Music Therapy and Pain Perception in Adults with Chronic Pain

(Walworth, D., Rumana, C. S., Nguyen, J., & Jarred, J., 2008, p. 355)

50 million Americans suffer chronic pain spending over $100 billion a year on pain management.  Chronic pain is the most common reason individuals pursue medical treatments and 88% of doctors felt that their medical training did not prepare them for treating this pain.   Pain is a growing problem that is becoming even harder to treat (Schim, 2004, p. 4).

         There are many causes and traits of chronic pain.  Pain can be caused by many diseases, disorders, injuries, or have no known cause.  However, chronic pain is defined as pain that lasts for six or more months and is not a warning sign or telling of some other health concern.  This pain could be caused by the back, rheumatoid arthritis, osteoarthritis, angina, the head, or by injury to any body part (Schim, 2004, p.5-6).

 Two mechanisms that are important in the cause and perpetuation of pain are inflammation and neuropathy.  This damage or defect of tissue and the nerves and nervous system play a significant role in pain. Sensitization also plays a role in chronic pain, causing increased activity in neurons, decreased pain thresholds, and a strong response to stimuli.  Many patients suffering chronic pain have a poor quality of life, decreased physical ability, and lower overall health scores. Not only do individuals have lousy physical health, their mental health is affected, with heightened anxiety, little self-control or endurance, and approximately 50% suffering depression (Schim, 2004, p.5-6).  Patients begin to feel like the victim of their pain, which begins a vicious cycle of feeling consumed and controlled by pain. This cycle can lead to lowered overall functioning, ability to work, emotional distress, and poor social life (Davis, 2008, p. 310-312 ).

         Dr. Lenore Schvankovsky and Peter Guthrie developed a list of the ten essentials of a patient. This applies not only to a hospitalized patient, but a patient with any condition.  An individual needs to understand their illness and limitations, maintain a social life, prevent putting things off due to illness, exercise, and continue living life. They also believed it to be extremely important to adapt to the medical setting with their family while learning and using coping methods which reduce anxiety or fear of illness.  Music therapy brings a sense of warmth and familiarity to an unfamiliar setting like the hospital environment and helps meet these needs by giving social, emotional, and motor reinforcement (Davis, 2008, p. 319).

            It is difficult to establish goals when working with chronic pain because of the variety in diagnosis and symptomology. Treatments and therapies for pain differ greatly amongst individuals based on their condition. Common treatments include medication, physical or occupational therapy, acupuncture, or other alternative therapies. Treatments focus on treating pain related symptoms because the pain itself is so difficult to treat (Schim, 2004, p.8-10).

         Like the treatment and therapies used to treat chronic pain, there are not standard therapeutic goals, but specific goals that are targeted to each individual and their condition.  Creating realistic goals is an important step in treating and managing chronic pain. Mayo Clinic has developed a system called SMART goals, which is an acronym for specific, measurable, attainable, realistic, and timely. Some generalized goals that could be applied to any illness or condition are to exercise, focus on maintaining good overall health, reduce medications, manage emotions, and find balance (Bruce, 2014, n.p.).  The most common goals among pain management include better comfort, well-being, control, and involvement in treatment (Bailey, 1985, p.26). It is also important to lower tension, pain perception, anxiety, and stress (Music Therapy with Specific Populations, 2010, p. 4).

         Music therapy is used among patients suffering chronic pain to try and achieve these goals.  For most effective treatment, a patient’s musical background or preferences are always considered in order to come up with the best plan.  Familiar, patient-preferred music has been known to reach patients who are distant or isolated and may help build relationships and increase communication (Bailey, 1985, p.26). Music therapy when used as a distraction from pain, helps lessen pain perception, anxiety, and stress. Not only does music therapy help improve quality of life, it has been shown to improve respiration, blood pressure, cardiac output, relax tension, and shorten hospital stays (Music Therapy with Specific Populations, 2010, p. 4).  Combined with other therapies, music therapy helps to increase patient’s endurance. Music can lessen the patient’s attention to unpleasant parts of therapy, such as repetition or pain and lead to improved results (Davis, 2008, p. 319).

         Anxiety, fear, and tension not only add to the awareness of pain, but also increase muscle tension that interferes with breathing and increases overall pain perception (Davis, 2008, p. 319).  Common goals of music therapy with this population are to distract from anxiety and stress, to elevate mood, and achieve better overall thoughts and feelings. Music helps provide a steady tempo for rhythmic breathing and structure for release of tension (Music Therapy with Specific Populations, 2010, p. 4). The feeling of pain can become less when it is no longer the focal point, and the mind focuses on a positive stimulus such as music (Davis, 2008, p. 321).

         Music therapy has been shown to affect biologic and physical factors such as a stronger immune system, higher oxygen saturation, and significantly lower counts of salivary cortisol, a stress hormone (Bailey, 1985, p.27). Interventions such as singing, dancing, playing instruments, guided listening, lyric analysis, and songwriting are commonly used (Walworth, 2008, p. 356-357). Music  is often used in rehab facilities to help divert the patient’s attention from the pain and lessen overall pain perception (Lim, 2011, p. 125). Music therapy can trigger the release of endorphins, which work as the body’s natural pain killers and improves overall well-being. With the use of music therapy patients have experienced improved effects from pain killers and anesthetics, and have not required as much medication (Davis, 2008, p. 324). 

         As chronic pain has become the most common ailment in America, the importance for understanding and adequate research has risen. Since chronic pain affects so many aspects of the mind and body, it is crucial to address and manage the struggles that suffering causes along with learning to live a functional life.  By creating realistic goals and treatment plans to improve quality of life an individual can begin to understand their condition. Though there are many causes and conditions creating chronic pain, understanding a condition becomes the foundation of a strong treatment plan and the ability to manage pain.

-Rachel Buchheit, Music Therapy Intern

References

Bailey, L. M. (1986). Music therapy in pain management. Journal of Pain and Symptom  Management, 1, 25-28. Retrieved August 12, 2019, from https://www-sciencedirect-  com.bunchproxy.idm.oclc.org/science/article/abs/pii/S0885392486800240

Bruce, B., & Harrison, T. (2014) Mayo Clinic Guide to Pain Relief (2nd ed.).  Google Books.  https://books.google.com/books?id=sO4aDAAAQBAJ&printsec=frontcover&dq=Mayo+        Clinic+Guide+to+Pain+Relief&hl=en&newbks=1&newbks_redir=0&sa=X&ved=2ahUK EwiotoKYuoPnAhURSN8KHbASBxgQuwUwAHoECAYQCA#v=onepage&q=Mayo% 20Clinic%20Guide%20to%20Pain%20Relief&f=false

Davis, William B., Kate E. Gfeller, and Michael Thaut. (2008). Chapter 11: Music Therapy,    Medicine, and Well-Being. In The American Music Therapy Association,  An    Introduction to Music Therapy: Theory and Practice (pp. 305-41). Silver Springs,         Maryland. The American Music Therapy Association.

Lim, H., Miller, K., & Fabian, C. (2011). The Effects Of Therapeutic Instrumental Music         Performance On Endurance Level, Self-Perceived Fatigue Level, And Self-Perceived        Exertion Of Inpatients In Physical Rehabilitation. Journal Of Music Therapy, 48.2, 124-   148.  

American Music Therapy Association. (2010). Music Therapy with Specific Populations: Fact Sheets, Resources & Bibliographies: Music Therapy and Pain Management.  American Music Therapy Association. https://www.musictherapy.org/assets/1/7/MT_Pain_2010.pdf

Schim, J. D., and Stang, P. (2014). Overview of pain management. Pain Practice, 4.1, 4-21.                 https://web-a-ebscohost-com.bunchproxy.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=1&sid=c777f73e-03f1-4aa7-8222-e3194f921782%40sessionmgr4007

Walworth, D., Rumana, C. S., Nguyen, J., & Jarred, J. (2008). Effects of live music therapy     sessions on quality of life indicators, medications administered and hospital length of stay    for patients undergoing elective surgical procedures for brain. Journal of Music Therapy, 45.3, 349-360. https://search-proquest-com.bunchproxy.idm.oclc.org/docview/1092829/fulltextPDF/EFBC5892C2754446PQ/1?  accountid=8570

“What’s Inside You is Inside Me, Too : My Chromosomes Make Me Unique” by Deslie Quinby and Jeannie Visootsak, MD

         Each year around 6,000 babies are born in the U.S. with Down syndrome, making it the most common chromosomal condition. Down syndrome is a disorder caused by an extra copy of the 21st chromosome, which is where the name “trisomy 21” comes from. Common physical traits of Down syndrome include small stature, low muscle tone, upward slanting eyes, and small ears. Down syndrome also causes mild to moderate developmental and cognitive delays, but these are no indicator of the amazing things people with Down syndrome can accomplish. Children with Down syndrome go to school, participate in extracurricular activities, and have friends and families like you and me (National Down Syndrome Society, n.d., para. 1)!

Deslie Quinby and Jeannie Visootsak. MD  teamed up to write, “What’s Inside You Is Inside Me, Too : My Chromosomes Make Me Unique,” a story teaching kids about Down syndrome. Quinby is a mom and businesswoman who has a son with Down syndrome. She is a member of the Atlanta Down syndrome community and an active parent advocate. Dr. Visootsak is a board-certified Developmental-Behavioral Pediatrician at Emory University School of Medicine and the director of the Down Syndrome Clinic at Emory. Outside of her work at Emory, Dr. Visootsak serves on the Professional Advisory Council for the National Down Syndrome Congress and is an Advisory Board Member on the Down Syndrome Association of Atlanta (Quinby & Visootsak, 2014, p. 3).

The story “aims to inform people about Down syndrome in a full illustrative way. In the process, it also explains chromosomes and their role in making every living thing special” (back cover). The book is illustrated by Michael Johnson, making it a perfect resource for teaching kids about Down syndrome. It begins by teaching kids about chromosome pairs and how they make up who we are. Every person has 23 pairs of chromosomes for a total of 46. These chromosomes decide traits like eye color, hair color, and skin tone. When someone is born with 1 extra chromosome, they have 47 chromosomes or trisomy 21. This is called Down syndrome (Quinby & Visootsak, 2014, p. 4-16).

 Down syndrome was discovered by Dr. John Langdon Down who realized he had several patients who acted and looked very similar. When making this realization, he began to notice that patients had similar facial features like upslanting eyes, a small nose, a tongue that protrudes, and small ears. The patients also had similar developmental delays. His research and discovery of these commonalities led to the disorder being named “Down” syndrome.  “What’s Inside You Is Inside Me Too,” goes on to discuss that although someone may look or act different, we all have a lot in common. Children with Down syndrome feel the same emotions, enjoy the same activities, and love their friends just like everyone else (Quinby & Visootsak, 2014, p. 24).

This book is an amazing resource for parents and teachers. It can be used in the home to help parents teach their kids about children with special needs and start the conversation of ways to be a friend to someone who may seem different. It can be used in the classroom as an educational tool to teach children how to interact with their peers and be kind to everyone. The story encourages friendship and inclusion. “What’s Inside You Is Inside Me, Too,” teaches that our differences are what make us unique and even though someone may seem different, they are our friend too.

“What’s Inside You Is Inside Me, Too” contains additional resources for parents or teachers in the back. “Down syndrome 101,” discusses general history of Down syndrome, common characteristics, and health problems associated with Down syndrome. It answers questions about child development and maximizing your child’s potential, encouraging parents to become an advocate for their child.  This section is also beneficial to educators or anyone working with children who have Down syndrome. The overview gives a better understanding of ways to help students and became an advocate as well (Quinby & Visootsak, 2014, p.24-27).

“What’s Inside You Is Inside Me, Too,” can be found online at barnesandnoble.com or amazon.com .  We are so proud of Therabeat mom, Deslie Quinby, and the amazing work she is doing for the Down syndrome community!

 -Rachel Buchheit, Music Therapy Intern

References

Quinby, D., & Visootsak, J. (2014). What’s Inside You Is Inside Me, Too: My Chromosomes Make Me Unique.

National Down Syndrome Society. (n.d.). About Down Syndrome, Down Syndrome Facts. Retrieved February 20, 2020 from http://www.ndss.org           

Music Therapy in Pediatric Preoperative Care

Recently, a patient’s mother expressed concern over an extensive dental procedure for her child with autism. Her primary concern was her child’s anxiety prior to the procedure. The MT expressed that she would like to be present pre-op to help regulate anxiety before the operation if it all possible. 

This scenario leads to the question of how music therapy can be used to help pediatric patients in pre-operative conditions.  In a 2015 pilot study, 103 neurotypical pediatric patients participated in a music therapy preoperative program at an ambulatory surgical center (Gooding et al., 2015, pg. 191). These patients were between the ages of 2-9 years of age and set to undergo various procedures such as hernia repairs, dental restoration, tonsillectomies, adenoidectomies, and port-a-cath removals. Approximately 30-45 minutes before each procedure was to take place, a music therapist would provide a 20-minute session for the patient. Prior to the session, the music therapist used two standardized scales- the Modified Yale Preoperative Anxiety Scale (YPAS-m) and the Child-Adult Medical Procedure Interaction Scale- Short Form (CAMPIS-SF) to rate the patients’ anxiety and procedural distress. After the session, the music therapist completed the ratings again. Additionally, parents of the patients were given a questionnaire to fill out post-session as well.

Within this study, the music therapist utilized musical alternate engagement interventions. Ghetti (2012, pg. 3) defines these as “music [that] is used to motivate and structure the patient’s active engagement with the music stimuli and therapist in order to reduce awareness of the … anxiety-provoking stimuli”. In Gooding’s study, the music therapist used singing, songwriting/lyrics analysis, instrument play, movement to music, musical games, and music listening interventions to help the patient’s anxiety (Gooding et. al, 2015, pg. 193). Through these interventions, the music therapist was able to educate the patient on the procedure in a non-threatening manner, facilitate distraction, give outlets for self-expression, and help ease and transition the patient before their respective operation (Gooding et. al, 2015, pg. 192). Gooding found that there was improvement in both the patients’ affect and emotional expression, with 84.5% of patients showing a positive affect after the session, with only 23.3% of patients showing a positive affect prior to the session. Of the 73 parents/guardians that completed the questionnaire, the mean response to the statement “My child benefited from music therapy” fell between “Agree” and “Strongly Agree”. Additionally, the mean response of the statement “I benefited from music therapy” also fell between “Agree” and “Strongly Agree”. (Gooding et. al, 2015, pg. 197). 

In 2017, Millett & Gooding created another study that examined the potential differences in efficacy between active and passive music therapy interventions. Similar to Gooding’s study in 2015, those patients that received active music therapy interventions (musical alternate engagement) were engaged in a 15-minute session through active instrument play, a musical game, improvisation, and extensions/adaptations to help distract the patient (Millett & Gooding,, 2017, 468 ). An example of an active music therapy session plan can be seen below (Gooding et al., 2015, Table 2): 

Consequently, those patients elected to receive passive music therapy were aided through music-assisted relaxation interventions such as singalongs to family-preferred music or age-appropriate music. In this type of music therapy, music is used to “entrain and gradually reduce elevated vital rhythms” (Presner et. al, 2001, pg. 86). The music therapist began by entraining the patient to the music that she played. Entrainment was possible through the iso-principles of music therapy, a technique in which the music therapist initially matches the music to a patient’s mood and then gradually alters the music to change the temperament of the client. (Davis et. al, 2008, pg. 30). By the end of the session, the iso-principle guided the music therapist to decrease the music stimulation by playing less active picking patterns, play at a softer dynamic, and transition to less musical activity overall in order to bring the patient to a state of relaxation (Millett & Gooding, 2017, pg. 467). 

When comparing the two different types of music therapy interventions- active vs. passive- Millett & Gooding  (2017, pg. 460) found that there were no significant differences in the efficacy of either treatment. However, there was found to be significant reduction in both the patients’ anxiety as well as parental anxiety with either treatment. In studying the relationship between parental anxiety and patient postoperative behaviors, children with parents exhibiting anxiety were 3.2 times more likely to experience negative postoperative behaviors that could last 6 months after the initial procedure (Kain et. al, 1996, pg. 1238). Because of this, decreasing not only patient anxiety but parental anxiety is imperative to the well-being of the child, both pre- and post-procedure. 

Overall, in both the Gooding (2015) and Millett & Gooding (2017) studies, music therapy was viewed as an effective preoperative intervention not only for the patients but also their parents as well. Decreasing parental anxiety levels leaves the child feeling less anxious about the procedure as well, decreasing the chance of negative postoperative behaviors. While these findings were based on those of neurotypical children, research should be expanded to a more inclusive pool, including neurodiverse children as well. 

- Sarah Deal, Music Therapy Intern

References

Davis, W.B., Gfeller, K.E., & Thaut, M.H. (2008). An Introduction to Music Therapy: Theory 

and Practice (3rd ed.). The American Music Therapy Association. 

Ghetti,  C.M. (2012). Music therapy as procedural support for invasive medical

procedures: Toward the development of music therapy theory. Nordic Journal of

Music Therapy, 21, 3–35. https:// doi:10.1080/08098131.2011.571278

Gooding, L.F., Yinger, O.S., &  Iocono, J. (2015). Preoperative Music Therapy for Pediatric

Ambulatory Surgery Patients: A Retrospective Case Series. Music Therapy

Perspectives, 34(2), 191-199. https://doi.org/10.1093/mtp/miv031

Gooding et. al. (2015). Preoperative Music Therapy for Pediatric Ambulatory Surgery

Patients: A Retrospective Case Series- Table 2. [Photograph]. Retrieved from

https://doi.org/10.1093/mtp/miv031

Kain, Z. N., Mayes, L. C., O’Connor,  T. Z., & Cicchetti, D. V. (1996). Preoperative anxiety in

children: Predictors and outcomes. Archives of Pediatric Adolescent Medicine,

150(12), 1238–1245.

Millett, C.R. & Gooding, L.F. (2017). Comparing Active and Passive Distraction-Based

Music Therapy Interventions on Preoperative Anxiety in Pediatric Patients and

Their Caregivers. Journal of Music Therapy, 54(4), 460-478. 

Prensner, J.D., Yowler, C., Smith, L.F., Steele, A.L., &  Fratianne, R. B. (2001). Music therapy

for assistance with pain and anxiety management in burn treatment. Journal of

Burn Care & Rehabilitation, 22(1), 83-88. 

Using Orff Techniques in Music Therapy

Rhythm. Movement. Play. Success. Improvisation. Speech. These words, among others, encompass some of the key ideas behind Carl Orff’s philosophy of music education. Although the Orff approach was not created as a music therapy protocol, its core ideas of music, movement, rhythm, and improvisation are easily included in music therapy sessions (Darrow, 2008, p. 19). Orff methods are versatile, success-oriented techniques that can be used with music therapy populations across the lifespan.

Orff is a German approach to music education. Founder Carl Orff was interested in modern dance. In traditional ballet, music and movement were created separately; Orff wanted the music and movement to become one. Orff taught students how to create rhythm patterns using body percussion--snapping, clapping, patsching, and speech. After teaching the basics, Orff encouraged students to improvise over an ostinato rhythm pattern or drone (Ramsay, 2018, p. 9). Music Therapists use these Orff techniques in skilled music therapy settings to address therapeutic goals in both individual and group settings. 

In the late 1920’s, Orff’s travels inspired him to incorporate unpitched percussion instruments, such as marimba and recorders, into his technique. These types of instruments came to be known as Orff Instruments and are essential to the technique. Combining instruments and movement, Orff would begin by teaching children rhythmic patterns using body percussion and then transfer these patterns to instruments (Ramsay, 2018, p. 10). The Orff method of teaching gained popularity throughout the 1940’s and 1950’s and is still common in American and European music education classrooms. In more recent years, the approach has been gaining popularity in music therapy training (Ramsay, 2018, p .9). 

 Orff provides clients opportunities to participate in multisensory interventions. These may be playing, singing, moving, or listening. This variety gives clients multiple areas to succeed and, in the group setting, can reach clients with different strengths (Schumacher, 2013, p. 113). In working with groups, Orff encourages individuals to be creative. The improvisation required by the Orff approach encourages clients to move out of their comfort zones together, as well as build relationships, trust, and rapport among the group (Schumacher, 2013, p. 113). Common interventions used with children include therapeutic singing, songwriting, music and movement, and instrument play. All of these interventions can incorporate Orff techniques (Orff, 1989). 

A sample intervention is a structured instrument play. In a group setting, divide the group into three parts. Teach the first group rhythm number one by patsching (patting knees) and speaking the rhythm. Teach the second group rhythm number two by clapping and speaking the rhythm. Teach the third group rhythm number three by snapping the rhythm. Once the rhythms are successfully played on body percussion, transfer them to instruments. Review each rhythm with the instruments and give each group a chance to get comfortable with their rhythm before layering. Once all of the groups are comfortable playing their rhythms, signal certain groups to play softer and others to improvise over the background rhythms. This opportunity for variety and improvisation is fundamental to the Orff approach (Ramsay, 2018, p 9-11). 

The following intervention is an example of this technique. Begin by dividing the group into three sections and assigning parts. The first group will play the top rhythm by patsching or patting their knees. The second group will play the second rhythm by clapping their hands. The final group will play the third rhythm by snapping their fingers. Have each group practice their part individually and then together. Then, begin layering the parts. Once all groups can successfully play their body percussion rhythms, transfer the rhythms. The first group will play their rhythm on drums, the second group will play rhythm sticks, and the third group, shakers. Again, have each group play their part independently before layering the rhythms and fading the verbal prompts. 

This intervention addresses the following goals:

• Auditory processing by discriminating different sounds

• Social skills like cooperating in a group, listening to peers, impulse control, and attention

• Motor planning to execute rhythm and play of instrument  

• Improving Expressive language by chanting words in rhythm

Orff techniques are simple and easily adaptable to multiple populations. Patients respond well to interventions that are based on the Orff theory of education given their activity-oriented nature. Although this approach is typically associated with music education, the Orff approach is growing in popularity amongst music therapists. Orff interventions are a valuable tool for the music therapist since they are so easily adaptable and comprehensible. It also provides structure for the clients in music therapy sessions while leaving plenty of room for improvisation and self-expression. This allows for patients to feel safe and supported in their music making, leading to them feeling more comfortable within the setting of a group and a session. Orff interventions are something that any population can engage in and enjoy, and are supported through both past and present research. 

-Rachel Buchheit, Music Therapy Intern

References

Darrow, A., & American Music Therapy Association. (2008). Introduction to approaches in

music therapy (2nd ed.). Silver Spring, MD: American Music Therapy Association.

Schumacher, Karin. (2013). The importance of “Orff-Schulwerk” for musical social-integrative pedagogy and music therapy (English translation: Gloria Litwin). Approaches: Music Therapy & Special Music Education, 5(2), 113-118.

Orff, G. (1989). Key concepts in the Orff music therapy : Definitions and examples. London; New York: Schott.

Ramsay, S. (2018). Orff Schulwerk Certification Course: Level One Resource Book, 9-11. 

Meet Ms. Sarah

My name is Sarah Deal and I am thrilled to be starting my music therapy internship at Therabeat. While attending the University of Georgia, I was a double major in both music therapy and music education. I recently completed my student teaching specializing in elementary general music. Balancing two majors at one time has not always been easy but has been extremely rewarding working with so many people from all different walks of life. I am so excited to begin my journey at Therabeat in becoming a board-certified music therapist.

To me, one of the most special parts about working at In Harmony is the close-working relationship that the therapists have with each other, regardless of specialty. It is so incredible to witness therapists from the various areas (OT, PT, ST, and MT) come together to create a holistic course of treatment for our clients. Beyond just the knowledge shared, their interest in each child and their family is genuine as well. In observing pre- and post- treatment conversations between parents, caregivers, and therapists, it is very apparent that In Harmony is a truly nurturing environment for everyone involved. 

Going forward into my internship, I am eager to learn from the various specialists in the clinic. I hope that I am able to take knowledge and expertise from them and to become a more well-rounded music therapist for my own clients. Since I first walked into the clinic two years ago for mini-camp, I have wanted to be a Therabeat intern and feel so blessed to be living out my dream. 

Best, 

Sarah Deal, Music Therapy Intern