Complementary Medical Therapies for Pain Management

Music Therapy for Pain and Procedural Support in Pediatric Medical Settings

By Brian S. Jantz, MA, MT-BC, LPMT
Berklee College of Music
Boston Children’s Hospital
Boston, Massachusetts

Recently, in the pediatric medical community, there has been an increased interest in using integrative therapies to support medical procedures such as EEG testing, but many members of the clinical team are unsure of proper methods and expected outcomes (Davidson, 2014).  Music therapy is a growing field with new connections between clinical music, psychoendoneuroimmunology, and neuroscience now being researched and helping to inform music therapy methods.  

There is a clear need for ongoing research and education to increase awareness and understanding of the role music therapy can play as a treatment option in providing procedural support and pain management. Music therapy can potentially benefit patients undergoing testing, painful procedures, and suffering from chronic pain. The potential cost-effectiveness and reduced risk for patients considered in regards to possible decreased need for sedating and/or opioid medications should be of interest to hospital administration aiming to provide optimal care with a focus on harm reduction.  Ongoing research at Boston Children’s Hospital (BCH) is focused on helping to inform members of the clinical team of the specific areas in which music therapy most consistently benefits patients when facilitated according to strict predetermined treatment protocols.

Two areas of current ongoing research include music therapy as procedural support during EEG testing for patients with seizure disorders, as well as music therapy for pain management in patients with sickle cell disease. It is also important to consider that facilities such as BCH treat a large number of pediatric patients with neurodevelopmental disabilities (NDD), including autism. Having additional tools and training to effectively meet the needs of these patients is essential (Paasch et al., 2012). These patients, family members, and their clinical treatment teams will likely have interest in the results of research currently being conducted.

Research has been conducted on music therapy in the medical setting, and textbooks are describing protocols for these methods (Allen, 2013;, Dileo & Bradt, 2009; Hanson-Abromeit & Colwell, 2010; Hanser, 2016).  There is growing evidence to support music therapy as procedural support in pediatrics. Specific approaches have varied based on specific patient needs, and there are differences in theoretical perspectives amongst music therapists in the field. In a study assessing these differences and examining common theoretical framework found in music therapy literature, Ghetti (2012) defines procedural support as “the use of music and aspects of the therapeutic relationship to promote healthy coping and decrease distress in individuals undergoing medical procedures” (p. 6).

One of the primary differences involved music therapy aimed at distraction, as opposed to integrative approaches focusing on raising awareness of patient pain or discomfort and transforming the experience through a sense of empowerment and control. In the experience of music therapists at BCH, it has been necessary to thoroughly plan for every intervention based on all that is known about a patient prior to a procedure, while maintaining a high degree of flexibility regarding specific techniques and methods used during the intervention. This is true when working with different populations, as well as within a single session with individual patients. This requires an approach prioritizing ongoing assessment and evaluation so methodological adjustments can be made in the moment as patient needs change in order to maximize patient benefits.

This type of individualized approach to methods and techniques used is supported by the protocol outlined by Ghetti (2012) in the working model of music therapy as procedural support. This model describes several moderators affecting a patient’s experience of pain/anxiety including personal and contextual variables, as well as the intensity of the procedure. The filtering process creates patient perception of pain/anxiety, coping style, and related behaviors. Music therapists working from this model facilitate within a reflexive process of continuous reassessment and reevaluation  of the intervention to most effectively support patient needs.

Music therapy may be an ideal choice in many cases requiring a flexible approach to procedural support. Unlike sedating and opioid medications, the use of music is low risk and very rarely linked with negative side effects. In an analysis of research done involving music therapy as procedural support for a variety of pediatric procedures, Walworth (2005) concluded that hospitals similar in size to BCH could be significantly impacted in terms of cost-effectiveness. Costs could potentially be reduced not only due to reduced use of medication, but also due to the reduced need for additional RN supervision during procedures when music therapy is part of procedural support.

A systematic review of music therapy research focusing on procedural support conducted by Yinger and Gooding (2015) found results favoring the music therapy more consistent when measuring anxiety (50%) than pain (25%). Out of 50 studies meeting the criteria for inclusion in the review, only eight studies involved pediatrics and only four used live music. Recommendations for future studies included making clear comparisons between music intervention groups and treatment as usual, reducing risk for bias, and conducting new studies researching best practices specifically regarding music therapy as procedural support.  

A study conducted by Whitehead-Pleaux, Baryza, & Sheridan (2006) involved patients at Shriners Burns Hospital in Boston. The study evaluated the effect of music therapy on pain and anxiety in pediatric burn patients while undergoing donor site dressing change. This randomized controlled trial compared live music with verbal support as the control group.

The study used a relatively small sample size (N=14). Working from a gate theory of pain framework, the music therapist provided the experimental group with live music aimed at active engagement and reduced attention on pain perception. Results from the study were largely mixed and inconclusive due to inconsistencies including physiological measures e.g., stabilization was disconfirmed by pain/anxiety scales indicating this was not the patient’s reported exp erience. The study led to several recommendations for future studies including larger sample sizes and beginning the intervention five minutes prior to the procedure to maximize the potential effect of therapeutic relationship.

The theory underlying the use of live music therapy is that it is effective in promoting relaxation and engagement as a method of providing procedural support in pediatric medical settings. This theory was articulated by Dr. Joanne Loewy (2005) and has been used to study music therapy-induced relaxation/sleep vs. sedation in pediatric patients during EEG testing. This theory holds music therapy can be a safe, cost-effective means of promoting relaxation and an alternative to sedation that is essentially risk-free. The theory states that music therapy utilizing the iso-principle and aspects of rhythmic entrainment can influence the amount of sedating medication used if any, levels of stress and anxiety, and time needed for procedures. This impact may be due to the patient’s relaxation response and the primary influence this has on the physiological and psychological state of the patient.

Mondanaro (2013) provides a thorough description of clinical rationale for core methods and techniques used as procedural support, including use of clinical improvisation and music entrainment. A study conducted by Loewy et al. (2005) looked specifically at “safe and effective ways to achieve sleep/sedation in infants and toddlers undergoing EEG testing” (p. 323).

The study included 60 pediatric patients, ranging in age from one month to five years. “The results of the study found that music therapy may be a cost-effective, risk-free alternative to pharmacological sedation” (p. 323). In another study, Mondanaro (2008) examined “a working model of music therapy as an invaluable component to the psychosocial care of pediatric patients admitted for the diagnostic testing of epilepsy” (p. 102). In this study, “data collected over a four-year period in which 835 patients successfully underwent Video Electroencephalogram (diagnostic testing for epilepsy) without the use of sedation or medical controls reflect the efficacy of the model and may also suggest certain cost effectiveness as well” (p. 102).

While both of these studies show potential for music therapy to be a frontline support for procedures such as EEG testing, ongoing current studies at BCH aim to build on this research using consistent and appropriate methods and strict treatment protocols with a large number of patients as research subjects. The protocol for current BCH procedural support research includes only live music interventions utilizing techniques such as the iso-principle through clinical improvisation, active music engagement with patient-preferred music to refocus patient attention, and rhythmic entrainment to encourage patient relaxation response. Loewy (2005) highlights the effectiveness of using music as sedation in supporting EEG testing for infants and toddlers, but in a facility like BCH, music therapy is also supporting this procedure for older children. Many of these older children have also been diagnosed with autism or other neurodevelopmental disabilities. Providing research that includes patients from one month to eight years of age, potentially with pediatric patients diagnosed with developmental disabilities as well as seizure disorders, will help build on the few studies that have been conducted in this unique area of practice.

The field of music therapy is in need of more studies for specific areas such as this, but also with a major focus on the quality of the methods being used. In recent systematic reviews of current research a common theme is the need for research conducted using standardized protocols, consistent outcome measures, simple designs, competent execution, and reliable outcome measures (Naylor et al., 2011; Klassen et al., 2008; Mrazova & Celec, 2010).

In referring and assessing patients for music therapy, it is extremely important to consider the individualized needs of the patient. While some patients experiencing pain or anxiety may need active or receptive music to refocus attention, others will benefit more from an opportunity to transform or bring meaning to their experience through interventions such as clinical improvisation or clinical songwriting. Assessment is always ongoing, and adjustments are made based on patient responses in the moment. Clinical flexibility, a very low risk to patient safety, potential cost effectiveness, effectiveness as tool for pain and anxiety reduction, and the potential for harm reduction through reduced need for medication point to music therapy as part of providing patients with optimal care.

References

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  21. Yinger, O.S., & Gooding, L.F. (2015). A systematic review of music-based interventions for procedural support. Journal of Music Therapy, 52(1), 1-77.

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