Music Psychotherapy Approaches for Infants and Children Experiencing Pain by PAINWeek

Music Psychotherapy Approaches for Infants and Children Experiencing Pain Joanne V. Loewy

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Learning Objectives 1. List three intentions of integrative medicine 2. Review the impact of music as a function of release 3. Identity how music addresses pain response in infants 4. Describe how singing might serve as a function of gestalt in the expression of pain 5. Identify 3 varying scales for the assessment and evaluation of pain

Integrative Medicine ď&#x201A;§1960s-70s: Alternative Medicine ď&#x201A;§1980s-90s: Complementary Medicine ď&#x201A;§1990s-2009: Integrative Medicine

Integrative Medicine (cont’d)  Healing-Oriented medicine that: 1. Emphasizes the relationship between patient physician 2. Integrates the best of complementary and alternative medicine with the best of conventional medicine 3. Greater emphasis on “mind-body-spirit” connection 4. care has become more patient centered and inclusive of moods, attitudes, beliefs, environment, and culture 5. inclusive of the relevance of caregivers (including staff) in offering treatment Maizes, V., et al (2002). Integrative medical education: Development and implementation of a comprehensive curriculum at the University of Arizona. Academic Medicine, 77, 851-860

1994: The Louis & Lucille Armstrong Pediatric Music Therapy Program

Evidence: Multiple Sources • The Patient (observed) • The Patient’s words • The Patient’s music RAW DATA

• The Therapist’s observation • The Therapist’s interpretation USE OF SELF

• The Literature • The Data-hypothesis • The Data-surprise RE-SEARCH

• Team Reports • Family Reports • Past History USE OF OTHERS

Under Treatment of Pain  Marks Rm, Sacher EJ: Under treatment of medical in patients with narcotic analgesics. Ann Int Med 78: 173-181, 1973  Cohen FL: Post surgical pain relief: patient’s status and nurses’ medication choices. Pain 9:265-274, 1980.  Donovan M. Dillion P., McGuire, L.: Incidence and characteristics of pain in a sample of medical-surgical inpatients. Pain 30:69-78, 1987  Morgan JP, Puder KS: Postoperative analgesia, variations in prescribed and administered opioid dosages. In: Adv pain respiratory therapy (11); Hill CS Fields WS (editors): Raven Press, 1989;  Eland JM Anderson JE, The experience of pain in children. In: Pain: a source book; Jacox A (ed); Little Brown and Co.,1977.  Beyer JE, et al: Patterns of postoperative analgesic use with adults and children following cardiac surgery. Pain 17:71-80.  Perry, S., Heidrich, G.: Management of pain during debridement; a survey of US burn units. Pain 13: 267-280,1982.  Schechter, NL, et al: Status of pediatric pain control: a comparison of hospital analgesic usage in children and adults. Pediatrics 77:11-31, 1986  Offsay, JB: The pain of childhood leukemia: a parent’s recollection. J Pain Sympt Management: 174-178, 1989  Fowler-Kerry S: Adolescent oncology survivors’ recollection of pain. In: Adv Pain Res ther (15); Tyler DC, Krane EJ (eds): Raven Press, 1990.

Multiple Types of Pain

Woolf C. Ann Intern Med 2004:140:441-451.

Distinguishing Nociceptive and Neuropathic Pain Neuropathic Pain

Nocicpetive Pain  Adaptive  Identifiable stimuli that normally produce tissue damage  Usually self-limiting  Transmitted by structurally and functionally intact pain pathways  Examples: post-operative pain, burns, ischemic pain •

 Maladaptive  Often spontaneous (ocurring without identifiable stimuli)  Often chronic  May involve structural and functional changes in pain pathways  Examples: polyneuropathy (eg, diabetic, HIV), trigeminal neuralgia, central poststroke pain Clinical pain syndromes occur along a spectrum from nociceptive to neuropathic

• Nociceptive and neuropathic pain may coexist in the same patient Portenoy RK, Kanner RM. Definition and assessment of pain. In: Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice, 1996:4. Galer BS, Dworkin RH. A Clinical Guide to Neuropathic Pain; 2000:8-9.

The Multiplicities of Pain – Etiologies, Pathways, Mechanisms, and Treatment  Multiple types of pain etiologies

– Nociceptive, inflammatory/joint-related, non-inflammatory/non joint-related, neuropathic

 Multiple pain pathways

– Multiple ascending and descending pain pathways (excitatory/inhibitory)

 Multiple pathological pain mechanisms

– Peripheral nervous system input: peripheral sensitization, ectopic discharge – Central nervous system processing: central sensitization, structural reorganization, decreases inhibition

 Multiple treatments

– Goal is to reduce excitability and/or increase inhibition – Multiple classes of medications can be used Woolf CJ. Ann Intern Med. 2004;140(6):441-451.

Potential Impact of Depression: Neurologic Impairment Atrophy of The Hippocampus in Depression

Control

Patient With Depression

â&#x20AC;˘ Compared to controls, patients with depression had smaller hippocampal volumes1,2,3 â&#x20AC;˘ These patients also exhibited verbal memory deficiits1,2

Images: JD Bremner 1: Bremner JD, et al. Am J Psychiatry. 2000;157(1):115-118. 2: Sheline Y, et al. J Neurosci. 1999: 19: 5034-5043. 3: Neumeister A, et al. Biol Psychiatry. 2005;57:935-937.

Goals Of Neuropathic Pain Treatment  Primary Goal = reduction in pain  Secondary Goal – Improvement in physical function – Reduction in affective distress – Improvement in quality of life

 Achieving these goals is predicated upon

Turk DC. Clin J Pain. 2000;16(4):279-280. Belgrade MJ. Postgrade. 1999;109(6): 127-140.

Music as Medicine  Music as a Physiological Intervention for Pain – Directly and Indirectly

 Music can reduce stress and anxiety pre & post-operatively  Music can treat depression  Music can influence biochemical messengers related to pain – Neurotransmitters, hormones, cytokines, peptides – Result can be improved emotions, lowered stress response, increased immune function, reduced inflammation, production and activity, calming of the interpretation of pain intensity, stimulation of endogenous opiate effects, activated parasympathetic drive

Music as Medicine (cont’d)  Music as a Physiological Intervention for Pain – Music can activate dopaminergic pleasure-seeking areas otherwise stimulated by sex, food, drugs – Music can stimulate certain sex hormones, receptor proteins and stress hormones to enhance neurogenesis – Music can moderate the stress response by regulating neurotrophins in the hypothalamus

Music as Medicine (cont’d)  Music as a Physiological Intervention for Pain – Music can reduce levels of cortisol and stress hormones, prolactin, tumor necrosis factor, interleukins, adrenaline/norepinephrine, plasminogen activator – Music can increase levels of endorphins, oxytocin, growth hormone, antitumor signaling, T cells, immunoglobulins, natural killer cells

Pain Assessment

Ongoing Reassessment of Pain  Use valid, reliable, and consistent assessment tools  Perform reassessment at appropriate intervals  Document assessments – Pain relief – Changes in pain intensity – Interference with function – Adherence to pain management plan – Adverse effects of medication NRS=Numeric Rating Scale; BPI=Brief Pain Inventory. 1. McCaffery M, Pasero C, eds. Pain: Clinical Manual. 2nd ed. St. Louis, Mo: Mosby, Inc; 1999:36-102. 2. APS. Guideline for the Management of Cancer Pain in Adults and Children. Glenview, Ill: American Pain Society; 2005.

Musical Sedation – NICU/Maternity – Sickle Cell Anemia Pain Crisis – EEG, Endoscopy, OR, ER – Spinal cord injuries – Pain medicine and palliative care – Oncology – Emergency and intensive care – ‘Song of Kin’-threadline finding

Music Sedation vs. Pharm Sedation Dependent Variable

Music Therapy (N = 33)

Chloral Hydrate (N = 31)

Length of

Mean: 66 min Std.dev: 25.6908

Mean: 226 min Std.dev: 94.8713

Mean diff: 160 min Sig. (2-tailed) = .000

Time to achieve

Mean: 23 min Std.dev: 16.3613

Mean: 32 min Std.dev: 24.2579

Mean diff: 9 min Sig. (2-tailed) = .236

Level of

Median: 3 Intraquartile range: 0

Median: 4 Intraquartile range: 0

Median diff: 1 Assymp. sig. (2-sided) < .001

sleep/sedation

Distribution Of Four Background Characteristics Between Subjects Assigned To Intervention By Music Therapy And Chloral Hydrate Background

Music Therapy (N = 34)

Chloral Hydrate (N = 24)

Age

Mean: 2.44 Std.dev: 1.50

Mean: 3.21 Std.dev: 1.38

p = .053

Gender (M=male/F=female)

M = 20 (58.8%) F = 14 (41.2%)

M = 12 (50%) F = 12 (50%)

p = .506

Caretaker (P=present/A=absent)

P = 13 (38.2%) A = 21 (61.8%)

P = 10 (41.7%) A = 14 (58.3%)

p = .792

Sleep deprived (Y=yes/N=no)

Y = 21 (61.8%) N = 13 (38.2%)

Y = 13 (54.2%) N = 11 (45.8%)

p = .563

The Percentage Of Children Successfully Sedated With Chloral Hydrate (50%) vs. The Children Successfully Asleep Using Music Therapy Only (97.1%)

Growing Evidence on Pain Management in Children  The Effects of Music Entrainment on Postoperative Pain Perception in Pediatric Patient. Bradt, J. Music and Medicine, July 2010, vol. 2 no. 3 150-157  The Effect of Music and Imagery to Induce Relaxation and Reduce Nausea and Emesis in Patients with Cancer Undergoing Chemotherapy Treatment. Montserrat, M. Music and Medicine, July 2010, vol. 2 no. 3 174-181  Music therapy as an adjunctive treatment in the management of stress for patients being weaned from mechanical ventilation. Hunter, B.,Oliva, R.,Sahler, O, Gasser, D., Salipante, D., Arezina, C. J Music Ther. 2010, Fall;47(3):198-219.  Developing music therapy approaches to pain management in hospitalized children pp. 57-64. Edwards, J. (2005). In C. Dileo and J. Loewy (Eds.). Music therapy at end of life. Cherry Hill, NJ: Jeffrey Books.

NICU Clinical Trials: Creating Womblike Sound Environment & Impact of Music on Bonding for Neonates  Incorporating body sounds: live music-Gato box (heart beat), Ocean disc (womb sounds), Familiar voices and or melodies (parent/caregiver songs of kin, chanting, universal lullaby)  Orchestrating the phase of music-the music shifts and is entrained with the infant’s vitals  From composed to improvisational  From fully played to minimal  Assistance with feeds, sleep, quiet alert states, transitions & caregiver stress/bonding  A two year study: Multi-site, 11 hospitals in the Northeast USA

NICU Multisite Study: Clinical Trials

N=60 matched for age, sex, Intervention randomly assigned 30 minute period Loewy, J. Hallan, C., Friedman, E., Martinez, C. Sleep/Sedation in Children Undergoing EEG: Comparison of Chloral Hydrate & Music Therapy Journal of PeriAnesthesia Nursing, Volume 20, 5, 323-332, October 2005. American Journal of Electroneurodiagnostic Technology 46, 4, 343-355, Dec 2006

Research Projects  Effects of an Integrative Music Therapy Program on the Perception Noise in the SICU: A Patient, Caregiver, and Physician/Nurse Environmental Study n=120  Clinical Music Improvisation and Infusion Study at St Luke's Roosevelt. Music therapists are investigating the impact of clinical music improvisation on resiliency of patients receiving infusion therapy. n=75  The Impact of Music Therapy on State Anxiety in Cancer Patients Undergoing Simulation (Radiation Therapy) n=60  The Effect of EMT on Anxiety Levels and Perception of Waiting Time in the Radiation Oncology Waiting Room n= 80  The Effects of Music Therapy in the Recovery of Patients Undergoing Spine Surgery. Music therapists are measuring the effects of live music applications in pain and recovery of SPINE patients. n=75  Complete EEG Sedation Study: Chloral Hydrate vs. Entrained Lullabies n=60  Heather-on Earth Multi-site Music Therapy Study: n=270 10 NICU’s (Heather on Earth)-TRAINING-International Summit-Remo  AIP (Asthma Initiative Program): n=200+/Clinic/3 schools-Bronx, Brooklyn, Lower East Side  Music for AIR (Advances in Respiration) n=200 Clinic, CCR, Nursing Homes

Unidimensional Pain Assessment Scales Visual Analog Scale

Verbal Pain Intensity Scale No pain

Mild pain

Moderate pain

Severe pain

Very severe pain

Worst possible pain

No pain

Pain as bad as it could be

0-10 Numerical Rating Scale

0 No pain

5 Moderate pain

Faces Rating Scale 8

10 Worst possible pain

No hurt

Hurts little bit

Hurts little more

Hurts even more

Hurts whole lot

Hurts worst

Adapted from McCaffery M, Pasero C, eds. Pain: Clinical Manual. 2nd ed. St. Louis, Mo: Mosby, Inc; 1999:36-102 with permission from Elsevier.

Pain Assessment Tools Unidimensional scales1

Multidimensional scales

• Numeric Rating Scale • Verbal Rating Scale • Visual Analog Scale • Faces Pain Rating Scale • Brief Pain Inventory1 • McGill Pain Questionnaire1 • Neuropathic Pain Scale2 1. Brunton S. J Fam Pract. 2004;53(suppl 10):S3-S10. 2. Galer BS et al. Clin J Pain. 2002;18:297-301.

Pain  Clinical Interventions – The perception of pain may be reduced through drumming, gonging, toning and other releaseoriented music making experiences – Active music listening techniques including music visualization, redirection and music-assisted relaxation may alter the perception of pain. – Clinical improvisation provides an alternative, nonverbal means of release for a patient in discomfort – Using the voice, as in toning, may stimulate the connection between the body, breath and feeling states-increasing integration

Recent Articles from ‘Music & Medicine’  The Neural Correlates of Temporal Structure in Music Daniel J. Levitin, PhD  Effects of Music on Physiological and Behavioral Indices of Acute Pain and Stress in Premature Infants: a Literature Review and Experimental Study Mark Tramo, MD, PhD, Miriam Lense, PhD cand; Caitlin Vanness, MST Jerome Kagan, PhD, Margaret Doyle Settle, RNC, MSN, Jonathan Cronin, MD  The Role of Music and Music Therapy in Aphasia Rehabilitation Meghan L. Hartley, MA, LCAT, MT-BC, Alan Turry DA, LCAT, NRMT Preeti Raghavan, MD  Biased Emotional Preferences in Depression: Decreased Liking of Angry and Energetic Music by Depressed Patients Marko Punkanen, PhD, Tuomas Eerola, PhD, Jaakko Erkkilä, PhD  Stabilization Music Therapy Model and Process: 512 China Sichuan Earthquake Crisis Interventions Jennifer Hsiao-Ying Tiao Shih, MT Register for free online access to Volume 1-3 http://mmd.sagepub.com

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MUSIC AND MEDICINE Editors Joanne V. Loewy, DA, LCAT, MT-BC

The Louis Armstrong Center for Music and Medicine Beth Israel Medical Center, New York, NY, U.S.A. Ralph Spintge, MD Sportkrankenhaus Hellersen, Luedenscheid, Germany,

and the University for Music and Drama HfMT, Hamburg, Germany Music and Medicine is a new international journal that offers an integrative forum for clinical practice & research of applied music in medical settings & allied institutions. Empirical research studies, clinical case reports, and applied models explicating theory and practice across the health, behavioral and neurosciences. Emphasis is placed on research practices that integrate music, music psychology, music cognition, music neurology, music therapy, and infant & early child development applied medical practice and knowledge. Research and clinical practices related to music psychotherapy and wellness practices is inclusive of the health of musicians Methodology favor quantitative and qualitative research outcomes.

Topics include                

Analgesia and Music Sedation Cancer Care: Active and Receptive Music Approaches Cardiology and Rhythm Clinical Improvisation in Health and Disease Dementia, Stroke and Music Memory Environmental ICU Music Infant Stimulation Medical Conditions and Treatment of Musicians Mood Disorders and Music Psychology Music in Transition: NICU, Hospice to End of Life Music in Surgery: Pre-op to post-op Music in Traumatic Response and Injury Neurologic Music Approaches Pain and Palliative Medical Music Strategies Psychosocial Music Interventions Respiratory Music Advances: Asthma, CF, COPD

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Titles available from Satchnote Press based on research at The Louis Armstrong Center for Music & Medicine

Contact Info & Training Joanne Loewy DA, LCAT, MT-BC JLoewy@chpnet.org Telephone: 1.212.420-2704 Mailing Address: Beth Israel Medical Center Louis Armstrong Ctr Music & Medicine 6 Silver 21- 1st Ave & 16th St NY, NY 10003 Website: www.musicandmedicine.org We offer trainings for MDs, RNs and others. 2 day, weekly and monthly orientations and observations-hands on experiences.

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