQ) in 1975. The McGill Pain Questionnaire
provides a subjective measure of pain and categorises pain under the
three psychological dimensions mentioned earlier:
(1) Sensory Qualities (referring to the temporal, spatial, pressure and thermal qualities of pain - similar to identifying the physical dimensions of pain)
(2) Affective Qualities (referring to the fear, tension and autonomic qualities of pain - similar to identifying the feelings associated with pain.)
(3)
Evaluative Qualities (referring to the subjective
overall intensity of the pain experience - similar to identifying the
meaning of the pain experience.)
The MPQ is the most widely and frequently used multi-dimensional measure of pain and has been used to assess pain in a variety of settings (Melzack 1975, Melzack 1987b). However, it has only demonstrated moderate reliability and has been criticised in terms of its difficult vocabulary and for not having a standard scoring format (Colwell 1997). A short form of the MPQ (SF-MPQ � see Appendix B) was published in 1987 (Melzack 1987b). This was developed to use in situations in which the standard MPQ took too long to administer. The SF-MPQ is also considered a functional instrument and is considered particularly useful when self-administration is required (Wall 2000). It is more suited to the type of research to be carried by persons not of the medical profession and therefore ideal for this particular study.
The survey of previous studies revealed a number of common themes:
(1)
The pain process involves emotion, previous experience,
expectation and environmental effects (Zimmerman et al 1989).
(2)
Most studies abdicate the human element of live performance in
favour of recorded music (Aldridge 1996, Gerber 1998).
(3)
Music can relieve the cycles of anxiety and fear that can
intensify pain experiences while refocusing attention onto pleasing
sensations. Emotions can influence the pain experience rather than
being a reaction to it (Mcgill-Levreault 1993).
(4)
All patients will not respond to the same type of music so a
variety of styles should be considered (Zimmerman et al 1989, Smith et
al 1997). In fact nearly all the studies reviewed suggested that
preferred music (i.e. Own choice) would be most effective and
preferential in reducing perception of pain (Parente 1976). Maranto
(1993) stated that various factors were important and should be
considered carefully when using music as a passive therapy. E.g.
familiarity with the music, preference for the music, history and
associations with the music, characteristics/elements of the music.
Maranto (1993) also suggested that trained musicians responses to the
music would be more intense than that of a non-musician.
(5)
Sound intensity of any type depends upon the listener, so the
patient should control the volume (Bonny 1968, Zimmerman et al. 1989,
Smith et al 1997).
(6)
Use of headphones will help in blocking out environmental noise
(Bonny 1968, Long & Johnson 1978 as cited in Zimmerman et al.
1989, Smith et al 1997).
(7) Music as a therapeutic method is more effective when the suggestion that it will decrease pain is given (Maslar 1986, Zimmerman et al. 1989, Smith et al 1997). Both sound and the suggestion appear to be necessary for the music to have any effect (Lavine et al 1976).
In summary, there have been numerous studies dealing with pain management, and musical involvement in this management. The literature search revealed a number of unresolved issues, which this research investigates. The major purpose of this study is to investigate, evaluate and determine the effects of listening to music with positive suggestion of pain reduction on self-reported pain with a view to seeing if the therapy was more effective for people for whom music was considered important i.e. Musicians.
Based
on the review of previous research, two empirical studies were
designed and carried out to investigate whether
participants who listened to music with positive suggestion of pain
reduction would have a positive difference between the pre and post
diary testing scores of the Short Form McGill Pain Questionnaire and
Visual Analogue Scale, compared to those who did not listen to music
and whether levels of musical training had any influence on the
outcome.
I
also believed that participants who listened to music of their own
choice with positive suggestion of pain reduction would have a larger
difference between the pre and post diary testing scores of the Short
Form McGill Pain Questionnaire and Visual Analogue Scale, than those
who listened to music selected by the researcher.
Empirical
Studies
Because
pain is subjective and not easily measurable by the medical
profession, it was decided that some method of self-reporting was
inevitable and appropriate. Case studies and diaries had been used in
previous research (e.g. Colwell 1997) and so that is why this method
was decided upon. So that the research could also be quantitative (as
opposed to being solely qualitative) previous research methods were
adopted and adapted to fit the purpose of this study. While previous
research had used the time consuming and cumbersome McGill Pain
Questionnaire, it was found that there was in fact a Short Form McGill
Pain Questionnaire, which was far better suited to the needs,
requirements and skills of this researcher.
Method
A
questionnaire (See Appendix A) was compiled, asking various
demographic questions, including questions to establish previous
musical experience, musical preferences and what sort of pain and
duration of the pain experience the participant had. It was also
established if the participant was on medication for pain relief
already, since the purpose of the study was to investigate the use of
music alongside conventional treatment. The questionnaire also asked
if alternatives to conventional treatment had already been undertaken
to establish whether the participant might be more open to the
positive suggestion that music would relieve the pain experience.
(Although age and gender were asked for, they were not used in
analysis.) The questionnaire was used to gather information about the
pain experiences of individuals, what their levels of musical training
were and how important music was to each individual. This was to help
ascertain if indeed the more important music was to the pain sufferer,
the more effective music would be as adjunct analgesia.
This
questionnaire was distributed freely at a pain clinic. It was also
published on the Internet with announcements of my intentions to
various Internet based Pain Lists/Email Groups.
Results of the Questionnaire
Of
150 questionnaires, 127 were returned. This is an unexpectedly high
return rate. One can only assume that people in continuous pain are
driven to find relief of any kind.
57% of participants were women and 43% were men.
88% had already tried many alternative treatments (like Homeopathic, Acupuncture, T.E.N.S. etc) and were open to the suggestion that music may help relieve pain as an adjunct therapy.
93% already listened to music on a regular basis and 75% already used music to alter their mood illustrating the usefulness of music in this area. And as we already know from the literature previously published, mood can have both positive and negative influences on the pain experience.
96% of the sample considered music so important that they had wanted to, had or still played an instrument or sang illustrating the individuals �need� for music.
64% had already attempted to use music as analgesia, which showed that people do intuitively seek out what they know may help. Remember, the ancients used music for a variety of purposes, including healing. It could be considered that it is in our nature to use music as therapy.
The questionnaire was very helpful and suggested that people in pain are willing to try just about anything to relieve their suffering. As previously stated 75% already used music to alter their mood and as stated before, mood and anxiety can play a large part in the perception of pain. The fact that so many people already listened to music regularly, confirmed my suspicions that music would be an ideal adjunct therapy given that most people have readily available the facilities and the abilities to use music in this way. Interestingly enough though, the people who I believed would be helped most (i.e. Musicians) were the people most likely NOT to listen to music even.
Many participants in the questionnaire offered opinions as to why music was already helpful to them:
�It lets my mind wander back to those days.�
�It transports your mind to a different time of your life. Like when you hear a song, and you remember what you were doing at the time you first heard it! And during that time while your having a flashback, your mind wanders off the pain.�
�It aids relaxation.�
�It keeps me busy � keeps my mind occupied.�
�I do believe that music can help you relax��very much so���
The most common theme amongst the comments was that of the �Darling, they�re playing our tune� syndrome. As suggested by the literature, associative connections may help with relaxation and distraction and therefore the pain experience. This correlates with Bunt and Pavlicevic�s (2001) Iconic Connections (where a particular sound can link musical characteristics to an external musical event) and Intrinsic Connections (where connections are made between the emotional experiences of the �client� and the structural aspects of the music) and also Dowling and Harwood�s (1986) indexical (association with an event).
These comments confirm the research identified in the literature concerning diversion from pain and also with the literature involved with music and emotional response.
Study Two: Diary
Method.
Fifteen volunteers, who had intimated they were interested in participating in further research, were selected randomly from the questionnaire responses and asked to keep a diary over the period of a month.
Participants
The participants were of mixed gender and of ages 17 � 58. Most were in employment, one was still at school and two, although well educated and previously employed, were unable to work because of the severity of their pain. For the purpose of this study it was decided that a musician was a person who played/had played or sang/had sung and had received formal instruction of some sort, no matter what level they were at. Conversely, a non-musician was a person who had never played or sung, nor had never received formal tuition. There were 8 Non-musicians and 7 Musicians with the skill level amongst the musicians varying from beginner to professional.
The sample was divided into three groups of 5 participants:
Group
one relaxed only for a ten (10) minutes per day for the duration of
the study.
Group two listened to music of their own choice and relaxed for ten (10)
minutes per day for the duration of the study.
Group three listened to the researcher's choice of music, that the
literature review has suggested most suitable for the purpose, for ten
(10) minutes per day for the duration of the study.
Both 'Listening' Groups were asked to listen at the same time each day (where possible) with headphones and I also implied that I knew that the listening or relaxing would help their pain tolerance.
This was in the hope of positively influencing the outcome since previous research had suggested the use of positive suggestion.
This produced a record of what was listened to and observations of Pain perceived. In addition, there was Pre and Post Diary testing using the Short Form McGill Pain Questionnaire (Melzack, R. 1987b, See Appendix B). The SF-MPQ asks the patient to answer questions describing their pain and assigns numerical values on responses. The lower the score, the less pain perceived. Administered before and after keeping a diary, produced data that was compared to ascertain the effect of listening to Music as adjunct painkiller.
Equipment
The
recordings supplied for Group Three were compiled from suggestions
made in the literature search and my own personal recommendations.
Tracks 1, 2, 7, and 9 had been mentioned specifically in the
literature. I had no idea of what else to include but having studied
the suggestions of what might or might not be suitable as pain
relieving music, the other tracks were selected by myself. I wanted to
include a large variety of styles, vocal, instrumental, modern and not
so modern examples. Every participant within group three (3 musicians
and 2 non-musicians) commented on the variety of the music and all
asked to retain the CD compiled for them.
The tracks on the Researcher�s Choice CD were:
1. Pachelbel - Canon
2. Faure - Pavane
3. O'Carolan - O'Carolan's Receipt for Drinking
4. Jenkins - Cantus - Song of Tears
5. Mahler - Adagietto from Symphony No. 5
6. Enya - Watermark
7. Albinoni - Adagio
8. Trad. - An Gille Ban
9. Offenbach - Tales of Hoffmann
10. Enya - When Evening Falls
11. Trad. - An Artaireachd Ard
12. Jenkins - Adiemus
13. Rodrigo - Adagio from Concierto de Aranjuez
I
believed that participants who had listened to music with positive
suggestion of pain reduction would have a positive difference between
the pre and post diary testing scores of the Short Form McGill Pain
Questionnaire (SF-MPQ) and Visual Analogue Scale (VAS), compared to
those who did not listen to music. I also believed that participants
who had listened to music of their own choice with positive suggestion
of pain reduction would have a larger difference between the pre and
post diary testing scores of the Short Form McGill Pain Questionnaire
(SF-MPQ) and Visual Analogue Scale (VAS), than those who listened to
music selected by the researcher.
In addition, I believed that listening to music would particularly make a difference to the pain threshold and pain felt for those for whom music plays a large part in their life. I.e. Musicians.
Results
As already mentioned, every participant within group three (3 musicians and 2 non-musicians) commented on the variety of the music and all asked to retain the CD compiled for them. This was because they felt there was some positive benefit (i.e. pain relief) from their use of the CD. But was musical intervention of benefit?
Figure 2 The
SF-MPQ
results for all three groups.
Figure 2 shows the Short Form McGill Pain Questionnaire results for all three groups (See Appendix C for full results of SF-MPQ). Visual analysis of the graph shows some benefit of intervention, with intervention having reduced the pain scores in all three groups with both musicians and non-musicians showing improvement. The greatest benefit, surprisingly, was within group three. This was in contradiction to the literature, which had suggested that a patient�s own choice of music would be most beneficial for the relief of pain. Perhaps this increased benefit and improvement in the pain score was because the researcher is a highly trained musician who chose the music very carefully or perhaps this is because music was used as an adjunct therapy and not as a sole treatment. But is this result statistically significant?
Using SPSS, the Paired t-Test was selected because this test is used when comparing the means of two sets of observations from the same individuals. The test was used to establish if there was any significant benefit for the use of music as an intervention. The dependent variable was pain. (See Appendix D for full results of Paired t-Test.)
Within group one (relaxation alone), the perception of pain was not significantly altered � although there was an improvement (t = 1.083, df = 4, p< 0.340, two-tailed).
Within group two, the perception of pain was also not significantly affected with the use of own choice of music as an adjunct analgesia � although there was a larger improvement than for group one (t = 2.003, df = 4, p< 0.116, two-tailed).
Within group three, the perception of pain was also not significantly affected with the use of the researcher�s choice of music as an adjunct analgesia � although there was a larger improvement than in Group One and Group Two (t = 2.029, df = 4, p< 0.112, two-tailed).
The results were therefore not as significant as hoped for. This may be because of the small sample of people used, and the impersonal way in which the study was carried out but there is enough evidence to warrant further research and use of music as an adjunct therapy.
Because I also wanted to investigate if there was a relationship between the effectiveness of music as analgesia and levels of musical training, I wanted to compare the results of the musicians and non-musicians. I initially selected the Independent T-test to analyse the results as it is normally used to compare means from two independent groups of individuals but latterly decided to use a Two Factor ANOVA (Analysis of Variance). ANOVA allows the investigation of more than one independent variable and is an enormously useful statistical procedure used within Psychological research (Brace et al 2000). This allowed the researcher to see if there was any interaction between the Condition (Relaxation, Own Choice Music and Researcher�s Choice Music) and the levels of musical training (Musician/Non-Musician). (See Appendix E and Appendix F for full results of both the Independent T-test and ANOVA.)
There was no significance as to whether music as adjunct analgesia worked better when the level of musical training was increased (F = .318, p = .5866).
There was no significant interaction between the factor of musical training and which group the participant was in (F = 1.169, p = .3539).
Figure 3
This was surprising because graphical analysis (see Figure 3) showed a visibly increased effectiveness in music as adjunct analgesia in the Musicians from Group Two (own choice music). This was also affirmation of the suggestions made in the previously published literature, which stated musicians would react more intensely, but alas it was not statistically significant result.
Discussion
So it appears from this study that the use of music leads to improvement in the pain experience although it is not a statistically significant improvement. However, the methodology was quite na�ve and the sample used in this investigation was quite small because it was not possible to randomly select subjects from the population. The study was also of a short period and it may be that a more lengthy study would be more appropriate for cases of chronic pain. Individual influences combined with this researcher�s inadequate methods might account for the few instances of contradiction concerning the effects of music. Active music therapy may be more appropriate than passive in the case of chronic pain also.
Despite some inconsistencies the majority of the research has a positive outcome. Nonetheless the sample was representative of pain sufferers and although the results of this research were not overwhelmingly significant, it did show some benefit of using music as an intervention in pain therapy, with there being an increased benefit for those who have had some degree of musical training where they used their own choice of music.
In order to consider why there was some benefit of using music as adjunct analgesia, especially for musicians, it is useful to reconsider Gate Control Theory. This model (see Figure 1) suggested that pain is a two-way flow of information to and from the brain, and that the brain not only processes the information but also directly affects the 'gating mechanism' (Melzack & Wall 1965). This theory still remains the best available for explaining the puzzling characteristics of pain. By reconsidering this theory and applying what we know already from the literature review and our own empirical work, we begin to partly explain what may or may not be happening when music is used as an adjunct therapy.
Figure
4 shows the conditions that open and close the �gate� as
suggested by Melzack and Wall (1996) and collated previously in Figure
1. This researcher has made suggestions (bracketed and in italics)
as to why music may help the pain experience. The suggestions have
been substantiated with previous research where possible.
|
Conditions
that open the 'Gate' |
Conditions
that close the 'Gate' |
|
Physical
Emotional
Mental
|
Physical
Emotional
Mental
|
Figure 4
And what about the Placebo Response? Research has shown that there are large differences in susceptibility to placebos. The combination of both suggestion and prescribing a placebo can have a powerful influence on cognitive processes (Melzack & Wall 1996). As stated previously, placebos are more effective for severe pain and are more effective when the sufferer is under great stress and anxiety or suffers from 'state anxiety' (Melzack & Wall 1996). In short, the greater the implicit and explicit suggestion that pain will be relieved, the greater the relief obtained by the patient. Is it possible then, that music will be more successful when 'state anxiety' is greater? In this researcher�s sample, the greatest improvement was in a subject who appeared to the researcher as a very anxious person. Obviously this would have to be substantiated with �State� or Trait� anxiety testing of the subject, but it is worth investigating in further research.
And why does music work for some of the people, some of the time? What other factors are at work? Do personality traits have a role to play? The role of gender in the pain experience is not clear, and the relationship between male and female response was not investigated within this research either (because of the small sample size), but there may be some evidence to suggest that females respond more positively than males to music as an adjunct analgesia. Further research is warranted in this area.
To what extent does musical training have effect on the reduction of the pain experience? It is true that those who have studied the techniques of musical composition can more thoroughly appreciate the structure of a musical work than those who have not (Storr 1997). Mcgill-Levreault (1993) also suggested that the use of prior skills might reduce pain perception and it is well documented that Beethoven used music and composition as a distraction from his renowned suffering (Martin 2001). Do musicians react more to musical stimulus than non-musicians? This research showed some added benefit from being considered a musician, although it was not a statistically significant benefit. Clearly more research in this area with a larger sample size would help clarify this issue.
Moreover, music specifically mentioned for the relief of pain was mostly from the earlier periods of classical music and also from folk music. It is not clear why baroque music is most recommended but clearly more research would be of value, perhaps with a joint study involving members of the medical profession, music psychologists and musicologists. This may help identify what mechanisms and devices within the music lead to the relief of anxiety and pain.
For whatever reason, music is important to a large number of people � even those considered to be �non-musicians�. Is rhythm and music significant to us because of the influence of the mother�s pulse heard in the womb (Hoffman 1995)? The findings of a study by Shapiro, Marchette, Main and Redick (1992) into to neonatal pain during circumcision suggested that the pain reduction effect of music may hold true only when exposed to the more developed and conditioned interpretative brain centres of an adult (as opposed to that of a baby). A more cross-age study would provide more detail and insight.
Alas, the basic tradition of medicine has been to seek a single diagnosis and a single therapy (Melzack & Wall 1996), nevertheless there are pathological situations in all disease states in which the underlying mechanisms are so powerfully locked into an abnormal state that no one therapy can move the situation back to normal. Does music work more successfully when used in combination with other therapies? It would also be of value for a study to be conducted combining the skills and knowledge of medicine, psychology and music. A multi discipline approach incorporating musical, psychological and medical analysis and testing would be most interesting. It is fully justified to use a combination of therapies, which pull and push the system towards normality.
Additionally, the literature review revealed developments in the field of Music Medicine, nursing and algology (study of pain) that suggested the need for more stringent future research. Future research should also focus on the measurement of pain, what releases the bodies own pain-killing mechanism and the effect of music on the neurotransmitters involved (Maslar 1986).
Given that music does arouse strong emotions in people (Dowling and Hardwood 1986), and is accessible for everyone, a music programme could be developed for almost all patients. This makes music a highly attractive alternative to expensive and time-consuming treatments. The fact that music does help � no matter how significantly or insignificantly � makes a strong case for �music therapy�s� inclusion as part of all therapeutic programmes for the control of pain and it is certainly worthy of more research.
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Oritz, J.M. (1997) The Tao of Music: Sound Psychology Dublin: Newleaf
Parente, J.A. (1976) Music Preference as a Factor of Music Distraction Perceptual and Motor Skills 43: 337-338
Pincus, T. (1998) Assessing Psychological factors in chronic pain - a new approach Physical Therapy Reviews 3: 41-45
Pitts, M. & Phillips, K. (1998) The Psychology of Health London: Routledge
Reber, A.S. (1995) Dictionary of Psychology London: Penguin
Reilly, M.P., (1996) Relaxation, Imagery and Music as an Adjunct Therapy to Narcotic Analgesia in the Perioperative Period, in R. Spintge & Pratt, R.R. (editors) MusicMedicine Volume 2, Saint Louis: MMB Music Inc. 206-217
Schorr, J.A. (1993) Music and Pattern Change in Chronic Pain Advances in Nursing Science 15 (4): 27-36
Shapiro, A., Marchette, L., Main, R and Redick, E (1992) Pain Reduction During Neonatal Circumcision, in R. Spintge & R. Droh (editors) MusicMedicine, Saint Louis: MMB Music Inc. 131-136
Sloboda, J.A. & Juslin, P.N. (2001a) Psychological Perspectives on Music and Emotion, in Patrick Juslin & John Sloboda (eds.) Music and Emotion: Theory and Research Oxford: Oxford University
Sloboda, J.A. & Juslin, P.N. (2001b) Music and Emotion: Introduction, in Patrick Juslin & John Sloboda (eds.) Music and Emotion: Theory and Research Oxford: Oxford University
Sloboda, J.A. (1985) The Musical Mind Oxford: Oxford University Press
Sloboda, J.A. (1995) Musical Beginnings: Origins and Development of Musical Competence Oxford: Oxford University Press
Smith, N.K., Pasero, C. & McCaffrey, M. (1997) Using Nondrug Methods during procedures American Journal of Nursing 97 (8): 18-20
Spintge, R. & Droh, R. (editors) (1992) MusicMedicine Saint Louis: MMB Music Inc.
Storr, A. (1997) Music and the Mind London: Harper Collins
Tame, D. (1984) The Secret Power of Music: The Transformation of Self and Society Through Musical Energy Wellingborough: Turnstone Press Ltd
Wagner, M.J. & Menzel, M.B. (1977) The effect of Music Listening and Attentiveness Training on the EEG's of Musicians and Non-musicians Journal of Music Therapy 14 (4): 151-164
Wall, P. (2000) Pain: The Science of Suffering London: Phoenix
Whipple, B. & Glynn, N.J. (1992) Quantification of the Effects of Listening to Music as a Noninvasive Method of Pain control Scholarly Inquiry for Nursing Practice: An International Journal 6 (1): 143-156
Wolfe, D.E. (1978) Pain Rehabilitation and Music Therapy Journal of Music Therapy 15 (4): 162-178
Zimmerman, L., Pozehl, B., Duncan, K. and Schmitz, R. (1989) Effects of Music in Patients Who Had Chronic Cancer Pain Western Journal of Nursing Research 11 (3): 298-309
Appendix A
Pain Survey
Does Music Help Pain?
Pilot Study for Take Two Tunes and Call Me in the Morning: An Investigation into the use of Music as Adjunct Analgesia with special reference to the differences between Musicians and Non-musicians.
The aim of this research will be to ascertain if music can be used successfully as a complementary painkiller alongside conventional treatments. I will also be trying to ascertain if there is a relationship between being a musician or a non-musician and the effectiveness of music as an adjunct analgesia.
You can rest assured that all aspects of the research will remain confidential and that although the findings will be published, you will be simply referred to as a number or letter.
Please try to answer as many questions as possible:
----------------------------------------------------------------------------------------
Name
:
Email
:
Tel
:
|
Demographic
Information
Are
you? q
Married
q
Single q
Widowed q
Remarried q
Separated q
Divorced q
Committed
Relationship Education: q
Secondary
(Standard Grade/Higher/Advanced Higher/'O' Grade/CSYS/GCSE/A
Level) q
Further
Education (HNC/HND/Diploma) q
Higher
Education (BA/BSc) q
Postgraduate
Education (MA/MSc/PhD) If
currently employed, what kind of work do you do? If
currently unemployed or retired, please state area of employment
in which you were formally engaged. Do
you get regular exercise? q
Yes q
No q
Sometimes |
|
Pain
Information Where
does your pain occur? q
Head/Migraine q
Throat q
Shoulder q
Chest q
Arms q
Back q
Stomach q
Abdomen q
Legs q
Feet How
often does your pain occur? q
Constantly q
At
regular times q
At
irregular times Is
your pain? q
Totally
disabling q
Severe q
Distressful q
Tolerable q
Mild What
is the quality of your pain? (Tick all that apply) q
Ache q
Burning q
Cramping q
Deep q
Gnawing q
Muscular/joint q
Pulling q
Sharp q
Shooting q
Sickening q
Splitting q
Stabbing q
Throbbing q
Tiring-Exhausting |
|
Pain
Information (continued) Do
you receive prescribed medication for your pain? q
Yes q
No q
Sometimes Do
these medications control your pain to your satisfaction? q
Yes q
No If
you responded No, please indicate why: Have
you tried any alternative treatments for your pain? q
None q
Acupuncture q
Herbal q
Homeopathic q
Massage q
Meditation q
Nutrition/diet q
Skin
Magnets q
TENS
Unit q
Other
(Please Specify) |
Music Do
you normally listen to music? q
Yes q
No
(If no skip to Have you ever played a musical instrument or do
you sing?) How
much do you enjoy listening to Music? q
Very
Much q
Much q
It's
okay q
Not
at all What
Type of music do you like to listen to? q
Pop/Rock q
Country q
Classical q
Jazz/Blues q
Other
(Please specify)
____________________________________________ Do
you use Music to change your mood? q
Yes q
No q
Don't
know Have
you ever played a musical instrument or do you sing? q
I
still sing q
I
still play q
I
did sing q
I
did play q
I
would have liked to have learned how to play/sing q
I
never learned how to play/sing If
yes, please state what: Do
you think listening to music may offer some pain relief? q
Yes q
No q
Don't
know |
|
Have
you ever used music to distract you from your pain? q
Yes q
No Do
you still use Music to distract you from your pain? q
Yes q
No q
Sometimes Are
you interested in pursuing Music as a complementary analgesia? q
Yes q
No Are
you interested in participating in further Research into Music
as a complementary analgesia? q
Yes q
No I consent to the above information being used and published as part of a research paper on the understanding that I will be referred to simply by a number or a letter. Signed��������������������.. Dated��������.. Email to: |
Appendix B
SHORT-FORM McGILL PAIN QUESTIONNAIRE
Name: ______________________________________ Date: __________
Please describe your pain by selecting suitable descriptions and severities. Fill out as many or as little as you feel is appropriate.
|
|
NONE |
MILD |
MODERATE |
SEVERE |
|
THROBBING |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
SHOOTING |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
STABBING |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
SHARP |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
CRAMPING |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
GNAWING |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
HOT-BURNING |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
ACHING |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
HEAVY |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
TENDER |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
SPLITTING |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
TIRING-EXHAUSTING |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
SICKENING |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
FEARFUL |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
|
PUNISHING-CRUEL |
0) ________ |
1) ________ |
2) ________ |
3) ________ |
VAS - Visual Analogue Scale.
Please make a mark along the line to indicate your pain experience.
|
NO PAIN |
__________________________________________________ |
WORST POSSIBLE PAIN |
PPI - Present Pain Intensity
Please select a number
that best represents your present pain.
0 NO PAIN
1 MILD
2 DISCOMFORTING
3 DISTRESSING
4 HORRIBLE
5 EXCRUCIATING
Appendix
C
The
SF-MPQ results are shown below in Figure A, Figure B, Figure C.
|
Relaxation |
Pre
Diary |
Post
Diary |
Difference |
Musician? |
|
Person 1 |
14 |
15 |
+1 |
Y |
|
Person 2 |
29 |
14 |
-15 |
N |
|
Person 3 |
4 |
2 |
-2 |
N |
|
Person 4 |
23 |
26 |
+3 |
Y |
|
Person 5 |
32 |
28 |
-4 |
N |
|
Average/Mean |
20.4 |
17 |
-3.4 |
|
Figure
A
|
Own
Choice |
Pre
Diary |
Post
Diary |
Difference |
Musician? |
|
Person 1 |
41 |
45 |
+4 |
N |
|
Person 2 |
41 |
31 |
-10 |
N |
|
Person 3 |
15 |
8 |
-7 |
Y |
|
Person 4 |
9 |
5 |
-4 |
N |
|
Person 5 |
22 |
15 |
-7 |
Y |
|
Average/Mean |
25.6 |
20.8 |
-4.8 |
|
Figure
B
|
Researcher's
Choice |
Pre
Diary |
Post
Diary |
Difference |
Musician? |
|
Person 1 |
23 |
6 |
-17 |
Y |
|
Person 2 |
2 |
0 |
-2 |
Y |
|
Person 3 |
8 |
2 |
-6 |
N |
|
Person 4 |
43 |
36 |
-7 |
N |
|
Person 5 |
16 |
17 |
1 |
Y |
|
Average/Mean |
18.4 |
12.2 |
-6.2 |
|
Figure C
Appendix D
Results of Paired T-Test on SFQ Results investigating
the usefulness of music as adjunct analgesia.
Group
One
Paired Samples Statistics for Group One (Relaxation Only)
|
|
|
Mean |
N |
Std.
Deviation |
Std.
Error Mean |
|
Pair 1 |
PRE |
20.4000 |
5 |
11.45862 |
5.12445 |
|
|
POST |
17.0000 |
5 |
10.48809 |
4.69042 |
Paired Samples Correlations for Group One
|
|
|
N |
Correlation |
Sig. |
|
Pair 1 |
PRE & POST |
5 |
.799 |
.105 |
Paired Samples Test for Group One
|
|
|
Paired
Differences |
|
|
|
|
t |
df |
Sig.
(2-tailed) |
|
|
|
Mean |
Std.
Deviation |
Std.
Error Mean |
95%
Confidence Interval of the Difference |
|
|
|
|
|
|
|
|
|
|
Lower |
Upper |
|
|
|
|
Pair 1 |
PRE - POST |
3.4000 |
7.02140 |
3.14006 |
-5.3182 |
12.1182 |
1.083 |
4 |
.340 |
Group Two
Paired Samples Statistics for Group Two (Own Music Choice)
|
|
|
Mean |
N |
Std.
Deviation |
Std.
Error Mean |
|
Pair
1 |
PRE |
25.6000 |
5 |
14.79189 |
6.61513 |
|
|
POST |
20.8000 |
5 |
16.85823 |
7.53923 |
Paired Samples Correlations for Group Two
|
|
|
N |
Correlation |
Sig. |
|
Pair 1 |
PRE & POST |
5 |
.951 |
.013 |
Paired Samples Test for Group Two
|
|
|
Paired
Differences |
|
|
|
|
t |
df |
Sig.
(2-tailed) |
|
|
|
Mean |
Std.
Deviation |
Std.
Error Mean |
95%
Confidence Interval of the Difference |
|
|
|
|
|
|
|
|
|
|
Lower |
Upper |
|
|
|
|
Pair 1 |
PRE - POST |
4.8000 |
5.35724 |
2.39583 |
-1.8519 |
11.4519 |
2.003 |
4 |
.116 |
Group
Three
Paired Samples Statistics for Group Three (Researcher�s Music Choice)
|
|
|
Mean |
N |
Std.
Deviation |
Std.
Error Mean |
|
Pair 1 |
PRE |
18.4000 |
5 |
15.88395 |
7.10352 |
|
|
POST |
12.2000 |
5 |
14.83914 |
6.63626 |
Paired Samples Correlations for Group Three
|
|
|
N |
Correlation |
Sig. |
|
Pair 1 |
PRE & POST |
5 |
.903 |
.036 |
Paired Samples Test for Group Three
|
|
|
Paired
Differences |
|
|
|
|
t |
df |
Sig.
(2-tailed) |
|
|
|
Mean |
Std.
Deviation |
Std.
Error Mean |
95%
Confidence Interval of the Difference |
|
|
|
|
|
|
|
|
|
|
Lower |
Upper |
|
|
|
|
Pair 1 |
PRE - POST |
6.2000 |
6.83374 |
3.05614 |
-2.2852 |
14.6852 |
2.029 |
4 |
.112 |
Appendix E
Independent T-Test investigating the correlation between the effectiveness of music as an adjunct analgesia and musical training.
Group Statistics
|
|
musical ability |
N |
Mean |
Std.
Deviation |
Std.
Error Mean |
|
IMPROV |
musician |
5 |
-6.4000 |
6.84105 |
3.05941 |
|
|
nonmusician |
5 |
-4.6000 |
5.27257 |
2.35797 |
Independent Samples Test
|
|
|
Levene's
Test for Equality of Variances |
|
t-test
for Equality of Means |
|
|
|
|
|
|
|
|
|
F |
Sig. |
t |
df |
Sig.
(2-tailed) |
Mean
Difference |
Std.
Error Difference |
95%
Confidence Interval of the Difference |
|
|
|
|
|
|
|
|
|
|
|
Lower |
Upper |
|
IMPROV |
Equal variances assumed |
.181 |
.681 |
-.466 |
8 |
.654 |
-1.8000 |
3.86264 |
-10.70727 |
7.10727 |
|
|
Equal variances not assumed |
|
|
-.466 |
7.513 |
.654 |
-1.8000 |
3.86264 |
-10.80885 |
7.20885 |
There was not a significant difference between the conditions (t = 0.466, df = 8, p< 0.654, one-tailed). Being a highly trained musician made some difference to the use of music as an adjunct analgesia, but it is not significant difference.
Appendix F
StatView ANOVA Table for Pain Diff
|
|
DF |
Sum of Squares |
Mean Square |
F-Value |
P-Value |
Lambda |
Power |
|
Condition |
2 |
35.756 |
17.878 |
.418 |
.6707 |
.835 |
.097 |
|
Musical Experience |
1 |
13.611 |
13.611 |
.318 |
.5866 |
.318 |
.079 |
|
Condition*Musical Experience |
2 |
100.022 |
50.011 |
1.169 |
.3539 |
2.337 |
.191 |
|
Residual |
9 |
385.167 |
42.796 |
|
|
|
|
Means Table for Pain Diff
Effect: Condition*Musical Experience
|
|
Count |
Mean |
Std. Deviation |
Std. Error |
|
Relaxation, Musician |
2 |
2.00 |
1.414 |
1.000 |
|
Relaxation, Non-Musician |
3 |
-7.00 |
7.000 |
4.041 |
|
Own Choice, Musician |
2 |
-7.00 |
0.000 |
0.000 |
|
Own Choice, Non-Musician |
3 |
-3.33 |
7.024 |
4.055 |
|
Researcher�s Choice, Musician |
3 |
-6.00 |
9.644 |
5.568 |
|
Researcher�s Choice, Non-Musician |
2 |
-6.50 |
.707 |
.500 |
Fisher�s PLSD for Pain Diff
Effect: Condition
Significance Level: 5%
|
|
Mean Diff. |
Crit. Diff. |
P-Value |
|
Relaxation Only, Own Choice |
1.400 |
9.360 |
.7428 |
|
Relaxation Only, Researcher�s Choice |
2.800 |
9.360 |
.5156 |
|
Own Choice, Researcher�s Choice |
1.400 |
9.360 |
.7428 |
Fisher�s PLSD for Pain Diff
Effect: Music
Significance Level: 5%
|
|
Mean Diff. |
Crit. Diff. |
P-Value |
|
Musician, Non-Musician |
1.500 |
7.659 |
.6682 |
There was no significance as to whether music as adjunct analgesia worked better when the level of musical training was increased (F = .318, p = .5866).
There was no significant interaction between the factor of musical training and which group the participant was in (F = 1.169, p = .3539).
SPSS
Two-Factor Analysis of Variance
Between-Subjects Factors
|
|
|
Value
Label |
N |
|
Condition |
1.00 |
Relaxation
Only |
5 |
|
|
2.00 |
Own
Choice Music |
5 |
|
|
3.00 |
Researcher's
Choice Music |
5 |
|
Musical
Experience |
1.00 |
Musician |
7 |
|
|
2.00 |
Non-Musician |
8 |
Tests of Between-Subjects Effects
Dependent Variable: Pain Difference
|
Source |
Type III Sum of Squares |
df |
Mean Square |
F |
Sig. |
|
Corrected
Model |
133.233 |
5 |
26.647 |
.623 |
.687 |
|
Intercept |
309.878 |
1 |
309.878 |
7.241 |
.025 |
|
GROUP |
35.756 |
2 |
17.878 |
.418 |
.671 |
|
MUSIC |
13.611 |
1 |
13.611 |
.318 |
.587 |
|
GROUP
* MUSIC |
100.022 |
2 |
50.011 |
1.169 |
.354 |
|
Error |
385.167 |
9 |
42.796 |
|
|
|
Total |
864.000 |
15 |
|
|
|
|
Corrected
Total |
518.400 |
14 |
|
|
|
Estimated
Marginal Means
1. Grand Mean
Dependent Variable: Pain Difference
|
Mean |
Std. Error |
95% Confidence Interval |
|
|
|
|
Lower Bound |
Upper Bound |
|
-4.639 |
1.724 |
-8.539 |
-.739 |
2. Condition
Dependent Variable: Pain Difference
|
|
Mean |
Std. Error |
95% Confidence Interval |
|
|
Condition |
|
|
Lower Bound |
Upper Bound |
|
Relaxation
Only |
-2.500 |
2.986 |
-9.255 |
4.255 |
|
Own
Choice Music |
-5.167 |
2.986 |
-11.921 |
1.588 |
|
Researcher's
Choice Music |
-6.250 |
2.986 |
-13.005 |
.505 |
3. Musical Experience
Dependent Variable: Pain Difference
|
|
Mean |
Std. Error |
95% Confidence Interval |
|
|
Musical
Experience |
|
|
Lower Bound |
Upper Bound |
|
Musician |
-3.667 |
2.518 |
-9.363 |
2.029 |
|
Non-Musician |
-5.611 |
2.355 |
-10.939 |
-.283 |
4. Condition * Musical
Experience
Dependent Variable: Pain Difference
|
|
|
Mean |
Std. Error |
95% Confidence Interval |
|
|
Condition |
Musical
Experience |
|
|
Lower Bound |
Upper Bound |
|
Relaxation
Only |
Musician |
2.000 |
4.626 |
-8.464 |
12.464 |
|
|
Non-Musician |
-7.000 |
3.777 |
-15.544 |
1.544 |
|
Own
Choice Music |
Musician |
-7.000 |
4.626 |
-17.464 |
3.464 |
|
|
Non-Musician |
-3.333 |
3.777 |
-11.877 |
5.211 |
|
Researcher's
Choice Music |
Musician |
-6.000 |
3.777 |
-14.544 |
2.544 |
|
|
Non-Musician |
-6.500 |
4.626 |
-16.964 |
3.964 |
Case Summaries
|
|
|
|
|
|
|
Pain Difference |
|
Condition |
Relaxation
Only |
Musical
Experience |
Musician |
1 |
|
1.00 |
|
|
|
|
|
2 |
|
3.00 |
|
|
|
|
|
Total |
N |
2 |
|
|
|
|
Non-Musician |
1 |
|
-15.00 |
|
|
|
|
|
2 |
|
-2.00 |
|
|
|
|
|
3 |
|
-4.00 |
|
|
|
|
|
Total |
N |
3 |
|
|
|
|
Total |
N |
|
5 |
|
|
Own
Choice Music |
Musical
Experience |
Non-Musician |
1 |
|
4.00 |
|
|
|
|
|
2 |
|
-10.00 |
|
|
|
|
|
3 |
|
-4.00 |
|
|
|
|
|
Total |
N |
3 |
|
|
|
|
Musician |
1 |
|
-7.00 |
|
|
|
|
|
2 |
|
-7.00 |
|
|
|
|
|
Total |
N |
2 |
|
|
|
|
Total |
N |
|
5 |
|
|
Researcher's
Choice Music |
Musical
Experience |
Musician |
1 |
|
-17.00 |
|
|
|
|
|
2 |
|
-2.00 |
|
|
|
|
|
3 |
|
1.00 |
|
|
|
|
|
Total |
N |
3 |
|
|
|
|
Non-Musician |
1 |
|
-6.00 |
|
|
|
|
|
2 |
|
-7.00 |
|
|
|
|
|
Total |
N |
2 |
|
|
|
|
Total |
N |
|
5 |
|
|
Total |
N |
|
|
|
15 |
a
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