Free Nursing Essays - Music Therapy As A Science Is A Comparatively New Discipline, But As An Art, It Is Several Millennia Old
Music therapy as a science is a comparatively new discipline, but as an art, it is several millennia old. Hippocrates advised his followers to be aware of the healing properties of music. He was aware that music had the power to change the mood and indeed to change the perception of different afferent stimuli.
Although we do not have any direct evidence of this, there is anecdotal evidence from contemporaneous writings that Hippocrates used music in his hospital to promote the feeling of well-being and the healing processes.(Storr 1994)
Pythagoras could be argued to have carried out one of the first recorded observational studies on the subject when he observed that a series of musical tunes affected the mood of the listeners. He found that certain lively pieces played on rising made the listener:
Cheerful and energetic during the day and other soothing types of melody calmed them down, relieved them of the cares of theday and prepared them for agreeable dreams when they retiredto sleep.
It is not recorded whether Pythagoras was an advocate of the use of music modalities in the relief of pain, but it is believed that, like Hippocrates, he believed that it could be utilised to help promote a cure (Bunt 2001)
This could be argued to be the basis on which current music therapy is based, but in fairness, this basic observation has been subjected to varying degrees of both scrutiny and study, and our understanding of the phenomenon has progressed considerably over the intervening years. (Vickers 1998)
One substantial difficulty has not changed however. Most people would agree with Pythagoras' statement and observation on a purely subjective basis. There can be few of us who have not been aware of a subjective mood change when listening to an emotive piece of music. As a result of this, huge volumes have been written on the ability of music to alter different aspects of or lives. Most of this tends to be subjective and not possible to scientifically validate. The purpose of this literature review is to assess the writings and to select and analyse those that have a reproducibility and scientific rigour inherent in their structure. (NIH Panel 1996)
In today's world, music therapy has found various niche applications as well as more mainstream uses. Children with communication difficulties can appear to respond positively to music. Conditions such as autism, cerebral palsy and learning difficulties often include an element of communication failure, and a child who can have a tendency to become withdrawn and uncommunicative. Such conditions can respond to music therapy, perhaps by providing another, more easily accessible, channel of communication for the child and preventing some of the social withdrawal that can occur. (Zollman et al 1999)
Advocates of music therapy point to the fact that it can be useful in the field of severe or chronic adult mental illness by encouraging an individual into activity from a state of apathy or indolence, equally it can calm an excitable or manic patient. Others point to the therapeutic effects of playing an instrument to help explore inner (and perhaps unaccessed) emotions and feelings. In this review, we have been at pains to differentiate between the anecdotal and the investigated episodes, between the coincidental and the reproducible effects. (Inglis 1965). In this review however, we are focusing in specifically on those aspects of music therapy which are said to be effective in pain relief in a hospital setting.
In specific relation to music therapy and perceived pain levels, we shall specifically examine work in this field together with work that correlates reduction in anxiety levels with pain relief as many workers believe that one of the mechanisms of pain perception modulation is via the reduction of anxiety levels. (Hewlett et al. 2005).
Scientific background to the subject.
We shall start this literature review with a consideration of the neuroscience that underpins the subject.
Anatomy and physiology
It has long been recognised that sound waves give rise to nervous impulses in the cochlea organ of the inner ear. These impulses are conducted to the brain via the vestibulocochlar nerve (VIIIth cranial nerve) directly to the thalamus (a brain stem basal ganglion), and from there they are routed to the auditory cortex in the temporal lobes in both sides of the brain. This is similar to the structure of the visual pathways insofar as they also have a bilateral distribution in the cerebral cortex but the visual pathways do not go through the thalamus.
This simplified schema is significant on two levels. Firstly, (in the context of this literature review), it is significant because the auditory nervous pathways are modulated by the thalamus, which is also the primary brain centre for modulating the various pain sensations in the body. Secondly it is significant because the auditory input is actually processed on both sides of the brain simultaneously, so patients with unilateral brain damage (direct trauma or cerebral palsy for example), can still retain the ability to interpret music and sound adequately with the unaffected cortex (see on). This has to be contrasted with the centres that control speech, which are usually in the dominant temporal lobe, or motor and sensory control which is always specifically in the contralateral hemisphere.
Because of this quirk of evolutionary neuroanatomy, focal unilateral injury will always result in a specific deficit in speech, motor or sensory function (depending on the exact site). Unilateral injury will not generally however, produce significant impairment of the ability to interpret sound. (Ramos & Corsi-Cabrera 1989)
As with most clinical considerations, things are seldom as straightforward as the rather oversimplified schema that we have just presented. Sound can still be interpreted in the contralateral undamaged temporal lobe, but it is often mis-interpreted. Temporal lobe lesions can often manifest themselves with an inability to recognise or express pitch or rhythm although the ability to recognise and interpret speech can be independently unaffected (amusia) (Creutzfeldt & Ojemann 1989)
There is some conflicting evidence which may suggest that some of the higher functions of musical appreciation are actually carried out by the non-dominant (usually right) cerebral cortex. The truth of the matter is probably that different areas of the brain are actually specifically charged with performing different functions of interpretation and appreciation of musical sensations (Steele, Ball & Runk 1997)
Other researchers (Rauscher et al.1993) have looked at neuronal activity in the temporal lobe in response to different musical stimuli. In essence, patients were played either a folk song, the theme from Miami Vice or a Mozart song. The actual details of the experiment do not specifically help us in the considerations of pain management, but significantly, the investigators were able to demonstrate different levels of neuronal inhibition, (evidence of processing), with the different types of music. Interestingly they were also able to demonstrate specific neurones that responded to the beat or rhythm of the music with their action potentials.
The reason for including these rather peripheral considerations in this examination of the use of music in the relief of pain, is to make the point that there are specific, demonstrable and reproducible changes that are present in the brain, that are unequivocally triggered by specific types of music. Clearly this is a long way from demonstrating that music modifies pain transmission at a neuronal level, but it nonetheless provides good circumstantial evidence that the brain has specific pathways that can be clearly demonstrated to react to musical stimuli, and that these pathways share common anatomical locations with the pain modulating pathways. (Wood 1993)
Evidence in the literature of pain modulation
It has to be conceded that an examination of the literature reveals very little good quality experimental work which unequivocally relates music with pain relief. There is, however, a large amount of good quality literature and work which provides good circumstantial evidence of improving a patient's experience and tolerance of pain. We shall spend the next portion of this review examining and evaluating some of the more erudite and valuable of these pieces of evidence.
Ishii and his co-workers set out to investigate this link with a rather clumsily designed experiment which induced a modest degree of pain and discomfort. (Ishij et al 1993). The subjects were required to lie in a specific posture without movement for two hours a day and various bodily parameters were constantly measured.
The authors were able to demonstrate that there was a marked reduction in pain-associated parameters (irregular episodes of respiration, complaints and avoidance movements) when the experiment was performed with a classical music background.
A critical analysis would have to concede that the cohort size was too small to exclude statistical anomaly (five), and there was no matched control group as the subjects actually acted as their own controls. This experiment does however, provide some firm evidence that music can be demonstrated to reduce levels of discomfort, if not actual pain. (Haynes 1999)
Good and his colleagues produced a much more scientifically rigorous piece of evidence to demonstrate the point with their work on pain relief following abdominal surgery (Good 1995). They took a much larger cohort (84) patients who were due to undergo open abdominal surgery and randomly allocated them to four groups: music, relaxation, a combination of relaxation and music, and control. Their measure of pain relief was the much more expedient and direct method of quantifying the amount of post-operative analgesia that was asked for.
Their findings were that in assessing the very first movements after surgery, none of the interventions showed any benefit over the control group, but when considering the first 48 hrs. as a whole, over 89% of patients who had one form of intervention, had a reduction in the level of analgesia required when compared against the control group. Differences between the interventions were not statistically significant.
Palakanis (et al 1994) also looked at the more practical effects of music during painful and anxiety-provoking surgical procedures. This is the first study that we have looked at that actually was able to demonstrate convincingly that music reduces pain and anxiety levels in a practical way. Their study cohort was fifty patients and they used the STAI (State-Trait Anxiety Inventory) tool for assessing anxiety levels, and also measured parameters such as intra-operative heart rate and arterial pressure. They found statistically significant reductions in all parameters in the group which had music played to them when compared to controls.
It has long been recognised that the subjective perception of pain is associated with the concordant level of anxiety. (Macfarlane, Hunt, Silman 2000). Many researchers would concede that one of the possible mechanisms of music therapy acting on post-operative pain levels is by helping to reduce anxiety levels.
Augustin & Hains (1996) sought to evaluate the point by using a cohort of pre-operative patients (42) and randomising them to have a regime of music of their choice with standard pre-operative instructions or just the standard instructions alone in the two hours prior to their surgery. The authors measured parameters such as heart rate, blood pressure and respiratory rates as a measure of physical stress and anxiety levels. They were able to demonstrate significantly lower stress and anxiety levels in the experimental group when contrasted with the control group.
If we follow this thread of the argument and explore the belief by some workers that one of the basic mechanisms of pain relief is via the modulating effects of reducing anxiety levels (Hewlett et al. 2005), we can usefully examine the work of Winter (et al.1994) who anticipated the work of Augustin & Hains by two years, and specifically examined anxiety levels in pre-operative patients in the surgical holding area. Their findings were that patients in this area suffered less measurable stress when being allowed to listen to music than those who didn't. Unlike Augustin & Hains however, they didn't correlate their findings with levels of post-operative pain. (Chalmers 1998)
Barnason (et al 1995) followed a similar theme with a large cohort of patients who, arguably, were about to experience one of the most painful and anxiety producing surgical procedures, that of open heart surgery. The authors cunningly took advantage of the fact that these patients were routinely monitored for a huge number of parameters which correlated well with anxiety levels. They randomly allocated their cohort into three groups that had either music playing (alone), a music video or standard pre-operative care (alone).
Their results were more carefully and specifically analysed than the other studies that we have examined and showed that there was a significant improvement in mood amongst those patients who had music therapy and that the improvement in mood increased with the number of sessions offered. Interestingly, there was no demonstrable reduction in anxiety levels (as measured by the STAI). The most statistically significant finding (very significant in the light of the fact that this was a study on cardiac patients) was a reduction in both systolic and diastolic blood pressure in the music therapy group. Less significantly, the authors commented on the demonstration of a generalised relaxation in the intervention groups.
At this point we should make comment on more recent work which confirms and expands on the findings of the Barnason study. Bally (et al 2003) looked at a similar situation of patients undergoing coronary angiography, which is also a very stressful procedure. They added the modification that the patient was allowed to choose what music they listened to, how often and at what volume. They found that the results of adding this modification actually appeared to enhance the beneficial relaxing effect. The authors postulate that this may be because the patient is given back an element of control in the situation. This correlates well with the writings of Marinker (1997) who points out that concordance is a better concept of patient care and management than compliance. It is also in line with the concepts of empowerment and education in producing patient benefit (Kuhse et al 2001).
While we are considering the theme of cardiac centred interventions, we should also consider one of the forerunners of these investigations, which was a potentially confounding study. Zimmerman (et al 1988) carried out a study which looked at the beneficial effects of music in a coronary care unit for patients who had just experienced a myocardial infarction. The authors worked on the premise that anxiety was counterproductive in the recovery phase.
Their results showed that the tools that they used to measure anxiety levels (The STAI) did not register any statistically significant differences between the intervention and the control groups, but that when they considered the physiological indices (such as blood pressure and pulse rate), there was a marked difference between the groups. We should deduce from this finding that perhaps we should have a healthy degree of scepticism when deducing that a tool that purports to measure anxiety levels may well not actually cover those elements of anxiety which are directly related to the elements that are associated with physiological stress.
For the sake of completeness we should perhaps consider a similar study that was published the following year by Guzzetta (1989). It also was set in a coronary care unit and included patients that had experienced myocardial infarction. The structure of the investigation was slightly different insofar as there were three groups. Music therapy, relaxation and control. This is significant as the authors tried to differentiate between the effects of physical relaxation and the effects of music therapy. The results suggested that there was no statistical difference between the music therapy and relaxation groups in terms of physiological reduction in anxiety parameters, but very significantly, they found that both interventions produced a similar reduction in the level of post infarct complications. This, perhaps, is further circumstantial evidence, that music therapy exerts its effect through a common pathway with physical relaxation methods. (Benson & Klipper 1990).
We can examine a more direct approach that perhaps mirrors the attempts by Good (1995) to actually measure the analgesic requirements during surgery, and to see if these requirements could be modified by music therapy. Kock and his colleagues (et al 1998), decided to set up an investigation which was scientifically more rigorous that those that we have thus far examined, insofar as it was both randomised and controlled in its nature. Their experimental design was to select patients who were scheduled to have urological surgery under either sedation or spinal anaesthesia so that they were effectively "awake" during the procedure. They all wore headsets which would either provide, in the words of the authors favourable intra-operative music or simply screen out the extraneous noise. They measured the outcomes by assessing the amount of analgesia that each patient subsequently required.
The paper itself is extremely detailed in its analysis, but in essence, there is a demonstrable and statistically significant reduction in sedative and analgesic requirement in the group that had music therapy during their surgery when compared to those in the control group who didn't.
It is clear from the evidence that we have reviewed so far, that there is undoubtedly a pressing need for high quality studies to be carried out in this area. It is therefore with considerable interest that we should examine a call from The National Centre for Complementary and Alternative Medicine for volunteers for a study to examine the interaction between higher cortical stimulation (through music and other inputs) and pain perception. (Bradhaw DH 2005)
The formal study hypotheses are worth noting in detail
1) Performing a highly engaging listening task reduces psychophysiological arousal to painful stimuli.
2) Psychophysiological arousal to painful stimuli is a function of the complexity of the auditory signal.
3) Signal complexity and task difficulty interact to produce the greatest engagement and maximum reduction in psychophysiological arousal to painful stimuli.
It is their intention to use controlled electrical cutaneous stimulation to produce the painful stimuli so that they can be carefully graduated and unified. On the face of it, this would go a long way to provide the definitive answers that the previously reported trials have suggested, but not definitively proved.
Thus far, we have looked at trials which have found a positive correlation between music therapy and pain relief. In the interests of a balanced discussion, we should examine trials which have produced conflicting results.
The study by O'Callaghan (1996) looked at the efficacy of various types of potentially therapeutic interventions in the field of pain relief in palliative care. The author examines in some detail various postulates relating to the mode of action of music therapy. He refers to:
The psychological relationship between music and pain
The psychophysiological theory
Spinal mechanisms involved in pain modulation
The role of endorphins.
This paper is notable because it refers to these various theories, but does not add any results or comments that actually add to our knowledge on the subject. We mention it here because of its findings that music therapy, if used inappropriately, can actually aggravate the pain sensations.
Sadly, this paper highlights most of the infuriating short comings of some of the papers that we have reviewed here. It has the outward hallmarks of a respectable scientific paper but close examination of the subject matter shows that the majority of the findings are actually little more than anecdotal in their presentation. The author comments on the inappropriate use of music therapy but then does not tell us what use is considered to be inappropriate, neither does he tell us just what the adverse reactions actually were. This type of paper highlights the need to closely and critically examine the literature and not to accept a fact simply because it appears in print.
Of greater value to us is the Bandolier meta-analysis of various trials (some of which we have examined above), which was completed by Good (1996). It looked specifically at the evidence to support the use of music therapy in the rational treatment of post-operative pain. It considered 21 different trials and encompassed a total of 14 different therapeutic modalities (where music therapy was compared against another specific modality). Good comments on the fact that the trials are generally of poor construction and quality some don't even say how many subjects were included in the cohort or whether there was a control group for the stated outcome to be compared against.
His final meta-analysis included 21 trials, 19 being controlled and 11 being also randomised. His findings were that music therapy was reported to have been successful in 6/11 randomised trials, 7/8 of the non-randomised ones and both of the uncontrolled studies (which would appear to underline the need for both randomisation and controls).
As a consideration of all of the evidence, Good felt able to conclude that:
Relaxation / music therapy was effective in reducing affective and observed pain, but less effective at reducing sensory pain or opioid consumption.
Of enormous significance are his concluding comments, which we should consider in some detail. With the exception of the adverse effects that we have already mentioned in the O'Callaghan study, none of the 21 studies considered the possibility of any adverse effects and did not make any provision in the study design for looking for them.
Good considered all of the trials to be of poor methodological quality and therefore likely to be misleading. This echoes the comments that we have made above relating to the major methodological shortcomings in many of the trials. The majority of the trials were not randomised and none of them were methodologically blinded, which, from both a practical and a scientific viewpoint, leaves open the possibility of a major component of bias.
Where some studies compared several different modalities of treatment against a non-intervention group, the studies could not generally differentiate between the results obtained in each treatment modality simply because the design was such that they didn't assess a baseline of standardise the intensity of the pain that was being assessed. Some studies had very small cohorts. We have quoted examples of reported studies with five subjects (Ishij et al 1993). Such studies clearly do not have the power to differentiate between statistically significant results and results that occur just by virtue of chance.
The last major criticism, which is also perfectly valid, is that, without exception, none of the trials had made any provision to assess whether the subjects were carrying out the required procedures in a uniform (and therefore reproducible) fashion.
Good reviewed all of the evidence and sadly concluded that:
There is insufficient high quality evidence to show whether relaxation and music therapy is effective in the treatment of postoperative pain.
We would have to say that our findings in this review do not give any evidence that we could use to disagree with Good's findings.
It is therefore our hope that the proposed studied such as the one referred to above (Bradhaw DH 2005) will go a long way to remedy this deficit. It is a matter of some surprise to us that the quality of the literature in this area is actually so methodologically poor.
In this review we have considered the work of a number of different authors and researchers who have endeavoured to broaden our knowledge in the field of music therapy and pain relief. They have done this with varying degrees of success. In many areas, music therapy is still considered in the realms of complementary medicine.
In some quarters, this can be considered to be a rather derogatory abrogation, but the analysis of the scientific base of the literature here should leave us in little doubt that the quality of some of the research that has been done in this area - although informative and instructive - does not have the scientific rigour that research in other areas (for example pharmacology) would expect and require. We have commented where we have found evidence of double blinding, randomisation or control elements in investigations and a brief consideration of the papers discussed here will show that the majority do not contain all of these elements.
One has to observe that in order to get a new pharmacological agent onto the market today, one would require evidence far in excess of the quality of the evidence that has been examined in some of the quoted papers. Clearly, this should not be taken as suggesting that the evidence is not there, it is simply a comment on the fact that what is published, is not as rigorous as perhaps it might be (Vickers 2000). It may well be that it is this lack of rigour that is one of the reasons why some may regard music therapy as a complementary rather than a mainstream therapy.
The meta-analysis of Good (1996) is cited to underpin our comments in this area as it should be noted that Good is himself an author of research on the subject (as we have already commented and examined above)
One might conclude that there is a demonstrable increase in the quality of the structure and methodology of some of the newer and more recent studies. We only have to compare the structure and conclusions of the Zimmerman study with that of the Koch study (both quoted above), to find evidence to support that statement. It follows from this that integration comes from respect for the validity and reproducibility of the published evidence. (Vickers 2000). It is our hope that this analysis of the literature on the subject will strengthen this view.
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