|UFDC Home||myUFDC Home | Help|
This item has the following downloads:
EFFECTS OF LISTENING TO MUSIC AS AN INTERVENTION FOR PAIN AND
ANXIETY IN BONE MARROW TRANSPLANT PATIENTS
DAVID OTIENO AKOMBO
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
David Otieno Akombo
This dissertation is dedicated to two special people;
Barbara Achando and Andrea Alali.
I wish to thank Dr. John Graham-Pole, Dr. Russell Robinson, and Dr. Paul
Richards for their inspiration and encouragement. I also would like to thank Dr. John
Wingard, director of the Bone Marrow Transplant Program at Hospital at the University
of Florida (Shands at UF). I am also grateful for the assistance I received from the staff of
Shands at UF. My appreciation also goes to Ms. Mary Coons, Ms. Kimberly Duke, Ms.
Debra Franklin and Ms. Tammy Rowe for all their help, especially in recruiting patients
for my study. Many thanks also go to Dr. Joseph Riley III for his constant help in the
Many people on the faculty and staff of the University of Florida School of Music
and the Arts in Medicine (AIM) program at Shands at UF assisted and encouraged me in
various ways during my course of studies. I am especially grateful to Jill Sonke-
Henderson, Dr. Rusti Brandman and Susan Brender for their support.
My graduate studies would not have been the same without the social and academic
challenges and diversions provided by all my student-colleagues in the School of Music. I
am particularly thankful to Trent Weller, Steven Bingham, Don Devito, David Goldblatt,
and Brent Honky-Swanson for their willingness to read some portions of this dissertation,
and in offering some very useful suggestions. An enormous debt of gratitude can hardly
be repaid to my good friends, Sara Morris, Dan Chamberlin, and Donald Caton, who not
only proofread multiple versions of all the chapters of this dissertation, but also provided
many stylistic suggestions and substantive challenges to help me improve my
presentation and clarify my arguments.
Finally, this dissertation would not have been possible without the expert guidance
of my esteemed advisor, Dr. Timothy Brophy. Not only was he readily available for me,
as he is so generously for all his students, but he could always be counted on to quickly
respond to the drafts of each chapter of my work. His oral and written comments were
always extremely perceptive, helpful, and appropriate. But despite all the assistance
provided by Dr. Brophy and other committee members, I alone remain responsible for the
content of this dissertation, including any errors or omissions which may unwittingly
TABLE OF CONTENTS
A C K N O W L E D G M E N T S ................................................................................................. iv
LIST OF TABLES ....................................................... ............ ....... ....... ix
L IST O F A B B R E V IA TIO N S ................................................................... .....................x
ABSTRACT .............. .......................................... xi
1 IN TR OD U CTION ............................................... .. ......................... ..
T he P problem of the Study ............................................................................. ..... .3
R research H ypotheses .................. ................................ ........ ......... .. ..
L im itatio n s ................................................................................. 5
D definition of T erm s ................. ................................ ........ ........ .......... .......
Significance of the Problem .................................................................. .......................11
Implications of the Study to Music Education ..........................................................16
2 REVIEW OF THE LITERATURE ........................................ ........................ 20
In tro d u ctio n .......................................................................................2 0
Philosophical R ationales.................................................. ............................... 20
R atio n ale s ........................... .......................................2 1
Pythagoras (c. 560 c. 480 B .C .) ............................................. ............... 21
Plato (427 B .C 347 B .C .) ........................................ ........................... 21
Arthur Schopenhauer (1788 1860) ........................................ ...............22
R ene D escartes (1596 1650) ........................................ ......... ............... 22
Baruch Spinoza (1632 1677).................................... ........................ ......... 23
Summary and Implications of the Present Study ..............................................23
T theoretical R ationales ............................................................25
G ate C control T theory .................................................................. .. ................ .. 25
Specificity theories. ........................ .. .................. ... .... .. ........... 29
Pattern theories. .................. .. ............................................... .... 30
Nociception versus pain theories.................... .......... .................... 30
Implications of Gate Control Theory for the Present Study ............ ...............30
R research ............. .............................................. ...........................30
C clinical E effects of M music ......... ................. ....................................... ............... 3 1
Phenom enological Approaches ............................................................................ 32
Music and Healing in Non-European Traditions....... .. .....................................35
Music and Healing in Southeast Asia....................................... ............... 43
Music and Healing in European Traditions............ ................... ...............44
Music and Anxiety in the 20th Century ................................... .................47
Effects of M usic on A nxiety ...................... ..... ......................... ............... 50
Effects of M usic on Pain ....................... ....... .........................................59
Musical Preferences of Patients....................... .. .......................... 60
T y p e o f M u sic ............... ........ ................. ...................................6 2
M usic as a Form of D istraction .............. .......... .......... .......... ............... 65
Summary and Implications for the Present Study ............................................68
3 METHODOLOGY AND PROCEDURES................................................... 70
R e se arch D e sig n ................................................................................................... 7 1
S u objects ............... ....................................................................................... 7 2
Procedures ....... .................... ........ ............... 75
Modified Hartsock Music Preference Questionnaire .......................................79
V isual A nalogue Scale ......................................................... 79
D ata C o lle ctio n ..................................................................................................... 8 1
S a m p lin g .................................................................................................8 3
In stru m e n ts ........................................................................................................... 8 4
P hy biological P aram eters ...................................................................................... 84
Visual Analogue Scale (VAS) ..........................................................................85
P sy chological P aram eters ..................................................................................... 86
State-Trait A nxiety Inventory .................................. ....... ............... .... ...........87
S co rin g an d N o rm s ............................................................................................... 8 8
R eliab ility P ro cedu res........................................................................................... 8 9
V a lid ity ...............................................................................8 9
A u d io R eco rd in g ................................................................................................... 9 0
Statistical Procedures................... ..................90
In terp retatio n o f D ata ............................................................................................ 9 1
D ata M anagem ent .............................................................................................. 93
4 R E S U L T S .............................................................................9 4
Introduction .................. .........................................................................94
Sam ple Characteristics ......................................................... 94
Musical Preferences Questionnaire ................................ ...............95
Effect of the Music Intervention on Pain .....................................................96
Effect of Music Intervention on Anxiety ................................... ....... ...............98
Effect of Music Intervention on Systolic Blood Pressure (SBP) .............................99
Effect of the Music Intervention on Heart Rate ....... ....... ..... .................. 101
Effect of the Music Intervention on Respiratory Rate ............... ................103
R research H y p oth esis........................................................................................... 104
Summary of Results .......................... ......... 107
5 DISCUSSION AND RECOMMENDATIONS ...............................................109
F in d in g s .......................................................................... 1 0 9
Hypothesis 1 .................................... ................. ..................... 112
Hypothesis 2 .................................... ............................... ........113
Hypothesis 3 .................................... ................. ..................... 114
Hypothesis 4 .................................... ........................... ............115
Hypothesis 5 .................................... ........................... ... .........116
Issu e s .................................................... ................................ 1 16
Im plications for Future R esearch.................................... ............................. ....... 119
Implications for Future Clinical Practice ............................... .................... 119
Im plications for M music Education ........................................ ............... 120
Implications for Theory ........... ...... ........ ............................ 121
Limitations ............... ........ ........................ 122
S a m p le ..............................................................................12 4
C o n c lu sio n s......................................................................................................... 12 5
A DEMOGRAPHIC INFORMATION SHEET ..........................................................128
B VISUAL ANALOGUE SCALE (VAS) ...... ...............................................129
C STATE TRAIT ANXIETY INVENTORY (STAI) ..................................... 130
D DATA COLLECTION SHEET ................................................ 131
E MODIFIED HARTSOCK MUSIC PREFERENCE QUESTIONNAIRE .............132
F M U SIC A L SE L E C TIO N S ................................................................................. 133
G C O N SEN T FO R M ............................................................................................139
H COVER LETTER TO SUBJECTS ..................................... .........149
I COVER LETTER TO PARENTS .................................................................... 151
J INSTITUTIONAL REVIEW BOARD LETTER ..................................... 153
K POST-INTERVENTION QUESTIONNAIRE ............................................154
L IST O F R E F E R E N C E S ........................................................................................... 155
B IO G R A PH IC A L SK E T C H ..................................................................................... 178
LIST OF TABLES
1-1 Proportions of Bone Marrow Transplants by Disease at Shands at UF ................. 13
3-1 D ata C collection P process ........................................ .............................................82
4-1 R seasons for A dm ission.................................................. ............................... 95
4-2 M musical preferences........ ........................................................................ .... ..... 96
4-3 Mean Pain Readings from Visual Analogue Scale at Timed Intervals during
M music Intervention ................................................. ...............96
4-4 Visual Analogue Scale Scores Between Time 1 (T1) and Time 5 (T5)...................97
4-5 Mean Scores for the state portion of the State Trait Anxiety Index (STAI) at
Timed Intervals During Music Intervention.....................................................98
4-6 State Portion of the State Trait Anxiety Index (STAI) Scores Between Time 1
(T 1) and T im e 5 (T 5) ....................... .. ......................... .. ...... .... .. .... ...... 99
4-7 Mean scores for the Systolic Blood Pressure (SBP) at Timed Intervals During
M music Intervention ......................... ....... .. .. ........ ............... 100
4-8 Systolic Blood Pressure (SBP) Scores Between Time 1 (T1) and Time 5 (T5) ....101
4-9 Mean scores for the Heart Rate (HR) at Timed Intervals during the music
intervention..................................... ................................ ......... 102
4-10 Heart Rate (HR) Scores Between Time 1 (T1) and Time 5 (T5)...........................102
4-11 Mean Scores for the Respiratory Rate (RR) at Timed Intervals During Music
In terv en tio n ...................................................... ................ 10 3
4-12 Respiratory Rate (RR) Scores Between Time 1 (T1) and Time 5 (T5) ...............103
4-13 Mean Score on the Likert Scale for Those Preferring Music of a Longer
Duration and those who felt pleasant............... ............. ......................105
4-14 Responses to the Questionnaire...................... ..... ............................ 106
LIST OF ABBREVIATIONS
ABP Arterial blood pressure
ALL Acute lymphoblastic leukemia
AML Acute myelogenous leukemia
ANOVA Analysis of variance
ANS Autonomic nervous system
BMT Bone marrow transplant
BP Blood pressure
CAM Complementary and alternative medicine
CML Chronic myelogenous leukemia
ESWL Extracorporeal shock wave lithotripsy
GI Guided imagery without music
GIM Guided imagery with music
HR Heart rate
ICU Intensive Care Unit
IDEA Individuals with Disabilities Act
IRB Institutional Review Board
RR Respiratory rate
SI Self-generated imagery without music
SIM Self-generated imagery with music
SPSS Statistical Package for Social Sciences
STAI State-Trait Anxiety Inventory
VAS Visual Analogue Scale
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
EFFECTS OF LISTENING TO MUSIC AS AN INTERVENTION FOR PAIN AND
ANXIETY IN BONE MARROW TRANSPLANT PATIENTS
David Otieno Akombo
Chair: Timothy Brophy
Major Department: Music Education
Using the Gate Control Theory as the conceptual framework for this study, the effect
of music on the pain perception and anxiety of 15 bone marrow transplant (BMT) patients
was conducted. Subjects in the BMT unit listened to their choice of music for 30 minutes.
In this repeated measures design study, subjects served as their own controls. Data were
collected in a series starting from pre-intervention, during music intervention, and then
Data were analyzed to test the hypothesis that, following music listening, BMT
patients have a greater decrease in self-reported pain, anxiety, blood pressure, heart rate,
and respiratory rate compared to baseline reports. Subjects' pain perception was
measured by a numeric rating scale, the Visual Analogue Scale (VAS) and State Trait
Anxiety Inventory (STAI), for anxiety prior to and after the intervention session. Analysis of
data indicated a statistically significant difference in the subjects' pain and anxiety scores
following the musical sessions.
It is well recognized that pain and anxiety affect the autonomic nervous system
(ANS) activity and balance. The interaction among feeling states, immunity, and
autonomic function has been demonstrated by a number of studies. These studies show
that pain perception and anxiety stimulate sympathetic activity, increase cortisol ratio,
and suppress the immune system. These studies also demonstrate that positive emotional
states created by music enhance parasympathetic activity, increase physiological
coherence, reduce the cortisol ratio, and boost immunity.
Recent research has examined the physiological and psychological effects of
music in both healthy populations and in clinical conditions under anxiety and pain. This
research demonstrates that music helps reduce stress and negative emotions, while
increasing positive emotions. In particular, recent research shows that specifically
designed rhythmic patterns, tone textures, chord progressions, and harmonic resonances
help reduce anxiety, facilitate the experience of pain perception, and enhance the benefits
of stress-management interventions. Used regularly, music has been found to increase
dehydroepiandrosterone (DHEA), coherence in the ANS, reduce cortisol, improve
autonomic balance, and facilitating the entrainment of physiological systems.
The goal of this research is to extend this approach to the patient population aged
7 years and older who are receiving BMT. The study, conducted at Shands Hospital at the
University of Florida, examined the whether or not music can potentiate the
immunoenhancing effects of positive pain and anxiety states. Such interventions may
yield significant health benefits in healthy individuals as well as BMT patients who
exhibit both immunosuppression and autonomic imbalance.
"Listening to music has made me feel better. When you played Beethoven's Fifth
Symphony, I felt as though someone was scratching the cancer cells out of my
body," commented a 51-one-year old bone marrow transplant patient after music
Little research exists on music intervention on pain and anxiety in bone marrow
transplant patients. Music intervention is defined as "the use of music to influence the
patients' physical, mental, or emotional states before, during, or after medical treatment"
(Bruscia, 1989, p. 87). Despite the lack of research validating music intervention on pain
and anxiety, efforts are ongoing to develop and assess new evidence on the cathartic
nature of music. Existing evidence indicates that music can reduce the need for pain
medication by reducing pain perception, diminishing the amount of anesthetic patients
need before surgery, reducing the amount of time patients need to be in the hospital after
surgery, speeding the healing process, increasing endurance during exercise or physical
therapy, and helping regulate pulse, respiration, and blood pressure.
Pain and anxiety are common problems for bone marrow transplant patients during
infusion and following the transplant (Bottomly, 1998; Cleeland et al., 1994). Cancer-
related pain and anxiety have been reduced effectively through music listening (Bailey,
1983; Beck, 1991; Cook, 1986; Zimmerman, Pozehl, Duncan, & Schmitz, 1989). The
management of such pain and anxiety is a special challenge for all health care personnel.
Music appears to be particularly effective in the treatment of cancer-related pain
(Kerkvliet, 1990). It is well recognized that pain and anxiety can affect the activity and
balance of the autonomic nervous system (ANS). Smeltzer and Bare (1996) observed that
the contractions of muscles that are not under voluntary control, including the heart
muscle, secretions of all digestive and sweat glands, and the activity of certain endocrine
organs, are controlled by a major component of the nervous system known as the
autonomic nervous system (ANS). The authors also concluded:
The term autonomic refers to the fact that the operations of this system are
independent of the desires and intentions of the person. The autonomic nervous
system is not subject to one's will--that is, it is in a sense autonomous. (p. 1686)
Interaction among emotional states, immunity, and autonomic function have been
demonstrated by a number of studies, which showed that noxious stimuli, such as
physiological and psychological sympathetic activity, increase cortisol levels. These
stimuli also can alter the immune system, while positive emotional states can enhance
parasympathetic activity, increase physiological coherence, reduce the cortisol ratio, and
Recent research has examined the physiological and psychological effects of music
on both healthy and unhealthy populations, especially those experiencing anxiety and
pain. Bone marrow transplant patients have a greater decrease in self- reported pain,
anxiety, blood pressure, heart rate, and respiratory rate compared to baseline values
(Sahler, Hunter, & Liesveld, 2003).
In the present research, attention is focused on the possible benefits of using music
as an intervention on pain perception and anxiety in patients undergoing bone marrow
transplants. Recent data show that certain rhythmic patterns, tone textures, chord
progressions, and harmonic resonance help reduce anxiety, diminish the experience of
pain, and enhance the benefits of stress management interventions (McCraty, 1999). Used
regularly, music therapy has also been found to reduce cortisol levels, improve the
autonomic balance, and increase dehydroepiandrosterone (DHEA) levels.
Dehydroepiandrosterone is a steroid hormone made by the adrenal glands that acts on the
body and is converted into testosterone and estrogen (Regelson & Kalimi, 1994).
The goal of this research is to extend this approach to patients aged 7 and older
who are receiving BMTs. The study was conducted at Shands Hospital at the University
of Florida (Shands at UF). The investigation examined whether or not music can be
designed to potentiate the immunoenhancing effects of positive psychological states. This
study investigated whether or not the use of music, an inexpensive and non-invasive
method, could be used to enhance the management of pain and anxiety. The data,
combined with the existing literature, were examined to determine if the effects of music
in the intervention of pain and anxiety were likely to be autonomically mediated and
facilitated by increased physiological coherence. These interventions may yield
significant benefits to healthy individuals, such as schoolchildren, as well as to a variety
of clinical conditions in which immunosuppression and autonomic imbalance are
The Problem of the Study
According to Stewart (2005), bone marrow transplants are a relatively new medical
procedure now used to treat diseases once thought incurable. Since its introduction in
1968, BMTs have been used to treat patients diagnosed with leukemia, aplastic anemia,
lymphomas such as Hodgkin's disease, multiple myeloma, immune deficiency disorders,
and some solid tumors caused by diseases, such as breast and ovarian cancer.
A bone marrow transplant is used to treat diseases affecting the bone marrow,
which is a spongy tissue found inside bones (Stewart, 2005). The bone marrow in the
breastbone, skull, hips, ribs, and spine contains stem cells that produce the body's blood
cells. These blood cells include 1) white blood cells leukocytess), which fight infection;
2) red blood cells erythrocytess), which carry oxygen to and remove waste products from
organs and tissues; and 3) platelets, which enable the blood to clot. The purpose of a
BMT is to replace nonfunctioning or defective bone marrow with healthy stem cells. In
this process, the patient is administered drugs that kill all cells in the bone marrow, and
then he receives an infusion of healthy new cells. During this moment patients endure a
certain amount of psychological and physiological distress whenever they are
experiencing the treatment (Spintge, 1989). As the cancerous cells grow and expand in
the bone marrow, they cause pain and anxiety as they destroy normal bone tissue.
Despite opioid medication, moderate to severe anxiety and pain have been reported
during bone marrow transplants. The anxiety tends to exacerbate the level of pain (Voss,
2005). During a bone marrow infusion, the patient may experience any or all of the
following symptoms: chills, fever, hives, and chest pain. The researcher postulates that
music may alleviate certain pain and anxiety symptoms because music can make patients
feel much more confident about dealing with their pain (Voss, 2005). Pain is a psycho-
physiological entity and therefore requires to be treated via a multi-disciplinary
therapeutic approach (Rogers, 1995; Schorr, 1993).
The following five hypotheses are examined in this study:
1. Bone marrow transplant patients have lower levels of self-reported pain as
compared to the baseline measurements while listening to preferred music.
2. Bone marrow transplant patients have lower levels of state anxiety levels as
compared to the baseline measurements while listening to preferred music.
3. Bone marrow transplant patients have lower systolic blood pressure (SBP) as
compared to the baseline measurements while listening to preferred music.
4. Bone marrow transplant patients have lower heart rate (HR) as compared to the
baseline measurements while listening to preferred music.
5. Bone marrow transplant patients have lower levels of respiratory rate (RR) as
compared to the baseline measurements while listening to preferred music.
The subjects in this study include only those patients diagnosed with acute
leukemia, chronic leukemia, lymphoma, and multiple myelomas. These are conditions
marked by excessive growth and malfunction of plasma cells in the bone marrow, which
interfere with the production of red blood cells, white blood cells, and platelets. The
following nine conditions were not controlled in this study:
1. Factors that influence pain such as pain tolerance
2. Pain threshold
3. Previous pain experience
4. Interpretation of the pain
5. Cultural influences
6. Individual patient characteristics
7. Variability in the amount and type of analgesics being administered
8. Variability in the distribution of analgesics that result from disparities in age,
height, metabolic rate, and so forth
9. Pertinent patient demographic data
The researcher did not attempt to draw conclusions about the most prevalent
musical style in pain and anxiety management, but instead offered suggestions on the
most effective musical stimuli for pain and anxiety interventions in patients undergoing
BMTs. In this study, the researcher provided only a few examples of musical styles that
could be used in pain and anxiety intervention modalities in BMT patients.
Due to sampling specifications, the generalizability of this research may be limited.
For instance, only those patients who are undergoing a BMT were studied. In addition,
subjects were 7 years of age or older due to difficulties with self-reported pain
assessments of subjects who are younger than this age. Since listening to music is an
independent variable in this study, those subjects with hearing difficulties were excluded
from the study. Study sessions were initiated after 24 hours of baseline recorded indices
and four hours after analgesics were administered to decrease the probability of
measuring dependent variables prior to the peak drug concentrations. Patients undergoing
BMTs are routinely administered strong anti-anxiety drugs. Many of the patients were
also taking medications which affect their heart rate and blood pressure. It is not known
what effect, if any, these medications have on the study results.
Definition of Terms
Acute lymphoblastic leukemia (ALL), also known as acute lymphocytic
leukemia: This is a cancer of white blood cells, characterized by the overproduction and
continuous multiplication of malignant and immature white blood cells (referred to as
lymphoblasts) in the bone marrow. It is a hematological malignancy. It is fatal if left
untreated as ALL quickly spreads into the bloodstream and other vital organs (it is
therefore called "acute"). It affects mainly young children and adults 50 years old and
Acute myelogenous leukemia (AML), also known as acute myeloid leukemia:
This is a cancer of the myeloid line of blood cells. It is the most commonly diagnosed
type of adult leukemia, but it is rare among children. The malignant cells called
myeloblasts fail to mature into different types of blood cells, a process called
differentiation. If differentiation does not occur, myeloblasts accumulate and overtake the
number of healthy blood cells, spreading into the bloodstream and other vital organs. The
lack of healthy blood cells results in symptoms such as anemia and abnormal bruising.
Myeloid leukemias are characterized as "acute" or "chronic," based on how quickly they
progress if not treated. Patients with chronic myelogenous leukemia (CML) often show
no symptoms, and the disease can remain dormant for years before transforming into a
crisis, which is markedly similar to AML.
Analogue: This is compound that is structurally similar to another compound.
Anxiolytic: This is a medication used to reduce anxiety, tension, or agitation.
Anxiolytic music: This is sedative music considered to be slow (60-80
beats/minute), melodic, and instrumental (without words) such as slow jazz, harp music,
flute music, orchestral music, and piano music.
Autonomic: This is self-controlling, functionally independent.
Aplastic anemia: This form of anemia occurs when bone marrow ceases to
produce sufficient red and white blood cells. It may be induced by exposure to high levels
of toxic chemicals, radiation, and certain drugs.
Cortisol: This is a major adrenal glucocorticoid. It stimulates conversion of
proteins to carbohydrates, raises blood sugar levels, and promotes glycogen storage in the
Chronic myelogenous leukemia (CML): This is a form of chronic leukemia
characterized by increased production of myeloid cells in the bone marrow. The
overwhelming majority of cases of CML are due to a characteristic chromosomal
translocation termed the Philadelphia chromosome. It is traditionally treated with
chemotherapy, interferon, and bone marrow transplantation, but a specific inhibitor
(imatinib mesylate) has radically changed its management.
Complementary and Alternative Medicine (CAM): This is a group of diverse
medical and health care systems, practices, and products that are not presently considered
to be part of conventional medicine.
Dehydroepiandrosterone (DHEA): This is a steroid hormone made by the adrenal
gland that acts on the body much like testosterone, and it is converted into testosterone
Dicrotism: This is a condition in which the pulse is felt as two beats per single
Distraction: This is a condition where concentration of attention is disturbed,
difficult, or virtually impossible due to irrelevant stimuli.
Electromyogram (EMG): This measures body temperature.
Ethnomusic therapy: This refers to the e use of ethnic music for healing.
Eysenck's personality: Named after a prominent German psychologists Hans
Eysenck, this is a personality based his theory of extraversion, psychoticism and
neuroticism as advanced by Hans Eysenck which he observed that defined the cognitive
nature if humans.
Hodgkin's disease: This is a human malignant disorder of lymph tissue
(lymphoma) that appears to originate in a particular lymph node and later spreads to the
spleen, liver, and bone marrow. It occurs mostly in individuals between the ages of 15
and 35 years. It is characterized by progressive, painless enlargement of the lymph nodes,
spleen, and general lymph tissue.
Holistic healers: These are professionals trained in alternative methods of healing
the mind, body and spirit using programs like aromatherapy, astrology, hypnosis,
meditation, natural and energy healing, new age, spiritualism, yoga, massage therapy,
imagery, music and dance among others.
Leukemia: This is an acute or chronic disease of unknown cause in humans and
other warm-blooded animals that involves the blood-forming organs. It is characterized
by an abnormal increase in the number of leucocytes in the tissues of the body with or
without a corresponding increase in those in the circulating blood. It is classified
according to the type of leukocyte most prominently involved.
Lymphoma: This is a general term for various neoplastic diseases of the lymphoid
Multiple myeloma, also known simply as myeloma or plasma cell myeloma, or as
Kahler's disease after Otto Kahler, multiple myeloma is defined as a incurable
hematological malignancy of plasma cells, which are the cells of the immune system that
produce antibodies. Although it initially develops in the bone marrow, it spreads to the
peripheral blood, lymph nodes, and other organs. Despite therapy, its prognosis is
generally poor, and treatment may involve chemotherapy and a bone marrow transplant.
Music therapy: This refers to the prescribed use of music by a qualified person to
effect positive changes in the psychological, physical, cognitive, or social functioning of
individuals with health or educational problems.
Music therapy intervention: This is a form of intervention which includes:
singing; playing both composed and improvised music; creating song lyrics, melodies,
harmonies, and orchestrations; moving to music; and listening actively to music to
facilitate imagery and teach specific relaxation skills.
Nociceptor: These are receptors which are sensitive to painful mechanical stimuli,
extreme heat or cold, and chemical stimuli. All nociceptors are free nerve endings.
Non-Hodgkin's lymphoma: This is a type of cancer. A lymphoma is a general
term for cancers that develop in the lymphatic system. Hodgkin's disease is one type of
lymphoma. All other lymphomas are grouped together and called non-Hodgkin's
lymphomas. Lymphomas account for about 5% of all cases of cancer in the United States.
Nulliparous: This term is used to refer to a female who has never given birth to a
Opioids: Originally, these were agents that caused somnolence or induced sleep.
However, presently the term refers to any derivative, natural or synthetic, of opium or
morphine or any substance that has similar effects. Narcotics have potent analgesic
effects associated with significant changes in mood and behavior, and with the potential
for dependence and tolerance following repeated administration.
Pethidine: This is a drug used to treat moderate to severe pain.
State anxiety: This is a state which reflects a transitory emotional state or
condition of the human organism that is characterized by subjective, consciously
perceived feelings of tension and apprehension, and heightened autonomic nervous
State Trait Anxiety Inventory (STAI): This is a self-report inventory established
by Charles Spielberg (1976) to assess anxiety. The STAI is designed to differentiate
between the temporary condition of "state anxiety" and the more general and long-
standing quality of "trait anxiety" in adults. It consists of two categories with 20 items in
each category. One category measures how respondents feel "right now, "state anxiety"
and the other measures how one normally feels "trait anxiety."
Themes: Abstract constructs, which researchers identify before, during, and after
Unmet Analgesic Needs Questionnaire: This is a tool designed for cancer patients
designed by Zhukovsky (1994) to measure prevalence and intensity of pain, and identify
characteristics associated with unmet analgesic needs and dissatisfaction with pain
Visual Analogue Scale (VAS): This is a measurement instrument that measures
the amount of pain that a patient feels ranging across a continuum from none to an
extreme amount of pain. It consists of a horizontal line, 100 mm in length, anchored by
word descriptors at each end of the spectrum (e.g., "no pain" and "the worst possible
Significance of the Problem
The purpose of this study is to examine the effects of listening to music on pain and
anxiety in BMT patients. In this study, the researcher attempted to provide evidence as to
whether or not music can be used as an intervention for pain and anxiety through
empirical methods and discourses.
Music for healing is a practice that has persevered through time (Spintge, 1989).
From ancient times, music has been used to evoke potent forces, as well as for the
compassionate treatment of individuals with physical, mental, and emotional illness. This
practice is manifested through musical contexts by the dissemination of music as a
product of human behavior. The practice includes reflections on the philosophical,
religious, and ritualistic ideals aligning with a cosmic concept that there is an intrinsic
healing power in music (Flanagan & Jupp, 1996). The debate on the effects of music
upon the human body has been one of the most controversial topics in the field of holistic
and complementary therapies in health science. Peck (2002) observed:
Medications possess the notorious quality of being double-edged swords. This is
true ... of modern synthesized pharmaceuticals. While they benefit the patient, they
also pose risks of dangerous side effects. (p. 65)
For this reason, the application of music in pain management and the control of
anxiety in patients have become popular during the past several decades. Music is
considered to be a medium which eases anxiety, reduces pain perception, and increases
pain thresholds. Although music therapy is an established allied health profession and is
used with increasing frequency in the treatment of those with illnesses, a lack of
empirical research literature exists supporting the use of music in the mitigation of pain
and anxiety. In addition, many of these studies are insufficient, and their findings are
therefore often contradictory. Ikonomidou and Rehnstrom (2004) noted:
Most studies in the literature have not been carried out according to standard
principles for randomization or controlled circumstances, and statistical methods
have been poorly documented, thus advocates of music therapy have referred to
empirical database for positive effects of this intervention. (p. 274)
In this study, the researcher examined how listening to music affects bone marrow
transplant patients. In this study, the researcher examined how patients felt about
themselves, what benefits they derived from listening to music, and whether or not these
experiences carried meaning for them beyond the act of listening to music. Study
participants were recruited from Shands Hospital at the University of Florida (Shands at
UF), a community health care hospital serving North and Central Florida, as well as
adjacent parts of southeastern United States. During the past five years, Shands at UF
conducted transplants in 100 to 130 patients per year. Transplants in the Pediatric ward
fluctuated between 8% and 20% of all cancer patients. Table 1-1 shows the breakdown of
these patients by disease during the past five years.
Table 1-1. Proportions of Bone Marrow Transplants by Disease at Shands at UF from
1999 to 2004
Acute leukemia 25%
Bone marrow failure 15%
Other cancers 10%
The use of music in pain management as a form of analgesia has become popular in
the last 80 years (Spintge, 1989; Browning, 2000). Patients have demonstrated significant
results in studies involving the use of music with post-operative surgery, dentistry, spinal
cord injuries, pediatric treatments, and chronic pain (Browning, 2000). Additionally, in
this study the researcher examined how caregivers can benefit from this knowledge in
making better, more clinically astute interventions. Shultis (1999) stated:
The steadily decreasing length of inpatient hospital stays requires rethinking and
redeveloping, as well as retraining, in order for music therapists to work within a
new conceptual model. Decreased financial resources contribute to the pressure to
demonstrate the efficacy of music therapy in short-term treatment. (para. 3)
Scholars have definedpain in many ways. Chapman and Stillman (1996) defined
pain as a phenomenon of consciousness that does not exist outside the realm of
awareness. It is not an observable phenomenon and has no objective markers while it
defies objective measurement (p. 315). Pellino et al. (2005) stated:
Pain is a multidimensional experience, consisting of not only physical stimuli but
also psychological interpretations of pain. Internal processes, such as increased
anxiety, and external forces can influence how a person experiences pain. (p. 182)
Other scholars consider pain to be an independent sensation with specialized
peripheral sensory receptors (nociceptors). These receptors respond to damage and send
signals through pathways (along nerve fibers) in the nervous system to target centers in
the brain (Smeltzer & Bare, 1996). These brain centers process the signals to produce the
experience of pain. Merskey and Bogduk (1994) defined pain as: "An unpleasant sensory
and emotional experience associated with actual or potential tissue damage or described
in terms of such damage" (para. 11). While the phenomenon of pain itself is so elusive,
both scientists and allopathic healers have a myriad constructs to ponder in trying to
comprehend its correlates.
Anesthetists use all the medication at their disposal to control and reduce pain, but
in many cultures from the past, music healers and traditional medicine men used music
and herbs to bring healing to patients. This ancient practice is still in use today in some
societies. However, during the past decade, many scholars, who have turned their
attention to alternative therapies including music, have embraced the phenomenological
approach used by traditionalists. In this study, the researcher sought to find a meaningful
consensus from a scientific standpoint for this interaction. Voss (2005) stated:
Drugs alone sometimes aren't quite enough. We need to find additional ways to
decrease anxiety and pain. My belief is if patient anxiety and distress [are] reduced,
then pain is also reduced. (para. 7)
Epistemological thought on the use of music for health and how it was used in
ancient times is a fascinating field of study. It has nonetheless received limited attention.
With the exception of anecdotes about Pythagoras's ability to calm an agitated youth bent
on violence by having the piper change from one mode to another (Opsopaus, 2004), the
efficacy of music as a healing agent has been dismissed in the recent past. Music has
often been deliberately perceived as inconsequential to the development of modern
science. Fortunately, some scholars are beginning to address this field of inquiry. Many
current scholars are discovering that music can be cathartic for some patients. Gilchrist
(2002), a London-based physician, has written about the power of music to bring about
healing. He observed, "I am a very conventional doctor, but I do like to use other sources
for emotional problems where conventional medicine has little to offer" (p. x, para. 10).
On the power of music in Arabian societies, Alakbarov (2003) noted:
In the 13th century, the Turnini Dervishes (Mavlavi) considered that knowledge of
God was possible only when they fell into a trance brought on by listening to
special music and which slowly turned into a mystical dance. (para. 2)
As 21st century researchers, we carry out this research with the following five
questions in mind:
1. What effect does listening to music have on a patient's pain?
2. What effect does listening to music have on a patient's anxieties?
3. What effect does listening to music have on a patient's blood pressure (BP)?
4. What effect does listening to music have on a patient's heart rate (HR)?
5. What effect does listening to music have on a patient's respiratory rate (RR)?
This study was done to determine whether or not listening to music has any effect
on pain and anxiety levels in a select group of hospitalized persons. For the hospital
environment, these data may have tri-partite role; 1) to support the development of more
extensive music programs to support patients; 2) to support the caregivers; and 3) to
motivate the nursing caregivers. The increasing perception of nursing as a less desirable
career choice continues to have effects on the profession. Keating and Sechrist (2001)
observed that stressful working conditions night and weekend shifts, exposure to
contagious elements, reduced time for patient care, and employer policies that push
individuals to do more with less do not project the profession of nursing as an attractive
career choice, as it once was. With these far-reaching effects on the human capital, music
listening in this environment will thus possibly bring to and retain more individuals in the
field of nursing to lessen the nursing shortage. These potential outcomes will benefit the
well-being of the caregivers and the health of their patients.
The results from this research should facilitate the reappraisal of the competing
theories and disciplinary conflicts that have existed for more than two centuries between
music and medicine. There is inadequate research in the field of music and healing. In
addition, these few available studies report insignificant results from music intervention,
hence additional research is needed (Mok & Wong, 2005). The subject of music and
healing has a high profile in public awareness because of a series of scientific discoveries
in sound and imagery therapy. This study provided possible interpretations of the data,
based on the self-reported pain ratings found on a Visual Analogue Scale (VAS) and a
calculated anxiety rating derived from the State Trait Anxiety Inventory Scale.
Implications of the Study to Music Education
The effects of anxiety on children have become a national concern (Brophy, 1986).
Anxiety in children can be physically and emotionally debilitating. Physical problems,
such as headaches resulting from anxiety, are common among children (Giles, 1990).
Research during the last 20 years has built a good case for the effectiveness of music as a
therapeutic tool for reduction of anxiety in both adults and children in the school system
(Giles, 1990). Music plays a major role in helping students lower their anxieties, and
music has been used to reduce anxiety in many situations (Cobb & Evans, 1981;
O'Regan, 1979; Perettl & Swenson, 1974; Richter, 1984; Zimny & Weidenfeller, 1962)
and increase attentiveness (Wagner, 1975).
A wide range of emotional, stress-related problems, such as teenage suicide,
teenage pregnancies, delinquency, violence in school, physical and sexual abuse of
children, and drug trafficking among youth are of national concern (Zill, 1993). Crimes
committed by children, even murder, are increasing (Giles, 1996). Mental health
professionals and parents have witnessed a dramatic 25% increase in the numbers of
reported cases of seriously emotionally disturbed schoolchildren due to anxiety in the last
10 years (Zill, 1993). Giles (1996) observed that "emotional states of students should be
addressed their feelings are as important, perhaps more important than the lessons to
be taught" (para. 13). Misbehavior in schools is pervasive, and parents are concerned for
their children's safety while in school (Goodland, 1984). Many students in today's classes
are suffering from chronic stress and withdrawal, or they live in a constant state of anger
or rage. They cannot think clearly under these conditions; they are wrapped up in their
own little world. They carry these negative, unproductive emotions like baggage from
class to class, seemingly traveling in a morass of emotions that prohibits learning. In
extreme cases students become ill, and perhaps they may die or commit suicide
(Goodland, 1984; Giles, 1990).
Children with anxieties who display many signs of misbehaviors could be
described as "at risk," a precondition to becoming conduct-disordered. Giles (1990)
stated: "It is this group that is most prevalent in the classroom, and it is this group that
could be helped by music" (p. 11). Recently, such long-lasting, stress-related behaviors
have been described as personality disorders and conduct disorders, serious conditions
that should be given the same attention by school authorities as other debilitating physical
and emotional problems (Rizzo & Zabel, 1988).
In using music to heal schoolchildren, Giles (1996) observed:
Given the body of evidence for music's power to heal, one wonders why music is
not used more often in schools for those purposes. Music education needs to do
more than just cope with and manage the at-risk child. We should recognize the
potential for good that music can bring, select appropriate music and give it to our
students for a healthy tomorrow. (para. 18)
Music educators have recognized intuitively the powers of music. Giles (1996)
posed several questions worth noting:
How often have we seen students who were on the brink of failure in school lift
their self-esteem through music, and "find their way?" How many times have we
seen little sad faces light up to the strains of "Zip-eh-dee-doo-dah" or some other
happy song? (para. 4)
Giles (1996) observed that educators know in their hearts that music can do
something for these students. For many years, research has shown the efficacious nature
of music on physical and emotional states. Giles (1990) observed that children can be
helped to reduce stress in their lives, lift their self-esteem, and be inspired to an
emotionally healthy state of mind. During times of duress and anxiety, children can be
uplifted and given hope through music (Wagner, 1975).
The effects of music on anxiety within the school system can also be examined in
the context of other subjects. When referring to the effects of anxiety on math
performance in schools, Martin (2003) noted that in math and science classes, students
are often so uncertain that they become anxious, and this anxiety interferes with their
learning. Fumer and Berman (2006) observed:
When anxiety is reduced, students can become more successful at math, and be
better equipped to be successful in a world that is highly technologically and
mathematically oriented. (para. 21)
In today's world, we see strife and anxiety everywhere (Giles, 1996). American
schools, faced with violence and crime, are looking for hope and new direction. Giles
(1996), observing that children in school carry these anxieties from class, stated:
It is no wonder that so many are at risk for emotional problems, physically
debilitating conditions, and failure in school. There is no better time to bring music
into the schools as a healing force. (para. 6)
Music teachers can utilize the healing powers of music in the classroom to help the
students who need to reduce stress in their lives. Giles (1996) pointed out that we must
recognize and be more aware of the potential good in music to heal and produce
emotional health. It is imperative to study the psychological effects of music to alter
negative emotions, such as anger, rage, and depression, to feelings of contentment or
happiness. This research supports the idea that music can help students' anxiety. Giles
Few music teachers have made a serious effort to study the specific attributes of
music for healing, with the deliberate intention of incorporating health and healing
into the music curriculum. (para. 8)
Giles (1996) also pointed out that most educators recognize that slow, moderately
soft music is soothing. These styles of music can be used to uplift and calm students.
Recognizing these effects can assist the teacher in the selection of appropriate music for
students to hear or perform. Consciously selecting a piece of music for its emotional
effects, in order to promote emotionally healthy students, represents a new direction in
using music to promote health in schools. Alsalam et al. (1991) have estimated that 46%
of students in American schools are now at risk, virtually half of the student body
suffering from poverty or conditions leading to failure in school. Music educators are in
a position to help these students through music activities. When this new dimension is
added to the curriculum, students are involved in music activities that can ultimately
reduce the stress in their lives and replace them with new self-esteem (Giles, 1996).
REVIEW OF THE LITERATURE
In this chapter, the philosophical rationales that support this work are examined.
Relevant theories are presented, followed by selected literature on the efficacy of music
intervention on the physiology of patients and healthy populations.
"Pain can be an isolating event in the human experience. Whenever I am in pain, I
feel isolated from the society. This isolation brings me anxieties. When I am in pain
and listen to music, I feel connected to the society. Music helps me in this way"
commented a 68-year-old bone marrow transplant patient after music intervention.
Ancient healers and philosophers regarded music as a bridge between the body,
soul, and earth. The philosophical foundations of music and healing in Western culture
can be traced to classical antiquity. When it comes to this modem era, the Greek
philosophers are credited with the ideology of the cathartic nature of music. The subject
of music and healing, especially as revealed in its manifold and remarkable
manifestations--throughout Ancient Greece until the dawn of the 18th century--has never
been candidly and fairly examined in the European tradition. The only sound sources of
information are anecdotes, which provide eyewitness accounts of individual music
healers. The anecdotes reproduce evidence verbatim, as recorded in treatises of healing
Pythagoras (c. 560 c. 480 B.C.)
Pythagoras, who is sometimes regarded as the "Father of Psychotherapeutics,"
championed the discipline of nature in therapy. His philosophy was enshrined in the fact
that psychics and physics were inseparably mingled into a regimen of life. Pythagoras
conducted perhaps the world's first physics experiment. By playing strings of different
lengths, Pythagoras discovered that sound vibrations naturally occur in a sequence of
whole tones or notes that repeat in a pattern of seven. As with the seven naturally
occurring colors of the rainbow, there is an octave of seven tones. He conceived of the
universe as a vast musical instrument and reportedly heard the music of the spheres
(Koestler, 1959). Other thinkers in this arena, who are considered to be the greatest
writers on music in antiquity, were Plato and Aristotle, who reached the very pinnacle of
psychosomatic speculation. Both Plato and Aristotle believed in the unity of the soul and
body through the medium of scientific investigation.
Plato (427 B.C. 347 B.C.)
Plato believed that music occupied the leading position among the arts, where he
saw an analogy between the movement of the soul and musical progressions (qOopda).
While synthesizing Plato's ideals on the significance of music, Lang (1946) concurred:
"Therefore the aim of music cannot be mere amusement but perfection of soul and the
quieting of passions" (p. 13). These ideals were depicted in Plato's treatises, Laws,
Republic, Gorgias, Philebus, and the Temaeus. In Temaus, Plato described the numerical
(vibrational-musical) creation of the physical universe and the soul, which animates it.
Plato called his students to activate the ancient shrines and sacred temples of the earth
with sacred song, thereby employing perpetual choirs as if to imitate the harmonies of the
Heavenly Choir. Plato observed that "music is a prime factor in transformation ... for
music is medicine of the soul" (Schullian & Schoen, 1948 quoting Plato, p. 57)
Arthur Schopenhauer (1788 1860)
The effects of music on the mind are similar to those on the body. By listening to
music, a more recent philosopher, Schopenhauer (1788-1860), stated:
For a moment we are in touch with something outside the empirical realm, a
different order of being: we literally have the experience of being taken out of time
and space altogether, and also out of ourselves, even out of the material object that
is our body. (Magee, 1998, p. 144)
Schopenhauer, a German post-Kantian philosopher, who considered true
philosophy as art, regarded music as "a sort of super-art, transcending all the others in
metaphysical significance making, Wagner and Mahler regard their writings on music as
being the profoundest that there are" (Magee, 1998, p. 144). Schopenhauer's philosophy
was the biggest non-musical influence on the life of Richard Wagner (1813-1883). It was
due to Schopenhauer's metaphysical philosophy of loving-kindness or caritas ('ayatrl)
which Wagner discovered in 1854 that he developed his intuition regarding emotion in
the Parsifal (Raphael, 1969).
Aesthetic experience quits the will within us. Music is, according to Schopenhauer,
a direct manifestation of well-being. It is the voice of the metaphysical will. When music,
suitable to any scene, action, event, or environment, is played, it seems to disclose to us
its most secret meaning (Schopenhauer, 1958).
Rene Descartes (1596 1650)
Debates on the mind and body as a composite whole are evidenced in the writings
of these ancient philosophers and through later ones as well. According to Descartes'
famous dualist theory, human beings are composed of physical bodies and immaterial
minds. Descartes (1694) divided music into three basic component parts: 1) the
mathematical-physical aspect of sound; 2) the nature of sensory perception; and 3) the
ultimate effect of such perception on the individual listener. He characterized the process
of sensory perception as being autonomous, self-regulating, and measurable.
Baruch Spinoza (1632 1677)
Spinoza, whose writings are replete with acute psychological insights, disagreed
with Descartes' idea. In his masterwork, The Ethics, published in 1677 after his death,
Spinoza argued that body and mind are not two separate entities, but one continuous
substance. This concept contributed a great deal on affecting the body through the mind.
According to Spinoza, in fact, anxiety was "uncertain pain," an emotion that can be
overcome only by a stronger one. Music can bring about such stronger emotions; hence
music can be useful in these situations (Spinoza, 1910).
Summary and Implications of the Present Study
Music has played important roles in schools for almost two centuries. In Europe, it
has been used since early 1840s (Arveiller, 1980). For instance, in France, music
education was introduced into public schools, and the National Academy of Music was
created in Paris (Conservatoire). The idea was that music, through harmony, had the
power to develop positive emotions, eradicate animosity, and promote wellness
(Arveiller, 1980; Lecourt, 1992). For these reasons, the masses were educated through
music, and music was considered beneficial for those who were sick.
In Europe, the first students of the Paris Conservatory were also the first music
therapists, as they were sent into hospitals to give concerts and to offer music lessons to
psychiatric patients (Arveiller, 1980; Lecourt, 1992). During this time, the consideration
and the treatment of anxieties in schools and other mental illnesses began such as
psychiatry, which was developed by the work of Dr. Philippe Pinel (Bynum, Porter, &
Music therapy had, in essence, two main functions: a social and educational
function and a more psychological regulating role (Arveiller, 1980; Lecourt, 1992). The
social function was associated with nationalist objectives for which music constituted an
instrument of national regrouping and a relational model. Musical societies, such as the
Orpheons (choral groups and brass bands), developed throughout France (with national
and international exhibitions). The groups shared the conviction that music education for
the masses and workers would transform society and make people feel better (Arveiller,
1980; Lecourt, 1992). This music would also transform those with anxieties and reinstate
patients in what they referred to as a musically harmonized nation (Lecourt, 1992).
In addition to its social function, music also had a regulatory role in schools. Music
was expected to calm the restless students and stimulate the apathetic ones through mood
and behavior regulation. These objectives were mainly developed through having
students and patients listen to concert music. The students also organized musical events
in hospitals while offering music education courses for patients in the hospital (Arveiller,
1980; Lecourt, 1992).
Music has long been used to produce therapeutic physiological and psychological
results. Even though the historical and the philosophical debates on the efficacy of music
as a healing device are not the focus of this research, these rationales nonetheless provide
a background upon which the research is based.
These philosophers continued to influence psychologists in the science academies
in the centuries that followed. In the 18th and 19th centuries, pragmatists especially in the
United States, led by John Dewey (1859-1952) began a new revolution in philosophy.
They first confounded the scientific process of arriving at information. For the
pragmatists, the five-step scientific process was the source of ultimate reality. Instead of
relying on tradition, belief, religion, and myth about music and its efficacious nature to
heal illnesses, 18th and 19th century scientists changed the format of the intellectual
pursuit of knowledge. Tong (2003) observed that science is good at explaining concepts,
but not necessarily good in explaining why such concepts exist or for what
purpose. Assuming that science acts with perfect wisdom and does nothing in vain,
Dewey argued that every step of the scientific process is crafted for its proper function.
These ideas led scientists to theories of pain and anxiety.
Pain is the most common reason people seek help from the medical profession
(Sokka, 2003). The questions addressed in this study can be linked to several theories.
Based on these theories, health care providers use many approaches to treat pain, such as:
1) pain medication; 2) imagery; 3) deep breathing; and 4) music. Theories of pain have
evolved from foundations created by ancient philosophers who considered pain to be an
emotion. Aristotle (384 BCE 7, 322 BCE) the Greek scientist and philosopher called it
a "passion of the soul." The concept then progressed through time, culminating into the
pain theories of the 18th and 19th century psychologists.
Gate Control Theory
The Gate Control Theory of Pain was first proposed by Ronald Melzack and
Patrick Wall (1965). They suggested that there is a "gating system" in the central
nervous system (in the spinal cord where the nerves come in from an injury) that opens to
let pain messages through to the brain and closes to block them. Melzack and Wall were
governed by theories of evolutionary psychology in developing the Gate Control Theory
of Pain. One theory of evolutionary psychology holds that the evolution of intelligence in
any natural environment historically begins with the recognition of an entity's own body--
called the kinesthetic sense. Melzack and Wall suggested that the gate inhibits or
facilitates passage rather than completely opening or closing, so it opens more or restricts
the passage of pain signals. Pain is in the brain, according to Melzack and Wall (1965),
and only there. According to the Gate Control Theory of Pain, our thoughts, beliefs, and
emotions may affect how much pain we feel from a given physical sensation. The
fundamental basis for this theory is the belief that psychological, as well as physical
factors guide the brain's interpretation of painful sensations and the subsequent response.
These emotions and attention open and shut the "gate." Although the physical causes of
pain may be identical, the perceptions of pain can dramatically differ.
Pain perception was conceptualized in the Gate Control Theory as many non-
pharmacological interventions are based on this theory (Melzack & Wall, 1997). To date,
the Gate Control Theory, even though controversial, is the most influential and studied
theory in relation to the nature of pain (Tse, Chan, & Benzie, 2005). This theory provided
the conceptual framework for this study.
At the inception of this theory in 1965, Melzack and Wall (1965, 1983) proposed that a
neural mechanism in the dorsal horns of the spinal cord acts like a gate to increase or
decrease neural impulses from peripheral nerves to the central nervous system. Before
pain is perceived or responded to, the gate serves as a modulating factor. The gate is
influenced by large and small diameter fibers, chemical substances such as acetylcholine
and serotonin, and descending influences from the brain. A pain response is activated when
the number of impulses passing through the gate exceeds a critical level.
According to Cooper (1990) and Melzack and Wall (1983), free nerve endings in
the area of the injury serve as afferent pain receptors. When a sufficient number of these
fibers are activated over an area (spacial summation) and over a period of time (temporal
summation), the pain message is amplified and carried to the spinal cord via afferent
However, before nerve impulses can ascend to the brain, a portion of them must go
through the densely packed, diffusely interconnected nerve fibers called the substantial
gelatinosa. This region is found on both sides and throughout the length of the spinal
cord within the dorsal horns. Between this transmission, from sensory neurons to
ascending spinal cord neurons, that impulse pattern can be modified. Some fibers
continue to the thalamus, and others penetrate the reticular formation in the lower part of
the brain, then go to other sensory portions of the brain. Other fibers are carried along
pathways to the limbic system (Bonica, 1977; Melzack & Wall, 1983).
The substantial gelatinosa play a role in the inhibition and activation of neural
impulses. Injury produces signals that are transmitted from small diameter fibers to the
dorsal horns, which may activate the substantial gelatinosa in the spinal cord. This
activation then opens the gate in order to transmit the message further to the brain as
indicated in the schematic representation of the theory (see Figure 2-1).
The Gate Opens the
(Adapted from Carr and Mann 2000)
Figure 2-1. Schematic representation of the Gate Control Theory.
On the other hand, large diameter fibers may exert an inhibitory influence on the
cells in the substantial gelatinosa, which result in inhibition and closure of the gate,
preventing the continued transmission of the impulse to the brain. The reticular
formation and the limbic system also exert a powerful inhibitory control over
information projected by the substantial gelatinosa cells. When the level of
neurotransmitters (i.e., acetylcholine, prostaglandin) exceeds the level of
neuromodulators (i.e., serotonin, endorphins) at the synapse, the pain impulse continues
to the next synapse (Melzack & Wall, 1983).
According to the Gate Control Theory, many factors come into play in an
individual's perception and response to pain. Various psychological processes, such as
past experience, cultural learning, the meaning of the situation, individual pain
threshold, attention, and emotions, influence pain perception and response via action on
the spinal gating system (Melzack & Wall, 1965, 1983). The focus or attention an
individual gives to the painful experience may increase the intensity of the painful
experience. Several researchers have found distraction of attention--by means of
auditory inputs--effective in decreasing pain (Gardner & Licklider, 1959; Melzack,
Weisz, & Sprague, 1963). However, Melzack and Wall (1983) later found distraction to
be effective only if the pain was steady or if it rose slowly in intensity, such as in post-
operative pain. Subjects were able to use auditory stimulation to distract their attention
from the pain before it reached an intolerable level. Drever (1952) defined distraction as
"a condition where the concentration of attention is disturbed by irrelevant stimuli ... or
where concentration of attention is difficult or virtually impossible" (p. 72).
As spinal activity is initiated through the spinal pathways, the sympathetic nervous
system is also activated. The sympathetic nervous system response commonly referred
to as a "fight, fright or flight" response, contributes to the emotional response of the pain
experience (Cooper, 1990; Melzack & Wall, 1983). Janig (1990) proposed that
tachycardia, hypertension, tachypnea, and diaphoresis do not result directly from pain,
but instead are manifestations of the anxiety response.
Specificity theories consider pain as an independent sensation with specialized
peripheral sensory receptors (nociceptors), which respond to damage and send signals
along pathways (nerve fibers) in the nervous system to target centers in the brain. These
brain centers process the signals to produce the experience of pain (Kent & Molony,
Pattern theories consider that peripheral sensory receptors, which respond to touch,
warmth, and other damaging and non-damaging stimuli, give rise to painful or non-
painful experiences. These occurrences are a result of differences in patterns of the
signals sent through the nervous system (Kent & Molony, 2001).
Nociception versus pain theories
Nociception is detection of a noxious stimulus, whereas "pain" is an "experience,"
that is the product of the parts of the brain responsible for mental processing of the
noxious stimulus. According to Kent and Molony (2001), "Pain occurs in the brain and it
is only there that you can find it." (para. 3)
Implications of Gate Control Theory for the Present Study
The Gate Control Theory has important implications for pain control (Melzack & Wall,
1970). When pain messages reach the spinal cord, they meet up with specialized nerve
cells that act as gatekeepers, which filter the pain messages on their way to the brain
(Melzack & Wall, 1970). Music may trigger the brain to block out the pain messages by
keeping the gate closed. Melzack and Wall (1990) observed that "this method, we
believe, holds promise as an effective tool for the pain control" (p. 30).
Patients who have undergone bone marrow transplant report less pain and anxiety
after listening to music. Perhaps most intruding is that the therapy may also shorten
the time for the new marrow to start producing blood cells (Leingang, 2003,
This chapter presents previous research in areas related to the current study topic. It
includes past research on the efficacy of music intervention on the physiology and
psychology of both patients and healthy populations.
Clinical Effects of Music
Music therapy is defined as a systematic process of intervention wherein the
therapist helps the client to achieve better health using musical experiences and the
relationships that develop through them as dynamic forces of change (Bruscia, 1989).
Music in the health care setting is defined as "the use of music to influence the patient's
physical, mental, or emotional states before, during, or after medical treatment" (Bruscia,
1989, p. 87). The goal of the application of music in health care settings is the
improvement in a patient's physiological and psychological status through the processing
of music. In bone marrow transplant patients, the goal of music intervention is to reduce
pain and anxiety levels with beneficial physiological and psychological effects.
Music has been used as an intervention in health care settings to decrease pain and
anxiety during dental procedures, childbirth, surgical procedures, and terminal illnesses
(Cook, 1981; Standley, 1986). Standley performed a meta-analysis of 30 medical and
dental studies using music intervention. The average effect size--across all 55
physiological, behavioral, and psychological dependent variables analyzed--was 0.98,
indicating that the groups receiving music intervention scored almost one standard
deviation better than the control groups for each variable. No study has shown a negative
response to music. This meta-analysis supports the use of music to decrease stress and
pain in multiple health care situations.
The use of music has been recommended in critical care settings to decrease
psychological and physiological stress (Collins & Kuck, 1991; O'Sullivan, 1991). Cook
(1981) advocated the use of music as an intervention for patients exposed to altered
sensory environments, including increased, decreased, or distorted stimuli. Cook
hypothesized that in such situation, listening to music can normalize stimulation of the
reticular activating system, and it can decrease unpleasant stimulations. When people
listen to music, they process it through their reticular activating system, and they respond
individually to its pitch, tempo, rhythm, and volume. Listening to music alters the
prominence of environmental noise and serves as a coping resource.
Neither the sound nor musical notation of the music used for healing in ancient
civilizations remains. Apart from sparse written records, the only information provided is
from ancient inscriptions of musical instruments or music-healing ceremony paintings
unearthed by archeologists. Until the mid-19th century, the entire assessment of the
cathartic nature of music was based on sources such as the Bible, Talmudic and Sanskrit
texts, mythology, cosmology, or wisdom. Since these sources are clearly non-scientific,
scholars have disregarded all the efficacies therein with regard to health care.
In order to understand the rationale for this study, it is important to examine the
practice of using music for healing through these ancient cultural traditions. Even though
ancient approaches to the study of music and healing are purely anecdotal, this chapter
examines the literature, which defines the characteristics of music used in healing. The
chapter also illuminates the significance of music rituals, music and trance, and music in
healing. A significant body of literature shows profiles of usage of music in healing
among traditional societies in pre-colonial and post-modern Western and ancient
civilizations. Insufficient research exists to address the effects of music on pain and
anxiety among bone marrow transplant patients per se. But the literature reviewed herein
nonetheless provides a background on the role of music in healing with reference to pain
from both physiological and psychological standpoints.
For much of the history of mankind, music and healing have been universal
experiences. The practice of using music for healing has been an ongoing phenomenon
for millennia. Many scholars (Benenzon, 1997; Eliade, 1962; Friedson, 1998; Mullings,
1984; Nketia, 1962) have recognized the use of music for curative purposes. Benenzon
observed that the practice may be almost as old as music itself. Darrow, Gibson & Heller,
1985) suggested that the idea of using music to treat injury or disease is as old as
civilization itself (p. 18). Music and healing, as disciplines of inquiry, have their origins
in ancient civilizations, such as Mesopotamian, Egyptian, Hindu, and Chinese. In Egypt,
the use of music in healing was discovered at Kahum by Petrie in 1889, and the
archeological evidence showed that it dated back to 2500 B.C. (Podolsky, 1934). The
beginning in Greek civilization was during the era of Thales of Miletus (624-546 B.C.E),
the first known Greek philosopher, scientist, and mathematician (Ueberweg, 1972).
Early Greek legends show that in the year 600 B.C., Thales was credited with curing a
plague in Sparta through musical powers. At the very heart of Greek civilization, music
was divine. Demigods, such as Apollo, Amphion, and Orpheus, conjured up notes of
sonic energy into a revered purifier of body, soul, and mind (Grout & Palisca, 1996).
Davis (1999) addressed the historical perspectives of the practice of music therapy
where he noted that music was regarded as a special force over thought, emotions, and
physical health in ancient Greece. Music was described as an art exerting great power
(ethos) over human beings, and certain musical styles came to be associated with
particular peoples and deities. The kithara, a plucked string instrument, came to be linked
with Apollo, the god of the sun and reason. A loud double-reed instrument, the aulos,
came to be identified with Dionysus, the god of wine and ecstatic revelry. The most
important of the mythic musicians in ancient Greek culture was Orpheus, whose music
reportedly had the power to cause inanimate objects to move and even influence the
supernatural forces (Lippman, 1964). Nearly two centuries ago, in his monograph entitled
An Inaugural Essay on the Influence of Music in the Cure ofDiseases, Atlee (1804)
recommended the use of music in the treatment of diseases. Atlee argued that music
healing offered a unique, and occasionally instantaneous, power for healing. Innumerable
studies have been carried out since then.
Moreno (1995) observed that music in the Shamanic ritual can be considered a
stimulus that sedates and reshapes the left hemisphere of the patient's brain from
immediate temporal distractions, thereby liberating the right hemisphere to attend to the
conceptualized world of the spirits. Holistic healing is based on the belief that invisible
forces or spirits that affect the lives of the living pervade the visible world (Taussig,
1987). Moreno observed further that the Shaman trance process is determined by four
factors: 1) a specific stimulus; 2) the times of the day when music is played; 3) cultural
determinants; and 4) imagery of the spirits. For example, the specific timbre of the
instruments--together with the sound intensity--has variable effects on a patient. Certain
kinds of music are more effective during certain times of the day. When music is
performed, the patient not only interprets it within culturally defined norms, but also sees
into the future in order to reveal the deities' expectations for the people.
Moreno (1995) was concerned with music as therapy and music as guided imagery.
He observed that direct uses of music in therapeutic contexts bring about psychological
changes. He also noted that these changes are measured by overt behavior, while
physiological change is measured by standardized medical criteria. In comparing the
direct use of music in therapy and guided imagery, researchers (Marina, 1991; Moreno,
1995) concur that music assists patients in traveling to their unconscious to discover and
come to terms with important inner material.
Music and Healing in Non-European Traditions
In this study, this researcher makes reference to the concept of holistic healing
because the epistemological thought of the ancient civilizations being referenced--such as
long-standing health care practices from East Africa to Southeast Asia-creates the
ancient holistic approaches upon which all healing was based (Sommer, 1996). Holistic
healing is viewed to consist of multiple biological, psychological and social factors that
are interlinked (Lipowski 1977). Hassed, (1998) has observed:
The ancient view on healing was essentially a holistic one, i.e. an intimate
interaction of body, mind, environment and spirit. The human being, and the whole
of society and nature for that matter, was viewed as being intelligent, conscious and
ordered. Nature had laws and in order to stay well or to treat illness one had to
work with those laws. (para. 4)
Several scholars (Eliade 1962; Rouget, 1985; Moreno 1995) examined music and
healing in these ancient civilizations from a holistic healing perspective. For example,
Moreno, highlighted the use of ethnic music for healing, a concept which he called
"ethnomusic therapy" during his study of the holistic healers or Shamans of Brazil. He
observed that "music facilitates the Shaman's travels to the spirit world to establish those
connections that will be a benefit to the patient" (p. 331). Even though Moreno's study
was within the confines of Brazil, the myths revealed here share several parallels with
those of the Taita tribe of Kenya and the Balinese of Southeast Asia. Moreover, Moreno
noted the use of music in many world cultures as a vehicle for inducing a trance for the
purposes of healing while a holistic healer mediates the process. Moreno viewed
ethnomusic therapy as a discipline that considers the impact of music in ritual
performances upon the measured progress of the patient-participant with psycho-
physiological problems of a known etiology.
Moreno also connected cultural music-making to the existence of a deity. He
observed that music, as a part of the culture, is capable of transforming the mental state
and infusing supernatural healing in a patient within the cultural context. According to
Moreno, the supernatural healing that is achieved by way of communication between the
spirit and the patient is due to music. He contended that the auditory power of the drums
of the healer or Shaman induces changes in the alpha and theta waves within the brain.
These changes, in turn, induce a trance-like state, allowing the healer to fly to the sky to
encounter the spirits. This metaphysical effect of healing using music continues to
challenge many scientists (Mullings, 1984). Consequently, this idea has led many of them
to give credence to the thought that the uses of music in therapy may precipitate
epistemological issues of the "placebo" effect (Engel, Guess, Kleinman, & Kusek, 2002;
Mullings, 1984). Hart (1999) observed that the placebo response represents the
mysterious self-healing forces generated by the mind-body connection. According to
Shapiro and Shapiro (1972), the term placebo first appeared in the medieval Catholic
liturgy to describe a flattery, and since the 19th century, the term has been used to refer to
medicine given more to please than to benefit the patient. The word placebo (in Latin, "I
will please") has been defined as an inactive substance or preparation given to satisfy the
patient's symbolic need for drug therapy and used in controlled studies to determine the
efficacy of medicinal substances (Achterberg, Dossey, Gordon, Hegedus, Herrmann &
Nelson, 2006). The connection between the efficacies of music healing to the placebo
effect has been discussed (Engel, Guess, Kleinman, & Kusek, 2002). Observations have
also been made to support the fact that placebos still flourish in contemporary medicine
where antibiotics prescribed for viral colds and flu have proven to be ineffective. This has
led many scientists to believe in the placebo (Engel et al., 2002).
Whatever the nature of placebos, certain conditions clearly need to be met if music-
based healing is to take place. Moreno (1995) observed that one condition was a high
level of belief on the part of the patient. Sufficient belief, it seems, can trigger
physiological change. This belief is also true of the Taita, a Bantu-speaking tribe of
Kenya. Moreno's sentiments are that belief and trust in the powers of the supernatural are
catalyzed with music, and therefore music and belief must be present prior to healing.
This allegorical argument leaves the reader to choose one of the paradigms: music or
belief in the gods. Many authors (Eliade, 1962; Nketia, 1962; Mullings, 1984; Benenzon,
1997) seem to point to music as the most fundamental phenomena in healing. In many
parts of the non-Western world, a healer initiates the healing process. The music healer,
usually performs the healing process using several stages.
Kovach (1985) identified four stages. The first stage is the preparatory stage in
which the subjects, the audience, and the Shaman are prepared and initiated into the
process with slow rhythms and soft music. The process begins with a diagnostic test for
the patient. When a patient is diagnosed, usually by the Shaman and preferably in the
Shaman's home, both the client's immediate family members and the community are
invited to the healing ceremony. The second stage is the actualization of the spirit helpers
in which the medium of music, bells, and costumes are dedicated to the spirits. The healer
who normally plays ngoma mwazindika--a composite of text, song, and dance--provides
the beat and the tempo from patterns of established Taita traditions. The third stage is the
trance state, where, with the help of the Shaman, the patient's souls travels into the
ecstatic state where he meets the spirit as the ngoma mwazindika escorts his soul to
heavenly skies. After being exorcised, the soul then returns to earth anew. The fourth
stage is the termination of the ritual where consciousness and healing are achieved as
normality returns (Kovach, 1985).
According to the rich scientific and musical heritage of our ancestors, it therefore
seems that not only did the ancestors listen to music for enjoyment and entertainment, but
also they perceived music as a potent force in the prevention and treatment of various
diseases (Alakbarov, 2003).
The playing of music is intertwined with the creation concepts of many of the
world's cultures. The Taita of Kenya, for instance, have a culture whose cosmology
associates the creation of the world with superior powers that bring healing and comfort
through music. The Taita are a small ethnic group of people who live in a coastal
province of Kenya, close to the Tanzanian border to the east of Mt. Kilimanjaro. The
Taita's legend of creation is imbued with supernatural powers, and it is attributed to
musical powers. According to Taita cosmology, their country was created on regular and
irregular musical rhythms, which are manifested in the topography of the land where the
Taita live. The land is interspersed with mountains, plateaus, and valleys.
Throughout the ages, music played an important role when healing was needed. It
has been noted that in all cultures and at all times, healers knew the positive effects of
music. Even though the specific role and application of music in healing has been noted
in Africa, systematic studies of the variety of forms used in these processes have lagged
far behind for two possible reasons. One reason is that the use of healing music, among
the Taita of Kenya for instance, is an area instilled with esoteric beliefs. Another reason
is that the cultural notions of the etiology of diseases are still based on myth rather than
empiricism. For example, the belief in the vitality of the Taita ancestral spirits (pepo)
remains strong. While the Taita cosmology holds that there are two kinds of pepo,
beneficial and evil, the cosmology also associates the origin of all diseases with the evil
pepo orpepo shetani. Whenever an individual becomes is in pain, the general belief is
that the patient is possessed by the pepo. A healing ritual for the patient is then initiated
in which traditional music (ngoma) plays a core role in the healing pain and exorcising of
the spirit that brings illness to the patients.
The modern scientific and medicalized construction of pain provides a totally
different perspective. Efforts to effect an epistemological compromise between the
scientific objectivism and the non-scientific subjectivism has been a challenge for almost
two centuries (Turk & Melzack, 1992). Kaufman-Osborn (2002) has observed:
To the biomedical researcher, pain is understood not as a manifestation of some
disorder or malady stitched into the very seams of the cosmos, but as an aversive
effect occasioned by changes in various etiological mechanisms, including sensory
receptors, afferent neuronal relays, and spinal-cord, midbrain, or higher cortical
modulating systems. Read as an indicator of nociception, as a sign or symptom of
injury or disease, pain is to managed by removing its cause or, failing that, by
administration of analgesia (p. 137)
In adding credence to the traditional and cultural beliefs, Cornelius (1990) observed
that sound is used to reach outwards towards the deities. In turn, it is through the
vibratory matrix which sound provides that the deities themselves descend from the
spiritual abode to participate in the world of man. Cornelius' reflection provides new
insights into what Harper (1969) observed three decades earlier that dance is the vortex of
religious ritual. In her examination of the function of dance in Nigeria, Harper concluded
that the main purpose of dance was to appease the supernatural powers, solicit divine
protection, and give thanks to the guardian spirits of the community.
From a biomedical standpoint, Graham-Pole (2000) noted that "dancing is good for
your circulation, your balance, your fine muscle control, sense of self-esteem" (p. 140).
Africans generally tend to approach healing through music and dance. For example, in
northern Nigeria among the Hausa (Friedson 1998) observed that the sounds of the
garaya (a two-stringed plucked lute) and buta (a gourd rattle) call the divine horsemen of
the sacred city of Jangare to descend into the heads of b6orii, thereby healing the people
they have made sick.
However, the foregoing phenomenological practices of using music to cure
diseases have not gone without some challenges. Even though historical debates on the
efficacy of music as a healing device are not the focus of this study, a few instances are
worth mentioning. Early 19th century Americans used herbal remedies to deal with
common discomforts, such as colds or constipation. These remedies came to be called
"snake oil" (Carol, 2000). Snake oil was originally associated with Chinese railroad
laborers in the 1860s. As an opioid, snake oil, which had no addictive ingredients, was
given without restriction (Carol, 2000). Just as more scientists questioned the efficacy of
such remedies, Mullings (1984) questioned the legitimacy of music as a healing agent,
branding it merely as "brainwashing" technique (p. 181). In Mullings' view, it was the
excitement and exhaustion from music, rather than the music itself that led to alterations
in brain functioning (p. 181). Mullings observed that these changes promoted the
disruption of old behavior patterns and facilitated the promotion of new ones.
Specific musical instruments in Africa have been associated with affecting changes
in human health. Drums are an example of such important instruments. Throughout the
world, the drum has been used for healing purposes. The drum has also long been used in
tribal societies with holistic healing traditions while communicating with the gods.
Klower (1997) observed that "it is clear that the drum has been used since time
immemorial as a regular part of healing traditions, where it was used in religious
ceremonies, accompanied by singing and dancing" (p. 21). Klower also noted:
The drum is connected with the Shamanistic practices and rituals in all of Central
Asia, from Tibet to Northern Siberia, as well as those of the Eskimos and Native
Americans. (p. 21)
In West African wisdom teachings, Cottrell (2001) noted that emotional
disturbance manifests as an irregular rhythm which blocks the vital physical energy flow.
Cottrell also referred to current medical research, which has shown that stress is a cause
of 98% of diseases, such as heart attacks, strokes, and immune system breakdowns.
Recent biofeedback studies (Echenhofer, 1987; Harer, 1990; Spintge & Droh, 1992;
Turow, 2005) show that drumming along with one's own heartbeat alters brainwave
patterns and dramatically reduces stress.
Rhythm is the element of music that distinguishes it from other auditory stimuli
(Scartelli, 1989). Wertheim (1997) hypothesized that rhythm may have an impact on the
entire cerebral cortex and large subcortical areas. This information reaches the medial
geniculate by way of the ascending reticular formation. This formation activates the
limbic system and cortex. Ancient civilizations, such as those in Africa, however, do not
relate to disease from this perspective. Their understanding of the disease etiology is
embedded in their cosmological viewpoints.
Among the Taita, a regular and balanced meter is regarded as a sign of good health.
Even during improvisation, performers are expected to render an exact replica of a
standardized musical practice. Such mythologies can relay regular and replicated
rhythms to heal the person in an immediate and powerful way by removing blockages
and releasing tension. They can be seen in the performance of musical ensembles
(ngoma) as well. The lead drummer plays a glissando by gliding the left hand from the
middle of the drum to the edge (kusira ngoma). By doing this, the drummer not only
offers an emotionally expressive pattern at the climax of the healing ritual, but he also
provides functional significance to the healing process. During this moment, the drummer
sedates the beneficial spirit (pepo) so that it can descend and exorcise the evil spirit from
the patients. Kusira ngoma, which literally translates as "going beyond with music," is
the climax of the healing ritual and its ultimate extreme. This is the stage at which the
patient shivers, falls to the ground, and ultimately goes into a trance.
Many theories have been postulated regarding the condition of a patient in a trance
following a session of musical healing. Convulsions have been reported in some
instances (Erdtsieck, 1997). Some patients may be possessed by the pepo that comes with
the music, which causes them to run away from home. This running may simulate the
symptoms of one suffering from fugue (a kind of dissociative disorder). This disorder is
synonymous with the term kuchima napepo that means "to run with the spirit," as
opposed to "rolling with the spirit" (kugaragara napepo) (Erdtsieck, 1997). Fugue, or
"flight," involves presumed forgetting. It also refers to fleeing from one's home and
identity for days, months, or even years. Usually when people are stricken with fugue,
they flee from their home and move to a new location. They may give themselves a new
name or even choose a new group of friends. Once patients are brought back to their
original surroundings, they will usually remember a face or a place, but they will not
admit to remembering (Hollandsworth, 1990). In the case of the Taita, when such patients
hear the ngoma music, they run to the rhythm of the beat to maintain their health.
During this performance, the lead drummer controls the emotions of the patients
while they unlock their inner subconscious mind. In the middle of the performance when
the interlocking parts become intense, a state is induced in patients in which they begin to
dance pathogenically as they respond to the mwazindika drum, letting their souls soar into
the supernatural world to meet the deity. In a similar supernatural mediation, Cornelius
(1990) found that the bata drums are believed to be capable of talking and
communicating directly with the Orishas, or Yoruba gods, to bring healing.
As patients delve into their subconscious worlds, the healer plays a glissandi
(kusira ngoma) on the mwazindika. The healer, who occasionally wets his left thumb
with saliva and glides it from the edge to the middle of the drum, continues to pound
from the edge to the middle with his right hand until the patient stands and exits the
healing arena. Janzen (1978) wrote:
Music with the assistance of medicines brings out the speech in the sufferer, which
then indicates to the presiding witchdoctor mganga which spirit must be dealt with.
Specific instruments play distinctive rhythms appropriate to each spirit. (p. 126)
Music and Healing in Southeast Asia
The Balinese also believe that illnesses are a result of evil spirits who may be
inveigled by the malevolent goddess, Rangda, or through evil persons called orangjahat.
Larco (1997) observed that illness is a cultural construct, and, in the context of the
prevailing norms, the culture's perceptions for diagnosis and cure are efficacious. In the
midst of all the foregoing mythological patterns, both the Taita and the Balinese believe
strongly in the effects of music, which compel the white, or beneficial, gods to descend to
Earth to provide healing. For this reason, music is evidently ubiquitous in the healing
ceremonies of the Taita who use folk music and a healing drum ensemble, or ngoma.It is
also evident among some Balinese who use folk music with a healing ensemble, or
gamelan gong beri, or the 20th century gong kebyar. Jilek (1999) equated the therapeutic
effectiveness of indigenous treatment methods with the current Western therapies (Jilek,
In his research on the social role of music healers in Sri Lanka, Kapferer (1983)
stated that the exorcist must achieve a high status and reputation in order to exorcise
those in the higher caste (p. 42). Because of these expectations, healers are held in high
esteem. Findings in this study show that that belief in the healer himself as a member of
the high caste is essential as well.
Music and Healing in European Traditions
The first metamorphosis is mentioned and fully explained in the Musica Medicina
of Richard Browne (1605-1683), published after his death. Browne ran an apothecary in
Oakham in Rutland County, England where he stressed the possibility of a shift from
description and prediction to control, and the introduction of the manipulative standpoint
into the contemplative. Browne showed how to formulate scientific questions in a search
for causes of illnesses, which would lead to some tangible prognosis. He showed a
heightened interest in integrative care--the blending of complementary and alternative
medicine (CAM) with conventional medical practice. He therefore anticipated some
physiological reactions to music, and he proposed that music be used as preventive
treatment in health care. Browne himself favored "the fine Adagio and Allegro Parts in
Italian Operas" (p. 38). He concluded his 125-page essay with a lengthy discussion of
various diseases and how patients respond to musical stimuli. Music Medicina sets the
stage for scientific inquiry into the discipline by attempting to bring normativists and
scientists to the forefront of research in music and health care in order to improve the
quality of life (QOL) for humankind. Quality of life is a multidimensional concept an
individual's satisfaction or happiness with life in domains he or she considers important
Modem-day researchers are intrigued about treatment and therapy. They believe
that treatment and therapy can produce some kind of desired remedy, or change, and can
soothe, mollify, and channel energy in the state of the person who is ill or dying. In all
cases, the therapist is trying to make the patient's future, in some sense different from the
present. Browne (1729) developed nine cogent theories about music and medicine:
* Success in music does not depend on the proficiency attainable only by practiced
musicians but rather on success at one's appropriate ability and function levels.
* Music can change and evoke moods.
* Music can give rise to extra-musical associations.
* Emotions can cause psychosomatic disorders.
* Stimulating music and sedative music have differing effects on individuals.
* Music can influence physiological processes.
* Music may be harmful in treating some health conditions.
* Music has a wide variety of therapeutic applications.
* Music may be used in preventive health care.
The influence of Browne's treatises on the use of music as medicine has brought a
phenomenon change in the subject. Browne's contribution was followed closely by two
of his medical students: Benjamin Rush, who is regarded as the "father of American
psychiatry" and Samuel Matthews, whose publications Music in Medicine (1808) and On
the Effect of Music in Curing and Palliating Diseases (1806) contributed immensely to
the field of music and medicine.
Browne's theories led to the development of scientific approaches to music and
healing in the Western world. The implementations of these theories were seen in
Victorian England in the 1890s when the Society of St. Cecilia began to employ London
musicians to give concerts in London hospitals (Davis, 1989). Anecdotes and traces of
some quasi-scientific approaches to the field of music and healing in the United States
occur where music was performed for hospitalized patients. These anecdotes go as far
back as 1789 (Heller, 1987). Although elaborate therapeutic procedures fascinated 18th
century physicians, this period also produced pragmatic reformers who realized that
complementary and alternative medicine (CAM) would help match the standardized
scientific interventions. During this Age of Enlightenment, to borrow the ideas of Magner
(1992), social and medical reformers were inspired by the belief that it was possible to
improve the human condition through the application of aesthetics. The idea that listening
to music could cure illnesses reached its peak with the invention of the phonograph in
1877. The new invention provided music to greater numbers of hospitalized patients as
the cost of delivering this service became economically feasible (Taylor, 1981).
At the turn of the 20th century, scientists began to develop music therapy programs
in hospitals, by carrying out systematic studies in both England and the United States.
Treatment of World War I veterans led to the acceptance of psychiatry as a way to deal
with certain changes. World War II witnessed an amazing growth in the interdependence
of music and medicine, as doctors began to use music to help patients in what was known
as adjunct therapy (Schullian & Schoen, 1948). Patients responded very well, and, in
some instances, their stay in the hospital was shortened. Since then, many studies have
been carried out on pain and anxiety based purely on scientific models. Such experiments
were conducted in many regions of the world including Japan, Britain, Australia, and the
Music continues to have a place in contemporary healing. Regarding his work with
an autistic child, Alvin (1991) stated:
I hoped that in time, music could reach his subconscious and bring out his feelings
of aggression, fear or anger so that it could relieve his anxieties and tensions,
provide a non-threatening environment in which he could express himself freely
and find his identity; help him to develop his perceptual awareness and motor
control. (p. 32)
Research carried out by Neher (1961) suggested that repetitive African drum
patterns might promote an altered state of consciousness leading to healthful results
(Mullings, 1984). In fact, African music has been credited with affecting musical heart
rate rhythmicity (HRR), which is a specific kind of heart rate variability (HRV). The
heart rate variability corresponds to the predominance and cyclicity of (binary) patterns in
a series of respiratory rate interval differences (Bettermann, 2002).
Music and Anxiety in the 20th Century
Ladies and Gentlemen, my respected and beloved music friends! Music animae
levamen, music is medicine for our souls. (Rueger, 1991)
For the purpose of this study, the researcher makes reference to a myriad definition
of anxiety, including behaviorist and psychoanalytic points of view. Anxiety is a
biologically mediated response to stress or change (May, 1977). Anxiety has been
additionally defined as the apprehension cued by a threat to some value that the
individual holds essential to his existence as a person. Its special characteristics are the
feelings of uncertainty and helplessness in the face of danger (May, 1977; Selye, 1977).
Anxiety is a common phenomenon occurring in hospitalized patients, a condition
nurses deal with on a daily basis (Shuldham, Cunningham, Hiscock, & Luscombe, 1995).
Anxiety has been used as a nursing diagnosis, defined as a process that includes
constructs of stress and perceived threat resulting in states of anxiety that are transitory in
nature (Carpenito, 1993). Spielberger, Gorusch, Lushene, Vagg, and Jacobs (1983)
described a state of anxiety, as characterized by subjective feelings of tension,
apprehension, nervousness, and worry, and also by the activation or arousal of the
autonomic nervous system.
Selye (1977) defined anxiety as reactions to stress. A year later, Cannon (1978)
defined anxiety as "irritation of the entire organism and an activation of instinctive
defense mechanisms." He called these mechanisms "alarm reactions" which were identified
in many clinical studies. These pathophysiological reactions, which have also been referred
to as "psychovegetative reactions," can cause the patient more suffering (Bodley, 1974;
Birbaumer, 1977). These reactions can also make medical treatment more difficult and
reduce resistance in the organism (Gedda & Rizzi, 1962; Williams & Jones, 1968;
Wolpe (1958) defined anxiety as "a set of emotional predispositions attributed to a
special kind of circumstance" (p. 4). According to the National Institutes of Mental
Health, approximately 19 million Americans suffer from anxiety disorders (NIMH,
2006). Citing several scholars, Shultis (1999) showed: 1) how technology and research
have identified the physiological benefits of music on the immune system (Rider, Floyd,
Kirkpatrick, 1985; Lane & Wilkins, 1994); 2) the benefits of music for relaxation and
stress management (Davis, 1992); 3) the application of music to memory and attention
(Morton, Kershner, & Seigel, 1990); and 4) music-related long-term changes in the
behaviors of depressed elderly patients (Hanser & Thompson, 1994).
For the better part of the previous decade, scholars have researched the use of
music to control anxiety. Many scholars (Stevens & Phil 1983) have addressed
alleviation of stress and anxiety among students. Hammer (1996) studied the relationship
between music therapy and participants' perceived stress level. The participants were
engaged in a music therapy sessions that included relaxation techniques and guided
imagery. The State Trait Anxiety Inventory (STAI) was administered before and after the
music therapy session. In the experimental group, a slight reduction in the STAI levels
and a perceived decline in stress levels occurred after the music therapy sessions.
Vink (2001) reminded us of these opening lines of the book Die musikalische
Hausapotheke (The Musical Home Medicine Cabinet) written by the German
musicologist Christoph Rueger. As cited by Vink, in his work, Rueger (1991) described a
variety of musical recipes to cure an equally impressive variety of disorders. By closely
examining his laboratory, it is obvious that listening to Beethoven's Symphony No. 2
helps an individual cope with feelings of depression and doubt. Clark (1970) emphasized
this point by stating:
Beethoven's idea in regard to his own music was that it was his means of serving
humanity; the phrase "suffering humanity" was often on his lips and is to be found
in his letters. (p. xxx)
Rueger also stated the popular Goldberg Variations of Bach decrease sleeping
disorders created by anxiety (1991, p. 144). Shultis (1999) commented:
Rethinking the application of music therapy has required the development of
methodology that is observable and measurable, and can be applied to many
different treatment settings. (p. xxx)
Effects of Music on Anxiety
Patients undergoing a bone marrow transplant often experience anxiety in
anticipation of events that are unfamiliar, uncomfortable or have undesirable results.
Numerous studies have researched the effects of music on anxiety levels in different
types of subjects. Music is an easily administered, nonthreatening, noninvasive, and
inexpensive tool that can be used to calm the anxiety experienced by bone marrow
transplant patients. Lee, Chung, Chan, and Chan (2005) observed:
ICU patients are not only compromised by illness, but also exposed to a wide range
of stresses, including invasive treatments, the experience of pain, threat of death,
insufficient sleep, continual exposure to noise, reduced personal dignity and the
loss of interaction with family and friends. (p. 610)
Increased anxiety activates the sympathetic nervous system, as manifested by an
increased heart rate (HR), blood pressure, respiratory rate (RR), and neurohumoral
responses, possibly leading to a destructive anxiety syndrome (Lee, et al., 2005). Since
the first transplant in the 1950s, reports have been made that patients who underwent
bone marrow transplantation had a poor prognosis if they experienced anxiety prior to
and during transplantation (Illescas-Rico, Amaya-Ayala, Jimenez-Lopez, Caballero-
Mendez, & Gonzalez-Llaye, 2002).
Summers, Hoffman, Neff, Hanson, and Pierce (1990) hypothesized that test-taking
anxiety is decreased in nursing students listening to music with a rhythm of 60 beats
per minute due to synchronization between a subject's pulse and the music. An
experimental design with 45 subjects was used. No significant changes in the State-
Trait Anxiety Inventory (STAI) scores or test anxiety scores were noted between groups
or within groups over a period of time. STAI is a self-report inventory established by
Charles Spielberg (1976) to assess anxiety. No significant differences occurred in pulse
rates before and after testing in either the experimental or control group. However,
the standard deviation of the experimental group decreased, which might reflect a
statistically nonsignificant trend toward synchronization between the pulse and the
Four different studies assessed the effects of music on patients' anxiety in a
coronary care unit (Bolwerk, 1990; Elliot, 1994; White, 1992; Zimmerman, Pierson, &
Marker, 1988). Zimmerman et al. (1988) randomly assigned 75 subjects with suspected
myocardial infarction to one of three groups: 1) listening to relaxing music; 2)
listening to white noise; or 3) being subjected to a 30-minute period with no musical
intervention. State anxiety (as measured by the STAI), heart rate, blood pressure, and
digital skin temperature were compared before and after the music interventions. No
statistically significant decrease in state anxiety scores was noted in any group, but the
music intervention group had the largest decrease. No significant changes in
physiologic variables were noted among the groups, but pooled data revealed
significant differences over a period of time.
Bolwerk (1990) compared the effects of listening to relaxing music (n = 20) to a
control group (n = 20) of myocardial infarction patients who scored as being anxious on the
STAI at the baseline. Baseline differences in anxiety scores between music and control
groups were statistically nonsignificant. Post-intervention, however, the music group's
STAI scores were significantly lower (p < 0.007) compared to the control group. The
decrease in the music groups' pre- and post-intervention anxiety scores was also
significant (p < 0.001). In that study, music was helpful in decreasing anxiety in
myocardial infarction patients. A methodological difference from Zimmerman et al.'s
(1988) study, which may have influenced the results, was that Bolwerk provided three
sessions of music instead of one and each session had a greater period of time (three
days) from pre- to post-testing.
Elliot (1994) randomized 56 coronary care unit patients with unstable angina or
acute myocardial infarction into three groups: 1) classical music audiotape intervention; 2)
muscle relaxation audiotape; and 3) control (uninterrupted rest). Subjects received two or
three 30-minute intervention sessions over a period of 24 hours. No differences were
found among the groups in STAI scores, Hospital Anxiety and Depression Scale scores,
Anxiety Visual Analogue scores, heart rate (HR), or blood pressure (BP). The effect sizes
were 0.19-0.22, which demonstrate a degree of effect on anxiety. The small sample size in
each group may have resulted in a type II error. Also, the HR and BP assessments were
not concurrent with the interventions; therefore, changes in the HR and BP may have
occurred during the intervention period.
White (1992), used an experimental design similar to Zimmerman et al.'s (1988), and
compared the STAI scores, heart rate (HR), and respiratory rate (RR) in 40 myocardial
infarction patients. The experimental group listened to 25 minutes of relaxing classical
music, whereas the control group received 25 minutes of uninterrupted rest. A statistically
significant decrease in STAI scores post-intervention occurred for both groups: the
control group p < 0.02 and the intervention group p < 0 .001. Statistically significant
decreases in HR and RR were noted in the experimental group, but not in the control
The use of music as an intervention to reduce anxiety in post-operative coronary
artery bypass graft patients has also been evaluated. Barnason, Zimmerman, and Nieveen
(1995) randomized 96 patients into either music intervention, music-video intervention,
or scheduled rest groups. Subjects received their assigned intervention for 30 minutes
once daily on post-operative days 2 and 3. Patients were in either intensive care or
progressive care unit settings. No significant changes in anxiety, as measured by the
STAI and a numerical rating scale, were found. Subjects in the music intervention group
reported significant improvement in mood, as measured by a numerical rating scale
following the two music intervention sessions. No differences in the HR or BP were noted
between groups, but all physiologic measures had a main effect over a period of time,
demonstrating a downward trend that may reflect relaxation.
Moss (1988) researched the effect of self-selected music played from the pre-
operative to the post-operative period on state anxiety. A significant decrease in
STAI scores occurred in the experimental group compared to the control group. Thep
value was not cited. Weaknesses in this study were the small sample size (n = 17) and
administration of the STAI while the subjects were still recovering from anesthesia.
However, these findings are partially supported by the later work of Kaempf and
Amodei (1989), who evaluated the use of music in the pre-operative holding area.
This study randomized 33 subjects into an experimental and control group, comparing
pre- and post-intervention STAI scores, HR, BP, and RR. The experimental group
listened to sedative music for 20 minutes in the holding area, resulting in significantly
decreased STAI scores (p = 0.005) and RR (p = 0.002) post-intervention. Decreases in
systolic blood pressure (SBP) were marginally statistically significant (p = 0.055) in the
same group. The control group also demonstrated decreased STAI scores (p = 0.049) and
SBP (p = 0.029) between the baseline and post-intervention. The only change that was
significant between the groups was the decrease in the RR, which was significantly
greater (p = 0.047) in the experimental group. Both Moss and Kaempf and Amodei's
small-scale studies demonstrate a possible trend toward decreased anxiety with the use of
music in the surgical setting. Collectively, research supports the usefulness of music in
Recent studies (Campbell, 1997; Panksepp, 1995; Sloboda & Juslin, 2001; Tse, et
al. 2005) have shown that music lowers a patient's blood pressure, basal metabolism, and
respiration rates, and it increases the production of endorphins that reduce pain.
Endorphins are the body's natural pain medication hormones. Endorphins, when released,
make a person feel better, improve his mood, increase his pleasure, and minimize his pain
(Smeltzer & Bare, 1996). Considerable scientific rationale in the 20 century supports the
use of music to increase the production of endorphins and reduce pain and anxiety in
patients. Music's ability to alter pain and emotional states has long been known
experientially, and more recently this ability has been scientifically documented.
Studies continue to show the effects of music on human health. Brownley,
McMurray, and Hackney (1995) carried out research on the influence of music on
physiological and effective exercise responses in eight trained and eight untrained runners
under three music conditions ("no," "sedative," and "fast") during low-, moderate-, and
high-intensity exercise. Repeated-measures ANOVA revealed increased respiratory
frequency (RF) during fast music, as compared to the "no" music and "sedative" music
conditions (p < 0.01).
In an investigation on music and labor pain, Geden, Lower, Beattie, and Beck
(1989) carried out two studies to examine the effects of music on analogued labor pain
using volunteer nulliparous subjects who were randomly assigned to treatment groups (n =
10 per group). Assessments of treatments were made in a one-hour session involving 20
80-second exposures to a laboratory pain stimulus. The stimulus was patterned to
resemble labor contractions. In the first experiment, it was hypothesized that subjects
listening to easy-listening music would report lower pain ratings and cardiovascular
responses than subjects listening to rock music, self-selected music, or a dissertation
(placebo-attention) as compared to subjects in a no-treatment control group. Significant
group effects were found. Subjects spontaneously reported using imagery as a pain reduction
technique. In the second study, a combination of music and imagery was examined by randomly
assigning subjects to one of five groups: 1) self-generated imagery with music (SIM); 2) guided
imagery with music (GIM); 3) self-generated imagery without music (SI); 4) guided imagery
without music (GI); or 5) a no-treatment control. Again, significant group effects were obtained
for heart rate and systolic and diastolic blood pressures. Statistical analysis showed
significantly lower pain perception in the music group compared to the control group.
This finding is important for health care professionals; music may be an effective
treatment for women who have trouble coping with pain sensation.
In another study on the effect of music on stress levels, Migneault et al. (2004) examined
the effect of music on the neurohormonal stress response to surgery under general anesthesia.
Their study found that several pharmacological interventions reduced pre-operative stress
hormone release during surgery under general anesthesia. They also studied listening to
music and therapeutic suggestions, and found a positive effect on post-operative recovery
and the need for analgesics. In that study, they evaluated the effect of listening to music under
general anesthesia on the neurohormonal stress response to surgical stress, as measured by
appropriate medical procedures.
In a study on effective music and its effects on state anxiety, Rohner and Miller
(1980) observed that music in various institutions and other research settings has the
potential to reduce anxiety in high-anxiety subjects. They randomly assigned 10 sections
of introductory psychology students (n = 321) to one of four treatment conditions or to
the control group. The state portion of the STAI questionnaire was administered in a
counterbalanced fashion prior to and following the music (or no music) treatment. State
anxiety (S-Anxiety) refers to the subjective and transitory feeling of tension, nervousness,
and worries and may be characterized by activation of the autonomous nervous system, at
a given moment (Fountoulakis, Papadopoulou, Kleanthous, Papadopoulou, Bizeli,
Nimatoudis, et al., 2006). Results proved to be statistically nonsignificant. In addition, a
trend of sedative music having some anxiety-reducing effects upon high state anxiety
subjects was noted.
In an attempt to respond to the issue of whether or not singing promotes well-being,
Grape, Sandgren, Hansson, Ericson, and Theorell (2003) carried out an empirical study of
professional and amateur singers during a singing lesson. This study explored the possible
beneficial effects of singing on a patient's well-being during a singing lesson. Eight amateur
musicians were included, consisting of two males and six females between the ages of 28
and 53 years, and eight professional singers consisting of four males and four females,
between the ages of 26 and 49 years, who had been taking singing lessons for at least six
months. Five visual analogue scales (VAS)--sad-joyful, anxious-calm, worried-elated, listless-
energetic, and tense-relaxed--were scored before and after the lesson. In addition, a semi-
structured interview was performed. Heart rate variability analyses showed significant changes
over a period of time in the two groups for total power and low- and high-frequency power.
Power increased during singing in the professionals, but no changes occurred in the amateurs.
A power increase during singing in the professionals indicates an ability to retain more "heart-
brain connection," that is, more cardio-physiological fitness for singers. In another study on
anxiety, Yilmaz, Ozcan, Basar, Basar, Batislam and Ferhat (2003) carried out a study to
determine if music decreases anxiety and provides sedation with extracorporeal shock
wave lithotripsy (ESWL). Yilmaz et al. (2003) concluded that listening to music by patients
during the ESWL treatment is a feasible and convenient alternative to sedatives and anxiolytics.
Winter, Paskin, and Baker (1994) observed that many patients become stressed and
anxious prior to and after surgery, and one means of helping reduce anxiety in patients is
to incorporate music in the surgical holding area. In their study, they divided subjects into
two groups: one group of patients listened to music while a second group did not listen to
music. The researchers noted that patients who listened to music while in the surgical
holding area had significantly less stress and anxiety than those patients who did not
listen to music. Both groups spent similar lengths of time in the surgical holding area.
They concluded that all the patients preferred the musical intervention since they
experienced less anxiety.
Researchers at the Bryan Memorial Hospital in Lincoln, Nebraska, investigated the
influence of music therapy on the mood and anxiety of patients undergoing heart surgery.
Ninety-six patients, who underwent elective heart bypass surgery at the cardiovascular
intensive care and progressive care units of this midwestern community hospital,
participated in the study. Data relating to anxiety and mood were obtained through blood
pressure and heart rate using Spielberger's (1983) State-Trait Anxiety Inventory
(STAI). The study revealed that patients' mood ratings showed significant improvement
in mood among those patients who were in the "music therapy" group after the second
intervention. Significant main effects were also observed over a period of time for heart
rate, systolic and diastolic blood pressures in the music therapy group, which indicated a
generalized physiologic relaxation response. Reduced anxiety and improved mood were
indicated in all three groups, and the researchers noted that all the interventions
demonstrated generalized relaxation (Barnason et al., 1995). To support the use of music
in patients undergoing open-heart surgery, Voss (2005) noted:
Health care providers should feel confident in using music for post-operative open-
heart patients and should try it with other patients to decrease anxiety and pain.
From a clinical perspective, sedative music is low risk, and it is therefore
recommended in addition to pain medication to relieve anxiety and pain for cardiac
patients during chair rest following surgery. (p. xx)
In another study, Augustin and Hains (1996) examined the role that music therapy
plays in a post-operative setting for ambulatory patients. In the Day Surgery Unit of St.
Mary's Hospital in Mequon, Wisconsin, the authors investigated 42 ambulatory surgery
patients assigned to either an experimental group, which received music therapy along
with the standard pre-operative instructions, or a control group, which received the
standard pre-operative instruction alone. The results revealed that patients in the
experimental group showed significantly lower heart rates compared to those in the
control group. The experimental group also showed greater improvements in blood
pressure and respiration rate. The researchers concluded that music therapy offers
demonstrable benefits for ambulatory surgery patients and recommended that patients be
offered music as an effective option to help alleviate post-operative anxiety (Augustin &
Effects of Music on Pain
The arts are quintessentially holistic in their healing effects, promoting as they do
the personal and collective health of the body, mind and spirit. (Graham-Pole,
2005, para. 1)
The newest statistics on pain management have been addressed in recent research
(Magni, Marchetti, Moreschi, Merskey, & Luchini, 1993). The National Center for
Health Statistics estimates that 32.8% of the U.S. general population has persistent or
chronic pain symptoms (Magni et al., 1993). It is further estimated that 94 million U.S.
residents have some form of episodic or persistent pain, that is, pain associated with
cancer, migraine or tension headaches, chest pain, pain from diabetes with neuropathy,
arthritis, fibromyalgia, neuralgias, neck and back disorders, facial pain disorders,
functional or organic bowel disorders, or pelvic disorders (Gallagher, 1999).
Various types of music have been investigated as a means to decrease pain and the
need for analgesics. In a small laboratory study with 10 healthy female subjects, Whipple
and Glynn (1992) investigated the effect of soothing and stimulating music on tactile
thresholds, pain thresholds, HR, and BP. Collectively, their research supported the
usefulness of soothing and stimulating music in decreasing pain in subjects. Stimulating
music significantly increased pain and tactile thresholds, whereas soothing music
increased pain threshold but not tactile thresholds. No significant changes in HR or
BP were detected.
Heitz, Symrend, and Scamman (1992) randomized 60 post-anesthesia general
surgical patients into three experimental groups: 1) headphones with self-selected
music; 2) headphones with no music; and 3) no headphones. Analysis of variance
(ANOVA) yielded no significant differences in pain levels among groups, as measured
by a VAS, morphine use, HR, RR, or mean arterial blood pressure (ABP). However,
subjects receiving music rated their post-anesthesia care unit experience as being more
pleasant (p < 0.05) than the other groups rated their experience, both at one-day and
Good (1995) compared the individual and combined effects of jaw relaxation
and music in a control group on pain levels of 84 abdominal surgery patients during
their first post-operative ambulation. Subjects were randomized into groups and
instructed in the interventions pre-operatively using an audiotape. After the analysis of
the taped interventions for 2 postoperative days, 89% of experimental subjects reported
that music had helped them reduce sensation and distress of pain.
Musical Preferences of Patients
Podolsky (1934) noted that "Good music and good health are intimately associated
with each other" (p. 200). Perhaps the greatest challenge in the effective use of music in
health care settings is the selection of specific music pieces. Many scholars have defined
music differently. Brophy (2000) observed, "Music consists of melody, rhythm,
harmony, timbre, and form" (p. 40). Individual tastes and varied qualities of the music
may cause different physical and psychological responses (Gardner, 1990). Music
therapists and music healers sometimes believe that their own favorite music is
universally liked and therapeutic for everyone (Good et al. 2000). Elements of music
that should be considered include its drone, repetition, harmonics, rhythm, melody,
instrumental colors, form, and intent (Gardner).
During World War II, an assumption arose that wounded Hungarian soldiers
would recover quickly if made to listen to music of their cultural background; in this
case, Hungarian dances such as Johannes Brahms's No. 5 in G minor (Rorke, 1996).
The wounded Czech solders on the other hand, would respond well to Czech songs
(Rorke). Good et al. showed that cultural awareness, cultural knowledge, cultural
skill, cultural encounters, and cultural desire are all needed in this endeavor.
Music appropriate for stress reduction has a slow, steady rhythm, low-frequency
tones, orchestral effects, and a relaxing melody (O'Sullivan, 1991). The music must be
played at a comfortable volume level and have no negative associations for the listener
(Cook, 1981). The use of music in post-operative cardiac surgery patients in critical
care units should theoretically substitute pleasing, meaningful sounds for loud,
unfamiliar sounds, thus resulting in decreased levels of annoying noises.
Atlee (1804), completed a work entitled "An Inaugural Essay on the Influence of
Music in the Cure of Disease." Atlee advanced two music therapy concepts that are still
accepted today. He was a proponent of using music favored by the patient, and he
developed a therapeutic program relative to the patient's interests and background (Davis,
1987, quoting Atlee, 1804). Kopacz (2005) stated:
In choosing music for therapeutic purposes, one should take into account individual
differences connected with temperament traits, and most particularly with the need
for stimulation. Ignoring such differences could have contrary effects, unintended
by the therapist. Exceeding the optimal dose for musical stimulation or lack thereof
can produce symptoms of stress. Music with a high stimulative value, as preferred
by extroverts, may lead to stress in introverts. On the other hand, music with low
stimulative value, as preferred by introverts, may be a source of stress for
extraverts. (p. 234)
Musical preferences and their effect on different individuals have been debated
during the past decade. Knowledge of musical preferences is enormously significant in
the selection of music for therapeutic work (Kopacz, 2005). Research into personality-
dependent musical preferences has a long history, but little research has been conducted
on how such preferences affect those in pain or those with anxiety. Kopacz noted that
most of the research has been associated with Eysenck's personality dimensions:
extraversion, introversion, neuroticism, and psychoticism. Extroverts usually prefer
homogenous, lively, emotional, vigorous, and sensual music, whereas introverts prefer
intellectual, mystical, deep, introspective, and restrained music (Burt, 2003).
Research conducted by Fumham, Trew, and Sneade (1999) revealed that music, as a
means of stimulation, may aid cognitive activity in extroverts and suppress cognitive activity
among introverts. It would be interesting to see how this theory might be applied to patients
who are in pain or experiencing anxiety, and how these factors affect their musical preferences.
With this consideration in mind, the researcher decided to underscore the importance of a
narrower dimension of pain perception and its usefulness in the study of artistic preferences on
pain and anxiety.
Type of Music
Many pieces of great music will uplift you in body, mind and spirit. But of course
we all have different tastes in the sort of compositions we enjoy, be they classical,
country and western, jazz, or rock and roll. Music of different tempos and rhythms,
and played on different instruments, will also have varying effects on you.
(Graham-Pole, 2000, p. 122)
Music is defined as a complex of expressively organized sounds composed of some
key elements: rhythm, pitch, harmony, and melody (Alvin, 1991; Priestley, 1975).
Rhythm and melody have a common nature, being made up of vibrating movements in
variable frequencies. These frequencies foster the transmission of mechanical energy and
form the dynamic basis of music. The rhythmic structure, as well as the dynamic and
predictable nature of music, may be received by and resonate with different parts of the
body (Lee, et al., 2005).
The ideal music should be calming. The calming and soothing properties of an
appropriately chosen piece of music can help alleviate physical pain and anxieties. The
selection of music for the pain and anxiety experience is very important. The music must
be well balanced and somewhat stable in terms of harmony, rhythm, instrumentation,
melodic elements, tempo, and timbre. Overly dissonant intervals or harmonic
progressions should not be sustained during long periods of time, and the music that
exhibits tensions within tonality needs to be resolved (Spintge, 1989). Podolsky (1934)
observed "Good music and good health are intimately associated with each other" (p.
In this study, the pre-recorded audio music used was based on pieces selected by
the subjects. Favorite music was identified by the subjects and prerecorded on a CD. In
cases where the subjects were unable to select any music, the researcher used relaxation
and support music of a classical nature with definite melodic structure and generally little
dynamic variation. This kind of music fits Spintge's (1989) definition of anxiolytic
music. According to Spintge, music is anxiolytic if it has an effect on the cardiovascular
system, respiratory system, endocrine system, metabolism, motor system, exocrine
secretion and excretion, reception and perception. Examples of this music would include
Beethoven's Adagio from Piano Sonata #8 (Pathetique) and Gluck' s Dance of the
Blessed Spirits from Orpheus and Euridice.
Podolsky (1934) also examined the effects of different kinds of music where he
found that gay music such as Sousa's marches produced an accentuation of dicrotism, a
condition in which the pulse is felt as two beats per single heartbeat. Sedative music is
considered to be slow and between 60 and 80 beats a minute. It should also have a
melody and preferably be instrumental, such as slow jazz, harp music, flute music,
orchestral music, or piano music (Voss, 2005).
To achieve these effects, Spintge (1989) suggested four criteria:
1. Musical works should be selected according to duration, instrumentation,
dynamics, and interpretation. It is important that there are no extremes in
rhythm, melody, or dynamics and that instrumental rather than vocal music be
2. Patients should make their own selections.
3. The effects of individual pieces and combinations of pieces should be tested
and verified in ongoing clinical studies so that new trends and new
technologies can also be considered.
4. Recordings should be of high quality, yet technically simple and reliable
The type of music an individual listens to tends to influence his response to therapy
(Spintge, 1989). Podolsky (1934) discussed in detail an earlier 1918 study of the effects of
three rapid music selections on the heart rate and blood pressure. Patients listened to music
while cardiograms were continuously recorded. Polodosky found that when any of three rapid
music selections were played, a slight increase in heart rate and blood pressure resulted.
In another study, Ellis and Brighouse (1952) measured the heart rate and respiration of
36 students who were randomly selected from a group of college volunteers. Heart rate and
respiration were measured before, continuously during music therapy, and after 30 minutes of
music, over a three-day period. None of the music selections was accompanied by significant
changes in heart rate. For one selection that had a rapid rhythm, almost all the subjects
experienced an increase in heart rate.
In a study of 66 college students (Smith & Morris, 1976), music was played during
a testing procedure. Subjects were allowed to listen to the type of music they desired. A
greater decrease in anxiety occurred as reflected by exam scores in subjects who listened
to sedative music, compared to those who listened to stimulative music.
Kaempf and Amodei (1989) studied the effects of sedative music therapy on the
anxiety of 33 surgical patients in the operating room holding area. The experimental
group received 20 minutes of sedative music therapy via a tape recorder placed on a
nearby bedside stand, while the control group received no music therapy. Both groups
showed reductions in blood pressure and heart rate after the 20-minute period. However,
the music group had greater reductions in respiration than the control group had.
Summers et al. (1990) found that when 45 college students listened to fast rhythms,
their heart rates increased. However, slower rhythms of 60 beats per minute resulted in
lower heart rates and blood pressures.
Music as a Form of Distraction
Drever (1952) defined distraction as a condition where concentration of attention is
disturbed, difficult, or virtually impossible, as caused by irrelevant stimuli. Distraction is
regarded as a major influencing factor in the perception of pain. Gardner and Licklider
(1959) and Melzack et al. (1963) reported that pain is influenced by cognitive and
psychological activities, such as anxiety, expectations, and attention-distraction levels.
This is consistent with the Gate Control Theory of pain. Locsin (1981) observed that
attention switching might not always be easily achieved but may be learned and used to
aid in pain control. Pleasant music played repetitively may enhance distraction.
In the early 18th century, French dentists traveled through the countryside and
brought small orchestras in their caravans as a means of causing distracting to those who
were in pain or were anxious. The orchestral accompaniment was also found to distract
the patient's attention and that would result in his feeling less pain, thereby decreasing his
suffering resulting from the crude dental practices of the time (Good, Stanton-Hicks,
Grass, Anderson, Lai, Roykulcharoen, & Adler, 2001). The mind can exert a powerful
influence over the perception of pain. A distraction or stimulus can elicit changes in the
lower synapses of the sensory pathways, and this is influenced by the significance of the
stimulus and past experiences (Hernandez-Peon, Scherrer, & Jouvet, 1956). The
selection of sensory information with respect to pain occurs at successive synaptic levels
during its transmission, and it is under the dynamic control of the brain (Melzack et al.,
While researching the results of auditory stimulation on the perception of pain,
Melzack et al. (1963) exposed healthy males to four 15-minute sessions of pain, which
were repeated over a one-to three-day period. They found that this stimulation,
accompanied by suggestion, produced a marked increase in the tolerance duration of pain
compared to the control condition without auditory stimulation. When intense auditory
stimulation--without explicit suggestions--was given to reduce the subject's pain, the
auditory stimulation was found to have an insignificant effect. In addition, suggestion
alone without auditory stimulation was found to be ineffective in reducing perceived pain
(Melzack & Wall, 1983). Melzack and Wall (1983) concluded that distraction of central
attention (i.e., auditory stimulation) away from noxious inputs, together with central
nervous system involvement (i.e., from suggestion), could act on input patterns evoked
by noxious stimuli during their transmission.
Locsin (1981) conducted a study of 24 obstetric patients to determine the effects of
music therapy on post-operative pain. The women received 30-minute sessions of music
therapy every 2 hours during the first 48 hours post-operatively. Heart rates of the music
therapy group were significantly lower at 48 hours but not at 24 hours post-operatively,
compared to the control group. Analysis showed that blood pressure readings of the
music group were significantly lower than those of the control group at 24 and 48 hours
post-operatively. No significant changes were noted in respiratory rates at 24 or 48 hours
in the two groups. Post-operative patients, who listened to music therapy during the first
48 hours post-operatively, used less pain medication than patients in the control group.
When asked how the music therapy affected their post-operative pain, eight patients
responded that music lessened the pain and four stated that the music caused some form
of distracted to their pain perception. In addition, 100% of the subjects indicated that
they would recommend music for post-operative patients during the first two post-
operative days (Locsin). In a study of 17 adult post-operative patients, Moss (1988) found
that patients' musical preferences seemed to influence whether or not music therapy was
soothing. Patients reported that the music they selected helped them relax by providing a
distraction from external noises.
Updike (1990) suggested that a reduction of pain can result from a physical and/or
an emotional etiology. Pain may either be diverted via the concentration aspect of music
listening or may raise the pain threshold by use of specific music therapy selections.
Updike studied the effects of self-selected music therapy on 20 intensive care unit (ICU)
patients with various diagnoses. Significant reductions in systolic blood pressure and
mean arterial pressure were found when comparing pretest and posttest measures of
patients who listened to music therapy. A non-directive, open-ended questionnaire was
used to obtain data on patients' emotional responses before and after the music therapy.
Analysis of patients' moods indicated a shift toward a more desirable state of well-being.
Music therapy was found to reduce anxiety, depression, and pain experience. Listening to
music is a useful technique for distraction and reducing pain perceptions as an adjunct to
traditional pharmacological therapy. Distraction in this respect involves a change in focus. It is
condition where concentration of attention is disturbed.
Hernandez-Peon (1960) suggested a neurophysiological explanation for the effect
of music on humans. He thought that when a person is exposed to pleasurable sensory
stimuli, activation of sensory pathways results in the blocking of the transmission of other
sensations. Pain perception may therefore be reduced by inhibiting the psychological
feedback of noxious stimuli from the areas of surgical injury. Hernandez-Peon's study
supports the idea that music not only serves as a distraction, but if the type of music is
considered pleasurable, it may also block the transmission of other sensations.
Studies and observations discussed in this chapter have thus far revealed that both
ritual and scientific practices themselves produce therapeutic, psychological results
through altered states of consciousness. Even though historical debates on the efficacy of
music as a healing device are not the focus of this research, a few instances are worth
mentioning. Among the more modern researchers on this particular argument of the
influence of musical stimuli were Mullings (1984) and Sargant (1973) whose
controversial views on the efficacy of the cathartic nature of music acted as a catalyst for
subsequent research. In Sargant's views, it was violent dancing, which by brining on
perspiration, effected the cure. Mullings and Sargant observed that the new and healthier
behavior patterns facilitated following the musical stimuli brought desired change.
Summary and Implications for the Present Study
A review of the music therapy literature delineates at least three broad domains of
functioning where music therapy has successfully been utilized in the treatment of
emotionally disturbed children: 1) affect regulation; 2) communication; and 3)
social/behavioral dysfunction. Assessment and intervention in each of these domains
require strong grounding in developmental theory, which is a key component in the
training of music therapists. In the middle of the 20th century, music therapy was
identified as an intervention to treat impairments in effective functioning, including
reducing levels of anxiety (Cooke, 1969), and music therapy became a tool to improve
emotional responsiveness (Wasserman, 1972). Music therapy is well suited to help
improve communication deficits and stimulate nonverbal communication in children.
Numerous positive outcomes in improving social functioning, social awareness, and
cooperation (Werbner, 1966) and decreasing disruptive behaviors (Hong, Hussey &
Heng, 1998) have been reported. Conservative estimates from epidemiological studies
suggest that 8%, approximately 470,000 of the U.S. school population--have been
identified through their schools as exhibiting significant levels of anxieties (U.S.
Department of Education, 2001). As a benefit for children with anxiety, Hussey and
Layman (2003) summarized:
An advantage of music therapy is that it is an inherently non-threatening and
inviting medium. It offers a child a safe haven from which to explore feelings,
behaviors and issues ranging from self-esteem to severe emotional deregulation. (p.
Perron and Schonwetter (2001) observed that patients do not always receive
sufficient relief from opioids. They also noted that opioids may have undesirable side
effects, hence using intervention such as music would be appropriate.
METHODOLOGY AND PROCEDURES
This chapter is divided into six sections. In the first section, the 15 subjects
included in the study are discussed. The second section describes the procedures and
setting used during the study. The third section discusses the data collection process and
the instruments used. The fourth section includes the reliability procedures. The fifth
section presents the instruments that were used. The sixth section includes a description
of the statistical analysis.
Quantitative scientists argue that music in health care requires empirical study, but
that type of study cannot be simply observed or verbalized. Scientific orthodoxy stresses
the primacy of cause-and-effect accounts, and most empirical studies of this nature
operate at a meta-analysis level. The empirical method accepted by positivists, according
to Wheeler (1995), tests theories through procedures for scientific objectivity, including
careful observation of behavior, the isolation and manipulation of variables, and
hypothesis testing. Citing Hamilton (1994), Wheeler (1995) observed:
The roots of qualitative, as distinct from quantitative, research can be traced to an
eighteenth century debate between Descartes, who spoke of the importance of
mathematics and objectivity in the search for truth, and Kant, who suggested that
human knowing is dependent upon what goes on inside the observer. (p. 11)
The following discussion presents a methodology that incorporates an empirical
study based on scientific evidence. The basis of scientific inquiry is evidence derived
from observations made on the subjects and from experiments designed to test
hypotheses proposed to explain those observations. This chapter also presents a
discussion on the methodology based on data collected ethnographically, with a limited
amount of controlled experimental work. In this chapter, the researcher presents the
procedures under which the research study was conducted.
This research study used a repeated-measures design. In a within-subjects
design, each participant provides more than one response (Becker, 1999). In this
repeated-measures design, the participant responded both before the treatment and after
the treatment. This according to Becker (1999), is a typical within-subjects design.
According to Becker, the pre-post aspect of the design is a within-subjects factor. This
type of design is also known as a "repeated measures" design (Becker, para. 1). The
participants are assigned to an immediate treatment or a delayed treatment condition.
Measures of pain (using the VAS scale) and anxiety (using the STAI) scale were
recorded in five different time series (see Appendix D). In this time-based, repeated-
measures design, the repeated contrasts were useful in interpreting the time-main effect.
Assessments were made at five different times (see Appendix D).
Control was achieved by using the baseline readings of pain, anxiety, blood
pressure, heart rate, and respiratory rate. Each of the subjects received music intervention
for 30 minutes. Using the Visual Analogue Scale (see Appendix B), each subject was
asked to rate his pain level as follows:
* 24 hours before the beginning of the intervention (T1)
* Immediately before the intervention (T2)
* 15 minutes in-between the intervention (T3)
* 30 minutes at the end of the intervention (T4)
* 45 minutes post-intervention (T5)
Upon commencement of the first session, subjects enrolled in the study were given
the opportunity to choose the type of music they would prefer to listen to during the
study. The researcher used the Modified Hartsock Music Preference Questionnaire (see
Appendix D). The purpose of this questionnaire is to determine what type of music the
clients prefer (Hartsock, 1982). Using this questionnaire ten choices of music were
offered: Classical, Country, 20th Century, New Age, Jazz, World Music, Hip Hop/Rap,
Gospel, Rock, Other. The data collection method used in this study was self-report. Since
the analysis method in this research required comparing means, the t-test was most suited
since it is the most commonly used method to evaluate the differences in means between
groups (Glass & Hopkins, 1996). The assumptions of the t-test must be met in order to
provide the most powerful test of the hypothesis. If the assumptions of the t-test are not
met, then other statistical tests should be considered (Becker, 1999). The assumptions
* Assumption 1 (independence) is not met because I get more than one score from
each person: Therefore we used the paired samples t-test rather than the
independent samples t-test. The observations in the groups of data, such as pre and
post-test, are not independent.
* Assumption 2 (scale of measurement): The scale of measurement for the pain and
anxiety response measure is ratio.
The researcher chose other sets of supportive indicators for within-subject factors,
for example, SBP, HR, and RR levels brought about by different music, as determined by
subjects' musical preferences. The researcher achieved this by comparing the mean
differences as within-subject factors variables.
In order to investigate the effects of listening to music on pain and anxiety, 15
eligible patients (subjects) aged 7 and older from the Bone Marrow Transplant Unit at
Shands Hospital at UF participated in the study. Participants were interviewed
individually either in a clinic or in a private room within the BMT area. Four health care
professionals with medical or doctoral degrees assisted in conducting the structured,
semi-structured, and unstructured interviews. In this particular research the issue of
language barrier did not arise since all the subjects spoke English as their native language
or mother tongue.
Pregnant subjects were excluded from the study. Participants were interviewed
individually in a clinic or in a private room within the BMT area. Four health care
professionals with medical, doctoral, or nursing degrees assisted in conducting the semi-
structured interviews, assessing pain, state anxiety, and recording of the three vital signs
selected: blood pressure, respiratory rate, and heart rate. The health care personnel also
assisted in arranging meetings with the patients during the post-intervention period. The
subjects were required to be able to communicate in English because the research
instruments, such as the STAI scale, were designed in English. Patients excluded from
the research included those who: are incubated; have a hearing deficit; are unable to
speak and read English; require artificial pacing which would preclude assessment of
heart rate; are unable to give informed consent; those not oriented to time, place, or
person; and have complications.
Once the protocol was begun, patients were withdrawn from the study if: they
developed any complications; they requested that the intervention be terminated; and if
they were interrupted during the time for the music intervention by medical or nursing
care activities. If the patients were administered analgesic medication, efforts were made
to delay the study sessions until after the end of peak drug levels--about four hours from
the last time they had taken the medication.
Full panel Institutional Review Board (IRB) approval was obtained to conduct the
study in the BMTU. An explanation of the study was presented to each subject. If the
subject agreed to participate in the study, a signed consent form was obtained from the
subject and from the parent if the subject was between the age of 7 and 18.
Following the IRB approval, the subjects were recruited from patients requiring a
bone marrow transplant. After their admission into the BMT Unit, eligible patients were
informed about the purpose of the study. The patients who expressed a willingness to
participate in the study were asked to sign and provide salient information that would
help in data analysis. The data collected included:
* Sociodemographic data (age, gender, race)
* Diagnosis (reasons for BMT)
* Musical preference (subjects were asked to indicate which type of music they
would prefer to listen to)
The methods used in the data collection process included: self-reported pain;
patients' music preferences; and comments by the subjects recorded on the data
collection sheet (see Appendix D). The researcher then collected information regarding
the diagnosis of the subjects based on the available medical data. The information
included for example, neurologic status, leukemia, aplastic anemia, lymphomas such as
Hodgkin's disease, multiple myeloma, fear and anxiety, and so forth. Then the researcher,
with the help of research assistants, examined the physiological parameters, which
included the vital signs. This was done a day before the musical intervention. Other
points of interest included the sociocultural and psychospiritual concerns of the patients
toward music. The researcher engaged the patients in a dialogue to see if they listened to
music at home. If spiritual or gospel music was favored by the patient, the
psychospiritual issues were noted and documented, but not discussed with the patient.
The term "psychospiritual" refers to adding psychology to matters spiritual (McMahon,
2006; Reinert, 2000). McMahon, (2006) observed:
Psychospiritual would include one or more of the following innovations:
supplementing spiritual content with psychological concepts; interpreting or
explaining the spiritual through psychological concepts; validating the spiritual
through the alleged science of psychology; integrating the spiritual with
psychology ... the spiritualizing of psychology. (para. 3)
Other aspects that were discussed in the questionnaire included the level of musical
knowledge, such as formal and non-formal music education. In this context, the
researcher noted every patient's music listening experience prior to the music
Qualitative data analysis is a search for general statements about relationships
between categories of data (Marshall & Rossman, 1994), and no single right way exists to
analyze the data in a qualitative study (Leedy & Ormond, 2001). The researcher used the
data collection tool (see Appendix D) to provide the framework for the data analysis. In
this study, the researcher began with a large body of information and through inductive
reasoning (from particular to general), sorted and categorized the data, and gradually
condensed the data to a small set of abstract, underlying themes (Creswell, 1998; Leedy
& Ormond, 2001). An analytical search for what Creswell called "patterned regularities"
in the data was conducted. The researcher examined how listening to self-selected music
affected the following variables: self-reported pain, anxiety, blood pressure, heart rate,
and respiratory rate.
Also, using an inductive approach, the researcher examined the data for
unanticipated categories that may have emerged from the data. Efforts were made to
focus upon discovering salient themes, such as recurring ideas or patterns of musical
preferences, time of day, gender, and age that link people and settings together (Marshall
& Rossman, 1994). Analytical procedures fell into the following modes: organizing the
data; generating categories, themes, and patterns; and testing the emergent hypotheses
against the data (Marshall & Rossman, 1994).
Using researcher-constructed typologies to locate naturally occurring variations in
this researcher's observations, the salient, grounded categories of meaning held by the
participants (Marshall & Rossman, 1994) were identified. The researcher also created
several categories, based upon research questions and themes that emerged from the data.
These categories were then used to code the data initially for subsequent analysis. The
researcher looked for and described alternative explanations for the data and the linkages
among them as suggested (Marshall & Rossman). As suggested, this critical analysis
assisted in facilitating explanations that were the most plausible (Marshall & Rossman
The researcher used the Statistical Package for Social Sciences (SPSS base 11.5 for
Windows, 2002, SPSS Inc., Chicago, IL) for data management, analysis, and graphical
presentation of results. The data were entered as text into MS Word using codes. The
degree of the coding was based on three factors offered by Neuman (2000): the research
questions, the richness of the data, and this study's research purposes. The researcher
marked, labeled, and sorted the data in order to find relationships between music and pain
indices, music and anxiety indices, music and BP indices, music and RP indices, and
music and RR indices. Similarities or dissimilar trends, themes, and behavior were
examined. As new ideas, concepts, and themes emerged, the researcher recorded the data.
After the initial coding process and locating themes and assigning the initial codes
or labels to condense the large set of data into categories, the researcher then conducted
axial coding. Axial coding is a technique that facilitates building connections within
categories, that is, between categories and sub-categories (Neuman, 2000). The
researcher re-read the transcripts, reviewed the initial codes, organized the key concepts
into categories and concepts that clustered, and linked concepts and themes arising from
the observed and documented evidence from the study (Neuman, 2000; Leedy &
Ormond, 2001). Additionally, the researcher marked respondent quotes to support
summary statements (see Table 4-15).
For each individual who was analyzed separately, the researcher used the SPSS
computer software program to index, code/label, and extract themes. The researcher then
summarized the data and incorporated respondent quotations to support the data. The
summary was then cross-referenced with unfolding themes, differences in the
respondents' points of views, what they said, as well as their negative comments and
special concerns during music intervention.
An explanation of the study was presented to each subject, and when the subject
agreed to participate in the study, a signed consent form was obtained from the subject
and from the parent if the subject was aged 7 or older. The study was explained and then
a signed consent was obtained from each subject (see Appendix G). Demographic data
were collected from the patients and other data from the chart (see Appendix A). The
researcher neither influenced the patients' musical preferences, nor did the researcher
require the patients to choose from the provided categories. The given taxonomy based
on the Modified Hartsock Music Preference Questionnaire (Appendix E) acted only as a
guide for the patients to make their musical preferences appropriately. The varieties of
musical selections and categories are presented in Appendix F.
Approximately 24 hours before the start of music intervention, the researcher
conducted a pre-screening of the patients. The researcher then liaised with the health care
personnel in the BMT Unit, such as the nurses and physicians on duty; to make sure the
patient was in his room at an appropriate time following the infusion or to learn if the
patient had undergone any other pharmacological or non-pharmacological procedures
that would affect his ability to participate.
The researcher then discussed the concept of pain with the subjects and defined the
kind of pain patients should address in their self-evaluation. The researcher also
addressed the concept of comfort or the concept of having no pain in order to help the
patients understand the VAS numerical scale. Points of interest included presence of pain,
pain intensity, age of patient, language, condition, and a cognitively rate their pain using
the VAS pain rating scale, for example, "0 to 10." Other points of interest included their
anxiety at that particular moment. This was measured using the STAI scale (Appendix
C). For consistency, the pain assessment method was the same for all the patients.
The researcher then discussed with the patient and their families (Appendix G)
information about reporting pain intensity using VAS rating scales and available pain
relief and comfort measures, including discussion of the patient's musical preferences
selected from choice, (i.e., Baroque, Country and Western, Classical, Gospel/Religious,
Rock/Disco, Movie Soundtracks, Romantic, Jazz/Blues, other) (see Appendix E).
Modified Hartsock Music Preference Questionnaire
Modified Hartsock Music Preference Questionnaire was first developed in 1982 by
Jane Hartsock. The questionnaire was to determine if listening to favorite music affects
the levels of anxiety in the listener (Hartsock, 1982). Since then it has been used to assess
the usefulness of music in improving the quality of life for patients (Gerdner, 2000). The
questionnaire first consisted of short questions where the respondent selected the
appropriate answers from the given choices regarding his favorite piece of music: title,
performer, composer (in the case of classical music), and the title of the recording where
the work was to be found. This questionnaire was also used to obtain personal data
Findings from the Modified Hartsock Music Preference Questionnaire (see
Appendix E) guided the selection of individualized music. The researcher discussed and
dispelled misconceptions about pain and anxiety management, respectively. The
researcher then explained to the patients the purpose of music intervention, which is,
using the arts as Complementary and Alternative Medicine (CAM) to support the
controlled analgesia, and also to educate them about the use of nonpharmacologic
methods (e.g., relaxation with music). The researcher discussed potential outcomes of
pain and discomfort interventions using music. The researcher discontinued using a
subject from the study if the patient became uncomfortable with the study. The
researcher arranged for parents of pediatric patients to be present during music
Visual Analogue Scale
Approximately one minute prior to the music, heart rate and blood pressure were
recorded from a monitor at the nurses' station. The data were obtained from an arterial
line, which was already in place, using a Hewlett-Packard monitor. The equipment was
connected with a Transpac II Sorenson transducer in the first facility and from a
previously inserted arterial line, using a Hewlett-Packard monitor with a Baxter
transducer, in the second facility. The research assistants were able to record the vital
signs. The researcher then verified the choice of music with the patient using the
Modified Hartsock Music Preference Questionnaire. Patients were asked to rate their
pain with the Visual Analogue Scale (VAS). The VAS used in this study consisted of a
10-cm line anchored by two extremes of pain (see Appendix B). Patients were asked to
make a selection from numbers "0" through "10" that represented the patients' level of
perceived pain intensity. The VAS line was designed in such a way that "0" means no
pain at all and "10" means the worst pain possible.
Each subject was then advised that the music is believed to help reduce pain. Next,
the self-selected music was played using a portable CD player for the patients for 30-
minutes. The curtain was pulled down and doors closed to decrease white noise and other
nonessential sensory stimuli. The caregivers were notified that no interruption could
occur during the 30 minutes of music intervention.
Even though the music was self-selected, each musical selection was matched by
other selections that consisted of relatively uniform rhythm and tone quality and was
between 60 and 70 beats per minute. None of the music selections had words so the
patient's thoughts could focus on the music itself without the influence of a verbal
message. The musical selections were classified as follows:
* Country and Western
* Movie Soundtracks
Data collected during the study included: subjects' biographical information;
subjects' self-report of pain; anxiety measures; blood pressure; heart rate; respiratory
rate; music preference; and subjects' general comments related to the intervention. All
this information was recorded by the researcher on the data collection sheet (see
If patients expressed a willingness to participate in the study, and upon signing the
consent form, the following data were collected:
Sociodemographic data (age, gender, race)
* Diagnosis (reasons for BMT)
* Musical preference (subjects were asked to indicate which type of music they
would prefer to listen to)
The following variables were examined in the study:
* Pain: All the subjects completed standard assessments of pain each time before,
during, and after the musical intervention.
* Anxiety: All the subjects completed standard assessments of anxiety each time
before, during, and after the musical intervention.
* Vital signs: Vital signs of all the subjects were recorded each time before, during,
and after the musical intervention.
* Satisfaction: All subjects completed standard patient satisfaction assessments at the
end of the research after each musical intervention
Table 3-1. Data Collection Process
Tl 24 hours before the intervention (-24 h)
T2 Immediately before the intervention (0)
T3 15 minutes into the intervention (+15 minutes)
T4 At the end of the intervention (+30 minutes)
T5 15 minutes after the intervention (+45 minutes)
The day before intervention (24 hours T1), pain and anxiety scores were collected
from each subject in the study sample. This initial recording was aimed at assessing the
consistency of the pain, anxiety, and the vital signs prior to music intervention. The
second reading (T2) just before the music intervention, however, acted as the baseline
reading. The recording was also taken immediately before the musical intervention. After
every 15 minutes, more readings were taken and recorded on a sheet (see Appendix D).
After 30 minutes, the investigator then entered the room and discontinued playing
the music. Subjects were asked to rate their pain using the numeric VAS from the post-
intervention pain score. After 45 minutes, the researcher asked the patient to rate his pain
for the last time. This concluded the interview and the same procedure was repeated with
other subjects in the sample. The researcher then asked for comments from the subjects
related to the intervention, and he recorded these comments on the data collection sheet.
Subjects were allowed to make other music selections if they preferred another music
style during subsequent sessions.
Patients were asked whether or not the music was of some support during their stay
in the BMT Unit, and the degree of this support, as measured on an attitudinal scale.
Patients were also asked if they would have preferred not to listen to music. At the end of
the music intervention, patients were asked to indicate whether or not they would have
preferred to listen to music and the reasons for this preference. Patients' participation in
this study was entirely voluntary. Uncontrolled variables, such as sedatives, were
recorded on the patient interview sheet, as well as the type of analgesics taken.
The selection criteria of the music utilized in the Bone Marrow Transplant Unit
included the patient's cultural and religious background, which provided a personalized
approach. In all instances, the patient's musical preferences were of primary importance.
The researcher used the convenience sampling (also known as accidental
sampling). Convenience sampling approach that makes no pretense of identifying a
representative subset of a population, but rather, it takes people who are readily available
(Leedy & Ormond 2001). This sampling method is also referred to as a nonprobability
sampling technique, commonly used in exploratory research. This research therefore
included willing patients recruited from the Bone Marrow Transplant Unit at Shands
Hospital at UF. The criteria for inclusion were that the patients must be diagnosed with
any or a combination of the following: 1) acute leukemia; 2) chronic leukemia; 3)
lymphoma; and 4) multiple myelomas. The size of the sample depended on how
homogenous or heterogeneous the population was--how alike or different its members are
with respect to the characteristics of the research interest (Leedy & Ormond. The use of
the purposive convenience sampling strategy in this study does not presuppose
generalizability to all patients in this category.
This kind of sampling allowed the researcher to generate a representative sample of
the BMT patient population and eradicate the problematic issues of money and time
required to select the sample. As a result, this research may be most applicable to the
BMT setting. But this BMT Unit is a setting with people who are in dire pain and filled
with anxiety, hence, understanding their musical preferences is of great importance.
As illustrated (see Appendix D), the first data collection day (T1) was 24 hours pre-
intervention--a day for interaction. Patients were visited by the Primary Investigator (PI)
and trained assistants. The data collectors administered the two self-report scales: the
Visual Analogue Scale (VAS) for pain and the State Trait Anxiety Inventory (STAI) for
anxiety. The VAS is the most commonly used pain measurement tool in both research
and clinics. The VAS scales can very but generally, they consist of a 100mm line
bounded with two descriptors as no pain and worst pain possible. On the other hand, the
STAI distinguishes between a general proneness to anxious behavior rooted in the
personality and anxiety as a fleeting emotional state. The instrument consists of a 20-item
scale that is easy to read and can be administered verbally (see Appendix C). This process
was repeated immediately before the musical intervention (T2). Musical interventions
were then provided to the subject for a period of 30 minutes. Pain and anxiety were
measured after the first 15 minutes (T3), immediately after the intervention (T4), and 45
minutes post-intervention (T5).
The instruments used in this study measured two groups of variables: 1)
physiological parameters; and 2) psychological parameters.
A bedside monitor was used to collect systolic blood pressure, heart rate, and
respiratory rate. Data were collected at baseline before the bone marrow transplant, 24
hours before music intervention, immediately before the intervention, 15 minutes during
intervention, 30 minutes at the end of the intervention, and 45 minutes post-intervention.
Visual Analogue Scale (VAS)
The Visual Analogue Scale (VAS) used to measure the pain levels is one of the
most frequently used measurement scales in health care research (Gould et al., 2001). A
Visual Analogue Scale is an instrument that measures a characteristic or attitude that is
believed to range across a continuum of values and cannot easily be directly measured
Gould (2001) described the VAS as a horizontal line, 100 mm in length, and
anchored by word descriptors at each end, as illustrated (see Appendix B). The
descriptors range from "0" (no pain) to "10" (very severe pain). The amount of pain that a
patient feels ranges across a continuum from none to an extreme amount of pain. From
the patient's perspective, this spectrum appears to be continuous; therefore, his pain does
not take discrete jumps. The feelings are categorized as no pain, mildpain, moderate
pain, and severe pain. Many other ways exist in which the VAS has been presented,
including vertical lines and lines with extra descriptors (Gould 2001). The patient marks
on the line the point that he feels represents his perception of his current state.
The VAS, a pain rating scale (see Appendix B), was used to assess the patient's
perception of pain intensity. The VAS has been found to be superior to categorical scales
in differentiating between precise changes in degrees of pain. It is therefore more useful
in studies pertaining to analgesic efficacy. The VAS is a reliable categorical scale, but it
is more sensitive and valid because the VAS has a straight line continuum rather than
categorical responses (Sriwatanakul et al., 1983a). Reville, Robinson, Rosen, and Hogg
(1976) reported that, among 10 females in acute labor pain, a 10 cm VAS was as reliable
and sensitive as a 15 cm and a 20 cm VAS, even under the influence ofpethidine, a drug
used to deal with moderate to severe pain. Researchers conducted another study of 1,497
patients with various diagnoses, comparing the reliability of a 10 centimeter VAS and a
10 centimeter descriptive scale (Littman, Walker, & Schneider, 1985). The researchers
found a high correlation between the two scales among patients with post-operative pain,
orthopedic pain, and chronic cancer pain (Littman et al.). The reliability of the VAS
ranged from r = 0.82 to r = 0.93 (Littman et al.). The scale is considered to be reasonably
valid (McGuire, 1988). The limitations of the VAS include its unidimensional and linear
characteristic, and the inability of some subjects to understand how to use it due to the
abstract thought process required in interpreting personal pain intensity (Kremer,
Atkinson, & Ignelzi, 1981; McGuire, 1988). The VAS is considered easy to administer
and score, but may be confusing to some patients who have difficulty visualizing pain as
a straight line (Kremer et al., 1981; McGuire, 1988).
The State Trait Anxiety Inventory, which is the anxiety assessment tool, was used
to collect anxiety scores. It is one of the most popular tools used in clinical settings and it
is available in seven languages: 1) Dutch; 2) English; 3) German; 4) French; 5) Spanish;
6) Italian; and 7) Norwegian (Stouthard, Hoogstraten, & Mellenbergh, 1995). The STAI
is intended to help care providers assess anxiety and help patients according to their
needs. MacArthur & MacArthur (2006) have stated:
Among many instruments to assess anxiety, one stands out: the State-Trait Anxiety
Inventory. This does not mean that it is an ideal measure but it is the most
frequently used scale in research world-wide, and no other measure has received as
many foreign language adaptations and citations in the last three decades. Thus, it
is the standard in the field. (para. 8)
The STAI consists of a 20-item questionnaire with questions about how the patient
is feeling (see Appendix C). Data were collected at baseline before the bone marrow
transplant, 24 hours before music intervention, immediately before the intervention, 15
minutes during intervention, 30 minutes at the end of the intervention, and 45 minutes
The instrument that was used to obtain blood pressure and heart rate in the first
facility was a Hewlett-Packard monitor with a Transpac II Sorenson transducer. The
instrument that was used to obtain blood pressure and heart rate readings in the second
facility was a Hewlett-Packard monitor with a Baxter transducer.
Both Hewlett-Packard monitors provided bedside monitoring up to 12 continuously
monitored parameters. Included in these was EGG processing with heart rate and
hemodynamic processing with blood pressure (Hewlett-Packard, 1988). Both the
Transpac II Sorenson transducer and the Baxter transducer had electronic sensors that
transmitted electronic signals, that reflected changes in pressure from body fluid. The
Hewlett-Packard monitor was able to test itself each time it was turned on, giving
credence to the equipment's accuracy and stability. While in operation, the monitor
continually tested itself with a background mode that resulted in error messages if any
problems were found. The monitor had a numeric display for heart rate and
systolic/diastolic/mean pressures) derived from an arterial line. Regarding the reliability
of the equipment, Hewlett-Packard (1988) reports that the monitor has an accuracy within
two beats and 2% for a constant rate input. The input sensitivity was 40/uv/V/mmHg or
5/uv/V/mmHg. Automatic calibration was accurate within 1% (Hewlett-Packard).
State-Trait Anxiety Inventory
Anxiety was assessed with the State-Trait Anxiety Inventory-state portion (STAI-s)
(Spielberger et al., 1983). The STAI-s measures feelings of apprehension, tension,
nervousness, and worry. Scores increase in response to physical danger and
psychological stress. The scale consists of 20 statements that evaluate how respondents
feel "right now, at this moment," rated on a "1" (not at all) to "4" (very much so) scale.
The STAI takes approximately 5 tolO minutes to complete. An overall score is derived
by coding positive statements (e.g., Ifeel secure) and then adding all items. Possible
scores for each scale are between 20 and 80. A higher score indicates more anxiety. The
STAI has been used extensively and has reported reliability (Cronbach's alpha) ranging
from .83 to .92 (Spielberger et al.). Cronbach's alpha is an index of reliability associated
with the variation accounted for by the true score of the underlying construct (Cronbach,
1951). A sample item states, "Ifeelat ease."
The State-Trait Anxiety Inventory (STAI) was initially conceptualized as a research
instrument for the study of anxiety. It is a self-report assessment device that includes
separate measures of state and trait anxiety. According to Spielberger et al. (1983), state
anxiety reflects a transitory emotional state or condition of the human organism that is
characterized by subjective, consciously perceived feelings of tension and apprehension,
and heightened autonomic nervous system activity. State anxiety has a tendency to
fluctuate over a period of time and may vary in intensity. In contrast, trait anxiety denotes
"relatively stable individual differences in anxiety proneness." Trait anxiety refers to a
general tendency to respond with anxiety to perceived threats in the environment
(Spielberger et al., 1983).
Scoring and Norms
Scores on the STAI have a direct interpretation: high scores on their respective
scales mean more trait or state anxiety, and low scores mean less trait or state anxiety.
Both percentile ranks and standard (T) scores are available for male and female adults in
three age groups (19 to 39, 40 to 49, and 50 to 69), male and female high school and
college students, male military recruits, male neuropsychiatric patients, male medical