Release-Oriented Strategies in the Treatment of Acute Pain Crises

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Release-Oriented Strategies in the Treatment of Acute Pain Crises John Mondanaro MA, LCAT, MT-BC, CCLS

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Learning Objectives  Describe how music can be used as a non-pharmacologic intervention to facilitate tension release during acute pain episodes  Recognize the use of music therapy to optimize coping through reinforced autonomy, control, and mind-body awareness  Differentiate the advantages of live music over recorded music in the individualized care of patients experiencing pain

Music in Healthcare Music and Pain Music Therapy in Tension Release Strategies –Research –Video –Experiential

Release-Oriented Strategies

Music in Healthcare

Music and Health Clinic  Musicians and performing artists have specific medical and health needs related to the unique physical, mental and emotional demands of their profession. Performance can be stifled by – – – – –

Overuse injuries Scar tissue from surgical procedures Side effects from medication Anxiety, chronic fatigue, focusing difficulties Performers report a high incidence of depression and chemical dependency

 Interventions include: – – – –

Tonal intervallic synthesis Vibration Clinical music improvisation Music-assisted relaxation, guided visualization and stress management

Psychotherapeutic Support Expression Reflection Identify and reinforce existing coping strategies Catharsis Cultural, spiritual, social, familial connection Krout, R. The effects of single-session music therapy interventions on the observed and self-reported levels of pain control, physical comfort, and relaxation of hospice patients. AMJ Hospice Palliative Care. 2001; November/December 18,6:383-390. Azoulay, R. & Loewy, J. (Eds). Music, The Breath, and Health: Advances in Integrative Music Therapy. New York, NY: Satchnote Press; 2008.

Procedural Support  Educate and advocate for position comforting  Forming a plan that enlists caregivers in supportive roles  Identify and Reinforce existing coping strategies  Identify new strategies  Refocusing interventions – – – –

Music therapy entrainment Guided imagery Breathing techniques Story song

Loewy, J., Hallan, C., Friedman, E., & Martinez, C. Sleep/sedation in children undergoing EEG testing: A comparison of chloral hydrate and music therapy. Journal of PeriAnesthesia Nursing. 2005;(20), 5:323-331. Mondanaro, J. Music therapy in the psychosocial care of pediatric patients with epilepsy. Music Therapy Perspectives. 2008; 26,2:102-109.

Environmental Factors Harmful noise levels Mechanical sounds Harsh lighting Macdonald, R., Mitchell, L., Dillion, T., Serpell, M., Davies, J., & Ashley, E. An empirical investigation of the anxiolytic and pain reducing effects of music. Psychology of Music, 2003; 3:18. Available at: http://pom.sagepub.com/content/31/2/187. Mazer, S. Music, noise, and the environment of care: History, theory, and practice. Music and Medicine. 2010; 2,3:1-10. Whitaker, M. Sounds soothing: Music therapy for postoperative pain. Nursing 2010; 53-54. Available at: www.Nursing2010.com

Identifying and addressing opportunities to cultivate a work environment where all hospital community members feel respected, appreciated, and in turn are able to fully contribute to our mission

Conceptual model created by Lara K. Dhingra, PhD 2010 Co-Chief, Research Division, Attending Psychologist Department of Pain Medicine and Palliative Care Beth Israel Medical Center

 Current IRB Research  Heather-on-Earth Multi-site Music Therapy Study: n=272 (completed March, 2009)  AIP (Asthma Initiative Program): n=150/Clinic/3 schools-Bronx, Brooklyn, Lower East Side (Complete June 2010)  Music for AIR (Advances in Respiration) n=75 CCPH & Nursing Homes (on-going)  CAIR (Cardiac Advances in Respiration) (on-going)  EEG Sedation Study: Chloral Hydrate vs. Entrained Lullabies n=60(complete)  Helen Sawaya Resiliency Study-Chemo-Infusion n=75 (on-going)  SpineSurgery: Effects of Music in Recovery n=60 (on-going)  SICU-Impact of Live Music with Patients, Staff, and Caregivers n=120 (60 pts, 60 caregivers, 60, staff) (on-going)  Radiation Oncology Impact of Live Music on Coping and Resiliency n=90 (on-going

Our Publications

To Be Released Spring 2013 Featuring  Suzanne Hanser, EdD, MT-BC  Annie Heiderscheit, PhD, MT-BC  Nancy Jackson, PhD, MT-BC  Robert Krout, PhD, MT-BC  Joanne Loewy, DA, LCAT, MT-BC  Trisha Ready, PhD  Gabriel Sara, MD  Fred Schwartz, MD  Mark Tramo, MD  And more on HIV, NICU, Oncology, Psychiatric, Orthopedics

The effects of music on function such as cardiac output, respiratory rate, pulse rate, circulation, blood pressure, electrical conduction of tissues, fatigue, pain, and on general vibratory effects on the body have been studied since the end of the 18th century

Huang, S., Good, M., & Zauszniewski, J. The effectiveness of music in relieving pain in cancer patients: A randomized controlled trial. International Journal of Nursing Studies 2010;47:1354-1362. Diserens, C. The Influence of Music on Behavior. Princeton, NJ: Princetone University Press. (PhD thesis, University of Cincinnati, 1922);1926. Azoulay, R. & Loewy, J. (Eds). Music, The Breath, and Health: Advances Integrative Music Therapy. New York, NY: Satchnote Press; 2008. Sand-Jecklin, K., & Emerson, H. The impact of a live therapeutic music intervention on patients’ experience of pain, anxiety, and muscle tension. Holistic Nursing Practice. 2010; 12, 24,1:7-15.

“The meaning of pain affects the experience of pain” The 1965 comparative study of soldier’s perceptions of pain to that of civilians, showed that context, person’s past experience and/or mental state of mind contribute to the overall subjectivity of the pain experience Catalano, EM. Chronic pain control workbook. New Harbinger Publications, Inc. Oakland, CA. 1988.

“Pain is an emotion hence, emotion is a fundamental part of the pain experience and not a reaction to the sensory appreciation of pain�

Wells, C.,& Nown, G. The pain relief handbook. Firefly Books (U.S.) Inc. Buffalo, New York. 1998.

Acute Pain Events Feelings of loss –control –routine –momentum –sense of vitality & resilience

Wells, C., Nown, G. (1998).

In accordance with the gate theory, patients living with chronic pain and experiencing depression, despairing thought, or poor coping mechanisms may be prone to heightened experiences or perceptions of pain, because their relay stations/gates for pain information are open more than usual, allowing more pain information in

Melzack, R. (1993). Pain: Past, present, and future. Canadian Journal of Experimental psychology, 47,4, 615-29. Wells & Nown, 1998.

Norepinephrine, dopamine, L-dopa, serotonin, and enkephalins- all neurotransmitters involved in pain response are found mainly in the limbic system, and may play a crucial role in the mediation of both pain and emotion1 Music therapy intervention can elicit the release of these naturally occurring endorphins resembling the effects of Opioid analgesics without the risk of dependence 2,3 1. Bromm, B., Desmedt, J. Pain and the brain: From nociception to cognition. Raven Press, Ltd., New York, New York. 2. Mitchell, L., Macdonald, R., & Knussen, C. A survey investigation of the effects of music listening on chronic pain. Psychology of Music. 2007; 35,1: 37-57. 3. Macdonald, R., Mitchell, L., Dillion, T., Serpell, M., Davies, J., & Ashley, E. An empirical investigation of the anxiolytic and pain reducing effects of music. Psychology of Music, 2003; 3:18. Available at: http://pom.sagepub.com/content/31/2/187

A Systematic Review of 51 Studies Involving 3663 SubjectsChildren Through Adult (1867 music/1796 Control)

 Objectives: evaluate effect of music on acute, chronic or cancer pain intensity, pain relief, and analgesic requirements  Search Strategy: The Cochrane Library, MEDLINE, EMBASE, PsycINFO, LILACS< and references in retrieved manuscript  Selection Criteria: randomized control trials evaluating the effect of music on any type of pain in children or adults

Results

 Reduced pain  Increased number of patients who reported at least 50% pain relief  Reduced requirements or morphine-like analgesics Cepeda, M., Carr, D., Lau, J., & Alvarez, H. Music for pain relief. Cochrane Database of Systematic Reviews. 2006; Issue 2. Art. No.: CD004843. DOI: 10.1002/14651858. CD004843.pub2 Journal of Advanced Nursing. June 2006; 54:553.

In Cleveland Clinic study of 60 patients with osteoarthritis, rheumatoid arthritis or disc problems, most suffering from continuous pain in two or more body parts, music therapy eased the perception of pain in terms of: 21% reduction in pain 25% reduction in depression associated with pain Cepeda, M., Carr, D., Lau, J., & Alvarez, H. Music for pain relief. Cochrane Database of Systematic Reviews. 2006; Issue 2. Art. No.: CD004843. DOI: 10.1002/14651858. CD004843.pub2 Journal of Advanced Nursing. June 2006; 54:553.

Studies on the neurological effects of music indicate that at least 3 processes are stimulated  Center of the brain and limbic system where emotional responses of pain, pleasure, blood pressure, and body temperature are also processed  Activates a flow of stored memories across the corpus callosum leading to richer recall of association  Excite peptides, which release endorphins producing a natural deterrent to the experience of pain Mitchell, L., Macdonald, R., & Knussen, C. A survey investigation of the effects of music listening on chronic pain. Psychology of Music. 2007; 35,1:37-57. Macdonald, R., Mitchell, L., Dillion, T., Serpell, M., Davies, J., & Ashley, E. An empirical investigation of the anxiolytic and pain reducing effects of music. Psychology of Music, 2003; 3:18. Available at: http://pom.sagepub.com/content/31/2/187

Music Therapy in Pain Management  Cognitive: the potential for music to refocus an individual way from the pain

experience, associations, memory retrieval, life reflection, imagery & visualization

 Affective: music may alter mood disturbances associated with chronic and life threatening illness e.g. depression, anxiety, fear, anger, sadness

 Sensory: spinal mechanisms in pain modulation. Pain and music processed in the same neural pathways

 Role of Endorphins: music may stimulate the endogenous system of pain modulation

Magill-Levreault, L. Music therapy in pain and symptom management. J Palliat Care 1993 Winter;9,4:42-8.

Release-Oriented Strategies: The Pros and Cons of Live Music  Shift composition according to mood and preference of patient  Change tempo of music according to HR, RR of patient (entrainment)  Ability to control volume, regular dynamic shifts  Enhance a feeling of reciprocity otherwise unavailable  Provide clinical conditions and ongoing updates to medical team

 More expensive to implement a music therapy program  Generalizing results: difficult to quantify the effectiveness of individual music therapy treatment

Five Elements Of Music Contributing To The Efficacy Of Music Therapy Intervention Rhythm: affects both body and emotion- heart rate, respiration,

and brain waves are influenced by the vibrations of music toward stimulation or sedation Tone: determined by distinctive rate of vibration affects both physically and psychologically Melody: stimulates memory, emotion, images, associations Harmony: simultaneous vibration of several tones toward harmonious blend or strident dissonance in cycle of tension release Timbre: the unique quality of sound of an instrument - the human voice included, which elicits different emotional responses

Entrainment: [as a principal of physics] is employed when music is improvised to synchronize with a patient’s physiological and emotional presentation, and then shifted toward an easing of symptoms

Dileo, C., & Bradt, J. Entrainment, resonance, and pain-related suffering. In C.Dileo (Ed.) Music therapy & medicine: Theoretical and clinical applications (pp. 181-188). Silver Spring, MD: The American Music Therapy Association, Inc.; 1999.

Department of Orthopedic Surgery 2012 Joint Commission Certification in: Hip Replacement, Spine Fusion Surgery, Shoulder Replacement, and Knee Replacement Music Therapy Program “Best Practice”

Research  The Effects of Music Therapy in the Recovery of Patients Undergoing Spine Surgery – Randomized-Control-Double Blind – N=60 – Men or women age 40-55 – Anterior, Posterior or Anterior-Posterior Spinal Fusion – Active Release through drumming and/or singing – Passive through Visualization – Both support Mind-Body integration through the breath

Pain Scales Quantitative & Qualitative (CAS, VAS, TAMPA Scale, HADS)

Experiential Tension Release through active drumming Tension Release through harmonics Tension Release through intervallic synthesis Loewy, J. Tona Intervallic Synthesis in Medical Music Therapy in Voicework in Music Therapy: Research and Practice Baker, S & Uhlig (Eds):252-268, London: Jessica Kingsley Publishers. 2011.

“Music moves us beyond a world of

physical objects that closes in upon us” V. Zuckerkandyl

Submit manuscript through the Music and Medicine online submission and review system at: http://mc.manuscriptcentral.com/mmd

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